DOI: https://doi.org/10.21203/rs.3.rs-1703013/v1
Background: Nursing students are the upcoming contributors to the nursing workforce and their attitudes towards the profession depict the quality of care they will offer to patients upon qualification. This study aimed to determine the reasons for choice, attitudes, and perceptions of undergraduate nursing students towards their profession.
Methods: This cross-sectional study involved 165 nursing students from year one to year four registered in the two public universities in Uganda. The Attitude Scale for Nursing Profession was used to collect quantitative data. Focus Group Discussions were held to collect qualitative data about the reasons for choice and perceptions towards the nursing profession.
Results: Students chose the nursing program because of its availability, poor academic performance in high school, desire to pursue a medical-related course, failure to get admitted for Medicine and Surgery, low cut-off points for the Nursing course, and interest in nursing. The majority of the students (81.8%) had positive attitudes towards the nursing profession. There was a statistically significant difference between the mean attitude scores of nursing students according to the year of study, entry scheme into the University, and source of funding for the program. Perceptions about the nursing profession were based on their personal experiences, experiences of colleagues, and observation of how nurses are treated at work.
Conclusion: Although nursing students had positive attitudes towards the nursing profession, the majority of their perceptions about the profession were negative.
Nursing training institutions should ensure that students receive pre-nurse counseling and introductory courses about the profession to enhance the acquisition of an accurate perception of the nursing profession.
Although nurses constitute the largest group of healthcare providers, there is a worldwide suffering from the shortage of nurses to meet the demand of healthcare settings (1). This shortage will influence health care delivery and negatively affect patient outcomes resulting in a decline in overall health (2, 3).
The World Health Organization(WHO) International Council of Nurses discussion paper in 2020 estimated the global shortfall of nurses to have been 5.9 million in 2020 and projected it would rise to 10.6 million by 2030 (4). The shortfall is most severe in Africa, South East Asia, and the Eastern Mediterranean (5). Uganda, just like other areas of the world, is challenged by a nursing shortage, especially at Bachelor’s degree level. Certificate and diploma nurses form a large proportion of the nursing workforce in Uganda healthcare facilities, with only 3.24% of the total nursing workforce comprising a bachelor’s degree (6).
Resolving nurses’ attitudes towards their profession is an essential aspect of understanding the issue of nursing shortage since nursing education is negatively affected by negative attitudes towards the profession (7, 8). Nursing students are the upcoming contributors to the nursing workforce (9) and their attitudes towards the profession depict the quality of care they will offer to patients upon qualification (10).
Nursing is an extensively gendered profession with approximately 90% of the nursing workforce as females (1). The nursing workforce in Uganda consists primarily of a vast female population with only 21% as male nurses (11). Nurses or women in the health sector hold few leadership positions. It is argued that nurses with higher degree qualifications hold hope for the future and will assume leadership positions (12).
Lack of social recognition, lack of career prospects, family influence, and low job security were the main reasons high school students preferred military schools and technical occupations to the nursing profession according to a similar study in Greece (13). Additionally, historically and currently, nurses have been viewed as subordinates of the physician, an inferior profession whose destiny was to obey the Doctor’s orders (14, 15).
Nurses are not adequately recognized regardless of their enormous contribution to the health workforce. The nurses are exposed to difficult working conditions resulting in stress and fatigue (16). It is estimated that 30% of the nurses do not like the nursing profession because of low pay, bad administrative system, and work overload (7).
The Bachelor of Science in Nursing program has become a 4-year curriculum in many nursing schools affiliated with Universities in Uganda heavily influenced by the medical education model. At Busitema University and Makerere University, nursing students take the same basic courses as medical students during the first two years (17), which are mainly taught by Medical doctors rather than nurse educators. Little clinical experience is offered beyond learning laboratories, community placements, and clinical observation before the last two years when nursing students take a full-time clinical placement. Most nursing programs do not have a school-based clinical faculty. Most times, nursing staff in the teaching hospital serve as the clinical instructors for students. Most clinical teachers graduated from diploma-level nursing school, and if they have received a bachelor’s degree, it was obtained through continuing education, often self-study (18).
As professional perception greatly influences the development of nursing students and the future quality of nursing, exploring factors that influence this perception is very important. There are limited studies available in Uganda to know the current generations' attitudes and perceptions towards the nursing profession. Hence, this study aimed to determine the reasons for choice, attitudes, and perceptions of undergraduate Nursing students towards their profession.
A cross-sectional design with both qualitative and quantitative approaches was used.
The study was carried out in two accredited public Universities in Uganda, Busitema University Faculty of Health Sciences and Makerere University College of Health Sciences.
Busitema University Faculty of Health Sciences is located within Mbale Regional Referral Hospital along Pallisa Road, Mbale City, Eastern Uganda approximately 220 kilometers north-east of Kampala, the capital city of Uganda. The faculty was established in 2013. Both Undergraduate and Postgraduate programs are offered at the faculty, including the Bachelor of Science in Nursing program which was introduced in 2015 and has an average enrolment of 22 students per intake.
Makerere University College of Health Sciences is a semi-autonomous college of Makerere University located on Mulago Hill between the new and old Mulago Hospital in northeast Kampala, the capital city of Uganda. The Bachelor of Science in Nursing Program was introduced in 1993 in the then Faculty of Medicine as a full-time 4-year program with an average enrolment of 25 students per intake.
Bachelor of Science in Nursing students from first to the fourth year at Busitema University Faculty of Health Sciences and Makerere University College of Health Sciences.
The sample size was based on the total number of nursing students in the two universities. All Bachelor of Science in Nursing students at all levels of study in the two universities were invited to participate in the quantitative arm of the study since they were only 180 in number.
Participants for the qualitative arm were sampled by purposive sampling. Two students were selected from each year of study considering the gender and entry scheme of the student.
A survey was carried out to obtain quantitative data using a structured self-administered questionnaire consisting of three sections. The socio-demographic section included age, gender, religion, marital status, home area, the institution of study, year of study, prior academic qualification, father’s level of education, and source of funding for the academic program.
The second section was developed based on a literature review to assess the students’ ranking of the nursing profession, reasons for enrolment, and their plans after graduation.
The third section about attitudes was adopted from the Attitude Scale for the Nursing profession (ASNP). The scale was developed by Coban and Kasikci in 2011, consisting of 40 items. The attitude subscales are properties of the nursing profession, preference to the nursing profession, and general position of the nursing profession. There are 18 items (1–18) for properties of the nursing profession, 13 items for preference to the nursing profession (19–31), and 9 items for the general position of the nursing profession (32–40). It is a five-point Likert-type scale. 8 items containing negative statements are reversely scored. The minimum score for the scale is 40 points, the maximum score is 200. A total score of 120 and above indicates a positive attitude towards the Nursing profession. For this study, a 4-point Likert scale was used where strongly disagree signified 1 and strongly agree signified 4. The higher the scores obtained from the scale, the more positive the attitudes towards the nursing profession. The Cronbach’s Alpha internal consistency coefficient of the scale is 0.91.
A pilot study involving 10% of the Nursing students from Soroti University Faculty of Health Sciences was undertaken to ensure that the questionnaire met the study objectives. These students were not part of the study population.
Qualitative data was collected using a structured interview guide. Two Focus Group Discussions were held. All participants voluntarily provided informed consent before the start of the discussion. Each discussion involved both male and female, direct entry and diploma entry students from each year of study. The discussions were conducted in English and moderated by trained and experienced research assistants. Audio recordings were put in place to gather all the data.
Quantitative data was analyzed at three levels; univariate, bivariate, and multivariate levels. The responses were entered into an excel sheet which was exported to Stata version 15 statistical software for analysis. Univariate findings were described using frequency, proportions, and measures of central tendency.
Bivariate analysis of associations between the socio-demographic and attitude scores were assessed using the Chi-square test. A p-value < 0.05 was considered significant hence an association between the socio-demographic variable and attitude score.
Multiple logistic regression analysis was done for variables that were statistically significant at the bivariate level of analysis up to P-value < 0.2 to determine the relationship between socio-demographic variables and attitudes of the nursing students. Crude and adjusted odds ratios were used to represent the association between socio-demographic variables and the mean attitudes of the nursing students.
Qualitative data was analyzed following an inductive approach as follows; Data collected from the focus group discussions was transcribed from audio recording to text. The data was compiled into transcripts that were assigned to another researcher who was a co-coder. Before coding, the researcher read through the scripts to fully understand what was discussed. The transcripts were coded based on phrases, sentences, and paragraphs. The two researchers discussed and generated a final list of codes. Similar codes were identified and these were used to generate themes. Emerging themes were identified and considered as qualitative findings of the study. Verbatim quotes were also presented to back up the themes.
Out of the 165 participants who responded to the study, 86 (52.4%) were female. One hundred and ten (66.7%) were in the age group 20–24 years with a mean age of 25.3 ± 5.5 years (minimum 20, maximum 60). The majority 103 (80.6%) were single and 147 (89.1%) were Christians. Ninety-five participants (57.6%) were from urban areas and their fathers had attained tertiary education (55.2%). Regarding the institution of study, 84 of the students (50.9%) were from Busitema University. Forty-seven participants (28.5%) were in the third year of study. One hundred twenty-four participants (75.2%) joined through the direct entry scheme and had no prior nursing qualifications (75.2%). Furthermore, fifty-six participants (33.9%) obtained financial support to pursue the program through government sponsorship (Table 1).
| Variable | Frequency (n = 165) | Percentage (%) |
|---|---|---|
| Age 20–24 | 110 | 66.7 |
| ≥ 25 | 55 | 33.3 |
| Gender | ||
| Female | 86 | 52.1 |
| Male | 79 | 47.9 |
| Marital status | ||
| Married | 32 | 19.4 |
| Single | 133 | 80.6 |
| Home area | ||
| Rural | 70 | 42.4 |
| Urban | 95 | 57.6 |
| Religion | ||
| Christian | 147 | 89.1 |
| Moslem | 18 | 10.9 |
| Institution of study | ||
| Busitema University | 84 | 50.9 |
| Makerere University | 81 | 49.1 |
| Year of study | ||
| Year 1 | 42 | 25.5 |
| Year 2 | 32 | 19.4 |
| Year 3 | 47 | 28.5 |
| Year 4 | 44 | 26.7 |
| Entry scheme into the University | ||
| Direct entry scheme | 124 | 75.2 |
| Mature entry scheme | 41 | 24.9 |
| Prior academic qualification | ||
| Diploma | 41 | 24.9 |
| None | 124 | 75.2 |
| Father's education level | ||
| Illiterate | 10 | 6.1 |
| Primary | 26 | 15.8 |
| Secondary | 38 | 23.0 |
| Tertiary | 91 | 55.2 |
| Source of funding for the program | ||
| Government sponsored | 56 | 33.9 |
| Non-Government Organization | 32 | 19.4 |
| Parents/ Guardian | 48 | 29.1 |
| Self | 29 | 17.6 |
Seventy-four participants (44.9%) ranked the nursing profession second choice, followed by sixty-seven of them (40.6%) ranking the profession first choice. Additionally, 54 participants (32.8%) enrolled in the nursing program because of their A’ Level performance, 52 (31.5%) due to the desire to help others, 24 (14.5%) were advised by family and friends, 21 (12.7%) because of financial reasons and availability of jobs while the rest (8.5%) joined because of other reasons. Eighty-two participants (49.7%) had a nurse as a relative. Families of 102 participants (61.8%) had a positive reaction to their enrolment into the nursing profession. Seventy-four participants (44.9%) plan for higher education, followed by 21.8% for nursing administration (n = 36), 15.8% for teaching institution (n = 26), while 19 (11.5%) plan to change careers and only 10 (6.1%) plan to join bedside nursing after graduation.
Nursing students had numerous reasons for choosing the nursing profession. The reasons were; availability of the course, admission on merit, poor academic performance in high school, parents’ choice, desire to pursue a medical-related course, failure to get admitted for Medicine and Surgery, and low cut-off points for the Nursing course compared to Medicine and Surgery and interest in nursing.
The participants chose nursing because of their interest in the course. They considered nursing as their first choice at the time of completing high school and applied to join the nursing program. These participants had prior experience or information about the nursing program and therefore applied to join a profession about which they knew.
“I had the interest in nursing so I applied for it without applying for other courses and indeed I was taken on merit because. It was my favorite.” (APN2)
Some participants who were aware that they were academically weak also chose nursing. Admission to the nursing course was a privilege for they were not assured of joining a medical-related course at the University. These participants are content with the nursing program irrespective of social pressure and negative comments about the profession because they believe that their ability to pursue the program is a divine intervention, which would not have been possible without God.
“I used to pray to God to give me any medical course be it Medicine, Nursing, Anesthesia, any medical course because I was not very good at school so I knew my weakness. When I joined, many people were telling me to change the course because the course is not good but, I know who I am.” (APN3)
Some participants had mixed reasons for choosing the nursing profession. The reasons were; availability of the course, low cut-off points, academic performance, and desire to pursue a course from a specific institution. Of these reasons, the desire to pursue a course at a specific institution dominated and was the main reason for their motivation to pursue the program. These participants had the desire to study in a particular University irrespective of the program and so applied to only that institution with an idea that it is where they belong.
“I did not decide to do nursing myself; I was given nursing at the University based on my academic performance. Also, since the admission document showing who has received what was showing that I was given nursing, it was the best option at the moment. I got converted and had to pursue it since I wanted a course from Makerere.” (APN9)
“I wanted to deal with human beings but still I only wanted to study at Busitema University, at least that am sure of. Looking at the cut-off points, I knew nursing would be assured so I applied for only nursing at Busitema.” (APN7)
Other participants were straightforward about choosing the nursing profession because it was the last option. These participants considered medicine and surgery as their first choice but since they failed to get the required points, they took up nursing as a last resort to join the medical field. At the time of admission, these participants were not happy about pursuing the nursing program but later accepted and found comfort in the fact that nursing is also a profession in the health sector.
“When I was studying, my interest was to do medicine and surgery but many times things do not turn out the way you expect so since I failed to get admitted for medicine and surgery, I resorted to joining. In a nutshell, nursing was the last resort to entering the medical field.” (APN8)
“At first, I never wanted to do the course; I wanted to find myself working in a hospital but as a doctor and not a nurse. A doctor is a very big title I wanted just that title. I never wanted anyone to call me a nurse because most people undermine nursing and I also had that mentality that nursing is a weak course until I started doing the course.” (APN11)
The mean attitude score was 129.9 ± 12.3 (minimum 87, maximum 153). One hundred thirty-five students (81.8%) had positive attitudes towards the Nursing profession. Items in “Properties of the Nursing profession” attracted the highest mean score of 61.9(SD 5.9) and items in the General position of the Nursing profession had the lowest mean score of 27.5(SD 2.6) (Table 2).
| ASNP Subscale | Mean | SD | Minimum | Maximum | |
|---|---|---|---|---|---|
| Properties of the Nursing profession | 61.9 | 5.9 | 35 | 71 | |
| Preference for the Nursing profession | 40.4 | 6.5 | 20 | 52 | |
| The general position of the Nursing profession | 27.5 | 2.6 | 19 | 34 | |
The item “I think communication is crucial in nursing” attracted the highest mean score (3.8), while “Nursing cannot afford any mistakes” attracted the lowest mean score (2.0) among properties of the nursing profession.
“I prefer being unemployed rather than practicing nursing” attracted the highest mean score (3.4) while “I would not like my children to become nurses” and “Nursing is not preferred as a profession unless one has no other choices left” attracted the lowest mean (2.8) on preference to the nursing profession.
The item “I think nurses among all health-care personnel communicate the most with patients” attracted the highest mean (3.7) while “Nurses work under very difficult conditions” attracted the lowest mean(1.7) on the general position of the nursing profession.
There was a statistically significant difference between total attitude scores of nursing students according to the year of study (p = 0.009), entry scheme into the University (p = 0.011), and source of funding towards the academic program (p = 0.024) as shown in Table 3.
Table 3: Comparison of total attitude scores with socio-demographic characteristics
| Variable | Negative attitude Freq (%) | Positive attitude Freq (%) | P-value |
|---|---|---|---|
| Age | 0.392 | ||
| 20–24 | 22 (73.3) | 88 (65.2) | |
| ≥ 25 | 8 (26.7) | 47 (34.8) | |
| Gender | 0.509 | ||
| Female | 14 (46.7) | 72 (53.3) | |
| Male | 16 (53.3) | 63 (46.7) | |
| Marital status | 0.051 | ||
| Married | 2 (6.7) | 30 (22.2) | |
| Single | 28 (93.3) | 105 (77.8) | |
| Home area | 0.766 | ||
| Rural | 12 (40.0) | 58 (42.9) | |
| Urban | 18 (60.0) | 77 (57.0) | |
| Institution of study | 0.186 | ||
| Busitema University | 12 (40.0) | 72 (53.3) | |
| Makerere University | 18 (60.0) | 63 (46.7) | |
| Year of study | 0.009 | ||
| Block 1 | 7 (23.3) | 67 (49.6) | |
| Block 2 | 23 (76.7) | 68 (50.4) | |
| Religion | 0.141 | ||
| Christian | 29 (96.7) | 118 (87.4) | |
| Moslem | 1 (3.3) | 17 (12.6) | |
| Entry scheme | 0.011 | ||
| Direct entry scheme | 28 (93.3) | 96 (71.1) | |
| Mature entry scheme | 2 (6.7) | 39 (28.9) | |
| Father’s education level | 0.507 | ||
| Illiterate | 3 (10.0) | 7 (5.2) | |
| Primary | 4 (13.3) | 22 (16.3) | |
| Secondary | 9 (30.0) | 29 (21.5) | |
| Tertiary | 14 (46.7) | 77 (57.0) | |
| Source of funding | 0.024 | ||
| Government sponsored | 13 (43.3) | 43 (31.9) | |
| Non-Government Organization | 3 (10.0) | 29 (21.5) | |
| Parents/ Guardian | 13 (43.3) | 35 (25.9) | |
| Self | 1 (3.3) | 28 (20.7) |
The results in Table 4 show that being a nursing student in Block 2, funding by a Non-Government Organization, and by oneself were significantly related to positive attitudes towards the nursing profession with crude odds ratios of 0.31(0.12,0.76 CI), 2.92(0.76,11.17 CI), and 8.47(1.05,68.36 CI) respectively.
The adjusted odds ratios for students in Block 2 years of study and students funded by Non-Government Organizations were 0.26(0.09,0.71 CI) and 4.46(1.09,18.19 CI) and were statistically significant at 5%.
| Variable | Mean score | SD | Crude Odds ratio (95% CI) | Adjusted Odds ratio (95% CI) | ||
|---|---|---|---|---|---|---|
| Year of study | P-value | P-value | ||||
| Block 1 | 132.4 | 12.3 | 1 | 1 | ||
| Block 2 | 127.9 | 12.0 | 0.31(0.12 ,0.76) | 0.011 | 0.26(.094,0 .71) | 0.008 |
| Source of funding for the program | ||||||
| Government sponsored | 129.1 | 13.5 | 1 | 1 | ||
| Non-Government Organization | 131.8 | 10.9 | 2.92(0.76,11.17) | 0.117 | 4.46(1.09,18.19) | 0.037 |
| Parents/Guardian | 127.2 | 12.7 | 0.81(0.33,1.98) | 0.650 | 1.45(0.54,3.92) | |
| Self | 133.8 | 9.7 | 8.47(1.05,68.36) | 0.045 | 4.28(0.38,48.25) | |
Perceptions of the participants about the nursing profession were based on their personal experiences, experiences of colleagues, and observation of how nurses are treated at work.
Two positive perceptions were identified about the nursing profession, nursing is a good and enjoyable course and nursing provides an opportunity to interact more with patients. The majority of the participants appreciated nursing as a good course and the perceptions were expressed as themes discussed below;
Overall, the respondents perceived nursing as a good and enjoyable course, which imparts knowledge needed to care for patients and manage illnesses. Nursing is a good profession because it provides an avenue to serve and care for patients. The participants were content with pursuing the course and had a passion to practice nursing.
“It has been my favorite, am proud of it and want to explore more about how lives are saved, and how to care for the sick. To me it is good because we are working to take care of the patient, irrespective of the course one is doing, we are all geared towards a common goal.”(APN2)
“I have learned many things; I now know what I am capable of doing as a nurse. As long as you know what to do and are competent, you will always get something to do and even if you do not get something to do, it does not mean you just go back home and sit, no, that makes no sense because we have a lot of information to give.” (APN6)
Nursing as a profession facilitates interaction with patients. Nurses are often the first caregivers to patients and spend more time, talking to the patients and providing all the necessary care to them. Nursing is a close relationship between a nurse and a patient aimed at protecting, promoting, and restoring the well-being of patients.
“You are going to be with the patient right from the time they are brought in up to the time they are discharged when they have improved. So you are in charge of the patient’s life, by the patient’s side, everything depends on you. When they are not able to do something, you help them achieve it or do it for them.” (APN7)
“I did not join because I wanted nursing but as time went on, I started liking the profession, even the patients at the moment because there is direct interaction with the patients. We are always with the patients.”(APN5)
Whereas some of the participants had positive perceptions about the nursing profession, a greater number had negative perceptions. Eight negative themes were identified as discussed below;
The participants expressed that the nursing profession creates a good public image because of the care nurses offer and the quality time nurses spend with the patients.
“You are near patients, caring for them. It gives you a good public image.” (APN4)
The participants also perceived nursing as a profession that is not popular among the public. According to the participants, the public knows little about the graduate nurses and this has discouraged them from joining the profession. The nursing profession is more vibrant at the certificate and diploma level of qualification and this has created so many questions for the participants about why they chose to pursue a Bachelor’s degree instead of starting at the Certificate or Diploma level.
“People are not sensitized enough about this profession, when you say you’re a nurse at Bachelor’s level, someone wonders what you do, the difference between you and a doctor. People are discouraged from joining the profession. With time students will even stop enrolling into the profession because of fear of what they are going to go through.”(APN10)
“Nursing is not so much recognized, I think because of the way it was initially done; people know it as something that stops at lower levels.”(APN7)
Nursing students had a very poor image of the nursing profession. The profession was described as one that lacks creativity, leans more on history, is not well streamlined, and ignores other key aspects of the profession focusing only on clinical work. The participants saw no specific role they play as a profession in practice and do not advance with a career in nursing because they were afraid to progress and yet remain nothing.
“There is a problem with the people in nursing; lack of creativity and leaning more on history. We keep on looking at people with ancient ideas shaped by a history of the profession and yet they decide what we have to practice so we are always rotating around the same axis. There are things, which should change such as the way senior nurses expect to be treated. ” (APN9)
“It is really hard because most of us wonder, what we are going to do and that is why when you ask the students one on one, they will tell you how they feel when they end up doing the same thing that everyone else is doing, you will see that we don’t see a future in it.”(APN6)
The participants narrated that the various stakeholders marginalize the nursing profession. Nurses are minimized; they are not accorded the respect they deserve despite being the backbone of the healthcare system. According to the participants, the responsible authorities do not handle the issues raised by nurses with urgency.
“It is very unfortunate that people do not appreciate or recognize you. You will bear witness to how the nursing profession is marginalized by respective authorities. This is expected because this seems to be a female-dominated profession and anything that is comprised of women, people tend to underlook it, and people do not look at it as something urgent.” (APN6)
Nursing was described as a very hectic profession where nurses are always attached to patients spending a lot of time with patients and lacking time for themselves and their families. The participants expressed that nurses work for so many hours, doing a lot of work and they were afraid to join the profession.
“Bedside nursing is one of the most hectic activities that a nurse has to undergo because it is a close relationship between you and the patient and you always need to do the needful. This ranges from turning the patient, wound dressing. You always have to be on standby.”(APN2)
“We want to have better standards of living and if we do bedside nursing then we should value our time. If you spend 18 out of 24 hours on the wards, when will you have time for your family and do other personal businesses?”(APN10)
The nursing profession was labeled as one that exposes nurses to vast challenges ranging from threats to personal safety to physical and psychological torture. Bedside nurses are more vulnerable to torture and so are the nursing students who are often psychologically tortured by students pursuing other courses and experiences of seeing people die.
“We always look up to clinical work which has exposed us to vast challenges. People tell you they were slapped or disrespected at the clinic. If someone wants to venture into a field they can find comfort. We are being traumatized so being tortured over and over, and in most challenging situations, a nurse is the first to fall so, people see it as a profession of cowards.” (APN9)
“ Of course, the worst thing is losing patients because of some reasons, maybe when you were able to do something but for some reasons you can’t do it because somebody else has to do it, sometimes we are not able to do something about it because of resource constraints.” (APN6)
“Nursing students, if you’re not strong you may even leave the profession. There is a feeling of a minority like when a person tells you, “Oh you are doing nursing, sorry for you” so it creates an inferiority complex, someone feels down that they will not succeed in this world.” (APN4)
Nursing training provides skills and confidence to practice but nurses are not allowed to practice what they are taught at school.
The nursing profession was displayed to have restrictions about what a nurse can and cannot do, although nursing students are equipped with information, skills, and confidence to practice during the training. Additionally, most nurses upon qualification choose to work in the clinical setting and neglect the other fields of nursing such as research and leadership in nursing.
“At the end of it all, what you are taught is not what you are going to practice. It may end in school, you are not going to clerk a patient, you are just going to be looking through the notes a doctor has made.” (APN8)
“This is a vast profession that gives little. It almost gives a third of what its content is, in the context of Bachelor nursing. We have so many roles to play. I used to look at the roles of a nurse and they were vast, but people center more on the clinical work which has more repercussions on them.” (APN9)
The ratio of bachelor nurses to lower cadre nurses in practice is low, partly because bachelor nurses are discouraged from practice because of the low pay but most importantly because the employers prefer to recruit and employ nurses with certificate and diploma levels of qualification as opposed to nurses with Bachelor’s degree level of qualification.
“We are training to become Bachelor nurses but we have Certificate nurses and Diploma nurses. Some people say certificate nurses are preferred for employment for example in private hospitals because, for a Bachelor nurse, you will automatically want to earn a lot of money.”(APN3)
“You’re studying but people are telling you, where will you get a job, private sector employs certificate nurses, only the government employs bachelor nurses, who will connect you to get a government job. You need money to get a government job, where will you get the money.” (APN4)
The participants stated that they were minimized by other health professional students, their educators, and senior nurses. The senior nurses tend to respect other health professional students and treasure them while looking down on nursing students and questioning their skills and abilities.
“As a student, am underlooked by physicians on the ward and wherever we are. The medical students look at us like a class lower than them. Even the nurses, our colleagues already in the field consider students of other courses to be more important than us.”(APN5)
“We are not considered as something, we are always minimized, and they feel like we are doing nothing in the medical field. Of recent, I read, when the current interns were striking and one had written something that nurses are useful idiots and I felt bad but had nothing to do.” (APN1)
“People believe Bachelor nurses do not know anything, they are fresh from A’ Level, full of theoretical knowledge but don’t have much hands-on. Sometimes even on the wards, those nurses look at you and say, it’s just the papers but there is nothing much you can do, actually I even know more than you.” (APN8)
The participants described the leadership in nursing as a broken leadership, one that does not fight for the rights and safety of nurses. The nursing leaders as stated, do not mentor the young generation and instead make decisions that lead to the suffering of members of the profession.
“If there is even a chance to fight for their rights, you know every human being must come out to fight for their rights but sometimes they tend to say such statements, ‘For me, I was called to love and serve’ which is okay but if something needs action, you should come and act. ” (APN9)
Additionally, the participants expressed that the pay nurses receive is too little and not realistic yet their expectation would be, good pay as an incentive to motivate them in doing their work. Nurses are underpaid although they do a lot of work. Nurses work for long hours yet earn less compared to the hectic nature of work they do
“Jobs are there but is the juice worth the squeeze? Is the pay worth the work you are going to do, if someone has seen that going the other side is a better place for me, why settle for less somewhere where you are not even appreciated?”(APN9)
“Many of us after finishing opt for other fields outside nursing just because we know we shall be underpaid yet we have invested a lot to study. Now, we are nursing students but at the end of it all, we are going to join the nurses out there. If those people are crying, do you think we shall yearn to join them and also cry, no.” (APN10)
This study was carried out to determine the reasons for choice, attitudes, and perceptions of undergraduate nursing students towards the nursing profession. Out of the 165 participants who responded to the study, 86 (52.4%) were female. One hundred and ten participants (66.7%) were in the age group 20–24 years. The majority 103 (80.6%) were single and were Christians (89.1%). One hundred twenty-four participants (75.2%) joined through the direct entry scheme. Fifty-six participants (33.9%) were financially supported to study the course through government sponsorship.
Reasons for choosing the nursing profession included availability of the course, admission on merit, poor academic performance in high school, parents’ choice, desire to pursue a medical-related course, failure to get admitted for Medicine and Surgery, low cut-off points for the Nursing course compared to Medicine and Surgery and interest in nursing.
The majority of the nursing students (44.9%) ranked the nursing profession second choice. This highlights that the students like the program although most of the students enrolled in the nursing program after failing to meet the minimum requirements for the Bachelor of Medicine and Bachelor of Surgery course, which was their first choice. These results are in agreement with a similar study by Fathi et al. (2015) where most of the students ranked the nursing profession second after a physician.
Less than half of the students (49.7%) had a nurse as a relative. This was consistent with a study by Patidar et al. (2011) where the majority of the nursing students did not have any family members in the nursing profession because those already in the nursing profession did not want their relatives or children to join the nursing profession.
The majority (44.9%) of the nursing students planning for higher education. This can be explained by the students’ desire to specialize and attain a specific role to play in practice as opposed to remaining as a general nurse and performing the same roles as every other nurse. Specialized nursing also improves the quality of patient care (20). The findings from this study are similar to a study by Rabia Allari (2020) where most students desired higher education.
More nursing students planned to change careers (11.5%) than those intending to join bedside nursing (6.1%). This can be explained by the students’ description of bedside nursing as the most hectic experience a nurse can go through, associated with poor working conditions, unfair treatment, lack of time for personal responsibilities and family, and most disappointing, the low pay. Therefore, nursing students leave the profession in search of opportunities with better pay, where they get value for the time they spend working moreover in comfortable conditions.
The mean attitude score was 129.9 ± 12.3 (minimum 87, maximum 153). One hundred thirty-five students (81.8%) had positive attitudes towards the Nursing profession. This was consistent with another study in which 62.07% of the students had favorable attitudes towards the nursing profession (22). However, the findings from this study are higher than those reported by Noruzi Kooshali et al.( 2012) where only 65.4% of the nursing students had positive attitudes towards the Nursing profession.
Items in “Properties of the Nursing profession” attracted the highest mean score of 61.9(SD 5.9) and items in the General position of the Nursing profession had the lowest mean score of 27.5(SD 2.6). This is consistent with a study by Midilli & Durgun (2017) where characteristics of the nursing profession attained the highest mean score of 88.60 ± 2.25 and the general position of the nursing profession with the lowest mean score of 35.83 ± 1.98. The students’ attitudes were most positive towards the properties of the nursing profession that include; dedication, regular and long-term education, the existence of a special body of knowledge and skills, ethics, autonomy, power for quality service, valuing, and the existence of professional associations (Ghadirian et al., 2014). These properties create an impression of nursing is a noble profession centered around education, advocacy, and care for patients (26). On the other hand, the low mean score of attitudes towards the general position of the nursing profession can be explained by the public view of nursing as a troubled profession that is not independent (27, 28) which creates a feeling of inferiority among the nursing students.
There was a statistically significant difference between total attitude scores of nursing students according to the year of study (p = 0.009), entry scheme into the University (p = 0.011), and source of funding for the academic program (p = 0.024).
The majority of the nursing students in the clinical years of study (76.7%) had negative attitudes compared to students in preclinical years of study (p = 0.009). At the multivariate level, there was a significant relationship between being a nursing student in clinical years of study and positive attitudes towards the nursing profession with crude odds ratios of 0.31(0.12, 0.76 CI) and adjusted odds ratios of 0.26(0.09, 0.71 CI). This finding can be attributed to the hectic clinical practicum and stressful experiences faced by clinical year students such as being minimized by doctors and senior nurses on the wards. These findings were consistent with a similar study carried out in Western Turkey by Midilli & Durgun (2017), where attitudes of nursing students became more unfavorable with increasing years in school. This was due to the high ambitions and expectations students have when joining the University, which are subsequently lost as they meet difficulties in the profession. However, the findings from this study were not consistent with a study by (ten Hoeve et al., 2017) where the attitudes of nursing students improved over time during the years of study due to exposure to the process of nurse education and clinical experiences.
Nursing students who joined the University through the direct entry scheme (93.3%) had more negative attitudes towards the nursing profession compared to mature entrant students (p = 0.011). This is possibly due to a lack of exposure to knowledge about the profession and a lack of prior practice in the nursing profession. Mature entry students on the other hand have more interest and satisfaction with the profession due to prior involvement with nursing practice.
Nursing students whose source of funding was government sponsorship or parents had more negative attitudes (43.3%) towards the nursing profession compared to students sponsored by self or Non-Government Organizations (p = 0.024). This is possibly because students sponsored by government sponsorship were offered the program and probably had no interest but were enticed by the sponsorship. Similarly, students sponsored by parents/guardians missed out on government sponsorship because they did not meet the cut-offs to join medicine or nursing on scholarship and therefore had to settle for nursing as the only remaining option.
Nursing students funded by Non-Government Organizations were 2.92 times more likely to have positive attitudes towards the nursing profession compared to students funded by government sponsorship. Nursing students whose source of funding was self were 8.47 times more likely to have positive attitudes towards the nursing profession compared to students funded through government sponsorship. Students who sponsor their studies are mature entrants who have prior exposure to the nursing profession and therefore more interested in nursing.
The participants in this study described nursing as a good and enjoyable profession because it provides an avenue to serve and care for patients. Providing care to patients is one of the key reasons nursing is positively perceived along with other reasons like having a key role in improving health through health education(29).
Nursing students join nursing education with different ideas about nursing due to limited public knowledge about the nursing profession (30). ). Their choice of a nursing career is based on perceptions from stereotyped and idealized images (Zulu, 2015) in books, the internet, and media programs that feature friends, family members, and nurses encountered in the healthcare setting. Participants in this study joined the course with perceptions of nursing as a weak course. Occasionally, such preconceived perceptions about nursing are not realistic and are therefore altered by the reality of practice during or after the course of study.
During the first two years, the nursing students take the same basic courses as medical students. Thereafter, the students learn clerkship skills and management of common disorders in addition to general nursing procedures during the clinical years. However, in practice, there are restrictions on what a nurse can and cannot do. The roles of a nurse are limited to administering prescribed drugs and reading notes already written by the doctor. Nursing is a vast profession, a nurse has numerous roles to play centered around leadership, advocacy, change agent, teaching, and caring for patients among others (26). Nurses however tend to focus on the clinical roles and neglect the others that would otherwise enable them to advocate for their professional growth.
In practice, nurses work for long hours yet earn less compared to the hectic nature of work they do. The participants expressed that nurses' pay is too little and not realistic. These findings are in agreement with a study by (31) where 72% of nurses wanted to leave the profession because of low salaries. Proper remuneration of nurses improves nurses' performance, thereby motivating nurses to provide quality care to the patients. More employees are also attracted to join and get retained in the profession (32).
Leadership in nursing is crucial in influencing and motivating nurses to work together and achieve professional goals. Good leadership in nursing improves patient outcomes and increases the satisfaction of nurses with their work (33). Nurse leaders should possess the skills needed for effective leadership to motivate, inspire and influence nurses to work together to achieve. Various styles of leadership have different results on patient outcomes, the satisfaction of nurses, and the overall increase in productivity (34).
Nursing training institutions experience pressure from healthcare organizations and communities to increase student enrollment and graduate more nurses to fill current vacancies in preparation for the future need. Nursing positions in Uganda are expected to grow at an average of 8% per year to over 120,000 nurses by 2030 (World Health Organization, 2020).
Currently, 30% of approved nursing positions are still vacant (Ministry of Health of Uganda, 2020). Although greater enrollment may be the solution, it may not be sufficient to solve the nursing shortage since some students admitted to a nursing education program drop out on realizing that nursing is not a career meant for them. Similarly, nursing graduates leave the profession and pursue other career interests upon discovering differences in perceptions they originally had when joining the nursing program.
The study participants provided the following suggestions to improve the nursing experience;
Streamlining the nursing profession and recognizing nursing at Bachelor’s level in the country, with a clear structure and job description for the different cadres in nursing
Embracing specialty in nursing to increase efficiency; will solve the problems of all nurses doing the same thing and lead to the delivery of quality care to the patients.
Proper representation by nursing leaders, mentorship, and orientation in all aspects of the profession
Encouraging professional upgrading; nurses trained at certificate level should be pushed to pursue higher qualifications; those at Bachelor’s degree level should be encouraged and mentored to pursue a Master’s and Ph.D. This will command respect for the profession.
Increment of nurses’ salary according to the level of training; the establishment of a clear salary scale for the nurses at Bachelor’s degree level and beyond will motivate more students to join the nursing profession.
Employment of Bachelor’s level nurses in the public and private sectors to eliminate the struggle to get jobs has led to many students leaving the profession even after graduation.
Promoting the safety of nurses by providing personal protective equipment and medical equipment needed to perform nursing procedures.
The study was carried out in two public universities therefore the findings cannot be generalized to private nursing institutions in Uganda. It would be interesting to compare findings from public and private universities in the future.
Although nursing students had positive attitudes towards the nursing profession, the majority of their perceptions about the profession were negative. The choice to study nursing is based on academic performance and the availability of the course.
Nursing training institutions should ensure that students receive pre-nurse counseling and introductory courses about the profession to enhance the acquisition and maintenance of an accurate perception of the profession. This will enable students to choose the nursing profession willingly and experience a higher level of satisfaction with their practice as a nurse after graduation.
There is a need for further research on attitudes and perceptions of undergraduate nursing and other health professional students from all public and private universities in Uganda.
There is a need for further studies to determine whether attitudes towards the nursing profession affect motivation and nursing practice.
The study also recommends four years longitudinal study of the attitudes and perceptions of nursing students to determine how the attitudes and perceptions change over time.
ASNP: Attitude Scale for Nursing Profession, IRB: Institutional Review Board, MRRH :Mbale Regional Referral Hospital, NCHE : National Council for Higher Education, WHO: World Health Organization
Acknowledgments
We acknowledge the support from the Department of Nursing of Busitema University and our dear participants who gave us their honest views about the nursing profession.
Research funding
Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health, U.S. Department of State’s Office of the U.S. Global AIDS Coordinator and Health Diplomacy (S/GAC), and President’s Emergency Plan for AIDS Relief (PEPFAR) under Award Number 1R25TW011213. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.”
Authors’ contributions
This study was carried out with substantial contributions from all authors. Author NIM conceived and designed the study, and participated in data collection, analysis, and manuscript writing. Authors NR, LS, and DJS were research supervisors who participated in the study conception, design, preparation for approval, and proofreading of the results and manuscript. Author NR wrote the first draft of the manuscript and managed the analyses of the study and JSI conducted critical reviews. All authors read and approved the final manuscript.
Consent for publication
Not applicable
Availability of data and material
All data generated or analysed during this study are included in this published article and its supplementary information files or and on OSF data base in the following link: https://osf.io/rkjh7/?view_only=37ada0709e0645e5bfd31e7f628cacfa
Competing interests
The authors declare no competing interests.
Ethical Approval and consent to participate
Ethical clearance was sought from Mbale Regional Referral Hospital Review Ethical Committee to carry out the study. The study was approved under IRB approval number MRRH-2021-89. Administrative clearance was obtained from the Dean of Makerere University College of Health Sciences to carry out the study at Makerere University.
Informed consent was obtained from the respondents. They were informed about the benefits of participating in the study, possible risks, and the freedom to withdraw without consequences. The participants were assured of confidentiality, their name and registration numbers were not included anywhere in the questionnaire. All methods were performed in accordance with the relevant guidelines and regulation.
Author’s details
1Busitema University Faculty of Health Sciences, Department of Nursing
2Busitema University Faculty of Health Sciences, Department of Community and Public Health