Study Design, Sample and Settings

This study uses the descriptive multi-centered research design. The study population consisted of 991 freshman baccalaureate students enrolled in the Faculty of Nursing, Faculty of Health Sciences and School of Health Nursing Department of two private and four state universities in Turkey and Cyprus in the fall semester of the 2018-2019 academic year. Of the study population, 88.1% was reached. Without any sample selection, 874 freshman nursing students of faculty of nursing, faculty of health science nursing department and school of health nursingdepartment students who volunteered to participate in the research were included in the study.

Data Collection Tools

A two-part questionnaire was used as the data collection tool.

a) Introductory Information Form: The form, prepared by the researchers in accordance with the literature, contains 16 closed-ended questions to investigate the socio-demographic characteristics of the students and their views on the nursing profession (^{Dost & Bahçecik, 2015}; ^{Glerean et al., 2017}; ^{Wu et al., 2015}).

b) Image of Nursing Profession Scale: The scale, developed by ^{Dost and Bahçecik (2015}), consists of six sub-scales and 42 items. The Likert-type scale has 11 items in the professional qualifications sub-scale, 10 items in the working conditions sub-scale, 8 items in the gender sub-scale, 5 items in the education sub-scale, 5 items in the professional status sub-scale, and 3 items in the external image sub-scale. The scale is scored by "Strongly agree: 5 points", "Agree: 4 points", "Neutral: 3 points", "Disagree: 2 points", "Strongly disagree: 1 point". Negative items in the scale include the items numbered 8, 14, 15, 17, 18, 20, 21, 22, 23, 24, 25, 26, 28, 29 and 31. Responses of negative items on the scale were reverse coded. The scores on the scale range from 42 to 210. As the score from the scale increases, nurses' perceptions of their professional image also increase positively. The Cronbach's Alpha value of the scale was 0.885 (Dost & Bahçecik, 2015).

Data Collection

The study data were collected on September 24-28, 2018, the first week of the academic year. In order to determine the intelligibility and usability of the prepared questionnaire, a pilot study was applied to 100 students, which is 10% of the target sample size. It was determined that the statements in the questionnaire were understandable and therefore no modification was necessary. The questionnaire and the scale were applied to students in a classroom setting using the face-to-face interview technique. Filling the questionnaires lasted 15-20 minutes on average.

Data Analysis

SPSS 25.0 (SPSS Inc., Chicago, IL, USA), a statistical package program used in social sciences, was used for the analysis of the study data. Number, percentage, mean and standard deviation were used for the data representation. Suitability of the data for the normal distribution was tested by the Kolmogorov-Smirnov test. The data with normal distribution were tested by independent samples t-test for two groups and one-way analysis of variance. For the results, p<0.05 was considered statistically significant.

Ethical Consideration

In order to collect study data, approval of the Ethics Committee of the Nursing Faculty of a university (05-03/118-2018), written consents of the nursing students and permissions from the studied universities were obtained.

Characteristics of the Nursing Students

The average age of the nursing students included in the study was 19.09±1.87 years, and 77.3% was female. Of the students, 73.3% (n=641) was studying at a state university, 26.7% (n=233) was studying at a private university, 48.0% (n=420) was at the Faculty of Nursing, 42.6% (n=372) was at the Faculty of Health Sciences, and 9.4% (n=82) was at the School of Health. Looking at the cities of the students, where they received education, 30.2% (n=264) was studying at Izmir-Turkey, 21.5% (n=188) was at Manisa-Turkey, 17.8% (n=156) was Nicosia-Cyprus, 12.2% (n=107) was at Afyonkarahisar-Turkey, 9.4% (n=82) was Adıyaman-Turkey, and 8.8% (n=77) was at Istanbul-Turkey.

Nursing Students Perceptions of the Nursing Profession Image

The factors about the nursing students' perceptions of the nursing profession image, 21.2% (n=185) had a healthcare professional in the family, and 19.8% (n=173) had a nurse in the family. Of the students 75.4% (n=659) was found to choose the nursing department willingly, and 52.0% (n=454) chose it in the first place, according to the university entrance exam results. The students, 64.7% (n=565) preferred the nursing profession because of the possibility of finding a job. Of the students, 85.5% (n=747) was glad to choose the nursing profession. The students, 31.0% (n=271) were hospitalized before beginning nursing education, while 30.8% (n=269) received nursing care before beginning nursing education. Of the students, 79.5% (n=695) was found to consider the image of the profession while choosing the nursing department. The distribution of the nursing students according to their socio-demographic characteristics is presented in Table 1.

The Image of Nursing Profession Scale Scores

The average score of the nursing students on the Image of Nursing Profession Scale was found 152.2±11.4 points. When the sub-scales of the scale were examined, their scores were 46.2±4.1 points in the professional qualifications sub-scale, 28.0±3.4points in the working conditions sub-scale, 27.7±4.3 points in the gender sub-scale, 19.9±2.1points in the education sub-scale, 18.3±4.1points in the professional status sub-scale, and 11.9±2.7 points in the external image sub-scale. The distributions of the nursing profession image scale score and the sub-scale score averages were presented in Table 2.

There was no statistically significant difference between the average scores in the Image of Nursing Profession Scale in terms of the high schools, where the students have been graduated from, the universities they studied at, presence of a healthcare professional or nurse in the family, the rank of choosing the nursing department in the university entrance exam results, the status of previous hospitalization, and the status of receiving nursing care before (p>.05).

The Image of Nursing Profession Scale score averages were found to be higher in female students than male students, in nursing students who study in the Faculty of Health Sciences than the students who study in the Faculty of Nursing and the School of Health, in students who choose the nursing department willingly than the students who choose the nursing department unintentionally, in students who are satisfied to be in the nursing profession than the students who are not satisfied, in students who chose the nursing profession due to its better social status than the students with other reasons, with a statistically significant difference (p<.05). Table 3 shows the comparison between the nursing profession image scale score averages, socio-demographic characteristics and perceived nursing image factors.

Discussion

As a result of the study, the nursing students were found to have a good level of perceptions of professional image towards the nursing profession. In the small number of studies on the subject in Turkey, students' perceptions towards the image of nursing profession were found to be moderate (^{Özkan et al., 2017}) and good level (^{Dost & Bahçecik, 2015}; Özdelikara et al., 2015), and they were found to perceive the nursing profession positively (^{Özakgül et al., 2017}; Temel et al. 2018).

There was no statistically significant difference between the status of having a healthcare professional or nurses in the families of the students and the nursing profession image scale score averages. Studies have shown that having a healthcare professional or a nurse in students' families does not have an impact on the image of nursing, but leads to positive views on general professional qualifications (^{Abbas et al., 2020}; ^{Özkan et al., 2017}; Temel et al., 2018). The study findings are parallel with similar studies conducted in Turkey.

In the study, the major reason for preferring the nursing profession was the ease of finding a job, as expressed by the students. However, there was no statistically significant difference between the image scale score averages of the students who preferred the profession because of the possibility of finding a job and the students who did not. In the studies, the students were found to choose the nursing profession mostly due to the higher employment opportunity, and a significant relationship was found between the professional image score averages (^{Glerean et al., 2017}; ^{Degazon et al, 2015}). In the study of ^{Law and Arthur (2003}), the majority of students stated that they chose nursing due to the interest towards the profession. In the study by ^{Özkan et al. (2017}), 37.5% of the students were found to strongly agree with the statement "Nurses have more career opportunities". In the study, it was found that the students who chose the nursing profession because of its good social status had higher overall score averages on the image scale for the nursing profession, and that the difference was statistically significant. In addition, it was found that students who considered the image of the profession while choosing nursing had higher overall score averages on the image of the nursing profession scale than other students, and that the difference was statistically significant. In the majority of the studies on the subject, it is observed that the students prefer the nursing profession due to the higher opportunity of finding a job (Glerean et al., 2017; Glerean et al., 2019; Özkan et al., 2017). Therefore, it is believed that young people take this issue into consideration when choosing the profession and make their profession choices based on concerns about employment (Elmorshedy et al., 2020; Glerean et al., 2019; ^{Liaw et al., 2016}).

In the study, it was found that the students received the highest score from the 'professional qualification' sub-scale. Most of the students were found to agree to the expression 'Nursing is a profession that requires patience' in this sub-scale. The majority of nursing students have stated that patience is a characteristic that nurses should have (^{Özkan et al., 2017}). Studies show that nursing students have a positive attitude towards the professional qualifications and the perceived image of the profession (^{Glerean et al., 2019}; ^{Elibol &Seren, 2017}; ^{Özakgül et al., 2017}). The results of our study are in line with the literature.

When the 'working conditions’, sub-scale was examined, it was found that the majority of students agree the statements "Nurses' workload is high", "Nurses have more career opportunities", and "Nurses have heavy working conditions". In the study by ^{Özkan et al. (2017}), more than half of the students were found to strongly agree with the statement "Nurses have heavy working conditions'', and a few of the students were found to strongly agree with the statement "Nurses have more career opportunities". In their study, ^{Kiwanuka (2010}) found this rate as 78%. Although it is known that the nursing profession has heavy working conditions, it is among the preferred professions due to more opportunities to find a job (^{Abbas et al., 2020}; ^{Glerean et al. 2019}; ^{Wu et al., 2015}).

In the study, when the 'gender' sub-scale was examined, the students' agreement rate for the statements 'Only women should be in the nursing profession' and 'Only men should be in the nursing profession' was found to be very low. The society's perspective on the nursing profession is changing with the increase in the number of male nurses in recent years. It can be stated that the professional sexist approach is gradually diminishing in societies, which has a patriarchal cultural structure (^{Abbas et al., 2020}; ^{Girvin et al., 2016}).

The World Health Organization (2009) and the Official Gazette of the Republic of Turkey (2007) assert that only those who have four years of undergraduate education should be granted the right to receive a nurse's title. In the study, when the education sub-scale of the Image of Nursing Profession Scale was examined, the majority of students were found to agree with the expression "Nursing requires university-level education". In line with these results, it can be stated that nursing students base their professional knowledge and skills on a scientific basis.

When we look at the "professional status" sub-scale in the study, it was found that the majority of students agreed the expressions 'Nursing is a well-known/recognized profession in the society', 'Nursing is a respected profession in the society', and 'Nursing is a profession appreciated by the society'. In the literature, nursing students have reported a lack of appreciation and respect towards the nursing profession (^{Abbas et al., 2020}; ^{Chauke et al., 2015}; Elmorshedy et al., 2020). It can be stated that nursing students are influenced by society's perception of nursing.

Limitations of the study

The study was restricted to nursing students of six universities. Therefore, the results cannot be generalized to all nursing students. The application of the study to a larger number of nursing students with the same questionnaire may yield different results.

Implication for nursing and health policy

Shortage for healthcare professionals is increasing rapidly all over the world. The number of nurses is insufficient to provide adequate and quality care. The results of this study, which investigated the effect of perceptions of professional image on the profession preferences of nursing students, will shed a light to further studies on the factors affecting the choice of profession. The results of this multi-centered study, which was conducted in six different universities, are believed to contribute positively to the planning to be carried out to improve the image of the nursing profession.