An-Najah National University

Faculty of Nursing

2014-2015

Perception that Community Hold about NursesAnd Nursing as a Profession.

Submitted of the Requirements for the Bachelor's degree in nursing, Faculty of medicine and health sciences, at An-Najah

National University, Nablus, Palestine.2014

Prepared by

Abd Rahman Sawalmeh Mustafa Salah Nuha Jarar…

Supervisor

Dr. Maryam Altell

2014- 2015

Introduction:

Nursing is a health care profession, which is focused on the care of individuals, families, and communities; so that they can attain, maintain, or recover optimum health. Nurses care for individuals of all ages and cultural

backgrounds who are healthy and ill in a holistic manner based on the individual's

physical, emotional, psychological, intellectual, social, and spiritual needs (Patidar et al.,

2011). Society recognizes nursing as a profession which provides a valuable and essential

service for maintenance of the health of the people. When nurses take up nursing, they

enter into an unwritten contract with society. Society gives them the mandate to perform

nursing which is a social function that carries social responsibility. Society holds certain

expectations from members of the nursing profession, based on a relationship of trust

(Searle & Pera, 1995). Any form of malpractice by nurses would endanger the safety and

welfare of society and thus harm the relationship between the nursing profession and

society. The nurses have a duty to uphold high standards of nursing practice which is

what society values about nursing. If they fail to meet these standards and expectations,

nursing loses its meaning, professional integrity and good image (Kunene, 2001).

Image is part of a profession. It’s the way that profession appears to other

disciplines and to the general of health care. Image and the perception of the profession

impact recruitment of students, the view of the public, funding for nursing education and

research, relationships with healthcare administrators and other healthcare professionals,

government agencies and legislators at all levels of government, and ultimately, the

profession’s self-identity (Finkelman & Kenner, 2013). Despite the great advances in the

nursing profession, nurses still face considerable challenges related to its image that

impact on status, power and the ability to affect changes in health care. Where, a negative

image of nursing has a number of negative consequences, it has impacts on the quality

and quantity of persons who choose nursing as a profession (Mahran & Al Nagsha,

2012). Nurses' image has always been a concern for those in the profession. The decision

to enter nursing, to remain in nursing and to promote nursing, may be the result of nurses'

perception of the image of the profession (Emeghebo, 2012). Nursing is a profession that

has long been troubled with its public image. The public has a stereotypical view of

nursing, in which nurses may be regarded as less intelligent than doctors, dependent on

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doctors, powerless and underpaid (Tang et al., 1999). The public who are constantly

presented with an inaccurate and negative nursing image will view a career in nursing as

undesirable (Mahran & Al Nagsha, 2012). Various people have different understandings

of the nursing profession based on prior events in their lives since perceptions are

subjective (Achilles, 2009).

PROBLEM STATEMENT:Nursing profession and nurses’ image has always been a concern for those in the

profession. The decision to enter nursing, to remain in nursing and to promote nursing, may be the result of this public perception. And due to different factors, public may develop different perceptions and image regarding nursing and nurses which might negatively affect the profession.

AIM OF THE STUDY:The study aimed to find out the perception that community hold about nurses

and nursing as a profession.

STUDY OBJECTIVES:To identify the perceptions of the community members in relation to:

1- Image of nursing as profession.

2- Image of the nurses

3- Factors affecting perception.

SIGNIFICANCE OF THE STUDYThis study aimed to find out the perception that community hold about nurses and

nursing as a profession. The results might be useful for improving the image of nursing and nurses among public, and improving and maintaining the professional integrity of nurses and nursing profession.

STUDY QUESTIONS:1- What is the image that community members hold toward nurses?

2- What is the image that community members hold toward nursing as profession?

3- What are the factors affecting their perceptions?

4- Dose the image differ among West Bank directions from North to South?

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LITERATURE REVIEW:

1- HISTORICAL PERSPECTIVE OF NURSINGDuring the 19th century, two opposing images of nurses were identified. Florence

Nightingale represented a symbol of excellence and gave the nursing profession

acceptance and public respect. But Sairy Gamp, a midwife created by Charles Dickens in

"Martin Chuzzlewit," was depicted as old, fat, rough and unsightly - in Dickens' words,

"unclean, uneducated, untrained and unreliable." (Hereford, 2006).

A fantastic growth of the nursing profession occurred during the early 1980s and through

the first world war. Nurses became the invisible heroes of the war, the helped transferring

the injured, help people die peacefully, and providing first aid for the solders (Murray,

2002).

At 1920s, the image of the bright nurse ended, nurses were viewed as subservient

to physicians and the public image of nurses declined, they were also viewed as romantic

servant for doctors, also the negative public image targeted the poor working conditions

of nursing (Murray, 2002).

During World War two, the nurse shortage time and economic decline because of

the war effort, the media started to improve the nursing image by promoting poster for

the nurses images with heroes of the war which improved the recruitment of nurses.

Following World War 2 nursing remained a profession of high status and was considered

an occupation for women that was courageous, admirable and one of leadership (Satterly,

2004)

From the 1960s to the present time, nurses has been portrayed as hedonistic,

romantic, frivolous, sexual and cast in demeaning roles. During this period of time, a

popular writer (MASH) wrote a novel called Margaret "Hot Lips", which was about the

nursing characteristics (Tunstall-Pedoe, 1998). According to a study by Kalisch et al.

(1986), in the early 1970s, TV imaged nurses as dependent and sympathetic, having little

skill and knowledge.

2- NURSING IN ISLAM:Even the glorious image and appreciated statues of the early Muslims nurses who

volunteered to provide services at time of the Prophet Mohammad (570 – 632 AD), recruitment and retention challenges and shortages were also exist. At the beginning of

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the Islamic era, fourteen hundreds years ago, there was a need to defend the newly

formed Muslim community. Unlike Arab women of pre-Islamic era, the women role was

limited to charge their men to fight. At the other hand, Muslim women have been

volunteered as nurses in the battle field. Their role included giving water to the thirsty,

transfer the martyrs, and providing the old tradition weapon to fighters, in addition to first

aid provided (Meleis & Hasan, 1980; Sultan, 1990). Those women were called (Al-

Asiyat), this name indicated their role in alleviating the pain and easing the

suffering(Mahir, 1970). The participation of these women in the war gave them a rise in a

religious duty which later on developed into more social and organized health services.

Prophet Mohammad (PUH) gave these women the same honor given to the men fighters,

and the swags collected at the end of the battle were divided on the fighters and these

women (Sultan 1990, Al-Osaimi 1994). Also the Prophet Muhammad encouraged his

wives and daughters to do the same things the “Al-Asiyat” do.

Nursing services were not limited to only one critical situation such as the wars. It

has been documented that Rufidah Al-Aslamiah, one of the most famous early nurses in

Islam, had constructed a tent near the Prophet Mosque, where she was providing nursing

care to those who needs care out of the battle field. The prophet Muhammd used to

emphasize Rufidah Al-Aslamiah tent regularly and check up the situation (Mahir, 1970).

Not only Rufaidah was a practical nurse, but also she was a teacher. In her school, a lot of

volunteer Muslim women learned nursing skills and how to care for ill and wounded

Muslims. History has recorded names of women who worked with Rufaidah: (Om

Amara, Om Ayman, Safiyat, Om Sulaim, and Hind) . (Miller, 2004).

Nursing care in the Islamic culture, just like the western societies, was started for

religious causes (Meleis & Hasan, 1980).Nursing at that time was encouraged for it’s

spiritual values and the human role made by nurses . However, nursing image has

transformed in most Muslim countries in low-statues images (Sultan 1990).

3- HISTORICAL OVERVIEW OF NURSING IN PALESTINE: A. The Turkish rule: (1517-1917)

The health services were poor and primitive. Popular medicine were generally used for treating diseases. As well as treatment by native practitioner depending very

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much on trial and error .In this period nurses were trained by physicians who worked in the hospital.

B. The British mandate: (1921- 1948)During this period, some hospitals were established in major cities in Palestine where

British nurses taught Arab girls nursing for three years. The graduates of this program were

offered certificates from “ the diploma of health, government of Palestine “

C. Jordanian control over West Bank including East Jerusalem and the Egyptian control of Gaza: ( 1948-1967 )

In these era the first nursing school was established in1951 at Augusta Victoria

hospital in Jerusalem. This school was the main source of graduating staff nursing to the

area then Saint John's school for Practical nurse in 1960 in Jerusalem and Saint Luke’s

school for practical nurse in Nablus in 1965. In Gaza, the Christian missionary society

started training nurses in the British hospital (Alahli Al Arabi hospital). Then, the Baptist

school of nursing was established in 1956 to aid in graduating nurses to meet the

tremendous needs of nursing services in the Gaza strip.

The main events effecting nursing in this era was the initiation of the Palestinian nursing association (P.N.A) in 1956 in Jerusalem by the stuff nurse Betty Majaj and obtaining membership in international council for nurses in England.

D. Israeli occupation of West Bank and Gaza strip –1967 till 1994

After the 1967 war, all health services institutions were taken over by the Israeli

government. Those who worked there received a little promotion, and limited continuing

education opportunities. Creating of refugee camps supported the need to establish some

nursing school to fulfill the increasing need for nurse in order to offer needed health

services for refugees. For example Ibn Sina government nursing school, Maqased school

of nursing West Bank and Al-Hukama practical nursing school in Gaza were established.

4-NURSING EDUCATION:

Nursing education attained a formal status in the 1860’s and that is where

Florence Nightingale comes in. Many associate the history of nursing with Florence Nightingale alone, as she became a worldwide symbol for her services to nursing. She was the one responsible for setting up the first nurse training school at St Thomas'

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Hospital, London, in 1860. Florence Nightingale devised a complete curriculum on nursing practices and for the first time nursing education was defined.

This was the point that nursing was being taken seriously by the world. In 1885,

Japan came with the first nursing institute and the next year United States followed. Today, nursing has become a major industry with many areas of specializations.

Lillian Wald initiated the idea of visiting nursing when she began teaching a

home nursing class in the late 1800s. Following the American Nurses Association and the

Nurses and New Zealand initiative, other countries around the world began to regulate

nurses on a national basis. Yale University in 1923 was the first nursing education that

was established in the United States on the basis of education rather than the needs of

hospitals. This really set the stage for the future of education and since then, universities

across the nation have developed nursing programs of their own, such as Columbia

University in the 1950s.

Today nursing education has traveled the road to development to such an extent

that it is available at college campuses, via online courses, and even through nursing

continuing education. Men and women who want to become nurses can do so around

their schedule and take advantage of all the study options for this amazing profession.

This also includes proper specialization and allows for nursing continuing education. The

History of Nursing is a sure shot sign that the future of this field is bright.

Some researcher have argued that nursing education that produces diploma and

associate degrees-prepared nurses, has restricted the development of nursing profession

(Letvak, 2001; Whittock et al., 2002; Karaoz, 2004). Whittock (2002) highlighted the

gender differences in nursing, he added that nursing is female dominant profession, but in

the future, more men will participate in nursing in countries where higher qualifications

are required. Whittock et al. (2002) suggested a correlation between the level of

education , public perception of the profession, and the numbers of men entering the

profession. A research made by Hemsley-Brown and Foskett (1999) asked the question

why anyone would enter the nursing profession field and not the medicine branch, his

finding were consistent to what found by Al-Rabiah (1994) that those participants would

enter nursing because their degrees at the high schools did not allowed them to enter the

medicine branch.

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Park (2007) discussed that BSN education, higher education, and specialization

are most of the times linked to professionalism and have been reported as the top

peritonitis for most of the nurses in the western countries. Park (2007) examined a sample

of newly graduated nurses between 1994 and 2000. He reported that theses students focus

was to promote their career priorities, gain more experience, and be more specialized in

nursing.

Rambur (2005) argued that personnel with baccalaureate degree in nursing have

higher degree of professionalism as compared with those with associate and diploma

degree in nursing. He also suggested that bachelor degree is associated with social return

on educational investment. Watson (2006) argued why nursing most of the time is not

considered to be a profession. Watson research found that three factors that may be

largely attribute nursing to be not a profession is: Nurses are trained more than they are

educated; nurses are handmaiden to physician; and nurses are not accountable for their

actions.

Literature review on the Middle East and the Arab word (Hasan, 1980; Salman,

2003) mentioned that negative perception of nursing has been relatively linked to low

level of education required to study nursing and these results are opposite to what found

by Park (2007) in the western countries that public understand the high qualification,

complexities and difficulties encountered by nursing students required to be a nurse.

El-Sanabary (2007) found that there is prevalent perception that diploma level

education is low level and technical. He also suggested that all nurses should seek for

upgrading their level of education, as minimum to be BSN. As mention by Whittock

(2002), the four years nursing programs and other higher and lower programs such as

diploma level, are not without their own challenges.

Aamodt (2002) conducted large scale quantitative study on the Norwegian nurses and he was interested to understand the reason behind students entering the nursing profession. The most reported statements were “do something useful” and “help people”.

Also he found that the decision of the theses young people was not made on the base of financial matters, but rather on the matter of interest and enjoyment.

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5- IMAGE OF NURSES AND NURSING PROFESSION:The image of both nurses and nursing has been the focus of a number of research

projects globally (Huffstutler, Stevenson, & Mullins, 1998). The image of both nurses

and nursing as a profession are vital in the successful recruitment and retention of staff in

the healthcare industry (Meiring, 2010). In addition, Waters (2005) believes that nurses

are the backbone of the healthcare sector and are fundamental in the delivery of quality

care for all the inhabitants of a country (Waters, 2005). While Sullivan (2004) argued that

nurses are invisible, even they comprise the backbone of the health care system. Sullivan

added that nurses skill, knowledge, judgment, and competencies, are only reflection, not

reality. Gordon (2005) agreed that nurses are invisible because consumers may not

recognize that they are interacting with a nurse, or they may think someone is a nurse

who is not. (Finkelman & Kenner, 2013) explained the invisibility of nurses. When

patients go to their doctor’s office, they interact with staff, and often these patients think

that they are interacting with a registered nurse (RN). When in the hospital, patients

interact with many staff members, and there is little to distinguish one from another, so

patients may refer to most staff as nurses. Jones (2010) argued that public is now aware

about nurses and the value of the nurses. Jones (2010) conducted a study to assess the

responses of the public if someone told them that he is a nurse. He found that majority of

responses are positive. At the same time, he found public were not aware about the

education required to be a nurse. He concluded that public are not aware for the wide

variety of specialization a RN can choose later on after his/her graduation from the

bachelor degree.

Roberts and Vasquez (2004) conceptualized the nursing image and concluded

factors that directly influence the nursing image. These factors included educational

preparation, and socialization in addition to hierarchical structure between physicians and

nurses in clinical settings. Takase et al. (2001) agreed with Roberts and Vasquez (2004)

and several factors that may influence the image as history and role of nursing,

stereotypes of nursing, nurses were portrayed as sex objects. Brodie et al. (2004) also

agreed with previous mentioned factors and added that hard working condition and poor

pay of nurses affect their image on the society. Achilles (2009) believed that living near a

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health center, or near a hospital will affect the public perception. He found that those who

live near a health center have brighter image toward nursing rather than those who lives

away from a health center. Achilles (2009) also argued that having a nurse in the family

will significantly influence the perception toward the profession.

Finkelman & Kenner (2013) noted that public perceptions of nurses and nursing are

typically based on personal experience with nurses wherever they work or advance their

services for the public. Finkelman & Kenner (2013) believed that this will narrow the

view of the profession, because this experience may not be sufficient and accurate

reflection of the image of whole nurses. Gazzaz (2009) agreed with Finkelman (2012)

that the image of nurses is based basically on the personal experience, but this experience

may be affected by the condition and the emotions.

Another important factor found to impact the public perception of nurses is the media. Fletcher (2007) supposed that what is already perceived about nurses is almost from the perspective of media and not from the perspective of nurses. Kalisch et al.

(1986) studied the characteristics and traits of nurses portrayed in American TV’s.

Kalisch et al. (1986) concluded that those pre-university students will not choose nursing

as a carrier choice as this profession was ridiculed and jeered in the media. At 1987, the

same authors reviewed the media for nursing image. They found five influential images

of five successive period of time: between the 1850 and 1920, the Angle of Mercy; 1920

to 1930, the Girl Friday; 1930 to 1945, the Heroine; between 1945 and 1965, the Mother;

between 1965 and 1982, the Sex Object. Grossman (1989) agreed that media prefers to

portray nurses as poor, underpaid, and overworked. Fletcher (2007) and Roberts and

Vasquez (2004) believed that media portrays nurses as handmaidens to physicians,

female, single, and under 35 years of age. Surfacing the claim, that those who follow the

media have negative image toward nursing, Lippman and Ponton (1989) selected 19

academic staff from different universities in the United States, and found that this

academic staff perceived nurses as educated, respected, and autonomous. These findings

may be harmonic to Begany (1994) who argued that less than ten-percent (10%) of the

public believes about nursing is influenced by newspapers, advertisement, and TV shows.

Kalisch et al. (2007) conducted a longitudinal (2001-2004), comparative research to examine the image of nursing on the internet. The research found that (70%) of the

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internet websites showed nurses as intelligent and educated, while (6.1%) showed nurses

as lack of intelligence, and (4.1%) lack of education. In approximately (60%) of websites,

nurses have been shown as accountable, respected, and trustworthy. Also the research

made a comparison between the image of nurses at 2001 and 2004. Results suggest that

the variables committed, creative, powerful, scientific, authoritative, and autonomous has

been significantly decreased at 2004, while at 2001 was better much than 2004. At the

other hand, the variables attractive, competent, sexually promiscuous, and cool have

significantly increased since 2001 till 2004. In addition to compression of the previous

variables, (29%) of the websites at 2001 had all nurses pictures as females, while only

(1%) of the websites had all men pictures. At 2004, the number of all female pictures

decreased to (24%), and the male pictures increased to (3%). The researcher concluded

that there are many positive nursing sites on the internet, but unfortunately they don’t

emerge as top results on the famous search engine.

Kunene (2001) and Meiring (2010) assumed that South African public had a

negative perception toward nurses. The results of the booth research were contrary to the

assumption, Kunene (2001) found that nurses are rated as “Very good”, and majority of

the participants appreciated nurses, while only (16%) of the participants rated nurses as

bad. Kunene (2001) explained this on the basis of previous bad personal experience.

However, the study conducted at (2001) was small-scale study; Meiring (2010)

conducted a study at larger scale. And the results were the same found at 2001. Meiring

(2010) concluded that even the nursing and nurses were positively viewed in the

community; it’s not a choice of profession for their sons. These findings are consistent to

what found by (Mahran & Al Nagsha, 2012). She found that 87.8% of the Saudi

community disagree to teach their sons and daughters nursing, and the majority of those

who chosen to teach their sons nursing are afraid to face criticism from their extent

families. Mahran & Al Nagsha (2012) and Meiring (2010) concluded that majority of

people can’t understand the complexities of nursing as a carrier. At the other hand,

Donelan (2008) found that majority of Americans would like to recommend Nursing as a

future profession for others

Brodie et al. (2004) studied the public perception toward nursing using qualitative interview, he found that nurses were viewed as doctor handed, poor paid, works under

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hard conditions, in addition those who currently study nursing (at the time of the study)

will have limited opportunities for career advancement. Roberts and Vasquez (2004) also

studied the public perception of nurses, they found that image of nurses presented to the

public often is far different from the image nurses wish to project. Donelan (2008) in her

report discussed the public perception of nursing. She found that public valued and

acknowledged the “skill, “knowledge,” of nurses. At the same hand, public reported that

nurse are “overworked”. Public also described nurses as “helper”. Roberts and Vasquez

(2004) asked the public to put a mental picture for the world “Nurse”, and they found that

many people see nurses as handmaidens to physicians, wearing white caps and stockings,

and surrendering their chairs to physicians. (70%) of the participants studied by Donelan

(2008) reported that, they know, nurses have higher degrees of education. Donelan

(2008) concluded that the image of nursing is gradually becoming positive in the society

and the public are becoming more aware about the value of nursing profession. Palmer

(2007) also studied the public perception of nursing. He found that public perceives

nurses as just someone who assist the doctor during and after the treatment of the illness,

assisting the patient in keeping up his personal hygiene, dressing the patient, and giving

the prescribed medication for the patients.

Mahran & Al Nagsha (2012) hold a descriptive exploratory study to explore the

impact of public image on turnover intention of female students from joining to nursing

profession at Saudi Arabia. Mahran & Al Nagsha (2012) found that the Saudi community

holds negative perception toward nursing profession, and this factor contributed

significantly to turnover intention of Saudi nurses in general, and female nurse’s student

specially. Also she found that most of the families were able to differentiate between

being a nurse or a physical doctors, as the study revealed that families want their sons to

be doctors rather being a nurse.

Takase et al. (2001, 2002) conducted a correlational study to investigate the

discrepancy between the public’s and nurses’ perceptions of the image of nurses. The

study sample consisted of 80 Australian nurses and 80 non-nurses subjects. He found that

nurses often view themselves more positively than the public. Takase et al. (2001, 2002)

concluded that these discrepancies in the image may result in nurse- nursing-environment

misfit

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Schweitzer et al. (1994) studied the image of nurses at hospital settings, his

sample consisted of two groups. Group one includes registered nurses, and group tow

includes non-nursing subjects present at hospital (physicians, administrators, and other

hospital employees’). Schweitzer et al. (1994) found seven stereotypical images of

nurses. These image are: “angel of mercy”, “girl Friday”, “careerist”, “bureaucratic”,

“sex object”, and “heroine”. The highest image rated by nurses was the “bureaucratic”

image, and the highest image rated by other employs was “angel of mercy” image. Both

groups agreed that nurses have the “careerist” image.

Emeghebo (2012) carried out a study to explore the image of nursing as perceived

by nurses at Columbia. This qualitative study studied a sample of 13 nurses ranging in

experience from senior student nurses to registered nurses, with over 21 years of

experience in direct patient care, participated in in-depth interviews. Three themes

emerged during the analysis. These themes were very important on how nurses perceive

the profession. The themes are a) Role of Nurses, b) Nursing Knowledge, and c) Attitude

of Nurses. Emeghebo (2012) discussed the changing image perceived by new nurses. She

found that nursing students have positive image toward the profession just before they

engage in the work in the profession, and this image starts to change as they progress in

the carrier. She explained this change on the bases of working environment and

interactions with others in the health care field. She concluded that nurses working in

hospitals had developed negative perception of the profession.

An article publish by Sheth (2011) at the internet, she asked a question if (nurses)

really reflect a positive image of nurses. Nurses often don’t get the respect they deserve

and the profession is ridden with a plethora of stereotypes. The good news is public

perception of the field is gradually shifting as qualified nurses are becoming in demand

(Sheth, 2011). She added that one reason of misconception regard nurses is that the

images of the effective and intelligent nurses are too few in the media, real life, and even

in fiction. Moreover, she proved that public are unaware of nurses through exploring

images on the people mind, these images are really for nurses, but they are not connected

with nurses in their minds. Most of people often watch doctors defibrillate on TV, but in

real, nurses who defibrillate most of the time. If people knew that nurses defibrillated

instead of physicians, we’d have 16-year-old fells lining up down the street trying to get

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into nursing (Summers & Summers, 2004). According to Saver (n.d.), another reason

why the public might not understand the scope of nursing practice is that individual

nurses haven’t done enough to help people understand what nurses can do for -- and with

-- them to maintain health.

Achilles et al. (2009) studied a new sub population that consisted of 100

secondary schools students at Tanzania. He studied the perception and awareness of these

students toward nursing profession. He found that, most of the students were aware of

nursing as a profession, at the other hand, this study showed difference from a similar

study (Bordi & Rixon, 2004) carried out in India where the students’ knowledge of

nursing as a profession was poor. Although the students were aware of nursing as a

profession, only 10% of them have chosen nursing as first choice of carrier. Achilles et

al. (2010) concluded that although students were aware of nursing as a profession, they

were not aware about the complexities of the profession and only 10% of the participants

would chose nursing as a career.

Bordi et al. (2004) were worried about public negative perceptions for nursing

recruitment. They used a survey, interview, and focus group methodologies to investigate

the experience of students at two British universities to discover their understanding and

interest in the nursing profession. His research team found that many students were

surprised by the high academic standards required to be a nurse from the aspect of

nursing education and the knowledge, skills, and responsibilities rests with the nurses.

They found also that these students thought nursing and nurses are lacked of respect, and

had low morale, underpaid, and overworked. They added that the image of nursing might

not be changed unless compensation and working conditions were adequately addressed

at national policy levels and institutional level.

Another study conducted by Patidar et al. (2011) to explore the perception of

outgoing nursing students towards nursing profession and perceived future job

orientation. His Semi-structured questionnaire was filled by 530 nursing student at state

Punjab at India. Patidar et al. (2011) found that (83.2%) of the students were self

motivated to join nursing, and (69.6%) of the students perceived nursing as a way to get

recognition in the society. Also (69.4%) nursing student perceived their profession as

dignified and respectful profession in the society. These results reflect the positive image

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the students have about nursing. Moreover, Patidar et al. (2011) found that (52.5%) of the

urban students were interested to join nursing teaching or becoming clinical preceptors.

On contrary, the rural students were predominantly (50% of the students) interested to

join bed side nursing.

Donelan (2008) discussed the consequences of the negative image of nurses on

the health care system. The report attributed this negative image to shortage of nurses

encountered at United States. She added if these negative perceptions persist by the

public, it will affect the recruitment of nursing students. This may cripple access, quality,

and safety to millions of Americans. She concluded that Americans are perceiving

nursing as inferior profession, which led to discrimination in nurses as (79%) of nurses at

2008 are non-Hispanic whites.

Nursing care is the process of “building a relationship” involving patient’s goals,

preferences and choices, attending to the medical, emotional, social and spiritual needs

using strengths of interdisciplinary resource. Hence, to provide quality care, a nurse must

know what patients expect from the nurse (Palmer, 2007).

Patient satisfaction with nursing care is an indicator of quality care (Palmer, 2007).

Schmidt (2003) conducted a study to discover the patients’ perception of the nursing care

they receive in the hospital settings. He identified four patient perception categories of

nursing care. These categories are: “Seeing the individual patient”, “Explaining”,

“Responding and watching over”. 'Seeing the individual’ explains the unique nature of

the nursing care experience for each patient. 'Explaining' denotes the informal but

essential explanations given by nurses. 'Responding' denotes the character and timeliness

of nursing staff's responses to patient requests or symptoms. 'Watching over' represents

the surveillance activities of nursing staff (Schmidt, 2003).

Several studies have been done at India to compare patient satisfaction from

nursing care provided at private and governmental hospitals (Joshi, 2002; Bhattacharya,

2003; and Kapzawni, 2004) and they found patient satisfaction from nursing care at

private hospital is greater than nursing care provided at governmental hospitals. A study

conducted by Sharma & Kamra (2013) to compare the nursing care at private and

governmental hospital. They found that (8.2%) of patient admitted to the governmental

hospital were dissatisfied with nursing care, at the other hand, only (0.7%) of the private

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hospitals patients were dissatisfied with nursing care. Booth the private and governmental nurses were poor provider of emotional support and communication. The mean percentages for communication were 76.8% and 56.9% respectively.

For most health organizations, being able to communicate effectively with the

public is a top priority (Rideout, 2008). The role of nursing involves interaction with

clients, peers and other health professionals. This role is enhanced when nurses have a

good command of communication skills (Poroch & McIntosh, 1995). One of the essential

components of the process of communication is the ability to communicate assertively.

Assertive persons are better able to confront problems in a constructive manner and do

not remain silent. The problems that the nursing profession has with its image have been

influenced by nursing’s silence, the inability to be assertive (Finkelman & Kenner, 2013).

A study conducted by Poroch & McIntosh (1995) on barriers to assertive communication skills found that nurses are lack of assertive communication skills with patients and their families.

“Communication is a means of persuasion to influence the other, so that the

desired effect is achieved”, (Aristotle, 384 BC- 322 BC). A study conducted by Kunene

(2001) on nursing image and the study measured the effect of communication on nursing

image. The study found that (80%) of the participants rated nursing communication as

excellent and good. At the other hand, those who rated nursing communication as poor

(20% of the participants) emphasized that nurses most of the time provides poor

explanation about what is going to be done for them, and patients are left without clear

understanding of their condition and treatment.

Kelly (1985) also admonished and induced nurses from ignoring the patients’ and

clients’ fundamental rights to privacy and information is both to betray humanity and to

invite dissatisfaction. And this may result in negative perception toward nurses’ image.

Kelly (1985) argued that nurses do not give themselves enough time to listen to patients’

complaints and pain; this may be due to most of the times nurses appear to be in hurry.

This is a violation of the human right to be heard. Also Kelly (1985) concurred with

Arnold (2002) that communication is an essential part of the nurse-patient interaction, in

addition to patient family and relatives, therefore nurses must communicate very well.

21

A study designed by Change (2003) to determine if the demographic data of the

population has an effect on the perception of nursing care. The demographic

characteristics studied included age, gender and cultural background. Change (2003)

found that patients who were older, female, and from aged care wards perceived that

physical aspect of nursing care were more important than did patients who were younger,

male, and from medical wards.

Whilst nursing is still generally perceived to be a 'feminine' profession, a number

of men practice as nurses (Lodge, 1997). Also people may view that male nurses must

not be in the field of nursing, because men in general are lack of capability to care as

compared with women (Palmer, 2007). Patients (male and female) are exposed to be

encountered by male or female nurse. It’s important to consider patients’ preference for

the nurse gender under certain situation, as this situation may provoke patient anxiety

(Ekstrom, 1999). Research also found that patients take into consideration the technical

expertise of the nurse taking care about them (Greenhalgh, 1998). Many studies reported

that female patients prefer female nurses (BaÈck & Wikblad, 1998). At the other hand,

male patients also admire this trend, but the degree is lesser than female patients’

preference (Kerssens, 1997). For some patients, it may be ‘confusing and embarrassing’

to be cared by a male nurse, this may be due to either of sex role stereotyping related to

the profession or culture, either low experience of the male nurse (Lodge, 1997). This

may reflect the old believe of Lynn (1975) that community believes nursing is for

females and not for males. A recent study by Chur-Hansen (2001), she replicated a study

at 2000 that was performed at 1984 to measure the preference of male and male nurses

with age, gender, and previous experience. Results approved the same results of the study

conducted at 1984 that female patients prefer female nurses, while male patients prefer

male nurses.

Mahran & Al Nagsha (2012) summarized several factors she found affecting

nursing image. One of these factors that contributed to the negative image on her study

was the rotating shift system and long working hours which may contribute to the social

un acceptance of nursing as a profession. Another qualitative study by Gazzaz (2009)

discussed the Saudi Nurses’ Perceptions of Nursing as an occupational choice. Gazzaz

(2009) discussed and linked the poor image of nursing at Saudi Arabia to several factors,

22

these factors agreed with Mahran & Al Nagsha (2012). These factors included the

gender-mixing, long working hours and shift system that rendered nursing as socially

unacceptable occupational choice. Participants of Gazzaz (2009) study included nurses

and non-nurses subjects, at the same time there was agreement among all participants,

male and female, sing and married that working on the rotating shift is physically and

mentally exhausting, and it contributes to social isolation for nurses from the

environment they live in. Hamdi & Al-Hyder (1995) and Al-Johari (2001) agreed that the

nurses working environment in general, and rotating shift in nursing were frequently

factors cited as major obstacles to study nursing in the Middle-East cultures. Also Gazzaz

(2009) highlighted that career in nursing would reduce women’s chance of getting

married.

Achilles (2009) discussed the payment of nurses and its effect on their image on

the public. He found that public perceives nurses as poor and underpaid, and they have

low remuneration. This is strongly connected with public perception toward nurses.

Brodie et al. (2004) also agreed with Achilles (2009) in that public perceive nursing as

low paid profession. Donelan (2008) find the correlation between the nurses payment and

their image, she found that majority of the public believes that nurses are working in hard

condition, at the same time, they are underpaid.

Albert et al. (2008) conducted a research to assess and examine nurses’ image by

assessing of eight pant uniforms as perceived by pediatric patients, adult patients, and

adult visitors. Patients and visitors may perceive nurses as professional based on uniform

color and style. Nurse image may affect patient and visitor trust and satisfaction with

nursing care (Albert et al., 2008). He found that results vary depending on the age of the

participants, in adults participants; score for the white uniforms were higher than scores

for uniforms with small print, bold print, or solid color. At the other hand, white uniforms

score increased with the subject age. Albert et al. (2008) concluded that with aging, the

adults’ perception of nurses is based on uniform color and style. Another research has

been done with the same purpose by Bednarsk et al. (2008) at the United States; the study

verified the connection between uniform of nurses and the nursing image. He also found

a relation between age and uniform; the higher the age of the participant, the white

uniform is more favorable.

23

Saver (n.d.) argued the various approaches the image of the profession can be

advanced and perfected by. “Every time we talk with a patient, a family member, a

friend, a neighbor, or anybody else who knows we’re a nurse, we are representing the

profession, we need to portray the profession in a positive way” Saver (n.d.). Voting for

those who may contribute and support a better nursing class in the society, also at the

organizational level, it’s important to build public relation with public affairs department,

so it can send press releases that that highlights news about nurses.

Takase (2002) and colleagues added that nurses have been offering and providing an

extraneous effort to advance and improve their image in the society and public, in order

to improve their position on the society. Takase emphasized the importance of nursing

leaders’ role in encouragement and promotion of positive self-concept and

professionalism to get over nursing stereotyping those results in restraint in the

contribution of nursing practice.

24

METHOD:

1- DESIGN:A mixed qualitative and quantitative approach has been adopted to investigate the

image of nurses and nursing profession in the west bank. For quantities approach, cross

sectional approach was used, and for qualitative data, unstructured interview was used.

2- SETTINGS:

Study took place at the West Bank cities. West Bank cities are considered to be

over 15 cities. West Bank shares boundaries to west, north, and south with Historic

Palestine (1948 Boundaries), and to the east, across the Jordan River, with Jordan. West

Bank has an area, according to Ministry of Tourism and Antiques, of 5,655 km2

(published 2013), and it resembles about 21% of the land of Historic Palestine.

Population of the West Bank according to Palestinian Central Bureau of Statistics

(PCBS) statics at 2014 equals 2,790,331 people. 6 cities have been chosen from the West

Bank cities using simple random technique. The cities that have been addressed at the

study are Jenin, Nablus, Tulkarem, Ramallah, Bethlehem, and Hebron, these cities also

are distributed from North to South across the West Bank. These cities are considered to

be the largest cities at the West Bank. These cities are well known to have public

activities at the med-day.

3- POPULATION:The general population of the study was every Palestinian person who lives in the

West Bank districts /cities.

A- Inclusion criteria:

1- Have the Palestinian nationality.

2- Over 21 years old.

B- Exclusion Criteria:

1- Not belonging to a medical staff, or heath specialties student.

4-SAMPLE:For the quantitative part of the study, the sample size “162” has been estimated by

computer program developed by Raosoft (2004) with confidence interval of (95%) and

margin of error equals (7.67%). For the qualitative part, 12 participants were chosen to

conduct the interview.

25

5- SAMPLING METHOD:A. Cluster sampling method was used.

B. Each city population in the west bank was determined

C. The six major population cities in the west bank were chosen.

D. According to proportionate statistical method, the participants from each up mentioned were determined.

E. From each city, the participants were recruited using the equation (Sample size/

Proportion for each city) and the result number of equation was used to determine

the participants from the passing participants. (Annex “B”: for population and

sample distribution.)

6- DATA COLLECTION TOOL:

For qualitative part of the study, unstructured interview was used. The following key questions were asked to conduct the interview.

1- What is your perception toward nurses and nursing profession in the West

Bank?

2- Why do you have such perception?

For quantitative study, questioner was developed based upon previous studies (Kunene, 2001; Takase, 2005; Mahran, 2012; Achilles, 2010; Donelan, 2008; Patidar, 2011; Brock, 2010). The questioner consisted of 6 parts and 51 closed-question.

(Questioner: Annex “A”)

The first part (Q1-Q11): the demographic data, which includes the gender, age, marital status,…, and place of residency. It also includes question if the participants have any disease, or they have relatives who are nurses.

The second part (Q12-Q17): of the questioner is composed of 6 question to assess the relationship of participants with nurses, and measure if it’s direct or indirect experience with nurses.

The third part(Q18-Q23): of the questioner is composed of 5 Likert scale questions regarding the quality of nurses services and rate of communication and attitudes of nurses.

The fourth part (Q24-Q31): of the questioner is composed of 8 questions to assess the perception of participants regarding the nursing profession.

26

The fifth part (Q32-Q47): of the questioner is composed of 16 question, divided into 2

groups, the first group question is to assess the participants perception regarding male and

female nurses, and the second part is compare the nurse who works in the governmental

or private hospital.

The last part(Q48-Q53): of the questioner is composed of 6 statements regarding factors affecting nursing education.

Questions statement are “Likert scales” and have 3 choices (Agree, Neutral, or Disagree), or Yes or No questions.

7- VALIDITY AND RELIABILITY OF THE INSTRUMENT:The study questioner has been developed in English language, and then translated

to Arabic language, and it was back translated to English. The questioner was validated

using expert opinion (5 nursing educator) for the appropriateness of content, wording,

and scaling. Based upon experts comments, some modification were approved (mainly

framing). From statistical wise, the demographic data intervals were changed. Also the

framing of some questions has been changed, in addition to suggestion of adding a new

part to the questioner (part of comparison of nurses who works in the specialized hospital

and those who works in the governmental hospitals).

-PILOTING (QUANTITATIVE):A pilot study was conducted at 10% of sample size to determine the instrument

feasibility, and to identify reading and understanding difficulties, and the length and the

time required for filling the questioner, in addition to any difficulties in understanding the

questions. The results of the piloting study founded that there is difficulties to understand

a question, and the question was deleted. Pilot study analysis with SPSS showed

Cronbach’s alpha was 0.712.

8- FIELD WORK:For qualitative data, tow participants were selected from each city to be conduct

face-to-face interview, after explaining the time needed for the interview.

And for quantitative data, after the participants were chosen randomly from the population to be included in the study, they were asked to stop and fill the face-to-face questioner with the research team. The research aim and objectives were discussed with

27

every participant. The participants were given the right and the choice to fill the questioner or not.

The research is concerned with public perception, so it should be hold at public

places. At Jenin, the research took place at “Abu Bakir St.” and the city center, which are

the most public places at the city. Jenin is famous with its fertilized and agricultural land.

While at Tulkarem, the coastal city, research took place at “Al-Salam St.” and “Paris St.”

and the city center. At Nablues, one of the well-know cities in whole the Middle east with

its sweets and Kunaffah, the research took place at the city center and the commercial

mall, in addition to “Sufian St.”. At Ramallah, the political capital of Palestine, the study

took place at “Almanarah” and “Al’sa’ah” city centers, in addition to “Al-Ersal St.”. At

Bethlehem, the birthplace of Jesus, the research took place at “Al-Mahed Square” and the

city center. At Hebron, the biggest commercial city in Palestine, the research took place

at the city center, old city markets, and the commercial malls.

9- ETHICAL CONSIDERATION:Institutional Review Board (IRB) at An- Najah approved the study after

reviewing the study proposal. Informed consent was obtained verbally from the

participants after explanation of purpose of the study and they were assured of

confidentiality. Voluntary participation was emphasized.

10- DATA ANALYSIS:For the qualitative data, thematic approach was used to analyze the data. And for

the quantitative data, data were coded, edited and analyzed using PC application;

Statistical Packages for Social Science (SPSS) version 20 for windows. Varity of tested

were used to analyze the data , Cross-tabulation, Chi-Square, Bivariate correlation, One

Way-Anova, and post hoc tests.

11- SCORING SYSTEM:The scoring system of the questioner composed of two parts; negative and

positive statement (Annex “C”). Each positive statement has been given the following

scores: (1= Disagree, 2= Neutral, 3= Agree). And the negative statement has been given

the following scores: (3= Disagree, 2= Neutral, 1= Agree). The highest and lowest score

a person can achieve in questions regarding perception of nurses range from “6” to “18”.

And the highest and lowest score a person can achieve in questions regarding perception of nursing profession range from”9” to “27”. The midpoint “12” and “18” were

28

considered to be the separator for positive and negative perception regard nurses and nursing profession, respectively (<12 = negative, ≥12= positive) and (<18 = negative,

≥18= positive) .The highest point a person can achieve, the more positive image he had.

.The positive image code was “2” and the negative image code was “1”.

29

RESULTS- QUANTITATIVE PART.

1. Socio-Demographic Data.Table (1) Distribution of percentage of participants regarding their socio-demographic

data.Item No %Geographic Distribution

North (Jenin, Tulkarem) 40 25%Middle (Nablus, Ramallah) 57 35%South (Hebron, Bethlehem) 65 40%

Total 162 100.0Sex

Male 90 55.6Female 72 44.4

Total 162 100.0Age Group

21-30 117 72.231-40 29 17.941-50 10 6.251 < 6 3.7

Total 162 100.0Marital Statues

Married 71 43.8Single 88 54.3Widower 1 .6Divorced 2 1.2

Total 162 100.0Place of Residency

City 86 53.1Village 69 42.6Camp 7 4.3

Total 162 100.0

Item No %Educational Level

University 100 61.7School 62 38.3

Total 162 100.0Work Statues

Yes 115 71.0No 47 29.0

Total 162 100.0Moth Income

500-999 48 29.61000-1999 50 30.92000-2999 37 22.83000 < 27 16.7

Total 162 100.0Disease Statues

Yes 25 15.4No 137 84.6

Total 162 100.0Presence of a nurse in family or friends

Yes 148 27.8No 88 72.2

Total 162 100.0

Table (1) shows that (40%) of the participants were from South of West Bank,

and (53.1%) were living in the city. (55%) of the participants were male. (72%) of them

were within the age group (21-30) year. (54.3%) were single. (61.7%) of the participants

were university and college based education. (71%) of the participants have a job and

they work. (15.4%) of the participants have any disease at the time of survey. (27.8%) of

the participants have one or more PN or BSN nurse in the family or relatives, while

(63.6%) of the participants have friends who are nurses.

30

2. Experience of participants with nurses in the West Bank.Table (2) Distribution of participants regarding their experience with nurses in the West Bank.

Item No %Have you ever been hospitalized?

Yes 89 54.9No 73 45.1

Total 162 100.0If yes, Governmental or Private hospital?

Private 46 28.4Governmental 55 34.0Not admitted 61 37.7

Total 162 100.0How many times do you need nursing services?

Never Need 84 51.9Once 45 27.8Twice 20 12.3

Three times 13 8.0Total 162 100.0

Previous bad experience with nurses?Yes 40 24.7No 122 75.3

Total 162 100.0Satisfied with nurses in the West Bank

Yes 116 71.6No 46 28.4

Total 162 100.0Do you trust nurses ?

Yes 105 64.8No 57 35.2

Total 162 100.0

Table (2) shows that (54.9%) of the participants were hospitalized. And (34%) of

them were admitted to governmental hospitals. It also shows that (27.8%) of the

participants need nurses services “One” time per month. In addition (75.3%) of the

participants have no previous bad experience with nurses. Moreover, (71.6%) of them

were satisfied with nurses in the West Bank. It also indicated that (64.8%) of them trust

nurses.

31

3. Evaluation of nurses and nursing care:Table (3): Distribution of mean, standard deviation and percent of participants regarding nurses and nurses care.

Bad Good ExcellentStatement Mean ±SD No % No % No %Standards/Quality of care 2.01 .479 18 11.1 125 77.2 19 11.7Communication with patients 2.00 .590 28 17.3 106 65.4 28 17.3Communication with patient family 1.91 .644 41 23.3 94 58.0 27 16.7Attitudes towards patients 1.97 .605 32 19.8 103 36.6 27 16.7Nursing Uniform 2.38 .715 22 13.6 56 34.6 84 51.9Who to blame if any error in the care 2.07 .661 Nurse Physician Othersprovided to patients 30 18.5 91 56.2 41 25.3

Total 2.06 - 17.3 - 54.6 - 23.3

Table (3) indicated that (77.2%) of the participants rated quality of nursing care as “Good”. It also indicated that (65.5%) of them rated nursing communication as

“Good”. In addition (58%), (36%) of them rated communication of nursing team with

family, and attitudes towards patients as “Good” respectively, and (51.9%) rated nursing

uniform as “Excellent”. Regarding the event of any problem in the care provided to

patient, (56.2%) of participants agreed on blaming “Physicians”.

4. Perception of participant toward nursing profession:

Table (4): Distribution of mean, standard deviation, and percentage of participants regarding their perception of nursing profession.

N Question Answers No. % Mean ±SDo.

Is it appropriate for nursing No 18 11.11 profession to be named Yes 144 88.9 1.89 0.315

“Nursing”

Nursing profession is Disagree 5 3.12 Neutral 6 3.7 2.90 0.389humanitarian. Agree 151 93.2

Work in the field of nursing is fit Disagree 59 36.43 Neutral 31 19.1 2.08 0.898to a certain class of society.

Agree 72 44.4Disagree 8 4.9

4 Nursing profession tired. Neutral 29 17.9 2.72 0.549Agree 125 77.2

Employment opportune in the Disagree 47 29.05 Neutral 47 29.0 2.13 0.835field of nursing is few.

Agree 68 42.0

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Most of people perceive nursing Disagree 98 60.56 Neutral 26 16.0 1.63 0.841profession as inferior profession.

Agree 38 23.5

Nursing profession honest. Disagree 16 9.97 Neutral 40 24.7 2.56 0.669

Agree 106 65.4

Table (4) Shows that (88.9%) of participants agreed that “Nursing” is the

appropriate name for the profession. (93.2%) of them perceived nursing profession as

humanitarian. (65.5%) believed that nursing profession is “Honest”.(44.4%) of them

believed that nursing profession fits a certain class of society and (23.5%) agreed that

people perceive nursing as “Inferior profession”. (77.2%), (42%) of the participants

agreed that nursing profession is “tiered”, and the opportunity for working is “few”,

respectively.

5-A. Perception of participants toward nurses.

Table (5-A): Distribution of mean, standard deviation, and percentage of participants regarding their perception of nurses.

No Question Answers No. % Mean ±SDHealth 133 82.1ProviderWhat is the role of the nurse, as

1 Servant 6 3.7 1.39 0.893you might think?Educator 12 7.4HP & E 11 6.8

Do you prefer male or female Male 73 45.12 Female 71 43.8 1.66 0.670nurse?

Booth 18 11.1

I appreciate those who works as Disagree - -3 Neutral 15 9.3 2.91 0.291nurses

Agree 147 90.7

Those who work as nurses are Disagree 22 13.64 Neutral 46 28.4 2.44 0.722honest

Agree 94 58.0

I agree that my wife/ husband Disagree 38 23.55 Neutral 30 18.5 2.35 0.836to be a nurse

Agree 94 58.0I hate my children to work in Disagree 69 42.6

6 the field of nursing because of Neutral 42 25.9 1.89 0.856the environment surrounding Agree 51 31.5

I hate that my son is dealing Disagree 83 51.27 Neutral 39 24.1 1.73 0.833with patients directly

Agree 40 24.7

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I think in teaching one of my Disagree 38 23.5 2.30 0.8268 Neutral 38 23.5sons nursing

Agree 86 53.1Financial benefits Disagree 23 14.2 2.40 0.725

9 for workers is small in nursing Neutral 52 32.1compared with other specialties Agree 87 53.7

The working hours of workers Disagree 25 15.4 2.37 0.73810 Neutral 52 32.1in the nursing are inappropriate Agree 85 52.5

I encourage always to study Disagree 19 11.7 2.49 0.69811 Neutral 44 27.2nursing

Agree 99 61.1

Table (5-A) Shows that (82.1%) of the participants believed that the nursing role is “Health Care Provider”. And only (45.1%) of them prefers the “Male Nurses”.

(90.7%) of them also appreciate those who works as “Nurses”. (58%) of the participants

perceive nurses as “Honest”. (58%), (53.1%) of participants agreed that one of the

spouses to be a nurse, and to teach one of their children nursing, respectively. It also

Shows that (61.1%) of participants always encourage others to study nursing. (42.6%) of

them liked that their children to work in the field of nursing regardless of the

environment condition. Regarding financial benefits (53.7%) believed that it’s low, and

in relation to working hours (52.5%) believed that it’s inappropriate.

5-B. Comparison between nurses in the governmental and private sectors. Table (5-B): Distribution of mean, standard deviation, and percentage of participants regarding their perception regarding nurses of governmental and private hospitals.

No. Question Answers No. % Mean ±SD

Nurses in the private hospital Disagree 32 19.81 Neutral 27 16.7 2.438 .803provide better care.

Agree 103 63.6

Attitudes of nurses in the Disagree 38 23.52 Neutral 29 17.9 2.351 .837private hospital are better.

Agree 95 58.6Nurse in the private hospital Disagree 35 21.6

3 reflect better impression on the Neutral 35 21.6 2.351 .815profession Agree 92 56.8

Nurse in the private hospital is Disagree 52 32.14 Neutral 47 29.0 2.067 .842more honest

Agree 63 38.9

Table(5-B) indicates that (63.6%) perceived that nurses in the private hospitals

are providing better care than those who works at the governmental hospital. Also

34

(58.6%) believed that attitude of private hospitals nurses is better than those in the

governmental. In addition it shows that (38.9%) perceived nurses in the private hospitals

are more honest. In addition (56.8%) believed that private hospital’s nurses’ reflect better

impression on the profession.

6. Factors concerning nursing education.

Table (6): Distribution of mean, standard deviation, and percentage of participants regarding their perception regarding nursing education.No. Question Answers No. % Mean ±SD

Do nursing profession requires BSN level, or BSN 142 87.71 the PN level is enough to practice the PN 20 12.3 1.12 .330

profession

2 Do nurses update their medical information Yes 111 68.5 1.31 .466continuously? No 51 31.5

3 Dose the recent political issues in Palestine Yes 103 61.6 1.38 .488have an impact on the image of nursing? No 59 38.4

4 Do nurses have high degrees of education Yes 103 63.2 1.6 .483(Master,Dr…) like other health profession? No 59 36.8

5 There must be a national plans for developing Disagree 10 6.2 2.94 .241nursing competencies. Agree 152 93.8

6 Habits in Palestine have an impact on the Disagree 49 30.2 2.40 .922choice of nursing as a profession. Agree 113 69.8

Table(6) indicates that (87.7%) of participants believed that nursing profession

requires BSN level to practice the profession. (63.2%) of participants knows that nurses

have high degrees of education like other health profession. Also (68.5%) believed that

nurses updates their medical information continuously. (61.6%) of participants believed

that political issues in Palestine have an impact on nursing image. Also (93.8%) agreed

that there should be a national plans to develop nursing competences. (69.8%) of

participants believed that habits in Palestine have an impact on the choice of nursing as a

profession.

35

7.Community Image toward nursing profession and nurses.Table (7): Distribution of participants percentage regarding their image toward nursing profession and nurses.

Nursing Profession ImageNo. %

1.00 29 17.92.00 133 82.1Total 162 100.0

Nurses ImageNo. %

1.00 39 24.12.00 123 75.9Total 162 100.0

Table (7): Shows that (82.1%), (75.9%) of participants have positive image toward nursing profession and nurses, respectively.

8. Geographical differences of nursing profession and nurses image.

Table (8) Distribution of percentage of participants regarding the relationship between nurses image and nursing image with geographical distribution.

Nurses Image Value p. ValueGeographical Distribution 1.00 2.00 Total

North No. 5 35 40% 17.9% 30.1% 25%

Center No. 16 41 57% 35.9% 31.7% 35% 2.229 0.328

South No. 18 47 65% 46.2% 38.2% 40%No. 39 123 162

Total % within Geographical Area 24.1% 75.9% 100.0%% 100.0% 100.0% 100.0%

Nursing image Value p. ValueGeographical Distribution 1.00 2.00 Total

North No. 2 38 40% 13.8% 30.1% 25%

Center No. 14 43 57% 41.4% 30.8% 32.7% 3.329 0.189

South No. 13 52 65% 44.8% 39.1% 40.1%No. 29 133 162

Total % within Geographical Area 17.9% 82.1% 100.0%% 100.0% 100.0% 100.0%

Table (8) Shows that (82.1%), (75.9%) of participants have positive image

regarding the image of nursing profession and image toward nurses , respectively. It also

36

Shows that (38.2%), (39.1%) of the participants are from the “South”, and have positive

image regarding nursing profession, and nurses, respectively.

9. Type of hospitals and relationship with image.Table (9-A): Distribution of participants percentage and level of significance regarding the relationship with type of hospitals and nursing profession image and nurses image.

Nursing Image Value p. ValueType of hospital 1.00 2.00 Total

Private No. 6 40 46% 3.7% 24.7% 28.4%

Governmental No. 13 42 55% 8.0% 25.9% 34.0%

Not admitted No. 10 51 61 2.064 0.356% 6.2% 31.5% 37.7%No. 29 133 162

Total % within Hospital type 17.9% 82.1% 100.0%% 100.0% 100.0% 100.0%% of Total 17.9% 82.1% 100.0%

Nurses Image Value p. ValueType of hospital 1.00 2.00 Total

Private No. 6 40 46% 3.7% 24.7% 28.4%

Governmental No. 19 36 55% 11.7% 22.2% 34.0%No. 14 47 61 6.404 0.036

Not admitted % 35.9% 38.2% 37.7%% 8.6% 29.0% 37.7%No. 39 123 162

Total % within Hospital type 24.1% 75.9% 100.0%% 100.0% 100.0% 100.0%% of Total 24.1% 75.9% 100.0%

Table (9-A) Shows that (82.1%), (75.9%) of participants were having positive image regarding nursing image and nurses image, respectively. It shows that (25.9%),

(24.7%) who have positive image were having previous admission to governmental and private hospitals, respectively, with no significant differences (p. 0.356). While (3.7%),

(11.7%) of the participants having negative image regarding nurses were having previous admission to private, governmental hospitals, respectively, with a significant differences between the two groups (p. 0.036).

37

Table (9-B): Post hoc test results for differences of means regarding nurses image (dependent variable) in relation to hospital type (independent variable).

(I) Governmental Vs. (J) Governmental Vs. Mean Difference (I-J) Sig.private? private?

Private Governmental 0.21502* 0.036Not admitted 0.09907 0.696

Governmental Private -0.21502* 0.036Not admitted -0.11595 0.427

Not admitted Private -0.09907 0.696Governmental 0.11595 0.427

*. The mean difference is significant at the 0.05 level.

Table (9-B) shows that difference of mean was higher for “Private Hospital”.

Which means that private hospital has greater effect on participant’s image toward

nurses.

10. Communication and attitudes of nurses effect on image.Table (10-A): Distribution of participants percentage and level of significance between point of view of participants regarding communication, attitudes of nurses toward image of nurses.

Nurses ImageCommunication and attitudes of nurses 1.00 2.00 Total Value p. Value

Bad No. 13 17 30% 8.0% 10.5% 18.5%

Good No. 22 85 107% 13.6% 52.5% 66.0%

Excellent No. 4 21 25 7.702 0.021% 2.5% 13.0% 15.4%No. 39 123 162

Total % within communication 24.1% 75.9% 100.0%% 100.0% 100.0% 100.0%% of Total 24.1% 75.9% 100.0%

Table (10-A) Shows that (75.9%) of the participants were having positive image.

(52.5%) of participants who have positive image rated nursing communication as

“Good”, and it shows that (13.6%) of those having negative image, rated nurses image as

“Good” with significance differences between the two groups (p. 0.021).

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Table (10-B): Post hoc test results for differences of means regarding nurses image (dependent variable) in relation to communication of nurses (independent variable).

(I) communication (J) communication Mean Difference (I-J) Sig.

Bad Good -0.22773* 0.029Excellent -0.27333 0.053

Good Bad 0.22773* 0.029Excellent -0.04561 1.000

Excellent Bad 0.27333 0.053Good 0.04561 1.000

*. The mean difference is significant at the 0.05 level.

Table (10-B) shows that difference of mean was higher among participants who

rated communication as “Good”. Which means that communication has an effect on

nurses image.

11. Financial Benefits and it’s relation with nurses image.

Table (11-A) Distribution of participants percentage and level of significance between participants point of view and nurses image.

Nurses Image p.Financial Benefits are few 1.00 2.00 Total Value Value

Disagree No. 12 11 23% 30.8% 8.9% 14.2%

Neutral No. 11 41 52% 28.2% 33.3% 32.1%

Agree No. 16 71 87% 41.0% 57.7% 53.7%No. 39 123 162 11.716 0.003% within Financial 24.1% 75.9% 100.0benefits %

Total % within nurses image 100.0 100.0% 100.0% %

% of Total 24.1% 75.9% 100.0%

Table (11-A) shows that (75.9%) of participants have positive image toward nurses. It also shows that (57.7%) of participants who believes that nurses are underpaid have positive image toward nurses with significance differences between the two groups

(p. 0.003).

39

Table (11-B): Post hoc test results for differences of means regarding nurses image (dependent variable) in relation to financial benefits of nurses (independent variable).

(I) Financial benefits (J) Financial benefitsMean Difference (I-J) Sig.few few

Disagree Neutral -0.31020* 0.010Agree -0.33783* 0.002

Neutral Disagree 0.31020* 0.010Agree -0.02763 1.000

Agree Disagree 0.33783* 0.002Neutral 0.02763 1.000

*. The mean difference is significant at the 0.05 level.

Table (11-B): shows that difference of mean was higher among participants who

agreed that financial benefits for nurses were few. Which means, regardless of agreement

of participants on few financial benefits, they have positive image toward nurses.

12. Political issue and it’s relation with nursing image.(Table 12): Distribution of participant’s percentage and level of significance regarding the relationship with political issues in Palestine and nursing profession image.Political issue in Palestine effect on Nursing Imagenursing image. 1.00 2.00 Total Value p. Value

Yes No. 13 87 100% 44.8% 65.4% 61.7%

No No. 16 46 62% 55.2% 34.6% 38.3% 4.271 0.039No. 29 133 162

Total % within political issue 17.9% 82.1% 100.0%% within nursing image 100.0% 100.0% 100.0%% of Total 17.9% 82.1% 100.0%

Table (12) shows that (82.1%) of participants have positive image toward

nursing profession. It also shows that (65.4%) of participants who believes that political

issues in Palestine have an effect on nursing image, have a positive image toward nursing

profession with significance differences between the two groups (p. 0.039).

13. Customs in Palestine and it’s relation with nursing profession image.Table (13): Distribution of participants percentage and level of significance regarding the relationship with customs in Palestine and nursing profession image.

Customs in Palestine effect on Nursing Nursing ImageImage 1.00 2.00 Total Value p. Value

Disagree No. 16 33 49% 55.2% 24.8% 30.2% 10.402 0.001

Agree No. 13 100 113% 44.8% 75.2% 69.8%

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No. 29 133 162% within customs in 17.9% 82.1% 100.0Palestine %

Total % within Nursing Image 100.0 100.0 100.0% % %

% of Total 17.9% 82.1% 100.0%

Table (13) shows that (82.1%) of the participants have positive image toward

nursing profession. It also shows that (75.2%) of participants who agrees that customs in

Palestine have an effect on nursing image have a positive image with significance

differences between the two groups (p. 0.001).

14. Previous experiences with nurses and its effect on the image of nurses. Table (14): Distribution of participants percentage and level of significance regarding the relationship with previous bad experiences and nurses image.

Nurses ImagePrevious bad experience 1.00 2.00 Total Value p. Value

Yes No. 15 25 40% 38.5% 20.3% 24.7%

No No. 24 98 122% 61.5% 79.7% 75.3% 5.238 0.022No. 39 123 162

Total % within previous experience 24.1% 75.9% 100.0%% within Nurses Image 100.0% 100.0% 100.0%% of Total 24.1% 75.9% 100.0%

Table (14) shows that (75.9%) of participants have positive image toward nurses. And it shows also that (20.3%) those who have previous bad experience, have positive image toward nurses, with significance differences between the two groups (p. 0.022).

15. Satisfaction with nurse and it’s relation with nurses image.Table (15): Distribution of participant’s percentage and level of significance regarding the relationship between satisfactions of nurses in the West Bank and nurse’s image.Satisfied with Nurses in the West Nurses ImageBank? 1.00 2.00 Total Value p. Value

Yes No. 23 93 116% 59.0% 75.6% 71.6%

No No. 16 30 46% 41.0% 24.4% 28.4%No. 39 123 162 4.030 0.045% within satisfied with 24.1% 75.9% 100.0%

Total nurses% within nurses image 100.0% 100.0% 100.0%% of Total 24.1% 75.9% 100.0%

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Table (15) shows that (75.9%) of participants have positive image toward nurses.

It shows also that (75.6%) of those who are satisfied with nurses in the West Bank have

positive image toward nurses with significance differences between the two groups (p.

0.045).

16. Trust in nurses and it’s relation with image of nurses.

Table (16): Distribution of participant’s percenttage and level of significance regarding the relationship between trust in nurses and nurse’s image.

Nurses ImageTrust the nurse 1.00 2.00 Total Value P. Value

Yes No. 20 85 105% 51.3% 69.1% 64.8%

No No. 19 38 57% 48.7% 30.9% 35.2% 4.125 0.042No. 39 123 162

Total % within trust nurses 24.1% 75.9% 100.0%% within nurses image 100.0% 100.0% 100.0%% of Total 24.1% 75.9% 100.0%

Table (16) shows that (75.9%) of the participants have positive image toward nurses. It also shows that (69.1%) of those who trust nurses have positive image with significance differences between the two groups (p. 0.042).

42

Results- Qualitative Part:

Table (17): Perception toward nursing profession:Them Sub-themes

1. HumanitarianNoble 2. Honourable

3. Respect

Nursing responsibilities 1. Provide services2. Care about people

Table (18): Perception toward nurses:Them Sub-themes

1. HonestAngel of mercy 2. Self- sacrificing

3. Brave

Role of the nurse 1. Provide health services2. Physician handmaiden

Table (19): Factors affecting perception:

Them Sub-themes1. Hospitalization or primary health

Experience care.2. Relatives

Media 1. TV2. Internet

Categories that emerged identified the image of nursing and nurses as perceived

by community members in the West Bank. Participant’s responses reflected positive

image toward nurses and nursing profession. Themes that were closely related to nursing

profession image were classified into tow broad categories that reflected participant’s

perception. They were: noble and nursing responsibility (Table 17). Themes that were

closely related nurses were classified into two main categories. They were: angle of

mercy and role of the nurse (Table 18). Also themes emerged regarding factors affecting

their perception toward nursing profession and nurses were identified into two main

categories. These were: experience and media (Table 19).

1- Noble:

The theme identified as “noble” included data that described the perception and the images of nursing profession participants hold toward nursing profession. These

43

perceptions included humanitarian, honourable and respect. The participants believed

that nursing is a noble and truthful profession, and it’s a dignified profession.

A- Humanitarian: Participants perceived nursing profession as humanitarian profession; most of

them stated the word “humanitarian” by the time they hear the word “Nursing”. The perceived it as an empathetic and sympathetic profession that deals with human regardless their religion or cultural background. One participant stated that

الي ا الناس في بتهتم التمريض مهنة عنجد العالم، في انسانية مهنة اكثر هي التمريض مهنة انه “...... عتقد

".... فيه يهتم حدا عندها ماAnother participant thought that nursing profession is made from humanity, and

it’s present to deliver such thing:

اشي ...” هيك تعمل منشان موجودة اصال وهي وللناس للمرضى اإلنسانية تقديم فن هو “...التمريض

B- Honourable: Participants described nursing as a profession that has many aspects, and one of

these aspects is the honourable aspect. They believed it’s a moral, ethical and good

profession. One participant stated that:

بتستحق... " مهنة وهيك الوقت، نفس في وانسانية اخالقيه مهنة كثير المهنة وهاي الشريفة هالمهنة بح\ترم عنجد انا.”".... ويح\ترموها يحبوها انهم على الناس بتجبر وفعال لقب هيك

Also participants believed that nursing has many moral aspects which include the honour:

مهنة"... انها المهنة هاي فيها بتمتع الي المميزات اهم ومن وميزات، وجوانب معاني كثير والها عظيمة مهنة التمريض"... ونزيهة اخالقية

C- Respect:

Majority of participants assumed that nursing profession is respected profession, and they explained this on the basis that nursing is generous profession. One participant

said:

ألشخاص"... مناسبة كتير انها وبعتقد كتير المهنة هاي بح\ترم سمحتلي، ما ظروفي بس تمريض ادرس بتمنى كنتما زي بس الي، اشي انسب كان التمريض هاد، عطائي تناساب لمهنة وبحتاج معطاءة اني بحكولي الناس النه متلي

".... ادرسها سمحتلي ما الظروف حكيتلكAnother participant thought that after the hard situation that Palestine passing, and the

tender nursing is providing, it must be respected:

44

".. مح\ترم"... كثير التمريض هاي هااليام2 -Care providing:

The second theme emerged was “nursing responsibilities”. Participants identified

the role of nursing profession, as they perceived, is to provide health services, these health services, as stated by the participants, included physical and psychological

aspects. Tow sub themes were identified in this category, they were: provide services,

and care about people.

A- Provide services: Participants believed that the reason why nursing is present is to provide different

services to public:

"... للناس"... كاملة وتوعية صحية خدمات يقدم عشان انوجد التمريض اصالAlso participants showed that they are knowledgeable about the basic roles of

nursing as providing physical and psychological to patient:

الطوارئ"... ..." حاالت في خصوصا للناس ونفسيه صحية اساسية خدمات بقدم التمريضMoreover, participants were aware about the nursing specialty that is concerned

with geriatric patients:

"... العمر"... في والكبار للختيارية خصوصا صحية خدمات بقدم التمريضB- Care about people.

Participants perceived nursing profession as a profession to be applied in

everywhere, and not only restricted place like hospital or a health centre:

. بالعكس"... بعرف، ما مثل المستشفى في بس مش بتقدم التمريض هاألمة من واحد وكل وبالمجتمع بالمرضى العناية"... والمدارس الجامعات في وحتى الشارع وفي الدار في مكان كل في

Also nursing, as perceived by members, deal with different class, and different

cultures, and provide caring without bias:

ومركزهم"... المجتمع في قيمتهم اختالف على والناس المرضى في العناية مثل شغالت كثير فيها بتمارس عملية مهنة".... مسؤولين مش او مسؤولين صغار، او كبار سواء المجتمعي

Moreover, participants perceived who is going to work in field of nursing most

have special features, and not anyone is able to do providing care to public:

الصعبة"... األوضاع مع يتعاملو وبقدرو صعب وضعهم الي المرضى ويخدم يعالج انه قادر حاله بشوف الي الشخصقوي ..." قلب بدها مهنة هيك ألنه التمريض يدرسو الزم

45

3 -Angle of mercy: Participants have the traditional image of nurses as the angle of mercy, they

imagine nurses as perfect people wearing white caps and coats, and they handle the

patient very seriously, moreover they had the wellness to protect the patient even that will

cost them their lives. Three main subthemes were identified in this category. They were:

honest, self-sacrificing, and hero.

A- Honest:

Participants believed that nurses are truthful and honest , and they are the persons

that keep important secrets of the patients, at the same time, participants believed if one character of nurses reflects negative perception; this does not mean that all nurses are bad

or silly:

بشكل"... يعاملني كان فيهم واحد بس معي، وصادقين خلوقين كثير كانو الممرضين المستشفى في نايم كنت مش بس"... وبقدرهم بح\ترمهم بعدني الممرضين، عن نظرتي غيرت ما هيك مع بس منيح،

Also , nursing actions toward people should be calculated and improved, as they

were found to affect nursing image in people mind:

هذا"... على كثير احترمتها ومؤدبة، ومح\ترمة معي صادقة اخالقها كانت الممرضة، ولقيته جوالي ضيعت مرةالموقف..."

Also presence of a nurse in the family found to affect the image as one participant

added:مسؤولياتهم"... وبعرفو ومزوقين صدوقين كلهم انهم متأكد انا خالي، مثل الممرضين كل لو

"منيح...

B- Self-Sacrificing:

Participants perceived nurses as a person who have the wellness to sacrifices

of the community and public, and he can challenge anythe healthhimself for

face to full-fill his duties toward patients and people he caresphysiological stress he

about:

يؤذي"... يمكن التمريض انه بعرفو انهم وبالرغم المسؤولية، قد على دائما الممرضين لéكن احيانا، صعب التمريضنهار ..." ليل ساعة وعشرين اربعة المرضى راحة على سهرانين بضلو لéكنهم صحتهم

Also participants believed that nurse sometimes have the wellness to sacrifice his

life in order to save the wounded:

. كانو"... القصف تحت من الجرحى ينقذو عشان بس بحالهم ويضحو يموتو مستعدين الممرضين كانو غزة حرب في"... ينقتلو او ينقصفو معرضين

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Moreover, participants were very thankful to nurses, because sometimes nurses

scarify their rest and sleeping time to help others:

نومته"... دشر وهللا العندليب، في سنتين دارس ممرض جارنا، على اتصلت ومرتي الليل نص في مريض كنت مرة"... ابرة اعطاني واجا

C- Hero:

One of the image public hold toward nurses is “hero” image, they perceived the

nurses as someone who is very brave and work under hard and stressful condition to care

about his patients, and fear nothing to care about people:

هللا"... هالحركة في شجاع كثير كان الشارع، في مصاب ينقذ يحاول وهو استشهد ممرض قصة بعرف جنين فييرحمه..."

In addition, some participants thought nurses are invisible at hospitals, but they

provide the care in proper way:

يحكيلهم"... حدا وبستنوش العافية، يعطيهم هللا بيقدرو ما قد بعطو المستشفى في المجهولين الجنود همي الممرضينشكرا..."

4 -Role of the nurse: Participants thought nurses have many responsibilities and roles to provide to

patients, public and society. These roles mainly were driven into tow subthemes. They

were: health services, and physician handmaiden.

A- Provide health services: Participants believed that one of the main roles of the nurse is to provide different

health services to public, these services are wide enough to range from physical, to

emotional and psychological. One participant said:

قبل"... وبطمنوهم وبدعموهم نفسيه خدمات بقدمولهم للمرضى، المستشفى في خدمات كثير بقدمو الممرضين"... األدوية المرضى وبعطو العمليات

Also nurses were identified to help poor patient, who can’t tolerate their own needs:

ويقضو"... الحمام على يروحو انهم المرضى بعض وبساعدو كمان، وبحمموهم يوكلو قادرين مش الي المرضى بطعموحاجتهم..."

Moreover, one participants added that nurses and midwives are critically

important at the labour process, they help the pregnant women to bring a new life:

"... الوالدة"... خالل وصراخهم صواتهم بتحملو رحب صدر وبكل يولدو، انهم الستات بساعدو القابالت47

B- Physician handmaiden:

Some participants believed that some nurses are just handmaiden to physicians,

and they don’t have the responsibilities to take action into their own, also they believed that loss of this autonomy in a profession like nursing may violate quality of care

provided to patients:

وهادا"... خاطرهم، من اشي يعملو وبقدروش بحكوه الدكتور الي بعملو بس الممرضين بعض انه بالحظه الي يعني"... للمريض تشخصيه او حكمه في مخطأ يكون الدكتور يمكن النه بقلق األحيان بعض في االشي

Another participant stated that:

"... اكثر"... مش وبنفذ بسمع انه اللهم بس بعضهم هيك، من اكثر المرضى عن مسؤولين يصيرو الزم الممرضينMoreover, one participant believed that nurses most be physician handmaiden:

اي"... قبل الدوكتور اذن ياخذو الزم الشخصي، عاتقهم على او راسهم من اشي يعملو الزم الممرضين انه بعتقدش"... الممرضين من اكثر وبعرف افهم الدكتور دايما النه اشي،

5 -Experience: Experience with nurses wither direct or indirect appear to affect the public

perception. This experience may be acquired from being hospitalized or companion with

a patient:

الي" المرضى ومع معاه بتعاملو كيف الممرضين وشفت المستشفى في نايم عمي ابن مع كنت مرة عليك بخبيشبحده..."

Also it may be acquired from nurses at primary health care centres:

"... الناس"... مع بتعاملو وكيف هناك الممرضين وبشوف المخفية صحة في ضغط مريض عشني اراجع بروح دايما اناMoreover, having a nurse in the family or relatives found to affect the

participant’s knowledge about the complexities of the profession:

معيقات"... ..." من وبواجه يوم كل بشوف وشو الصعبىة هالحاالت مع بشتغلو كيف بخرفني ودايما ممرض صاحبيAnother participant said:

"... كتير"... وتعبان قدامه شايف مش يوم تاني بروح سهر شفت عليه يكون ولما ممرض اخوي6 -Media:

Also media found to have an effect on the perception of the participants, media

category includes tow subthemes, the TV and the internet. One participant said:

مرة"... والتلفزيون، للجرايد متابعتي من صراحة اكتسبتها التمريضوالممرضين عن نظرتي اناالممرضين ...." عن وحكو فلسطين في المستشفيات عن كمان برنامج شفت

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And another one added that:

عن"... شغالت بنزلو ودايما ممرض، يوميات اسمها البوك الفيس في صفحة على اليك عامل اناوقصص الممرضين

"... ممتعة وفيديوهات

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Table(20): Themes and subthemes with participants responses.

Theme Sub-theme Meaningful unitsR1: I think nursing profession is one of the highest humanitarian professions inthe world, it’s the caring about those who don’t have someone to care about.R2: The thing that drives nurses to work during bombing and war must behumanitarian.R3: When my son finished his high school, I advised him to enrol his self in the

Humanitarian field of nursing because I thought nurses fear the god, and so humanitarian.R4: The first thing that comes to my mind when I hear “Nursing” is humanity.(7/12) R5: I believe that nursing is the art of advancing humanity into people hearts.R6: When I was sixteen, I made an accident, and was transferred to “RafidyaHospital”, from that day, I realized what does it mean to be human.R9: I used to have negative perception toward medical field at all, until I gave abirth, I believe that midwifery profession is the art of providing humanity to

Noble women.R2: I perceive nursing as honest profession.R3: It’s a respected and honourable profession.

Honourable R5: Nursing has a high values, it's morale and honest.R7: I appreciate the nursing profession. It’s honourable(6/12) R8: I think nursing deserve to be voted as the highest honest profession at 2014.R10: Nursing is significant and meaningful profession, it has many features,....,honest.R1: I respect nursing more than any health speciality.R5: Recently many students engaged them self into nursing because it became a

Respect respected profession.R6: I respect this profession.(5/12) R11: I wished to study nursing, but conditions didn’t allow me. I respect it verymuch.R12: Nowadays nursing is recognized as respected profession.R1: I think nursing was invented to provide holistic services to the public.R2: Nursing is the profession that provides health services to patients.

Provide R6: I watched a TV programs about nursing and I remember nursing started toprovide basic rescues to injured solders.services R8: Nursing provides health services to the people.(6/12) R10: I think nursing support and provide essential health and psychologicalservices to patients and especially in emergency cases.

Care R11: Nursing provides services and support to elderly people.providing R3: Nursing essences is monitoring and helping ill patients.

R4: Nursing is connected with patient care.R5: Those who think themselves able to care about hard and critically ill people

Care about must study nursing.people R7: My uncle is a nurse, he used to tell me how he care about patients, I think(6/12) nursing is providing care to patients and in nice way.

R8: It’s caring about patients, public, and every person in the community.R11: It’s a practical profession, you practice alot of thing like caring aboutpeople from different class of the society.

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R2: Nurses are respected, moral, and honest very much.R7: If all nurses were like my uncle, I’m sure all of them are precise honest indelivering their responsibilities.R8: Nursing and nurses are honest as I told you.

Honest R9: Midwifes used to check me and my baby several times per hour, they werevey truthful and honest with my family.(7/12) R10: Once I lost my mobile, and the nurse found it for me, she was very moraleand honest with me.R11: When I was at hospital, nurses were very kind and honest with me.R12: Nurses must be straightforward and honest, if they were not, they will losethe integrity of the profession, and damage its image.R1: Nurses are carless toward themselves, they prefer to stay awake at night tocare patient rather than sleeping.R2: At Gaza war, they were ready to die in order to provide first aid to

Angel of wounded persons.R3: they deal every day with many dangerous and serious cases, and they aremercy not afraid to become ill.Self- R5: Nursing is hard sometimes, but nurses are responsible every time, even theySacrificing know it may harm their physical well-being, but they watch over the patient(6/12) twenty-four hour per day.R7: One of my relative is a nurse, once he was injured with infected needle, andhe was given a vacation to get rest and recover, but he did not accepted, heinsisted to take his medication while he was at shift.R8: Once I was ill at late midnight, my wife called our neighbour, he is a nurse,he dropped his sleeping and came to give me an injection.R2: Nurses are very brave.R3: Nurses are the invisible solders at hospitals.

Hero R4: Nurses fear from the god, and nothing else, even the hardest bacteria.R6: At Jenin, I know a story of a nurse killed trying to help injured patient at(5/12) the street, actually he was very brave.R10: Every Friday there is confrontation with Israeli forces at “Neline”, andnurses at the front lines to help the injured guys.R2: Nurses provides verities of support to patients, they support thepsychological aspect of the patients, and give him the medication.R3: I don’t see doctors at emergency room, the one who takes my bloodpressure is the nurse.R4: They administer medication and prepare patient files and support the

Provide health patient before the surgery.Health R6: Nurses feed patients who are unable to eat, and they may bath them, andservicesproviders help them to go toileting and they give injections.(7/12) R7: They give medication through needle that is positioned in the hand, and

apply feeding and glucose bags.R8: Nurses sometimes tell people about the medication required to care them,and they give muscle injections, and measure blood sugar and pressure.R9: Midwives help women to give birth, and support her during delivery, andthey bear the shouting of women’s during labour.

51

R1: Nurses must become more independent, some of them just listen fromthe managers or doctors what to do.

Physician R4: Some people think nurses present just to help the doctor, but I think thisis not true.handmaiden R5: I don’t think nurses can do anything on their own, they must take order(4/12) from the physician.R8: Some of nurses just follow what doctors say, and they do it even it waswrong thing.

R1: Hospitalization and my recurrent visit to the primary health care centres.Hospitalization or R3: Hospitalization at a governmental hospital.

primary health R5: I was companion with my cousin at the hospital and I saw nurses.care. R6: Hospitalization and direct contact with nurses.(6/12) R9: Hospitalization and dealing with midwives.

Experience R10: Hospitalization and recurrent visit to out-clinic patients.R2: Also one of my friends is a nurse.R3: My brother is a nurse.

Relatives R4: My friend is a nurse.(6/12) R7: My uncle is a nurse.

R10: my son's friend is a nurse.R12: my relative is a nurse.R2: I realized that nurses and nursing are having this bright image through

TV watching TV.R6: I watched a Turkish TV series, and another program about nurses.(4/12) R8: Once I heard about them at the Radio.Media R11: TV program.

Internet R4: Social media at the internet.R6: Through the news at the internet.(3/12) R8: Social media.

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Quantitative Data Discussion:

The results of the study, as indicated by Table (1), showed that less than the half

(40.1%) of the participants were from the south of the West Bank, ad nearly the half

(55%) of the participants were male, and majority (72%) of the participants were with the

age group (21-30) years.

Regarding the experience of the participants with nurses, as indicated by table (2),

more than the half (54.9%) have previous direct experience with nurses through

hospitalization. Table (9-B) shows that there is significant relationship (p. 0.036) between

those who were admitted to private and governmental hospital and their perception

toward nurses. Those who were admitted to private hospitals have more positive image,

and this is consistent with Kutney-Le et al. (2010) who found that public are more

satisfied with nurses at hospitals were the work environment and patent to nurse work

load is lower (private hospitals), at the same hand, Joshi (2002) found that public have

better perception toward nurses after the direct contact with nurses at private hospitals.

More than tow third (71.6%) were satisfied with nurses in the West Bank, and this result

were in the same line with Kutney-Le et al. (2010) that public are very satisfied with

nurses. Moreover, (64.8%) of participants trust nurses, and this is consistent with Nurses

topped Gallup’s annual survey (2013), the survey indicated that (82%) of participants

trust nurses, and respect them very much.

The results also showed that, most of the participants (77.2%) rated nursing care

quality as “good”, and this find is consistent to what found by Senarath et al. (2007) who

found that (81.8%) of population are satisfied with nurses at Sri Lanka. At the same hand,

Alhusban & Abualrub (2009) found that public at Jordan are moderately satisfied with

nursing care provided, in addition, more than the half (58%) of the participants rated

nursing communication as “good”, and this find are the same found by Kunene et al.

(2001) who found that (68%) of public rated nursing communication as “Good”, also

Kourkouta (2014) found that most of the public perceived nursing communication as

skilful and excellent. While a third (36%) of the participants rated the attitudes of nursing

as “good”, this finding were contradictory to what found by Kunene et al. (2001) who

found that (76%) of participants rated nurses attitudes as “Good” this findings were in

consistent to what found by Moceri (2014) who found that (76%) of the participants rated

53

nursing attitudes as “Good”. Half of the participants (51.9%) rated nursing uniform as

“excellent”. This finding is consistent with Loveday et al. (2007) who found that most of

the participants rated nursing uniform as “Good” .Moreover, regarding the question

asked, in event of any problem in the care provided to patient, more than half (56.2%) of

patient agreed to blame the doctor, this is consistent with Baker (2004) who found that

only (7.5%) of the participants agree to blame the “Nurse” and others agreed to blame the

“Physicians” or others responsible for patient care.

The study found, as indicated by table (7, & 9), majority of the participants

(82.1%) have positive image toward nursing profession, and this results is consistent with

Kunene (2001) and Meiring (2013) who found that most of the public have positive

image toward nursing profession. Also, as indicated by table (4), more than half of the

participants (93.2%), (65.5%) of the participants believed that nursing profession is

humanitarian, and honest, respectively. These results are consistent with Al-Omer (2004)

and El-Sanabary (1993) who found that majority of the public perceived nursing

profession as humanitarian, and honest . Also, table (4) indicated that less than the third

(23.5%) of the participants agreed that nursing profession is viewed by the public as

inferior profession, this results is within the same line with Mahran & Al Nagsha (2012),

they found that (92%) of the participants disagreed that public have an inferior look

toward nursing profession and nurses. Also (42%) of the participants agreed that working

opportunity in the field of nursing is few, and this is contradictory with Gazzaz (2009)

and Donelan (2008) who found that public believes that working opportunity is available

and people believes that there is shortage of nurses.

Table (5-A) indicated that, (82.1%) of the participants agreed that nurses role is

“Health Care Provider”, this is the same result found by Rideout (2008) who found that

public believes that nurses are present to provide heath. More than the half (54.9%) of the

participants preferred female nurses and this is consistent with Chur-Hansen (2001) who

found the same gender preferences in nursing care is present.

Also, results of this study indicated that (58%) of the participants agreed that

nurses were “honest”, this finding was inconsistent with Nurses topped Gallup’s annual

survey (2013), the survey indicated that nurses were rated as the top honest professionals

at 2013, at the same hand, Scally (2003) believed that nurses were the most honest

54

practitioners on the field of health. The results indicated that (61.1%) of the participants

encourage others to study nursing, and this is consistent with Mahran & Al Nagsha

(2012) and Tumulty (2001) who found that (82%) of the participants advise others to

study nursing, at the other hand, Emeghebo (2013) found that only (36%) of the

participants would encourage others to study nursing. Also results showed that (53.7%)

of the participants believed nurses are underpaid, and this was consistent to what found

by Achilles (2010) and Brodie et al. (2004) who found that public perceived and believed

that nurses are underpaid. Also , nearly the half (52.5%) of the participants agreed that

rotating shift, and working hours for nurses are inappropriate, and this is consistent to

what found by Hamdi & Al-Hyder (1995) and Al-Johari (2001), who agreed that rotating

shift in nursing is connected with public perception, and it may affect recruitment of

nursing students. Table (7, & 9) indicates that (75.9%) of the participants hold positive

image toward nurses, and this is consistent to what found by Emeghebo (2013) and

Hassan (2012) who found that majority of the participants have positive image toward

nurses.

The study results indicated table (5-B) indicated that (63.6%) of the participants

perceived nurses who are at private hospitals to provides better care, and (56.8%) of the

participants believed that private hospital nurses’ reflect better impression on the

profession, these results were at the same line with Sharma (2013) Who found that (8.2

%) of patient admitted to the governmental hospital were dissatisfied with nursing care, at

the other hand, only (0.7%) of the private hospitals patients were dissatisfied with nursing

care .

Results as table (6) indicated , majority (87.7%) of the participants believed that

BSN level is required to practice the profession, and this were in agreement with Rambur

(2005) and Park (2007) who found that public prefers nurses with high expertise and high

level of education , also (63.2%) of the participants knows that nurses have high degrees

of education like master and doctorate degree, these were in consistent to what found by

Lorraine (2002) and Nehring (2013) who believed that public perceived nurse as well

educated, have high skills and high level of education, also (61.6%) of the participants

believed that political issues in Palestine has an effect on the image of nursing. And

nearly tow third (69.8%) of participants believed that customs in Palestine

55

have an impact on the choice of nursing as a profession, and this is consistent with Murphy (2003) who found that cultural back ground of the society may affect public perception to nursing.

Qualitative Data Discussion:

The results of the qualitative data came to support the quantitative finding, as

majority of the qualitative interview have positive image toward nursing profession and

nurses. And as found by the quantitative data that more than half of the participants

(93.2%), (65.5%) of the participants believed that nursing profession is humanitarian, and

honest, respectively, the qualitative analysis emerged tow themes that are “Noble” and

“Angel of Mercy” describing the nursing and nurses as humanitarian and honest.

Also the qualitative data revealed that nurses role is to provide health services,

and this is one of the findings of the quantitative data. It shows that “82.1%” of the

participants agreed that nurse is health care provider. Qualitative interpretation confirmed

that direct experience of participants with nurses has an effect on the image of nursing.

However the majority of the respondent to the interview had positive image toward

nurses and nursing, but some of them seems to be affected by previous bad experience

with nurses, but they refused to generalize this perception to all nurses, and they limited

this experience to only some nurses. The quantitative analysis showed that there is level

of significance (p. 0.022) between those who had previous bad experience and those who

don’t, as those who have previous bad experience had less positive image

(Table 14).

The qualitative interpretation also emphasized the relation between the recent

political issue and war at Gaza, in relation to nurses image. Some respondent have more

bright image toward nurses because they were touched by nurses served at war, the

quantitative analysis showed a level of significance (p. 0.039) between those who

believes that political issues have an effect on nurses image (Table 6 & 12).

Also the subtheme “Self- sacrifices” for nurses agreed with the quantitative

results that (77.2%) of the participants believed that nursing profession is tiered (Table

4). In addition, the subtheme “Respected” confirmed that the public does not hold inferior

perception toward nurses as indicated by quantitative results that (60.5%) of the

56

participants disagreed that Most of people perceive nursing profession as inferior profession.

The themes emerged from qualitative data are consistent to what found

Schweitzer et al. (1994), as he found that community have several images in mind toward

nurses. Schweitzer et al. (1994) themes included the image of “angel of mercy”. This

image is consistent with the study finding, as the theme “angel of mercy” emerged during

interpretation of data. Also the category “role of nursing” is consistent to what found by

Emeghebo (2012). In this theme he disscuesed the expected role to perform by nurses in

the hospital, the actual work of nurses, and how nurses' work is perceived by nurses and

by others. The study finding demonstrated that the nurse has varity of roles including

caring about patients and sick people, also this is consistent with Emeghebo (2012) who

found that nurses roles included providing health services and basic life supoort to

patients.

Some particpanrs stated that nurses are brave, and they do their job even it’s risky,

this finding is consistent with Daly (2014) who found that public belives that nurses

fighting the Ebola virues are very brave. Also the respondets beived that nursing is

houoruable, and this finding is consistent with Al-Omer (2004) and El-Sanabary (1993)

who found that majority of the public perceived nursing profession as humanitarian, and

honest. Belcher (2004) believed that public perceived nurses as self-scarifying, and this

finding is consistent to what respondent found as many of them stated that nurses are

self-scarifying.

Regarding the factors affecting the participant’s image, it was found that the

media plays a role in forming the image of the public have toward nurses and nursing,

and this is consistent with Sheth (2010) who believed that media plays huge role in the

forming of nurses and nursing image. Moreover, most of the participants acquired their

image from their relatives or friends, and this is at the same line with Kunene (2001) who

believed that having a nurse in the family will affect the perception of the public toward

nurses.

57

Conclusion:

Most of the participants had positive image toward nurses and nursing profession as evidenced by qualitative and quantitative data results. And most of them believed that

“Nursing” is the appropriate name for the profession, and did not perceived it as inferior

profession. Moreover, majority of the participants believed nursing as profession is in

need for higher educational qualification. Also the community hold 3 positive image

toward nursing profession that is the “humanitarian, honorable and respected” image. At

the same time community hold three image toward nurses that is “honest, brave, and self-

sacrificing”

In addition, the following factors found to have an effect (significant relationship) on the nurses and nursing image among the participants;

1- Previous experience of participant with nurse inversely affected their perception toward nurses.

2- Communication of nurses has an inverse effect with the participants perception toward nurses.

3- Political issues and customs in Palestine were found to have positive effect on the image of nurses.

4- Type of hospitals and previous admission; the percentage of participants who have positive image were higher for those admitted to private hospitals.

Other factors that found have no effect and no significant relationship on nurses and nursing image included geographical distribution, age, gender, nurses uniform, times nurses services are needed, and participants level of education.

Although of these perceived positive image, still population don’t accept their sons to study nursing, and they don’t understand the complexities of the profession.

58

Limitation:

1. Lack of prior research on the perception of pubic toward nurses and nursing profession at Palestine.

2. Time to conduct the study and collect the data was limited.

3. Small sample size which may expose the results to bias.

Recommendation:

However community has positive image toward nursing profession, and nurses

improvement of the image is required to elicit and reduce the negative aspect public have

toward the profession and the professionals. This needs an extraneous effort by nurses

themselves, nursing mangers, and nursing students. At nurses level, nurses must attain

refreshment course after a certain period of time so they appear to the public as

knowledgeable and accountable personnel, also it’s emphasized for nurses to improve

their communication skills with patient and public. Communication is an important factor

that found to affect the public image. At nursing leader level, it’s recommended to

operate and effective measurement tool to review actions of nurses, and incompetence’s

in the field should be reported and corrected. For nurses student, they should encompass

themselves into the struggle of publicizing benefits of the profession. Moreover, regular

visits to secondary school to talk about the role of modern nurse and benefits of being a

nurse is highly recommended. Finally, it’s recommend to conduct similar study after

seven to ten years to compare the perception of the public at different period of time, and

to conduct the study with larger sample size.

59

Annex (A-1)

Questioner in Arabic:

" المجتمع" التمريضفي صورة حول استبانهالبيانات : األول الجزء

الديموغرافية

.1الجـــنــــــــــــــ

أنـثى ذكر س :15- 11 15- 11 11 -15العمـــــــــــــر:1.

11

فأعلى

.1الديــانـــــــــــــــ

ــة:

اإلسالمالمسيحيــة

ذلك غير.1

الحالةاالجتماعيـة:

متزوج أعزب

أرمل مطلق

.1 مكان

مخيم قرية مدينة الســـــــــكن :.6

المستوىالتعليمي:

..........................................................................................................................

؟ 7. تعمـــــــل ال نعم هـل

.8الدخل مستوى

) شيكل ) الشهـري222-155

1222-1555

1222-1555

1555

فأكثر أمراض؟ 2. أي من تعاني هل

نعم ال

ممرضــ 15. العائلة أفراد ال نعم ـة/احد

أصدقاءك 11. من ال نعم معارفك/احد: الممرضين : مع الدراسة في المشاركين تجربة الثاني الجزء

.12المستشفى دخلت وأن سبق هـل

ال نعم كمريض؟

.13أم خاص مستشفى هو فهل ، نعم كان إذا

؟ خاص حكومي قطاع

قطاع

حكومي.14

إلى فيها تحتاج الشهر في مرة كمممرض؟ ................................................................خدمات

.15مع سابقة سيئة تجربة أي لديك هل

ال نعم الممرضات؟/الممرضين.16

الممرضين راضعن أنت الضفة /هل في الممرضاتال نعم الغربية؟

Wِبالممرضــ 17. تثق ؟ /هل ـــة

ال نعم : التمريضية : بالخدمات تتعلق لعبارات تقيم الثالث الجزء

التمريض 18. طاقم من المقدمة الصحية الخدمات ممتاز جودة

سيء جيد

.19مع والتواصل االتصال

التمريض المريض طاقم سيء جيد ممتاز منالمريض 20. عائلة مع والتواصل سيء جيد ممتاز االتصال

.21مع والتعامل التصرفات

سيء جيد ممتاز المرضى

.22الموحد اللباس مظهرسيء جيد ممتاز التمريضي

.23على للمرضى، المقدمة العناية في مشاكل أية وقوع حال في

اللوم؟ تضع ـة/الممرض من

الطبيب

آخرينإلى : المشتركين نظرة الرابع الجزء

التمريض مهنة

.24التمريض مهنة اسم هل

التمريض"حسب" للمهنة مناسب

؟ ال نعم اعتقادك

.25مهنة التمريضهي مهنة

إنسانية

أوافق محايد موافق ال

60

.26اجتماعية طبقة يناسب التمريض في العمل

ذاتها بحد

موافق

أوافق محايد ال

متعبة 27. التمريضمهنة مهنة

موافق

أوافق محايد ال

متوفرة 28. للمرضين العمل فرص

موافق

أوافق محايد ال

.29التمريض مهنة إلى الناس من الكثيرون ينظر

دونية كمهنة

موافق

أوافق محايد ال

عالية 30. بنزاهة التمريض مهنة تتمتع

موافق

أوافق محايد ال :) إلى ) المشاركين نظرة أ الخامس الجزء

والممرضات الممرضين

الممرض؟ 31. وظيفة هي ما اعتقادك، حسب

خدمة مقدم

مثقف خادم صحيةWُ

؟ 32. الممرضة أم الممرض تفضل الممرض هل

الممرضةكممرضين 33. يعملون الذين الناس أوافق محايد موافق أقدر البالنزاهة 34. التمريض مهنة في يعمل من أوافق محايد موافق يتسم الزوجتي 35. تعمل أن التمريض /أوافق مجال في ابنتي أو أوافق محايد موافق زوجي ال

.36مختلفة العمل بيئة ألن التمريض، مهنة في أبنائي عمل أفضل ال

اليوم مدار أوافق محايد موافق على ال.37

بشكل المرضى مع ابني يعمل أن أفضل الأوافق محايد موافق مباشر ال

التمريض 38. مهنة أبنائي تدريساحد في أوافق محايد موافق أفكر ال

.39بالتخصصات نسبيا قليلة للممرضين الرواتب

أوافق محايد موافق األخرى المناسبة 40. غير للممرض المختلفة العمل أوافق محايد موافق أوقات الالتمريض 41. دراسة على دائما أوافق محايد موافق أشجع ال

:) القطاع ) في الممرضين بين مقارنة ب الخامس الجزءالعام الخاصوالقطاع

.42من أفضل صحية خدمه يقدم الخاص القطاع الممرضفي

العام القطاع أوافق محايد موافق الممرضفي ال

.43القطاع في تعامله من أفضل الخاص القطاع الممرضفي تعامل

أوافق محايد موافق العام الالمهنة 44. عن أفضل انطباع الخاص القطاع الممرضفي أوافق محايد موافق يعكس ال.45

القطاع من التعامل في صدقا أكثر الخاص القطاع الممرضفيأوافق محايد موافق العام ال

: المجتمع التمريضفي علىصورة مؤثرة عوامل السادس الجزءBُ

بكالوريوس

دبلوم .46كاِف الدبلوم مستوى أم البكالوريوس؟ مستوى على لدراسة بحاجة التمريض هل

؟ المهنة لمزاولة؟ 47. باستمرار الطبية معلوماتهم بتحديث يقومون الممرضين نعم هل

ال

.48التمريض صورة على تأثير لها مؤخرا الفلسطينية الساحة على السياسية األحداث هل

المجتمع؟ نعم في

ال.49

).. مثل ) دكتوراه ماجستير، عليا علمية شهادات يحملون الممرضين هلالطبية التخصصات ال نعم باقي

.50إلعداد التمريض مجال في وطنية خطة هناك يكون أن يجب

أوافق موافق الكفاءات ال

.51اختيار على تأثير لها فلسطين في العادات

أوافق موافق التمريضكمهنة ال

معنا لتعـــــاونكم شكـــــرا

61

Annex (A-2)

Questioner in English:

"Image of nursing profession and nurses in the West Bank societies"

Part I: Socio- demographic data

1- Gender: Male Female

2- Age: 15 -11 15 -11 15 -11 11<

3- Religion: Islam Christianity other

4- Marital status:

Married single Widow Divorced

5- Place of residence:

City Village Camp

6- Education Level:.....................................................................................................

7- Do you work? Yes No

8- Monthly income level:

222-155

1222-1555 1222-1555 1555 <

9- Do you suffer from any diseases? Yes No

10- Is one of your family members a nurse? Yes No

11- Is one of your friends a nurse? Yes No

Part II: Experience of participants with nurses in the West Bank.

12- Have you ever been hospitalized? Yes No

13- If yes, is it a private hospital or a government one? Private Hospital Governmental Hospital

14- How many times a month when you need to nurse services? ……………………………………………

15- Do you have any previous bad experience with nurses ? Yes No

16- Are you satisfied with the nurses in the West Bank? Yes No

17- Do you trust your nurse? Yes No

62

Part III: Evaluation of nurses and nursing care:

18- Standards/Quality of care Bad Good Excellent

19- Communication with patients Bad Good Excellent

20- Communication with patient family Bad Good Excellent

21- Attitudes towards patients Bad Good Excellent

22- Nursing Uniform Bad Good Excellent

23- Who to blame if any error happened in the care provided to patients Nurse physician Others.

Part IV: Perception of participant toward nursing profession:

24- Is it appropriate for nursing profession to be named “Nursing” Yes No

25- Nursing profession is humanitarian. Agree Neutral Disagree

26 Work in the field of nursing is fit to a certain class of society. Agree Neutral Disagree

27- Nursing profession tired. Agree Neutral Disagree

28- Employment opportune in the field of nursing is Available. Agree Neutral Disagree

29- Most of people perceive nursing profession as inferior profession

Agree Neutral Disagree

30 Nursing profession honest. Agree Neutral Disagree

Part V (A) Perception of participants toward nurses.

31- What is the role of the nurse, as you might think? Health Provider Servant

Educator

32- Do you prefer male or female nurse? Male Female Booth

33- I appreciate those who works as nurses Agree Neutral Disagree

34- Those who work as nurses are honest Agree Neutral Disagree

35- I agree that my wife/ husband to be a nurse Agree Neutral Disagree

36- I hate my children to work in the field of nursing because

of the environment surrounding Agree Neutral Disagree

37- I hate that my son deal with the patients directly Agree Neutral Disagree

38- I think in teaching one of my sons nursing Agree Neutral Disagree

63

39- Financial benefits for workers is small in nursing Agree Neutral Disagree

40- The working hours of workers in the nursing are inappropriate Agree Neutral Disagree

41- I encourage always to study nursing Agree Neutral Disagree

Part V (a). Comparison between nurses in the governmental and private hospitals

42- Nurses in the private hospital provides better care. Agree Neutral Disagree

43- Attitudes of nurses in the private hospital are better. Agree Neutral Disagree

44- Nurse in the private hospital reflect better impression on the profession Agree Neutral Disagree

45- Nurse in the private hospital is more honest Agree Neutral Disagree

Part VI: Factors affecting nursing education.

46- Do nursing profession requires BSN level, or the PN level is enough to practice the profession BSN PN

47- Do nurses update their medical information continuously? Yes No

48- Dose the recent political issues in Palestine have an impact on the image of nursing? Yes No

49- Do nurses have high degrees of education (Master,Dr…) like other health profession? Yes No

50- There must be a national plans for developing nursing competencies Agree Disagree

51- Habits in Palestine have an impact on the choice of nursing as a profession. Agree Disagree

Thank you

64

Annex (B)

Population and proportion of cities included in the study.

City Population of the city Sample from each cityHebron 300,000 49Bethlehem 10,000 16Ramallah 160,000 26Nablus 190,000 31Tulkarem 96,000 16Jenin 150,000 24

Total 906,000 162

Table (A) shows the population of each city, and the sample that has been chosen from each city.

65

Annex (C)

Positive and negative Statement:

Positive Statement Negative StatementQuestion Regarding Nursing

Nursing profession is humanitarian. Working in the field of nursing fit’s to certainclass of society.

Nursing profession honest. Nursing profession tiered.

Working opportunities are available. Many people perceive nursing as inferiorprofession.

Question Regarding Nurses

I appreciate nurses. I don’t prefer my son to work in the field ofnursing because of changing environment.

Nurses are honest. I don’t prefer my son to deal with patientsI agree that my spouse to be a nurse. directly.I think in teaching one of my son nursing. Financial benefits for nurses are few.I encourage always to study nursing. Rotating shifts are inappropriate.

Scoring System:

Answer Disagree Neutral Agree Cut PointPositive Statement 1 2 3 12Negative Statement 3 2 1 18

66

Annex (D)

Conceptual Definitions:

Practical nurse: A person who has had practical experience in nursing care but who is

not a graduate of a degree program in nursing. (The American Heritage® Medical

Dictionary, 2007)

Society : A nation, community, or broad group of people who establish particular aims, beliefs, or standards of living and conduct. (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier)

Health care provider: Any individual, institution, or agency that provides health services to health care consumers. (Mosby's Medical Dictionary, 8th edition. © 2009,

Elsevier)

Educator: A specialist in the theory and practice of education, An administrator of a school or an educational institution (The American Heritage® Dictionary of the English

Language, 2000)

Servant:

1. One who is privately employed to perform domestic services.

2. One who is publicly employed to perform services, as for a government.

3. One who expresses submission, recognizance, or debt to another.

(The American Heritage® Dictionary of the English Language, 2000)

Private Hospital:

1. a hospital similar to a group hospital except that it is controlled by a single practitioner or by the practitioner and the associates in his or her office;

2. a hospital operated for profit.

(Medical Dictionary Copyright © 2006 Lippincott Williams & Wilkins)

Governmental Hospital: A health care institution owned by a federal, state, or local

government; GHs have had a significant role in caring for the sick in the US, but are

regarded by some as anachronisms in an increasingly complex and costly health care

environment with increasing operating costs, economic recession, and governmental

budgetary restraints. (McGraw-Hill Concise Dictionary of Modern Medicine, 2002)

67

Impression:

1. a slight indentation, as one produced in the surface of one organ by pressure exerted by another.

2. a negative imprint of an object made in some plastic material that later solidifies.

3. an effect produced upon the mind, body, or senses by some external stimulus or agent. (Dorland's Medical Dictionary for Health Consumers, 2007)

Rotating Shift: A work schedule that changes on a regular, predictable basis. For example, an employee may work the day shift for three weeks followed by the evening shift for three weeks, and so on. (Farlex Financial Dictionary, 2012)

Patient: A patient is any recipient of health care services. The patient is most often ill or

injured and in need of treatment by a physician, physician assistant, advanced practice

registered nurse, or other health care provider. (McGraw-Hill Concise Dictionary of

Modern Medicine, 2002)

Profession: A profession is a vocation founded upon specialized educational training, the purpose of which is to supply objective counsel and service to others, for a direct and definite compensation. (New Statesman, 1917)

Carrier: The job or sequence of jobs a person has in his/her chosen field. A career may

or may not involve multiple jobs, but it generally remains in the same field of expertise.

Traditionally, one receives the necessary education or training to start a career, takes an

entry-level job, and gradually receives increasingly greater responsibility. ( Farlex

Financial Dictionary, 2012).

Nursing:

1-Nursing encompasses autonomous and collaborative care of individuals of all ages,

families, groups and communities, sick or well and in all settings. Nursing includes the

promotion of health, prevention of illness, and the care of ill, disabled and dying people.

Advocacy, promotion of a safe environment, research, participation in shaping health

policy and in patient and health systems management, and education are also key nursing

roles. (WHO, 2014)

Nursing image: The image that partly self-created by nurses due to their invisibility and their lack of public discourse. Nurses derive their self-concept and professional identity

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from their public image, work environment, work values, education and traditional social and cultural values. ( Andrews, 2007.)

Perception: is the organization, identification, and interpretation of sensory information

in order to represent and understand the environment. All perception involves signals in

the nervous system, which in turn result from physical stimulation of the sense organs

(Goldstein, 2009).

Community: The term community has two distinct commutative meanings: (1)

Community can refer to a usually small, social unit of any size that shares common

values. The term can also refer to the national community or international community,

and (2) in biology, a community is a group of interacting living organisms sharing a

populated environment (Barzilai, 2003).

Public:

1. Describing anything available to the population at large. For example, a publicly-traded company may be owned and traded by anyone with the money to buy shares.

2. Describing anything owned or administered by a government. For example, a municipality owns and maintains a public park. (Farlex Financial Dictionary, 2012)

Customs: A general term for an agency in a country responsible for controlling the flow

of goods into the country. Customs agencies attempt to prevent dangerous, hazardous or

illegal materials from entering the country, and also collect tariffs and other taxes. (Farlex

Financial Dictionary, 2012)

Image:

1-the general idea that the public has of a product, brand, or company. 2-the opinion of yourself, your company, or your community that you

deliberately try to create in the minds of other people (Campbell R. Harvey, 2012)

Hospital: An institution that provides medical, surgical, or psychiatric care and treatment for the sick or the injured. (The American Heritage, Dictionary of the English Language, 2000)

Quality of care: The degree to which health services for individuals and populations

increase the likelihood of desired health outcomes and are consistent with current

professional knowledge.” (Institute of Medicine, 2001)

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Staff nurse: An academic degree awarded on satisfactory completion of a 4-

year course of study in a college or university. The recipient is eligible to take the nationa

l certifying examination to become a registered nurse. (The American Heritagen,

Dictionary of the English Language, 2003)

70

Annex (E-1)

IRB approval latter

71

Annex (E-2)

Researcher IRB certificates

72

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References: (APA style)

1. Aamodt, P. (2002). Moral Motivation and the Battle for Students: the case of studies in nursing and social work in Norway. . Higher Education , 44 , 361-378.

2. Achilles, K. (2009). Image of Nursing Profession as Viewd by Secondary School Students In Itala District. The Dar-es-salaam Medical Students’ Journal , 12-18.

3. Albert, N., Wocial, L., & Trochelman, K. (2008). Impact of nurses' uniforms on patient and family perceptions of nurse professionalism. Applied Nurses Research , 21 (4), 181-190.

4. Alhusban, M., & Abualrub, A. (2009). Patient satisfaction with nursing care in Jordan. J Nurs Manag , 17 (6), 749-758.

5. Al-Johari, S. (2001). Factors Affecting Attitudes of Saudi Girls Toward Nursing Profession. Sociology Department, College of Art and Humanity, King Abdul-Aziz University.

6. Al-Omer, B. (2004). Knowledge, Attitudes, and Intention of High School Students towards the Nursing Profession in Riyadh City,. Saudi Medical Journal , 25 (2), 150-155.

7. Al-Osaimi, M. (1994). Nursing in Islamic Era. King Fahad National Library , 16-19.

8. Al-Rabiah, O. (1994). The Current Status of Nursing in Saudi Arabia - Critical Issue for Research. 112-126.

9. Arnold. (2002). Angels of Mercy. Journal of Advanced Nursing , 2 (18), 7-19.

10. BaÈck, K., & Wikblad. (1998). Privacy in hospital. Journal of Advanced Nursing , 27, 940-945.

11. Baker, R. (2004). Adverse events and patient safety in Canadian health care. CMAJ , 170, 353-354.

12. Bednarsk, Donna, & Rosenberg. (2008). Nurses' Uniforms and Perceptions of Nurse Professionalism. Nephrology Nursing Journal , 35 (2), 169.

13. Begany, T. (1994). Your Image is Brighter than ever. RN , 28-34. 14. Belcher, C. (2004). I’m No Angel: I am a nurse—and that’s enough. AJN , p. 104. 15. Bhattacharya, A. (2003). Study of Patient Satisfaction in a Tertiary Referral Hospital.

Journal of the Academy of Hospital Administration , 1-6. 16. Brodie, A., Andrews, G., & Thomas. (2004). Perceptions of nursing: confirmation, change

and the student experience. International Journal of Nursing Studies , 41 (7), 721–733.

17. Brodie, D., & Rixon, L. (2004 ). Perceptions of nursing: confirmation, change and the student experience. International Journal of Nursing Studies , 41 (7), 721-33.

18. Change, E. (2003). The influence of demographic variables and ward type on elderly patients' perceptions of needs and satisfaction during acute hospitalization. Int J Nurs Pract , 9 (3), 191-201.

19. Chur-Hansen, A. (2002). Preferences for female and male nurses: the role of age, gender and previous experience year 2000 compared with 1984. Journal of Advanced Nursing , 37 (2), 192-198.

20. Daly, M. (2014). Ebola Nurses Are As Brave As Soldiers. Retrieved 11 15, 2014, from http://www.thedailybeast.com/articles/2014/10/16/nurses-on-the-ebola-front-lines-are-as-brave-as-any-soldier.html

74

21. Donelan, K. (2008). Public Perceptions of Nursing Careers: The Influence of the Media and Nursing Shortages. Nursing Economics , 26 (3), 145-165.

22. Ekstrom, D. (1999). Gender and perceived nurse caring in nurse patient dyads. Journal of Advanced Nursing , 29, 1393-1401.

23. El-Sanabary, N. (2007). The Education and Contribution of Women Health Care Professionals in Saudi Arabia: the case of nursing. Social Science and Medicine , 37 (11), 1331-1343.

24. El-Sanabary, N. (1993). The Education and Contribution of Women Health Care Professionals in Saudi Arabia: the case of nursing. Social Science and Medicine , 37 (11), 1331-1343.

25. Emeghebo, L. (2012). The image of nursing as perceived by nurses. Nurse Education Today , 32, 49–53.

26. Finkelman, A. (2012). Leadership and management for nurses. pp. 211-2020.

27. Finkelman, A., & Kenner, C. (2013). The Image of Nursing: What It Is and How It Needs to Change. In Professional Nursing Concepts (2 ed., pp. 9298-9298). Jones & Bartlett Learning.

28. Fletcher, K. (2007). Image: changing how women nurses think about themselves - literature review. Journal of Advanced Nursing , 58 (3), 207-215.

29. Gazzaz, L. (2009). Saudi Nurses’ Perceptions of Nursing as an Occupational Choice. Dissertations Submitted to the University of Nottingham , 1-341.

30. Gordon, S. (2005). An end to angels. American Journal of Nursing , 105 (5), 62–69.

31. Greenhalgh, J. (1998). Nurse caring behaviours. Journal of Advanced Nursing , 27, 927-932. .

32. Grossman, D. (1989). High School Students' Perceptions of Nursing as a Career: a pilot study. . Journal of Nursing Education , 28 (1), 18-21.

33. Hamdi, O., & Al-Hyder, A. (1995). Factors Influencing the Decision of Choosing Nursing as a Career for Saudi Girls. Research Administration .

34. Hassan, J. (2012). Nursing Image in Qatar: Past, Present and Future. Middle East Journal of Nursing , 6 (4).

35. Hemsley-Brown, J., & Foskett, N. (1999). Career Desirability: young people's perceptions of nursing as a career. Journal of Advanced Nursing , 29 (6), 1342-1350.

36. Herefoed, M. (2006). Explaining the Reel Image of Nursing: How movies, television and stereotypes portray the nursing profession. Doctoral dissertation, University of Idaho, 2006 , 99-101.

37. Huffstutler, S., Stevenson, S., & Mullins, I. (1998). The public’s image of nursing as described to Baccalaureate prenursing Students. Journal of Professional Nursing , 14 (1), 7-13.

38. Jones, J. (2010). Nurses top honesty and ethics for 11th year: Lobbyists, car salespeople, members of Congress get the lowest ratings. Retrieved 10 25, 2014, from http://www.gallup.com/poll/145043/Nurses-Top-Honesty-Ethics-List-11-Year.aspx

75

39. Joshi, P. (2002). A study to find out the level of parents' satisfaction with paediatric nursing care whose children are admitted in Paediatric units of a selected hospital in Delhi . Published thesis of the University of Delhi .

40. Kalisch, J., Kapzawni, D & Hunk, D. (1986). An Analysis of the Impact of Authorship on the Image of the Nurse Presented in Novels. Research in Nursing and Health , 6 (1), 17-24.

41. Kalisch, B. (2007). The image of the nurse on the Internet. Nurs Outlook , 55, 182-188.

42. Kapzawni. (2004). A study to identify the level of satisfaction of mothers with postnatal care received and its relationship with selected factors in a selected hospital of New Delhi. Published thesis of the University of Delhi .

43. Karaoz, S. (2004). Change in Nursing Students' Perceptions of Nursing during their Education: the role of the introduction to nursing course in this change. Nurse Education Today , 24 , 128-135.

44. KELLY, L. (1985). Dimensions of professional nursing.

45. Kerssens, J. (1997). Patient preference for genders of health professionals. Social Science and Medicine , 44, 1531-1540.

46. Kourkouta, L. (2014). Communication in Nursing Practice. Mater Sociomed , 26 (1), 65-67.

47. Kunene, P. (2001). The image of the nursing profession as perceived by the community members of three adjacent residential areas of Empangeni in KwaZulu-Natal. Curationis , 35-41.

48. Kutney-Lee, A., Matthew, D., McHugh, D., & Douglas, M. (2010). Nursing: A Key To Patient Satisfaction. Health Affairs , 28, 669-677.

49. Letvak, S. (2001). Nurses as Working Women. RN , 73 (3), 675-676.

50. Lippman, D., & Ponton, k. (1989). Nursing's Image on the University Campus. Nursing Outlook , 37 (1), 24-27.

51. Lodge, N. (1997). A study to ascertain gynaecological patients' perceived levels of embarrassment with physical and psychological care given by female and male nurses. Journal of Advanced Nursing , 25, 893-907.

52. Lorraine, B. (2002). Does Public Image of Nurses Matter? Journal of Professional Nursing , 18 (4), 196-205.

53. Loveday, H., Wilson, J., Hoffman, P., & Pratt, J. (2007). Public perception and the social and microbiological significance of uniforms in the prevention and control of healthcare-associated infections: an evidence review. Advanced and Specialized Nursing , 8 (4), 10-21.

54. Mahir, S. (1970). Al-Asiyat. Great Adventures in Nursing , 1-11. 55. Mahran, S., & Al Nagsha, E. (2012). Impact of Perceived Public Image on Turnover

Intention of Female Students from Joining To Nursing Profession At King Abdul-Aziz University, Kingdom Saudi Arabia. Journal of Nursing and Health Science , 1 (1), 19-28.

56. Meiring, A. (2010). The image of nurses as perceived by the south African public. A dissertation submitted in fulfillment of the requirements for the degree of Master in the Department of Nursing Science, Faculty of Health Sciences, University of Pretoria, .

76

57. Meleis, A., & Hasan, S. (1980). Oil Rich, Nurse Poor: The Nursing Crisis in the Persian Gulf. The Nursing Crisis in the Persian Gulf. Nursing Outlook , 238-243.

58. Miller, K. (2004). Developing the Academic Nursing Practice in the Midst of New Realities in Higher Education. Journal of Nursing Education , 43 (2), 55-59.

59. Moceri, J. (2014). Nurses’ Knowledge and Attitudes Toward Pain in the Emergency Department. Journal of Emergency Nursing , 40 (1), 6-12.

60. Murphy, E. (2003). Qualitative Methods and Health Policy Research. New York: Aldine De Gruyter .

61. Murray, M. (2002). The nursing shortage. Past, present, and future, 32. Retrieved 11 25, 2014, from http://www.ncbi.nlm.nih.gov/

62. Nehring, V. (2003). A snapshot of nursing in Qatar . Nursing Education Perspectives , 24 (5), 226-229.

63. Palmer, A. (2007). The Real Public Perception of Nurses. Retrieved 10 13, 2014, from http://www.asrn.org/journal-nursing/249-the-real-public-perception-of-nurses.html

64. Park, J. (2007). Early Nursing Career Experience for 1994-2000 Graduates from the University of Nottingham. Journal of Nursing Management , 15 (4), 414-423.

65. Patidar, A., Kaur, J., Sharma, S., & Sharma, N. (2011). Future nurses' perception towards profession and carrier plans. Nursing and Midwifery Research Journal , 7 (4), 175-183.

66. Poroch, D., & McIntosh, W. (1995). Barriers to assertive skills in nurses. Aust N Z J Ment Health Nurs , 4 (3), 113-23.

67. Rambur, B. (2005). Education as a Determinant of Career retention and Job Satisfaction among Registered Nurses. Journal of Nursing Scholarship , 37 (2), 185-192.

68. Rideout, V. (2008). Television as a Health Educator: A Case Study of Grey’s Anatomy. Kaiser Family Foundation Report , 1.

69. Roberts, D., & Vasquez, E. (2004). Power: an application to the nursing image and advanced practice. AACN Clinical Issues , 15 (2), 196–204.

70. Salman, K. (2003). Women in Nursing in Islamic Societies. Oxford University Press , 292-309.

71. Satterly, F. (2004). Where Have All the Nurses Gone? The Impact of the nursing shortage on American healthcare. New York: Prometheus Books.

72. Saver, C. (n.d.). Nurses Should be Stronger.

73. Scally, R. (2013). Survey Finds Public Perceives Nurses as Ethical and Honest. Retrieved 11 1, 2014, from http://www.nursezone.com/nursing-news-events/more-news/Survey-Finds-Public-Perceives-Nurses-as-Ethical-and-Honest_28898.aspx

74. Schmidt, L. (2003 ). Patients' perceptions of nursing care in the hospital setting. Journal of Advanced Nurses , 44 (4), 393-399.

75. Schweitzer, S., Eckstrom, B., & Kowallek, D. (1994). The image of the staff nurse. Nursing Management , 25 (6), 88-89.

76. Searle, & Pera. (1995). Professional practice: a South African nursing perspective. Durban .

77

77. Senarath, U., Gunawardena, N., Senanayake, A., & Wijeratne, D. (2007). Patient satisfaction with nursing care and related hospital services at the National Hospital of Sri Lanka. Leadership in Health Services , 26 (1), 63-77.

78. Sharma, S., & Kamra, P. (2013). Patient Satisfaction with Nursing Care in Public and Private Hospitals. Nursing and Midwifery Research Journal , 9 (3), 130-141.

79. Sheth, S. (2011). Do You Reflect a Positive Image of Nursing? . Retrieved 10 17, 2014, from http://www.healthecareers.com/article/do-you-reflect-a-positive-image-of-nursing/158739

80. Sullivan, L., & Commission, S. (2004). Missing persons: Minorities in the health professions. Battle Creek, MI: W. K. Kellogg Foundation .

81. Sultan, F. (1990). Nursing in Jordan - Establishment, Development, and Ambition . Amman: Sultan Graphics.

82. Summers, S., & Summers, H. (2004). Media ‘Nursing’: Retiring the Handmaiden. Nursing Advocacy , 104 (2), 1-2.

83. Takase, M., Kershaw, E., & Burt, L. (Journal of Professional Nursing). Does public image of nurses matter. 2002 , 18 (4), 196–205.

84. Takase, M., Kershaw, E., & Burt, L. (2001). Nurse–environment misfit and nursing practice. Journal of Advanced Nursing , 35 (6), 819–826.

85. Tang, K., Duffield, C., Chen, J., Choucair, S., & Cree. (1999). Nursing as career choice: perceptions of school students speaking Arabic, Serbo-Croatian, Spanish, Turkish or Vietnamese at home. Australian Health Review , 22 (1), 107–121.

86. Tumulty, G. (2001). Professional development of nursing in Saudi Arabia. Journal of Nursing Scholarship , 33 (3), 285 – 290.

87. Tunstall-Pedoe, H. (1998). Did MONICA really say that? Did MONICA really say that? British Medical Journal. , 317 (7164), 1023.

88. Waters, A. (2005). Nursing is the most emotionally rewarding career. Nursing Standard , 19 (30), 22-26.

89. Watson, R. (2006). Is There a Role for Higher Education in Preparing Nurses? . Nurse Education Today , 26 , 622-626.

90. Whittock, M., Edwards, C., & MacLaren, S. (2002). The Tender Trap: gender, part-time nursing and the effects of "family-friendly" policies on career advancement. . Sociology of Health and Illness , 24 (3), 305-326.

78