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Perceptions of nursing graduates about the quality of their
undergraduate nursing education and training in
Thiruvananthapuram district, Kerala.
NEETHU.T
Dissertation submitted in partial fulfillment of the
Requirement for the award of
Master of Public Health
ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND
TECHNOLOGY, TRIVANDRUM
Thiruvananthapuram, Kerala. India – 695011
OCTOBER 2016
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DEDICATED TO MY GRANDMOTHER
SREEMATHI AMMA.
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ACKNOWLEDGEMENTS
First and foremost, I would like to thank god Almighty for his blessings to complete my
research work.
I would like to express my sincere gratitude to my guide, Dr Srinivasan. K, Additional
professor, Achutha Menon Centre for Health Science Studies (AMCHSS) for his
guidance throughout my research work.
I extend my sincere thanks to Dr. P. Sankara Sharma and Mrs. Jissa. V. T for clearing my
doubts whenever I was in need.
I thank all the faculty members of the AMCHSS, Dr. KR Thankappan, Dr. V Raman
Kutty, Dr. TK Sundari Ravindran, Dr. Mala Ramanathan, Dr. Biju Soman, Dr. Ravi
Prasad Varma and Dr.Manju.C for providing their valuable suggestions throughout my
study.
I do not have words to express my sincere gratitude and indebtedness to Dr.Malu Mohan,
PhD student for her encouragement and support since beginning of the study.
I would like to express my thanks to Prof. Prasanna. Y, Joint Director of Nursing
Education (JDNE) for her supporting my study.
I would like to express my thanks to Dr. Neethu Suresh, Sapna Mishra and all other PhD
students and my friends who helped me in completing the study.
I am grateful to my family for their support to complete my dissertation.
A special word of thanks to my sister Adhithya.T and brother Renjith.S for helping me
throughout the study.
I would like to express my thanks to all the respondents who participated in the study.
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CERTIFICATE
Certified that the dissertation entitled, “Perceptions of nursing graduates about
the quality of their undergraduate nursing education and training in
Thiruvananthapuram district, Kerala” is a bonafide record of original research work
undertaken by Ms. Neethu.T, in partial fulfillment of the requirements for the award of
the degree of “Master of Public Health” under my guidance and supervision.
Dr. SRINIVASAN. K
Additional Professor
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Trivandrum
Thiruvananthapuram, Kerala
October, 2016
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DECLARATION
I declare that this dissertation work titled “Perceptions of nursing graduates
about the quality of their undergraduate nursing education and training in
Thiruvananthapuram district, Kerala” is the result of my original field research. It has
not been submitted to any other university or institution for the award of any degree or
diploma. Information derived from the published or unpublished work of others has been
duly acknowledged and referenced in the study.
MS. NEETHU. T
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum
Thiruvananthapuram, Kerala. India -695011
October, 2016
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Table of contents
Contents Page
number
List of tables
List of Figures
Glossary of Abbreviation
Glossary of concepts used in the study
Abstract
Chapter 1: Introduction and Literature review……….…..
1.1Background………………………………………………………….
1.2 Literature review……………………………………………………
1.2.1 Motivation for choosing nursing……………………………….....
1.2.2 Perceptions about quality of nursing education and training……..
1.2.2.1 Educational environment……………………………………….
1.2.2.2 Instructors………………………………………………………
1.2.2.3 Methodology of education………………………….………….
1.2.2.4 Clinical education………………………………………………
1.2.3 Views and perceptions towards nursing profession………………
1.2.3.1 Recognition and value…………………………………………..
1.2.3.2 Shortage of staff…………………………………………...……
1.2.3.3 Economic security………………………………………………
1.2.3.4 Experience and educational level…………………….…………
1.2.3.5 Clinical environment…………………………………………....
1.2.4 Future intentions………………………………………………….
1-19
1-4
4-18
5
5-11
6
6
6-7
7-11
11-15
12-13
13-14
14
14-15
15
16-18
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1.2.4.1 Bed side nursing………………………………………………...
1.2.4.2 Teaching………………………………………………………...
1.2.4.3 Migration………………………………………………………..
1.2.4.4 Higher education in nursing……………………………...……..
1.2.4.5 Change of profession……………………………………...……
1.3 Rationale of the study……………………………………………..
1.4 Objectives…………………………………………………………..
1.4.1 Major objective………………………………………………...…
1.4.2 Minor objectives………………………………………………….
Chapter 2: Methodology…………………………………………
2.1 Study design…………………………………………………..……
2.2 Study setting………………………………………………………...
2.3 Study population……………………………………………………
2.4 Sample size estimation……………………………………………...
2.5 Sample selection procedures………………………………………..
2.6 Selection criteria……………………………………………………
2.7 Study variables and related definitions……………………………..
2.7.1 Outcome variables………………………………………………...
2.7.2 Predictor variables………………………………………………...
2.8 Data collection techniques and tools………………….……………
2.9 Data collection procedures………………………………………….
2.10 Ethical considerations……………………………………………..
2.10.1 Clearance………………………………………………………...
2.10.2 Confidentiality…………………………………………………..
2.10.3 Consent…………………………………………………………..
16-17
17
17
18
18
18-19
19
19
19
20-28
20
20
20
21
21-22
22
22-25
22-24
24-25
25
26
26-27
26
26-27
27
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2.10.4 Beneficence……………………………………………………...
2.10.5 Risks……………………………………………………………..
2.11 Data analysis………………………………………………………
2.12 Dissemination of results…………………………………………...
Chapter 3: Results………………………………………….
3.1 Basis characteristics of respondents…………………………….…
3.1.1 Type of the institution where nursing education was pursued…..
3.1.2 Socio-demographic characteristics………………………………
3.1.3 Source of financing nursing education……………………..……
3.2 Motivational factors for pursuing nursing education………..…….
3.3 Perceptions regarding quality of undergraduate nursing
education and training……………………………………….…………
3.3.1 Perceived characteristics of instructors…………………………..
3.3.2 Perceived characteristics of the infrastructure ………………...…
3.3.3 Perceived characteristics on clinical education……………...……
3.3.4 Perceived characteristics of the overall nursing education programme…..
3.4 Views on nursing profession……………………………………….
3.4.1 Professional identity………………………………………………
3.4.2 Self-image………………………………………………………...
3.4.3 Social position…………………………………………………….
3.5 Future career choices……………………………………………….
3.6 Association between the type of the institution from where they
graduated and the rating of teaching abilities of the instructors………..
3.7 Association between the type of the institution where they have
graduated and the rating of infrastructure of the institution……….……
27
27
27-28
28
29-63
30-32
30
30
32
32
33-42
33-35
36-37
38-41
41-42
43
43
43
43
44
45
46
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3.8 Association between the type of the institution from where they
graduated and the rating of clinical exposure they had during their
under graduation………………………………………………..………
3.9 Association between the type of the institution where they have
graduated and the rating of the clinical training they have received……
3.10 Association between the characteristics of the respondents,
individual domains on perceived quality of nursing education and the
rating of the overall nursing education…………………………………
3.11 Association between characteristics of the nursing graduates and
views on nursing profession…………………………………………….
3.11.1 Opportunity to serve humanity………………………………….
3.11.2 Association between characteristics of the respondents and view
on nursing profession as a source of economic security………………..
3.11.3 Association between characteristics of the respondents and view
on nursing profession as comparable with other professions…………..
3.11.4 Association between characteristics of the respondents and view
on nursing profession as a dignified and respectful profession………...
3.11.5 Association between characteristics of the respondents and view
on nursing profession as a way to get recognition in society…………...
3.11.6 Association between characteristics of the respondents and view
on nursing profession as an opportunity for better marriage offers…….
3.12 Association between characteristics of the respondents, rating of
the overall nursing education and plan to change the profession………
47
47
48-49
51-61
51
51-52
54
56-57
59
61
63
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Chapter 4: Discussion and conclusion……………………..…
4.1 Discussion…………………………………………………………..
4.2 Strengths and limitations of the study………………………………
4.3 Conclusions and recommendations…………………………………
References
Annexure 1: Institutional Ethics Committee Clearance letter
Annexure 2: Subject Information Sheet
Annexure 3: Informed consent form in English
Annexure 4: Self-administered questionnaire in English
65-76
65-74
74
75-76
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List of tables
Table
number
Heading Page
number
3.1.2
3.2
3.3.1
3.3.2
3.3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
Socio-demographic characteristics……………...
Motivational factors for pursuing nursing
education…………………………………………
Perceived characteristics about the instructors…..
Perceived characteristics about infrastructure …..
Perceived characteristics of clinical education…..
Views on nursing profession…………………….
Future career choices…………………………….
Association between the type of the institution from where
they graduated and instructors’ rating by the
graduates………………………………….
Association between the type of the institution and
infrastructure rating by nursing graduates…..
Association between the type of the institution and clinical
exposure rating……………………...
Association between type of the institution and clinical
training rating……………………………
Association between the characteristics of the respondents,
individual domains on perceived quality of nursing
education and the rating of the overall nursing
education………………………..
31
32
34
37
39
44
44
45
46
47
48
53
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3.11.2
3.11.3
3.11.4
3.11.5
3.11.6
3.12
Association between characteristics of the respondents and
view on nursing profession as a source of economic
security……………………..
Association between characteristics of the respondents and
view on nursing profession as comparable with other
professions………………
Association between characteristics of the respondents and
view on nursing profession as a dignified and respectful
profession……………...
Association between characteristics of the respondents and
view on nursing profession as a way to get recognition in
society………………
Association between characteristics of the respondents
and view on nursing profession as an opportunity for
better marriage offers …………..
Association between characteristics of the respondents,
rating of the overall nursing education and plan to change
the profession…….
53
55
58
60
62
64
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List of figures
Figure
number
Heading
2.9 Gantt chart for dissertation activity
3.1.3 Source of financing nursing education
3.3.1 Perceived reasons for rating the instructors as poor
3.3.2 Perceived reasons for rating infrastructure as poor
3.3.3.1 Perceived reasons for rating clinical exposure as poor
3.3.3.2 Perceived reasons for rating clinical training as poor
3.3.4 Perceived reasons for inadequate overall nursing education
programme
Page
number
26
32
35
38
40
41
42
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GLOSSARY OF ABBREVIATIONS
ABBREVATIONS FULL FORM
AND Associate Degree in Nursing
CNL Clinical Nurse Leader
DNSc Doctorate of Nursing Science
ND Nursing Doctorate
NLNAC National League for Nursing Accrediting Commission
CCNE Commission on Collegiate Nursing Education
AACN American Association of Colleges of Nursing
CME Christian Medical College
RAK Rajkumari Amrit Kaur College
MPHW-F Multy Purpose Health Worker Female
ANM Auxillary Nurse Midwives
GNM General Nursing and Midwifery
IGNOU Indira Gandhi National Open University
TNAI Trained Nurses Association of India
INC Indian Nursing Council
KNMC Kerala Nurses and Midwives Council
DME Directorate of Medical Education
KUHS Kerala University of Health Sciences
BSc Bachelor of Science
MSc Master of Science
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Glossary
Concepts used in the study
Graduate nurse: A person trained in the scientific basis of nursing, meeting certain
prescribed standards of education and clinical competence (Medical dictionary).
Perception: Perception by itself is merely defined as an idea, or an image you have as a
result of how you see or understand something (AS Hornbey, 2000).
Quality: The standard of something as measured against other things of a similar kind; the
degree of excellence of something (Oxford dictionary).
Motivation: The act or process of giving someone a reason for doing something
(Merriam-Webster dictionary).
Professional identity: It is a form of social identity which is related with group
interactions at work place and how people compare themselves with other professional
groups and make distinctions (Yazdannik et al., 2012).
Self-image: It is defined as the underlying mental representation which does not reflect
the reality in all its dimension (Bakalis, 2015).
Social position: It describes a person’s place in the social hierarchy (Lindemann 2007).
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Abstract
Background: Commercialization of nursing education has different effects. This study
aimed to examine the perceptions of nursing graduates about quality of nursing education
and training, views on nursing profession in terms of professional identity, self-image and
social position and the motivational factors for pursuing nursing education.
Methods: Crossectional study was conducted among 334 nursing graduates, who are
residing in four randomly selected administrative areas in Thiruvananthapuram district
using multi stage random sampling method. A structured self-administered questionnaire
in English developed by the principal investigator was used for data collection. Analysis
was done using SPSS version 21.
Results: Majority of the respondents were females (82.5%). Most of the respondents
graduated from private nursing colleges (47%). Self interest in nursing was reported as
the motivational factor pursuing nursing education by 44.3% of the graduates. Half of the
respondents perceived instructors characteristics as good. The characteristics of the
infrastructure were perceived as good by 56.9% of the graduates. About 63.3 % of the
graduates perceived clinical exposure as adequate. The characteristics of the clinical
training were perceived as good by 33.8% of the graduates. About 62.9% perceived
overall nursing education as adequate. Almost all of them perceived nursing profession as
an opportunity to serve humanity (96.4%).More than half of them perceived it as a source
of economic security (58.4%) and as a dignified, respectful profession (58.7%).Less than
half of them perceived it is comparable with other professions and a way to get
recognition in society (32.9% and 44% respectively) . Most of them (78.1%) perceived it
as not an opportunity for better marriage offers. About 25.1% of the graduates reported
that they would like to change their profession in the future.
Conclusion: The infrastructure, clinical education and overall nursing education were
influenced by the type of the institution from where the respondents graduated. In
addition, personal factors such as self-motivation, career options and other related things
have also influenced one to take-up this profession.
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Chapter One
Introduction
1.1 Background
Nursing education concentrates on the transmission of nursing knowledge, and assisting
nursing students to acquire the necessary skills and attitudes associated with nursing
practices (Salsali, 2005).
The goal of nursing education is to develop students to fully skilled independent
competent nurses. Nursing education comprises of theory and clinical education.
During industrialization, Sisters of charity developed nursing training program. The
Kaiserwerth School of Nursing was established in Germany in 1836 which provided
nursing training to students from various countries. Nightingale training school was
started in St Thomas hospital London in 1860. Some of the currently available nursing
programmes are Practical Nursing programme, Associate Degree in Nursing (ADN),
Baccalaureate degree in Nursing, Master’s degree and Clinical Nurse Leader (CNL),
Doctorate of Philosophy (PhD) ,Doctorate of Nursing Science (DNSc), Nursing Doctorate
(ND) .The professional bodies or organizations accrediting and ensuring quality of the
nursing education are National League for Nursing Accrediting Commission
(NLNAC),Commission on Collegiate Nursing Education (CCNE),American Association
of Colleges of Nursing (AACN),State Nursing Boards (Scheckal M) .
In India, first school for nursing course was started in General Hospital; Madras in
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1871. In 1946, the first graduation in nursing course was started by Christian Medical
College (CMC) Vellore and Rajkumari Amrit Kaur (RAK) College, Delhi (Patidar et al.,
2011). Currently there are six levels of nursing education in India. The non-university
level nursing educational programmes are Multy Purpose Health Worker Female training
{Auxillary Nurse Midwives [(ANM) or MPHW-F],Female Health Supervisor training,
General Nursing and Midwifery (GNM) ,Advanced Post certificate diploma courses and
University level nursing educational programmes include Basic Bachelor of Science in
nursing(BSc Nursing), Post Basic BSc Nursing (Regular),Post Basic BSc Nursing [Indira
Gandhi National Open University(IGNOU)], Advance Master of Science (MSc) in
Nursing, MPhil in Nursing, Ph.D in Nursing (Nursing Education in India,2013).
Professional bodies playing key role in the field of nursing education in India are Trained
Nurses Association of India (TNAI),which helped in the initiation of university level of
nursing education , Indian Nursing Council (INC),which sets standards and regulate the
nursing education in all parts of the country and it prescribes syllabus for ANM,GNM and
BSc nursing and State Nursing Council, which inspects and accredit schools of nursing in
the state (Dixit, 2011) In India, during 2004-2012, the number of nursing colleges in
India under government sector increased from 5% to 16%and the private nursing schools
and colleges of nursing produced 84%-94% of admission capacity (Nursing and
midwifery in India, 2012). In 2013, there are 1373 nursing colleges recognised by Indian
Nursing Council (Nursing education in India, 2013).
In Kerala, the first school of nursing was started in General Hospital,
Thiruvananthapuram; in 1943.The graduation in nursing was started first in Government
College of nursing, Thiruvananthapuram in 1972.
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The students were recruited for graduation in nursing through common medical and
engineering examination since 1983 (Government College of nursing Trivandrum, 2012).
Since 1990s, the globalisation has led to massive decrease of public expenditure in higher
education in India, which in turn affected Kerala also. In Kerala, when economy started
growing, the state shifted its priorities from education; the share of education in capital
expenditure came down from fifth five year plan to seventh five year plan. This prevented
the government from establishing government owned or government aided institutions in
the higher education sector. This vacuum was filled by self-financing professional
colleges in neighbouring states where the students from Kerala move to pursue higher
education. The movement of students to other states caused huge drain of money from
Kerala in the form of capitation fees. In order to prevent this huge drain of money, the
government established professional colleges in large number under private sector but the
under investment by the government in the sector led to massive increase in the private
costs of the students of these institutions. More than 80 % of the nursing colleges are
presently under self-financing stream (Haseena V.A and Shihabudeen N, 2014). The last
batch of nursing students, recruited to the graduation program through common entrance
examination was in 2008 (Government College of nursing Trivandrum, 2012). The
professional bodies involved in the field of nursing education are Kerala Nurses and
Midwives Council (KNMC), which plays role in establishment and maintenance of
uniform standards of nursing education in Kerala (Kerala Nurses and Midwives Council,
2016), Directorate of Medical Education (DME) which plays key role in establishing and
maintenance of teaching institutions (Official website of Directorate Of Medical
Education , 2016) and Kerala University of Health Sciences (KUHS) ,which affiliates all
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colleges imparting professional education in health care in Kerala (Kerala University of
Health Sciences - Official Website,2016). During 2012-2013, there are 118 nursing
colleges in Kerala in which five are under government sector (Kerala Nurses and
Midwives Council, 2013). Even though the competencies are covered in INC syllabus,
there exist lacunae in the implementation of actual clinical practice in nursing colleges
across the country (Bagga R et al., 2012).The evaluation of the effectiveness of the
teaching in nursing program will facilitate development of nursing education (Salsali,
2005).
The studies reviewed were mainly focussing on assessing the quality of nursing education
and training according to the students’ perceptions regarding quality of various courses of
nursing, characteristics of clinical placement during the nursing education, characteristics
of the teaching instructors. The present study is done among nursing graduates (pursued
four year nursing education course after their class twelve) from various nursing colleges
in Kerala.
The following section discusses the literature review of various studies which focuses on
quality of nursing education and training according nursing students or graduates’
perceptions.
1.2 Literature review
In this section, the findings from various studies related to the motivation behind pursuing
nursing education, perceptions regarding the quality of nursing education and training,
views about the nursing profession and the future intentions are discussed.
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1.2.1Motivation for choosing nursing profession
A study done in Saudi Arabia reported that for most of the students, the prime motivator
for choosing nursing was their own interest followed by other factors such as their
secondary school grade and to improve their financial status (Miligi et al., 2014).
According to a cohort study done in Taiwan among preregistered student nurses, most of
them opted nursing studies as their second or third choice (Lai et al., 2008). This was
supported by a study from Ireland (Mooney et al., 2008). A study done in Jordan revealed
that most of the nursing students chose nursing for financial security and availability of
work. The main motivators for choosing nursing profession were parents and friends
(Jarrah, 2013). This was supported by various studies in Saudi Arabia
(Miligi et al .,2014), Behrain (Eman et al., 2012), Ethiopia (Getu et al., 2015) .According
to a study done in United States of America , the most influential factor in deciding them
to choose nursing profession was the information and advices they received from the
practicing nurses (Buerhaus et al., 2005).According to the study done in Andhra Pradesh,
India, most of the students joined nursing for getting a government job and to settle early
in their life (Swarna , 2015).
1.2.2Perceptions about the quality of nursing education and training
The perceptions about quality of their nursing education and training are discussed here in
various domains such as educational environment, characteristics of the instructors and
also about the clinical education during their training.
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1.2.2.1Educational environment
A study done in United Kingdom reported that, the undesirable learning environment led
to their under valuation. Most of the students reported that the financial constraints they
faced were forcing them to discontinue their nursing studies (Last and Fulbrook.,
2003).According to the global standards for the initial education of professional nurses
and midwife which states that the institution should have accessible physical facilities in
classrooms, Information and Technology, pre-clinical laboratory and library (World
Health Organization, Nursing and midwifery human resources for health, 2009)
1.2.2.2Instructors
A study done in Australia reported that the nursing students were satisfied with the
support of their instructors (Lamont et al., 2015). A correlational study done in Palestine
stated that the nursing students perceived that their teachers could clarify their questions
and they have good personal and professional characteristic which diminishes the gap
between theory and practice thus creating a positive learning environment (Awad, 2015).
In contrast to this, an Iranian study among second to fourth year nursing students reported
that most of them had little satisfaction regarding theoretical education by the faculty,
relation between them. They were dissatisfied with the trainer’s performance (Hakim,
2013).
1.2.2.3Methodology of education
A qualitative study done in Jordan indicated that most of them felt that their lab training
was not adequate and they also suggested the inclusion of simulation in it, so that they
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feel they are in real settings (Saifan et al ., 2015).
1.2.2.4Clinical education
A qualitative study done in Philippines among fourth year nursing students reported that
they experienced stress and anxiety during their clinical placements, which has arisen due
to factors such as supervision by the instructors who were not in good terms with them
and the lack of familiarity with certain procedures and the wards during their clinical
placement (Tiwaken et al., 2015). This is supported by the study from Iran (Sharif et al.,
2005). In contrast to these findings a mixed study using cross sectional survey and focus
group discussion done in Kenya among preservice graduates and nursing supervisors to
evaluate the clinical training reported that the clinical placements were adequate and
could meet their clinical objectives (Nyangena et al., 2005). A study done in Taiwan has
shown that the nursing students recognized that their clinical practicum helped them to
increase their professional knowledge, develop patient care skills (Tseng et al., 2013).
The clinical education will be influenced by various factors such as role of instructors,
theory practice gap, staff in the clinical placement area and patients for their practice.
Role of instructors
A cross sectional study done in Iran among third and fourth year midwifery students
reported that the students perceived their clinical instructors should possess ability to
collaborate with other health care providers and the nursing students should get support
from their clinical instructors during their clinical education so as to promote the self-
confidence, independence and self-efficacy of the students (Valiee et al., 2015).
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A qualitative study done in Turkey revealed that the students desired their teachers to be
knowledgeable and clinical competent in their respective fields. A Jamaican study also
stated that the nursing students perceived the support from their instructors plays a crucial
role in supporting their learning process (Weaver and Lindon, 2015). A qualitative study
done in Philippines revealed that the nursing students stated that their expectations were
met by their clinical instructors. One of the most important expectations according to
students is maintaining a trusty relationship between the students and a clinical instructor
(Guzman et al., 2007). Another study from Philippines among fourth year nursing
students reported that they perceived clinical practice as a necessary component for their
learning process, which improves their competencies and helps them to become a
competent nurse. Most of them stated that their clinical instructors supervised them
during their clinical practice and helped them in improving their skills
(Tiwaken et al., 2015). According to a study done in Iran, nursing students described that
their teachers were playing evaluating role more than that of a teaching role (Sharif et al.,
2005). A mixed study done in Kenya among preservice graduates and nursing supervisors
to evaluate the clinical training reported that most of them were dissatisfied with the
clinical training they have received due to the lack of availability of the teaching faculty
which in turn affected the nursing education (Nyangenaval, 2011). According to a Delphi
study done in United Kingdom, the nursing students didn’t get adequate support from
their tutors during their clinical placement (Last and Fulbrook, 2003).
Theory practice gap
A qualitative study using narratives done in Jordan among the final year nursing students
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revealed that the nursing students experienced clinical leadership as a valuable tool in
bridging the gap between the theory and practice (Demeh and Rosengren, 2015). A study
done in Iran during 2005 described that there was a gap in what they learned in theory
classes and what they practice in the clinical placement area (Sharif et al., 2005). This
was supported by a Delphi study done in UK where nursing students revealed that their
theoretical component of education was given more emphasis than their clinical teaching.
So the students did not acquire adequate clinical skills even after the end of their
educational programme. Most of the students felt their clinical environment as
undesirable because it did not provide adequate nursing experience for their learning.
They also emphasised that they didn’t get adequate support from their tutors during their
clinical placement. A qualitative study done in Philippines among fourth year nursing
students also reported that the students experienced a gap between their theoretical
learning and their clinical practice (Tiwaken et al., 2015) and this was supported by the
study from Iran that the faculty members were emphasising more on theoretical education
with less focus on practical and developing students’ clinical decision making skills
(Hanbagherry et al., 2004).
Role of clinical staff in the clinical placement area
A qualitative study done in Finland reported that the nursing students gave importance to
the clinical practice in their learning. The students emphasised on the importance of
attitude of clinical staff as a part of learning experience. They felt that if they were part of
nursing care, it will provide them necessary opportunities for learning and to increase
their professional knowledge (Papp et al., 2002) .This was supported by a study
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conducted in Jamaica where the nursing students perceived that support from their
clinical staff plays a crucial role in supporting their learning process
(Weaver and Lindon, 2015). A qualitative study conducted in Turkey revealed that the
students’ learning was positively influenced by their good relationship with the staff and
they felt more self-confident while providing patient care (Elcigil et al., 2011). A study
conducted in Iran reported that the nursing students were motivated by witnessing the
nurses with better clinical knowledge and clinical competency. Further the nurses with
authority have motivated the nursing students. The lack of power to make decisions
among nurses, the low social status, extreme working conditions and concerns regarding
salary and employee benefit were the demotivating factors for nursing students. Further
they have perceived that they were not able to distinguish the work of nurses based on
whether they possessed BSc or MSc degree at the clinical settings. All the above
mentioned factors have demotivated them while pursuing their studies
(Nasrin et al., 2012). In contrast to these findings a study done in Australia reported that
nursing students were satisfied with the attitudes of their hospital staff towards the
students (Lamon t et al., 2015).
Patients for their practice
A study done from Iran found that nursing students perceived there was insufficient
number of patients while learning (Heidari and Norouzadeh, 2014). A qualitative study
done from Turkey reported that the clinical learning would positively facilitate by
providing care to patients with complicated disease conditions and this will in turn
increase self-confidence. The positive attitude of the patients towards the nursing students
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motivated their clinical learning (Elcigil et al., 2011). A study conducted in Jamaica
found that the nursing students perceived the contributors for positive learning were
opportunity for caring real patients, to practice what they have learned in theory and
sufficient resources in the clinical area. Majority of the students felt that they should get
more opportunities for learning in the clinical specialities (Weaver and Lindon, 2015).
1.2.3Views and perceptions towards nursing profession
Several studies have suggested that a number of factors influence the attitudes and
perceptions towards the nursing profession. Majority of the studies focused on the
perceptions of nurses, nursing students and perceptions of public towards the nursing
profession.
Positive perceptions towards nursing profession
Some of the studies showed positive perceptions and attitudes towards the nursing
profession.
An Ethiopian study among nurses revealed that more than half of them had good
perception towards nursing profession and most of them perceived it as a profession with
caring and compassion (Getu et al., 2015). This was supported by study from Jordan
(Jarrah, 2013) and by a triangulation study done in Bahrain among nursing students,
where most of them perceived nursing as a caring profession with provision of
comprehensive care(Eman et al., 2012).
A study conducted in Andhra Pradesh, India found nursing students considered nursing as
an opportunity to serve humanity (Swarna, 2015). Similar finding was reported by the
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studies from Mangalore, India (Kathreena et al., 2015). A study conducted in Punjab,
India reported that nursing students perceived nursing profession as an opportunity for
personal growth and means to settle abroad and for securing economic security and most
of them perceived nursing as a caring profession with ethical standards (Patidar et al.,
2011).
Negative perceptions and attitudes towards nursing profession
A study from Andhra Pradesh among nursing students reported that half of the nursing
students experienced nursing was not equal to other professions (Swarna, 2015). Similar
findings were reported by a study conducted in Punjab. Further, majority of students were
not having any family member or relatives in the nursing profession. From this the author
speculated that those who were already in the nursing profession didn’t want their
children or relatives to practice this profession (Patidar et al., 2011).
1.2.3.1Recognition and value
A study from Greece found that according to nurse’s perceptions, nursing profession has
social recognition and it has greater job opportunities that provided economic security.
However, most of the nurses felt that they lacked autonomy and majority of the nursing
students considered nursing as an undervalued profession, which according to them was
due to perception in the society that nurses subordinate the doctors. Further in Greece,
only fewer people chose nursing and this may be due to the media which plays an
important role in shaping the public opinion. They also suggested that, wrong ideals
propagated by television for the nursing profession made the high school students to
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believe that nurses were not able to handle administrative, organizational, research or
educational task. This has shaped a negative attitude towards nursing profession
(Bakalis et al., 2015). According to a study conducted in United Kingdom, the nursing
students felt that the hierarchical difference existed in levels of doctors and nurses and
this lead the doctors to ignore the nursing students. Lack of support from their tutors and
being ignored by other professionals were the two main reasons that they identified for
their undervaluation of the profession (Last and Fulbrook, 2003). A cohort study done in
Taiwan among pre-registered student nurses reported that the student nurses were the
ones who listens to the patients’ needs because of the shortage of working nurses but the
patients ,their families and other health providers did not trust them. The nursing students
also stated that there existed a gap between the social status of doctor and nurse (Lai et
al., 2008). A study done in Punjab reported that most of them did not perceive nursing as
a dignified and respectful profession (Patidar et al., 2011). In the contrary, a study
conducted in United States of America revealed that the nursing students felt that there
was sufficient recognition and respect for nurses (Buerhaus et al., 2011).
1.2.3.2Shortage of staff
According to a South African study conducted among general population assessing the
perceptions on image of the nursing profession found most of them were reported to have
a positive image of the nursing profession. The people who had expressed negative image
of nursing profession were related to the nurses’ poor commitment and not displaying
excellence. They have also expressed concern that the nurses lacked empathy; respect for
human dignity and nurses were not listening to patients. The author stated that this
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unacceptable behaviour of practicing nurses was due to their working conditions
including shortage of personnel. In such a situation one nurse should handle a large
number of patients in the hospital (Kunene et al., 2001). A study from Greece reported
that the nurses perceived that the image of nursing profession would be affected by the
shortage of staff and also due to inadequate funding by the state (Bakalis et al., 2015). In
a study done among nursing students in United States of America, they perceived that
nursing shortage will create stress and increase job burden among the existing nurses and
this may adversely affect the quality of patient care. On the other hand, most of the
students reported that the nursing shortage will lead to higher job opportunities and higher
pay (Buerhaus et al., 2005).
1.2.3.3 Economic security
A study from Ethiopia revealed that when monthly income level of nurses increases, it
will positively influence their perceptions of nurses towards the nursing profession
(Getu et al., 2015). A study conducted in UK among nursing students reported that many
of them experienced financial hardship. The students felt that nursing profession required
knowledge and skills to provide high quality care but even after that they were extremely
underpaid compared to other service providers with similar or lower educational
qualifications (Brodie et al., 2004).
1.2.3.4Experience and educational level
A Saudi Arabian study reported that most of the nursing students had positive attitude
towards the nursing profession .The students of younger age were having negative
attitude as compared to that of older age (Miligi et al., 2014). In contrast to this, a study
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done in Southern Turkey among working nurses reported that older nurses and nurses
having more experience have more positive attitude towards nursing profession than
younger nurses and nurses with less experience. This study also identified that nurses
with higher education level have more positive attitude towards nursing profession than
those with lower level of education (Coban et al., 2015). A Canadian study among first
and fourth year nursing students reported that the fourth year students considered nursing
as an important yet undervalued profession much more than their first year counterparts.
The students’ perceptions about nursing were negatively affected by their clinical
experiences (Grainger and Bolan, 2006).
1.2.3.5 Clinical environment
A study conducted in UK among nursing students reported that many experienced nursing
practice as stressful due to the physical hard work, discordance between theory and
practice and due to poor working conditions. They also perceived that the sense of being
undervalued, staff shortage, lack of sufficient equipment in the clinical settings and heavy
work load made the profession stressful (Brodie et al., 2004). A study from Ghana
among practicing nurses reported that according to their perspectives, the nursing students
showed respect towards the patient and they were ready to interact with the medical staff
and they were committed to their clinical work. The attitude of the students towards
clinical work worsened with advancement in the academic levels. Anxiety is one of the
key factors that led to poor attitude. Majority of the nurses perceived that they do not
have positive interaction with those students who had poorer attitude towards patient care
(Peasah et al., 2013).
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1.2.4Future intentions
A longitudinal study from Australia reported that many students were not having any
predetermined career choices while joining in nursing courses. The student peers, new
graduates, academic staff, registered nurses and service users influenced their career
choices. The career preferences were also influenced by their theoretical and clinical
experiences during their educational programme (McCann et al., 2010).
1.2.4.1Bed side nursing
A study from Jordan found that after graduation, majority of the nursing students wished
to opt bedside nursing. The students wished to choose bedside nursing for economic
security (Jarrah, 2013). As per a study done in Taiwan, majority of nursing students were
interested in choosing nursing as a career after their graduation. There was a positive
relationship between the self-perceived clinical ability among the nursing students and
their choice of remaining in the nursing profession. The positive effect was evident in
case of students with past exposure to nursing and their choice of nursing career
(Lai et al., 2005). According to another study from Taiwan the nursing students would
decide to become nurses if they could recognize their nursing competence through their
clinical practicum. The unsatisfactory nursing working environment, work over load,
stress will influence them in deciding to opt out of nursing (Tseng et al., 2013). A cohort
study from Taiwan among pre-registered student nurses reported that the support from the
staff nurse has positively influenced the students’ career preference to stay in the nursing
profession (Lai et al., 2008). A study from UK among nursing students reported that the
negative perceptions towards the nursing which arose due to factors such as dysfunctional
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team interactions discouraged the nursing students to stay in the nursing profession
(Brodie et al., 2012).
1.2.4.2Teaching
A study done in Jordan reported that after graduation, majority of the nursing students
wished to opt teaching and bedside nursing. The students desire to choose teaching
profession because it provides autonomy at their work, job satisfaction, better salary and
professional recognition (Jarrah, 2013). Similar findings was reported by the study from
Andhra Pradesh and Punjab in India that majority of them were interested in joining
teaching positions to avoid the image of a bed side nurse (Swarna, 2015) (Patidar et al.,
2011).
1.2.4.3 Migration
A study from Ethiopia among nurses revealed that most of them wished to migrate for
better career prospects (Getu et al., 2015). A study from South Africa among medical and
nursing students revealed that the proportion of nursing students who were interested to
emigrate within two years after graduation were more than the proportion of medical
students .Poor working conditions and the risk of occupational hazards associated with
HIV, TB were the main factors which forced them to opt emigration
(George and Reardon, 2012). A study from Punjab among outgoing general nursing, BSc
nursing and post basic nursing students showed that most of them expressed their interest
to migrate for better quality of life (Patidar et al., 2011). Desire to migrate was also
reported in a study from Andhra Pradesh. (Swarna, 2015).
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1.2.4.4Higher education in nursing
A study from Norway among first year nursing students reported that they perceived the
Bachelor degree in nursing as a basic qualification for further education and they wanted
to specialise in various nursing specialities. Further they stated that they ―did not want to
be an ordinary nurse ―that means they don’t want to work as a nurse by just washing and
feeding the patients (Rognstad et al., 2004). A study from Andhra Pradesh among the
final year nursing students reported that most of the students were interested to pursue
their higher education in nursing (Swarna, 2015).
1.2.4.5Change of profession
A study from Ethiopia among nurses revealed that more than half of the nurses had plan
to change their profession and the major factors that contributed for change were the low
salary followed by the work load and other administrative problems (Getu et al., 2015). A
study from Andhra Pradesh among the final year nursing students reported that lack of
autonomy in the working area might be one of the contributing factors for the desire to
change the profession (Swarna, 2015).
1.3Rationale of the study
Nursing profession is a career with so many opportunities. It promotes economic security
and due to these factors, more and more people are choosing nursing education after their
school level. Thus there is a rising trend in the number of nursing colleges in Kerala.
Whether the increased demand for nursing education exists only due to its financial
security or whether the students are interested in the career is still in question.
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Whether the motivational factor for pursuing nursing education influences the nurses’
intention to leave the profession in Kerala are not known. Nursing education consists of
theoretical education and clinical education. Clinical education plays an important role in
improving the competency of the nursing students and helps the nursing students to
develop into a fully skilled nurse but there are evidences from various studies indicating
gap between the theoretical learning and clinical practice in nursing education (Last and
Fulbrook, 2003; Nasrin et al., 2012; Patidar et al., 2011). The effect of commercialisation
of nursing education on its quality is unknown. To my knowledge, no studies are found to
be done in India to identify the nurses’ perception of quality of nursing education
training.
1.4 Objectives
1.4.1 Major objectives
To study the perceptions of nursing graduates about the quality of their
undergraduate nursing education and training.
1.4.2 Minor objectives
To determine the views of nursing graduates on nursing profession in terms of
professional identity, self-image and social position.
To identify the motivational factors among nursing graduates for pursuing nursing
education.
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Chapter Two
Methodology
2.1Study design
This was a crossectional study design.
2.2Study setting
The study was conducted in selected four administrative areas in Thiruvananthapuram
district.
2.3Study population
1 Target population
This study aimed to generalise the study findings to all nursing graduates who have
pursued nursing education from various nursing colleges in Kerala and are residing in
Thiruvananthapuram district.
2 Source population
The nursing graduates, who have pursued their nursing education from nursing colleges
in Kerala, registered in Kerala Nurses and Midwives Council (KNMC) from 2013-2015
and have residential address in Thiruvananthapuram district.
3 Study population
The nursing graduates who have pursued their nursing education from nursing colleges in
Kerala, who have registered in KNMC from 2013-2015 and were residing in the selected
administrative areas of the Thiruvananthapuram district.
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2.4 Sample size estimation
The sample size was calculated using Open Epi version 3.03a. The total number of
nursing graduates who were registered in the Kerala Nurses and Midwives Council during
2013-2015 and who were residing in Thiruvananthapuram district were about 1200. The
sample size was calculated using an anticipated percentage of dissatisfaction among the
nursing students concerning the method of theoretical education and method of clinical
education as 41.7% with 95 per cent confidence interval and design effect as 1 which was
obtained from a university based study conducted in Iran (Hakim, 2015). The sample size
was estimated to be 286. Assuming a 20% nonresponse rate, the estimated sample size
was 343. This was rounded off to 350.
Justification: sample size was calculated based on the percentage of dissatisfaction
concerning the nursing education among the nursing students in a university based study
in Iran.
2.5 Sample selection procedures
The required sample size was obtained by multi stage random sampling method. The list
and contact details of nursing graduates who have completed Bachelors of science in
nursing from different nursing colleges in Kerala ,and have registered in KNMC
during 2013-2015 was obtained. From that, graduates having residential address in
Thiruvananthapuram district were generated. In Thiruvananthapuram district, there are six
revenue divisions called Taluks. From that, four taluks (Thiruvananthapuram,
Chirayinkeezhu, Varkala and Nedumangad) were randomly selected. The nursing
graduates with residential address in these respective revenue taluks were further listed.
There were about a total of 714 nursing graduates in these taluks. The list consisted of
228, 208, 146 and 132 nursing graduates from Thiruvananthapuram, Chirayinkeezhu,
Varkala and Nedumangad taluk respectively. Among that, 112, 102, 72 and 65 nursing
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graduates were randomly selected from Thiruvananthapuram, Chirayinkeezhu, Varkala
and Nedumangad taluks proportional to the number of nursing graduates present in each
of the thaluk. The questionnaires were distributed to the graduates as per their personal
convenience after obtaining the written informed consent.
2.6 Selection criteria
Inclusion criteria
All nursing graduates residing in the selected administrative areas of
Thiruvananthapuram district and graduated from any nursing college in Kerala
and have registered in KNMC during the years 2013, 2014, 2015.
Nursing graduates who have consented to participate in the study.
Exclusion criteria
The nursing graduates in Thiruvananthapuram district registered in KNMC during
the years 2013, 2014 and 2015 and have graduated before 2013.
The nursing graduates who were presently not residing in the selected
administrative areas of Thiruvananthapuram district.
2.7 Study variables and related definitions
Nursing graduate is operationally defined as the graduate who has pursued four years of
degree in nursing (BSc. Nursing) from different nursing colleges in Kerala, and have
registered in Kerala Nurses And Midwives Council.
2.7.1 Outcome variables
Motivational factors for pursuing nursing education: The factors that
motivated the graduate to pursue nursing education. This is a categorical variable.
The responses were classified into three categories; self interest in nursing,
motivated by others and increased career opportunities.
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Perceptions regarding quality of nursing education and training:
The way in which the nursing graduates interpreted the standards or quality of the
nursing education and training in terms of characteristics of instructors,
characteristics of infrastructure, characteristics of clinical education and
characteristics of overall nursing education programme offered by the institution
where they graduated.
Views on nursing profession in terms of professional identity, self-image and
social position
Professional identity:
Professional identity is nurses’ concept of nursing and functioning as a nurse
(Fagermoen, 1997). Data on professional identity were collected using three
categorical variables. They were nursing profession as an opportunity for serving
humanity, source of economic security and comparability of nursing profession
with other professions. The responses were classified into two categories, yes and
no.
Self-image:
The way in which nurses perceive themselves in their working environment
(Cowin, 2001). Data on self-image were collected using a categorical variable. It
was nursing profession as a dignified and respectful profession. The response was
classified into two categories, yes and no.
Social position:
The social position of nurses describes the nurses’ place in social hierarchy.
Data on social position were collected using two categorical variables. They were
recognition of nursing profession in society and its opportunity for better marriage
offers. The responses were classified into two categories, yes and no.
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Future career choices: The career path of the nursing graduates in the future.
Data were collected using five categorical variables. They were continue nursing
profession in India, plan to go abroad, Post-graduation in nursing, teaching
positions, and plan to change the profession. Responses of each of the categorical
variables were as above.
2.7.2 Predictor variables
Socio-demographic characteristics
Age: Age of the respondents in completed years at the time of data collection.
Sex: Sex was reported by the respondents under two categories male or female.
Place of residence: Data were collected as categorical variable under the two
categories rural and urban area.
Religion: Data were collected as categorical variable under three categories;
Hindu, Muslim, Christian.
Marital status: Data were collected as a categorical variable under two
categories; married and unmarried.
Current designation: Data were collected as categorical variable. Responses
were later categorised as Staff nurse and others.
Ever worked as a staff nurse: The data were collected as categorical variable
only from those who were currently not working as a staff nurse. Responses were
categorised as yes and no.
Duration of work: Data were collected as categorical variable. Responses were
categorised into nil, less than one year, 1-2 years, more than 2 years.
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Current monthly income: Data were collected as categorical variable. The
responses were later categorised into less than or equal to 25000 and more than
25000.
Type of the institution: The institution from where nursing education was
pursued by the nursing graduates. The data were collected as a categorical variable
under three categories; government, private and cooperative colleges.
Source of financing nursing education: The source of money by which the
nursing graduate paid the nursing education he or she received. Data were
collected as categorical variable under the categories; parental income,
scholarships, educational loan.
2.8 Data collection techniques and tools
The data were collected using structured self-administered questionnaire in English
developed by the principal investigator based on the literature review to capture the
following
Basic characteristics of the respondents which included socio demographic
characteristics, the institution where they have studied and their source of
financing nursing education.
Motivators for pursuing nursing education.
Perceptions about the quality of their undergraduate nursing education and
training in domains such as instructors’ characteristics, infrastructure
characteristics, clinical education and overall nursing education program.
Views of nursing graduates on nursing profession in terms of professional
identity, self-image and social position.
Future career choices of the graduates.
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2.9 Data collection procedures
Data collection was carried out during the period June 10th
to August 31st 2016.Principal
investigator firstly contacted the participants through phone and obtained verbal consent
for participating in the study. Then informed consent form was distributed to the
participants personally according to their convenience. The structured questionnaire in
English was distributed to the participants after obtaining the informed consent and the
questionnaire were collected back according to the convenience of the participants.
Fig 2.9: Gantt chart for dissertation activity
2.10 Ethical considerations
2.10.1Clearance
The study protocol was approved by Institutional Ethics Committee (No:
SCT/IEC/910/MAY-2016) of Sree ChitraTirunal Institute for Medical Sciences and
Technology, Trivandrum (Annexure I).
2.10.2 Confidentiality
The name of the participants was not collected during the study. Each participant was
given a unique identification number. The identities of the participants were kept
anonymous. The identity and the responses given by participants will not be disclosed to
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anyone under any circumstances at anywhere. All the copies of filled questionnaire and
consent form will be kept under the custody of principal investigator and will be
destroyed when they are no longer needed.
2.10.3 Consent
Written informed consent was obtained from the participants before administering
questionnaire. The participants had the freedom to refuse at any stage of the study
The data collected will be used for research purpose only.
2.10.4 Beneficence
There was no direct benefit for the participants by participating in the study, but it is
possible that the findings of the study will enhance scientific knowledge and may enable
to develop policies related to improve nursing education.
2.10.5 Risks
There was no harm or risk to health of the participants by participating in this study.
2.11 Data analysis
The data collected were coded .Completed questionnaires were sorted out entered and
cleaned using SPSS for windows version 21.Cross validation and consistency check was
done.
The p value of <0.05 was considered as significant with 95 % confidence interval.
Univariate analysis
It was done for all variables for assessing the measures of central tendency, frequency and
proportions in the sample.
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Bivariate analysis
It was done by cross tabulation of various categorical variables with the outcome
variables using Pearson chi-square test to find out significant associations between
predictor variables and outcome variables. The p value less than 0.05 were considered
statistically significant.
2.12 Dissemination of results
The findings of this study would be disseminated through publication of papers in
research journals.
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Chapter Three
Results
The study was conducted among 334 nursing graduates, who were residing in randomly
selected four administrative areas of the Thiruvananthapuram district. The non-response
rate was 4.6%, which was less than anticipated non response rate of 20%.This chapter
describes the findings of the study. The present chapter has sections based on the
objectives. First section is on the characteristics of the respondents that includes basic
characteristics such as the type of institution where the graduate has pursued his or her
nursing education, socio-demographic characteristics of the respondents, source of
financing for nursing education and motivational factors that made them to pursue
nursing education, perceptions on quality of nursing education and training, views on
nursing profession in terms of professional identity, self-image and social position and
future career choices. The second section is presenting the bivariate analysis on outcome
variables and various characteristics of the respondents.
Univariate analysis
Characteristics of the respondents
This section is further divided into four. The first section describes the type of the
institution from where they pursued their nursing education. The second section describes
the socio-demographic characteristics of the respondents. The third section describes the
graduates’ source of financing for nursing education and the fourth section describes the
motivational factors for pursuing nursing education
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3.1 Basic characteristics of the respondents
3.1.1 Type of the institution where nursing education was pursued
Nearly half of the graduates have pursued their nursing education from private nursing
colleges in Kerala (47%).The proportion of respondents graduated from government and
cooperative nursing colleges were 34.1 % and 18.9 % respectively.
3.1.2 Socio-demographic characteristics
Table 3.1.2 presents the socio-demographic characteristics of the respondents. The age of
the respondents ranged from 22 to 29 tears, with a mean age of 24.79±1.69 years. Among
the respondents 17.7% were males, 63.2% were from rural areas, 70.4% were currently
unmarried and 58.7% were Hindus. More than half of the graduates were working
currently as staff nurse (58.4%). Among those who were not working currently as a staff
nurse, 10.1 % had never worked as a staff nurse. Among those who were+ currently
working as a staff nurse or others who had ever worked as a staff nurse, more than half of
them worked as staff nurse for one to two years (51.6%).Almost 82.9% of the
respondents received a monthly income less than or equal to 25000 rupees.
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Table 3.1.2: Socio-demographic characteristics of the respondents (N=334)
Variables Total Government
(114)
Private
(157)
Cooperative
(63)
n (%)
Age
Mean Age 24.79±1.69* 25.06±1.766* 24.93±1.54* 23.94±1.67*
Range 22-29 22-28 22-29 22-29
Sex
Female 275 (82.3) 96 (34.9) 127 (46.9) 52 (18.9)
Male 59 (17.7) 18 (30.5) 30 (50.8) 11 (18.6)
Place of residence
Rural 211(63.2) 75 (35.5) 92 (43.6) 44 (20.9)
Urban 123(36.8) 39 (31.7) 65 (52.8) 19 (15.4)
Marital status
Married 99(29.6) 32 (32.3) 48 (48.5) 19 (19.2)
Single 235(70.4) 82 (34.9) 109 (46.4) 44 (18.7)
Religion
Hindu 196 (58.7) 59 (30.1) 93 (47.4) 44 (22.4)
Muslim 44(13.2) 17 (38.6) 18 (40.9) 9 (20.5)
Christian 94(28.1) 38 (40.4) 46 (48.9) 10 (10.6)
Current
designation
Staff nurse 195(58.4) 75 (38.5) 76 (39.0) 44 (22.6)
Others** 139(41.6) 39 (28.1) 81 (58.3) 19 (13.7)
Ever worked as a
staff nurse(N=139)
Yes 125(89.9) 38 (30.4) 73 (58.4) 14 (11.2)
No 14(10.1) 1 (7.1) 8 (57.1) 5 (35.7)
Duration
of work (N=320)
Less than one year 87(27.2) 35 (40.2) 33(37.2) 19 (21.8)
1-2 years 165(51.6) 51 (30.9) 84 (50.9) 30 (18.2)
More than
2 years
68(21.3) 27 (39.7) 32 (47.1) 9 (13.2)
Monthly income
<=25000 277 (82.9) 87 (31.4) 137 (49.5) 53 (19.1)
>25000 57 (17.1) 27 (47.4) 20 (35.1) 10 (17.5)
*mean age and standard deviation, **others include student in nursing speciality, student
in other fields, working in other fields, not engaged in any job
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3.1.3Source of financing nursing education
Figure 3.1.3show that the parental support was the source of financing for nursing
education for more than half of the respondents(53.6%).Educational loan was the source
of financing nursing education for about 36.8 % of the nursing graduates.
Fig 3.1.3: Source of financing for nursing education
* Number of respondents=334
3.2 Motivational factors for pursuing nursing education
Table 3.2 shows that self-interest in nursing was reported as the motivational factor for
pursuing nursing education for 44.3 % of the graduates. The proportion of graduates who
were motivated by self interest in nursing was higher among those who pursued nursing
education form private institutions compared to their counterparts.
53.6 %
9.6 %
36.8 %
0
30
60
90
120
150
180
210
240
270
300
330
360
Parental income Scholarship Educational loan
Number of respondents
Source of financing nursing education
Parental income
Scholarship
Educational loan
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Table3.2: Motivational factors for pursuing nursing education (N=334)
Total Government Private Cooperative
Motivational factors n (%) n (%) n (%) n (%)
Self interest in nursing 148 (44.3) 45 (30.4) 74 (50) 29 (19.6)
Motivated by others 90 (26.9) 38 (42.2) 39 (43.3) 13 (14.4)
Increased
31 (32.3)
44 (45.8)
21 (21.9) career opportunities 96 (28.7)
3.3Perceptions regarding quality of undergraduate nursing education
and training
All the graduates responded that their college was affiliated to Indian Nursing Council.
The perceptions of nursing graduates about their undergraduate nursing education and
training was studied under four domains .They are perceived instructors’ characteristics,
infrastructure characteristics, characteristics of the clinical education they have received
and the characteristics of their overall nursing education programme.
3.3.1 Perceived characteristics of the instructors
Instructors’ characteristics included the rating of the teaching abilities of their instructors
according to nursing graduates, reasons for rating poor, MSc nursing adequacy and the
areas where teachers need improvement.
Table 3.3.1 shows the perceived characteristics about the instructors. Only half of the
respondents rated the teaching abilities of their instructors as good. . Inadequate MSc
nursing faculty were reported by 15.6 % of the respondents. Majority of them (74%)
perceived that the instructors’ ability to enhance theory to practice has to be improved.
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Less than half of the respondents reported that the instructors’ ability to facilitate students
to provide nursing care based on nursing process (Nurses uses a scientific method to
ensure the quality of patient care which includes six phases. They are assessment,
diagnosis, objective, planning, implementation and evaluation) and their doubt
clarification skills to be improved. Only few of them reported that the ability to promote
clinical skills of the students, extracurricular activities and the interaction with the
students needs to be improved.
Table 3.3.1: Perceived characteristics about the instructors (N=334)
Variables n (%)
Rating teaching abilities of the teachers
Good 167 (50)
Fair 114(34.1)
Poor 53 (15.9)
MSc nursing adequacy
Adequate 282 (84.4)
Inadequate 52 (15.6)
Areas where teachers need improvement**
Doubt clarification skills 92 (27.5)
Ability to enhance theory to practice 247 (74)
Nursing care based on nursing process 157 (47)
Promote extracurricular activities 21 (6.3)
Interaction with the students 32 (9.6)
Promote clinical skills 13 (3.9)
*Adequate means at least one MSc nursing faculty is present to teach each of the nursing
specialities, Inadequate means if at least one MSc nursing faculty is not present to teach
in any one of these nursing specialities.
**Multiple responses are recorded.
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Fig 3.3.1describes the perceived reasons for rating the instructors as poor , Among those
graduates who rated the teaching abilities as poor, majority of them mentioned poor
practical orientation of instructors (includes lack of supervision by the teachers in the
clinics, lack of their ability to correlate theory to practice) as the reason for rating poor
(66%). Poor interpersonal relationship (lack of autonomy to the students and the rude
behaviour of the teachers towards students) was mentioned as the reason by more than
one third of the respondents (39.6%). Inadequate training acquired by the instructors
(most of the teaching faculties were not postgraduates, teachers were not able to organise
or conduct seminars and conferences related to the academics) was reported as the reason
by 17% of the respondents.
Fig3.3.1: Perceived reasons for rating the instructors as poor
* Number of respondents=53, ** Multiple responses recorded
39.6 %
66 %
17 %
0
10
20
30
40
50
60
Poor
interpersonal
relation
Non
practically
oriented
Inadequate
training
Number of
respondents
Poor interpersonal
relation
Non practically oriented
Inadequate training
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3.3.2Perceived characteristics of the infrastructure
The perceptions of nursing graduates about the infrastructure of the institution where they
graduated include the rating of infrastructure of their parent institution, reasons for rating
it as poor and the areas where infrastructure require improvement.
Table 3.3.2 shows the perceived characteristics about the infrastructure of the parent
institution. The infrastructure of the institution was rated as good by more than half of the
respondents (56.9%). Nearly half of the graduates reported the preclinical lab training
should be improved (44.3%). About 41.9% of the graduates mentioned that computer
facilities in the college need improvement. Improvement in equipment’s and facilities for
preclinical lab training, library facilities, LCD projector and OHP facilities and
improvement in classrooms were reported by less than half of the respondents.
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Table 3.3.2: Perceived characteristics about the infrastructure of the parent
institution (N=334)
Variables n (%)
Rating infrastructure of the parent institution
Good 190 (56.9)
Fair 108 (32.3)
Poor 36 (10.8)
Areas where
infrastructure need improvement**
Good spacious classrooms 36 (10.8)
LCD projector and OHP facilities 52 (15.6)
Computer facilities 140 (41.9)
Adequate updated library 86 (25.7)
Equipment’s and facilities in preclinical lab 109 (32.6)
Adequacy of preclinical lab training 148 (44.3)
Others* 7 (2.1)
*Others include facilities for extracurricular activities, facilities in the parent hospital,
hostel facilities and transportation facilities. **Multiple responses recorded
Fig 3.3.2 ; depicts the perceived reasons for rating infrastructure of the parent institution
as poor, Among those who rated it as poor, majority mentioned college related factors
(lack of proper college campus, poor facilities for extracurricular activities, poor
transportation facilities, lack of separate nursing college, lack of proper auditorium and
lack of adequate toilet facilities)as the reason (80.6%). Classroom related factors (include
lack of proper ventilation in the classroom, inadequate AV aids, and inadequate number
of classrooms) and hospital related factors (lack of parent hospital for the institution,
poor facilities in the parent hospital) were mentioned as the reason for rating poor by less
than half of them.
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Fig 3.3.2: Perceived reasons for rating infrastructure of the parent institution as
poor
*Number of respondents=36. **Multiple responses recorded
3.3.3 Perceived characteristics on clinical education
The perceptions of nursing graduates about the clinical education were studied under two
domains. They were the perceived characteristics of the clinical exposure they had and
the clinical training they had received during their nursing education. The characteristics
of clinical exposure included the rating of the clinical exposure they had (Whether they
were able to see adequate number of diverse cases during their clinical postings) and the
reasons for perceiving clinical exposure as inadequate according to them. The clinical
training characteristics include the rating of clinical training they had received, reasons
for rating clinical training as poor and the areas where clinical training required
improvement.
80.6 %
22.2 % 19.4 %
0.00
4.00
8.00
12.00
16.00
20.00
24.00
28.00
32.00
36.00
College relatedfactors
Classroomrelated factors
Hospitalrelated factors
Number of respondents
Reasons for rating infrastructure poor
College related factors
Classroom related factors
Hospital related factors
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39
Table 3.3.3 shows the perceived characteristics of the clinical education. About 37.7% of
the nursing graduates did not witness adequate number of diverse clinical cases during
their clinical postings while pursuing nursing education.
Table 3.3.3: Perceived characteristics of clinical education (N=334)
Variable n (%)
Rating of clinical exposure they had during their under graduation
Adequate 208 (62.3)
Inadequate 126 (37.7)
Rating clinical training they had received
Good 113 (33.8)
Fair 112 (33.5)
Poor 109 (32.6)
Areas where clinical training need improvement*
Equal emphasis on theory and clinics 169 (50.6)
Sufficient opportunities 165 (49.4)
Support from hospital staff 196 (58.7)
Favourable attitude from hospital staff 198 (59.3)
*Multiple responses recorded
Fig3.3.3: depicts the perceived reasons for inadequate clinical exposure. Among those
who didn’t perceived adequate clinical exposure, non multispecialised parent hospital was
reported as the reason for perceiving inadequate clinical exposure by more than half of
them (54.3%). The other reasons mentioned were lack of sufficient patients in the hospital
where they received the training, inadequate number of diverse cases and inadequate
exposure to emergency cases or complicated disease conditions.
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Fig 3.3.3.1: Perceived reasons for rating clinical exposure as inadequate
*Number of respondents=126, **Multiple responses recorded
The table 3.3.3 also describes that clinical training received were rated as good by only
33.8 % of the nursing graduates. More than half of the respondents reported they needed
improvement in the attitude of senior nursing faculty towards them (59.3%) and support
from the hospital staff (58.7%).About half of them felt that equal emphasis should be
given to theory and practice. Improvement in sufficient opportunities for practice in real
situations was reported by nearly half of the graduates (49.6%).
Fig 3.3.3.2 describes that among the graduates who rated clinical training as poor, more
than two third of the respondents mentioned minimum opportunities (lack of own hospital
for the institution, lack of sufficient patients, hospital rule didn’t allow the students to do
advanced nursing procedures on the patients, lack of training to handle emergency
54.3 %
18.9 % 14.2 %
18.9
0
20
40
60
80
100
120
140
Nonmultispeciality
parenthospital
Inadequatenumber ofeach case
Inadequateemergency
casesexposure
Insufficientpatients in
parenthospital
Number of
respondents
Non multispeciality parent hospital
Inadequate number of each case
Inadequate emergency cases exposure
Insufficient patients in parent hospital
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41
situations and to work independently) as the reason (83.5%). Instructors’ related factors
(lack of proper supervision in the clinics, not efficiently enabling the students to provide
nursing care based on nursing process) were reported as the reason by 14.7% of them.
Stressful clinics (lack of support from the hospital staff, rude behaviour of instructors
towards students in front of the patients, overloaded assignments, and standing for many
hours during the clinical posting periods) were mentioned as the reason by16.7% of them.
Fig 3.3.3.2: Perceived reasons for rating clinical training as poor
*Number of respondents= 109, **Multiples responses recorded
3.3.4Perceivedcharacteristics of the overall nursing education programme
The perceptions of nursing graduates about the overall nursing education programme
were collected. It included the rating of the overall nursing education .It included whether
the overall nursing education programme they have received helped them to become an
independent competent nursing professional and reasons for perceiving inadequate. The
overall nursing education was perceived as adequate (helped them to become a
competent, independent nursing professional) by 62.9% of the respondents and rest of
14.7 %
83.5 %
16.5 %
0
20
40
60
80
100
120
140
Instructor
related
factors
Minimum
opportnities
Stressful
clinics
Number of
respondents
Instructor related factors
Minimum opportnities
Stressful clinics
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42
them felt it as inadequate (37.1 %).
Fig3.3.4: describes the perceived reasons for inadequate overall nursing education
programme. Among those who perceived the overall nursing education as inadequate,
minimum opportunities for practice was mentioned as the reason by most of them
(65.3%).Lack of training to practice independently was reported as the reason by 29% of
them, lack of correlation between theory and practice was mentioned by 11.3% of them
and factors related to instructors (such as lack of proper supervision) was reported by
6.5% of them.
Fig 3.3.4: Perceived reasons for inadequate overall nursing education programme
*Number of respondents: 124, ** Multiple responses recorded
29 %
65.3 %
6.5 % 11.3
0
20
40
60
80
100
120
140
Non independent
training
Minimum
opportunities
Instructors'
related factors
Theory-practice
gap
Number of respondents
Non independent training
Minimum opportunities
Instructors' related factors
Theory-practice gap
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3.4 Views on nursing profession
The views on nursing profession were studied in three terms .They were professional
identity, self-image and social position. Table 4.4 shows the nursing graduates’ views on
nursing profession in terms of professional identity, self-image and social position
3.4.1 Professional identity
Most of the graduates perceived nursing profession as an opportunity to serve humanity
(96.4%) Nursing profession was also perceived as a source of economic security by more
than half of the graduates (58.4%). On the other hand, only one third of them perceived it
as comparable with other professions (32.9 %).
3.4.2 Self-image
The nursing profession was perceived as a dignified and respectful profession by more
than half of the nursing graduates (58.7 %).
3.4.3 Social position
The nursing profession was perceived as a way to get recognition in society by 44% of
the graduates. About 78.1% of the graduates did not perceive it as an opportunity for
better marriage offers.
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Table 3.4: Views about nursing profession * (N=334)
Variables n (%)
Professional identity
Opportunity to serve humanity(N=332) 320(96.4)
Source of economic security 195 (58.4)
Comparable with other professions 110 (32.9)
Self-image
A dignified and respectful profession 196 (58.7)
Social position
A way to get recognition in society 147 (44)
An opportunity for better marriage offers 73 (21.9)
*Multiple responses recorded
3.5 Future career choices
The future aspirations of the nursing graduates were collected and are discussed below.
Table 3.5shows the future career choices of the nursing graduates. More than half of them
have reported that they would like to go abroad (54.8%).Teaching positions as a career
choice was reported by half of the nursing graduates. Less than half of them would like to
continue nursing profession in India (47.6%) and do post-graduation in nursing
(44.6%).Only 25.1 % of the respondents wanted to change the profession.
Table 3.5: Future career choices * (N=334)
Variables n (%)
Continue nursing profession in India 159 (47.6)
Plan to go abroad 183 (54.8)
Post-graduation in nursing 149 (44.6)
Teaching positions 167 (50)
Plan to change the profession 84 (25.1)
*Multiple responses recorded
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Bivariate analysis
The following section includes the bivariate analysis (using Pearson chi square test)
between main outcome variables and selected characteristics of the nursing graduates.
The two tailed p value less than 0.05 were considered statistically significant and the p
value less than 0.001 were considered highly significant.
3.6 Association between the type of institution from where they graduated and the
rating of teaching abilities of their instructors.
Table 3.6 describes the association between the type of the institution from where
respondents graduated and rating of instructors according to the graduates. Instructors’
rating did not seem to vary according to the type of the institution where nursing
education was pursued.
Table 3.6: Association between type of the institution where they graduated and
instructors’ rating by the nursing graduates
Instructors' rating of the parent
institution
Type
Good Fair Poor Total p value of
the institution
Government 58 (50.9) 42 (36.8) 14 (12.3) 114 (100) 0.586
Private 78 (49.7) 49 (31.2) 30 (19.1) 157 (100)
Cooperative 31 (49.2) 23 (36.5) 9 (14.3) 63 (100)
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3.7 Association between the type of the institution where they graduated and the
rating of infrastructure of the institution
Table 3.7 describes the association between the type of institution from where nursing
education was pursued and the infrastructure rating of the institution .Proportion of
graduates who rated infrastructure as good was lowest among those pursued their nursing
education from government colleges compared to others. The type of the institution
where the graduates have pursued nursing education was found to be significantly
associated with the rating of infrastructure of the institution where they graduated.
Table 3.7: Association between type of the institution and infrastructure rating by
the nursing graduates
Infrastructure rating of the parent
institution
Type of
the institution Good Fair Poor Total p value
Government 46 (40.4) 55 (48.2) 13 (11.4) 114 (100) <0.001**
Private 102 (65.0) 34 (21.7) 21 (13.4) 157 (100)
Cooperative 42 (66.7) 19 (30.2) 2 (3.2) 63 (100)
**Highly significant
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47
3.8 Association between the type of institution where they graduated and the rating
of clinical exposure they had during their under graduation.
Table 3.8 depicts the association between the type of the institution where the graduates
have pursued their nursing education and the clinical exposure rating by them. The
proportion of nursing graduates who perceived adequate clinical exposure during their
nursing education was higher among those who pursued nursing education from
government nursing colleges compared to others. The type of the institution from where
nursing education was pursued was found to be significantly associated with clinical
exposure rating by the graduates.
Table3.8: Association between type of the institution and clinical exposure rating
Clinical exposure rating of the
parent institution
Type Adequate Inadequate Total p value
of the institution
Government 113 (99.1) 1 (0.9) 114 (100) <0.001*
Private 63 (40.1) 94 (59.9) 157 (100)
Cooperative 32 (50.8) 31(49.2) 63 (100)
*Highly significant
3.9 Association between the type of institution where they graduated and the rating
of the clinical training they have received.
Table 3.9 describes the association between the type of the institution from where the
graduates pursued their nursing education and the rating of clinical training they have
received. The proportion of nursing graduates who rated clinical training as good were
higher among those who have graduated from government nursing colleges compared to
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48
others. The type of the institution from where they graduated was found to be
significantly associated with the rating of clinical training by the nursing graduates.
Table 3.9: Association between type of the institution and clinical training rating
Clinical training rating of the parent
institution
Type
Good Fair Poor Total p value of
the institution
Government 78 (68.4) 32 (28.1) 4 (3.5) 114 (100) <0.001*
Private 25 (15.9) 47 (29.9) 85 (54.1) 157 (100)
Cooperative 10 (15.9) 33 (52.4) 20 (31.7) 63 (100)
*Highly significant
3.10 Association between the characteristics of the respondents, individual domains
on perceived quality of nursing education and the rating of the overall nursing
education.
Table 3.10 describes the association between the type of the institution where they
graduated, motivational factors for pursuing nursing education, individual domains on
perceived quality of nursing education and the rating of the overall nursing education they
have received. The proportion of nursing graduates who perceived adequate overall
nursing education was higher among those who graduated from government nursing
colleges compared to others. It was higher among those who were motivated by self
interest in nursing compared to their counterparts.
The proportion of graduates who perceived overall nursing education as adequate was
more among those who perceived instructors as good compared to others. The overall
nursing education did not seem to vary much with infrastructure rating. The proportion of
graduates who perceived overall nursing education as adequate was more among those
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49
who perceived clinical exposure as adequate and those who perceived clinical training as
good compared to others.
The type of the institution from where they graduated, rating of instructors, clinical
exposure and clinical training were found to be significantly associated with the rating of
the overall nursing education received by the graduates. On the other hand motivational
factors for pursuing nursing education and infrastructure rating were not found to be
associated with rating of the overall nursing education.
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Table3.10: Association between characteristics of the respondents, individual
domains on perceived quality of nursing education and the rating of the overall
nursing education.
Overall rating of nursing education
of the parent institution
Adequate Inadequate Total p value Variables
Type of the institution
Government 102 (89.5) 12 (10.5) 114 (100) <0.001**
Private 69 (43.9) 88 (56.1) 157 (100)
Cooperative 39 (61.9) 24 (38.1) 63 (100)
Motivational factors
Self interest in nursing 101 (68.2) 47 (31.8) 148 (100) 0.153
Motivated by others 55 (61.1) 35 (38.9) 90 (100)
Increased career opportunities 54 (56.3) 42 (43.8) 96 (100)
Individual domains on
quality of
nursing education
Instructors' rating
Good 118 (70.7) 49 (29.3) 167 (100) <0.001**
Fair 72 (63.2) 42 (36.8) 114 (100)
Poor 20 (37.7) 33 (62.3) 53 (100)
Infrastructure rating
Good 118 (62.1) 72 (37.9) 190 (100) 0.689
Fair 71 (65.7) 37 (34.3) 108 (100)
Poor 21 (58.3) 15 (41.7) 36 (100)
Clinical exposure rating
Adequate 182 (87.5) 26 (12.5) 208 (100) <0.001**
Inadequate 28 (22.2) 98 (77.8) 126 (100)
Clinical training rating
Good 108 (95.6) 5 (4.4) 113 (100)
Fair 93 (83.0) 19 (17.0) 112 (100)
Poor 9 (8.3) 100 (91.7) 109 (100) <0.001**
**Highly significant
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3.11 Association between characteristics of the nursing graduates and views on
nursing profession.
Professional identity
3.11.1. Opportunity to serve humanity
Almost all perceived nursing profession as an opportunity to serve the humanity (96.8%)
3.11.2 Association between characteristics of the respondents and view on nursing
profession as a source of economic security.
Table 3.11.2 describes the association between the socio-demographic characteristics,
type of institution where graduated , motivational factors for pursuing nursing education
and nursing graduates’ view on nursing profession as a source of economic security. The
graduates’ views about nursing profession as a source of economic security did not seem
to vary between males and females and the place of residence. The proportion of nursing
graduates who perceived nursing profession as a source of economic security was higher
among Christians compared to others. It was higher among married graduates compared
to unmarried. The proportion of nursing graduates who perceived nursing profession as a
source of economic security was higher among those who were currently working as staff
nurse compared to others. The graduates who were earning monthly income greater than
25000 rupees perceived nursing profession as a source of economic security higher than
the others.
The proportion of nursing graduates who perceived nursing profession as a source of
economic security was higher among those who had pursued nursing education from
government nursing colleges compared to others
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The view on nursing profession as a source of economic security did not seem to vary for
the motivational factors for pursuing nursing education.
The monthly income and type of the institution from where they graduated were found to
be significantly associated with the view about nursing profession as a source of
economic security. The sex of the graduates, place of residence, marital status, religion,
current designation and motivational factors for pursuing nursing education were not
found to be associated with the view about nursing profession as source of economic
security.
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53
Table 3.11.2.: Association between characteristics of the respondents and view on
nursing profession as a source of economic security
Nursing profession as a
source of economic security
Variables Yes No Total p value
Socio-demographic
characteristics Sex
Male 34 (57.6) 25 (42.4) 59 (100) 0.897
Female 161 (58.5) 114 (41.5) 275 (100)
Place of residence
Rural 125 (59.2) 86 (40.8) 211 (100) 0.677
Urban 70 (56.9) 53 (43.1) 123 (100)
Religion
Hindu 117 (59.7) 79 (40.3) 196 (100) 0.166
Muslim 20 (45.5) 24 (54.5) 44 (100)
Christian 58 (61.7) 36 (38.3) 94 (100)
Marital status
Married 64 (64.6) 35 (35.4) 99 (100) 0.132
Unmarried 131 (55.7) 104 (44.3) 235 (100)
Designation
Staff nurse 119 (61.0) 76 (39.0) 195 (100) 0.246
Others 76 (54.7) 63 (45.3) 139 (100)
Monthly income
≤25000 151 (54.5) 126 (45.5) 277 (100) 0.002*
>25000 44 (77.2) 13 (22.8) 57 (100)
Type of the institution
Government 79 (69.3) 35 (30.7) 114 (100) <0.001**
Private 74 (47.1) 83 (52.9) 157 (100)
Cooperative 42 (66.7) 21 (33.3) 63 (100)
Motivational factors
Self interest in nursing 87 (58.8) 61 (41.2) 148(100) 0.988
Motivated by others 52 (57.8) 38 (42.2) 90 (100)
Increased career opportunities 56 (58.3) 40 (41.7) 96 (100)
*p value <0.05 (statistically significant), **highly significant
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54
3.11.3 Association between characteristics of the respondents and view on nursing
profession as comparable with other professions.
Table 3.11.3 describes the association between the socio-demographic characteristics,
type of institution where graduated and motivational factors for pursuing nursing
education and the graduates’ view on nursing profession as comparable with other
professions. The proportion of graduates who perceived nursing profession comparable
with other professions was higher among females compared to males and it did not seem
to vary much with the place of residence, marital status and type of the institution where
they graduated. The proportion of graduates who perceived nursing profession not
comparable with other professions was higher among Muslims compared to others. It was
higher among those who were not currently working as staff nurses compared to its
counterpart and it was higher among those who earned monthly income less than or equal
to 25000 rupees compared to others.
The proportion of graduates who perceived nursing profession not comparable with other
professions was higher among those who were motivated by others compared to others
The place of residence, religion, marital status, type of the institution where graduated,
motivational factors for pursuing nursing education were not found to be associated with
the view on nursing profession as comparable with other professions, whereas sex of the
graduate, monthly income and current designation were found to be significantly
associated with the view on nursing profession as comparable with other professions.
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55
Table 3.11.3: Association between characteristics of the respondents and view on
nursing profession as comparable with other professions.
Nursing profession is
comparable with other
professions
Variables Yes No Total p value
Socio-demographic
Characteristics Sex
Male 12 (20.3) 47 (79.7) 59 (100) 0.023*
Female 98 (35.6) 177 (64.4) 275(100)
Place of residence
Rural 68 (32.2) 143 (67.8) 211 (100) 0.404
Urban 42 (34.1) 81 (65.9) 123 (100)
Religion
Hindu 66 (33.7) 130 (66.3) 196 (100) 0.871
Muslim 13 (29.5) 31 (70.5) 44 (100)
Christian 31 (33) 63 (67.0) 94 (100)
Marital status
Married 35 (35.4) 64 (64.6) 99 (100) 0.541
Unmarried 75 (31.9) 160 (68.1) 235 (100)
Designation
Staff nurse 49 (25.1) 146 (74.9) 195 (100) <0.001**
Others 61 (43.9) 78 (56.1) 139 (100)
Monthly income
≤25000 99 (35.7) 178 (64.3) 277 (100) 0.016*
>25000 11 (19.3) 46 (80.7) 57 (100)
Type of the institution
Government 38 (33.3) 76 (66.7) 114 (100) 0.987
Private 51 (32.5) 106 (67.5) 157 (100)
Cooperative 21 (33.3) 42 (66.7) 63 (100)
Motivational factors
Self interest in nursing 50 (33.8) 98 (66.2) 148 (100) 0.783
Motivated by others 27 (30) 63 (70.0) 90 (100)
Career opportunities 33 (34.4) 63 (65.6) 96 (100)
*p value <0.05 (statistically significant), **highly significant
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Self - image
3.11.4: Association between characteristics of the respondents and view on nursing
profession as a dignified and respectful profession
Table 3.11.4 describes the association between the socio-demographic characteristics,
type of institution from where they graduated, motivational factors for pursuing nursing
education and their view on nursing profession as a dignified and respectful profession.
The proportion of nursing graduates who perceived nursing profession as a dignified and
respectful profession was higher among females compared to that of males. It did not
seem to vary much with the place of residence and marital status. The proportion of
nursing graduates who perceived nursing profession as a dignified and respectful
profession was higher among Christians compared to others. It was higher among those
who were working as staff nurse compared to others. The proportion of nursing graduates
who viewed nursing profession as a dignified and respectful profession was higher among
those who were earning monthly income more than 25000 rupees compared to others.
The proportion of nursing graduates who perceived nursing profession as a dignified and
respectful profession was lower among those graduated from government institutions
compared to others. It was higher among those who were motivated by self interest in
nursing compared to others.
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The sex of the graduate, place of residence, religion, marital status, current designation,
monthly income and motivational factors were not found to be associated with the view
about nursing profession as a dignified and respectful profession. The type of the
institution from where they graduated was found to be significantly associated with their
view on nursing profession as a dignified and respectful profession.
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Table 3.11.4: Association between characteristics of the respondents and view on
nursing profession as a dignified and respectful profession
Nursing profession is dignified
and respectful profession
Variables Yes No Total p value
Socio-demographic
Characteristics Sex
Male 28 (47.5) 31 (52.5) 59 (100) 0.054
Female 168 (61.1) 107 (38.9) 275 (100)
Place
of residence
Rural 125 (59.2) 86 (40.8) 211 (100) 0.786
Urban 71 (57.7) 52 (42.3) 123 (100)
Religion
Hindu 108 (55.1) 88 (44.9) 196 (100) 0.092
Muslim 24 (54.5) 20 (45.5) 44 (100)
Christian 64 (68.1) 30 (31.9) 94 (100)
Marital status
Married 55 (55.6) 44 (44.4) 99 (100) 0.451
Unmarried 141 (60) 94 (40) 235 (100)
Designation
Staff nurse 118 (60.5) 77 (39.5) 195 (100) 0.421
Others 78 (56.1) 61 (43.9) 139 (100)
Monthly income
≤25000 161 (58.1) 116 (41.9) 277 (100) 0.647
>25000 35 (61.4) 22 (38.6) 57 (100)
Type of the institution
Government 55 (48.2) 59 (51.8) 114 (100) 0.005*
Private 95 (60.5) 62 (39.5) 157 (100)
Cooperative 46 (73.0) 17 (27.0) 63 (100)
Motivational factors
Self interest in nursing 94 (63.5) 54 (36.5) 148 (100) 0.218
Motivated by others 47 (52.2) 43 (47.8) 90 (100)
Increased career opportunities 55 (57.3) 41 (42.7) 96 (100)
*p value<0.05 (statistically significant)
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Social position
3.11.5: Association between characteristics of the respondents and view on nursing
profession as a way to get recognition in society
Table 3.11.5 describes the association between socio-demographic characteristics, type of
the institution from where they graduated, motivational factors for pursuing nursing
education and their view on nursing profession as a way to get recognition in society. The
proportion of graduates who perceived nursing profession as a way to get recognition in
society was higher among females compared to males. The view did not vary much with
the place of residence, marital status and current designation. The proportion of graduates
who perceived nursing profession as a way to get recognition in society was more among
Christians compared to others. It was higher among those who earned a monthly income
less than or equal to 25000 rupees compared to its counterpart.
The proportion of graduates who perceived nursing profession as a way to get recognition
in society was lower among those from government colleges compared to those from
other colleges and it was higher among those who were motivated by self interest in
nursing compared to others.
The place of residence, religion, marital status, current designation, type of institution
where graduated were not found to be associated with this view about nursing profession.
The sex of the nursing graduate, monthly income and motivational factors for pursuing
nursing education were found to be significantly associated with the view about nursing
profession as a way to get recognition in society.
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Table 3.11.5: Association between the characteristics of the respondents and view on
nursing profession as a way to get recognition in society
Nursing profession has recognition
in society
Variables Yes No Total p value
Socio-demographic
Characteristics Sex
Male 18 (30.5) 41 (69.5) 59 (100) 0.021*
Female 129 (46.9) 146 (53.1) 275 (100)
Place
of residence
Rural 90 (42.7) 121 (57.3) 211 (100) 0.513
Urban 57 (46.3) 66 (53.7) 123 (100)
Religion
Hindu 87 (44.4) 109 (55.6) 196 (100) 0.508
Muslim 16 (36.4) 28 (63.6) 44 (100)
Christian 44 (46.8) 50 (53.2) 94 (100)
Marital status
Married 42 (42.4) 57 (57.6) 99 (100) 0.704
Unmarried 105 (44.7) 130 (55.3) 235 (100)
Designation
Staff nurse 88 (45.1) 107 (54.9) 195 (100) 0.626
Others 59 (42.4) 80 (57.6) 139 (100)
Monthly income
≤25000 129 (46.6) 148 (53.4) 277 (100) 0.038*
>25000 18 (31.6) 39 (68.4) 57 (100)
Type of the institution Government 45 (39.5) 69 (60.5) 114 (100) 0.472
Private 72 (45.9) 85 (54.1) 157 (100)
Cooperative 30 (47.6) 33 (52.4) 63 (100)
Motivational factors
Self interest in nursing 74 (50) 74 (50) 148 (100) 0.042*
Motivated by others 30 (33.3) 60 (66.7) 90 (100)
Increased career
opportunities 43 (44.8) 53 (55.2) 96 (100)
*p value < 0.05 (statistically significant)
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3.11.6Association between characteristics of the respondents and view on nursing
profession as an opportunity for better marriage offers.
Table 3.11.6 describes the association between the socio-demographic characteristics,
motivational factors for pursuing nursing education and the view on nursing profession as
an opportunity for better marriage offers. The proportion of graduates who perceived
nursing profession as an opportunity for better marriage offers was higher among females
compared to females. The view on nursing profession as an opportunity for better
marriage offers did not seem to vary with the place of residence, marital status and
monthly income. The proportion of graduates who perceived nursing profession as an
opportunity for better marriage offers was lower among Muslims compared to others. It
was higher among those who were working currently as staff nurse than others.
This view on nursing profession did not seem to vary with the motivational factors for
pursuing nursing education.
The sex of the respondents, place of the residence, religion, marital status, current
designation monthly income and motivational factors for pursuing nursing education were
not found be significantly associated with the view on nursing profession as an
opportunity for better marriage offers.
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Table 3.11.6: Association between characteristics of the respondents and view on
nursing profession as an opportunity for better marriage offers.
Nursing profession as an
opportunity
for better marriage offers
Variables Yes No Total p value
Socio-demographic
characteristics Sex
Male 8 (13.6) 51 (86.4) 59 (100) 0.089
Female 65 (23.6) 210(76.4) 275 (100)
Place of residence
Rural 47 (22.3) 164 (77.7) 211 (100) 0.808
Urban 26 (21.1) 97 (78.9) 123 (100)
Religion
Hindu 39 (19.9) 157 (80.1) 196 (100) 0.06
Muslim 6 (13.6) 38 (86.4) 44 (100)
Christian 28 (29.8) 66 (70.2) 94 (100)
Marital status
Married 21 (21.2) 78 (78.8) 99 (100) 0.853
Unmarried 52 (22.1) 183 (77.9) 235 (100)
Designation
Staff Nurse 47 (24.1) 148 (75.9) 195 (100) 0.239
Others 26 (18.7) 113 (81.3) 139 (100)
Monthly income
≤25000 61 (22.0) 216 (78.0) 277(100) 0.872
>25000 12 (21.1) 45 (78.9) 57 (100)
Motivational factors
Self interest in
nursing 29 (19.6) 119 (80.4) 148(100) 0.651
Motivated by others 22 (24.4) 68 (75.6) 90 (100)
Increased career
opportunities 22 (22.9) 74 (77.1) 96 (100)
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3.12 Association between characteristics of the respondents, rating of the overall
nursing education and the plan to change the profession.
Table3.12 describes the association between the socio-demographic characteristics;
motivational factors for pursuing nursing education, type of institution from where they
graduated, rating of the overall nursing education and the plan to change the profession.
The proportion of graduates would like to change profession was more among males
compared to females. It did not seem to vary much with the place of residence and the
type of institution from where they have graduated. The proportion of graduates who
would like to change profession was more among Muslims compared to others. It was
more among unmarried graduates compared to married ones.
The proportion of graduates who would like to change profession was higher among
those who were motivated by others compared to their counterparts and it was higher
among those who perceived inadequate overall nursing education compared to others.
The sex of the graduates, motivational factors for pursuing nursing education was found
to be significantly associated with the future choice of plan to change the profession. The
marital status, place of residence, religion, type of institution where graduated and rating
of the overall nursing education were not found to be associated with the plan to change
the profession.
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Table 3.12: Association between characteristics of the respondents, rating of the
overall nursing education and the plan to change the profession.
Plan to
change the
profession
Variables No Total p value Yes
Socio-demographic
characteristics Sex
Males 25 (42.4) 34 (57.6) 59 (100) 0.001*
Females 59 (21.5) 216 (78.5) 275 (100) Place of residence
Rural 58 (27.5) 153 (72.5) 211 (100) 0.197
Urban 26 (21.1) 97 (78.9) 123 (100)
Religion
Hindu 45 (23) 151 (77) 196 (100)
Muslims 15 (34.1) 29 (65.9) 44 (100) 0.305
Christians 24 (25.5) 70 (74.5) 94 (100)
Marital status
Married 19 (19.2) 80 (80.8) 99 (100) 0.103
Unmarried 65 (27.7) 170 (72.3) 235 (100)
Type of the
institution Government 32 (28.1) 82 (71.9) 114 (100) 0.645
Private 38 (24.2) 119 (75.8) 157 (100)
Cooperative 14 (22.2) 49 (77.8) 63 (100)
Motivational factors
Self interest in nursing 29 (19.6) 119(80.4) 148(100) 0.002*
Motivated by others 35 (38.9) 55 (61.1) 90 (100)
Increased 20 (20.8) 76 (79.2) 96 (100)
career opportunities
Overall rating
Agree 48 (22.9) 162 (77.1) 210 (100) 0.209
Disagree 36 (29.0) 88 (71.0) 124 (100)
*p value <0.05 (statistically significant)
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Chapter four
Discussion and Conclusion
4.1 Discussion
This chapter discusses about the findings. Present study was conducted among
334 nursing graduates residing in four randomly selected administrative areas of
Thiruvananthapuram district. Most of the respondents were females and were
unmarried. This proportion was consistent with other study from Andhra Pradesh,
India (Swarna, 2015). The objectives of the present study were to study the
perceptions of nursing graduates about the quality of their undergraduate nursing
education and training, determine the views of nursing graduates on nursing
profession in terms of professional identity, self-image and social position and to
identify the motivational factors that helped to pursue nursing education.
In current study, self-interest was not a motivational factor for nursing education
for more than half of the graduates. This is in confirmation with the study from
Ethiopia, where only 19.1% of the nursing students were motivated by their own
desire (Getu et al., 2015). On the contrary, studies from Punjab and Andhra
Pradesh reported most of them were self-motivated to pursue nursing education
(Patidar, 2011) (Swarna, 2015).
In present study, the perceptions about quality of nursing education and training
were studied under four domains. These were instructors’ characteristics,
infrastructure characteristics, characteristics of clinical education and
characteristics of the overall nursing education.
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As per current study, the teaching abilities of the instructors were not perceived
good by half of the respondents. They elicited lack of practical orientation by the
instructors, poor interpersonal relationship and inadequate trained instructors as
the reasons for negative perception. This was in confirmation with the study from
Iran, where nursing students were not satisfied with their teacher’s performance
and their relationship (Hakim, 2014). On the contrary, a study from Philippines
reported that nursing students perceived their clinical instructors met their
expectations (Guzman et al., 2007). In the present study, most of the graduates
perceived that the instructors’ ability to enhance theory to practice have to be
improved and less than half of them perceived that instructors’ ability to help
students to provide nursing care based on nursing process and skills for clarifying
doubts needs to be improved. This is in confirmation with the findings of a study
form Iran where according to students’ perception; teachers gave more emphasis
on theory than practice (Hanbagherry et al., 2004). Contrary to these findings, a
study from Palestine reported the nursing students perceived that their instructors
clarified their doubts and they had a professional and personal relationship with
instructors that could reduce the theory-practice gap (Awad, 2015). Present study
found that about 15.6 % of the respondents perceived that they did not have at
least one MSc nursing faculty in each of the nursing speciality. This is in contrary
to the Indian Nursing Council (INC) resolutions which prefer at least one MSc
nursing faculty in each of the mentioned nursing specialities (Resolutions -Indian
Nursing Council, 2012).
Findings in the current study showed that infrastructure characteristics were not
perceived good by 43.1% of the respondents. The class room related factors,
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college related factors and hospital related factors were mentioned as the reasons
for poor perception. Further a considerable proportion of the graduates reported
that the preclinical lab training, equipment and facilities in preclinical lab,
computer facilities and library facilities needed improvement. This is against the
global standards for the initial education of professional nurses and midwifes
which emphasised the need for accessible physical facilities in classrooms,
Information Technology, pre-clinical laboratory and library in all the institutions
(World Health Organization, 2009). According to another study from Brazil, more
than half of the students rated the facilities in preclinical lab as average or poor
(Felix, 2016).This is in contrary to present study, where less than half of the
graduates perceived that facilities of preclinical lab need improvement.
As per the current study, 37.7 % of the respondents felt that the clinical exposure
was not adequate. This is in agreement with the study from Nepal in which the
professional nurses perceived that the clinical exposure for students studying in
many nursing colleges were inadequate (Subedi and Deena, 2014). Present study
found that 66.2% of the respondents perceived clinical training was not good. One
of the Kenyan studies also reported the similar finding where nursing students
were not satisfied with the clinical training (Nyangena et al., 2011). As per the
current study, lack of adequate number of specialities, inadequate number of
diverse cases, inadequate exposure to emergency cases and insufficient patients in
the parent hospital were mentioned as the reasons for perceiving clinical exposure
as inadequate. This is in confirmation with a study from Iran, which found
students perceived insufficient patients for practice (Heidari and Norouzadeh,
2015). One of the studies from Turkey highlighted that the students perceived that
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providing nursing care to patients with complicated disease conditions will help in
growth of their professional life (Elugil et al., 2011). As per the current study, the
reasons reported for perceiving clinical training as poor were instructor related
factors (lack of proper supervision by the instructors during clinical training),
minimum opportunities for practice and stressful clinical experience. This is in
confirmation with studies conducted in United kingdom, out of which one study
revealed that the students did experience stress and anxiety during clinical training
due to physically hard work (Brodie et al., 2004) and the another one disclosed
that they did not get adequate support from their tutors during their clinical
placement (Last and Fulbrook, 2003). In the current study, a considerable
proportion of graduates perceived that the attitude of the senior nursing faculty,
support from the hospital staff, sufficient opportunities for practice and equal
emphasis on theory and practice to be improved. A study from Turkey highlighted
that students perceived good relation with the instructors and nurses in the hospital
would facilitate in their clinical learning process (Elcigil et al., 2011). The present
study is in agreement with a study from Jamaica, where the students perceived that
they needed more opportunities for learning in the clinical learning (Weaver and
Lindon, 2016).Contrasting to findings of current study, an Australian study stated
that the nursing students were satisfied with the attitude of the hospital staff
towards them (Lamon et al., 2015).
The present study showed that 37.1% of the graduates perceived overall nursing
education as inadequate. This in confirmation with a study from Nepal where the
professional nurses perceived that the overall quality of nursing education has
recently declined (Subedi and Deena, 2014). As per the current study, minimum
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opportunities, lack of correlation between theory and practice were mentioned as
the reasons for perceiving it as inadequate. This is in confirmation with a study
from Philippines, where the students perceived that a gap existed between their
theoretical learning and clinical practice (Tiwaken et al., 2015). In the present
study, the perceived characteristics of the overall nursing education varied
according to instructors’ characteristics, characteristics of the clinical exposure
and characteristics of clinical training. Most of the graduates who perceived
overall nursing education as inadequate were those who discerned characteristics
of instructors as poor, clinical exposure as inadequate and clinical training as poor.
This was in confirmation with a study from Nepal, where the professional nurses
perceived clinical education as an important component for maintaining the
overall quality of nursing education and they felt that the clinical exposure and
clinical training were inadequate for students in many nursing colleges due to
insufficient number of patients in the clinical placement area (Subedi and Deena,
2014).
The current study showed that type of the institution, where the nurses pursued
their graduation, was found to be associated with the perceived characteristics of
infrastructure, clinical exposure, clinical training and overall nursing education.
Most of the graduates, who perceived characteristics of clinical exposure, clinical
training and overall nursing education as adequate or good, were those who
completed their graduation from government nursing colleges whereas
characteristics of infrastructure was perceived good by those who graduated from
Private Nursing Colleges. Similar findings have also been reported in a study from
Nepal, where professional nurses perceived that privatization of the nursing
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education has led to decline in the quality of the overall nursing education (Subedi
and Deena, 2014) and National Knowledge Commission (NKC) working group on
medical education in India is also raising the same point (Higher education: The
underbelly of privatisation, 2008). A report from Kerala also confirm the findings
of the present study, stating that the pass percentage of students from private
colleges was lower as compared to pass percentage of students from government
colleges for various medical courses conducted by KUHS in 2012 (Swara, 2012).
In the context of infrastructure in Indian scenario, it has been found that the
private engineering colleges are seemed to have better infrastructure but some of
the government engineering colleges lack good facilities (Ankita, 2015). The
present study also pointed out the similar thing but in nursing Profession. On the
contrary, another study from India stated that the infrastructure facilities in the
private colleges are poor (Ravi, 2015).
Further, the current study also found that 58.4% of the graduates perceived
nursing profession as a source of economic security, 67% perceived that it is not
comparable with other professions, 58.7% perceived it as dignified and respectful
profession, 56% perceived that nursing profession is not recognised in society and
78.1% perceived nursing profession as not an opportunity for better marriage
offers. These findings are in confirmation with a study from Andhra Pradesh
(Swarna, 2015).
As per the current study, almost all respondents (96.8%) perceived that nursing
profession is an opportunity to serve humanity which is similar to the findings of
the studies carried out in Andhra Pradesh and Punjab (Swarna, 2015) (Patidhar,
2011) .
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In current study, it has been found that males and females were having different
views on both regarding comparability of nursing profession with other
professions and as a way to get recognition in society. Mostly male graduates gave
negative responses compared to females. It can be further illustrated from the
findings of the following studies. The entry of the males into nursing profession
was considerably less compared to females (Samporter, 2008).The incongruity
between the gender and professional identity was perceived by the males who
were working in female dominated jobs (Wallen et al., 2014). According to a
study conducted in Egypt and Jordan, male nurses perceived that the image of the
nursing profession was inhibited by the public view (Ibrahim et al., 2015).
In present study, the motivational factors for pursuing nursing education was
found to be associated with the view that whether nursing profession is a way to
get recognition in the society and most of the graduates who had positive view
about nursing profession as a way to get recognition in the society were those who
were motivated by self interest in nursing. The possible reason for this may be that
the socio-economic background of the graduates’ family might have influenced
their view because in our study, most of the graduates who were motivated by self
interest in nursing studied in private nursing colleges. The cost of education in
private colleges is high, so most of the respondents who pursued education from
private colleges may be coming from family with higher socio economic
background.
The present study also found that the type of institution, where respondents did
their graduation was associated with the view of nursing profession as a source of
economic security and a dignified, respectful profession. Most of the graduates
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who had the positive view on economic security belonged to government colleges.
It may be due to the fact that as per our study most of the graduates who perceived
overall nursing education as adequate were from government colleges and this
might have enabled them to succeed in competitive exams for securing job. On
the contrary, job opportunities were found to be equal irrespective of the type of
the institution (Woodruff, 2013). Most of the graduates who had negative view on
nursing profession as a dignified and respectful profession were those who
completed their graduation from government institutes. This may be due to the
reason that in the current study, most of the respondents who have graduated from
government colleges were currently working as staff nurses. The staff nurses
might be having negative view due to the poor working environment or other
factors which they were currently experiencing during their practice.
In current study, it was found that both staff nurses and others category varied
with their response on the view whether nursing profession is comparable to other
professions. Most of them, who had negative view, were those who were working
as staff nurses as compared to others. The reason could be that these staff nurses
are comparing themselves with other high grade health care professionals which
they would be witnessing daily during their practice.
As per the current study, the difference in opinion was found between the
graduates, who were earning monthly income less than or equal to 25000 rupees
and those who were earning more than 25000 rupees, about nursing profession as
a source of economic security and a way to get recognition in society. Most of the
graduates who had positive view on nursing profession as a source of economic
security were those who were earning monthly income greater than 25000 rupees.
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This was in confirmation with a study from Ethiopia which found that the increase
in the monthly income had positively influenced the nurses’ perceptions towards
the nursing profession (Getu et al., 2015). Most of the graduates who had positive
view on recognition in society were those who had monthly income less than or
equal to 25000 rupees compared to others. This could be due to the reason that in
the present study, most of the graduates who were earning a monthly income
greater than 25000 rupees were currently working as staff nurses. The present
experiences of the staff nurses such as the attitude of other health care
professionals and patients or bystanders towards them might have influenced this
view. There can be another possibility that the socio economic background of the
graduates’ family might have influenced their view.
In the present study, it was found that less than half of the respondents would like
to continue nursing profession in India or to pursue higher education in nursing.
Half of the respondents reported that they would like to acquire teaching positions.
These were in agreement with a study from Andhra Pradesh (Swarna, 2015). The
current study also found that, more than half of them would like to go abroad
(54.5%).Similar findings were reported by a study from Punjab where 58 % of
nursing students preferred going abroad (Patidar, 2011). The findings of the
present study also revealed 25.1% of the respondents would like to change the
profession. A study from Andhra Pradesh also reported almost similar finding
(18.7 %). This is in agreement with the present study (Swarna, 2015). Contrasting
findings were reported by a study from Punjab which highlighted that 56% of the
respondents would like to change the profession (Patidar, 2011). The current
study found that the future career choice of changing the profession varied
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between males and females. Most of them who had future career choice to change
profession were males. In our study, most of the graduates who had negative
views on the nursing profession were males and this might have made them plan
to change the profession. The present study also found that the graduates’ plan to
change profession varied as per motivational factors. Most of the graduates who
have plan to change profession were those who were not motivated by self-
interest. This was consistent with the findings from Finland where the nurses, who
wished to change their field did not opt nursing education as their primary choice
(Flinkman et al., 2013).
4.2 Strengths and limitations of the study
Strengths
To my knowledge, no study being conducted to assess the perceptions of nursing
graduates about the quality of nursing education and training in India.
Data collection and analysis was done by principal investigator herself that avoids
inter-observer bias.
The study had high response rate (95%)
Limitations
Self-perceived data are reported, so there is a chance for social desirability bias.
The questionnaire did not include any questions on socio economic background of
the graduates at the time of joining their under graduation. The socio-economic
background might have affected their decisions to opt nursing, their views on
nursing profession and their career choices.
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4.3 Conclusion and recommendations
According to Nightingale, nursing is the act of utilizing the environment of the
patient to assist in his/her recovery. For better nursing care it is important to
develop competencies of nurses. Hence, the nursing education aimed at
developing skills related to theory and clinical practice to enhance competencies.
In India, this has been regulated by number of agencies such as Indian Nursing
Council, Department of Medical Education in the respective states and Health
University. In reality, the quality of nursing education varies between the
government and private institutions offering nursing courses. Our study brought
these differences in terms of the quality of instructors, infrastructure, content of
courses related to theory and clinical practice and the overall quality of courses.
From the earlier chapters it is clear that there is a difference in the above aspects
of nursing education. This adversely affects the delivery of care in health
institutions. In addition, personal factors such as self-motivation, career options
and other related things influenced one to take-up this profession. This shows how
an important profession such as nursing is not given due importance by the system
with proper care. This ultimately led some to leave the profession and look for
other avenues. If we do not give due importance to nursing education, it will lose
its importance in the state like Kerala from where the best nurses are drawn in
different countries of the world. Specifically, we need to have stringent
enforcement of guidelines on nursing education, ensuring minimum wages for
nurses, and create a conducive environment for nurses as whole to practice with
self-respect. In addition, we need to give equal weightage in other avenues to
nursing qualifications par with other modern medicine qualifications. Further
qualitative exploration should be incorporated to understand the views of current
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nursing professionals, nursing students, nursing faculty and policy makers, which
can give better insight into the concerns affecting current nursing education.
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Page 101
ANNEXURE: 2
Achutha Menon Centre for Health Science Studies,
Sree Chitra Tirunal Institute for Medical Sciences & Technology,
Trivandrum- 695011, Kerala
SL NO:
ID NO:
Perceptions of nursing graduates about the quality of their undergraduate nursing
education and training in Thiruvananthapuram district, Kerala
SUBJECT INFORMATION SHEET
Hello, I am Neethu.T, studying Master of Public Health (MPH) at Achutha Menon Centre
for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and
Technology, Trivandrum. I am required to do a dissertation as part of my curriculum. The
topic of my study is “Perceptions of Nursing graduates about the quality of their
undergraduate nursing education and training in Thiruvananthapuram district, Kerala”. I
request you to spend some time to participate in the study, which will take about 20-30
minutes. I have prepared a questionnaire asking your responses for your perception on
nursing profession, factors that motivated you to choose the profession, career
opportunities available with the trained nurses and perceptions on the quality of nursing
education and training.
Benefits from participation
There is no direct benefit for you by participating in the study, but it is possible that the
findings of the study will enhance scientific knowledge and may enable to develop
policies related to improve nursing education
Page 102
Discomfort/ harm from participation
There will not be any harm or risk to your health by participating in this study
Voluntariness
Your participation in the study is purely voluntary and you may withdraw from the study
at any point of time or may refuse to answer some questions and it will not involve any
form of penalty.
Confidentiality
I assure you that the information provided by you ,will only be used for research purpose
and personal details of participants will be codified and will be kept safely with the
principal investigator and will not be disclosed to anyone. Anonymity will be maintained
throughout. The questionnaire will be destroyed when they are no longer needed. In case
of any queries or doubts regarding this study you may contact me at the following
address. For additional queries, you may contact the Member Secretary, Institutional
Ethics Committee (IEC) of SCTIMST.
Researcher Member Secretary
Neethu.T Mala Ramanathan
MPH Scholar Institutional Ethics Committee Secretary
Phone: 9496022262 SCTIMST
Email:[email protected] Phone: 0471-2524234
Email: [email protected]
Thanking You
Neethu.T
Page 103
ANNEXURE: 3
SL.NO:
ID NO:
CONSENT FORM
I have read the details in the information sheet. The purpose of the study and my
involvement in the study has been explained to me. I understood that the participation in
this study is purely voluntary. In addition, I understood that my identity and personal
information will be kept confidential. I know that I can withdraw my participation at any
time during the study without any explanation. I have also been informed who should be
contacted for further clarifications.
I,…………………………………………. agree to participate in the study.
Place:………………………………………..
Date:………………………………………..
Signature ………………
Name of the researcher………………………..
Signature of the researcher…………………….
Page 104
ANNEXURE-4
Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal
Institute for Medical Sciences & Technology, Trivandrum- 695011, Kerala.
SL NO:
ID NO:
Perceptions of nursing graduates about the quality of their
undergraduate nursing education and training in Thiruvananthapuram
district, Kerala.
GENERAL INSTRUCTIONS TO FILL THE QUESTIONNAIRE
1. Please read all the questions and answer each question by a tick mark as your response
in the most appropriate one
2. Write your answers in words in the blank spaces provided if needed.
3. Do not need to write your name on the questionnaire
4. Please see the instructions provided for certain questions
5 After filling the questionnaire, please check and ensure that you have answered all the
questions
SERIAL NUMBER
PARTICIPATION IDENTIFICATION NUMBER:
PLACE…………….
DATE OF COMPLETING THE QUESTIONNAIRE (dd/mm/yy): _ _/_ _/_ _ _ _
*(to be filled by the principal investigator)
Page 105
SECTION A
SL
NO:
QUESTIONS RESPONSES
Socio-demographic characteristics
1 Age in completed years …………………….. Years
2 Sex (1) Male
(2) Female
3 Place of residence (1)Rural
(2) Urban
4 Marital status (1) Married
(2) Unmarried
5 What is your current designation
Skip to question 7 if response is 1
(1) Staff Nurse
(2) Lecturer
(3) Student in nursing speciality
(4) Student in other fields
(5 )Others please specify
Page 106
6 Have you ever worked as a Staff
nurse after your nursing graduation?
If no please skip to question 8
(1) Yes
(2) No
7 For how long you have worked as a
staff nurse?
(1) less than one year
(2) 1-2 years
(3 )More than 2 years
8 What is your monthly income in
Rupees?
(1 )Less than 5000
(2 )5001-10000
(3) 10001-25000
(4 )25001-50000
(5) More than 50000
(6) Nil
10
Religion
(1) Hindu
(2) Muslim
(3 )Christian
(4) Others (specify)
Page 107
SECTION B
Institution
11 What is the type of the institution
where you have completed your
nursing graduation?
(1) Government
(2) Private
(3) Cooperative
(4) Others(specify)
Motivational factors for pursuing nursing education
12 What was your primary reason
behind pursing nursing education?
(1) My own interest in nursing
(2)Motivation from parents or friends or
relatives
(3) Due to increased career opportunities
(4)Interest in medical field.
(5)Others (specify)
Financing nursing education
13 Who funded your nursing
education?
(1) Parent
(2) Scholarships
(3) Educational loan
(4) Others (specify)
Page 108
Views on nursing profession
14 How do you view the nursing
profession?
(1)Opportunity to serve humanity
(2)A way to enjoy economic
security
(3) It is like any other profession
practiced by people qualified in a
professional education
(4) A Dignified and respectful
profession
(5) A way to get recognition in
society
(6) An opportunity to get better
marriage offers
(1) Yes (2) No
(1) Yes (2) No
(1 )Yes (2) No
(1 )Yes (2 )No
(1) Yes (2) No
(1 )Yes (2 )No
Page 109
Career path
15 What are your future career
choices?
(1)To continue in nursing
profession in India
(2) Plan to go abroad
(3)Post-graduation in nursing
(4) Teaching positions
(5)Plan to change profession
(6)Others (please specify)
(1) Yes (2) No
(1) Yes (2) No
(1) Yes ( 2) No
(1)Yes (2) No
(1) Yes (2) No
(1) Yes (2) No
SECTION C
Perceptions of nursing graduates about the quality of their undergraduate nursing education
and training
Sl.No: Questions Response
1 Was your nursing college affiliated to Indian
Nursing Council when you were doing under
graduation?
1 Yes
2 No
3Don‟t know
Page 110
Instructors’ characteristics
2 How do you rate the teaching abilities of your
undergraduate instructors in general?
Skip to question 4 if response is 1 or 2 or 3
1 Excellent
2 Good
3 Fair
4 Poor
5 Very poor
3
If you consider the teaching abilities of your
instructors to be poor or very poor, could you
please explain why do you think so?
……………………………
……………………………
…………………………....
4
Did you have teaching faculty with MSc nursing
in each of the nursing specialities you studied
during your undergraduate nursing education?
(1)Medical Surgical Nursing
(2) Paediatrics nursing
( 3) Obstetrics and Gynaecology nursing
(4 )Community Health Nursing
(5)Psychiatry Nursing
(1)Yes ( 2) No
(1)Yes (2 )No
(1) Yes (2) No
(1 )Yes (2) No
(1) Yes (2) No
Page 111
5 According to you, which are the areas where
your instructors need improvement?
(Multiple responses are possible)
1Doubt clarification skills
2 Ability to enhance the
students „skill to relate theory
to practice
3 Help students provide
nursing care based on
nursing process
4Others
(Specify)
General infrastructure in the college
6 How do you rate the general infrastructure
facilities of the college (at the time when you
were a student there) where you have completed
graduation?
Skip to question 8 if response is 1 or 2 or 3
1 Excellent
2 Good
3 Fair
4 Poor
5 Very poor
Page 112
7 If you consider the infrastructure of your
institution at the time when you were a student
there to be poor or very poor, could you please
explain why do you think so?
…………………………….
……………………………
……………………………
……………………………
……………………………
……………………………
8 According to you, which are the areas where
your institution needed improvement?
Multiple responses are possible
1 Good spacious class rooms
2 LCD projector and OHP
facilities in the class room
3 Computer facilities in the
college
4 Adequate and updated
library with text books in
good condition
5 Adequate equipment and
facilities in preclinical lab
6 Adequacy of preclinical lab
training
7 Others
Specify
Page 113
Clinical Education
Respond to the statement
9 I believe that I am exposed to adequate number
of diverse clinical cases during my
undergraduate training, which has enabled me to
be a confident and independent nursing
professional
Skip to question 11 if your response is 1 or 2
1 Strongly agree
2 Agree
3 Disagree
4 Strongly disagree
10 If your response to the previous question was
either 3 or 4, then could you please explain why
do you think so?
……………………………
……………………………
……………………………
……………………………
……………………………
……………………………
…………………………….
11
What was the bed occupancy rate of the parent
hospital of your college?
……………………………
12 How do you rate the clinical training that you
received as a part of your undergraduate
training?
Skip to question 14 if response is 1 or 2 or 3
1 Excellent
2 Good
3 Fair
4 Poor
5 Very poor
Page 114
13 If you consider the clinical training that you
received as poor or very poor, then could
explain why do you think so?
……………………………
……………………………
……………………………
……………………………
……………………………
……………………………
……………………………
……………………………
…………………………
14 According to you, which are the areas where the
clinical training you received needed
improvement?
Multiple responses are possible
1 Equal emphasis on clinical
learning and theoretical
learning
2 Sufficient opportunities to
practice procedures taught in
classrooms
3 Support provided by the
hospital staff during clinical
learning
4 Favourable attitude and
behaviour by senior nursing
faculties and other hospital
staff.
Page 115
15
Respond to the statement
I believe that the overall undergraduate training
I received has prepared me well to confidently
and competently practice as an independent
nursing professional.
1 Strongly agree
2 Agree
3 Disagree
4 Strongly disagree
16 If the answer to previous question is 3 or 4, then
please explain why do you think so?
……………………………
……………………………
……………………………
……………………………
……………………………
……………………………
……………………………
……………………………
….
