This study is aims to determine the image of nursing profession among high school students and make comparisons on the basis of variables which might influence the image of nursing. This descriptive and comparative research data were collected by using the Information Form and the Nursing Image Scale. The research sample was performed with 618 students of five state high schools. It was seemed that the nursing image of the students in the study was moderately positive but they were unwilling to make preference nursing. One of the most significant results of the present study is the importance of the close environment and the presence of factors leading to more knowledge about nursing in creating a positive image of nursing in Turkish high school students. We believe that organization of programs or projects and the use of the written and visual media will lead to positive attitudes related to nursing.
High school students, Image, Nursing, Turkey
The worldwide gap in nursing points to the fact that there are some common problems in nursing all over the world . According to Organization for Economic Co-operation and Development (OECD) data, problems in nursing are more significant in Turkey, where the number of nurses is less than that of other OECD countries, and take only about one fifth of the OECD average (1.7 nurses per 1,000 population in 2011) . Although it has been found that there is the shortage of nurses worldwide and in Turkey, it can be observed that high school students do not want to choose nursing as a career [3,4], which is in the lower rank in their professional careers list [5-7].
Looking at the reasons for why high school students do not prefer nursing their career selection at phase in the decision making about their profession reveals that the majority do not like to work in the health sector, the working conditions are hard, powerless and lacked autonomy, they have other professions in their dreams, the income is not satisfactory and nursing has a low social status [7-10]. Although there are many factors influencing the choosing of profession, it is seen that the society's perceptions influence student's decision to become nurses [6,11].
The image of nursing perceived by nurses and society influences the participation of new nurses in the profession . In recently studies show that myth, misconception and stereotype which harms the image of nursing still exist; the majority of nurses are misunderstood by the society . At the same time, it is reported that the society's nursing image does not correspond with the facts defined by nurses and the public is not aware of what nurses do and what their reality is . The fact that high school students are influenced by the society's negative image of nurses and have inadequate knowledge influences student's willingness to prefer nursing and thus, the number and quality of students [10,14,15]. Development of a positive social image related to nursing is highly important in terms of increasing the number of students who will prefer nursing as well as motivating students, who choose nursing as a career [13,16]. Thereby, Matutina  stated that it is highly important to determine middle/high school student's perceptions related to nursing through reliable and valid data collection instruments and there are limited numbers of studies on this subject.
This study aims to determine the image of nursing among high school students in the Istanbul sample from Turkey through a valid and reliable data collection instrument and make comparisons on the basis of variables which might influence the image of nursing. The identification of nursing image in high school students will contribute to determining Turkish society level of knowledge and perceptional problems related to nursing. The research questions included the following:
1) What is the image of nursing among the high school students?
2) What are the socio-demographics characteristics that affect the image of nursing among the high school students?
3) What are the factors which might influence the image of nursing among the high school students?
4) What is the relationship between The Nursing Image Scale score and willingness scores to choose nursing?
The data were collected from three general and two vocational high schools in five different socio-economic locations of Istanbul. The rationale for selecting Istanbul to conduct the study is its status as the most crowded city to which people from the smallest locations migrate.
In the Turkish National Education System, high school education covers all general, vocational, and technical educational institutions with at least 4-year curricula. High school education is comprised of high schools which administer a variety of programs like general, vocational and technical schools and students have the opportunity to be trained upon orientation to one of these programs . In Turkey, there is a two-stage system, which includes Access to Higher Education Exam and the Undergraduate Placement Exam which determines the achievement score for entrance to undergraduate programs . Students are placed in formal undergraduate programs according to achievement points through a central placement system.
The population of the study comprised final year high school students (n = 856) studying at three general (one High School and two Anatolian High School) and two vocational (Anatolian Imam Hatip High School) educational institutions in affiliated to Istanbul, Directorate of National Education in the 2010-2011 educational year. In this respect, the sampling comprised 618 students who were selected by purposive sampling and who agreed to participate in the study. Overall response rate of the questionnaire was 72.2% (n = 618). The mean age of students was 17.50 ± 0.67 (min: 17 - max: 22).
The data were collected by means of an Information Form and Nursing Image Scale. It took approximately 10-15 minutes per each student to complete the questions.
The Information Form developed by the researchers included 14 closed-ended questions on socio-demographic (gender, location, family income, school) data and factors (health care workers in near surroundings, nurse relative, obtaining information…etc.) which might influence student's image of nursing.
The Nursing Image Scale (NIS) was developed by Özsoy  in order to determine individual's image of nursing profession. The psychometric features of the scale were analyzed by Çınar and Demir  and its Cronbach's alpha coefficient was found to be 0.81. The answers were of 3-point Likert type, including the options "I agree", "I partially agree" and "I do not agree". The scale comprised 25 positive and 3 negative statements (Appendix: Scale-NIS). The lowest score to be obtained from the scale was 28, while the highest score was 84 with the higher scores pointing to a positive image of nursing [20,21]. It included three subscales consisted of general appearance (1-7 statement), Communication (8-13 statement), Occupational and Educational Characteristics (14-28 statement) . The cronbach's alpha coefficient of NIS was found to be 0.80 for this study (n = 618).
The collected data were assessed by using SPSS (Statistical Package for the Social Sciences) 15.0 software program. In the data analyses, numeric and percentile distribution, independent samples t-test, one-way analysis of variance, and Tukey's HSD post-hoc significance tests were used. In addition, the relationship between student's willingness to select nursing and the total scale scores was determined by using Pearson correlation test. The statistical significance level was accepted as p < 0.05.
Consent was taken from the Office of Governor of Istanbul, Directorate of National Education and the secondary schools where the study was carried out. Students were assured that the research results will only be employed for scientific purposes and their names will be kept confidential and volunteering principle was taken into consideration in the filling out of the questionnaire.
This study was based on descriptive study design. The convenience sampling was performed for high school students of the selected five state schools in Istanbul city of Turkey. As random sampling was not used, the results of this research cannot be generalized.
It was found out that high school student's image of nursing is positive and at an average level. In the ranking of student's scores of NIS subscales, it was revealed that the highest score was from the general appearance and the lowest score was in Occupational and Educational Characteristics (Table 1).
Table 1: Item total score of the NIS and its subscales (n = 618). View Table 1
As can be seen in Table 2, a significant difference between student's gender and scores from the scale was not obtained (p ˃ 0.05). Otherwise, female students had higher mean scores than the male students on the Occupational and Educational Characteristics subdimension (p < 0.05). It was observed that students who spent the majority of their lives in a town had more positive nursing image than those who spent their life in the city (p < 0.01). In the comparison of the nursing image of students from different school types, it was found that Anatolian Imam Hatip High School students had a more positive image of nursing than that of Anatolian High School students (p < 0.01) (Table 2).
Table 2: Comparison of socio-demographics characteristics and item total score of the NIS and its subscales (n = 618). View Table 2
Among the high school students who participated in the study, who had health care workers in their near surroundings (p < 0.05), who had a nurse relative (p < 0.001) and who knew people who direct others nursing (p < 0.01) had a more positive image of nursing. In addition, it was obtained that students who learned about nursing at school had a more positive image of nursing than those who learned about nursing via the media, which is statistically significant (p < 0.05).
Those who did not want to choose nursing and who were indecisive had a more negative image of nursing than those who preferred nursing (Table 3).
Table 3: Comparison of factors which that might affect and item total score of the NIS and its subscales (n = 618). View Table 3
Students were asked to rate their willingness to choose nursing profession on a scale of 10-point Visual Analogue Scale and it was found that the mean willingness rate was 1.74 ± 2.76 (min: 0 - max: 10) (n = 601). A poor positive relationship was observed between the Communication (C), the Occupational and Educational Characteristics (OEC), the total NIS and the willingness score to choose nursing but it can be stated that this relationship was statistically significant (r = 0.115, r = 0.173, r = 0.179, p < 0.01, respectively). On the other hand, it was seen that the their General Appearance (GA) scores were positive and strong (r = 0.086, p < 0.05) (Table 4).
Table 4: Correlations between NIS and its subscales and willingness to choose nursing (n = 601). View Table 4
The findings showed that nursing images of the high school students were the average level. The findings obtained in this study were similar to the findings of Özsoy , which pointed at that the image of nursing in the Turkish society is at a medium level. At the same time, previous studies have reported that high schools in Turkey have a positive image of the nursing profession [5,9]. On the other hand, studies with high school samples and university students have illustrated that student's view nursing through a traditional perspective and have negative nurses images in Turkish society [3,11,22]. Also, the finding that student's image of nursing is at an average level is not in line with the finding of Law and Arthur  that students perception of nursing as a career scores are above the average. We believe that this can be accounted for lack of knowledge about nursing of the high school students in the sample.
Female high school students had more positive image of nursing than the male high school students on the Occupational and Educational Characteristics subdimension in this sample. It has been observed that nursing is still perceived to be a profession since the majority are women [8,11] and therefore female students are more interested in the profession than males [3,6]. In Turkey "nurse" means "sister" in English. And nursing is still seen a female profession in Turkey therefore many males did not want to choose the profession of nursing . The removal of the gender issue from the title "No one else other than Turkish women can do nursing" in the Nursing Law  in Turkey in 2007, the increase in male nurses and the news about male nurses have made a positive impact, we believe that the concept of male nurse is still new for Turkey and changing this will take time.
In the literature, it was not found that finding that the image of nursing becomes more positive while the population of the place (location) where high school students spent the majority of their life decreases. However, it was shown by studies that that socio-economic status influences job selection. Indeed, a study performed by Eskimez, et al.  has been shown that students of medium socio-economic status choose nursing at a significantly higher rate than those with high socioeconomic status, in Turkey. Also, it is considered that this finding might be related to the ease of access to nursing services and the student's satisfaction with the service they receive. The finding that student's images of nursing differ in terms of school types is one of the most interesting results of the present study. In the present study, it was observed that students from religion-oriented high school (Anatolian Imam Hatip High School) had a more positive image of nursing than students from other (general) school type. Similarly, in the study performed by Sarikaya and Khorshid's  on nursing students, it also had reported a difference between student's reasons for choosing nursing in terms of school types, which implies that students are influenced by the philosophy of their high school or students select schools on the basis of their philosophy. In addition, this finding is supported by previous study which documented that secondary school students stated helping others as one of the most significant reasons for choosing the nursing profession . This is thought to stem from the fact that these schools philosophy corresponds with that of nursing which supports "helping others".
It was also found that the presence of health care workers in the close environment, having a nurse relative and people who direct people to nursing positively influence the image of nursing. Similarly, previous studies have been obtained that in the selection of profession, the knowledge and attitudes of not only students but also families and the close environment are important [9,15,23]. Furthermore, it is known that prior to selecting a profession; students obtain information from people performing their target profession in addition to their school and relatives/acquaintances [3,11].
In the present study it was also obtained that students who learned about nursing through the media had a more negative image of nursing. Similarly, in a study performed in Turkey, it was seen that 35.92% of the news about nurses involve negative individual relations, suicide, medical errors and news, which do not reflect the scientific aspect of nursing . This finding shows that the media reflects the negative aspects of nursing and high school students are influenced by the media. Murray's  study reports that students make decisions on the basis of the programs they watch and personal experiences and 65% of the students state that movies/television help them understand nursing. This finding is similar to Neilson and Lauder  the previous findings that the media forms the main source of information for the majority of the students; however, it does not have an important effect on their perceptions of nursing as a career  and decision to become a nurse .
It was appeared that the relationship between the Communication (C), the Occupational and Educational Characteristics (OEC), the total NIS and the willingness score is rather poor. So it can be said that this results from misunderstanding and lack of knowledge about nursing of the students. As the perception of the students regarding the general appearance of the nurses increases to a positive direction, the willingness for choosing of the nursing increases.
It was also found that student's willingness to choose nursing in the university selection duration is at a considerably low level, and those who want to choose nursing have a more positive image of nursing. Research into identifying high school student's thoughts on nursing also indicates that students state that they will not prefer nursing . Similarly, in the study performed by Law and Arthur's  on secondary school students from Hong Kong, it was shown that only 8.9% of those who replied to the question (28%) scored their level of willingness between 8 and 10 point in VAS and those who did not want to select nursing had more positive perceptions related to nursing. Also, it is emphasized that those who obtain knowledge on the nursing profession  and those who obtain positive information about the nursing profession are more willing to choose nursing .