Full length article| Volume 15, 101028, May 01, 2022

# Perceptions toward the nursing profession among Ethiopian nurses: A mixed-method study

Open AccessPublished:March 23, 2022

## Abstract

### Introduction

The aim of the present study was i) to determine nurses' perception, ii) to identify factors associated with nurse's perception, and iii) to explore nurses perception towards nursing profession among nurses working in public hospitals in the West Shewa zone, Central Ethiopia.

### Material and methods

A mixed method study was done among 243 randomly selected nurses from May 25-June 20, 2020. Quantitative data were collected using structured self-administered questionnaire and in-depth interview were collected from nurses (n = 11). Quantitative data were analyzed using SPSS version 25 and qualitative data were analyzed through thematic analysis.

### Results

In this study, 54.6% [95%CI (48.0%, 61.0%)] had a good perception towards nursing profession. Those nurses who had a Bachelor of Science in Nursing (BSN), OR = 3.00, 95% CI; 1.55–5.80, P = 0.001, those who earn a monthly salary of 6194 ETB and 3,934 Ethiopian Birr (ETB), OR = 2.28, 95% CI; 1.01–5.16, P = 0.001, Nurse working in primary, OR = 4.39, 95%CI; 1.39–9.95, P = 0.001 were more likely to have good perception towards Nursing profession than those nurses who had a Diploma, those who earn a monthly salary of less than 3,934ETB, and nurse working in Referral hospital respectively.

### Conclusions

Nearly six in ten nurses in the study area had a good perception of the nursing profession. Nurses' level of education, monthly salary income, and type of hospital were nurses working in should be considered for improving nurses’ perception towards their profession and thereby to keep the experienced nurses in their profession.

## 1. Introduction

Perception is defined as the ability to perceive and take awareness of something through the senses. It can also be defined as an idea, creed, or image that you have as a result of the way you see or understand something.
• Hornbey A.
The Advanced Learner's Dictionary of Current English.
Nurses' perceptions toward the Nursing profession may vary according to their age, education, social and work experience, among other reasons.
• Hornbey A.
The Advanced Learner's Dictionary of Current English.
Nurses' poor perception toward the nursing profession results in low job satisfaction and it also leads to an intention to leave their profession which can increase nurses' shortage and create a crisis in the nation's health care system which in turn results in poor quality of health care delivery.
• Hanlon Teresa O’
Define Professionalism in Nursing.
• Kozier B.
• Erb G.
• Berman A.
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Registered Nurses Association of Ontario
Healthy Work Environment Best Practice Guidelines, Professionalism in Nursing.
According to Florence Nightingale's theory, nursing has gone from an underpaid and undesirable career to a highly acclaimed and respected profession.
• Lewis M.
• Urmston J.
Flogging the dead horse: the myth of nursing empowerment?.
Gender stereotyping, poor pay, and poor working conditions are among factors leads to nurse's poor perception.
• Roger W.
• Ian J.
• Amandah L.
• et al.
Perceptions of nursing: a study involving nurses, nursing students, patients, and non-nursing students.
On the contrary, nursing has also been perceived as a caring and nurturing profession which demands a higher physical and emotional strength, patience, and knowledge.
• Shafeah M.
Nurses' perceptions of nursing as a profession and its impact on their intention to leave their career. IOSR.
Many factors might affect the nurses' perceptions regarding to their profession which can includes individual or personal, social, economic, cultural, spiritual, organizational, and other external professional factors.
• Lewis M.
• Urmston J.
Flogging the dead horse: the myth of nursing empowerment?.
Although Nurses constitute a majority of health care professionals; they are largely invisible and have been overlooked about what they do and how they do it. The profession is considered to have a limited role in decision making, lack of professional confidence, fear, insecurity, and a sense of inferiority.
• Salmonson Y.
• Everett B.
• Cooper M.
• Lombardo L.
• Weaver R.
• Davidson P.M.
Nursing as the first choice predicts nursing program completion.
Many experienced nurses are leaving this profession or field and young people are not selecting nursing as a potential career because of the above mention reasons. In the United Kingdom (UK) 25% of nursing students were estimated to leave the profession, and in Canada, 40% of the nursing students quit their studies. Africa as a whole falls below the minimum standard, with 185 health workers for every 100,000 people. The nursing profession is predominantly recognized as the females' profession and is limited to bedside care and drug administration instead of being considered as skilled and well-educated nursing professionals who could play important roles in health care.
• Brodie D.
• Andrews G.
• Andrews J.
Perception of nursing.
American Association of Colleges of Nursing, (AACN)
Fact Sheet: Nursing Shortage.
• Saleh M.Y.M.
• Nassar O.S.
• Amre H.M.
• Froelicher E.S.
Nursing Students perceptions of nursing: a descriptive study of four cohorts.

Jamie White. The Image of Nursing: What it Is and How it Needs to Change, Jones & Bartlett Learning 86-106.

There is a shortage of nursing professionals in the world. American Association of Colleges Nursing study showed that there will be a shortage of 9 million nurses by the year 2030, which poses a serious threat to patient safety. How individuals perceive themselves and how they are perceived by others are an important part of the relationships between nurses, other healthcare providers, and the families they serve.
• Moore M.
Perceptions of Nurses and Mothers in Four Studies of the Peripartum Period.
• Ibrahim A.
• Tawfiq A.
Associate Nursing Students' Perceptions toward a Nursing Profession in Jordan.
• Donelan K.
• Desroches C.
• Dutwin D.
Public Perception of Nursing Careers.
• Prudence P.M.N.
• Samuel A.
• Edward A.
Psychosocial Factors Influencing the Perception and Choice of Nursing as a Profession.
There is a scarcity of data on the nurses' perception toward nursing profession and the factors associated with it among nurses working in public hospitals in developing countries, including Ethiopia. The current study would help nurse's administrators and hospital managers to understand the nurse's perception towards nursing profession and to improve factors that contribute for poor perception towards nursing profession in the study area. Thus, aim this study was to assess nurses' perception towards the nursing profession and associated factors among nurses working in public hospitals found in the west Shewa zone, Oromia region, Central Ethiopia.

## 2. Material and Methods

### 2.1 Study settings

The study was conducted from May 25 – June 20, 2020, in the West Shewa zone, the central part of Ethiopia. West Shewa zone is bordered on the south by the southwest Shewa zone and the Southern Nations, Nationalities and Peoples Regional State, on the southwest by Jimma zone, on the West by East Wollega zone, on the northwest by Horo Gudru Wollega zone, on the north by the Amhara Regional State, on the northeast by North Shewa, and on the East by Oromia Special Zone surrounding Finfinne. Its capital Ambo town is located 114 km to the west of Addis Ababa-the national capital city. According to the report from the west Shewa zonal health department, west Shewa had 22 districts with a total population of 26, 52,781 during the study period. The zone had 8 public hospitals, 91 health centers, 482 health posts, and a total of 570 Nurses working in those public hospitals.

### 2.2 Study design and population

This cross-sectional study design used a mixed-methods approach. All nurses working in public hospitals found in the west Shewa zone during the study period were a source population, while all randomly selected nurses working in public hospitals found in the west Shewa zone were the study population. Nurses who were working in public hospitals in west Shewa zone were included in this study and Nurses who were on study leave during data collection period were excluded in this study.

### 2.3 Sample size and sampling technique

The sample size was calculated using single population proportion formula with the following assumptions: 95% confidence interval (CI), 5% margin of error, and the prevalence of Nurses perception toward nursing profession (p = 52.4%) from a study done in Debre Birhan town, Ethiopia, 2015.
• Mikiyas A.G.
• Bogale E.S.
Assessment of Nurse's perception towards their profession and factors affecting it in Debre Berhan town governmental health institution, Debre Berhan, Ethiopia.
Therefore, the sample size was determined as follows: Thus, n =
$n=(1.96)2(1−0.524)(0.524)(0.05)2,n=≈384$

Where; Z = 1.96 with 95% of confidence internal.
• p = prevalence of Nurses perception toward nursing profession q = 1-p
• d = margin of sampling error tolerated (0.05)
• n = the required sample size.
Therefore, by adding 10% non-response rate (384 + 38), n = 422 was taken and since the source population is < 10,000, the finite population correction formula was employed
$n=ni1+niNn=4221+422/570,n=243$

Where n = Sample size from finite population.
• ni = Sample size from infinite population
• N = Total number of Nurses working public hospitals
Thus, the final sample size was found to be 243 Nurses.
The calculated sample size was proportionally allocated to each public hospital for the quantitative part, while the Sample size for qualitative analysis was determined based on data saturation ideas. The interviewed was done for 15 nurses until the data was saturated. The study participants were selected through a simple random sampling technique by lottery method using their list from each hospital's human resource department as a sampling frame. Among the 238 study participants, 15 nurses further consented to take part in the in-depth interview (9 nurses from Ambo University Referral Hospital and 6 nurses from Ambo General Hospital).

### 2.4 Data collection and quality control

Data were collected using 35 Nursing Dimension Inventory Stem questions which were adopted from the study conducted in the UK and Spain
• Brodie D.
• Andrews G.
• Andrews J.
Perception of nursing.
was used for the quantitative part of this study. The questionnaire was translated from the English language to the local language (Afaan Oromoo) translated back to English by two different language experts. The quantitative data collection tool consists of socio-demographic variables (Age, sex, marital status, educational status, salary, and work experience), occupational factors (types of hospitals Nurses working in), 35 Nursing dimension inventory stem questions, and two questions related to nurses future perceptions towards the nursing profession.
• Abdelmaksoud Farida S.
• Eglal A.A.W.
Nursing staff 'perception regarding factors affecting their performance in selected governmental hospitals in Egypt.
• Liya W.
Assessment of Nurses' Perception towards a Nursing Profession in Public Hospitals under Addis Ababa Health Bureau.
For the qualitative study, a semi-structured interview guide was developed by reviewing works of literature and used for an in-depth interview. The questions were used to collect how nurses perceive the nursing profession, what influences the nurses' perception towards the nursing profession, and what makes them quit their job.
For the quantitative part, five Bachelor of Science in Nursing (BSN) collected the data through a structured self-administered questionnaire and supervised by two MSc Nurses. The study participants were independently responded to the question without data collectors interference and those study participants who were selected by lottery method gave data for data collectors in separated room alone. The researchers were not present during the data collection rather checking the completeness the data after it was collected by data collectors. For the qualitative part, one BSc Nurse collected the data through an in-depth interview conducted in a local language (Afaan Oromoo). The data were recorded by audio recorders supported by note-taking.
To assure the data quality, the questionnaires were translated into local languages. The data collectors and supervisors were given one day's orientation on the study tool and the data collection approach. The first author (MRT) provided a one-day orientation for data collectors and supervisors about the purpose of the study, the tools, ethical issues, and the interview approaches. Before the actual data collection, the data collection tools were pre-tested among 5% of the sample size (12 nurses) in Tullu Bollo hospital which is found in southwest Shewa zone-a a nearby zone to the study setting. The reliability and validity of the study tool were estimated. The result of reliability tests showed that Cronbach's alpha for the 35 Nurses Dimension Inventory Stem question was 0.83 on the pre-test. After pre-test and revision from experts, some modifications were incorporated for its validity. Then necessary comments and feedbacks were incorporated into the final instrument.
Qualitative data quality was ensured by enhancing the trustworthiness and rigor of the study findings. The in-depth interview records and the note-taking were transcribed immediately after the interview was conducted.

### 2.5 Data processing and analysis

The collected quantitative data were checked for completeness, entered into EpiData version 3.1, and exported to SPSS version 25 for analysis. Data were cleaned by running the frequency and cross-checking any missing variable from the hard copy. Nurses perception towards nursing profession which was measured by a value of a 35 nursing dimension inventory stem questions having a 1 to 5 point likert scale (1 = not important to 5 = very important). It was scored on a scale of 35–175 with a score of 35–119 (< mean value) is regarded as a poor perception while a score of 120–175 (≥ mean value) is regarded as good perception. Reliability tests for the assessment tool showed that Cronbach's alpha was 0.83 on pre-test. After pre-test and revision from experts some modifications were incorporated for its validity. Descriptive statistics were calculated by bivariate statistical analysis. The normality of the data was checked, and mean was used. Multivariable regression was performed using bivariate Analysis. More than two independent variables were measures against the dependent variable to control confounder. Variables that yield p-value of <0.25 in bivariate analysis were considered as candidate for multivariable logistic regression. For measuring the strength of the association between the outcome and independent variables, adjusted odds ratios (AOR) along with 95% confidence interval (CI) were calculated. The fitness of the model was tested by Hosmer Lemeshow's goodness of fit test, and accordingly, the model was considered fit because it was insignificant (yield p > 0.05). Finally, statistical significance was declared at a p-value <0.05.
For the qualitative data, thematic analysis was done in this study. First, all interviews were audio-recorded and the data collector took additional notes. The recorded tape has listened and transcriptions were read and re-read several times carefully. From the potentially important and provisional notes, the researcher noted the interrelationships, connections, and patterns that emerged in data. The audio recordings were transcribed verbatim, leaving out the 'aahs' and 'oohs' sounds to create verbatim written accounts. Thematic analysis was conducted to identify themes and subthemes. According to Braun & Clarke, thematic analysis is a method for identifying, analyzing, and reporting patterns (themes) within data.
• Braun V.
• Clarke V.
Using thematic analysis in psychology.
The process of analysis in this study started first, to familiarize data, notice, and look for patterns of meaning and issues of potential interest in the data. This phase is followed by generating initial codes and searching for themes, reviewing themes, and defining and naming themes. Second, the coded transcripts were done independently to create a list of themes. Finally, the results were written.

## 3. Results

### 3.1 Socio-demographic characteristics of study participants

Two hundred thirty-eight, (97.9%) of the participants fully responded to the questionnaires but five (2.1%) questionnaires were incomplete and rejected from the analysis. One hundred thirty (54.6%) were females. About half of the study participants, 124 (52.1%) were married and 146(61.3%) were BSc holders. Regarding work experiences, 128(53.8%) of respondents had less than five years of work experience with the mean year of work 5.81(±4.893 SD) (Table 1).
Table 1Socio-demographic characteristics of Nurses working in public hospitals of West Shewa zone, Oromia region, Central Ethiopia, 2020 (n = 238).
VariablesFrequencyPercent (%)
Sex
Female13054.6
Male10845.4
Age group (years)
20–2912251.3
30–3910343.3
40–49135.4
Mean ± SD30.05(SD ± 5.190)
Marital Status
Married12452.1
Unmarried10443.7
Others104.2
Education level
BSc degree14661.3
Diploma9238.7
Work experience in years
≤412853.8
5–85723.9
≥95322.3
Mean ± SD5.81 (±4.893)
Monthly income in birr
<39343816.0
3935–61937531.5
6194 and above12552.5
Mean ± SD5962.68 (±1796.052)
Types of hospital nurses work in
Primary Hospital11648.7
General Hospital6527.3
Referral Hospital5723.9
Note: a separated & divorced.

### 3.2 Nurses perception towards nursing profession

Approximately, one hundred twenty (SD = 26.844) was the mean perception score of study participants. More than half of nurses, 130 (54.6%) [95% CI (48.0%–61.0%)] had good perception towards nursing profession and the remaining 45.4% (n = 108) had poor perception (Fig. 1).

### 3.3 Why do nurses want to leave their profession?

Among the study participants of this study, 117 (49.2%) reported they have an intention to leave the nursing profession. The main reason that caused an intention to leave the nursing profession was work burden, 52.14% (88), followed by the low salary which was 35.04% (Fig. 2).

## 4. Factors associated with nurses’ perception

In a Bivariate Analysis; sex, educational status, year of work experience, monthly income, and the types of hospital Nurses working in were significantly associated with nurse's perception towards their profession (Table 2).
Table 2Bivariate analysis of nurses' perception towards nursing profession among Nurses working in public hospitals in the west Shewa zone, Oromia region, Central Ethiopia, 2020 (n = 238).
VariablesCategoryPerceptionCOR(95%CI)
Good

N (%)
Poor

N (%)
SexMale54(50.0)54(50.0)0.71(0.43, 1.19)
Female76(58.5)54(41.5)1
Educational statusDiploma57(62.0)35(38.0)1
BSc degree73(50.0)73(50.0)1.63(0.96, 2.77)
Work experience≤4 years65(50.8)63(49.2)1
5–8 years35(61.4)22(38.6)1.54(0.82, 2.91)
≥9 years30(56.6)23(43.4)1.26(0.66, 2.41)
Monthly income in Birr<393416(42.1)22(57.9)0.67(0.31, 1.47)
3935–619373(60.3)48(39.7)1.41(0.80, 2.50)
≥619441(51.9)38(48.1)1
Types of hospital Nurses work inPrimary Hospital18(31.6)39(68.4)0.33(0.16, 0.69)
General Hospital74(63.8)42(36.2)1.25(0.67, 2.33)
Referral Hospital38(58.5)27(41.5)1
Note: COR= Crude Odd Ratio.
In multivariable logistic regression analysis, only educational status, monthly income and the types of hospital nurses were working in sustained their association with nurse's perception towards their profession. Those nurses who had a Bachelor degree (BSc) were 3 times more likely to have good perception than those nurses who had diploma [AOR: 3.00 (95% CI: (1.55–5.80)], p = 0.001 and those who earn a monthly salary of 6194 ETB and above were 2.28 times more likely to have good perception than those who get less than 3934ETB [AOR: 2.28 (95% CI: 1.01–5.16)], P = 0.001. The likelihood of having a good perception was 4.39 times more likely among Nurses who were working in primary hospitals compared to those who work in Referral Hospital [(AOR: 4.39 (95%CI: (1.39–9.95)]. Those nurses working in general hospitals were 6.09 times more likely to have good perception than those who were working in Referral Hospital [(AOR: 6.09 (95%CI: (2.84–13.01)], P = 0.001 (Table 3).
Table 3Factors associated with nurses' perception among Nurses working in public hospitals in the West Shewa zone, Oromia region, Central Ethiopia, 2020 (n = 238).
VariablesCategoryPerceptionCOR(95%CI)AOR(95%CI)
Good

N (%)
Poor

N (%)
SexMale54(50.0)54(50.0)0.71(0.43, 1.19)*0.67 (0.38, 1.18)
Female76(58.5)54(41.5)11
Educational statusDiploma57(62.0)35(38.0)11
BSc degree73(50.0)73(50.0)1.63(0.96, 2.77)*3.00(1.55, 5.80)**
Work experience≤4 years65(50.8)63(49.2)11
5–8 years35(61.4)22(38.6)1.54(0.82, 2.91)*0.57(0.23, 1.41)
≥9 years30(56.6)23(43.4)1.26(0.66, 2.41)1.267(0.55,2.93)
Monthly income in Birr<393416(42.1)22(57.9)0.67(0.31, 1.47)0.61 (0.20,1.89)
3935–619373(60.3)48(39.7)1.41(0.80, 2.50)*2.28(1.01, 5.16) **
≥619441(51.9)38(48.1)11
Types of hospital Nurses work inPrimary Hospital18(31.6)39(68.4)0.33(0.16, 0.69)*4.39(1.93, 9.95)**
General Hospital74(63.8)42(36.2)1.25(0.67, 2.33)6.09(2.84,13.01)**
Referral Hospital38(58.5)27(41.5)11
Notes: ** p-value < 0.05. AOR = Adjusted Odd Ratio.

## 5. Themes

Fifteen in-depth interviews were conducted. Three main themes emerged from the data, and these were 1. Nurses' characteristics and content of nursing work 2. What influences the nurses’ perception about the nursing profession, and 3. What makes nurses quit their jobs or leave their nursing profession? These are supported by quotes in nurses' own words.

#### 5.1.1 Nurses characteristics

This theme emerged from five in-depth interviews during which nurses described their perceptions towards the nursing profession. Nurses highlighted a Nurse's characteristics when Nurses were well in physical conditions. They described a suitable character for the nurse as brave, social, and which requires the ability to cope with stress and good physical condition. “As a Nurse, you have to lift people frequently and thus must be in a good physical condition so that you can do that. Nurses have to lift patients and move them from one place or position to another, feed patients, take them to the toilet and help them to the shower.” (A 33 years male nurse from Ambo General Hospital).

#### 5.1.2 Content of nursing work

This theme emerges from seven interview participants. Theoretical competence was described as a legal competence related to nursing work. Understanding the rights, responsibilities, and competencies related to the laws that guide nurses to work and having knowledge in anatomy, physiology, hygiene, equipment needed, and medications related to nursing work. Working skills such as professional nursing skills, communication skills, and management skills are needed in the nursing profession. Nurses recognized nursing tasks such as helping and caring for patients, being beside the patients, and making independent decisions in the nursing profession. “In my experiences, nurses were seen as assistants to doctors who have an assistance role in inpatient care. For instance, nurses were said to support and assist doctors and should perform all the tasks left over by doctors. I think if Nurses have to take every order from physicians/doctors and must apply it; there is no need to waste four years in university/colleges/nursing schools to graduate in BSc Nursing.” (A 36 years male nurse from Ambo University Referral hospital) Said,” Nurses have no power to decide on anything rather than doing what they are ordered by the doctor.” Nurses are making no decisions; physicians are in a position to make overall decisions in inpatient care. Almost all the decisions come from doctors even to give pain killers such as paracetamol."

#### 5.1.3 Career development in the nursing profession

A career in nursing was discussed among nurses through education opportunities, nurses' employment conditions, and future career options in ‘nursing. One Nurse gave the following explanation: “I know many Nurses who worked for more than ten years in public hospitals without getting any opportunity for further education. Getting the opportunity for further education remained very rare in this hospital.” (A 29 years female nurse from Ambo University Referral hospital).

### 5.2 Theme 2

#### 5.2.1 Personal factors

Personal factors include skills acquired and knowledge of the nurse which determine how she/he responds to the physical, cognitive and psychosocial demands of the work. Included among these factors are commitment to patient care, personal values, and self-confidence. Provided the following explanation: “I believe that Nurses must be strong enough physically, knowledgeable and cooperative. But, what I have seen in this hospital was different. Some of the nurses act carelessly in their daily activities.” (A 29 years female nurse from Ambo University Referral hospital).

#### 5.2.2 Family members related factors

Family members influence nurse's perceptions. Especially husband's influence was seriously mentioned during the interviews. One female Nurse reported that her husband is against her activities in nursing, hoping for something better. Another Nurse said “My husband frequently asked me to resign my job as a nurse. He always told me not to continue with nursing because he doesn't want me to be wound care provider or dressing changer.” (A 35 years male nurse from Ambo University Referral hospital).

#### 5.2.3 Media related factors

The nurses described using media such as the internet, radio, and television to get information about the nursing profession. However, the media's view about nursing was reported as being negative. The real image of nursing should be promoted and Nurse Academicians need to be more active in public discussions or on media and raise the visibility of nursing science/profession to support and promote professionalism. “Nurses work in the hospital and the views of the general public for nurses are very far away from the reality. So, I think that media must be able to work on these gaps, and nurse educators must influence the stakeholders to expose really who the nurses are.” (A 27 years female nurse from Ambo General Hospital).

#### 5.2.4 External professionals’ factors

Close teamwork is an essential element in healthcare. Nurses were seen to work in collegial teams and also with other healthcare professionals, such as doctors, midwives, and laboratory personnel. “Many health care professionals take care of a single patient. So, as a nurse, you have to be able to work and communicate with them. But nurses were meant to report the patients' information to the doctors and consult them when needed. However, in reality, most of the time the relationship is described with nurses being inferior to doctors and nurses are considered as doctors' helpers.” (A 28 years male nurse from Ambo University Referral hospital) “I think that my colleagues are helpful and supportive. There is good cooperation between nurses in the surgical ward.” (37 years male nurse from a hospital).

#### 5.2.5 Occupational factors

Occupational factors are characteristics of the scope of practice, interdisciplinary relationships, nature, and role of the profession. These factors are the scope of practice, level of autonomy, and interdisciplinary relationships. One Nurse said: “I have seen many nurses in this hospital; they did not know the scope of their nursing practice and some of them were practicing out of their job descriptions. Nursing is working to get many other positive aspects than salary. The pleasure of helping others was mentioned as a positive side of nursing work.” (A 39 years male nurse from Ambo General Hospital).

### 5.3 Theme 3

#### 5.3.1 Work habit

Four participants felt that the heavy workload was difficult to manage effectively within the working hours in a day. One nurse said that: “I will change my job within the coming one year because of the heavy work burden, low salary, bad attitude of the physicians for nurses, how the chronic nurses'(nurses who worked long years) especially female nurses perceive their profession and the image the general public have for the nursing profession.” (A 27 years male nurse from Ambo University Referral hospital).

#### 5.3.2 Educational career

Nursing education was described as an opportunity for further education as good for a nurse. “As to me, there is a limited chance for professional development. I have been working for six years in this hospital, but till now I did not get a chance for further education. Not only me but also I have one friend who has worked for several years and changed his profession because of a lack of opportunity for education. So, within a short time, I will be changing my profession.” (A 41 years female nurse from Ambo University Referral hospital).

One nurse said that: “I do not allow anyone to give me unfair decisions from the administrative bodies. The last time I saw a nurse who breaks a rule in this hospital and got a written warning letter, but similarly, I saw a physician with a similar mistake but did not get even an oral warning. Upon seeing such a very biased treatment, I decided to leave the profession.” (A 28 years male nurse from Ambo General Hospital).

## 6. Discussion

This study was conducted to assess the perception of nurses towards the nursing profession and factors associated with it among nurses working in public hospitals of West Shewa Zone, central Ethiopia. We found that more than half, 54.6% [95%CI (48.0, 61.0)] of study participants had a good perception of the nursing profession. Educational status, monthly income, and types of hospital nurses were working in were factors associated with their perception of the nursing profession.
The prevalence of good perception in this study is consistent with similar previous studies from Debre Berhan, Ethiopia (52.4%)
• Mikiyas A.G.
• Bogale E.S.
Assessment of Nurse's perception towards their profession and factors affecting it in Debre Berhan town governmental health institution, Debre Berhan, Ethiopia.
• Liya W.
Assessment of Nurses' Perception towards a Nursing Profession in Public Hospitals under Addis Ababa Health Bureau.
However, it is lower than the study done at Mekelle Town in Tigray, where 124 (91.8%) of nurses had a favorable attitude toward the nursing profession.
• Zaid T.G.
• Gerezgiher B.A.
Assessment of nurses knowledge and attitude towards nursing profession at public hospitals in Mekelle town, Tigray, Ethiopia.
This difference might be attributed to differences in the study settings, variations in the sample size, and differences in sampling techniques.
We found that nurses who had a Bachelor of Science in Nursing (BSN) were more likely to have a good perception of a nursing profession than those nurses who had a diploma. Similar findings were obtained from, Jordan
• Ibrahim A.
• Tawfiq A.
Associate Nursing Students' Perceptions toward a Nursing Profession in Jordan.
• Liya W.
Assessment of Nurses' Perception towards a Nursing Profession in Public Hospitals under Addis Ababa Health Bureau.
This might be because as the educational level advances, the awareness about the role of nurses and job description could increase resulting in a better perception.
Furthermore, nurses who earn a monthly salary of ≥6194 Ethiopian Birr (ETB) were more likely to have a good perception than those who earn <3934ETB. Similar findings were previously reported from Debre Berhan, Ethiopia [19], and Malaysia where good salary; stability, and low stress were the primary factors that influence joining the nursing profession.
• Asma K.
• Iram M.
• Ali W.B.
• Syed A.G.
Assessment of nursing student perception towards, nursing profession in Sir Ganga Ram Hospital and Ittefaq Hospital Trust Lahore, Pakistan.
This implies that as the nurses get an increase in their monthly salary, their perception towards the nursing profession also gets increased.
Nurses working in Primary and General Hospitals were more likely to have a good perception than those who work in a Referral Hospital whereas nurses working in General hospitals. This finding is similar to study reports from Addis Ababa, Ethiopia.
• Liya W.
Assessment of Nurses' Perception towards a Nursing Profession in Public Hospitals under Addis Ababa Health Bureau.
In the current study, we found that nearly half, 117(49.2%) of the nurses who participated in this study had an intention to leave their profession. The main reason to cause the intention to leave their nursing profession was reported as work burden 88(52.14%) and the second leading cause was low salary, 56 (35.04%). This finding is similar to study reports from Al-Jamhory Teaching Hospital nurses were intended to leave their profession due to low salary, work burden, inconvenient environment, and administration issue.
• Hanaa H.M.
• Ahmed K.S.
Assessment of nurses' perception about the nursing profession in Al-Jamhory Teaching Hospital.
This finding is lower as compared to the previous Ethiopian studies from Debre Birhan (53.4%),
• Mikiyas A.G.
• Bogale E.S.
Assessment of Nurse's perception towards their profession and factors affecting it in Debre Berhan town governmental health institution, Debre Berhan, Ethiopia.
Jimma town (56.4%)
• Gizaw A.B.
• Lema T.B.
• Debacho W.W.
• Geremossa G.M.
Intention to stay in nursing profession and its predictors among nurses working in Jimma zone public hospitals, south west Ethiopia.
• Liya W.
Assessment of Nurses' Perception towards a Nursing Profession in Public Hospitals under Addis Ababa Health Bureau.
Ethiopia and also American nurses had an intention to leave their profession because of workload; burnout and quality of care at the workplace that has also influenced nurses’ intention to leave their job.
• Hanaa H.M.
• Ahmed K.S.
Assessment of nurses' perception about the nursing profession in Al-Jamhory Teaching Hospital.
,
• Atefi N.
• Abdullah K.L.
• Wong L.P.
• Mazlom R.
Factors influencing registered nurses perception of their overall job satisfaction: a qualitative study.
These differences might be due to recent salary increments for nurses in Ethiopia which could have positively influenced their perception and intention. The qualitative study also supported this idea as one of the participants revealed “I will change my job due to work burden, low salary, and pressure from a physician, how the chronic nurses' especially female nurses' perceive their profession and the view of the general public have for the nursing profession".
This study also revealed that personal factors, family members, media, occupational factors, and other health care providers influence nurses' perception of the nursing profession. This is in line with the previous studies in Addis Ababa, and Debre Berhan, Ethiopia in which occupational (50%), individual (20%), salary (71.8%), skill and knowledge of nurses (52.4%), policies and regulations at the provincial/territorial, national and international level (34.0%) respectively were factors that affect nurses perception towards nursing profession.
• Mikiyas A.G.
• Bogale E.S.
Assessment of Nurse's perception towards their profession and factors affecting it in Debre Berhan town governmental health institution, Debre Berhan, Ethiopia.
,
• Liya W.
Assessment of Nurses' Perception towards a Nursing Profession in Public Hospitals under Addis Ababa Health Bureau.
The qualitative aspect of this study has supported this finding as one respondent stated.” I believe that nurses must be physically strong, knowledgeable, and cooperative. But, what I have seen in this hospital was different. Some nurses act carelessly.
Nurses who participated in the present study highlighted that “Nurse thinks to change the jobs within the coming one year because of work burden, low salary, and bad attitude physicians had for nurses and most of the decisions come from doctors even to give pain killers such as paracetamol”. This finding was supported by a study from Iran which has revealed that ‘one Nurse was happy with her job as a nurse but she is working with few leave or rest and with low salary and ‘I do not know who I am. Am I a nurse, auxiliary nurse, or secretary? We are responsible for everything because there is no enough staff.
• Mohsen A.H.
• Marzieh K.
• Negin M.A.
Nurses' Perception of Occupational Stress and its Influencing Factors: in Kashan University of Medical Sciences, Kashan, Iran.
Many times patients may suffer from pain for a couple of hours, and I cannot give him/her even one acetaminophen (pain medication) without doctors’ orders.
• Atefi N.
• Abdullah K.L.
• Wong L.P.
• Mazlom R.
Factors influencing registered nurses perception of their overall job satisfaction: a qualitative study.
This indicated that there is an influence from physicians, salary, stressful working environments, and others that could result in nurses change their nursing profession.
For future researchers.
• Future studies should do studies with case-control and/or comparative designs may determine true predictors of nurse's perceptions and differences in terms of type of working hospitals.
For Clinical implications for nursing managers and policymakers.
• Those Nurse with positive attitude toward their profession expected to give standardized and better clinical service than those with negative attitude. Therefore identifying those with negative attitude and working to change their attitude has clinical implication.
• Nurses should get the more education opportunity to develop their career.
• Implement initiatives to improve nurses' benefits such as incentives.
One of the strengths of this study was that it used a mixed-method approach not to miss the qualitative factors that could affect nurses' perceptions. But, since the in-depth interviews were conducted only in Ambo General and Ambo University Referral Hospitals which might not fully represent the conditions of nurses working in the remaining public hospitals. The cross-sectional nature of the study could not enable it to establish a cause-effect relationship between the outcome variable and the covariates.

## 7. Conclusions

Nearly six in ten nurses in the study area had a good perception of the nursing profession. Nurses' level of education, monthly salary scale, and type of hospital the nurses were working in should be considered for improving nurses' perception towards their profession and thereby to keep the experienced nurses in their profession.

## Ethical approval and consent to participate

Ethical approval to conduct this study was obtained from the ethical clearance committee of Ambo University, College of Medicine and Health Science (Ref. No: PG/40/2020). An official letter was sent to the west Shewa zonal health department. Written and signed consent was obtained from all study subjects for their participation after the nature of the study is fully explained to them in their local languages. The study participants were informed that data will be kept private and confidential and used only for research purposes. Confidentiality of the responses was maintained by coding. Personal privacy and cultural norms were maintained as promised.

## Availability of data and materials

The data and all supporting materials used in the preparation of this manuscript are freely available from the corresponding author at reasonable request.

## Funding

The funding for this study was obtained from Ambo University as part of a master thesis for the first author (MRT). The funding body has no role in designing the study, collection, analysis, and interpretation of data, in writing the manuscript, and whether to publish the paper or not.

## Declaration of Interest/Competing Interest of Statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

## Authors’ contributions

All authors made substantial contributions to the conception and design of the study, acquisition, analysis, and interpretation of data took part in drafting the article or revising it critically for important intellectual content and gave final approval of the version to be accountable for all aspects of the work.

## Acknowledgments

The authors are thankful to Ambo University for the financial supports to conduct this study. Our thanks also go to west Shewa zonal health office staff, the study participants, data collectors, and field supervisors for their direct or indirect contributions to this study.

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