Nursing Students' Perception and Associated Factors Towards the Nursing Profession at Selected Health Science Colleges in Addis Ababa, Ethiopia: A Cross-sectional study.

doi:10.21203/rs.3.rs-5047846/v1

Background: Understanding nursing students' perceptions of their profession is crucial issue for improving educational programs, enhancing support systems, and ultimately preparing competent and compassionate health care professionals.

Objective: This study aimed to assess nursing students' perceptions and the associated factors of the nursing profession at selected health science colleges in Addis Ababa, Ethiopia.

Methods: A cross-sectional study was conducted from Feb 19- Mar 19, 2024, among nursing students at four health science colleges. Data was collected by using structured interview questionnaires after preparation and validated by using expert review from randomly selected undergraduate Nursing students enrolled in the four health science colleges of Addis Ababa. And organized students' socio-demographic characteristics, perceptions towards nursing, and associated factors and presented Descriptive statistics, Bivariate and multiple logistic regression analysis were computed using SPSS version 26.

Results: A total of 267 nursing students participated in this study yielding a 100% response rate. The majority (57.3%) of the students had a positive perception of the nursing profession. Factors significantly associated with positive perception included female gender, higher family income, and having a close family member who is a nurse. Factors associated with negative perception included poor clinical supervision and inadequate resources in clinical settings. From this, 82% (n=219) of the study participants were female nurses. Being female (AOR = 5.77; 95% CI: 2.47 – 13.44), competitive salary like other professions (AOR = 3.48; 95% CI: 1.81 – 6.66), having reasons for enrolling in the nursing profession (AOR= 4.39; 95% CI:2.37– 8.13) were significantly associated with the perception of nurses towards their profession.

Conclusion: Nursing students generally had a positive perception of the nursing profession. However, factors related to the clinical learning environment heavy workload, lack of professional autonomy, and poor remuneration was associated with a negative perception. Addressing these factors through improved clinical placements, and awareness creation towards the nursing profession should be implemented before and after students join the nursing school.

Perception

nursing students

nursing profession

Ethiopia.

The nursing profession plays a crucial role in healthcare delivery, yet there are concerns about the perceptions of nursing students towards their profession. Previous studies conducted in Ethiopia have highlighted various factors that influence nursing students' perceptions, including social status, workload, and job satisfaction. However, there is limited research on the current state of nursing students' perceptions and the associated factors in the context of Addis Ababa, Ethiopia.

What this study adds

Nursing students' overall perceptions of the nursing profession were generally positive, with the majority viewing nursing as a noble, caring, and respected career.
Significant factors associated with more positive perceptions included having a family member in the nursing profession, exposure to clinical placements, and higher academic performance.
Perceived challenges included heavy workload, low social status, and inadequate salary and benefits compared to other healthcare professions.
The results can inform efforts to improve nursing education, address misconceptions, and enhance the recruitment and retention of nursing students in Ethiopia.

How this study might affect research, practice, or policy

This study provides valuable insights into the perceptions and attitudes of nursing students in Addis Ababa towards the nursing profession. Understanding the factors that influence students' views on nursing can inform efforts to improve the recruitment, retention, and training of nursing professionals in Ethiopia. For research, this study establishes a baseline understanding of nursing students' perspectives that can guide future investigations into the evolving trends and determinants of nursing career choice in the region and for policy, this research can inform workforce planning and development strategies to strengthen the nursing pipeline in Ethiopia. Policymakers may use the findings to implement policies and programs that promote nursing as an attractive and viable career path, thereby helping to address shortages of nursing personnel and improve healthcare service delivery.

1.1. Background

The majority of workers who offer healthcare services are nurses, and they are essential to the delivery of quality treatment in all healthcare settings. Nursing is the backbone of health sectors, but it has not found its place ¹. Nurses account for almost 50% of the global healthcare workforce, and their deficits pose the single biggest challenge for many healthcare systems². Globally, in the 21^stcentury, the demand for nursing is growing³. A model predicts that global demand for nursing workers will increase to 36 million workers by 2030, which is more challenging in low and middle-income countries⁴. With China as an example, the ratio of nurses to the 1000 population is 2.3, compared with 12.9 in Germany in 2017⁵. In health-related areas, it is clear that there are different perceptions of nursing. Perception by itself is merely defined as an idea, belief, or image you have as a result of how you see or understand something. The perception of nursing may vary depending on age, educational level, social and professional experience⁶. Perception plays a key role in preparing the shape of an individual as a person and as a professional. Perception has an important role in molding the shape of an individual as a person and as a professional. To build up and to grow a profession, it requires strong power positive perception, and positive attitude of its workers⁷. The way in which nursing students view the field has a direct bearing on their performance, recruitment, retention, and self-concept⁸.

According to a study conducted in Taiwan, feelings of satisfaction served as the primary motivator for nursing students to select the field as their profession. Just 4(3.1%) people said that entering this field requires having an optimistic outlook. At the graduating level, 69 nurses (53.5%) decide to pursue a career in nursing because it offers them both work and educational opportunities. Of these, 12 (or 9.3%) desired to change careers, whereas 36 (or 27.9%) were in academia. Social animosity was cited by 63 respondents (48.8%) as a major factor in nursing students' decision to pick this vocation⁹.

In order to understand students' decision to choose nursing as a career, a multifaceted viewpoint on career choice needs to be investigated ¹⁰. Students' perceptions about the nursing profession may have the biggest impact on their decision to search for better possibilities to learn more about it. One of the most significant decisions a student will ever make is selecting a career, which will positively impact how they build their sense of self and find their calling in life¹¹.

In Ethiopia, a variety of elements, including the background of one's parents, the communications within communities, and spirituality in many fields, greatly influence one's choice of employment¹².

1.2. Statement of the problems

A large number of nursing student dropouts during and after school is one of the biggest issues facing the nursing profession today. Currently, between 15% and 20% of nursing student’s worldwide drop out of school every year. In particular, among recently graduated nurses, these staffing shortages may have unfavorable consequences on the quality of nursing care provided by current nurses, leading to burnout, lower jobs satisfaction, and more turnover¹³. According to projections made by the World Health Organization (WHO), there will be a 12.9 million deficit of nurses by 2035. Data revealed that 89% of these nursing shortages occurred in low- and lower-middle-income nations, with significant gaps in nations in Africa, South-East Asia, and the Eastern Mediterranean⁴.

Despite this, nurses' contributions and methods are often disregarded and they remain unnoticed. It's believed that the profession plays a small part in decision-making and is characterized by anxiety, uncertainty, and a feeling of inferiority. A growing number of professional nurses are leaving the profession, and young individuals are not selecting nursing as a career ^{14, 15}. According to the results of another Italian study, young people think that nurses are underpaid for the substantial and difficult training they receive, the hard effort they put in, and the challenging and occasionally unpleasant tasks they undertake. It demonstrated that the public values nursing despite the significant challenges and sacrifices it frequently entails; nurses are viewed as persons who perform tasks that most other people would find unpleasant. Thus, this work garners respect and recognition from society¹⁶. According to 25% of Indians surveyed on the public's perception of nursing and career influence, people think that nurses are rude to patients and have a dirty jobs¹⁷.

Numerous unfavorable social conceptions of nursing, including gender stereotyping, poor academic standards, few career options, and inadequate pay and working conditions, have been identified by researchers. More significantly, these beliefs may have an impact on the number of people entering the nursing field^18,19. A Research study indicates that 81.8% of undergraduate nursing students in Ugandan study that evaluated their attitudes and perceptions of nursing profession said they had positive attitudes toward it. However, nursing was seen as an unpopular, low-paying career that favored hiring people from lower social classes.

A study conducted in Ethiopia on 243 nurses' perceptions of the nursing profession revealed that 54.6% of nurses had positive perceptions. Nurses' opinions of the nursing profession are favorable in these regions. To maintain experienced nurses in their profession and to improve nurses' perceptions of their career, factors such as education level, monthly compensation scale, and type of hospital worked in should be taken into account¹⁵. The results of this study will assist academics and researchers in organizing more extensive investigations and implementation.

1.3. Significant of the study

Nurses are deeply invested in the well-being and health of persons in their communities. They are responsible for the physical, mental, and emotional well-being of others. Because this care frequently relies on patient compliance, the public's image of nursing has important implications for the profession. This study provides valuable insights for researcher, policy maker and the study population, and the public at large. This cross-sectional study provides valuable insights into nursing students' perceptions and attitudes towards the nursing profession in Addis Ababa, Ethiopia. The findings can inform future research on factors influencing nursing students' career choices and help identify areas for improvement in nursing education and recruitment. The study's methodology and results can serve as a foundation for similar investigations in other regions or at the national level. And understanding nursing students' perspectives is crucial for developing effective policies and interventions to address the nursing workforce shortage in Ethiopia. The study's findings can guide policymakers in designing targeted programs to promote the nursing profession, improve working conditions, and enhance the overall appeal of nursing careers. This information can ultimately contribute to strengthening the healthcare system and improving patient outcomes. Nursing students' perceptions of their profession are shaped by a complex interplay of educational experiences, personal motivations, societal influences, and mental health considerations. Understanding these factors can help educators and administrators create supportive environments that foster positive perceptions, ultimately leading to a more robust nursing workforce. Therefore, this study aims to conduct on Nursing students’ perception and associated factors towards the Nursing profession at selected health science colleges in Addis Ababa, Ethiopia

This conceptual framework illustrates the relationship between the dependent variable of nurses’ perception of their profession and the independent variable of student nurses: socio-demographic characteristics, and associated factors or predictors as depicted in Figure 1 below. This conceptual framework was adopted after reviewing different literature on the perception of nurses towards nurse professionals and factors associated with this perception ^{7, 9, 20, 21}.

Research questions

What is the perception of nursing students towards their profession?
Is there an association between nursing students’ perceptions and its predictors?

3.1. General objective

To assess nursing students’ perception and associated factors towards nursing profession at selected health Science Colleges in Addis Ababa, Ethiopia, 2024.

3.2. Specific objectives

· To determine the perception of nursing students towards nursing profession at selected health Science Colleges in Addis Ababa, Ethiopia.

· To identify factors that affect nursing students’ perception toward nursing at selected health Science Colleges in Addis Ababa, Ethiopia.

4.1. Study area

The study was conducted in Addis Ababa city administration which is the largest and the most populated city in the country and where Africa Union is headquartered. It is home to almost all ethnic groups in Ethiopia. According to the 2021 population and housing census program a total population of 3,147,000 and estimated 530 km2 with altitude ranging from 2200 to 3000m above sea level, an average temperature 22.8 Co. In Addis Ababa city administration, there are around Twenty-Five private and three public, and one defense/military nursing training institution providing undergraduate nursing training program. For the current study, four randomly selected training colleges were included (namely: Addis Ababa University, Menelik II Health Science College, Alkan Health Science, and Ayer Tena Health Science College). Currently, 135 nursing students at Addis Ababa University, 140 nursing students at Alkan HSC, 120 nursing students at Menelik II HSC, and 269 nursing students at Ayer Tena HSC are attending the training program^{15, 20}.

4.2. Study design and period

A descriptive cross-sectional study design was conducted among randomly selected Bachelor of Science in nursing students from February 19 to March 19, 2024.

4.3. Study population and eligibility criteria

The study population consisted of Bachelor of Science in nursing students in their 2nd, 3rd, and 4th years from the four randomly selected health science colleges in Addis Ababa who met the eligibility criteria. Only those nursing students currently attending the specified classes during the data collection period were included in the study; first-year students were excluded because they were undertaking a basic course.

4.4. Sample Size Determination, Sampling Procedure, and technique

The sample size was determined using a single population proportion formula while considering the following assumptions: a 95% confidence interval (CI), a 5% margin of error, and a prevalence rate (P) of 50%. Consequently, very limited research has been conducted on the perceptions and associated factors regarding the nursing profession among health science students in the study area.

The formula for calculating the minimum sample size (n) was applied, and after accounting for a 10% nonresponse rate, the final sample size was determined to be 267 students.

The study involved a total of seventeen government-owned and private-owned health science colleges (HSCs) that offer nursing training programs in Addis Ababa. Simple random sampling was used to select four out of the 17 nursing colleges. The total number of nursing students at the selected health science colleges was 664. Students were then distributed proportionally across the four selected colleges, with second-, third-, and fourth-year students being selected using simple random sampling techniques.

4.5. Definition of terms / Operational definition

Nursing student – refers to any person who is officially enrolled in the College of Nursing in order to pursue a BSN degree. This includes registered nurses (RNs), students enrolled in distance education programs, and special students, whether they are pursuing a BSN degree alone or in conjunction with another degree.

Nursing profession –would refer to the holistic conscious and continuous caring for and helping the patient ^{22, 23.}

Perception – it refers an idea or image that is formed as result of the way you see or understand something ²⁴.

Positive perception: –Those who were scored greater than or equal to mean value^{25, 26}.

Negative perception –Those who were scored score less than mean value^{26, 27}.

4.6. Variables

Dependent variable: Nursing student perception

Independent variables: Age, Sex, Year of study, social and other factors

4.7. Data collection instrument and procedure

4.7.1. Data collection instrument

Data were gathered using a structured questionnaire adapted from prior studies^22,2⁴^.. The questionnaires were prepared in English and consisted of three parts.

The first part collected socio-demographic characteristics, including age, sex, year of education, religion, and reasons for enrollment in the Faculty of Nursing, family reactions to the students' enrollment, and prior information received before joining the department.

The second section included 22 items assessing nursing students’ perceptions, using a five-point Likert scale. This scale ranged from "strongly disagree" (1) to "strongly agree" (5), allowing participants to indicate their feelings about each issue. Perception toward the nursing profession was measured with these 22 items. The mean and standard deviation for each respondent were computed, resulting in an average mean of 3.04 and a standard deviation of 1.19. A score equal to or above the mean was considered indicative of a positive perception, while a score below the mean indicated a negative perception of the nursing profession.

4.7.2. Data collection procedure

Students who met the inclusion criteria were selected using systematic random sampling from a sample size that was proportionally distributed across each year. Relevant information on student perceptions and associated factors was gathered through a self-administered structured questionnaire.

Two nursing students and one senior supervisor with a BSc in Nursing and experience in data collection were selected and trained for this purpose. The data collectors and the supervisor received half a day of training on the relevance of the study, the confidentiality of client information, eligibility criteria, and data collection methods.

4.8. Data processing and analysis

The collected data were checked for completeness, relevance, and accuracy before analysis, interpretation, and organization. The Statistical Package for Social Sciences (SPSS) version 26 was used to enter and analyze the data. Descriptive data analysis results were presented using frequency, percentage, mean, and standard deviation.

To determine whether there was a relationship between professional perception and the independent variables, bivariate logistic regression with a 95% confidence interval (CI) was employed. Following this, multiple logistic regression was used to analyze all variables with p-values less than 0.25; a p-value of ≤ 0.05 with a 95% confidence interval was considered statistically significant. Multicollinearity among independent variables and model fit were also examined.

Ultimately, the findings were compared and discussed in relation to those of other studies, and the results were presented using descriptive text, tables, graphs, and charts.

4.9. Data quality control

Two days of training were conducted for two data collectors and two supervisors on the content of data collection materials, clarity, and data collection procedures by the principal investigator. A pretest was implemented on 10% of the total sample at Yanet Health Science College to examine the validity and reliability of the methods and materials. The principal investigator made the necessary amendments based on the findings.

The overall Cronbach's Alpha for this tool during the pretest was 0.622 (62.2%), prompting further adjustments. The accuracy of the questionnaire and the average time taken to complete it were also estimated accordingly.

5.1. Socio-demographic characteristics

A total of 267 nursing students were selected to participate in this study with a 100% response rate. Among these, a total of 219 (82%), of participants were female. A larger proportion of the respondents 167 (62.5%), were in the age group of 21-25, 22 (8.2%), were in the age group of 15-20 and 78 (29.2%), were in the age group of 26-30. With their academic year of the study, the majority of the respondents, about 178 (66.6%), were above the third year, and 89 (33.3%), were second, and below years. As depicted in Table 1 below, the religious characteristics of the study participants reveal that 102 (38.2%), were Muslims followed by 92 (34.5%) Orthodox, and 67 (25.1%), Protestants.

Table 1: Sociodemographic characteristics of nursing students in selected health science colleges in Addis Ababa, Ethiopia, 2024.

Variables			Frequency (n= 267)		Percent
Gender	Male	48		18.0
	Female	219		82.0
Age	15 – 20 years	22		8.2
	21 – 25 years	167		62.5
	26 – 30 years	78		29.2
Educational year	Second Year	89		33.3
	Third Year	101		37.8
	Fourth Year	77		28.8
Religion	Orthodox	92		34.5
	Muslim	102		38.2
	Protestant	67		25.1
	Catholic	5		1.9
	Others	1		.4
Family's reaction to student' enrollment	Positive	208		77.9
	Neutral	45		16.9
	Negative	14		5.2
Having relatives / friends in nursing field	Family	77		28.8
	Friends	76		28.5
	I don’t have	114		42.7
Having information before joining the collages	Yes	103		38.6
	No	164		61.4
Did you have a reason for enrollment	Yes	161		60.3
	No	106		39.7

The majority of the students' families, 208 (77.9%), have a positive reaction to their children's enrollment in nursing school. More than half of the respondents, 153 (57.3%), had either a family member or a friend in the nursing profession, while 114 (42.7%) did not have any relatives or friends in this field. Additionally, over half of the participants (61.4%) reported that they did not have any information about the nursing profession before joining college.

Regarding their motivations for joining the faculty of nursing, more than half of the study subjects (52.2%) cited a desire to help others, while 19.9% were influenced by their academic performance in secondary school. Furthermore, 80% of the students joined nursing school due to the availability of job opportunities, and the remaining 9.9% did so based on their families' advice.

5.2. Perception towards nursing profession

Perceptions of the nursing profession were assessed using a Likert scale questionnaire. The items used to evaluate the perceptions of the study participants demonstrated good reliability, with a Cronbach’s alpha of 0.622.

About 81.2% of the participants agreed or strongly agreed that nursing is a respected profession in the health sector (mean = 3.95, SD = 1.148). More than 88% perceived that nursing is not merely an occupation but rather a profession (mean = 1.84, SD = 0.692). Additionally, 76.7% of the participants believed that nursing is not exclusively a women’s profession (mean = 2.04, SD = 0.943). More than 63% perceived nursing as a well-respected profession in society (mean = 3.4, SD = 1.111). However, about 68.5% did not believe that the nursing profession is independent, where nurses make their own decisions (mean = 2.52, SD = 1.333). Furthermore, over 68% disagreed with the notion that nurses are professionals who simply follow doctors' orders without question (mean = 2.54, SD = 1.428). About 78.6% of the respondents would not recommend nursing as a career for their children (mean = 2.46, SD = 1.158). However, more than 75% perceived nursing as a profession that provides care for patients in ethical and standard ways while maintaining their privacy (mean = 3.75, SD = 1.217). More than half of the respondents did not consider the nursing profession to be equal to other professions in the health system (mean = 3.08, SD = 1.434).

The perceptions of the nursing profession were measured using a Likert scale consisting of 22 items. The mean and standard deviation for each respondent were computed, resulting in an overall average mean of 3.04 and a standard deviation of 1.19. A score equal to or above the average mean was considered a positive perception, while a score below the mean indicated a negative perception of the nursing profession. As depicted in Figure 2 below, about 153 (57.3%) of the respondents had a positive perception of their profession.

5.3. Factors Affecting Nursing Students’ Perception

Some beliefs about the nursing profession are held by individuals, and the current study reveals that approximately 176 (66%) of respondents did not believe that interpersonal communication skills and gender differences could affect nursing students’ perceptions of their profession. More than half of the respondents felt that being disrespected by others, personality traits, or educational level would not impact their perception (55%, 56%, and 59%, respectively). About 67% of the study participants believed that their confidence would not affect their perception of the nursing profession.

Nearly half of the respondents believed that occupational overload and staff shortages could influence their perception of the nursing profession. More than 62% of participants felt that a low salary for nurses could significantly impact their perceptions, while 58% believed that conflicts with other professions could also affect their views. Additionally, about 153 (57.3%) of the respondents indicated that the risk of occupational exposure would influence their perception of their profession.

Furthermore, approximately 52.8% of study respondents agreed that administrative policies could affect their perception of the nursing profession, and 54.7% believed that social and governmental factors had an impact. As depicted in Figure 3 below, more than half of the participants responded that their poor attitude toward the nursing profession, the nature of the profession, and feelings of dependency (53.6%, 56.9%, and 57.3%, respectively) did not affect their perception of their profession.

Binary logistic regression was conducted to examine the association between nursing students’ perceptions of their profession and each independent variable separately, using a cutoff point of 0.25 for the p-value. Variables with a p-value of less than 0.25 were considered candidate variables and included in the multivariate logistic regression analysis. This analysis aimed to ascertain the effects of socio-demographic, individual-related, and social image factors on students’ perceptions of their profession.

In the bivariate analysis, factors such as gender, age, family reactions to enrollment, having relatives or friends in the nursing profession, lack of confidence, work overload, poor attitudes toward the profession, conflicts with other health professionals, low salary, and reasons for enrollment were significantly associated with nursing students' perceptions of their profession at a p-value of 0.25.

Based on the statistically significant cutoff points (p-value < 0.25) from the bivariate logistic regression analysis, we organized these variables to enhance the power of the test, select potential candidate variables, and rule out confounders. These variables were then included in the multivariate logistic regression analysis to determine the final factors significantly associated with perceptions of nursing.

In the multivariable logistic regression analysis, gender, beliefs about low job salary, and having reasons for enrollment were significantly associated with perceptions of nursing.

As shown in Table 2 below, female students were five times more likely to have a positive perception of their profession than male respondents (AOR = 5.77; 95% CI: 2.47 – 13.44). Respondents who believed that nursing offered a competitive salary, similar to other professions, were three times more likely to have a positive perception than those who felt nursing had a lower salary (AOR = 3.48; 95% CI: 1.81 – 6.66). Additionally, the likelihood of a positive perception was more than four-fold higher among participants who had specific reasons for enrolling in the nursing profession compared to those without such reasons (AOR = 4.39; 95% CI: 2.37 – 8.13).

Table 2: Factors associated with perception of nursing students towards their profession at selected health science college in Addis Ababa, Ethiopia, 2024.

*Variables*	*Category*	*Perception*		*COR (95% CI)*	*AOR (95% CI)*	*p-value*
*Variables*	*Category*	*Positive*	*Negative*	*COR (95% CI)*	*AOR (95% CI)*	*p-value*
Gender	Male	14 (29.2%)	34 (70.8%)	1	1	0.000**
Gender	Female	139 (63.5%)	80 (36.5%)	4.22 (2.137 – 8.333)	5.77 (2.47 – 13.44)	0.000**
Age	15 – 20 years	17 (77.3%)	5 (22.7%)	1	1	0.053 0.278
	21 – 25 years	73 (43.7%)	94 (56.3%)	4.37 (1.54 – 12.42)	3.45 (0.98 – 12.08)
	26 – 30 years	63 (80.8%)	15 (19.2%)	0.81 (0.25 – 2.54)	0.46 (0.11 – 1.85)
Family reaction	Positive	120 (57.7%)	88 (42.3%)	1	1	0.197 0.156
	Neutral	29 (64.4%)	16 (35.6%)	0.75 (0.38 – 1.47)	0.58 (0.25 – 1.32)
	Negative	4 (28.6%)	10 (71.4%)	3.41 (1.03 – 11.22)	2.83 (0.68 – 11.91)
Relative/friends	Family	39 (50.6%)	38 (49.4%)	1.29 (0.72 – 2.31)	1.77 (0.80 – 3.89)	0.155 0.957
	Friends	49 (64.5%)	27 (35.5%)	0.73 (0.40 – 1.33)	0.97 (0.44 – 2.15)
	Don’t have	65 (57.0%)	49 (43.0%)	1	1
Confidence	Yes	42 (47.7%)	46 (52.3%)	1.78 (1.06 – 2.99)	1.24 (0.61 – 2.50)	0.542
Confidence	No	111 (62.0%)	68 (38.0%)	1	1	0.542
Work overload	Yes	68 (52.7%)	61 (47.3%)	1.43 (0.88 – 2.34)	1.11 (0.59 – 2.12)	0.730
Work overload	No	85 (61.6%)	53 (38.4%)	1	1	0.730
Attitude	Yes	77 (46.4%)	89 (53.6%)	3.51 (2.03 – 6.06)	1.84 (0.99 – 3.40)	0.051
Attitude	No	76 (53.6%)	25 (46.4%)	1	1	0.051
Conflict with other professional	Yes	95 (60.9%)	61 (39.1%)	0.70 (0.43 – 1.14)	0.65 (0.34 – 1.23)	0.189
Conflict with other professional	No	58 (52.3%)	53 (47.7%)	1	1	0.189
Competitive salary	Yes	80 (64.5%)	44 (35.5%)	1	1	0.000**
Competitive salary	No	73 (51.0%)	70 (49.0%)	1.74 (1.06 – 2.85)	3.48 (1.81 – 6.66)	0.000**
Reason for enrollment	Yes	115 (71.4%)	46 (29.6%)	4.47 (2.64 – 7.55)	4.39 (2.37 – 8.13)	0.000**
Reason for enrollment	No	38 (35.8%)	68 (64.2%)	1	1	0.000**

**Statistically significant at p-value < 0.05; is odds ratio for reference category.

Nursing students' perceptions are shaped by a complex interplay of personal, educational, and societal factors. Understanding these perceptions can help educators and healthcare organizations support nursing students more effectively, ensuring a positive transition into their professional roles. An unfavorable perception among nursing students can have negative consequences, including deterring individuals from pursuing a career in nursing. If students are repeatedly exposed to a negative image of nursing profession, they may find it unappealing. Nurses make up the vast majority of health service personnel in the healthcare sector, providing direct and ongoing care to hospitalized patients. Their primary focus is the patient's condition, and they are often recognized as playing a significant role within healthcare facilities.

This study aimed to explore nursing students' perceptions of their profession and identify the variables influencing these perceptions. The results reveal that 57.3% of study participants had a positive perception of their profession. This finding is consistent with studies conducted in Ethiopia, Bangladesh, and Saudi Arabia, which reported positive perception rates of 54.6%, 58.2%, and 59.1%, respectively ^11,25,26,27.. In contrast, this result is lower than studies conducted in Yemen, Zambia, and Ethiopia, which reported rates of 85.3%, 70%, and 68%, respectively ^{28, 29, 30}. These differences may be attributed to variations in study periods and methodologies.

According to the findings, gender was a statistically significant factor influencing perceptions of nursing. The results indicated that female participants were five times more likely to have a positive perception compared to male participants. This finding aligns with research conducted in Yemen and Ethiopia, which also indicated that females had more positive perceptions of their profession ^{23, 31}. Another study conducted in Norway found that female nursing students were more motivated than male students to pursue specializations and professional interests, yet were less likely to seek leadership roles, prioritizing family care and traditional nursing roles ³². This aligns with findings from other studies highlighting gender disparities within the health sector, suggesting that female nurses may perceive themselves as more approachable and collaborative than their male counterparts ^{33, 34, 35}. Historically, nursing has been a female-dominated profession, which has contributed to social biases that discourage men from entering the field ^{27, 35}

The perception of those who believed that their salary was competitive with other professions was more favorable than that of their peers. This study revealed that nurses who viewed nursing as having a competitive salary were three times more likely to have a positive perception of their profession. This finding is consistent with a study conducted in Ethiopia ^{28, 30}, which indicated that nurses with higher salaries had better perceptions than those with lower salaries. Research conducted at Al-Jamhory Teaching Hospital in Mosul City found that 72% of nurses planned to quit their jobs due to low pay ^36. In contrast, another study indicated that nurses in independently run healthcare institutions were more satisfied with their career prospects and financial rewards compared to those in the civil service system ³⁸. This dissatisfaction with salaries and incentives has been supported by other studies, which found that 77.6% of respondents believed nursing did not offer high financial rewards and reported general job dissatisfaction. The nursing profession continues to face challenges related to low pay and poor working conditions, which significantly impact nurses' perceptions, even if indirectly ^38,39.

Current study participants who had specific reasons for attending nursing school were four times more likely to develop a positive perception of their profession compared to those who did not have clear reasons. A study examining reasons for enrollment in nursing school found that students with clear motivations reported greater satisfaction than those without. Additionally, research conducted in Indonesia indicated that students who entered nursing school for specific reasons had better satisfaction and perceptions than their peers. Motivations such as a desire to help others, personal callings, and the influence of friends and family significantly shaped these students' views. These factors contribute to their motivation, empathy, compassion, and favorable impressions of the nursing profession ^{2, 27, 38.} Understanding the reasons behind enrollment can help promote nursing education and attract more students.

In this study, approximately 60% of participants reported having reasons for choosing to engage in nursing school. A desire to help and care for others was the main reason cited by 52.2% of participants ³⁹. A similar study confirmed that half of the respondent nurses reported wanting to help others, particularly their families. The desire to make a positive impact on others' lives is a fundamental motivation for nursing students, who value the interpersonal engagement that is essential to nursing practice. Other reasons mentioned by participants included advice from family and friends ^{37, 38}.

Twenty percent of respondents indicated that good grades in secondary school influenced their decision to enroll in nursing school, while about 18% chose nursing due to the perceived ease of obtaining a job after graduation. A similar finding noted that financial considerations were identified by a minority of participants who began their nursing education following scholarship offers. A study in China found that students’ inclinations to pursue nursing education were significantly influenced by both academic achievement and familial support ^{38, 39}.

The knowledge and skills acquired in nursing education are critical for providing safe and ethical patient care. Identifying the competencies learned and envisioned in nursing education can help nursing institutions enhance their educational processes.

7.1. Strength of the study

The study instrument was comprehensive, pretested and modified before the actual data collection.

7.2. Limitations of the study

The study employed a quantitative approach using self-administered questionnaires to evaluate nursing students' perceptions and associated factors. Researchers should take this matter into account when measuring professional perception.
A temporal relationship between the independent variables and the outcome variable could not be established due to the cross-sectional nature of the study design.

8.1. Conclusion:

The findings revealed that the majority of nursing students (57.3%) had a positive perception of the nursing profession. Factors such as family influence, prior exposure to nursing, and academic performance were significantly associated with positive perceptions. In contrast, heavy workload, lack of professional autonomy, poor remuneration, and insufficient clinical placements, simulations, and interactions with practicing nurses contributed to negative perceptions. These issues hinder students from gaining a better understanding of the day-to-day responsibilities and challenges of the profession.

Addressing these factors is crucial for strengthening the recruitment and retention of nursing students to meet the growing healthcare needs. The findings underscore the importance of promoting and sustaining positive perceptions of the nursing profession among nursing students.

8.2. Recommendations

Based on the study findings, the following recommendations are made:

· Nursing education institutions should strengthen career counseling and mentorship programs to provide nursing students with a deeper understanding of the profession and its benefits.

· The Ministry of Health and the Ministry of Education should collaborate to raise awareness and promote the nursing profession among the general public, especially in rural communities, to improve societal perceptions of nursing.

· Nursing associations and regulatory bodies should advocate for better working conditions, competitive salaries, and professional development opportunities for nurses to enhance the overall image of the nursing profession.

· Further research should be conducted to explore the long-term impact of the identified factors on nursing students' perceptions and their career choices.

AAU: Addis Ababa University, ANA: American Nurses Association, BSC: Bachelor of Science, ETB: Ethiopian Birr, GC: Gregorian calendar, MSC: Master of Science, RN: Registered Nurse, SPSS: Statistical package for social science, UK: United Kingdom, WHO: World Health Organization.

Acknowledgement

The authors would like to acknowledge Addis Ababa University College of Health Sciences School of Nursing and Midwifery, and the study participants, and administrator of the study institutions for their unreserved support during data collection.

Ethics approval and consent to participate

Written ethical clearance was obtained using the protocol number (ref. Number): SNM/02/2024 from the Institutional Review Board (IRB) of Addis Ababa University (AAU), College of Health Sciences, School of Nursing and Midwifery. A formal letter was submitted to the respective Health science colleges and written permission was obtained from each institution. After a detailed explanation of the aim, procedure, benefits, acquired from the study and rights of the participants. Informed consent was obtained from all the study participants. Confidentiality of information was maintained under secured custody; no unauthorized person had access to the information and names or other identifiers were not recorded. The study was performed in accordance with the Declaration of Helsinki guidelines and regulations.

Consent for publication: applicable.

Availability of data and materials

All the important data have been incorporated into the manuscript. If necessary, the corresponding author was contacted to obtain additional documents.

Competing interests

This thesis is submitted as a partial achievement of the requirement for an MSc degree from the School of Postgraduate Studies at Addis Ababa University. This thesis has been deposited in the Library of Addis Ababa University and is made available to the user under the rules of the library. The authors declare that they have no conflicts of interest.

Funding

Funding for this study was not provided by any institution or agency, but some stationary items, such as A4 size papers for photocopying data collection questionnaires, pencils, and research advisor assignments, were provided by the Addis Ababa University postgraduate office.

Authors’ Contributions

This study is the result of joint research, and the contribution of each author is comparable to the others. The roles of each author are as follows:

Conceptualization: Teshome Habte, and Boka Dugassa.

Data curation: Boka Dugassa, and Teshome Habte.

Formal analysis: Rahmet Hassen.

Investigation: Rahmet Hassen.

Methodology: Rahmet Hassen, and Teshome Habte

Project administration: Rahmet Hassen, and Teshome Habte.

Software: Rahmet Hassen, and Boka Dugassa

Supervision: Teshome Habte, and Boka Dugassa.

§ Validation: Teshome Habte, and Boka Dugassa.

§ Visualization: Teshome Habte, and Boka Dugassa

§ Writing – original draft: Rahmet Hassen.

§ Writing – review & editing: Teshome Habte, and Boka Dugassa

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No competing interests reported.

Nursing Students' Perception and Associated Factors Towards the Nursing Profession at Selected Health Science Colleges in Addis Ababa, Ethiopia: A Cross-sectional study.

Status:

Version 1

Abstract

Figures

What is already known on this topic

1. Introduction

1.3. Significant of the study

2. Conceptual framework

Research questions

3. Objectives of the Study

3.1. General objective

3.2. Specific objectives

4. Methods and Materials

5. Result

5.1. Socio-demographic characteristics

5.2. Perception towards nursing profession

5.3. Factors Affecting Nursing Students’ Perception

6. Discussion

7. Strength and Limitations of the study

8. Conclusion and Recommendations

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1