Nursing continues to be one of the most trusted professions (Stone, 2019). In 2020, the nursing profession celebrated the 200th anniversary of the birth of Florence Nightingale and the 100th anniversary of the Nurses Registration Act 1919, legislation bringing regulation and recognition for nurses. These milestones prompted the authors to explore perceptions of nursing in the 21st century. In 2021 there were almost 745 000 registered nurses, nursing associates and midwives in England and Wales (Nursing and Midwifery Council (NMC), 2021). Nursing is complex and multifaceted; nurses work across all fields—at home, close to home and in hospital (Health Education England, 2017).‘Registered nurse’ is a legally protected title in the UK, yet there is still no clear definition. In addition, the term ‘nurse’ is not a protected title but whether this should be regulated is a contemporary topic of discussion. There is an ongoing debate regarding whether the title ‘nurse’ should also be protected in law. For example, registered nurses who are removed from the NMC register are still legally entitled to call themselves a ‘nurse’, regardless of the reason for their removal (Mitchell, 2021).
The Royal College of Nursing (RCN) describes nursing as:
‘The use of clinical judgement in the provision of care to enable people to improve, maintain or recover health, to cope with health problems and to achieve the best possible quality of life, whatever their disease or disability, until death.’
RCN, 2003: 3
The NMC describes nurses as making:
‘An important contribution to the promotion of health, health protection and the prevention of ill health.’
NMC, 2018: 3
These definitions appear all-encompassing, informing the purpose of nursing. However, a definition presents complexities due to the variety of nursing contexts and roles. The RCN (2003) argued that a definition is needed because we may need to describe nursing to those who do not understand it, to influence policy, and for the development of curricula. We should consider differences between registered professionals and those who provide nursing care, cognisant of the high level skills and knowledge the registered nurse requires (Beasley, 2006).
Henderson (1964) argued that the unique functions of nurses relate to maintaining independence and reaching recovery. She said that each nurse should look inwardly to develop their own concept of nursing, rather than following an authoritative definition. The International Council of Nurses (ICN) (2002) emphasised the broad spectrum of nursing responsibilities and roles across varied environments. It also acknowledged the role of the nurse educators within educational settings, contributing to the development of health policy, research and education. We should therefore consider the defining characteristics of a nurse, particularly to guide development of a single definition and its applicability within a diverse, multicultural society.
Austgard (2008) suggested that traditional perspectives towards nurses are rooted in faith and religion, a concept conflicting with ideas within popular culture, the media and social media (Hallam, 2000). The history of nursing may impact on current perceptions of what a nurse is (Hall and Ritchie, 2009). Nursing is often described as vocational (White, 2002) and we should consider the social, cultural, humanitarian and ethical dimensions of nursing when formulating a definition. Arguably, stereotypical notions of nursing persist (Jinks and Bradley, 2004; Weaver et al, 2014; Sollami et al, 2015). In seeking to professionalise nursing, we must consider the impact of gender bias on conventional definitions of the profession (Yam, 2004). Some 77% of the nursing workforce is female, yet only 37% of senior roles are held by women (NHS Digital, 2018). Anthony (2004) suggested that gender connectivity—the opportunity to identify with those of the same gender in the same role—can be lacking for male nursing students because there are fewer male nurse educators than females. These considerations are relevant in definition development, given current shifts in societal attitudes to gender classification.
Life experiences and how they relate to the expectations of nurses should not be underestimated (Taylor, 2003; Hamilton and Essat, 2008); although many people have perspectives on the role of the nurse, these may not accurately represent reality. Caring is considered a fundamental component of nursing (Romero-Martín et al, 2019), yet it is arguably an individualised, contextual concept (Finfgeld-Connett, 2008). Brykczyns (1997) suggested caring has become a ‘contractual issue’ because it is what nurses are paid to ‘do’.
There are shortages in the nursing workforce (RCN, 2017), yet in England and Wales the role of the nurse is being expanded to include proficiencies such as leading and managing nursing care, co-ordinating care, and improving the safety and quality of care (NMC, 2018). Over the past 30 years, nurse training has changed from largely work-based learning to degree-level study. Although Hallam (2000) questioned whether degrees make better nurses, the benefits of nurse education have been well established and accepted. Aiken et al (2014) identified a link between decreased mortality and nurse training to bachelor's degree level. Arguably, enquiries such as the Francis report (2013) evidenced poor nursing care, despite the introduction of degree-level education.
Definitions of the scope of nursing are often historic, and a contemporary understanding of nursing has not yet been fully explored within the literature. A focus on a contemporary definition of nursing is therefore timely and is ever more relevant as the nursing family expands and evolves to include the role of the nursing associate. A definition of nursing will develop a clearer role identity and support the recruitment and retention of high-quality registered practitioners. This pilot study aimed to test a survey aimed at exploring views of nursing and to identify concepts associated with nursing so that a definition could be developed.
Aims
The aims of this pilot study were to:
- Test a survey exploring views of nursing in the 21st century in the UK
- Identify concepts associated with the term nursing, which would influence a larger study
- Highlight potential differences between the perceptions of healthcare workers and non-healthcare workers about what nursing is
- Identify further areas of inquiry related to future nursing practice.
Methods
Design
This pilot study used an electronic survey consisting of 15 open and closed questions. Of these, four were demographic questions, four were closed questions and seven were open questions. Two of the questions used a Likert array to determine agreement/disagreement with 18 statements related to nursing. These statements were influenced by historic literature and perspectives on nursing. Ethical approval was granted for this study by the university's Health and Social Care Ethics Committee in 2019.
Data collection
The survey was advertised via social media, emails and a university virtual learning environment with an invitation to participate. The range of participants in this survey was intended to be broad and inclusive, with the aim of testing the viability and usefulness of the survey. The survey was hosted in Microsoft Forms on Office 365. Beginning with participant briefing information and a confirmation that the respondent was over the age of 18 years, consent was obtained within the same form at the beginning of the process. If a respondent was under the age of 18, they were diverted out of the survey and prevented from completing it. The survey was open for a period of 3 months, followed by one month's ‘cooling-off’ period to allow participants to remove their data before analysis. Data were stored in line with General Data Protection Regulations requirements and no participants requested the removal of their data.
Data analysis
Data were exported from Microsoft Forms and transferred to Microsoft Excel (Microsoft Office Professional Plus, 2016). Descriptive statistics were collated for closed questions, including demographic questions. Responses to the Likert arrays were transcribed to numerical integers (strongly disagree=1, strongly agree=5). The higher the number, the stronger the agreement with the question. Mean values were calculated for all responses to each question and placed in a table for comparison (Table 1). Mean values were also calculated for respondents involved in nursing (registered nurses, student nurses, nursing associates and trainee nursing associates), allied health professionals, doctors, members of the public, carers and non-carers to determine if any differences were present between these groups. Because of the small sample size, inferential statistics were not performed on this data because results would not have adequate power to demonstrate meaningful insights.
Table 1. Mean values associated with question per respondent group
| Number of responses in each category | Nursing is a science | The elements of nursing are all but unknown | Nursing is an art | There is a legal definition of nursing | A definition of nursing is important | People are born to be nurses | Gender is not important in relation to being a nurse | Nurses are paid to care | Nursing is low in the hierarchy of professions | Education makes nurses better at their role | Registered nurses are subordinate to medical doctors | All nursing practice is care | Nurses are required to have an emotional investment in the people they care for | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Average score for all | (n=72) | 3.67 | 2.51 | 3.67 | 3.57 | 3.89 | 3.08 | 4.5 | 3.38 | 2.74 | 4.03 | 2.38 | 3.13 | 3.4 |
| Average score for RN, SN, NA, TNA | (n=43) | 3.72 | 2.4 | 3.67 | 3.6 | 3.88 | 3.19 | 4.56 | 3.12 | 2.93 | 4.07 | 2.21 | 3.28 | 3.49 |
| Average score for AHPs | (n=6) | 3.17 | 2.67 | 3.5 | 3.67 | 3.83 | 3.17 | 4.33 | 3.33 | 2.5 | 3.83 | 2.67 | 3.5 | 4.17 |
| Average score for doctors | (n=5) | 3.6 | 2.8 | 4.2 | 2.8 | 3.4 | 3 | 4.8 | 3.8 | 1.6 | 4.4 | 1.6 | 2 | 2.8 |
| Average score for members of the public | (n=18) | 3.72 | 2.67 | 3.56 | 3.67 | 4.06 | 2.83 | 4.33 | 3.89 | 2.67 | 3.89 | 2.89 | 2.94 | 3.11 |
| Average score for carers | (n=14) | 3.5 | 2.57 | 3.57 | 3.29 | 3.79 | 2.71 | 3.79 | 3.14 | 2.86 | 3.86 | 2.29 | 3.21 | 3.43 |
| Average score for non-carers | (n=58) | 3.71 | 2.5 | 3.69 | 3.64 | 3.91 | 3.17 | 4.67 | 3.43 | 2.71 | 4.07 | 2.4 | 3.1 | 3.4 |
Key: AHP=allied health professional; NA=nursing associate; RN=registered nurse; SN=student nurse; TNA=trainee nursing associate
Natural language responses to open questions were collated into bodies of text per question for all respondents, for respondents involved in nursing (registered nurses, student nurses, nursing associates and trainee nursing associates) and for non-nurses as a comparison group. These bodies of text were then analysed with Linguistic Inquiry and Word Count (LIWC). LIWC is a natural language analysis software package that determines the linguistic nature and content of words in written texts. The software gives objective information pertaining to the tone of voice, the positivity or negativity of the text, the strength of the writing and if the text is analytical (Tausczik and Pennebaker, 2010). LIWC provides objectivity in the text-analysis process, thereby increasing validity, rigour and reliability of the study. LIWC provides a measurement of (Pennebaker et al, 2014):
- How analytical the text is: higher scores are indicative of greater use of prepositions and text complexity
- Emotional tone: this determines whether the text has a positive tone or negative tone, with 50 being average
- Clout: this refers to the strength of the text and is affected by the use of personal pronouns, indicating greater ownership of the text written
- Authenticity: this refers to the words in the text associated with humility, honesty and vulnerability.
Results and discussion
This pilot study recruited 72 participants from professional and non-professional backgrounds. Most participants were aged 22 to 59 years (89%) (Table 2). Registered nurses represented a large proportion of respondents (38%) as did members of the public not in a healthcare profession (25%) (Table 3). Most participants were employed either full time or less than full time (76%) (Table 4). Some 19% of participants declared themselves to be informal carers, with the remainder not having informal carer responsibilities. Participants' genders were not recorded (Hyde et al, 2019).
Table 2. Distribution of respondents' ages
| Age (years) | Number | Percentage |
|---|---|---|
| Under 18 | 0 | 0% |
| 18–21 | 5 | 7% |
| 22–29 | 13 | 18% |
| 30–39 | 21 | 29% |
| 40–49 | 13 | 18% |
| 50–59 | 17 | 24% |
| 60–69 | 2 | 3% |
| 70–79 | 1 | 1% |
| 80–89 | 0 | 0% |
| 90–99 | 0 | 0% |
| 100+ | 0 | 0% |
Table 3. Distribution of respondents' professions
| Profession | Number | Percentage |
|---|---|---|
| Registered nurse | 27 | 37% |
| Registered nursing associate | 2 | 3% |
| Student nurse | 9 | 13% |
| Trainee nursing associate | 5 | 7% |
| Allied health professional | 6 | 8% |
| Student allied health professional | 0 | 0% |
| Doctor | 5 | 7% |
| Student doctor | 0 | 0% |
| Healthcare administrative staff | 0 | 0% |
| Members of the public not in a healthcare profession | 18 | 25% |
Table 4. Distribution of respondent employment status
| Employment status | Number | Percentage |
|---|---|---|
| Employed full time | 40 | 55% |
| Employed less than full time | 15 | 21% |
| Unemployed | 1 | 1% |
| Apprentice | 3 | 4% |
| Student | 9 | 13% |
| Retired | 4 | 6% |
This pilot study examined views of nursing in the 21st century. It aimed to identify concepts associated with the term ‘nursing’ and influence a larger study, highlighting differences between healthcare and non-healthcare workers.
A significant number of respondents were health or care professionals who were not nurses. Their contribution is valued due to the interprofessional working environment. Results suggested that doctors considered nursing an art more than other respondents, which could indicate that doctors view their own role as scientific rather than artistic, or they lack insight into the broad role and competencies of a nurse (ICN, 2002). Nursing has a holistic and scientific knowledge base (Yam, 2004) which could result in more creative or diverse approaches to interventions. Nurse and doctor respondents agreed that education equals better nurses, correlating with the findings of Aiken et al (2014). Most respondents supported this perspective, considering nursing as intellectual and practical. Additionally, all respondents agreed that nursing involves professional judgement.
Respondents who were non-health professionals could lack insight into the reality of the nurse's role, perhaps valuing the softer skills associated with the artistic side of nursing, over skills and competencies (Hoeve et al, 2014). Respondents who were members of the public attributed greater importance to a definition of nursing than others, this could be because they do not understand the role but want to hold nurses accountable (Grander and Hagedorn, 1997). Understanding boundaries between healthcare roles can assist the general public in seeking out and consulting appropriate professionals, reducing confusion about where areas of practice overlap. These considerations are important because some members of the public may not appreciate nurses' expanding skills and competencies, as noted by Hoeve et al (2014). Doctor respondents were less likely to perceive that nurses had an emotional investment in care. Weng et al (2008) suggested social skills and associated emotional intelligence may be lacking in some medical professionals. These findings could be influenced by the limited sample size or by the type, age and specialty of the doctor.
Generally, respondents did not view nurses as low in the healthcare hierarchy, a viewpoint held more strongly by doctor respondents than others. This was supported by the findings that doctor respondents did not view nurses as subordinates. Past research has identified that nurses may have conceded passively to doctors (Sweet and Norman, 1995). Doctor respondents identified most strongly that nurses have power; this is an interesting perspective and could be due to the expanding role and specialties of the nurse. This could represent a shift in attitude by doctors regarding the role of the modern nurse. Continued cautious interpretation is required due to the small sample size.
Uniforms are often considered an important component of nursing heritage (Shaw and Timmons, 2010). This study suggests that doctors responded most positively to nurses being in uniform. Further investigation around uniforms may provide clarity of the nursing role as multiple variations in uniforms can cause confusion for practitioners and patients (Skorupski and Rea, 2006). In addition, wearing uniforms may ‘inspire public confidence’ in the role (Jacob, 2007).
There was a significant number of responses from carers in this study. Carers were less likely to agree that gender does not matter in nursing than non-carers. This could be due to the personal experiences of respondents and may arise because carers are more likely to be one gender than another (Dahlberg et al, 2007). Women are more likely to be nurses, with 89% being female (NHS Digital, 2018), potentially reflecting societal gender roles (Arber and Ginn, 1995) or gender stereotypes and social biases against women. Although there has been a shift in the roles and responsibilities women undertake in society, women are more likely to care for older adults within their family (Phillips, 2000). All respondents agreed that nurses are paid to care, possibly related to nursing as an occupation and paid profession.
Most respondents agreed that nursing is an inclusive profession. This response was verified by two separate questions: one enquiring about nursing as inclusive and one enquiring about nursing as exclusive. This confirmed participants were reading and understanding the survey as expected; however, this is based on the assumption that inclusivity and exclusivity are mutually exclusive concepts. The inclusivity of nursing is an important consideration due to current nursing shortages (RCN, 2017) to enable individuals to enter the profession without risk of alienation or prejudice.
All respondents disagreed that individuals do not have to be registered to be a nurse. There has been discussion regarding protection of the nurse title (Leary, 2017; Leary et al, 2017). This response, while not saying someone has to be registered to be a nurse, does still reflect a recognition that registration exists and has a role.
In addition to Likert questions, this survey provided opportunities for respondents to submit natural language answers, allowing authenticity and freedom of response (Table 5). Linguistic analysis demonstrated a generally positive tone when discussing nursing. All responses were highly analytical, had a high tone, and were more positive than negative. This was expected as nurses are typically trusted, respected, and held in high regard (Stone, 2019). Respondents involved in nursing wrote more authentically than others (9.3 compared with 2.94), demonstrating they understand their own profession. Although more authentic when discussing the purpose of nursing, they wrote with a less positive tone, and less clout, authenticity and positive emotion when discussing the features of nursing. This indicates that respondents did not necessarily analyse the features of their roles. Nursing respondents wrote with more positive emotion than non-nursing respondents about what a nurse is and does, demonstrating that these respondents maintain a positive opinion of themselves and have professional pride. External influences and perspectives on nursing are often negative, reflecting the profession as being challenging and difficult (Brodie et al, 2004).
Table 5. Results of linguistic analysis of natural language responses
| Question | Analytic | Clout | Authentic | Tone | Positive emotion | Negative emotion |
|---|---|---|---|---|---|---|
| What do nurses do today? (All responses) | 87.16 | 78.60 | 8.52 | 94.52 | 6.27 | 1.77 |
| What do nurses do today? (Non-nursing responses) | 89.57 | 78.74 | 7.75 | 90.42 | 6.23 | 2.32 |
| What do nurses do today? (Nursing responses only) | 85.39 | 78.51 | 9.04 | 96.33 | 6.30 | 1.41 |
| What do you consider to be essential qualities and characteristics of a nurse? (All responses) | 93.58 | 85.60 | 6.04 | 99.00 | 21.96 | 1.65 |
| What do you consider to be essential qualities and characteristics of a nurse? (Non-nursing responses) | 96.40 | 91.89 | 3.41 | 99.00 | 24.73 | 1.43 |
| What do you consider to be essential qualities and characteristics of a nurse? (Nursing responses only) | 91.66 | 81.54 | 7.84 | 99.00 | 20.60 | 1.76 |
| What do you consider to be the features of professional nursing? (All responses) | 90.49 | 71.02 | 21.53 | 96.65 | 7.23 | 2.26 |
| What do you consider to be the features of professional nursing? (Non nursing responses only) | 93.26 | 75.56 | 28.81 | 99.00 | 10.38 | 2.42 |
| What do you consider to be the features of professional nursing? (Nursing responses only) | 88.88 | 68.66 | 18.42 | 86.69 | 5.70 | 2.18 |
| What is a nurse? (All responses) | 91.57 | 93.04 | 1.88 | 99.00 | 10.15 | 1.45 |
| What is a nurse? (Non-nursing responses only) | 90.11 | 92.71 | 1.65 | 99.00 | 8.94 | 1.04 |
| What is a nurse? (Nursing responses only) | 92.28 | 93.21 | 2.01 | 99.00 | 10.80 | 1.67 |
| What is care? (All responses) | 77.11 | 90.41 | 5.09 | 99.00 | 10.02 | 0.98 |
| What is care? (Non-nursing response only) | 74.21 | 90.55 | 5.39 | 99.00 | 10.82 | 1.03 |
| What is care? (Nursing responses only) | 78.59 | 90.33 | 4.95 | 99.00 | 9.59 | 0.96 |
| What is nursing? (All responses) | 95.59 | 72.30 | 6.36 | 99.00 | 9.62 | 1.07 |
| What is nursing? (Non-nursing responses only) | 97.24 | 70.16 | 2.94 | 99.00 | 9.20 | 1.15 |
| What is nursing (Nursing responses only) | 94.37 | 73.48 | 9.30 | 99.00 | 9.86 | 1.02 |
| What is the purpose of nursing? (All responses) | 96.51 | 83.00 | 2.83 | 99.00 | 10.50 | 0.95 |
| What is the purpose of nursing? (Non-nursing responses only) | 95.14 | 82.68 | 1.83 | 99.00 | 10.18 | 0.51 |
| What is the purpose of nursing? (Nursing responses only) | 97.17 | 83.20 | 3.66 | 99.00 | 10.69 | 1.22 |
Responses from non-nurses were more analytical and written with more clout when they discussed the essential qualities and characteristics of nurses, perhaps holding nurses to account, expecting particular qualities and characteristics. Respondents involved in nursing may focus more on the process and product of their work, rather than their personal qualities.
Limitations and strengths
As a pilot study, limited sample size prevented inferential statistics being calculated. Future exploration requires power calculations to determine the minimum number of participants for more generalisable results. There was not an equal distribution of respondents among the groups, potentially preventing meaningful comparison due to skewed data. A small number of participants were unsure how to answer the question ‘What do you consider to be the features of professional nursing?’. These responses were included in the analysis, but only provide limited insight. All respondents answered all questions, providing a complete dataset.
Recommendations
The authors make the following recommendations:
- Further research is required to understand the nature, scope and complexity of nursing in the 21st century
- Any future studies should involve a very large sample size to increase the validity, reliability, and rigour of the study
- Future studies should enquire further into the required attributes, qualities and characteristics of nursing
- It would be useful to determine if there are professional differences between the fields of practice and of registration
- In future studies, concerted efforts should be made to gain further insights into the context of respondents and their experience of nursing and the associated professions to determine if there are differences emerging
- It should be considered that there may be multiple definitions of nursing, applied to different areas and fields of practice and registration
Conclusion
This pilot study has considered contemporary perspectives of the nurse and the nursing profession, concluding that nursing is a complex, multifaceted profession. There was a general lack of clarity regarding the role of nursing, with a lack of recognition of the depth and breadth of the role. Some perspectives could be considered outdated or stereotypical, for example, the importance of uniforms as a professional image. Despite these perspectives, the overall view of nursing was that it was positive and authentic although not easily definable. Respondents recognised the importance of registration, and that nurses have power, although the scope of this needs further exploration. They felt nursing was an inclusive profession, as well as being broad and wide ranging.
Without further research it is impossible to define nursing. It is clear we do need a definition of nursing if we are to thrive as a profession in the 21st century. The COVID-19 pandemic has arguably changed the public's perception of nurses and health professionals. Repeating this study post-COVID-19 pandemic may yield different results. There are historic definitions of nursing that are arguably not applicable to contemporary nursing practice. Any definition would need to include the rapidly expanding nature, scope and role of nursing. With the introduction of other regulated nursing roles, registered nurses are no longer alone in the practice of professional nursing. There are present and future challenges for nursing and a definition may help us to face these together. Without defining nursing, we cannot understand ourselves, let alone our place in the future of health and care practice.
KEY POINTS
- Nursing is an historic, complex and multifaceted profession
- The nursing profession needs a definition to make comprehensive and meaningful contributions to health and care
- This pilot study involved a small-scale study of responses to a survey, which found that people viewed nursing in a positive way. They spoke about nursing with authenticity and demonstrated varying understanding of the role of nursing
- There were differences in understanding of the role of nursing between respondents
- A definition of nursing is needed to ensure nursing remains fit for practice in the 21st century
CPD reflective questions
- Reflect on your own role as a registered nurse or health professional: what is your own personal philosophy of nursing?
- Consider the impact of your own life experiences on your role as a registered nurse or health professional: what individual perceptions and experiences do you bring to your professional practice?
- Do you feel historical perspectives of nursing continue to affect your contemporary practice?
- How might you contribute to the contemporary understanding and definition of nursing?