Keywords: Altruism; Nursing graduates; Nursing students; Nursing image; Promotion

Introduction

The largest group of healthcare providers is nurses; therefore, the growth and sustainability of the nursing profession are a global concern [1]. There is a worldwide critical nursing shortage which is partially attributed to the public image of nursing [2]. There is evidence of a poor perception of nursing within the profession causing high rates of attrition of student nurses and newly qualified nurses [3] and which has consequences for both recruitment and retention [4]. These concerns present a serious risk to the future of the nursing profession. In order to assure a sufficient supply of nurses, there is a need to find innovative strategies in several areas, especially altering the image of nursing, eliminating negative stereotypes and making a career in nursing more attractive by building a more professional image of nursing.

What makes one profession more preferable than another? Literature studies show image is an overriding component, especially relating to recruitment for the profession. Images of nurses and nursing have an impact on the choice of nursing as a career among the future generation of nurses. Nurses are healthcare professionals who possess a great deal of knowledge, skills, and competencies. However, the public does not always realize and value these attributes that nurses have acquired through education and development [5]. Understanding the development and preservation of popular messages and images, in relation to the profession, has consequences on the recruitment of future generations of professional nurses [6]. Therefore, identification of the nursing image among college students is critical to help resolve the nursing shortage and to plan for the future [7].

Understanding the perception of nursing students about their profession will help in identifying misconceptions and information that could be helpful in planning public change of the nursing image. A negative image has negative consequences in the quality and quantity of people who choose nursing as a profession; whereas, a positive image leads to several positive professional outcomes. The perception of nursing students towards the nursing image has an impact on their self-concept, self-esteem, recruitment, retention, and performance. As a result, nurses with a positive professional image will have more and stronger relationships with their patients, peers, and community [8] stated that the intention to stay in the nursing profession was high in students whose professional image was high.

Nursing students' perception of the nursing image is varies [9] found that nursing students believe that nursing is a noble profession and admired by many people in the society. Most of their respondents chose nursing as a profession because of job security, good pay, self-actualization, and love of the profession. [10] found that the two main factors which affected student's selection of nursing as a profession were altruistic motivation and professional interest. Materialistic factors, such as social status and good salary, had less influence. However, the students in the sample were not a representative sample, rather a convenience sample. Therefore, they can't be taken as representative of the views of most nursing students Eley et al (2010) researched the reasons for entering and leaving nursing, in Australia, and found that altruism was identified by student nurses as one of the main reasons for entering nursing. In a survey in Australia, nursing students' reasons for entering nursing programs were personal and career-related. The personal reasons such as job security, being able to help and care for people, the ability to enter tertiary education and the love of nursing, were more dominant [11,12].

Other researchers have found that nursing students can also be found to be generally less altruistic and more pragmatic [13] revealed a mix of positive and negative perceptions of the nursing image among student nurses. The main negative perception was of the working conditions of nurses [14] found that nurses perceived their profession positively and that there was no significant correlation between the image of nursing to nurses' intention to emigrate. In a cohort of Bahraini nursing students, positive perceptions about nursing were expressed; even though, the public image of nursing in Bahrain was perceived as a low paying, low-status job involving excessive hard and unpleasant work [15]. In a Korean cohort of nursing students, satisfaction with nursing as a career and clinical practicum were related to nursing image and their satisfaction. Nursing image was also correlated positively with self-esteem and their nursing professional value [16].

At present, the image of nursing in Arab countries is improving and nursing is considered as one of the appreciated and recommended professions [17]. Views of the nursing image among student nurses may change at different stages of their studies; research has shown both positive and negative perceptions of students [18] found that nursing students begin their nursing education with stereotypical, fanciful and imprecise images of nursing that change over the years of their education. However, most of the student nurses remain with some traditional and idealistic beliefs from their first to the fourth year of studies [19,20] in a longitudinal study, found that students held a positive image of nursing and as they progressed in their BN program it became significantly more positive; whereas [21] found that nurses at the beginning of their career, have a positive image of the role of nurses but as they progress through their career, they have negative perceptions of their nursing roles. The perception of others of the nursing roles and the RN's perception of their ability to provide compassionate safe care influence these negative perceptions [22] claims that new graduate nurses were found to have a high role conception in professional, competence and service scenarios. She also found that there was no association between role conception and age, gender, educational level or previous healthcare experience. Role conception did not significantly affect job satisfaction.

Wish for Promotion (Career Progression) and Retention: In Australia [23] found that career progression in nursing affects turnover, with many nurses considering changing jobs for the purpose of progression. Nursing students, in Australia, have also indicated that the main factor for leaving nursing would be the lack of career progression [24]. On the other hand, candidates from low SES backgrounds are not only less likely to participate in higher education overall, but also less likely to participate in high-status degrees and enroll in the most prestigious universities [25]. The nursing profession is not considered prestigious and candidates who enroll in the nursing program do not always have a wish for promotion. It has been shown that students don't have enough knowledge about career planning [26] and that not much is known about students' aspiration toward career development [27]. The effect of wish for promotion on the image of nursing, among student nurses', has hardly been studied; therefore, this will be one of the aims of our study.

It is also important to identify and analyze the factors that cause these different perceptions of the nursing image among nursing students, in order to promote the nurses' professional image and to explore the influence of the nursing image on intention to stay in the nursing profession.

The researchers of this study believe that in order to better understand the image of nursing, it would be best to divide the issue of the image of nursing into two variables:

nurses' role image and nursing profession image. We believe that these two variables will give a superior understanding of the nursing image.

Purpose of the Study: The aim of this study was to examine the factors related to the nursing students' image toward the nursing profession and the nursing roles and their influence on their wish for promotion and their intention to stay in the nursing profession (Figure 1).

The Research Questions:

1. Is there a positive correlation between the students' nurses' roles image and the nursing profession image?
2. Is there a positive correlation between students' level of altruism and students' nurses' roles image and the nursing profession image?
3. Is there a positive correlation between students' wish for promotion and students' nurses' roles image and the nursing profession image?
4. Is there a difference between the students' gender and students' nurses' roles image and the nursing profession image?
5. Is there a difference between the students' religion and students' nurses' roles image and the nursing profession image?
6. Is there a correlation between students' nurses' roles image and the nursing profession image and the students' intention to stay in the profession?
7. Are the variables students' nurses' roles image and the nursing profession image mediator variables between altruism, gender, religion and wish for promotion to the intention to stay in the nursing profession?

Materials and Methods

A cross-sectional study was carried out at two academic nursing schools in Ruppin Academic Center. The study approved by the Ethical Committee in Ruppin Academic Center and all the subjects have signed on an informed consent form to participate in the study. The study included 223 student nurses (83.7% respondents rate). Data was collected during the year 2016. A pilot study (N = 20) was conducted to evaluate the process of data collection, length of the questionnaire, and perceptibility.

Changes were made on the tool in accordance with the pilot study's findings. Participation of the students was voluntary.

• Questionnaire: A structured questionnaire was used to collect data. The questionnaire contained five sections:

1. 1. Sociodemographic background: Ten items related to the nursing students' sociodemographic variables like sex, age, year of education and religion.
2. 2. Nursing students' self-image: This questionnaire related to the nursing students' image of nursing (professional self-image) based on the questionnaire from Toren, Kerzman & Kagan, (2011).The questionnaire included ten items relating to the image of nurses such as communication skills, intelligence, nursing's status, and others. The scale of each item ranged from 1 to 5 (1 indicating a negative value and 5 indicating a positive value). Student nurses signified their views, for each item, on a 5-point Likert scale. Cronbach's alpha was 0.78.
3. 3. Image of the nursing profession: This part of the questionnaire is about the professional image of the clinical area in which the participants practiced and was taken from the Altman questionnaire (1995). This questionnaire consisted of 10 matched items (positive and negative), each stating features of the nursing profession, such as challenging nursing practice, interesting clinical area, and others. Two polar statements were given where the items were rated on a scale of 1(a negative value) to 5(a positive value). Cronbach's alpha was 0.89.
4. 4. Altruism questionnaire: as it can be called human altruism, or helping others, was taken from Bachner-Melman, R., Zohar, A. H., Ebstein, R. P. and Bachar, E., (2007). The questionnaire consisted of 15 items related to altruism. The scale ranged from 1-5, 1 indicating "not correct at all" and 5 indicating "correct". For example: "I am willing to sacrifice a lot to make other people happy". The Cronbach's alpha of this scale was 0.63.
5. 5. Intentions to stay in the profession and wish for promotion after graduation: Students were asked two questions regarding their intentions to stay in the profession and their perceptions about their wish for promotion after graduation. They were asked to indicate their views on a 6-point scale. Each question had a Likert scale which ranged from 1 to 6, a value of one indicating "not at all" and a value of 6 indicating "very true".

The statistical tools used in this research were chosen according to the nature of the study and the characteristics of the variables. The statistical program used was SPSS 20. The tests used were: frequencies, Pearson correlation tests, T-tests, and a multi-hierarchical regression test.

• Ethical Considerations: The Ethics Committee of The Ruppin Academic Center approved the study.

2. Results

Two hundred and twenty-three nursing students participated in this study. The socio- demographic data Table 1,2 showed that 63% of the participants were Jews, of which 7% were males and 37% were Muslims and Christians, of which 43% were males. The sample was composed mostly of traditional and religious students (61%) and students in their first and second year of studies (68%).

Our research questions were: Are there positive correlations between the students' image of the nursing profession and the nurses' roles and are there positive correlations between the research variables.

Furthermore, we examined whether the variables nursing profession image and nursing roles image were mediator variables between altruism, gender, religion and wish for promotion to the intention to stay in the nursing profession.

Table 3 displays the results of the Pearson correlation tests performed concerning the variables: altruism wish for promotion, nursing roles image, nursing profession image and intention to stay.

Results according to the research questions:

1. Is there a correlation between the students' image of the nurses' roles to the image of the nursing profession?

The Pearson correlation test found a significant correlation (r=.65, p<.001) between the students' image of the nurses' roles and the image of the nursing profession. The higher the level of the image of the nurses' roles, the higher the image of the nursing profession by the nursing students.

2. Is there a correlation between the level of altruism of nursing students and their image of the nursing roles and the image of nursing profession?

A significant positive correlation was found in the Pearson test (nursing roles; r=.22; p<.001); (Image nurse profession; r=.25, p<.001), between the level of altruism of nursing students and their image of the nursing roles and the image of nurse profession. The higher the level of altruism, the higher the image of nursing roles and nursing profession.

3. Is there a correlation between the nursing students' wish for promotion and their image of the nursing roles and their profession?

A significant positive correlation was found in the Pearson test (image nurse profession; r=.34, p<.001); (Image nurse roles; r=.20, p<.001) between the nursing students' wish for promotion and their image of the nursing roles and their profession. The higher the wish for promotion, the higher the image of nursing roles and nursing image profession.

4. Are there differences between the students' gender, and their image of the nursing roles and profession?

The independent t-test found differences between gender and their image of the nursing roles and profession. As can be seen in Table 4, female students have a more positive image of the nursing roles and profession than the male students.

5. Are there differences between the students' religion and their image of the nursing roles and profession?

T-test found no significant differences among Jews and non-Jews regarding the image of the nursing profession and nursing role.

1. Is there a correlation between the image of the nursing roles and their profession and the students' intention to remain in the nursing profession?

A significant positive correlation was found in the Pearson test between the image of the nursing roles and their profession and their intention to remain in the nursing profession (Image nurse profession; r=.35, p<.001); (Image nurse roles; r=.32, p<.001). The higher the level of the image of the nursing roles and profession, the higher the intention of the nursing students to remain in the profession.

2. Are the images of nursing roles and nursing profession median variables between altruism, gender, religion and wish for promotion to the intention to stay in the nursing profession?

In order to build a comprehensive model of the respective influences that each of the variables have on the intention to stay in the nursing profession, we built a linear regression model in which the intention to stay in the nursing profession was the dependent variable and all the other variables of our model (gender, altruism, religion, wish for promotion) were the independent variables.

Linear regression with two block analysis had been run in order to answer the research question. In the first block, the level of altruism, gender, religion, and wish for promotion was entered. In the second block, the level of images of nursing roles and profession were added to the regression equation. The linear regression results are shown in Table 5.

The two significant predictors of the intention to stay are the wish for promotion and the nurses` role image, which explains 32% of the variance of the dependent variable.

Discussion

The primary purpose of this study was to examine the factors related to the nursing students' image toward the nursing profession and the nursing roles and their correlations to their intention to stay in the nursing profession. We found two significant predictors for the intention to stay wish are the wish for promotion and the nurses` role image, which explain 32% of the variance of the dependent variable. This finding can be explained by the fact that nursing students, who have a positive image of the nursing profession and have aspirations for professional development, will want to remain in the profession. It is also possible to assume that the students are pleased with their studies, and it should be a recommendation for nursing educators to find ways to promote the nursing image among the students and to present the multiple opportunities for advancement in the profession.

A significant indicator of predicting graduate retention may be the development of the students' nursing self-concept. A prerequisite for the academic development of a profession's identity is professional self-concept which is closely related to self-concept [28] found that general self-concept is a strong predictor of graduate nurse retention. An undesirable public image has a damaging influence on nurses' self-concept and the development of their professional identity [29] found that nurses' work contributes to their professional development and satisfaction and their findings acknowledged the inseparability of identification with nursing and commitment to nursing. Nurses need to promote public alertness about the various aspects of nursing practice and the opportunities of the profession by presenting themselves more clearly to the public thus rising their public image and in turn their own professional self-concept.

We found differences between the student's gender and the image of the nursing roles and profession. Female students were found to have a more positive image of the nursing roles and profession than the male students(p< 0.001). The research results of [30] found that Arab male nurses differentiate themselves and their roles from female nurses. Another study found that male nurses, more than female nurses, had lower professional identity. The males’ main motivations were good marketing and being close to medicine: “Nursing attracts people because its employment is high” [31,32].

Conclusion

Nursing educators must pursue ways to encourage their graduate students to stay in the nursing profession and to seek career progression (wish for promotion). Despite the variety of professional opportunities, the majority of students are not aware of them, and that is why career planning is a strategic method which should be developed during their years of education. Nursing educators should, therefore, help students recognize nursing career opportunities and support them in planning their careers.

It is our duty as nurse educators to start taking action, as part of the nurses' curriculum to empower the nursing students. It is therefore recommended:

1. To present and explore before the students the various opportunities in this profession and their advancement and implications.
2. To strengthen nursing students' sense of professional pride.
3. To train the students to deal with situations related to the low professional image of the nurse's status through simulations.
4. To bring in keynote of nursing speakers, nurse innovators, who should be as a role model to the students, and an aspiration for their future career.
5. To advance positive thinking, assertiveness, and useful and effective tools among nursing students, to achieve efficient, respectable and professional cooperation with all other role partners such as doctors, administrators and more.

More research is needed to determine why the image of nursing is lower amongst the male gender. It would also be interesting to find out more about the relationship between religion and the nursing image, specifically the cultural reasons for the differences between Arabs and Jews considering the nursing image.

In conclusion, it is seems that if all the above be accomplished during the training and study phase of the nursing students; the nursing graduate will begin her professional career with pride and serve as a change agent to empower the nurses' role and strengthen the personal and professional image of the nursing profession.