A Metaphorical Analysis of Postgraduate Nursing Students' Perceptions of the Nursing Profession

Abstract

Background: Metaphorical analysis of nursing presents a valuable opportunity to describe, understand, and explore this profession. Objective: The aim of this study was to analyze through metaphor how nurses receiving postgraduate education perceive the nursing profession. Methodology: This mixed methods, descriptive study included 85 postgraduate nursing students who volunteered to participate. The data were collected using a Descriptive characteristic data such as age, employment status and duration were collected and the students were asked to complete the statement "A nurse is like .... because...". The metaphors were coded and categorized, then analyzed for associations with the students' descriptive characteristics. Results: It was found that 81% of the postgraduate nursing students were master degree, 93.7% were female; and their average age was 27±4.73. According to the findings of the study, the postgraduate nursing students identified 50 metaphors for the nursing profession that were grouped into 13 categories based on conceptual themes. Of the 50 metaphors produced by the participants, 38 (76%) metaphors were positive and 12 (24%) metaphors were negative in nature. The two most common metaphors were "mother" (n=7, 8.8%) and "angel" (n=7, 8.8%). Conclusions: Metaphors can be used as a powerful intellectual tool to describe, bring multifaceted meaning to, and develop new insights about the nursing profession with our cognitive perceptions.

Headnote

Abstract

Background: Metaphorical analysis of nursing presents a valuable opportunity to describe, understand, and explore this profession.

Objective: The aim of this study was to analyze through metaphor how nurses receiving postgraduate education perceive the nursing profession.

Methodology: This mixed methods, descriptive study included 85 postgraduate nursing students who volunteered to participate. The data were collected using a Descriptive characteristic data such as age, employment status and duration were collected and the students were asked to complete the statement "A nurse is like .... because...". The metaphors were coded and categorized, then analyzed for associations with the students' descriptive characteristics.

Results: It was found that 81% of the postgraduate nursing students were master degree, 93.7% were female; and their average age was 27±4.73. According to the findings of the study, the postgraduate nursing students identified 50 metaphors for the nursing profession that were grouped into 13 categories based on conceptual themes. Of the 50 metaphors produced by the participants, 38 (76%) metaphors were positive and 12 (24%) metaphors were negative in nature. The two most common metaphors were "mother" (n=7, 8.8%) and "angel" (n=7, 8.8%).

Conclusions: Metaphors can be used as a powerful intellectual tool to describe, bring multifaceted meaning to, and develop new insights about the nursing profession with our cognitive perceptions.

Keywords: Nurse, nursing profession, nursing perception, metaphor, postgraduate student.

Introduction

The Turkish Language Society defines metaphor as a figure of speech involving "a word used to convey an idea other its real meaning by way of association or comparison" or "using a word or a concept in a way that conveys meanings beyond its accepted literal sense" (www.tdk.gov.tr). Metaphors are cognitive models that help people understand a phenomenon by means of another phenomenon (Saban, 2008). It serves as an expression of how a concept or phenomenon is perceived by comparison with more familiar concepts (Yilmaz, Gocen & Yilmaz, 2013). This involves explaining or describing an abstract concept by relating it to a concrete concept, focusing on the similarities between the two (Senel, 2016).

In recent years, 'metaphor' has been utilized in numerous educational studies in the national and international literature to determine what meaning individuals attribute to various concept (Alger, 2009; Botha, 2009; Inbar, 1996; Guerrero & Villamil, 2002; Shaw, Massengill, & Mahlios, 2008; Forceville, 2002; Aydin, 2010; Aydin & Unaldi, 2010; Coskun, 2010; Kaya, 2010; Kaya, Coskun & Aydin, 2010; Saban, 2004; Saban, 2008; Saban, 2009; Saban & Kocbeker, 2006; Toremen & Doş, 2009; Arslan & Bayrakci, 2006; Ozturk, 2007; Cerit, 2008). These studies focused on the use of metaphor to analyze how the participants perceived concepts and phenomena such as "teacher", "university instructor", "student", "information", "manager", "inspector", "school", "culture", "geography", and "'climate".

For nurses, metaphors are a means "to better understand their skills, knowledge, and attitudes; to consolidate these qualities and reflect them through their behavior and lives; and to creatively express their feelings and opinions" (Sharoff, 2007). Metaphorical analysis of nursing presents a valuable opportunity to describe, understand, and explore this profession. In addition to imbuing the nursing profession with multifaceted meaning and providing new insights, metaphors can also enable a deeper understanding of how nurses define, prioritize, and internalize their practice (Sharoff, 2009). Sharoff (2007) described the metaphoric perceptions of nurses as a window to the nursing practice and its ambiguities and complexities (Sharoff, 2007). Many metaphor studies have been conducted on ethical concepts related to therapeutic care in nursing with a focus on raising nurses' awareness, and on nursing itself (Sharoff ,2007; Milton, 2009; Wurzbach, 1999; Engebretson, 2002; Gokenbach, 2006; Sharoff, 2013). As the nursing profession has developed and progressed through history, the metaphors related to nursing have also changed. At the end of the 19th century, nursing metaphors expressed "loyalty to doctors and patients", whereas 20th century changes in social structure and perceptions of self-worth (e.g., participation in the decision-making process) led to the emergence of new metaphors (Sharoff, 2009; Wurzbach, 1999). The contradiction between the legal metaphor of advocacy and the academic metaphor of rationalist thought about ethics were expressed as 'ethical responsibilities and preferential services" in the 1960s and 1970s (Sharoff , 2009). In a qualitative study of holistic nursing, some of the themes that emerged from the metaphors used by the participating nurses were "butterfly, desire to change"; "universe or being more than physical beings"; "lights or radiating lamps"; "guiding angel" ;and "an ocean wave or wave of change " (Sharoff, 2009).

These studies offer insight regarding how nurses have perceived the nursing profession and which metaphors they used in their respective time periods. There are no studies in the literature about metaphors used by postgraduate nursing students to express their perceptions of 'the nursing profession". This study is the first conducted in Turkey to evaluate the perceptions of postgraduate nursing students about the nursing profession using metaphorical analysis, and therefore makes a novel contribution to the literature in this area.

Our metaphorical analysis of how nurses receiving postgraduate education perceive the nursing profession was based on the following research questions:

* What metaphors do the students use to express their perceptions of the nursing profession?

* Into what conceptual categories can the metaphors be grouped?

* How do the categorized metaphors differ between age groups?

* How do the categorized metaphors differ according to work experience?

Methodology

Research Design: The research was conducted as a mixed methods (qualitative/quantitative), descriptive study.

Research Setting: The study was conducted between June 25 and August 25, 2017 with postgraduate nursing students attending a university in Izmir, Turkey.

Study Sample: In qualitative studies, sample size is determined during the course of the study. Data collection is discontinued when data saturation is reached and the data become repetitive (Erdogan, 2014; Streubert & Carpenter, 2010). Therefore, using the purposive sampling approach, 85 nursing students aged 18 years and over who agreed to participate in the research were selected as the study sample.

Ethical Considerations: Prior to the study, approval was obtained from the university ethics committee and written consent was obtained from the student volunteers after the purpose and nature of the study was explained both orally and in writing. (Ethics committee approval date and number: 23.06 2017-05/16 and 214-2017).

Data Collection Instruments: A "Descriptive Characteristics Information Form" and "Semistructured Question Form" were prepared by the researchers based on a review of the literature. Data were collected in face-to-face interviews with the participants who had provided written consent.

Descriptive Characteristics Information Form: The form comprised 8 questions concerning the participants' age, gender, marital status, number of children, education level, postgraduate program, employment duration, and employment status.

Semi-structured Question Form: Previous studies in which data were collected by means of metaphors were used as a model when preparing the semi-structured open-ended question form consistent with the qualitative research method (Kale & Cicek, 2015; Cerit, 2006; Gibson & Zellmer-Bruhn, 2001; Gecit & Gencer, 2011; Kaya, Isik & Caliskan, 2013). The postgraduate nursing students participating in the study were asked to create a metaphor expressing their perception of the nursing profession and explain the reasons for this perception. To do this, the participants were asked to express their opinions by completing the statement "A nurse is like_ because...", focusing on a single metaphor. While the "like_" phrase was the source of the metaphor, the "because..." part of the sentence was included to give the participants a chance to reflect their perceptions by explaining the basis of or rationale behind the comparison. The students were under no time constraints when creating the metaphors. This handwritten, participant-completed form was the main data source for the study.

Data Analysis: The metaphors created by the participants were presented using the following steps:

1. Data Classification

2. Categorization

3. Ensuring Validity and Reliability

4. Statistical Analysis

Data Classification: The metaphors generated by the participants were listed in alphabetical order. This was based on a single, clearly expressed metaphor created by each student. The metaphors were coded simply (such as ant, angel). The 50 metaphors obtained from the study were first analyzed in terms of usability. Six of the Semistructured Questions Forms completed by the 85 postgraduate nursing students in the study were not included in the analysis for several reasons, including unintelligible statements, contradiction between the metaphor and the explanation, or no explanation given for the metaphor. The other 79 Semi-structured Questions Forms were included in the analysis.

Data Categorization: The metaphors and their explanations were reviewed and grouped according to conceptual definitions of the nursing profession. The data were categorized based on the content of the metaphors and the frequency and originality of the comments. The resulting metaphors were then analyzed and interpreted using an inductive method, content analysis.

Ensuring Validity and Reliability: Reliability and validity are two important criteria to enhance the credibility of research findings. How the data are collected by the researchers and detailed description of how they are reported are important measures of the validity of results obtained in qualitative studies (Erdogan, 2014). To ensure the validity of the research, we have presented the data analysis process in detail and each metaphor was presented in the most suitable category. Care was taken that the participants included in the study represented all branches of the nursing field.

Three researchers worked in accordance throughout the study and reached a consensus decision in the event of disagreement. To enhance the study's reliability, expert opinion was solicited from two nursing academicians independent of the researchers in order to verify the relevance of the 50 metaphors to the 13 thematic categories. The expert consultants were given a list of the 50 metaphors in alphabetical order and another list including the titles of 13 different categories, and asked to match them. The matches made by the consultants were compared to those made by the researchers. Reliability was based on the following formula: Reliability = Agreement / (Agreement + Disagreement) (Erdogan, 2014; Streubert & Carpenter, 2010).

For qualitative studies, reliability ratios of 90% or over indicate acceptable reliability (Saban, 2009; Saban & Kocbeker, 2006). The consultants classified five of the metaphors (tree, Swiss Army knife, peace, hero, and star) differently than the researchers. Therefore, the reliability ratio of the study was calculated as 91% (50/ [50+5] =0.91).

Data Analysis: The participants' sociodemographic data, the obtained metaphors, and the thematic categories were evaluated using SPSS 20.0 statistics software. The chi-square test was used for comparison of descriptive characteristics by theme. When expressing participants' descriptive characteristics, categorical values (gender, marital status, number of children, education level, postgraduate program, and employment status) were expressed in number (n) and percent (%), while mean values were calculated for continuous variables (age and employment duration).

Results

The descriptive characteristics of the research participants are shown in Table 1. The 50 metaphors produced by the participants are presented in Table 2. The two most common metaphors were "mother" (n=7, 8.8%) and "angel" (n=7, 8.8%). These were followed by "slave " (n=4, 5%) and "Swiss Army knife " (n=4, 5%).

The metaphors produced by the participants were grouped into 13 thematic categories according to their commonalities. The metaphors named by the students were collected under the related category according to the descriptions and definitions. The 13 thematic categories and the distribution of the 50 metaphors produced by the participants within those categories are shown in Table 3.

Category 1

The "complementary" category consisted of 8 metaphors (16%) produced by 18 (22.7%) of the students. The most common metaphors in this category were "mother" and "Swiss Army knife" (Table 3).

"A nurse is like a mother; just like a mother devotes herself to caring for her child, a nurse who properly practices her profession approaches and cares for her patients with the same tenderness, devotion, knowledge, and skills... " (24, female).

"A nurse is like a Swiss Army knife, practicing both the duties assigned to her and many other jobs that she is capable of, even though they are not in her job definition... " (25, female).

Category 2

The "self-sacrificing" category consisted of 3 metaphors (6%) produced by 10 (12.6%) of the students. The most common metaphors in this category were "mother" and "family" (Table 3).

"A nurse is like a mother, she cares for her patients almost like a mother does, with warmth and positivity. She does whatever she can to help the patient recover and feel good" (24, female).

"A nurse is like family, supporting the patients during their hardest times. She focuses all her love and attention on them" (27, female).

Category 3

The "helpful" category comprised 4 metaphors (8%) produced by 10 students (12.6%). "Angel" was the most common metaphor in this category (Table 3).

"A nurse is like an angel, helpful and good-hearted" (24, female).

"A nurse is like an angel, an individual who benefits humanity and is devoted to their work" (23, female).

Category 4

The "source of knowledge/power" category included 6 metaphors (12%) produced by 9 (11.3%) of the students. The most common metaphor in this category was "robot" (Table 3).

"A nurse is like a robot, ...both the health care system and the working conditions are inadequate, and the result is robots who do not even have time to rest" (27, female).

"A nurse is like a robot, expected to provide service around the clock, her feelings often disregarded" (27, female).

Category 5

The "useful" category consisted of 6 metaphors (12%) produced by 8 students (10.1%). "Tree" was the most common metaphor in this category (Table 3).

"A nurse is like a tree; the benefit she provides increases as she grows and develops... she brings people happiness and peace of mind" (24, female).

Category 6

The "hard-working" category consisted of 4 metaphors (8%) produced by 6 students (7.5%). The most common metaphor in this category was "bee" (Table 3).

"A nurse is like a bee; she loves to work, always running from one patient to another and caring for them with devotion and a smile on her face... she brings light with her knowledge and skills" (39, female).

"A nurse is like a bee, hard-working and knowledgeable. She not only fulfills her own responsibilities, but also the responsibilities and duties of the teams and has the ability to guide them" (32, female).

Category 7

The "professional" category comprised 4 metaphors (8%) produced by 8 (10.1%) of the students. In this category, the most common metaphors were "professional" and "artist" (Table 3).

"A nurse is a professional; the nursing profession is based on scientific foundations" (27, female).

"A nurse is professionalism, diagnosis, care, and treatment. it is a holistic occupation" (27, female).

"A nurse is like an artist, she must always combine her theoretical knowledge and practice with care, creativity, and the skill to handle difficult situations" (27, female).

"A nurse is like an artist, who not only acts as a caregiver that maintains and supports people 's vital activities, but also touches people 's lives as if they are her masterpiece, and is the sum of values that initiate change " (23, female).

Category 8

The "building block" category consisted of 6 metaphors (12%) created by 7 students (8.8%). The most common metaphor in this category was "star" (Table 3).

"A nurse is a like a star, always shining... an important and integral part of the health care system " (29, female).

"A nurse is like a skeleton, forming the skeleton crew of a department. transport, communication, diagnosis, treatment... there is a bone extending to each area" (26, female).

"A nurse is like the column of a building, ...the key component that holds the team up. She is involved in every part of patient care... without her, the team falls apart or into chaos " (25, female).

Category 9

The "undervalued" category consisted of 4 metaphors (8%) produced by 7 (8.8%) of the students. "Slave" was the most common metaphor in this category (Table 3).

"A nurse is a like a slave, ...goes on working because she does not realize the place she fills within the health care system. She has not yet gone beyond the limits of how her team and society perceive her profession and has not yet discovered the power she actually possesses" (34, female).

"A nurse is like a slave, because of the working hours and working conditions... they are like people who have no choice but to work" (23, female).

Category 10

The "crusader" category comprised 5 metaphors (10%) created by 6 students (7.5%). The most common metaphor in this category was "flower" (Table 3).

"A nurse is like a flower, enlivening a place and reducing patients ' discomfort with their interventions" (27, male).

"A nurse is like a flower, bringing comfort and beauty to any setting" (26, female).

Category 11

The "holistic caregiver" category consisted of 5 metaphors (10%) produced by 5 (6.3%) of the students. The metaphors used in this category were "the Earth", "mirror", "scale", "hero", and "building block" (Table 3).

"A nurse is like the Earth; she cares for everyone regardless of race, gender, ethnicity, or socioeconomic status" (28, female).

"A nurse is like a mirror, ... she observes the individual's bio-psycho-social needs and provides care to protect and improve the integrity of their existence" (27, female).

Category 12

The "informative" category consisted of 3 metaphors (6%) produced by 3 students (1.2%). These metaphors were "computer", "machine", and "smart phone" (Table 3).

"A nurse is like a machine; she must be well-equipped, and never stop or run out of energy " (30, female).

"A nurse is like a computer, systematically performing many duties and responsibilities " (25, female).

Category 13

The "guide" category comprised 3 metaphors (6%) produced by 3 students (1.2%). These metaphors were "guide", "rudder", and "soil" (Table 3).

"A nurse is like a guide, leading the individual in diagnosis, treatment, health care, and health enhancement behaviors " (23, female).

"A nurse is like a rudder, directing the patient in the journey from illness to health with her care. If health care is an endless ocean offered to the patient, the nurse should steer towards health on this unknown journey with a map that provides the most appropriate individualized care, through research, inquiry, providing guidance when problems arise, able to truly see when they look and to feel when they touch" (30, female).

Of the 50 metaphors produced by the participants, 38 (76%) metaphors were positive and 12 (24%) metaphors were negative in nature. The 62 students (78.5%) who produced positive metaphors emphasized the nursing profession as being helpful, caring, healing, and an integral and essential building block in the health care team. The 17 students (21.5%) who produced negative metaphors emphasized that nurses are not compensated for their efforts, are obliged to do work other than their official duties, are the first responders to all problems, and are not duly valued or appreciated. The chi-square test showed that as employment duration increased, the proportion of positive metaphors decreased and the proportion of negative metaphors increased (p<0.005) (Table 4). Age group analysis showed that the proportion of positive metaphors in participants aged >31 was lower than those in the other age groups, but the difference was not statistically significant (p>0.005).

Comparison of age groups and categories revealed that the most common category among participants aged 20-25 years was the selfsacrificing category. Comparison of employment duration and categories showed that participants with 1-5 years of work experience produced metaphors predominantly in the self-sacrificing, useful, building block, and holistic caregiver categories (n=17, 100%). However, chi-square analysis revealed no significant differences in categorical distribution of participants' metaphors according to age group or employment duration.

Discussion

In the 20th and 21st centuries, social, economic, technological, scientific, and political powers have brought about dramatic changes and advances in the field of health care, both globally and in our country. Naturally, nursing practices have also been influenced by these developments in health care services. Conventional nursing involved providing care, comfort, and assistance, whereas modern nursing is a professional discipline that combines practical skills with scientific knowledge. Despite its relatively brief history, modern nursing has become a dynamic profession in which high-level knowledge, skills, are attitudes are displayed (Cinar & Olgun, 2013).

The planning of this study was based on the question of whether these developments in the nursing profession have affected the way the nursing students perceive the profession, and if so, how their perceptions have changed over time and how they are metaphorically expressed.

In another analysis of nurses' metaphorical perceptions of their profession, Kale and Cicek (2015) reported that the most common metaphors used by the nurses were slave (16.4%), laborer (15.4%), and angel (13.2%) (Kale & Cicek, 2015). In that study, nurses used metaphors that described the difficulties of the profession and the poor working conditions (slave, laborer, bee, machine, robot, Atom Ant, watch) as well as metaphors glorifying the profession (angel, mother, sibling, epitome of patience, godsend, harbor, street lamp) (Kale & Cicek, 2015). Sharoff also reported metaphors expressing positive perceptions of the nursing profession (butterfly, universe, light, angel, ocean) (Sharoff, 2009).

In our study, the most common metaphors among postgraduate nursing students were mother (8.8%), angel (8.8%), slave (5%) and Swiss Army knife (5%). The participants produced metaphors that emphasize the strengths of the nursing profession (mother, angel, artist, tree, family, flower, star, world, guide, professional) as well as metaphors for the difficulties of the profession (slave, Swiss Army knife, robot, factory, machine, buffer, burned-out candle). The metaphors in our study are similar to those in the literature.

The "hands-on" metaphor has long been used in the history of nursing to reflect the patient careoriented approach. "Hands" express the essence of nursing, both the physical touch and the relationship with the patients. This metaphor suggests a more profound meaning of the nursing relationship with the intention to contribute to the healing process of both the self and others (Sharoff, 2009; Engebretson, 2002). Mother and angel metaphors were also the most common in our study, pointing out the healing aspect of nursing with their senses of caregiving and helpfulness.

While the advances in nursing have positively influenced perceptions of the profession, conventional approaches result in more negative perceptions. Just as ambiguities in the job description are reflected in the confusion of duties and responsibilities, the scientific and professional nature of the specific knowledge, skills, and behaviors are expected to be reflected in the metaphors produced by the participants. When the most common metaphors were analyzed at the end of the study, the top categories were complementary, self-sacrificing, helpful, useful, and hard-working. These categories mostly involved the conventional roles of the nurses. Fewer students produced metaphors in the categories of professional, source of knowledge/power, holistic caregiver, crusader, and guide, which reflect the modern aspects of nursing.

We observed that participants with longer employment duration were less likely to use positive metaphors towards the nursing profession. As employment duration increases, the participants may become physically and psychologically exhausted by the difficulties of the job and the intense working conditions, leading to fewer positive metaphors about the nursing profession. It has been posited in other studies that this phenomenon may also be related to organizational factors such as nurse salaries, personal rights, poor or dangerous working conditions, lack of qualifications, and lack of recognition, and to social factors such as poor communication while providing health care and not feeling valued (Kale & Cicek, 2015; Tortumluoglu, Daştan and Verep 2004). However, another study reported that as employment duration increased, the use of negative metaphors about the profession decreased and positive metaphors increased (Kale and Cicek 2015).

In a study by Tunc on the factors affecting nursing and health care students' choice of profession, it was found that most of the nursing students (69.8%) perceived the nursing profession from a conventional perspective as "caring for and helping patients" (Tunc, Akansel & Ozdemir, 2010). Consistent with those findings, we also observed that most of the students in the present study used metaphors in the complementary, self-sacrificing, helpful, useful, and hardworking categories, which reflect conventional nursing roles.

Impact Statement: This study is the first conducted in Turkey to evaluate the perceptions of postgraduate nursing students about the nursing profession using metaphorical analysis, and therefore makes a novel contribution to the literature in this area. The use of metaphors to discover the perceptions, definitions, and new meanings related to the nursing profession can be a powerful tool for explaining concepts in nursing research. In qualitative research, analyzing perceptions through metaphors enables us to consider a broad spectrum on the concepts.

Conclusion: The metaphors produced by the nursing students in the present study are important insights into their perspectives of the nursing profession. These metaphors reveal the strengths and weaknesses of the nursing profession and what nurses experience while fulfilling their roles and responsibilities.

Acknowledgement: The authors thank all students who participated in this study.

The Name and Address of the Place of Study: Ege University Faculty of Nursing, Kazımdirik, 35100 Bornova, Izmir Turkey

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