First year pre-registration nursing student perceptions of community nursing roles: a thematic analysis

Nursing is often considered a rewarding career, with many opportunities to develop personally and professionally (Seitovirta et al, 2018). Perceptions of nursing roles are frequently informed by peripheral sources, which may create an unrealistic image of the contemporary nurse for students embarking upon their professional journey (Glerean et al, 2017). Pre-registration nursing education can provide an opportunity to develop role modelling, generate a sense of belonging to a profession, and may act as a critical foundation for both future academic and clinical experiences (Hill, 2020). Student nurses are the future of the nursing workforce and, as such, must be prepared for complex roles, which may manifest in a different way in reality than portrayed by external media (Slattery et al, 2016).

This study examines the perceptions of a cohort of pre-registration student nurses relating to community nursing roles, to establish their understanding of the diverse nursing roles to be found in the community setting. Students' underpinning knowledge is instrumental in managing personal expectations; their consideration of future placement learning opportunities; and in preparing them for their role in a professional workforce over the course of undergraduate education. These research findings may help to inform development of the current curricula to incorporate community care as an attractive future career option and enhance the student experience for pre-registration nurses.

Background

The Nursing and Midwifery Council (NMC), in its standards for the pre-registration nursing, identified that it is essential to equip student nurses with the skills required to work across both community and secondary care settings (NMC, 2018). This can be achieved by ensuring student nurses have practice learning opportunities in a variety of settings, as a means of meeting the holistic requirements of people across all age groups prior to registration.

The nursing workforce accounts for approximately one-quarter of NHS staff, with registered nurses acknowledged as the largest qualified professional workforce in the UK (Hill, 2020; National Audit Office [NAO], 2020). Nevertheless, the nursing profession faces a recruitment and retention crisis due to its high staff turnover, shortage of nurse educators and an unbalanced workforce distribution (Haddad et al, 2022). Policies have identified the need for a shift from hospital to community care in services, but this ambition has not yet been realised, with priority areas such as primary care, mental health and learning disabilities still in decline (Department of Health and Social Care [DHSC], 2019a; Buchan et al, 2019a). It must be recognised that measuring the total primary care workforce is difficult because of its vast array of clinical professionals and other contributing non-professional, independent providers (Maclean et al, 2014).

Key documents, such as ‘Advancing our health: prevention in the 2020s’; and the NHS Long Term Plan, emphasised health promotion and disease prevention as a key strategy in healthcare (DHSC, 2019a; 2019b). Despite this, the indications are that nursing has an ageing workforce verging toward retirement. These shortages are mainly prevalent in the community, with nursing numbers in 2018 estimated to have fallen to half of the 2010 total (Royal College of Nursing [RCN], 2018). Statistics reveal that the number of school nurses dropped by another 3.1% during 2018/2019 across England, despite research suggesting these services provide a cost-effective preventative approach (Buchan et al, 2019a). A recent audit by the Royal College of Paediatrics and Child Health (RCPCH) reported that only 14.9% of acute services are sustained by round-the-clock community children's nursing provision (RCPCH, 2018). It has been reported that 60% of health visitors have expressed concern that a focus on just those at risk will dilute the notion of a universal service, due to understaffed caseloads (Institute of Health Visiting [IHV], 2018).

The expansion of workloads and the pressure exerted by the COVID-19 pandemic mean that community nurses are in the background, ‘silently’ delivering complex care to people in their own homes (Green et al, 2020). The World Health Organization (WHO) echoes this sentiment, and notes that nurses are the eyes and ears of the communities they serve, having intimate knowledge and skills that require long-term investment in areas of recruitment, education and leadership (WHO, 2020a).

The COVID-19 pandemic enhanced the profile of nurses, but the positive portrayal of the profession in the media has come under scrutiny due to the trend of using hero discourse to normalise a nurse's exposure to risk and compliance to practice (Mohammed et al, 2021). Barrett and Heale (2021) highlighted concerns relating to public perceptions of nurses as self-sacrificing angels, with superhuman qualities. Barrett and Heale (2021) acknowledge that, while this is well-meaning rhetoric, it can contribute to misconceptions surrounding the high-level skillset actually required for the role. In 2021, the UK witnessed a 32% year-on-year increase in nursing applications, with a 40% rise in male applicants and a 39% increase from those over 35 years. This is thought to have been triggered by the efforts of nursing professionals during the COVID-19 pandemic (Ford, 2019; University and Colleges Admissions Service, 2021). However, it is unclear whether this surge in applications is due to the perception of nurses reaching ‘meteoric heights in the public's mind’ (Launder, 2020). Although this has stimulated enrolment, it can be argued that this elevated perception of nursing only applies to acute care settings, as the positive surge in public opinion is rooted in the context and conditions of a global pandemic where critical illness, requiring urgent care, has been most visible. According to the King's Fund (2019), community services are poorly understood compared to other parts of the NHS, despite their vital contribution in improving health outcomes. Consequently, we may surmise that student nurses' initial perceptions of the nursing contribution of community services may also be misguided.

If such misplaced perceptions are evident, as a follow-up measure to this research, the research team will then seek to raise awareness of contemporary nursing roles as a way of changing student nurses' perspectives, enhancing the appeal of community roles in an attempt to address the deficit.

Objectives

The objectives of this study were to understand the perceptions of current first year pre-registration students relating to community nursing roles on the Nursing BSc (Hons) programme of a university in the north west of England, assessed via a series of questions. For the purpose of the study, community nursing was defined as nursing outside of a traditional hospital setting.

Methods

Design

The study design used the qualitative method of a survey, collecting data using an online questionnaire comprising three open questions and one closed question. The questions were structured and directive in order for the research team to identify a baseline of students' knowledge and any substantive gaps on commencement of their nursing education. Obtaining two types of data concurrently during the same data collection session has been acknowledged to be challenging (Creswell and Clark, 2017). The study generated theory from the data collected and, therefore, draws on the concepts of a grounded theory study (Holloway and Galvin, 2017).

The students were in the second week of the pre-registration nursing education programme and, therefore, did not possess any pre-established curriculum knowledge, which would promote bias. The introduction of a voting system via a real-time audience engagement app to capture the information may also have accounted for the high participation and response rate.

Participants

Eligible participants were recruited during the second week of the pre-registration nursing programme of study. The total nursing cohort comprised of 350 students, with 267 adult, 53 mental health and 30 child nursing students; all were invited to participate, with 282 pre-registration student nurses taking part. A population study can be described as a group of individuals who share a common characteristic, from which the researchers seek knowledge or information (Allen, 2017). In this research, the commonality was that all the participants were student nurses embarking on a new programme of study.

Data collection

Data were collected in two group sessions, with students accessing an online questionnaire on the same day as the sessions took place. The online questionnaire was accessible to all students with a mobile or connective device, such as a laptop or tablet, preserving anonymity. This method was beneficial, as it enabled the researchers to gather information in a limited time with minimal resources.

The four questions asked were as follows:

• ‘Can you identify different nursing roles that you would find in the community?’
• ‘Do you see yourself working in the community upon qualification?’
• ‘What portrayals of community nursing can you recall that you have seen in TV/film/programmes/book or other media sources?’
• ‘Which words do you think best descr ibe community nurses?’

The respondents' results were instant, and the students were given the opportunity to ask questions after the session.

Data analysis

The study utilised the method of thematic analysis, which assists in identifying and interpreting patterns and meaning within qualitative data (Vaismoradi, 2016). According to Nowell (2017), qualitative research is increasingly recognised and valued, and thematic analysis can be used alongside this to identify, organise and report themes. Hence, a robust thematic analysis can produce valid findings and is useful for investigating perspectives and insights within qualitative studies, such as the proposed study (King, 2004; Braun and Clarke, 2006).

Methodological considerations

The researchers considered the limitations to this study once data were evaluated. Firstly, the study intentionally employed simplistic questions and a design that could not explore the students' answers in any depth. A longitudinal study of this cohort may provide the opportunity to further clarify areas of ambiguity that the initial survey group has exposed.

The study also relied on a certain level of digital literacy and the capability of the students to use mobile devices to access the questionnaire. This did not prove problematic, as demonstrated by the high response rate. However, there may still have been connectivity or user experience issues that could have prevented or hindered participation.

The researchers have confidence that the above limitations have not undermined the purpose of the initial study. outcomes contribute to limited literature available on this subject.

Ethical considerations

Ethical approval was granted through the participating university (approval reference number: 21/NAH/011). Information about the study, including its potential significance and the risks and benefits of participation, were communicated to the students prior to their participation, which is a best practice requirement (Bowrey and Thompson, 2014). Participation was voluntary, and consent was implied by the participants' decision to actively engage in the questionnaire. Respondents were provided with time to ask questions before and after the study and were aware that they could withdraw from the study or decline to take part at any point without consequence. These are in keeping with the underlying principles of nursing practice, as stated within the NMC Code of Professional Conduct (2018).

Findings

The participation rate varied across the four questions; from a cohort of 350 students, there was a mean response rate of 240 (68.5%). Some explanations for non-response from participants could be time constraints, with respondents having limited time to consider their answers. A lack of knowledge or ability to answer all questions, or connectivity problems, may also explain these variances.

Community nursing roles

Nursing students were asked to identify different nursing roles they would find in the community, with 233 participants providing responses. Participants were able to give multiple answers, with most providing at several answers. Figure 1 demonstrates the number of responses to describe the role.

Working in the community

Students were then asked if they could visualise themselves working in the community upon qualification. Between two groups, 268 students responded. Figure 2 demonstrates the number of students and their answers in percentages.

Sources informing perceptions

The next question aimed to explore the effect that TV, films, programmes, books and other media sources may have had on students' perceptions of community nursing. Some 229 students answered this question. Television, in the form of dramas, news, documentaries and popular series, featured most prominently as being influential to students. The results were split into main themes in order of popularity (Table 1).

Words to describe community nurses

Some 228 participants were able to use words to describe community nurses; the responses were formulated into a word cloud (Figure 3).

Discussion

‘Can you identify different nursing roles that you would find in the community?’

Question 1 provided multiple answers, and a diverse range of nursing roles were suggested. District nursing roles proved to be the most familiar, followed by clinical nurse specialists, which are arguably perceived as the most ‘clinical’ of nursing roles. Associated nursing tasks were also popular; while this did not demonstrate the participant's knowledge pertaining to a specific role, this is not to be discouraged. Bloomfield et al (2015) declared that by showcasing the diverse roles, responsibilities and skills of primary healthcare nurses, myths about it being of a lower status or less skilled can be dispelled. This may have indicated that the identification of a nurse's role by the participants was task-driven.

The frequency rate for non-professional, other professional disciplines and non-specific nursing terms, such as ‘nursing response team’, being mentioned by participants is concerning, but does indicate the potential for education regarding roles within a future curriculum. Education relating to the roles and responsibilities of a variety of community nurses is essential, in order to improve the students' knowledge and associations with the roles moving forward. On a related note, Norman's (2015) qualitative interpretive study investigated the views of young people of secondary school age regarding their perceptions of community nursing. It was found that community roles were not perceived as ‘real’ nursing, and most community nurse experiences were associated with older family members receiving interventions at home (Norman, 2015). This study indicates that education relating to community nursing roles needs broader dissemination than initially considered, to underpin knowledge prior to commencing nurse education.

Community and public health nursing roles are complex and require autonomy and leadership. There is a strong focus on safeguarding the wider public, promoting behavioural changes and sustaining therapeutic relationships. Health visitors, community paediatric nurses and school nurses are specific examples of these complex roles, which had low recognition among the participant groups. The qualities needed for these roles may not be appreciated by pre-registration nurses at this stage in their education; as a result, they may underestimate how diverse and multifaceted community nursing really is (van Iersel et al, 2018).

‘Do you see yourself working in the community upon qualification?’

This question gave the opportunity for definite answers from participants as to whether their career would steer them into working in a community environment. Student nurses are from a variety of different backgrounds at the start of their pre-registration journey, and some individuals may be able to anticipate the rewards that community nursing can offer. It is unclear whether previous adverse experiences or personal desire and choice are underlying reasons for certain students who do not visualise themselves in a community setting upon qualification; this is an area worthy of further more detailed exploration. Emeghebo's (2012) study reported that images of nurses are often focused on the public's image of the profession, as opposed to nurses' opinions and experiences. Emeghebo (2012) acknowledged that students are often astonished at the scope of the learning preparation required during their nurse education. This could indicate that, in relation to those students who were unsure or dismissive of community nursing roles on qualification, there is an opportunity to change their perceptions over the course of their programme. Expanding the pre-registration knowledge base from one that is increasingly secondary care-focused will reinforce positive perceptions of community nursing.

‘What portrayals of community nursing can you recall that you have seen in TV programmes/films/books or other media sources?’

During this study, it became apparent that student nurses had, either currently or in the past, largely watched popular TV programmes, many of which are located in an emergency care setting. It can be argued that this may influence their perception of nursing as a career. However, it is difficult to ascertain whether students will be inspired by entertainment that is glamorised and whether media truly influences their decisions. According to Arias (2018), media can persuade individuals to accept what they are seeing as the social norm, but can also act as an informative learning vehicle. This relates to a systematic literature search of 522 papers, with 39 peer reviewed articles assessed by van Iersal et al (2016), who concluded that many student nurses start their career informed by media representations. These dictate that hospital-based nursing is more advanced, with community nursing perceived as requiring less technical skills and offering higher workloads. However, community nursing makes up a much larger proportion of the health service than secondary care, relying on autonomous, highly skilled practitioners (Harris et al, 2013). Participants' answers from the current study encompassed media portrayals of many healthcare roles and occupations, not just those depicting community roles. Erroneous characterisations of nurses in the media can disseminate inaccurate messages by portraying professionals as reactive practitioners, which can be superficial, stereotypical and damaging to the nursing profession (McAllister et al, 2013).

The emergent theme of ‘international drama’ revealed that the majority of programmes related to healthcare roles consumed by participants were based in US hospitals. Weaver et al (2013) studied viewing habits of nursing students and discovered a potential cultural divide in doing so. Those who spoke English at home watched fewer TV medical dramas than those who did not speak English as a first language. This may prove significant to the adjustment of nursing recruitment processes, as it challenges the expectation that students garner similar ideas about nursing roles from television programmes and media. Medical programmes could raise the profile of nursing and provide recruitment and pedagogical benefits, if used correctly, widening the scope for nurse education (Weaver et al, 2013).

It could be argued that the students' interpretation of the question resulted in a heavy focus on television programmes, as there was a low frequency rate of references to factual news sources and documentaries. The profile of nursing has been raised considerably within the media as a consequence of the pandemic, and global recognition for registered nurses has never been greater (Stillwell, 2019). The WHO designated 2020 as the year of the nurse and midwife on the bicentenary year of Florence Nightingale's birthday to demonstrate the awareness of growing a global nursing workforce (WHO, 2020b). This concentrated on all aspects of nursing and emphasised public health and community nursing roles as key areas for development, which is something potential nursing students may have been exposed to. However, it is thought that media drama, as a medium, can activate multiple senses, support reflection by the experience of others and enable the embodiment of new knowledge (Arveklev, 2018). This may help to explain why television dramatisations are so memorable.

‘Which words do you think best described community nurses?’

The words highlighted in the wordcloud (Figure 4) demonstrated the similar responses given by both groups of students prior to consolidation of the data. Predominant words describing community nurses were associated with personal qualities, such as ‘caring’, ‘compassion’ and ‘kindness’. Although these are generally perceived as positive attributes, they are far from the dynamic, task-driven and emergency-focused professional qualities identified in earlier themes. Timmins et al's (2018) study of student nurses discovered that students identify honesty and altruism as the most essential values in nursing practice. It was reported that students fear that healthcare pressures may have resulted in nursing practices that now focus on task-orientated activities, which can deprioritise the interpersonal, compassionate aspects of the role (Timmins et al, 2018). If this finding is accurate, it does not bode well for recruitment into community nursing positions. Nonetheless, the focus of this study is participants new to nurse education; therefore, the potential to better integrate, educate on and celebrate the attributes required for community and public health roles is achievable.

Generally speaking, participants may have simply lacked insight into the level of care the community sector provides. The aforementioned media sources focused on emergency care delivery, and the terms ‘busy’, ‘challenging’ and ‘courageous’ were some of the least frequently used to describe community roles. McCann et al's (2010) longitudinal study proposed that the coveting of enhanced technical nursing skills by student nurses was influenced by depictions in the media and reinforced during clinical practice rotations. McCann et al (2010) observe that, if a student's preference is to work in acute care at the beginning of their nurse education, this will typically remain unchanged, although it is possible to change disparaging perceptions relating to other career pathways. This provides further reassurance that, through providing more comprehensive education and further developing the nursing curriculum, student nurses may more frequently opt for community nursing roles. Nursing career development frameworks (NMC, 2018; Health Education England, 2022) allude to personal experience being the most influential factor during clinical and educational placements (van Iersel et al, 2016). Therefore, adopting a varied range of placement models across both public and voluntary agencies can inform and inspire student nurses to consider a long-term career in the community (Cable et al, 2015). In addition to this, practice assessors and supervisors who are respectful, caring and empathetic are known to be positive role models and create students who are more engaged and empowered (Porteous and Machin, 2018). Therefore, the more caring attributes identified in this study could be the qualities that attract students to community nursing roles.

Conclusion

This study suggests that student nurses' perceptions of community nursing roles are ambiguous and complex. The impact of the media is strong and comes in several guises, but it is also the case that students' prior experiences with and their personal opinions of the nursing profession all act as sources of influence. From an international perspective, clinicians, academics and professional bodies must contemplate an alliance to urgently promote community nursing strategies. Engaging with media sources and institutions in order to achieve a more accurate and improved representation of community nursing roles and practices is critical, as this can demonstrate the value and reality of these to a wider audience, benefitting recruitment, education and practice. Universities have an opportunity to integrate community nursing and public health education into the pre-registration curriculum from conception. From the practitioner's perspective, strong leadership, role modelling and positive student experiences may help to nurture nursing students' interest in community roles. This will not only validate community nursing as a challenging and desirable professional pathway, but can also act to enrich and diversify the skills required to develop and maintain a sustainable community nursing workforce.

Key points

• Community nursing recruitment is essential to sustain the workforce.
• Students' understanding of community nursing roles are ambiguous.
• Perceptions of nursing are influenced by media sources.
• UK universities must develop educational plans to endorse community nursing.

CPD reflective questions

• How would you describe community nursing roles?
• Do you think media sources contribute to the perception of the nursing profession?
• How should community- and hospital-based nursing placements for students be divided and allocated?
• How can we improve the uptake of community nurses?