Professional Image of Nursing and Midwifery in East Africa: An Exploratory Analysis

doi:10.21203/rs.3.rs-20789/v1

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Research article

Professional Image of Nursing and Midwifery in East Africa: An Exploratory Analysis

https://doi.org/10.21203/rs.3.rs-20789/v1

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published 06 Mar, 2021

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Background: Evidence suggests that there is a negative image of nursing and midwifery that does not promote nursing and midwifery as attractive career options. Furthermore, there is a paucity of studies documenting how nursing and midwifery is perceived in East Africa, and where such studies exist they are country-specific. The aim of this study was to explore views regarding the image of nursing and midwifery among nurses and midwives in three East African countries, Kenya, Tanzania and Uganda.

Methods: An exploratory descriptive cross-sectional study administered online using Survey Monkey Questionnaires assessed the views and perceptions of nurses, midwives and doctors regarding the image of nursing and midwifery professions. Descriptive statistics and Pearson’s Chi square tests were used to analyse the data. All analyses were performed using SPSS version 24.

Results: A total of 551 participants took part in the study. The majority were females (61.8%), registered nurses/midwives (45.8%), and aged 30-39 years (34.2%). The majority of the respondents were from Kenya (39.7%) and Uganda (32.9%). About two-thirds of the nurses and midwives in this study perceived nursing/midwifery as both trusted and respected professions and expressed having a level of control over how their image was portrayed. Conversely, the nurses and midwives were conscious that the public had mixed responses about the nursing/midwifery professions specifically, some members of the public described nurses/midwives as professionals, knowledgeable and caring, others perceived nurses/midwives to be rude, cruel, unkind, lazy, unkempt, and maids.

Conclusion: This study offers an interesting insight about the image of nursing/midwifery in East Africa. Findings from this study will inform policy makers and educators about key concepts that affect the image of nursing and midwifery in East Africa. The findings will be used to design marketing materials to help improve the image of nursing and midwifery in the region and other African countries.

Nursing

media image

nursing

midwifery

public perception

nursing workforce

History of Nursing and Midwifery

There is a long history of the role nurses and midwives within society. During the ancient Greek civilization period, it was documented that the Hebrews developed rules for ethical human relationships, mental health, and disease control through the Ten Commandments and Mosaic Health Code. Nurses cared for sick people in the home and the community and also practiced as nurse-midwives [1]. Famous midwives in history included Shiprah and Puah - two Hebrew midwives mentioned in the bible. They were instructed by the Pharaoh to kill any Egyptian male children they delivered, but disobeyed his orders and as a result, Moses was saved [2].

Florence Nightingale is widely credited with establishing modern nursing and midwifery as professions. She clearly saw the professions as equal partners with doctors, working alongside in a mutually beneficial relationship [3]. In the early 19th century the dominance of the predominantly male medical professions came to the fore and care of the sick became institutionalized and providing care a financially driven incentive [4]. Professionalism in nursing has seen slow progress in several decades owing to factors such as poor educational standards, male dominance in health care, and the pervading Victorian belief that women were surbodinate to men [5]. This dominance was especially prevalent in midwifery as male midwives in the Western world (soon to be called obstetricians) gained control of childbirth by excluding traditional midwives from accessing formal education [4].

Several factors have been associated with the image of nursing and midwifery professions and how it affects care. Regrettably, factors such as nurse to nurse bullying, hostile clinician behavior and disruptive behavior have been found to adversely impact on patient care and reduced work performance [6]. The way patients perceive nurses affects the care relationship, with patients and families who perceive nurses positively also viewing nurses as enhancing their quality of life in long term care [7]. Hospital work environments may not offer enough autonomy for nurses in their workplaces [8] yet autonomy and decision making affect how nurses and others perceive the power, status and role of nurse midwives in healthcare.

A Middle East Example

Work in the Middle East to explore public perceptions of the role of the midwife found that women did not know that such a role existed, despite having received antenatal care at a midwifery led clinic. When questioned about their visibility, the midwives responded that the women referred to them as ‘doctora’ (the physician) and none of the midwives corrected this [9]. In some cases nurses and midwives themselves need to take some responsibility for this, as the image is partly self-created by nurses due to their invisibility and lack of marketing [10].

Perceptions in High Income Countries

In high-income countries, the public understand the role and appreciate nurses and midwives. In addition, nurses and midwives consistently top public surveys about professionals who they trust, yet there is a shortage of suitable applicants for both professions [11]. However, the high public regard for nurses and midwives does not appear to encourage or motivate young people to choose nursing and midwifery as a positive career choice [12].

Perceptions in Low- and Middle-Income Countries

In low- and middle-income countries, the shortage of nurses and midwives is marked [13] and there are varying views regarding nurses and midwives. In South Africa, the results of a study on the image of nurses and nursing as perceived by the South African public showed that despite the negative image portrayed by the media, there is a generally positive public response to nursing and nurses in South Africa. However, only 43% of the respondents indicated that they would want their children to become nurses. Nursing was not viewed as a career choice and the public did not seem to understand the complexities of a nursing career [14]. In India, 25% of respondents in an image of nursing and career influence study stated that the public perceive nursing as a dirty job and nurses as being rude to patients [15].

In East Africa, the shortage of nurses compared to international averages is clear. According to the World Health Organization [16], East Africa has approximately 0.94 nurses and midwives per 1,000 inhabitants. This falls below the African region average of 1.2 per 1,000 and the global average of 2.92 nurses per 1,000. The State of the Worlds Midwifery Report in 2014, estimates that the unmet needs for nurses and midwives is 55% in Kenya, 26% in Tanzania and 73% in Uganda [17]. This shortage of nurses and midwives may be due, in part, to the image and perception the general public and other professionals have on nursing and midwifery professions.

In order to explore contributors to the shortage of nurses and midwives, the views of nurses and midwives were sought to elicit perceptions of the role and image of nursing and midwifery in East Africa. This study explored perceptions regarding image of nursing and midwifery in three East African countries, Kenya, Tanzania and Uganda.

Deriving from the literature review, the following conceptual framework showing the relationship between variables has been generated to guide the study:

Conceptual Framework

Study Rationale

The majority of existing studies reviewed about image of nursing and midwifery were conducted in the context of high income countries in Europe and North America. Although these studies have established that members of their populations held higher regard for nurses than other professionals [18] other countries professionals ranked nurses and midwives lower than doctors [19]. Furthermore, nurses regarded their role in a more positive image than their patients and fellow health care workers such as doctors [19].

In addition, there is a paucity of studies documenting how nursing is perceived in East Africa. Therefore, it is of interest to investigate the nurses´ and midwives´ perception regarding the image of nursing and midwifery in the East African context. This study is of ultimate importance to better understanding and improving the image of nursing and midwifery within East Africa. It attempts to fill a knowledge gap arising from lack of similar research on the topic within the region. In addition, it aims to generate scientific evidence for supporting nursing and midwifery associations to positively promote nursing and midwifery and address negative perceptions of the profession.

Objectives

To determine views of nurses and midwives regarding the image of nursing and midwifery across East Africa
Identify strategies for promoting a positive image of nursing and midwifery in East Africa

Our study aims to answer the following research questions:

Research Questions:

What are the views of nurses and midwives regarding the image of nursing and midwifery across East Africa?
What strategies can be used to promote a positive image of nursing and midwifery in East Africa?

Study Design

This is an exploratory cross sectional descriptive study with use of online quantitative survey tools consisting of structured, semi-structured questions and Likert scales. Questionnaires were designed to assess the view and perceptions of nurses and midwives regarding the image of nursing and midwifery professions.

Study Setting

This study was conducted across three East African countries namely Kenya, Tanzania, and Uganda.

Study Population

All registered nurses and midwives who are members of nursing and midwifery professional associations or regulatory councils in the study settings.

Inclusion Criteria

Respondents were recruited into the study if they meet the following criteria:

Nurses and midwives in active practice within East African health care sector

Working in East Africa public or private sector

Belonging to or being a member professional association or regulatory council within the country

Exclusion Criteria

Expatriate nurses and midwives working within the three East African countries.

Data Collection Tool

Data was collected using validated questionnaires. The questionnaire focused on the nurses and midwives’ perception of their own profession. In addition, doctors’ perception of the profession of nursing and midwifery was sought. The questionnaires focused on three main areas, namely: 1) view of nurses and midwives regarding their own profession; 2) perception of how other healthcare professionals and members of the public view nursing and midwifery profession and their role; and, 3) how the image and perceptions of nursing and midwifery can be improved.

Data Collection Procedures

We administered questionnaires to the nurses/midwives through Survey Monkey- an online platform for administering questions to respondents who may not be reached for face-to-face interviews. It is convenient, cheap and saves time. After uploading the questionnaire on the Survey Monkey platform a unique link was sent to each participant. The invitation is a single use invitation link that was deactivated once a respondent is able to fill in the questionnaire, to prevent study respondents from repeating participation in the study. The keyed in responses was automatically be encrypted and collated in the survey monkey database. The encryption key was accessible to the research team only. Participants’ responses cannot be viewed by other participants.

Sample size

The sample size was calculated using the Thrusfield formula [20] for estimating proportions defined as:

𝑛 = (𝑧𝑑)2𝑝𝑞

Where: n = Sample size

z = Linked to 95% confidence interval

p = Expected proportion of nurses and midwives imaging

q = 1-p

d = Relative desired precision

Given that we are not aware of the value of the expected proportion, p the study used 50%, assuming 95% level of significance and 5% desired precision.

The estimated number for the study was 385. However, due to finite populations of nurses and doctors of approximately 40,000, a total of 382 nurses and midwives were required for the study after adjusting based on the following formula:

n(adj) = (Nxn)/(N+n)

Sampling Technique

The email addresses of research participants were obtained through their respective nursing/midwifery professional associations. The participants were randomly selected using MS Excel. The selected participants were then invited via email containing information on the study, consent form and a personalized link to the tool.

Operational Definitions

Term	Definition
Age	In years
Gender	Male/Female/Others
Profession	Nursing/midwifery
Cadre	RN, EN, BScN
Experience	In years
Image	Image is a summary of how nursing and midwifery profession is perceived by nurse/midwives and other disciplines. It was measured using an image index generated using principal component analysis of the following: Professional View of Nurses/midwives Impact of Nurses/midwives on others Other healthcare professionals’ perceptions of Nursing & Midwifery Professions. Nurses and Midwives belief of how the public perceive their professions.

Data Management

All data were kept confidential and stored securely in accordance to research ethics governing human participants. No identifying information was stored, and only basic demographic data was collected. Data was stored within AKU secured electronic folders and only accessible by the investigators of the study.

Data Analysis

Data was checked for completeness and consistency then entered into SPSS version 24. Descriptive statistics was used to describe; sample characteristics, professional views of the nurses, impact of nurses on others, doctors and other professional perceptions of nursing and midwifery profession and nurses’ belief of how others perceive their profession.

Comparison between how nurses/midwives perceive their profession versus how other professionals perceive the nursing profession was analyzed using Chi Square test. Other comparisons include between cadre (EN/RN/BScN) between country (Kenya, Tanzania & Uganda) using Chi Square test with a p-value of less than 0.05 considered statistically significant.

A total of 551 participants took part in the study (Table 1). A majority of them were females (n=316, 61.8%), aged 30-39 years (n=172, 34.2%) and registered nurses/midwives (n=234, 45.8%). A majority of the respondents were from Kenya (n=203, 39.7%) and Uganda (n=168, 32.9%). Among the respondents from Kenya, the mean age was 38.5 years (SD: 9.4 years) and average years of practice was 14.4 (9.7) years.

Table 1. Characteristics of the study participants by Country

	Kenya (n, %)	Uganda (n, %)	Tanzania (n, %)	Total (n, %)	p-value
Nationality / Sample	203 (39.7)	168 (32.9)	140 (27.4)	511
Age, years
Age (Mean, SD)	38.5 (9.4)	39.4 (13.1)	37.5 (10.6)
20–29	38 (19.1)	47 (28.3)	41 (29.7)	126 (25.1)
30–39	73 (36.7)	54 (32.5)	45 (32.6)	172 (34.2)	0.099
40–49	55 (27.6)	30 (18.1)	27 (19.6)	112 (22.3)
50+	33 (16.6)	35 (21.1)	25 (18.1)	93 (18.5)
Gender
Male	79 (38.9)	46 (27.4)	70 (50.0)	195 (38.2)	0.000
Female	124 (61.1)	122 (72.6)	70 (50.0)	316 (61.8)
Professional Groups
Enrolled nurse/midwife	1 (0.5)	31 (18.5)	16 (11.4)	48 (9.4)
Registered nurse/midwife	40 (19.7)	92 (54.8)	102 (72.9)	234 (45.8)	0.000
Registered Community Health nurse	116 (57.1)	5 (3.0)	0 (0.0)	121 (23.7)

Highest Qualification
Certificate	1 (0.5)	34 (20.2)	15 (10.7)	50 (9.7)
Diploma	105 (51.7)	58 (34.5)	45 (32.1)	208 (40.7)	0.000
Degree	72 (35.5)	50 (29.8)	47 (33.6)	169 (33.1)
Master/PhD	25 (12.3)	26 (15.5)	33 (23.6)	84 (16.4)
Years of Practice
Mean (SD)	14.4 (9.7)	15.6 (12.8)	12.1 (10.3)
0–5	43 (21.6)	40 (24.2)	47 (35.1)	47 (35.1)
6–10	44 (22.1)	37 (22.4)	33 (24.6)	33 (24.6)
11–15	33 (16.6)	22 (13.3)	16 (11.9)	16 (11.9)	0.084
16–20	30 (15.1)	23 (13.9)	8 (6.0)	8 (6.0)
20+	49 (24.6)	43 (26.1)	30 (22.4)	30 (22.4)
Direct patient care
Yes	172 (84.7)	141 (83.9)	108 (77.1)	421 (82.4)	0.158
No	31 (15.3)	27 (16.1)	32 (22.9)	90 (17.6)
Does public perception of nursing and/or midwifery determine how nurses and/or midwives conduct their work
Yes	89 (55.3)	68 (44.4)	37 (36.6)	194 (46.7)
No	72 (44.7)	85 (55.6)	64 (63.4)	221 (53.3)	0.010

Nurses/Midwives Professional View

In Table 2, most nurses/midwives strongly agree or agree that nursing and midwifery is a calling (87.2%), and that they are powerful (87.5%) and trusted professions (82.5%). Nurses also strongly agreed that they have a level of control over how their image was portrayed (84.9%) and that they are effective advocates for their profession (71.1%).

Table 2. Nurses and midwives professional view

	Strongly disagree/ Disagree (n, %)	Not Sure (n, %)	Strongly Agree/ Agree (n, %)
Nursing and/or midwifery is my calling	43 (8.5)	22 (4.4)	441 (87.2)
My family wanted me to become a nurse and/or midwife	187 (37.0)	92 (18.2)	226 (44.8)
There is a shortage of nurses and/or midwives in my country	81 (16.0)	13 (2.6)	411 (81.4)
Nursing and/or midwifery are powerful professions	54 (10.7)	9 (1.8)	441 (87.5)
Nursing and/or midwifery are trusted professions	50 (10.0)	38 (7.6)	414 (82.5)
Nursing and/or midwifery are respected professions	165 (32.7)	46 (9.1)	294 (58.2)
Nurses and/or midwives can control how their image is portrayed	42 (8.3)	34 (6.8)	428 (84.9)
Nurses and/or midwives are affectively assertive	103 (20.6)	80 (16.0)	318 (63.5)
Nurses and/or midwives are effective advocates for their profession	115 (22.9)	30 (6.0)	356 (71.1)
Nurses and midwives have pride in their profession	109 (21.7)	63 (12.6)	330 (65.7)

Nurses/Midwives Impact on Others

As shown in Table 3, female nurses generally felt that how nurses present themselves to their patients mattered a lot (84.3%). Male nurses felt that how nurses greet their patients had a great effect on the image of nurses/midwives (77.3%). On the other hand, female nurses pointed out that having updated skills and knowledge on practice among nurses had a big effect on their image (80.1%).

Table 3. Nurses/Midwives Impact on Others by gender

	No effect (n, %)			Little effect (n, %)			Great effect (n, %)
	Male	Female	Total	Male	Female	Total	Male	Female	Total
How nurses and/or midwives present themselves to patients	2 (1.1)	9 (2.9)	11 (2.2)	39 (20.6)	40 (12.8)	79 (15.8)	148 (78.3)	263 (84.3)	411 (82.0)
Whether patients and families feel that nurses and/or midwives show compassion	5 (2.7)	12 (3.9)	17 (3.4)	61 (32.6)	123 (39.6)	184 (37.0)	121 (64.7)	176 (56.6)	297 (59.6)
How nurses and/or midwives dress and appear at work	8 (4.3)	17 (5.5)	25 (5.0)	39 (20.7)	52 (16.9)	91 (18.4)	141 (75.0)	239 (77.6)	380 (76.7)
How nurses and/or midwives are portrayed in the media	16 (8.5)	17 (5.5)	33 (6.7)	58 (30.9)	76 (24.8)	134 (27.1)	114 (60.6)	214 (69.7)	328 (66.3)
How nurse and/or midwives greet patients	7 (3.8)	16 (5.1)	23 (4.6)	35 (18.9)	57 (18.3)	92 (18.6)	143 (77.3)	238 (76.5)	381 (76.8)
Whether nurses and/or midwives keep their skills and knowledge up to date	7 (3.8)	10 (3.2)	17 (3.4)	48 (25.8)	52 (16.7)	100 (20.1)	131 (70.4)	250 (80.1)	381 (76.5)
How nurses and/or midwives behave professionally	3 (1.6)	9 (2.9)	12 (2.4)	32 (17.3)	47 (15.1)	79 (15.9)	150 (81.1)	256 (82.1)	406 (81.7)
How medical professionals interact with nurses and/or midwives	10 (5.5)	12 (3.9)	22 (4.5)	50 (27.3)	88 (28.5)	138 (28.1)	123 (67.2)	209 (67.6)	332 (67.5)

Moreover, as highlighted in Table 4, nurses in Kenya felt that factors such as how nurses/midwives greet patients (84.3%), nurses keeping their skills and knowledge up to date (85%) and nurses behaving professionally (93%) have a great effect on their image. Nurses in Uganda felt that how medical professionals interact with nurses/midwives had a great effect (74.9%) on their image.

Table 4. Nurses/Midwives Impact on others by nationality

	No effect (n, %)			Little effect (n, %)			Great effect (n, %)
	Kenya	Uganda	Tanzania	Kenya	Uganda	Tanzania	Kenya	Uganda	Tanzania
How nurses and/or midwives present themselves to patients	0 (0.00)	1 (0.6)	10 (7.4)	16 (8.0)	18 (10.8)	45 (33.3)	183 (92.0)	148 (88.6)	80 (59.3)
Whether patients and families feel that nurses and/or midwives show compassion	7 (3.5)	4 (2.4)	6 (4.6)	54 (27.1)	61 (36.3)	69 (52.7)	138 (69.4)	103 (61.3)	56 (42.8)
How nurses and/or midwives dress and appear at work	6 (3.0)	5 (3.0)	14 (10.5)	28 (14.1)	27 (16.4)	36 (27.1)	164 (82.8)	133 (80.6)	83 (62.4)
How nurses and/or midwives are portrayed in the media	8 (4.0)	39 (23.8)	51 (38.6)	44 (22.1)	39 (23.8)	51 (38.6)	147 (73.9)	115 (70.1)	66 (50.0)
How nurse and/or midwives greet patients	4 (2.0)	7 (4.2)	12 (9.2)	27 (13.6)	23 (13.8)	42 (32.1)	167 (84.3)	137 (82.0)	77 (58.8)
Whether nurses and/or midwives keep their skills and knowledge up to date	3 (1.5)	5 (3.0)	9 (6.8)	27 (13.5)	29 (17.5)	44 (33.3)	170 (85.0)	132 (79.5)	79 (59.9)
How nurses and/or midwives behave professionally	0 (0.00)	2 (1.2)	10 (7.6)	14 (7.0)	25 (15.1)	40 (30.3)	185 (93.0)	139 (83.7)	82 (62.1)
How medical professionals interact with nurses and/or midwives	5 (2.5)	7 (4.3)	10 (7.6)	50 (25.3)	34 (20.9)	54 (41.2)	143 (72.2)	122 (74.9)	67 (51.2)

Image and perception of nursing and midwifery by other health care professionals’

Generally, nurses in the three study areas (Kenya, Tanzania, and Uganda) felt strongly that they were respected and valued (61.7%). Nurses in Uganda strongly disagreed (58.2%) that medical doctors have a high regard for them as nurses (Table 5).

Table 5. Health care professionals’ perception of nursing and midwifery by gender as reported by nurses/midwives

Doctors’ and other health care professionals’ image and perception of nursing and midwifery	Strongly disagree / Disagree (n, %)		Not Sure (n, %)		Strongly Agree/ Agree (n, %)
	Male	Female	Male	Female	Male	Female
I feel respected and valued in my work as a nurse and/or midwife	65 (35.1)	87 (28.2)	17 (9.2)	20 (6.5)	103v (55.7)	202 (65.4)
Medical doctors have a high regard for nurses and/or midwives	104 (56.2)	140 (45.3)	17 (9.2)	31 (10.0)	64 (34.6)	138 (44.7)
Other health professionals have a high regard for nurses and/or midwives	71 (39.0)	117 (38.0)	32 (17.6)	48 (15.6)	79 (43.4)	143 (46.4)
Medical doctors regard nurses and/or midwives as equal partners in patient care	116 (63.7)	183 (59.2)	15 (8.2)	25 (8.1)	51 (28.0)	101 (32.7)
Advancing my nursing/midwifery knowledge and competencies improves my image as a nurse and/or midwife	11 (6.0)	15 (4.9)	1 (0.6)	4 (1.3)	170 (93.4)	289 (93.8)
Nurses and/or midwives have autonomy in making decisions regarding patient care	80 (44.0)	115 (37.6)	12 (6.6)	18 (5.9)	90 (49.5)	173 (56.5)
Collaboration between physicians and nurses and/or midwives improves patient health outcomes	6 (3.3)	10 (3.3)	1 (0.6)	0 (0.00)	175 (96.2)	298 (96.8)

Table 6. Public image by nationality as reported by nurses/midwives

	Strongly disagree / Disagree (n, %)			Not Sure (n, %)			Strongly Agree/ Agree (n, %)
	Kenya	Uganda	Tanzania	Kenya	Uganda	Tanzania	Kenya	Uganda	Tanzania
The public has a high regard for nurses and/or midwives	70 (36.3)	44 (26.8)	39 (31.7)	25 (13.0)	6 (3.7)	27 (22.0)	98 (50.8)	114 (69.5)	57 (46.3)
Nurses and/or midwives are not valued by society	108 (56.3)	103 (62.8)	34 (27.9)	14 (7.3)	10 (6.1)	24 (19.7)	70 (36.5)	51 (31.1)	64 (52.5)
My professional behavior affects my image	13 (6.8)	24 (14.6)	35 (29.4)	5 (2.6)	4 (2.4)	18 (15.1)	174 (90.6)	136 (82.9)	66 (55.5)
Showing compassion and care is important	2 (1.1)	1 (0.6)	4 (3.3)	0 (0.0)	0 (0.0)	1 (0.8)	189 (99.0)	163 (99.4)	117 (95.9)
It is important for nurses and/or midwives to have good customer service skills	5 (2.6)	1 (0.6)	3 (2.5)	3 (1.6)	1 (0.6)	1 (0.8)	183 (95.8)	161 (98.8)	117 (96.7)
Marketing nursing and/or midwifery to the public is important	9 (4.8)	12 (7.3)	4 (3.3)	5 (2.7)	6 (3.7)	6 (5.0)	174 (92.6)	146 (89.0)	110 (91.7)
Humanity is an essential component of my role	5 (2.6)	0 (0.0)	4 (3.3)	0 (0.0)	1 (0.6)	1 (0.8)	186 (97.4)	163 (99.4)	116 (95.9)
The public has a positive image of nursing and/or midwifery	70 (37.0)	56 (34.2)	45 (37.5)	30 (15.9)	17 (10.4)	32 (26.7)	89 (47.1)	91 (55.5)	43 (35.8)
Nursing and/or midwifery have varied career paths	34 (17.8)	14 (8.6)	15 (12.4)	8 (4.2)	6 (3.7)	20 (16.5)	149 (78.0)	143 (87.7)	86 (71.1)
Nursing and/or midwifery is challenging and rewarding	14 (7.5)	11 (6.7)	13 (10.7)	7 (3.7)	4 (2.4)	7 (5.8)	167 (88.8)	149 (90.9)	101 (83.5)

Table 7. Public image by gender

	Strongly disagree/ Disagree (n, %)		Not Sure (n, %)		Strongly Agree/ Agree (n, %)
	Male	Female	Male	Female	Male	Female
The public has a high regard for nurses and/or midwives	52 (29.6)	101 (33.2)	21 (11.9)	37 (12.2)	103 (58.5)	166 (54.6)
Nurses and/or midwives are not valued by society	83 (47.4)	162 (53.5)	22 (12.6)	26 (8.6)	70 (40.0)	115 (38.0)
My professional behavior affects my image	22 (12.6)	50 (16.7)	8 (4.6)	19 (6.3)	145 (82.9)	231 (77.0)
Showing compassion and care is important	3 (1.7)	4 (1.3)	0 (0.0)	1 (0.3)	172 (98.3)	297 (98.3)
It is important for nurses and/or midwives to have good customer service skills	3 (1.7)	6 (2.0)	3 (1.7)	2 (0.7)	167 (96.5)	294 (97.4)
Marketing nursing and/or midwifery to the public is important	9 (5.2)	16 (5.4)	2 (1.2)	15 (5.0)	162 (93.6)	268 (89.6)
Humanity is an essential component of my role	2 (1.2)	7 (2.3)	2 (1.2)	0 (0.0)	170 (97.7)	295 (97.7)
The public has a positive image of nursing and/or midwifery	60 (34.5)	111 (37.1)	29 (16.7)	50 (16.7)	85 (48.9)	138 (46.2)
Nursing and/or midwifery have varied career paths	22 (12.6)	41 (13.6)	11 (6.3)	23 (7.6)	141 (81.0)	237 (78.7)
Nursing and/or midwifery is challenging and rewarding	16 (9.3)	22 (7.3)	8 (4.7)	10 (3.3)	148 (86.1)	269 (89.4)

PERCEIVED ROLES OF NURSES AND/OR MIDWIVES

Nurses/Midwives perception of their role

Nurses/midwives perceive their role as that of advocating for the patient, taking care of patients, promoting health, nursing and supervisory as well as policy making (Table 6).

Perception of the role of nurses and/or midwives by other health care professionals as reported by nurses/midwives

Most nurses/midwives reported that other healthcare professionals perceive the role of nurses as being professional, offering care in an assertive and compassionate manner. They perceive nurses to be provider of patient care and timely communication. They believe nurses are knowledgeable, competent, experienced, and respected.

How do members of the public perceive the role of nurses and/or midwives?

The public perceive the role of the nurses as that of providing care to patients in a compassionate, caring, kind, respectful and professional manner. Specifically, nurses are perceived to have good knowledge, customer care skills, approachable, kind, and competent and have effective communication skills (Table 7).

ATTITUDES TOWARDS NURSES AND MIDWIVES

Attitude of healthcare workers towards nurses and/or midwives

The nurses/midwives surveyed believe that other healthcare workers are perceived to have varying attitudes about nurses/midwives. While some healthcare professionals view nurses/midwives as professional, knowledgeable, and caring. Some healthcare workers view nurses/midwives as inferior, rude, lazy, lacking, less, dirty and maids.

Public attitude of members of the public towards nurses and/or midwives

Similar to the perception of other healthcare workers, the members of the public also have both positive and negative views about nurses and midwives. The public views them as trustworthy, educated, respected, savers and helpers. However, they also view them as doctors, rude, thieves, failures, less, cruel, unkind, corrupted, harsh, poor and maids.

To our knowledge, this is the first multi-site study undertaken to explore the professional image of nursing and midwifery in East Africa. Of note, the concept of image has been a longstanding challenge to the nursing profession. Our key findings present two distinct perspectives. On one hand, the nurses/midwives have a more positive viewpoint about their professions. For example, about two-thirds of the nurses and midwives perceived nursing/midwifery as both trusted and respected professions. In addition, they expressed having a level of control over how their image was portrayed and that they are effective advocates for their profession. They also strongly feel valued and respected by doctors, other healthcare professionals, and members of the public.

From the perspective of the respondents, healthcare workers and the public had mixed responses about nurses/midwives. For example, healthcare workers think that nurses/midwives are professionals, knowledgeable and caring. Similarly, some members of the public perceive nurses/midwives as trustworthy, savers, helpers and also knowledgeable. However, other doctors, healthcare workers and members of the public had negative perceptions about nurses/midwives. Specifically, some nurses/midwives are perceived by both groups to be rude, cruel, unkind, lazy, unkempt, and maids.

The diverse findings reported in our study are comparable with previous studies. For example, Takase, Maude, and Manias [21] conducted a mixed-methods study comparing nurses’ self-image versus their perceived public image in Australia and how the latter affects their work behaviour, the authors reported that nurses rated their aptitude for leadership more positively than they thought the public viewed them. In addition, Takase and colleagues [21] found that both self-image and public-image were significant in predicting job behaviours. Similarly, several studies show that nurses have positive perception about their profession, a comparative study conducted among Egyptian and Jordanian male nursing students [22] reported that the participants in both countries were highly positive and optimistic about their profession independent of the views of the public, albeit the latter was considered crucial by the male nurses. Additionally, a qualitative study conducted in Tanzania, East Africa, showed that nurses feel professional pride which makes them discharge their duties independent of public perceptions, though the nurses expressed some limitations and inadequacies- related to staff shortages and inadequate equipment to provide optimal care [23].

The positive perceptions and self-image described by the nurses/midwives in our study could potentially be explained by other factors such as the limited interaction of nurses/midwives with the public. For example, in a discussion paper, [10] explored the public image versus self-concept and professional identity of nurses and similar to our results, ten Hoeve and colleagues reported that the public image of nursing is diverse and incongruent. The authors also posited that nurses’ invisibility was a major contributor of the incongruity and diverse views of the profession in the public domain, thus, recommending that nurses utilize all available media including social media and the internet to promote their profession and increase their visibility.

In contrast, studies conducted in Germany revealed that nursing as a profession was perceived positively by the public than the nurses themselves [24], owing to lower job satisfaction and low self-esteem among the nurses. It is not uncommon for nurses to have a negative perception about their profession, for example, a cross-sectional survey that examined the professional image of nursing among nurses working in tertiary hospitals in Southeastern Nigeria [25] revealed that majority of the participants had negative perceptions about the profession, citing factors such as poor remuneration, stereotyping of the profession, and low levels of appreciation among others.

Furthermore, a recent systematic review on contemporary public perceptions of nursing [26] found the following factors to guide public perception of nurses: misrepresentation of the nursing profession by the media; incongruence- nurses not respected but trusted; poor understanding of the role of nurses; and how entertainment value was derived from demeaning nurses. Albeit not explicit, the negative perception of nurses/midwives reported in our study echo the findings of the review by Girvin and colleagues [26], such that even among healthcare workers, there seems to be limited appreciation and understanding of the core role of nursing/midwifery. Extraordinarily, as shown in our study and previous studies [10, 24, 27], the appearance and behavior of a few nurses/midwives is often used to characterize and define the image of nursing/midwifery- the largest healthcare profession in the world [28].

It is imperative to acknowledge that nurses and midwives will be an integral part of achieving universal health coverage globally. However, with the ever-increasing challenges such as chronic staffing shortages, inadequate equipment, uneven distribution of nurses/midwives, low remunerations, and increased pressure from changing disease patterns facing the nursing profession in low- and middle-income countries, the need to strengthen nursing and midwifery cannot be overemphasized. Specifically, the pervasive healthcare staffing shortage in many East African countries leads to task shifting in many of these countries where nurses have been reportedly carrying the burden of care for other professions [29–30]. It is not uncommon to find nurses in East Africa taking up the role of doctors, lab technicians, pharmacists etc. exposing them to working beyond their scope of practice without any training or relevant skills and legal protection. This task shifting may influence the image of nursing/ midwifery with respect to how they perceive themselves and their profession and how others perceive them.

In the present study, the three countries (Kenya, Tanzania, and Uganda), require a multi-stakeholder approach to address the factors responsible for the negative perceptions of nurses/midwives by the public and healthcare workers. These approaches should include long-term innovative strategies that include the use of social media platforms and increased public engagement to promote nursing and midwifery. Remarkably, over one-third of our participants were males- indicating that nursing and midwifery are embraced as career options by the male gender in the East African region. These figures are promising particularly because nursing as a profession suffers from public stereotyping and historically perceived to be a female-dominated profession [31].

In spite the strengths of our study, a few limitations exist. For example, being an exploratory study design, we propose to use quantitative methods only to establish the initial perception of the nursing and midwifery profession. In addition, the scope of the study has been limited to two sets of respondents namely i) nurse and midwives, and ii) doctors and other health workers. Although we acknowledge that triangulating data collection methods and sources of data is beneficial, this may come in a regional follow up study. Another limitation is that the public’s perception was explored through the nurses and midwives and not directly from the public. Much as this could be a limitation, it highlights that the nurses and midwives in the three countries are acutely aware of how they and their profession are perceived in the public.

In view of our findings, we propose some recommendations. First, we recommend that the Nursing and Midwifery Councils and Associations of Kenya, Tanzania and Uganda employ strategies such as on-going context-specific continuing professional development trainings (CPDs). Second, the Councils and Associations need to develop and improve existing guidelines on ‘how nurses and midwives’ interact with patients. Third, there is need for a detailed examination of public’s perception of nurses and midwives in the three countries and the East Africa region.

In conclusion, our study offers an interesting insight about the image of nursing/midwifery in East Africa and we recognize that more work needs to be done in the region to promote this noble profession. Findings from this study will inform policy makers and educators about key concepts that affect the image of nursing and midwifery in East Africa. The findings will be used to inform further research and design marketing materials to help improve the image of nursing and midwifery in the region and other African countries.

AKU

Aga Khan University

BScN

Bachelor of Science in Nursing

CPDs

Continuing Professional Development

Enrolled Nurse

Microsoft

Ethics approval and consent to participate

This study was approved by the following ethics committees i) Aga Khan University Ethics and Review Committee, Tanzania (reference: AKU/2017/121/fb); ii) National Commission for Science, Technology and Innovation, Kenya (reference: NACOSTI/P/18/72132/23322), and iii) THETA Research Ethics Committee, Uganda (reference: Uganda T-REC007/18). Respondents were informed of the voluntary nature of participation, risks of participating in the study and benefits. Online informed consent was obtained from all participants prior to participation in the study.

Consent for publications

All respondents have granted the authors permission to publish and disseminate their responses.

Availability of data and materials

The data generated or analyzed in this study are available from the corresponding author on reasonable request.

Funding

We thank Johnson & Johnson Foundation for the funding of the strengthening associations project and Aga Khan Foundation for the support in the implementation of the larger strengthening associations project. The funders had no role in the design, conduct, or reporting of this study.

Authors’ contributions

The research was designed and implemented by EWN in Kenya, GE in Uganda and CM in Tanzania. Eunice provided the overall coordination of the programme as the PI. Primary data analysis was done by AMS and secondary data analysis done by EWN, CM and GE. The findings were discussed and agreed upon by EWN, AMS, GE and CM. The manuscript was drafted by AMS and then critically reviewed and revised by EWN, CM and GE, who made intellectual contribution to the final draft of the manuscript. All authors have read and approved the manuscript.

Competing interests

The authors declare no competing financial or non-financial interests that might have influenced this research.

Acknowledgements

We acknowledge the participants who took the time to take part in this study.

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Professional Image of Nursing and Midwifery in East Africa: An Exploratory Analysis

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Abstract

Background

History of Nursing and Midwifery

A Middle East Example

Perceptions in High Income Countries

Perceptions in Low- and Middle-Income Countries

Conceptual Framework

Study Rationale

Objectives

Research Questions:

Methods

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Supplementary Files

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