Running Head: CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS Capstone Project: The Marketed Image of Nursing to Prospective Students of Canadian Baccalaureate Nursing Programs By Heather Elliott #219666 Submitted in Partial Completion of NURS 690 Advisor: Dr. Sonya Grypma, PhD, RN Second Reader: Dr. Joan Boyce, PhD, RN Trinity Western University October 20, 2011 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS ii Table of Contents Abstract v Acknowledgements vi List of Tables viii Chapter One: Introduction and Background 1 Introduction 1 Project description. 1 Project purpose and objectives. 2 Background 3 A baccalaureate standard. 3 Character and nursing. 4 The importance of an honest message. 4 Definition of Terms 10 Outline of Paper 12 Chapter Two: Literature Review 15 Introduction 15 Search and Retrieval Strategies for Literature Review 15 Literature Review 15 Conclusion 23 Chapter Three: Research Design, Methodology and Procedures 25 Introduction 25 Communication Theory and Representing Nursing 25 Design 28 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS iii Sampling 28 Procedures 29 Observation and data collection. 29 Analysis. 31 Written materials. 31 Photographs and illustrations. 32 Film representations. 33 Institutions with language requirements other than English. 33 Ethics 34 Scientific Quality: Reliability and Validity 35 Limitations 36 Conclusion 37 Chapter Four: Findings 39 Introduction 39 Nursing: A National Image Marketed by Baccalaureate Nursing Programs 39 What nursing is: Symbols, roles & goals. 41 Who nurses are: Character, characteristics, skills and abilities. 44 Where nurses work: Human populations and environments. 47 What nurses do: Behaviour and work. 49 Becoming nurses: Selection criteria, education approaches and curricular foci. 52 Regional differences. 55 Language differences. 56 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS Calling all nurses: Promoting commitment and persistence in nursing. iv 57 Summary of Findings 60 Conclusion 64 Chapter Five: Discussion 66 Introduction 66 The Honesty of the Image 66 Accuracy. 70 Internal Consistency. 70 External Consistency. 71 Commitment in the Image 74 Persistence in the Image 75 Conclusion 75 Chapter Six: Conclusions and Recommendations 77 Introduction 77 Conclusions 77 Recommendations 78 References 85 Appendix A: Programs for Analysis 91 Appendix B: Data Collection Excel Spreadsheet 100 Appendix C: Code Book for Analysis 101 Appendix D: Program Photographs 102 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS v Abstract This qualitative descriptive study examined and compared the online marketing materials of 90 baccalaureate nursing programs in Canada. It explored the prevalent physical and affective characteristics of nursing as marketed to prospective nursing students in five different regions of Canada (Eastern, Northern, Central, Prairie, and Western). The study examined Canadian nursing program websites for their emphasis on (1) descriptions of the symbols roles and goals of nursing, (2) the character, characteristics, and qualifications of nurses, (3) the human populations and physical environments wherein nurses work, (4) the behaviours and work of nurses, (5) the selection criteria of nursing students and nursing education approaches, and (6) representations of commitment & persistence by nursing students and professional nurses. The study found that the Canadian image of nursing as marketed on baccalaureate nursing websites varies according to region, with marked differences noted between online marketing materials of Francophone and Anglophone program websites. The study findings raise questions about the “honesty” (congruence) of marketing images, and highlight the lack of “commitment” and “persistence” as attitudes and behaviours necessary for nursing practice in Canada. This study has implications for prospective students of nursing, nursing educators, nursing program developers, nursing recruiters, and governing nursing organizations and associations. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS vi Acknowledgements I would like to acknowledge all who have taken part in this work with me. I may be marked ‘the researcher’, but I did not come to this alone or by my sole motivation. Foremost, I give thanks to God through Jesus Christ for always amazing grace and mercy. Thank You for that ad at a bus-stop that was inspiration for this work. You are everawesome, ever faithful. To my parents, Rick and Anne and brother, Jeffrey: without your unwavering support I could not have survived. You are gifts from God to me. Two years have taught me how Love can accomplish infinitely more than we can ever imagine. Thanks for reminding me to enjoy this. To my incredible advisory team, Dr. Sonya Grypma and Dr. Joan Boyce, and program director, Dr. Sheryl Reimer-Kirkham – your guidance and enthusiasm have been indispensible throughout this project. Thank you for seeing it in me before I quite believed it. I am deeply grateful. To my friends, new and life-worn: I love you deeply, and am honoured at how you have cared, listened, prayed and taken me up on offers of ice-cream and coffee dates. To my colleagues in Palliative Care at Elizabeth Bruyère Hospital: Thank you for taking a beginner nurse and fledgling researcher under your wing two years ago, and helping me to fly. You make me proud daily to walk onto the floor and work as a nurse with laughter, thoughtfulness, skill and compassion. Lastly, to the faculty of the School of Nursing at Trinity Western University: Thank you for your faithful service to God and to others through Nursing, and for the wisdom you’ve each CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS shared over cups of coffee and tea. You are deeply cherished mentors and colleagues, and images of Nursing to me. Much peace. vii CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS viii List of Tables Table 3.1. Regional comparison, by province. 32 Table 4.1. Frequency (percent) of occurrence of individual nurse and/or nursing student, by gender (* Central region: Breakdown by province). 46 Table 4.2. Dialectical themes, by region. 56 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS ix CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 1 The Marketed Image of Nursing to Prospective Students of Canadian Baccalaureate Nursing Programs Chapter One Introduction The path toward a career in nursing is a varied one. Influences of demand, remunerations, vocation, personal suitability, academic performance, and social persuasion are each invitations to a career that is as diverse and varied as the paths it takes to become a nurse. Yet nursing is most certainly a distinct and valuable profession, with specific aims and actions, and based upon a growing body of disciplinary knowledge, melded with that of professions that have historically worked alongside nurses and informed nursing practice. The landscape of Canadian Baccalaureate nursing education represents the diversity of the country’s geography and the people of Canada. Breadth and variety of profession and nation are represented in the photographs, illustrations, film and written representations available to prospective nursing students when visiting the websites of Canadian Baccalaureate nursing programs. This is a time where Canadian nursing boasts of practice opportunity and confronts national shortage, and such a time demands consideration of how nursing education promotes the profession, from Coast to Coast. Project description. This study is a qualitative analysis of written descriptions, film, photographic and illustrative representations of nursing projected to prospective students of Canadian baccalaureate nursing programs through online program-marketing materials including program websites, and relevant, program-related links. The aim of this study is to explore the characteristics of nursing (and nurses) represented in these materials. This has particular CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS relevance to the prospective Canadian nursing student; students’ understanding of nursing is shaped (and persistence through Nursing education is influenced) by their primary interaction with promotional and admissions material of their prospective program and institution (Tinto, 1993 in Hayes, 2007). This study takes particular interest in the congruence of the message of Canadian Baccalaureate nursing programs regarding characteristics and values for professional nursing practice (e.g. commitment and persistence) presented to prospective students. These characteristics and values are related through written descriptions and images included in the websites of Canadian baccalaureate nursing programs. This study is based upon the web-based, promotional materials of ninety, current baccalaureate nursing programs recognized by the Canadian Association of Schools of Nursing (CASN, 2006; see Appendix A). Project purpose and objectives. A prospective student’s first interaction with professional nursing education can begin with the promotional materials produced by nursing programs of Canadian post-secondary education institutions. At this point of interaction with professional institutions of nursing education, the nursing profession is typically explained and program criteria are outlined for the prospective student. The materials offered by Canadian baccalaureate nursing programs allow prospective students to confront qualities and characteristics of professional nursing, and consider the feasibility of their engagement in it. This project aims to produce a comprehensive, national representation of the image(s) of nursing projected to prospective students of Canadian baccalaureate nursing programs, with interest to the ‘honesty’ and the ‘fullness’ of this representation of nursing. Honesty, concerns the congruence of the image portrayed of nursing education and practice by Baccalaureate 2 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 3 programs in Canada, with historical and current realities. Fullness is similarly interested in congruence, but in this case the emphasis is upon the accuracy of marketing materials to portray an image of nursing representative of the diversity and complexity of nurses' education and practice. This research aims to explore the following questions: 1. What are the prevalent physical and affective characteristics of nursing as marketed to prospective students of Canadian baccalaureate nursing programs? 2. What characteristics of the prospective student are emphasized? 3. What is the character of the message from Canadian baccalaureate nursing programs to prospective students about professional nursing? Background A baccalaureate standard. A baccalaureate degree has become the educational standard for entry into practice for Registered Nurses in Canada. Since 1998, moving from the East to West, the provinces and territories of Canada have transitioned entry-to-practice registered nursing programs from diplomas to baccalaureate degrees (CNA, 2009). A degree in nursing from an accredited educational institution makes first-time registrants eligible to write the Canadian Registered Nurses Exam (CRNE), who if successful, are entitled to practice professional nursing as a Registered Nurse (CNA, 2001). A unique exception is the province of Quebec, wherein the systems of education and professional nursing are differently structured. The distinctions of nursing education and practice in Quebec include the requirement of proficiency in French, evidenced by passing the Office Québécois de la langue française (OQLF) exam and a shorter duration of post-secondary nursing education with fewer required clinical hours (Queen’s Printer for Ontario, 2010). Quebec has also developed its own registration exam, CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 4 thus those wishing to practice nursing in Quebec must write the Ordre des Infirmières et Infirmièrs du Québec (OIIQ) professional examination in lieu of the CRNE (2006-2011). Despite differences, institutions offering nursing education in Quebec and/or a Francophone context were considered vital in describing a cohesive image of Canadian nursing. Character and nursing. Nursing is a profession which recognizes persons as “whole” beings, thus requiring its practitioners to exercise skill in various domains of human outworking – cognitive, affective, social and physical. Nursing’s professional demands coincide with its professional rewards of caring for other persons in need or in achieving the maintenance of health (Potter & Sams, 2006). The process of considering a baccalaureate nursing program is an interactive one for the prospective student (hereafter “prospect”), who evaluates him or herself against the projected demands of that career for congruence and desire (Tinto, 1987). The importance of an honest message. The representation of nursing has been a topic of concern and discussion, both in Canada and globally in academic literature and professional articles. Current public perceptions of nursing appear robust. Recent online, public polls of adults from Canada, the United States and United Kingdom, revealed respondents held highest respect for the nursing profession in all three nations, in relation to other professions such as farming, medicine and law (Angus Reid Global Strategies, 2009). A similar public poll of American’s revealed that publically nurses are the most highly regarded in terms of honesty and ethics – for ten consecutive years, nurses have held the top position of this survey (Gallup Organization, 2010). Polls such as these give nursing a glimpse into what nursing means beyond itself, and into the sort of image we cast professionally. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 5 While the above account is certainly flattering, such glowing public perception of nursing has traditionally been unbalanced; perpetuated by what nursing historian, Kirby would term “an emotive misrepresentation of nursing” (p 2726) in her work on the historical representation of nursing, recruitment and retention (2009). A common historical misperception of the profession was that of a “golden era”, characterized by vocation-inspired and caring people taking up the tasks of nursing, with lavish care and time. Such perceptions of nursing have impacted nursing recruitment, retention and image – serving to foster disillusionment when actual practice confronts partially-informed perceptions. As Kirby denotes, nursing during the 1930’s and 1940’s, a time that many sentimentally long to re-enact, was at a considerably different place professionally than such idealism supposes. Wartime had brought upon a desperate need for nursing professionals, and clouded the perception of nursing with a comforting nostalgia, and humble heroism. The realities of nursing at these times were hard. And, in the peace years following the Second World War, nursing struggled to maintain its body of professionals and recruit others into the profession; the actions which nurses took for professional protection, stability and public safety affected public perceptions of their humility and softness, causing society to question if nursing’s motivations were self-serving. A recent American study by Escober, Scotese, Berman, Thaler, Fairchild, Gould & Mezey, took interest in web-based images of nursing and their effect on the portrayal of the profession to incoming nursing students (2007). Their findings indicated a consistent use of “positive” images to portray the nursing profession reflected in photographs of people smiling and in relative good health. Portraits of infants and children dominated the use of adult and elderly persons in the promotion of nursing. The concern of this study was the marketing of nursing practice as a fundamentally exciting, energetic experience, and one predominated by the CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 6 care of children – healthy children. Furthering this theme, a preliminary study by Shepherd indicated that students entering nursing specialities dealing with children had a tendency to be within the youngest age bracket of nursing students (18-20 years of age) (2008). Students of a younger age were less likely than older students to perpetuate through their nursing education and into practice. Many studies have shown an interest in perceptions of nursing by prospective and current nursing students, with various levels of practice experience and levels of education. A Canadian study by Grainger & Bolan compared first and fourth year nursing students’ perceptions of the nursing career (2006). Their findings included a decrease in student perceptions of nursing as a caring profession and one that is socially valued. The fourth year nursing students indicated an increase in their perception of nursing as a profession of expertise, with nurses who advocate for and provide resources to persons, working as active members with multiple health professionals. They also felt less strongly than first year students of the adequacy of compensation nurses’ received for their work. Bolan & Grainger’s concern was the impact of image dissonance on the retention of nursing students and young nursing professionals, in the light of the significant student attrition rates in Canada (CNA, 2003). A study of first-year, Irish nursing students was undertaken by Dunnion, Dunnion & McBride, to explore the students’ reasons for entering the profession of nursing (2010). The study was driven by actual and projected shortages in nursing personnel similar to those experienced in Canada, as well as reports of decreases in enrolment to the nursing profession in the wake of equally lucrative, and less demanding career options. Students indicated that there was a resonance between projected images and assumptions of nursing, fitting with their personal characteristics and career/life goals. The students’ predominant reason for entering CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 7 nursing education was desire to care, followed by a desire to fulfill a lifetime desire. Students also indicated that nursing fulfilled financial and career stability, and offered opportunities for global travel as other appealing characteristics of nursing that caused them to enter the profession. Nursing educators O’Brien, Mooney & Glaken took interest in that which impacts student perception of nursing, in their study of first-year nursing student impressions of nursing prior to field exposure in Ireland (2008). Students’ predominant perception of nursing in this study was caring; most students expressed innate desire to care and help people, and perceived they would be satisfied in a career that offered opportunity to care. Findings also showed that students perceived that male nurses were considered negatively within Irish society, and that nursing was projected as a primarily female profession within media images of nursing and nurses. The final component of the study considered students’ perceptions of their coursework prior to practical experience – the majority indicated that they found it strange that they must learn to care and communicate. Most students placed greatest value upon the clinical skill components of courses, and placed little or no importance on the extra-nursing courses of a liberal arts education, such as sociology, and psychology in their development as professional nurses. This study marked the difficulties faced by nursing students to reconcile their perceptions of nursing practice, with the academic preparation of professional nurses. In addition to portrayal of nursing, studies have shown interest in the effect of personal attributes and characteristics, upon prospective students’ choice of nursing as a career path. Law & Arthur investigated a series of demographic factors, personal characteristics, and individual professional perceptions which influenced high school students’ decisions to undertake nursing education (2003). Most importantly students desired a career in nursing because they currently CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 8 found enjoyment in activities associated with nursing: caring, working with people, and taking on personal challenges; this was followed by financial compensation, length of training and status. An associative relationship was noted between a student’s intention to study nursing, and being female, as well as interest in biology, and student grade point average. A correlation was found between students’ positive perception of nursing as a career, and their intent to study nursing, as well as their previous experiences with nursing professionals. In a smaller study of nursing education in Brazil, researchers focussed upon the characteristics and behaviours of the ‘good nurse’ presented by educators to nursing students (de Arajuo Sartorio & Lourdes Campos Zoboli, 2010). According to this study, ‘good nurses’ were advocates, leaders, dutiful, welcoming, competent and excellent enactors of skill and authority. The ‘goodness’ of the nurse was related to personal and professional character and ethics. Researchers, Rossiter and Yam, examined the effect of a second-language in mediating the image of nursing to Australian high school students (1998). The study considered the effect of first-language culture on perceptions of nursing, as well as the potency of second-language media portrayals of nursing on non-English-speaking students. Findings revealed that these students preferred “professional” careers (such as medicine or law), with only one female student desiring to be a nurse. Students desired careers which they perceived as socially and financially rewarding. Nursing was described as a career of caring, of technical and interpersonal skill, of undertaking unpleasant activities, but lacking in enjoyment, status, power and reward for these efforts. This study revealed the certain need to take action, not only in the positive promotion of professional nursing to high school students, and their parents of ethnic minorities, but also addressing broadly and concretely the concerns of current nursing professionals in the practice environment. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 9 The works illustrate that marketing efforts of nursing have had a history of representing and misrepresenting the nursing profession, and encourages the faithful marketing of nursing by those institutions recruiting the future workforce of the nursing profession. Nursing-related marketing literature has become increasingly concerned with this incongruence, and interest in the ‘reality’ or ‘realness’ of the nursing image has resulted. The present study focussed on the concept of honesty for its capacity to encompass the truth of the reality of nursing, to connote value and vision, and to expect integrity in movement toward those goals and visions, when considering the character of the image of nursing presented by Canadian baccalaureate nursing programs. Reporting on the development of a marketing scheme to improve the image of nursing publically and to encourage the recruitment and retention of prospects into nursing practice, Morris explains the ongoing research of a British department of health through surveys, group discussions and interviews on perceptions of nursing (2010). As in the public polls previously mentioned, this research similarly revealed in 2010 that nursing was viewed in a positive light: dedicated, honourable and socially vital. Negative perceptions of being a nurse also persisted (i.e. subservient, stagnant, lacking variety of lifestyle, and performing menial, often unpleasant tasks). A large portion of this research has led to efforts to manage and improve the image of nursing, by promoting best work environments (i.e. adequate staffing), dealing constructively with poorly performing professionals (i.e. education and career mentoring), and placing emphasis on becoming an ‘open and honest’ profession-wide focussing on excellence in basic, nursing practices (2010). Hoke studied the effect of a nursing promotion presentation to urban middle school students in the Western United States (2006). This study was similarly interested with the CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 10 accuracy of student’s perception of nursing in the career choosing process. Of greatest concern was the basis of this decision upon “stereotyped and idealized images” (i.e. Caucasian females as nurses, nurses characterized by passive demeanours work to complete the orders of physicians, and nursing as predominantly supportive, bedside activity) unmediated by experience (p 94) guiding the prospective student’s thought-process and the opportunity for students to choose careers other than nursing that are by appearance, more lucrative. What nursing education says about nursing creates expectations in and of the prospect, and for that individual, an image of professional nursing. Nursing students and newly graduated nurses must integrate themselves between idealized and realistic versions of nursing practice; this is a struggle with students of Baccalaureate nursing programs in Canada engage in throughout their course of nurses training (Grainger et al., 2006). Definition of Terms Marketed: This signifies those promotional materials and information that are put forth to inform prospective students of the character, quality and/or requirements of professional nursing education, and professional nursing practice. Where institutions drew the attention of future students to pages of academic calendars, course descriptions (which would otherwise be considered documents intended for admitted student) the study considered them in analysis for their influence upon the image of nursing put forth by Baccalaureate nursing programs. Prospective student(s): This refers to any individual considering, but not yet exposed to, formal nursing education. Prospective students include persons of any gender, of any ethnicity, and of any age who have the educational and/or life experience required to apply for training programs of professional nursing. A prospective student may also be referred to as a prospect in this study. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 11 Canadian: Indicates any educational institution situated within the country of Canada. Prospective students may or may not originate from the country of Canada, to participate in Canadian nursing training. Baccalaureate: This pertains to nursing programs through which graduates attain a degree from an accredited educational institution. For the purposes of this study, baccalaureate bridging programs (Post-Diploma RN, Post-Practical Nurse) were not included. In the province of Quebec, programs indicated “BAC” or “formation initiàle” were considered equivalent to Baccalaureate degrees in other Canadian provinces. Characteristics: Refer to the physical, social, emotional and spiritual attributes, dress, gestures, behaviours, relationships, roles, context and physical environments observed of nursing students, and professional nursing used in online marketing materials by Canadian baccalaureate nursing programs and institutions. Image: Refers to a grouping, or groupings of characteristics, to represent an idea in fullness. A nursing image includes individual photographs and/or illustration, and written description of characteristics and activities. The collection of many nursing images together, creates a larger, fuller representation of professional nurses and professional nursing practice. Commitment: Refers specifically to intents, behaviours and activities, expected of and undertaken by professional nurses, which is responsive to being given a “charge or trust” (Merriam-Webster, Inc. 2011a, no page). Commitment also indicates a pledge by an individual that one will continuously acknowledge and outwork that responsibility in the future. Persistence: This refers to the act of being persistent. Persistence indicates that which endures for a long and continuous period of time, and remains along an intended course (Merriam-Webster, Inc., 2011b). CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 12 Honest: Describes an unsolicited, openness and frankness that is innocent, plain and respectable. Honest revelation of reality is neither fraudulent nor deceptive, a truth derived from a legitimate source. The reputation of that which is ‘honest’ conveys a trustworthiness that has been earned and has integrity (Merriam-Webster, Inc., 2011c). In this study, honesty of promotional materials considered three separate facets of honesty: a) accuracy of the image: the truth of the image as a reflection of the reality of nursing, b) internal consistency of the image: the honest reflection of the reality of nursing within an individual program, and c) external consistency of the promotional materials: representing an honest reflection of nursing education and practice throughout Canada. Fullness: This describes that which contains all of its parts. In the case of a human being, this includes the domains of personhood: spiritual, physical, emotional, social, developmental and intellectual (Potter et al., 2006a). To describe nursing, one looks not only to the work of professional nursing but also the ‘fullness’ of who individual nurses are, the ‘fullness’ of their places of work, the ‘fullness’ of their abilities and capacities’, the ‘fullness’ of their educational background and the influence of their research, and finally, the ‘fullness’ of the impact of their professional goals, their work in society and the reach of nurse’s care. Outline of Paper Chapter Two describes in detail the results of a comprehensive literature search, on the topics of nursing image, characteristics of nursing, nursing student perceptions of professional nursing and student attrition. The results of the literature reveal a gap in our current knowledge of projected image of nursing from Canadian nursing education program to prospective students. Chapter Three describes the research methodology, design, sampling and research methods utilized in this study. An explanation of ethical considerations is detailed for this study. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 13 The procedures implemented for scientific rigour and reliability are explained, and a discussion of the study’s limitations is included within this chapter. Findings were analysed by region (Eastern, Central, Prairie, Western and Northern), language (English and French), and by material format (written description, photographic or illustrated image, and video). Chapter Four includes a thematic description of study findings in the following themes: what is nursing, who nurses are, where nurses work, what nurses do, becoming nurses, and commitment to nursing across Canada. This chapter describes these findings by integrating written and visual/film representations of nursing to present a cohesive, national image of nursing. Not merely focussing on the broad image of nursing observed in the online marketing materials of Canadian Baccalaureate Nursing programs, subtle differences in nurses and practice between Canadian regions are noted in this chapter as well. Chapter Five provides discussion of study findings, and the current status of nursing images projected to prospective students of Canadian Baccalaureate Nursing studies. Discussion surrounds themes of the honesty of the presented image, and the representation of commitment and persistence in the image. Chapter Six provides conclusions regarding the image of nursing portrayed to prospects of Canadian Baccalaureate nursing programs. This chapter makes recommendations to nurses individually and collectively to action in the interest of nursing, and the honesty of the relationship between nursing image and student progression through professional nursing education and practice. Recommendations demand personal integrity of each nurse and extend to exhort Baccalaureate programs, provincial and national associations to portray nursing education and practice in an honest manner - promoting the commitment and persistence of nursing students and professionals. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 14 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 15 Chapter Two Introduction This chapter discusses the extent of our current consideration on the effect of nursing image toward the prospective student and through to the professional nurse. A literature review for the purposes of this study revealed a gap in our current knowledge between the marketed image of nursing to prospective students and the behaviours and characters of students who are attracted to the message currently presented. This chapter includes the method and manner in which the researcher chose, observed and gleaned descriptive data (i.e. written, film and photographic representations) from promotional materials for the purposes of study. Following this, a detailed summary of analysis procedures is provided. Written, photographs, illustrations and video materials were considered in distinct categories first, and later were interpreted together as the fullness of image of nursing by baccalaureate education programs. Search and Retrieval Strategies for Literature Review Initial CINAHL, PubMed, Ovid and MedLine searches began with keywords, nursing and marketing, and eventually included, image, attrition, character, persistence, and commitment in order to obtain a broad understanding of the gap. GoogleScholar was employed utilizing the same keywords to search for extraneous articles. After preliminary review of these articles, the researcher employed the use of footnote searches on key articles for the retrieval of referenced works (Polit & Beck, 2008), leading the researcher to seminal works on the topics of student attrition and marketing methods - capturing the extent and character of this current gap in nursing knowledge. Literature Review CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 16 The Canadian Nurses Association released a projected national shortage of sixty thousand nurses by the year 2022 (2009). This shortage, produced by multiple social, political and economic factors affects all professional nurses, and the wider community of those benefitting from nursing care in Canada. Shortage impacts upon the work environment of the professional nurse and the outworking of nursing practice and this in turn reflects upon our professional image (MacDonald & McIntyre, 2006). Persons considering careers in nursing must be made aware of the whole realities of current professional nursing in Canada. Tinto, a scholar in the area of student attrition explains that for attainment of a larger career goals, “the more accurate and realistic those expectations [of program and university] are, the more likely it is that the resulting choice will lead to effective match” between student and program (1987, p 62); Tinto’s work highlights the potency and interaction of the recruitment message with the prospective student. Incongruence between student pre-education perceptions of nursing and confrontation with practice reality are attributed to decreased student satisfaction in Canadian nursing education programs and correlated with nursing student attrition (Grainger & Bolan, 2006). Canadian baccalaureate nursing programs boast a startling thirty percent attrition rate of nursing students at present (CNA, 2003). Another thirty percent of Canadian baccalaureate nursing graduates leave nursing within the first year of professional practice. The field of marketing is itself in the midst of change. In an article by Abela & Murphy, the authors noted, in recent marketing theory development, a compartmentalization of ethical theory from business education and practice, and discussed the various marketer-consumer tensions that arose from these situations (i.e. violations of consumer autonomy, target marketing vulnerable populations, and unsafe, disrespectful applications of the labour force to maximize profit)(2008). The authors then suggested a service-dominant logic as a framework for future CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 17 marketing with the potential to honour the aims of both ethics and business, while addressing dilemmas arising from weakened ethics in marketing practice. A literature review by Nill & Schibrowsky, studied the frequency of ethics-related literature in published marketing journals and those of other disciplines through the period of 1981 to 2005 (2007). Their work observed a decrease in studies of Internet-related marketing issues such as privacy and discrimination related to opportunities available to those with access to the Internet that had previously peaked in the early 2000’s. Also noted was an increased interest in both ethical marketing of goods and consumer ethics. Interest in social issues, such as a marketer’s responsibility toward society and stakeholders, however had received only approximately five percent of topical attention during the studied twenty-four year period. Overall, their study revealed that research into ethics in marketing issues has decreased in frequency in the past 10 years; the authors stated this marked the evolution of marketing ethics “into a specific sub-discipline” from a position of prominence in general marketing discourse (p 272). Increased emphasis has been placed on marketing the positive attributes of professional nursing in an effort to confront the seemingly negative aspects of nursing work – thus strong emphasis is placed upon job flexibility, reasonable wages, job security, career excitement and the use of state-of-the-art technology. A survey taken by the Canadian Association of Schools of Nursing described the efforts of Canadian baccalaureate nursing programs to address the current nursing shortages, and to bolster numbers in the future; 25 of the 91 member programs responded. Respondent institutions observed increases in admission and enrolment as a result of their efforts; yet no mention of increased rates of persistence to graduation were suggested CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 18 (2003). Nursing education institutions have utilized marketing as a method to promote professional nursing as a career choice for prospective students of their Baccalaureate programs. In a theoretical discussion highlighting the interface between nursing practice and branding, author Dominiak asserts that the benefit of branding nursing accurately and consistently has positive implications for the matching of potential students to nursing education and practice (2004). Dominiak investigated the potential use of a branded marketing scheme for nursing, providing the profession “the opportunity to send a message regarding the value inherent in its products and services” (p 295). Branding an image of nursing is one activity to address the various, unreconciled images associated with the nursing profession - eliminating misunderstanding related to nursing’s value and function in society and healthcare. Dominiak also noted that branding is a powerful tool in the recruitment process, where matching values of the prospective student with the values of nursing is critical. Hughes indicated that nursing education marketing struggles to define its audience: from the prospective student, the future employers, benefactors, to the community of individuals, families and groups who will eventually be cared for by the students and graduates of the institution (2000). Hughes’ article illumines the issues of quality in nursing education portrayal, and ineffective use of marketing principles for the benefit of nursing image. Good nursing education relies in good part upon attracting a sufficient body of nursing students; but, as Hughes puts it, “no matter how good the product is, it will only sell to a market that wants and values it” (p 766). Marketing is a valuable tool and significantly untapped resource by the nursing profession which is in certain need of a cohesive, professional image. Utilizing marketing, nursing education programs exercise their creativity and autonomy in sharing an accurate portrayal of nursing in their marketing materials. Morris provided a report CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 19 tracking the development of a marketing campaign, designed to augment public confidence in the profession of nursing as well as recruit individuals committed to professional nursing in England (2010). Marketing strategies were aimed at attracting “the right people” to enter nursing practice, to encourage and support excellent practice and to encourage current nursing professionals, while having a positive impact upon public perceptions of nurses and nursing practice. Three areas of messaging were used to combat poor images of nursing, poor practice, and poor recruitment of prospects to nursing. These included, emphasizing the characteristics and benefits of professional nursing, illuminating the positive impact and privilege of working as a nurse, and complimenting the challenge of nursing, emphasizing the accomplishment of those individuals who are able to rise to the demands of professional nursing. The work of this article is to invigorate interest and investment into excellent and assertive marketing campaigns for the nursing profession in England. Addressing the discrepancy of incoming student awareness of both satisfying and desirable attributes of nursing practice, authors Crow, Hartman, and McLendon, conducted a survey of nursing faculty members in the southern United States who had experience as practicing nurses and nursing educators (2009). Eliciting their perspective on “realistic job previews” (p 317) to inform incoming students of the actual requirements, expectations, environments, rewards and challenges of the career, the respondents’ responses resounded with affirmation of practices to give prospective nursing students a realistic view of the profession (i.e. job shadowing, program preview sessions), although there was disagreement with whether the current practices of nursing education programs and healthcare organizations did this well. Reporting on the development of a marketing scheme to improve the image of nursing publically and to encourage the recruitment and retention of prospects into nursing practice, CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 20 Morris explains the ongoing research of a British department of health through surveys, group discussions and interviews on perceptions of nursing (2010). As in the public polls previously mentioned, this research similarly revealed in 2010 that nursing was viewed in a positive light: dedicated, honourable and socially vital. Negative perceptions of being a nurse also persisted (i.e. subservient, stagnant, lacking variety of lifestyle, and performing menial, often unpleasant tasks). A large portion of this research has led to efforts to manage and improve the image of nursing, by promoting best work environments (i.e. adequate staffing), dealing constructively with poorly performing professionals (i.e. education and career mentoring), and placing emphasis on becoming an ‘open and honest’ profession-wide focussing on excellence in basic, nursing practices. Though making the profession more appealing, current utilizations of marketing strategies have not been implicated in improving the persistence of prospective students through nursing education and into committed nursing practice. In an Australian study, researchers Bosco, Ward & Styles elicited illustrations and perceptions of nursing from first year nursing students (2001). A questionnaire was distributed to students, to glean their images and expectations of nursing, as well as their motivations for entering nursing, and negative and positive factors which influenced this choice. Students were also asked to illustrate their perceptions of themselves as future nurses. Students were aware of the personal benefits of caring for others, the employment and financial security, and the opportunities for travel that a career in nursing afforded them. Researchers found that students consistently perceived their future to be happy (or smiling), and were primarily interested in pediatric or maternity settings; in contrast, the care of those in palliative and geriatric environments, those where nurses managed body fluids, and those requiring shift work were perceived negatively by students. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 21 Students consistently drew representations of nursing with a traditional, clinical environment consisting of a bed-bound patient, nurses dressed in nursing uniforms or dresses with nametags, and common instruments such as, intravenous poles, fluids and tubing, stethoscopes, and syringes with needles. Students most frequently responded with goals of nursing related to their self-efficacy and validation socially – for example, desire to perform to one’s maximum ability and provide best care, and to acquire a secure job in a career that supported values of altruism and justice. One concern arising from this study, was the narrow view these beginning students had of the complexities of care – wherein, their perspective of nursing selected the “comfortable” and “happy” aspects of nursing practice, but ignored – or as one student stated, was “scared about the responsibility” taken on by professional nurses (p 4). In 2007, Laureen Hayes published an article documenting her research into the recruitment strategies of Ontario baccalaureate nursing programs, with concern for the optimization of educational resources to reduce student attrition and maximize the use of nursing education. The study consisted of a review of pertinent literature, from which interview questions were developed. Individual interviews were conducted with academic Deans of Nursing, key faculty members and institutional liaisons of three Ontario universities. The interviews revealed a consistent concern with the marketing of primarily positive aspects of the nursing profession, in perpetuating unrealistic expectations of the career for prospective students. Recruitment activities were additional commitments undertaken by faculty members, demanding their already strained resources, or were the responsibility of institutional marketing liaisons with less familiarity with professional nursing. Respondents indicated that secondary school students were selected through a computerized-lottery system, ranking them solely upon academic performance; mature students were subjected to a more thorough CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 22 assessment. Educators expressed varied opinion of academic performance as ‘the gold standard’ for selecting nursing students. Less objective interviews, references, and personal essays were considered invaluable to the selection of appropriate candidates. Hayes also found a consistent marketing emphasis upon the “popularity” of the three institutions, without profiling the type of individual best suited for successful study at each institution. Hayes went on to indicate concern for the dominance of “positive attributes” of nursing in recruitment messages which provided potential students with an unrealistic representation of nursing with which to decision-make for becoming a nurse (p 265). A study of Bachelor of Science in Nursing-program online nursing images by Escober, et al., presented similar findings of those portrayed as nurses (2007). Photographs were studied for presence of the nurse, the demeanour of nurse and patient/client(s), and the age of patient/client(s) interacting with the nurse. Fewer than 4% of the online images featured older adults interacting with a nurse. Photographs of children were more likely to be featured on the homepage of a Bachelor of Nursing website than photographs of older adults. Images of children tended to be larger in scale than those featuring older adults. Additionally, nearly 70% of older adults featured in the studied photographs were smiling, compared to 39% of children. The authors argued that this overrepresentation of children and underrepresentation of older adults skewed the perception of those entering the nursing profession from the reality of an aging population. The images depicted in Bosco, et al. (2001), Hayes (2007), and Escober, et al. (2007) described the clinical, technological focus of students perceptions are consistent with the tenants of the philosophical paradigm, positivism, which favours scientific method – valuing that which is directly observed and manipulated with scientific technology (Risjord, 2010). Positivism CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 23 heavily influenced the development of modern medicine - and due to the interrelationship of nursing with the medical profession, professional nursing at times expresses positivistic values. Intent and commitment are included amongst the personal attributes influencing a student’s persistence throughout endeavours such as university education; these dispositions in turn “serve to colour the character of individual interactions” throughout a student’s educational experience (Tinto, 1987, p 39). A study by Law & Arthur in Hong Kong revealed an influential relationship between a student’s perception of nursing and the student’s intent to study nursing. Students with intent also indicated a willingness to engage in the activities of nursing, including those that might be perceived negatively (2003). Tinto explains later in his work, Leaving College, “a person’s willingness to work toward the attainment of his/her goals is an important component of the process of persistence” (1987, p 44). It is the imperative, responsibility and challenge of nursing program recruitment to provide students with an accurate educational and professional image of nursing that resonates with the attributes of potential students and capitalizes upon their will to complete the required training. Conclusion The findings of this literature review reveals the Canadian dilemma of a significantly high rate of nursing students who do not complete nursing training, nor persist beyond the first year of professional practice. The literature suggests that discrepancy between student expectations of both Baccalaureate program and profession can impact student satisfaction and persistence through nursing education and into practice as a registered nurse. In recent years, much effort has been placed upon augmenting the image of nursing in order to influence poor public opinion and increase student enrolment to nursing programs. Studies have shown a prevalence of culturally positive images of nursing, including images of nurses smiling, nurses CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 24 with children, and smiling, happy patients. Furthermore, evidence from this review suggests that nursing students enter nursing education with simplified, positive attitudes of the nursing profession, and during the course of nursing education, those perceptions (and students’ satisfaction with nursing) change to incorporate a realistic understanding of nursing practice. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 25 Chapter Three Introduction In this chapter, the foundations, procedure and ethical considerations for this study are explained. For this study, the researcher considered communication theory as an important foundation for observing the material studied, and guiding the analysis of data. Similarly, marketing literature was reviewed to inform the researcher’s understanding of marketing mechanisms and ethics, and their various applications – in particular relation to the profession of nursing. Communication Theory and Representing Nursing The study relied heavily upon communication theory, in detecting and analysing the webavailable promotional materials for various full and partial representations of Nursing. Semiotics is a branch of communication theory, dealing with the study of signs and symbols – verbal and nonverbal. Within this field of study, a sign refers to a stimulus that indicates a certain condition; for instance, a nametag displaying the letters, or signs, R.N., indicate the type and level of licensure the wearer of the nametag has. Symbols are a complex collection of signs which connote meaning, both personal and/or shared (Littlejohn & Foss, 2008). A stethoscope is an instrument of assessment utilized by healthcare professionals – but its image can also connote expertise of the wearer, the scientific bent of the healthcare profession, the importance of good-health check-ups, and of focussed assessment during illness. Non-verbal factors (static and active) also contribute to the fullness of a message. The space or context in which ideas or signs are communicated impacts their interpretation. The same stethoscope found in the laboratory of veterinary scientist would evoke an entirely different set of meanings for an observant of online Baccalaureate education marketing materials. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 26 Humans utilize non-verbal cues within their body actions and posture to communicate signs and symbols; these are groupings of behaviours which connote meaning (Littlejohn, et al., 2008). Messages increase in complexity and fullness with the presence of active, non-verbal signals in a communication. According to communication theorists J. Burgoon & A. Bacue, non-verbal behaviours and signals are indiscrete, continuous and have the potential to communicate a multiplicity of meanings within the context used and by the communicator’s intent (2003). The meaning within the act of hand-holding depends upon the relationship between two individuals, the strength of grip, the distance of the hand from each participants body, the temperature and humidity of the skin, and the circumstance perpetuating the act – a need for comfort, fellowship, reassurance, restraint, steadying, or strength. Proxemics and haptics, respectively refer to the studies of social space and distancing, and of touch in human social interaction (Greene & Burleson, 2003) – that is, how actors within the field of image interacted within a given environment, communicated the fullness of a message of nursing within “a constellation of cues” (Burgoon & Bacue, 2003, p 187). Thus the physical environments, of clinical and community spaces combined with the social environment of patients, clients, families, and other health professionals impact the image of nursing conveyed to those observing. In this study, a patient would be expected to be an individual toward whom the attention and skill of the nurse are oriented– the nurse is likely to position his or herself nearer the patient or patient bed, comforting with a gesture of touch, maintaining eye contact and facial attention toward the patient and administering treatment to a patient – the context of this relationship, conveys a sense of urgency or need for the nurse-patient relationship to be more physically close. Whereas a nurse-client relationship is represented by an interaction where the nurse assumes a CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 27 posture of polite physical distance from a client and maintains their attention and efforts toward the needs of the client. The nurse-client relationship is most often conveyed through a transaction of information or of education, and communicates the sense of relevance of the interaction, but not the same need or urgency requiring close physical proximity and attention. A patient and a client can be the same individual in the nurse-other relationship dependent upon the context bringing the two parties together. Likewise in the current study, the researcher considered families to be groupings of young to middle aged adults caring for younger children, or an older adult in relationship with an elderly spouse and/or adult children and grandchildren (none of whom were acting in health professional roles). Some families might be represented multiethnic families, but a strong sense of parental responsibility and care would be communicated through the proximity of the parental adults toward the younger children. The nurse’s orientation would be toward those with responsibility for and interest in the care of the individual patient or client (i.e. parents of an infant or older adult children of an elder with advanced illness). Other healthcare professionals often supplement the image of a nurse in a medical, clinical setting. Relationships with other health professionals are represented through coordinated, patient-directed care activities that are situation or process-driven. For example, two nursing colleagues push a patient bed down the hall toward an operating theatre, or a physician and nurse viewing the film of an X-ray to determine goals of care. Other health care professionals may be enacting other means of patient care beyond the scope of nursing practice, for instance, physiotherapists enacts range of motion activities with a post-operative patient, while the nurse titrates an infusion of intravenous medication for that same patient. These CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 28 included physicians, surgeons, administrators, dental health professionals, researchers, physiotherapists, and paramedics. Design This project is a qualitative descriptive study presented in the format of a written thesis, studying online materials for the promotion of nursing education and professional nursing. Web-based educational marketing is readily accessible to prospective students considering careers in nursing. In a recently released review from online media surveyor, comScore, Inc., Canadians were identified as the largest users of the Internet globally in 2010; over 22 million individual Canadians accessed the Internet in Canada (2011). Nursing programs increasingly utilize web media to disseminate information and images regarding the nursing profession and educational offerings to prospective nursing students (Escober, Scotese, Berman, Thaler, Fairchild, Gould & Mezey, 2007). In the current study, the release of information and images from Canadian education institutions and nursing programs for the purposes of marketing allowed the data to be readily accessed by the researcher. Sampling Nursing training occurs in various forms within Canada. As the national accrediting body of nursing programs, the Canadian Association of Schools of Nursing is responsible for ensuring the quality of and mandate standards of nursing education in Canada (2011). The Canadian Nurses Association has endorsed those entering professional nursing to consider baccalaureate preparation as entry-to-practice for to the broadened scope of education and training the Bachelor of Nursing, Bachelor of Nursing Science or Bachelor of Science in Nursing affords the individual prospect (2011b). CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 29 At present, CASN acknowledges 91 baccalaureate nursing programs in Canada, representing 10 provinces and 2 territories (not including the Yukon Territory, which at present has no baccalaureate nursing programs) and their respective web URLs (CASN, 2006). One baccalaureate program had been discontinued since the compilation of this list (Centre for Nursing and Health Studies, 2009), thus the number of Baccalaureate programs studied was ninety in total. Procedures Observation and data collection. The study began with a survey of online promotional materials of each of the nursing programs as indicated by CASN (2006). These materials included but were not limited to: photographs and images, film and written descriptions of professional nursing, program components and requirements, course titles and descriptions, nursing student life, and testimony of nursing graduates. Though the aim was to study all data as a collective Canadian representation of nursing, data was collected in order of province/territory from East to West of the country and institutions numbered for ease of organization, and allowing for regional comparisons of nursing image. Since the study aim was to observe promotional materials directed at prospective students of Canadian Baccalaureate nursing programs, websites were observed in a systematic fashion that might be followed by the prospective student seeking information regarding professional nursing. At any point during website search, the researcher recorded in data-collection document any nursing image observed; this included promotion of nursing practice, students or program achievement on the home page of the institution. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 30 The researcher was led to each institutional site by following the web URL provided by the CASN list. The researcher would then scan the site for any images of nursing, or links providing information specifically for “prospective” or “future” students. If neither of these options were available, the researcher would then scan the site for “department”, “program” or “academic” information, which led to further links connecting the researcher to descriptions of baccalaureate nursing education. A number of program websites offered links to supporting organizations and documents – these included program brochures, academic calendars, and websites for organizations such as licencing College websites and the Canadian Nurses Association. These links were accessed when they might have been intuitive action of a prospective student desiring description of professional nursing. The information links to academic calendars and supporting websites were excluded on the basis that these documents were primarily documents “of the institution” and were prepared specifically as “academic” information that had already been mentioned elsewhere in the program information. The researcher utilized a self-developed worksheet when analysing the websites, to ensure focus upon elements pertinent to the research aim (see Appendix B). Three categories of promotional material were considered uniquely – written descriptions, photographic or visual images, and recorded video. Combined, these three elements interacted to provide an image of nursing to prospective students of Canadian Baccalaureate nursing programs. Descriptive materials encompassed any text that might describe nursing including: the characteristics of a nurse (academic, affective, social, physical, behavioural, and spiritual), the working environment of the nurse and the community of the nurse. The researcher maintained a journal of reflection, documenting critical decision points of inclusion and exclusion of website materials throughout preliminary observation and data collection, and the analysis process. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 31 Analysis. During preliminary data analysis, findings from the promotional materials across three broad categories of information were described as to attempt the fullest impression of nursing image as possible. They include 1) description of type of promotional materials utilized, 2) description of nursing image indicated through various media and written material, 3) description of values/behaviours/characteristics represented by images of nurses/nursing. The highlighted nursing characteristics/ values, and manner of image presentation, work in synergy to create a branded image of nursing to prospective students (Bosco, et al., 2001; Dominiak, 2004; Escober, et al., 2007). Through the process of analysis, consistencies within provinces and territories, and differences between significant geographic regions became apparent. The data was thus organized according to geographic region, beginning from Eastern Canada to the West coast: Maritime, Northern, Central, Prairie, & Western, allowing for observation of variations throughout the pan-Canadian nursing programs. Through the process of analysis a code book developed by the researcher was utilized to categorize and organize the data for meaningful and comprehensive analysis (Appendix C). Written materials. Written marketing materials were copied into individual word documents and numbered according to the institution’s study number. These written descriptions of each school were then read through once and coded. Some institutions included external links to nursing college web documents, and PDF program brochures; while these documents were collected in the retrieval, they were not included in the analysis when after first reading they did not contribute additional attributes of nurses or nursing practice. Relevant details of the written descriptions were CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 32 categorized by these codes; for each institution, the coded segments “A” through “L” were then transferred into an excel spreadsheet organized for each institution. During the data transfer, the written segments were reviewed again to ensure they were coded correctly. In preliminary analysis of findings, the researcher noted regional distinctions in program marketing materials across the country. For this study, marketing materials of Baccalaureate programs were organized and analysed according to groupings defined by geographic regions in Canada. Marketing materials were categorized by region according to the province or territory wherein the original Baccalaureate program was situated. This allowed for regional comparison of marketing materials, while analyzing the collected marketing materials for the comprehensive image of nursing. The following table outlines the provincial and territorial groupings within each geographic region: Table 3.1 Regional Comparison, by Province. Region Province and/or Territory Eastern Prince Edward Island, Nova Scotia, Newfoundland, New Brunswick Northern Nunavut, Northwest Territories Central Quebec, Ontario Prairie Manitoba, Saskatchewan, Alberta Western British Columbia Regional comparison of materials was undertaken by creating a separate table for every region studied, which allowed for the amalgamation of all written data according to coded category. The data of each region was then read by coded category several times to glean the most prevalent and distinctive traits of that Canadian region for that category. Photographs and illustrations. Seventy-eight of Canadian baccalaureate nursing programs utilized photographs or illustrations to depict an image of nursing in their online promotional materials. Photographic CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 33 and illustrative materials were observed by the researcher in their natural web-environment, and detailed notes were taken to describe the nature and action of nurses, and their surroundings. Particular attention was paid to note gender, ethnicity, manner and behaviour, dress, nursing actions, and physical and social environment. Data from these observations were then similarly coded using the code book. Film representations. Twenty videos were made available through online links; nine of those were suitably accessible for study - one non-narrated Francophone film, with easily translatable headings and eight Anglophone films. Four films were not included due to a French-language competency beyond the scope of this study and the remaining seven were excluded due to inactive or nonfunctional links. Videos were accessed, viewed and transcribed by the researcher. Actors in each video were observed first for physical descriptors, such as gender, ethnicity and dress. Attention was also paid to the environment wherein the actors played – clinic, nursing lab, classroom, community setting; this environmental survey included the presence of other participants, such as patients, clients, family & community members and other healthcare personnel. Verbal dialogue and descriptions were transcribed verbatim by the researcher and documented along with the descriptions of visual media. The culmination of the data gleaned from the video material was then reviewed and coded using the code book. Institutions with language requirements other than English. Nationally, three languages were represented in Baccalaureate nursing programs: English, French and Inuktitut. Websites were written predominantly in English or provided translations to English; nine program websites were written exclusively in French. Initial CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 34 navigation and observation of these nine, French-language baccalaureate nursing program websites were done in the site`s original language by the researcher, who is currently employed as a Registered Nurse in a bilingual healthcare institution and has a working knowledge of the French language. The sites were then viewed using an online web-translation program, SDL FreeTranslation.com, to ensure that any terminology unfamiliar to the researcher was well understood (2009). The dialogue components all video content of Francophone institution were not recorded for the researcher’s lack of formal ability to translate; the activities of nurses and any photographic images of nurses in these films were recorded as well in the film section of the data collection document. Ethics The sample from which the data for this study will be drawn is composed of publically available online program descriptions and related images/video. The public nature of this data does not require the study to undergo institutional ethics approval (TWU Office of Research, personal communication, February 18, 2011). According to the Tri Council Policy Statement (2nd ed), research involving publically distributed material is exempt from Research Ethics Board review, when the material is: 1) “legally accessible to the public and appropriately protected by law; or 2) Publically accessible and there is no reasonable expectation of privacy” (Canadian Institutes of Health Research (CIHR), Natural Sciences and Engineering Research Council of Canada (NSERC), Social Sciences and Humanities Research Council of Canada (SSHRC), 2010, Sec 2.2) The information to be utilized for the purposes of this research is readily available in the public space of the World Wide Web. No individual persons are personally implicated in this study; CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 35 personal quotations and images reflecting the image of the nurse used on studied websites are released to their affiliated institution and protected within their copyrights (CIHR, et al. 2010). Nevertheless, the researcher is bound to treat these materials, and those they represent with integrity and respect, and to approach these materials with an awareness of personal bias. In order to facilitate awareness of this, the researcher maintained a reflexive journal alongside data collection, analysis and interpretation (Jootun, McGhee & Marland, 2009; Polit et al., 2008). Scientific Quality: Reliability & Validity The researcher took on the reflexive practice of journaling throughout all procedures of the study. Reflexivity is key to the qualitative process, enhancing “the quality of research through its ability to extend our understanding of how our positions and interests as researchers affect all stages of the research process” (Primeau, 2003, p 9). The researcher tracked emerging thoughts, assumptions and critical decision points at any point during the research process, to take account of one’s influence has upon the qualitative process, and to record the nature of relationship between researcher and topic (Jootun, et al., 2009). The reflexive process was a deliberate discipline, and one which proved to be motivation for the researcher, during more tedious moments of the work. For example: JOURNAL ENTRY: “I have finished the translated schools and am so glad. While I am enjoying the study’s findings, there is the temptation to skim – from sheer exhaustion and boredom, and from time pressure; thus invalidating the work and crushing my conscience. Patience is a virtue, as is persistence, and is attention – like a needing child and an exhausted mother…” The researcher also experienced disillusionment at points in the research, where one’s mind became saturated with the data, and the topic itself seemed common sense and CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 36 inconsequential. At these points the researcher found conversations with peers, nursing colleagues and her nursing advisory committee to be of great encouragement – their enthusiasm at the progress and the findings served as a reminder how truly compelling the study of nursing is. Data collection was done in a systematic fashion, from Eastern Canada to West, with one point of exception when the researcher encountered French-language institutions. Francophone institutions were the last to be observed due to the added translation process for each piece of web material. Web materials were considered first separately, as written descriptions, photographs/illustrations and films, before they were compared together, and later considered together as a cohesive image of nursing. Institutional website observations were done within a condensed time-frame to control for the effects of prolonged consideration of data already collected on websites observed later in the data-collection process. Limitations As has been argued, image, both written and visual are potent communication and motivational tools. This study focuses on the representations of professional nursing put forth by Canadian education institutions, though these are not the only images of nursing prospective students are exposed to and influenced by during career decision making. Additionally, the study sample included only those images and written descriptions that were available in online format, though nursing education programs and institutions offer a variety of print promotional materials, as well as compelling formal and informal personal interactions to share nursing with potential nursing students. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 37 Presenting a full image of nursing presented to prospects of Canadian Baccalaureate nursing programs, required the researcher’s awareness of the importance language used to communicate messages about professional nursing. Recognizing itself a foundational culture of Canada, French-Canadian nursing education emphasizes the importance of language in the context of Canadian nursing by requiring French-language competency and defining entry-level criteria for graduating nurses with a French, entry-to-registration exam in the province of Quebec. One program, in Nunavut, required competency in either Inuktitut or English as criteria for student selection. Expressions of nursing education and practice in language shape the Canadian image of nursing, and words project understandings of nursing in foundational, Canadian languages and cultures. As much as was possible, the researcher included web-based marketing materials representing the three noted languages: English, French and Inuktitut. There were no limitations to observation and analysis of the nursing programs with Inuktitut language requirements, as the website was also in English. It was however beyond the second-language competency of the researcher to transcribe narrations and verbal interviews of four Francophone video clips, and thus those video clips were excluded from analysis in this study. Conclusion This study is a qualitative descriptive analysis, observing and describing the marketing materials of 90 Baccalaureate nursing programs in Canada. Materials (written, photographic, film) were analyzed by type, drawing out themes descriptive of the profession of nursing. The data extracted from each marketing material type were analysed together, and the themes were more fully developed. Regional differences were noted when analysing the description of CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 38 nursing through the data, thus care was taken to organize the data according to region for comparison later. Attention was also paid to the primary language utilized (French or English), for its influence upon the description of professional nursing in the studied online marketing materials. Ethical review was not necessary for this study; however the researcher maintained commitment to the quality of this study. The researcher employed the use of reflexive technique throughout the data collection and analysis process to augment validity and reliability of the study’s findings, and the interpretation of those findings. Limitations of this study included barriers of collecting data from francophone films, which were beyond the scope of the researcher’s ability to translate. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 39 Chapter Four Introduction This chapter reports the prominent and distinctive features of the Canadian image of Nursing after analysing the online marketing materials of Canada’s Baccalaureate nursing programs, hereafter referred to as the” marketing materials”. Included within this image, are distinctive microcosmic pictures of the nurse expressed regionally (Appendix D), noting the diversity of the profession across Canada. This chapter presents: who nurses are, what they do, where they work, how they are educated, and how Canadian Baccalaureate programs consider commitment and persistence as part of their marketing scheme. Nursing: A National Image Marketed by Baccalaureate Nursing Programs This study analysed the marketing materials of ninety Canadian baccalaureate nursing programs. Seventy eight of those program websites displayed photographs and/or illustrations in their online marketing material. Nine videos were analysed from eight individual Baccalaureate nursing programs; five videos of four programs in the Central region and three in the Prairie region were analyzed – the West included one example of a film for marketing the image of nursing that was analyzed for this study. The placement of and responsibility for nursing program websites and marketing materials differed throughout the country. Program websites ranged from institution or department-driven explanations of degree requirements and professional details to School of Nursing Home pages, with extensive explanations of nursing. Promotional materials primarily arising from institutional websites, were more likely to be brief, concise, and focussed upon academic details, such as the process of new student application and prerequisites for entering the institutions and the Nursing program. Many of these websites had a marked emphasis upon CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 40 promoting that university or college for studying the discipline of nursing, and offered superficial explanation of professional nursing. These institutions were also the most likely to explicitly mention the fiscal rewards of nursing. Marketing materials arising from distinct Nursing program, Faculty of Nursing or School of Nursing websites were most likely to address philosophic, spiritual, social and historical foundations of nurses and nursing practice, and to explain the fundaments and goals of nursing education practices. The marketing materials of each program served two purposes: to promote nursing education and to promote the practice of nursing as a career. Attention upon institutional details and program specific elements, such as “unique curriculum”, an institutionally-developed “model” of nursing education, and the availability of “extensive clinical placement opportunities” promoted nursing education in marketing materials. Nursing education was promoted across Canada, most particularly by programs of the Central, Prairie and Northern region. The majority of data extracted from the marketing materials analyzed included information which described nursing education. To an extent this described aspects of nursing practice, however nursing education remarks, stressed heavily the supports available to nursing students, of physical and technological resources, expert faculty mentoring, and “safe” laboratories wherein to practice skills. A nursing career was promoted by marketing materials through slogans, and written descriptions aimed toward the prospective student. For instance, Baccalaureate education institution’s employed language of inclusion, such as “you have what it takes”, “now is the time to be a nurse”; of self-actualization, “be a nurse”, “you can do it”, “go that extra mile”, “be caring”; and of altruism, “make a difference”, and “be at the heart of healthcare” to promote a career in nursing. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 41 Program websites varied in the amount and sort of information made available to prospective students regarding professional nursing. Programs varied in their use of these descriptions, one program website simply explained the criteria necessary for admission, whereas many others were very detailed - commenting on the character of professional nurses, the intricacies and variety of nursing work, on the demand for nursing, and expressing disciplinary and philosophic foundations of nursing practice and education. What nursing is: Symbols, roles and goals. Across Canada, the picture of nursing is presented with consistency. The commonly depicted symbols, roles and goals of nursing offer simplified representations of what nursing is – defined by its artefacts, its place in healthcare and community, and its professional aims. In photographs and illustrations, nursing is commonly symbolized by iconic instruments: the stethoscope, needled syringe and nursing uniforms or ‘scrubs’. These symbols were commonly used to denote nursing, distinguishing nurses from clients, patients, families, communities, and other featured healthcare professionals. Nursing was described unanimously as a career of variety and opportunity. National and global nursing shortages, made more desperate by a large aging population and the large number of current nurses who will shortly reach retirement age, were common assurances of job availability for future nurses. Secure, lucrative salaries and opportunities for travel were among the other positive attributes of the profession highlighted for prospective nursing students. Prospective nursing students were tempted to “be anything, work anywhere”, have fun and excitement, work with people, be on the cutting edge, all while being well compensated and professionally respected. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 42 Programs varied in presentation of descriptions that tempered the blush of professional reward; they included alongside the benefits of professional nursing detailed outlines of the physical, mental and emotional demands of nursing practice, suggesting prospective students consider these as they consider nursing as their future career. Nurses were characterized by various aims and goals. In the Maritime region, nursing actions were portrayed as arising from a health promotion and illness/injury prevention orientation, focussing on health restoration and maintenance, and promoting self-care. The Maritime region emphasized nursing’s role in social justice action - promoting health for all by eliminating social disparities. The Central region emphasized goals of health maintenance, health promotion and disease prevention for the achievement and maintenance of optimal health, and the care of patients as key aims of nursing practice. Programs to the North emphasized service to remote, Northern and Aboriginal individuals and communities. The Prairie region elaborated that the goals of nursing were to promote health and wellness, to prevent illness and manage chronic diseases, care for the ill and support others through the process of death and dying. Health education and the strengthening the health and wellness of community were other key aims of nursing in the Prairie region. In the West, nursing’s goals were presented as being primarily to assist others to promote, protect and/or restore the health of individuals, families, communities, and groups and to support others through incurable illness. The acquisition of nursing knowledge to perpetuate nursing practice from a nursing perspective was also a promoted goal of nursing in the Western region. In addition to activities of health promotion and disease prevention and support, one Christian-based program perceived the aim of nursing as the outworking of loving God and other people as oneself. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 43 Nurses were employed in a variety of occupational roles; direct caregiving of the hospitalized individual was most often observed nation-wide in photographs and illustrations of nursing practice and training (Appendix E, Photos 2-7, 11, 13-16). Nursing roles that were emphasized in the Maritime region included, directed care-giving, educating, advocacy, nursing in various clinical specialities, providing community-based nursing service, and formulating policy. In the North, nursing roles that were mentioned in program marketing included staff nursing, education, researcher and leadership, occupational health nursing, community and public health nursing, and home care nursing. The Central region of Canada provided the greatest breadth of nursing roles including: direct care giving in acute, intermediate and chronic care facilities, community and public health nursing, education and research positions. This region highlighted nursing’s role in psychiatry, counselling, midwifery, palliative care, parish nursing, entrepreneurial, managerial, administrative, and policy development positions. Nursing positions requiring post-baccalaureate education, including advanced practice nurse, clinical nurse specialist and nurse practitioner were also described as potential roles for nursing student prospects to consider and aspire to in the Central region. The Prairie region described nursing roles in booth public and private practice, mentioning direct caregiving, public and community health nursing, occupational health nursing, rural nursing, home care, in-hospital, forensic and hospice nursing as roles of nurses. Roles of clinical nurse specialists, policy analysts, administrators, unit managers and program directors, educators and researchers were also prominent in descriptions of professional nurses in the Prairie region. Explicitly mentioned nursing roles in the Western region included greater emphasis on roles requiring further education, including: advanced practice nursing, nurse educators, research and scholarship, and CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 44 clinical nurse specialization. Nurses in the Western region were described by their roles in leadership, direct practice, and advocacy. Who nurses are: Character, characteristics, skills and abilities. Nurses were commonly described by characteristics of personality and ability, and were identifiable in photographs by reoccurring physical traits. These served to define professional standards of nursing activities, and social criteria of nurses’ behaviours, personal traits and expertise. The analysis of Baccalaureate marketing materials revealed a long list of noble character traits defining nursing professionals: willing, assertive, caring, safe, compassionate, ethical, flexible, patient, dependable, understanding, clinically skilled and competent. Every program reviewed expressed great confidence in the character, skill and ability of their graduate nurses in the nursing role. When compared regionally, nurses to the North were described as practical, educated, intuitive, independent, and leaders for nursing in the North. Nurses in the Maritime region were described by their primary health orientation, ethical and moral standards, their collegiality and community-mindedness, their commitment, social accountability, and cultural awareness. In the Central region, nurses were described as prepared, professional, educated, critical thinkers and qualified members of the health care team who are accountable, knowledgeable and skilled. In the Prairie region, nurses were characterised by stamina, competence, versatility, responsibility, and preparedness, fitted with a keen understanding of others, knowledge and experience. Nurses in the Western region of Canada were described as highly skilled, prepared professionals, autonomous and independent individuals with sensitivity to experiences of health and healing, critically reflective and physically, mentally and emotionally able in their roles as nurses. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 45 Identifying nurses in images for analysis was at once a simple and challenging undertaking, related to the changed and non-clinical roles of professional nurses today. In photographs, the nurse was most commonly identified by a neat, modest appearance, the wearing of a nursing uniform – plain or patterned, a stethoscope, a wrist-watch with second-hand, and supportive, white-coloured shoes. In the Maritime region, students were expected to dress according to a professional appearance policy. Centrally, nursing programs expected nursing students to be dressed in a professional and neat fashion; students were also responsible for having their own transportation. Nursing students of the Prairie region were commonly expected to wear nursing uniforms and to have stethoscopes; and students of the Western region of Canada were expected the same and repetitive emphasis was placed on nursing student’s owning or having access to a reliable vehicle for transportation. There was no explicit dress requirement for students of nursing in the Northern region; nursing students and nurses in the Northern region were photographed in patterned uniforms more often than those in other Canadian regions. Across Canada, there was a clear diversity of ethnicity, and gender of nurses and nursing students. Caucasian nurses and nursing students dominated photographic representations in Canadian baccalaureate nursing images. In the Central region of Canada, photographs of students of African, Asian, and Middle Eastern ethnicities were more frequent. Programs of the lower Western region revealed nurses and nursing students of Asian heritage. In the North, photographs of both Caucasian, and Aboriginal Canadians were seen equally represented as nurses and nursing students; Aboriginal Canadians were more likely to be represented in northern Baccalaureate nursing programs of the Prairie Region, and in the Western Region. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 46 Nurses or student nurses were predominantly young in photographs, which was consistent with recruitment aims and selection criteria focussed toward secondary school students for undergraduate nursing education mentioned in written materials. In written descriptions, gender was infrequently implicated as a descriptor of nurses; the discourse on professional nursing was gender neutral. Only four of the ninety programs nationwide explicitly mentioned nursing as a profession for males and females; three of these programs were found in the Central region, and one respectively in the Maritime and Prairie regions. Marketing photographs however represented a predominantly female-gendered profession. Nearly 80% of the individual nurses or student nurses in images presented by Canadian baccalaureate nursing programs were female. Almost all nursing educators depicted in photographs across Canada were female. Table 4.1 records the percent frequencies of male and female nurses and/or nursing students in photographic images across Canada. Table 4.1. Frequency (percent) of occurrence of individual nurse and/or nursing student, by gender (* Central region: Breakdown by province). Gender Maritime Northern Central* Prairie Western 18 9 25 16 13 Male (QU: 10; ON: 26) (%) 82 91 75 84 87 Female (QU: 90; ON: 74) (%) The Central region of Canada represented the highest proportion of males as nurses or nursing students in photographic images; one quarter nurses and nursing students depicted in photographs in the Central region were male. Yet, it is noteworthy that only ten percent of the nurses in photographs used for marketing nursing by programs in the province of Quebec were male. The Northern region depicted the smallest proportion of males in nursing; ninety-one percent of nurses or nursing students in photographs in this region were female. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 47 In video, females were similarly more common than males in depictions of nurses or student nurses; eighty-seven percent of incidences of individual nurses or student nurses were females. Film depictions revealed ninety percent were female in the Prairies and eighty-one percent in the Central region; a third of nurses or nursing students in the video of the Western region were male. Where nurses work: Human populations and environments. The most common environment photographed to depict the space where nursing education and practice is enacted was clinical, often including adjustable beds, blood pressure cuffs, intravenous poles, tubing and fluids, and simple oxygen masks. In written descriptions, nurses were consistently described as working in variety and diversity. Nurses were employed at the individual, familial, local, national and international levels. Nursing itself was considered an environment: wherein individual nurses independently, or in collaboration, exerted influence and worked toward positive professional, societal and healthcare change. The most commonly cited workplaces for nurses were medically-based care institutions, in a variety of medical specialty areas. Most commonly noted were those fields caring for maternal/infant patients or pediatric populations and fast-paced, high-technology care areas such as emergency care, critical care specialties, and intensive care. Infrequently mentioned care areas included palliative, hospice and tertiary care settings, rural healthcare settings and urban, street-health nursing. Professional nursing was also defined by the social environments where nurses are employed. Most commonly, nurses were described as working with individuals, families, groups, and communities, across the lifespan and of varying ethnicity. Individuals were characterized as clients, patients and customers, and at times were described by social supports CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 48 of family, social or community groups they existed within. Nurses could be employed in independent settings, with less daily contact with healthcare colleagues, and others worked as members of an intraprofessional or interdisciplinary team. Emphasis upon different nursing environments varied throughout the country, indicating the adaptability of the profession to changing geography, economy and demographics of Canadian communities. The Maritime region highlighted nurses’ work within the context of “professional, ethical and moral standards”, and a healthcare context characterized by constant, rapid change and reform. Emphasis was also placed on primary care environments, and acute hospital care settings. Regional emphasis was placed on care settings within acute hospitals in the North, and described as “physically and mentally challenging”. Long term care and home care settings were also mentioned in the North. The programs of the Central region expressed the greatest variety of healthcare settings wherein nurses were employed. The medical, acute care environment maintained dominance as the promoted workplace of the professional nurse. Ambulatory clinics, rehabilitation units, public health centres, community health settings, schools and industries, as well as remote and international settings were also featured in the Central region of Canada. Nursing environments of the Prairies were primarily characterized by the populations nurses worked with: infant/maternal, pediatric, acute and chronic medical, home care, and geriatrics. Prairie programs described a “wide range” of physical settings where nurses are employed: rural, regional, local, community, home, organizational, residential, inner city, correctional, industrial and international; and included “clinical” descriptors of a nurses space, including hospital beds, syringes and injection cannula, medications, and dressings. The programs of the Western region characterized nursing within the regulation and by the Standards of provincial Nursing Colleges and supported by a provincial union of nurses. Western schools CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 49 stressed the environment of professional nursing as one of diversity and collaboration, within nursing, with communities, families, other healthcare providers, and in various sectors of healthcare. What nurses do: Behaviour and work. The demeanour predominantly displayed by individual nurses in photographs and films across Canadian baccalaureate marketing was happy, and calm with a smile: shy or generous. Nurses were also attentive to the person or patient receiving assessment or care – this included focussed eye-contact, and/or the nurse’s body postured toward or near the care recipient in observation or comfort. A hand resting on an arm, or hand-holding, were common gestures of comfort and presence commonly acted out by nurses and student nurses in photographs. Another common behaviour revealed in photograph and film was intensity. In these media, nurses were shown taking up quick, responsive movement concentrated toward immediate needs of a patient or client. Similarly, written materials indicated responsive, fast-paced action addressing the critical need of patients and clients as a characteristic of nursing work nation-wide. In photographs and film, nurses were more likely to be presented in the task of providing direct care, independently or in a team to an individual patient or client. Photographs and films revealed nurses and nursing students in common clinical tasks of assessment: auscultating chests and blood pressures, palpating pulses, measuring temperatures, and reading cardiac monitors; preparation: drawing up of injectable medications, checking medications against Medication Administration records, and preparing sterile fields for aseptic techniques; and intervention: administering intradermal, subcutaneous, and intramuscular injections, administering oxygen with simple mask or nasal prongs, wound care, urethral catheter insertion, insertion of intravenous catheters and management of intravenous therapies, and in the emergent activities of CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 50 response to the critically ill patient. Film images predominantly presented nurses performing emergent tasks such as cardiopulmonary resuscitation and psychomotor skills, such as wound dressing and intravenous therapy maintenance. Nurse’s actions were impacted by the age of patients and clients, and number of individuals in their care. In photographic images of nurses interacting with groups of non-health care professionals, these groupings were more likely to represent families with young children or aging elders. Nursing activities were mediated by family structures; in the context of caring for an infant or younger child, a nurse was likely to be examining or assessing the child through play, while simultaneously communicating with the parental adult(s); a parent was often holding or supporting the child, providing comfort although instances of the nurse performing this act were observed as well. In interactions with older adults, a nurse’s activities were oriented toward the elder in assessment and explanation, while simultaneously communicating to adult children. Written explanations described nursing action in a similar manner, but were able to express the cognitive and emotional works of professional nurse in their work place tasks. Nurses’ actions were described in a manner oriented toward others, by caring, compassion, deliberate and focussed attention. Critical thinking, reflexivity, and integration of art and science for the provision of whole-person care were commonly noted cognitive nursing activities acknowledged across the country. Photographs of nurses in consultative poses were rare, yet consultation, collaboration, administrative and managerial work were consistently described as career activities. Written descriptions made prominent the consultative, analytical, and critically reflective activities of nurses. Film representations of nursing were better able to capture nurses and nursing students in CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 51 the act of analysis and consultation, but still these were rare among video representations of nursing. Regardless of working title or work place, nurses were described as leaders, and advocates. Leadership was displayed by activities of skill and integrity at the bedside, where nurses applied theoretical principles to practice to maintain the health and prevent illness of a patient (i.e. the maintenance of asepsis during wound dressing). Similarly, leadership and advocacy characteristics were represented by nurses participation in larger-scale, social advocacy situations across Canada and globally – as in photographs, depicting nurses employed in rural African villages providing relief aid. One film presented confident, competent nursing leadership by a graduate nurse as she transitioned through by her maintenance of personal health (i.e. jogging) and her independent focussed, and calm assessment of a patient’s needs, and appropriate and successful intervention (i.e. lung auscultation and administration of nebulized medication). The film depicted this nurse leaving work, attentive, confident – with head-held straight, looking forward, and relaxed. This confidence was attractive, and conveyed a sense of trustworthiness of the nurse’s intent and action. Two particular photographs, utilized in the promotional materials of Baccalaureate nursing programs stood out among the rest for the connotations they expressed of nursing; one each in the Western and Prairie region. The researcher was interested to have found these photographs for the marketing of nursing. Each presented individual nurse’s in poses that would contradict the presentation professional nursing as modest and collaborative, respectively. The first of these images included three scrubbed nurses: two females in the fore and mid-ground, and a male in the background. The first and most prominent female was positioned in a manner that was sensually suggestive, as was the next female nurse though less so – both CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 52 with backs arched, chests pushed forward, chins tilted slightly down with large smiles and generous eye contact. The male nurse’s positioning in the background was neutral, with arms crossed and a large smile (Photo 20). The second image was a copy of a local painting placed prominently on the website of a School of Nursing. Without any explanation of its meaning, but the title and author, this painting presented nursing in a variety of curious ways. All nurses were painted without faces – the nurse of prominent was painted at the centre of the image, wearing a white laboratory coat standing behind a large desktop computer – her body language connotes the act of reflection, her skin colour was Caucasian. Surrounding her, above, below and to the left most of the painting were several faceless figures with dark skin tones, wearing a traditional, white nursing dresses with white caps or in white, nursing habits. These figures are in various stages of aid, bending toward dark, male figures, and children in acts of service. To the right margin of the image, is a framed image of two Caucasian individuals, in graduation gowns facing back toward a lighted horizon, walking along a paved path surrounded by green (Photo 21). Becoming nurses: Selection criteria, education approaches & curricular foci. All Baccalaureate nursing programs noted academic requirements as admission criteria for prospects. These selection-criteria included the successful completion of high school grade 12, with previous courses in English and/or French, Math, Biology and Chemistry. Nursing programs admitted students with cumulative final averages of seventy-percent or greater. The province of Ontario selects high school students based solely upon a lottery system selecting for those with highest academic performance. Programs in other regions utilized other measures of selection, including personal and health care- related references, autobiographical essays, and interviews. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 53 Prospective nursing students across Canada were invocated to nursing education with a series of health requirements including, medical health assessments, current immunizations, yearly influenza vaccination, tuberculosis testing. Prospects were also required to gain cardiopulmonary resuscitation or basic life support training at the standard or health care provider level, standard first aid training, and in for some programs N95 respirator mask-fit testing for admission. Across Canada, nursing students were subjected to a Criminal Record Check, and some programs also required Child Abuse Registry screening. Some programs required Workplace Hazardous Materials Information System training and the signing of Confidentiality agreements prior to the beginning of study. Students of the Western region were required to provide proof of citizenship, or permanent resident status, and some programs required students to sign a copy of the provincial nursing college’s Requisite Skills and Abilities document, indicating their review and understanding of the expectations of professional nursing students. Across Canada, the language used to describe the education of professional nurses differed, signifying the different approaches employed by nursing educators to perpetuate the profession through students. In the Eastern region, nursing skills and capacities were ‘cultivated’, ‘developed’, ‘fostered’ and ‘nurtured’ in student nurses. Professional nursing was role modeled by nursing educators, and nursing students were professionally socialized. To the North, they were ‘educated’. In the Central Region, nursing students were ‘formed’, ‘disciplined’, ‘prepared’ and ‘equipped’. Nursing students in the Prairie region were ‘prepared’, and ‘engaged’ in partnership with nursing educators for learning. And students in the Western region, were ‘educated’, ‘encouraged’, ‘developed’, ‘engaged’ and ‘exposed’ to various settings of nursing practice through nursing education. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 54 Several Baccalaureate program websites expressed the unique curricular offerings. Fundamentally, curricula differed only slightly across Canada. All Baccalaureate nursing programs required core courses in human sciences: anatomy, physiology, microbiology, psychology, human nutrition and pharmacology. Courses in English, French or academic writing, professional communication theory, ethics, fundamentals of research methods, and leadership were among those courses deemed imperative for graduating professional nurses. Each program integrated nursing theory and practice courses with clinical and community experiences, where students learn to apply and sharpen their nursing skills. Despite heavy emphasis on community and primary healthcare, programs across Canada consistently required nursing courses in medical, surgical, maternity, pediatric, mental health and geriatric nursing specialty areas for the consolidation of nursing skill. Canada-wide, nursing students were engaged by a variety of learning approaches – learning the craft of nursing through lecture, independent study, small and large group discussion, online coursework, laboratory training formats, and mandatory, supervised and preceptored clinical experiences. Where programs differed was the specific emphasis curriculum placed upon each of these elements. Programs of the Maritime region, asserted a focus on process rather than content, to foster the skills and abilities necessary to develop responsible, competent professional nursing practice. In the North, the focus was shared in praxis, balancing academic learning with practical, clinical experience. The programs of the Central region, held the greatest emphasis upon academics, research, medical, professionalism and interprofessional collaboration. Baccalaureate education was regarded as the foundation to further nursing study, at the specialty, graduate and doctorate levels. In stark contrast, college programs of the Central region heavily emphasized the practicality of nurses’ training. The college-based Baccalaureate programs of CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 55 the Central region were the most ‘practice’-promoting of all programs, university and college across Canada. In the Prairie region, nursing programs focussed equally on health sciences and the humanities in training professional nurses, with a community and primary healthcare emphasis. Curriculum in the Western region placed most emphasis on student self-direction for learning, the promotion and maintenance of health and wellness throughout the lifespan, and the health and healing through episodic and chronic health challenges. Nursing programs of the Western Region also offered courses on nursing care to Aboriginal and First Nations’ populations. The Western, Prairie and Central regions of Canada, placed an increasing focus on stateof-the-art technology for the education of professional nurses. The use of computerized, simulation mannequins was heavily marketed as both a point of intrigue and of excellent clinical, medical training opportunity for student nurses. In contrast, non-institutional and non-medical environments, in local and international settings, were also listed as areas wherein valuable nursing skills could be developed. These included in-home, well-baby visits and community health practicums in remote communities of Northern Canada and in developing countries. Regional differences. Variety and diversity was expressed in marketing materials across Canada for the promotion of nursing. Marketing materials were fundamentally similar; in that they promoted a nursing program at the Baccalaureate degree level. Regional similarities were noted in analysis while observing programs of one region at a time, proceeding East to West across the country. Nursing practice and nursing education, and their promotion were as unique as the cultural composition of each region. They each describe nursing within a similar dialectical theme so to speak, where the Eastern region speaks of social hierarchy, public policy and justice, CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 56 the Western region frames nursing in language of healing, wholism, health and wellbeing. Programs of the Northern region use empowering language and illustrate to prospective students that they have the resources to make them excellent nurses. Reoccurring language in the Prairie’s describes nursing practice that professionally engages individuals and their larger communities, with skill and resourcefulness. The Central region of Canadian Baccalaureate nursing programs expressed the greatest diversity of descriptions of nursing – many programs simply informed prospects of nursing with lengthy lists of admitting criteria, nursing roles and academic requirements. There was a distinct sense of ‘choice’ of program in this region, orientating the prospective student as a consumer, and most programs of the Central region were focussed on the promotion of the institution or nursing program over the promotion of a nursing career. Programs of the Central region utilized language that emphasized the professional, academic, and technological aspects of nursing education and career, and at times, expressed negatively, “traditional roles” of “bedside nursing”. Table 4.2 describes a summary of dialectic differences in study findings between geographic regions, Table 4.2. Dialectical theme, by region. Eastern Dialectical Public policy theme Justice Social hierarchy Northern Empowerment Adequate resources Central Academic Professional Technological Diversity Choice Progress Prairie Professionalism Skill Resourcefulness Individual as part of community Western Health Healing Wholeness Language differences. Just as the culture of certain Canadian regions mediated the promotion of nursing in marketing materials, the influence of an entirely different language shaped the representation of nursing by Francophone nursing program websites. Nursing education was clearly defined by an CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 57 apprenticeship model in Francophone marketing materials , where nursing students are ‘formed’ or ‘stimulated’ to nursing practice through their studies. Program marketing materials written in English were more likely to express that student nurses are ‘developed’, ‘fostered’, ‘empowered’ or ‘nurtured’ into nurses. Another key difference between Francophone and Anglophone marketing materials were in their emphasis upon modern science and professionalism. Francophone programs were most likely to describe nursing as a science, demanding a background heavily influenced in the natural, applied and biomedical sciences. They were also most likely to be expressive about the mandatory conduct of nurses, characterized by professionalism, skill and knowledge utilization, predominantly in critical care situations as part of the workforce. Anglophone institutions were more likely to characterize nursing education and practice with ‘softer’ language, emphasizing the ‘art’ as well as the science of nursing, with emphasis upon personal reward, and upon autonomous practice. Language differences between Anglophone and Francophone nursing programs extended into non-verbal differences, which were observed in film and photographic marketing materials. Francophone nurses and student nurses were most often attired in white uniforms, whereas students and nurses of Anglophone displayed more variety of colours and pattern of uniforms. This gave nursing students and nurses in the Francophone context a distinct ‘clinical’ appearance. Calling all nurses: Promoting commitment and persistence in nursing. A variety of slogans were used in the marketing of nursing to prospective Baccalaureate students. In the Maritime region, nursing programs asked prospects if they were interested in a challenging career for the future, and one characterized by working with people. In the Northern region, prospects were encouraged, “You can do it!” and “Many exciting nursing opportunities CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 58 await you!” Program slogans of the Central region consistently stressed the personal creativity, flexibility, reward and caring focus of nursing practice for the prospective students: “It’s your degree. Create your future”, “Meet new challenges every day in this personally and financially rewarding profession”, “You crave a career that allows you the flexibility to work anywhere in the world with the option to specialize in an area of fascination…”, “If you reap rewards from comforting people”, and “if caring and compassion come naturally to you, perhaps you’re destined to become a nurse”. In the Prairie region, slogans that expressed the caring nature and community focus of nursing, and the fulfillment of personal dreams were prominent: “Be caring”, “help those in need as a part of a vital, in-demand field”, “Make a difference in your local community”, and “Your nursing education can take you anywhere you dare to dream”. Programs in the Western region promoted nursing as a means of exploring variety and influencing healthcare transformation, “Take this opportunity to be adventurous: explore diversity, appreciate difference, and expect the unexpected”, and “influence the practice of nursing and societal health nationally and internationally … team up with other health care professionals to promote and maintain health”. Many programs took the opportunity to express the dynamism and progress of the nursing profession through program marketing materials. One program in the Central region explained, “Nursing has evolved. The typical hospital nurse as we sometimes picture her in a white uniform and cap, changing dressings, sheets and bedpans, exists only in old movies”, another exclaimed to prospects, “Nursing looks different now”. Appeals to persistent character traits and behaviour were infrequently utilized for introductory slogans regarding nursing, although persistent behaviours, such as patience, meeting daily challenge and demand, and responding to need in the face of inadequate human and CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 59 physical resources were noted in by Baccalaureate programs across the nation. Instead, emphasis was placed upon the positive attributes of nursing practice. Challenging conditions and realities of nursing practice such as care for the bereft and dying, working with bodily fluids, and working in high-pressure situations demanding accuracy - that require a commitment to profession and others in order to persist in and promote the profession, were mentioned infrequently. Indeed, only two photographs in this study revealed a nurse’s work in these situations; and in these two ‘palliative’ photographs, neither one displayed the faces of patients or nurses, only two hands clasped – a younger atop one frail and cachexic (Photo 18). Commitment to nursing was expressed in a variety of ways; the term commitment was used sporadically, most often in describing a nurse`s orientation to another attribute of practice, and infrequently as an explicit requirement of professional nursing practice. The most prominent demand for commitment behaviour in professional nurses was in regard to their orientation toward perpetual updating of personal practice and intentional engagement in activities of `lifelong learning`. The next, included a commitment to advocacy, for the health and wellness of individual patients to large, populations. Programs of the Maritime region called for individuals who were committed to the improvement of health and quality of life and social justice, and thus to Nursing as a means by which so to do. Nursing in the Maritime region, was a profession one could ‘choose’. Northern programs did not explicitly state the need for commitment in professional nursing. In the Central region, nurses were committed to excellence, professionalism, continual learning, and involvement in changing healthcare for the future. The draw to professional nursing for students was described as ‘interest’, ‘enjoyment’, and professional self-actualization (i.e. meeting personal challenge and goals). The Prairie programs suggested congruence with students’ CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 60 interests and values as motive to enter nursing. Prairie programs also noted the need for students to willingly commit to this challenging yet rewarding career - dedicating themselves to a life of nursing study and nursing work. Programs of the Western region most commonly expressed the attributes and need for out-right commitment to professional nursing as a requirement for practice. Commitment in student nurses was described as actively developed by the mentorship of faculty members. Faculty efforts were shown to involve engaging students’ pre-existing motive, passion, devotion and interest in nursing, while provided an environment and educating within a context of support and expertise. Summary of Findings In summary, Canadian Baccalaureate nursing programs produced online marketing materials that were aimed, in varying degrees at informing and revealing the education and practice of nurses to prospective students, and challenging them to critically consider a career in nursing as well as encouraging and empowering them to embark upon a nursing career path. This study found that where marketing materials were institutionally-oriented marketing material, the image of nursing was described in lesser detail. Findings from the analysis of the marketing materials revealed the image of nursing to be a career of ‘opportunity and variety’, through the five study categories: what nursing is, who nurses are, what nurses do, and becoming nurses. Nursing was described by its icons: the dress of nurses - scrubs, and nurses’ instruments of assessment and intervention: the stethoscope and the needled syringe. Nursing was described by the variety and opportunity of the profession – the professional and personal rewards of job security, lucrative wages, travel opportunity, interpersonal practice, and a job full of interest and challenge. Prominent goals of nursing practice across Canada were response to societal need, health promotion, disease prevention, CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 61 service in urban and remote communities, caring for the acute and chronically ill, caring for persons across the lifespan, and to edify the practice of nursing through the development and use of nursing knowledge. Nursing roles extended from the classroom to the bedside, from remote community practice to urban communities, in acute, chronic and public health settings, caring for patient populations from before birth to after death. Regardless of practice setting, nurses across Canada were described by their role as leaders, and advocates. From the findings of this study, nurses in Canada were represented through images of predominantly young men and woman, and persons of Caucasian ethnicity; although in written descriptions, marketing materials encouraged diversity of ethnicity. Nurses were described as those who exemplify skill and capacity in their nursing knowledge and performance. They were characterized by personality traits including care, compassion, communication, patience, accountability, awareness and sensitivity and critical thinkers. Nurses were most often pictured wearing plain white or coloured scrubs, white nursing shoes, wrist-watches and carrying stethoscopes. The image of the nursing environment according to marketing materials was one of interpersonal context. Nurses were illustrated to work in a variety of interpersonal and interprofessional settings, for the care of persons and communities of Canada. These ‘human’ settings were characterized by diversity of persons across the lifespan, and of varying ethnicity. Nurses were most likely pictured with patients, other nurses, or physicians in photographs and films capturing nursing care. The most commonly implicated physical environment for the nurse in marketing materials was clinical – a predominantly medically-oriented institution, characterized by technological procedures, set within a rural or urban context. Nurses were also described in community settings, providing nursing care to Canadians without the walls of CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 62 hospitals, chronic and long-term care facilities – these nurses were described for their work in homes, industry, government organizations and research and education institutions. Nurses were noted to behave with joy, attention and comfort in their work, directed toward the patient, client or group receiving nursing care. In marketing materials, nurses were most often described to be in the act of nursing by the performance of psychomotor skills. These skills included focussed and comprehensive assessment of the well and ill person, performance of wound care, urinary catheter insertion, medication administration and the initiation and maintenance of intravenous therapy. Furthermore, nursing work was characterized by careful judgement, reflection, integrating arts and science knowledge for the performance of nursing care, collaboration, and providing consultation for their nursing expertise. Nurses were described to embody both leadership and advocacy. Potential nursing students were sought by criteria which heavily emphasized academic performance in natural and applied sciences, mathematics, and the primary languages of Canada. Few program marketing materials discussed criteria beyond these objective measures of fit; these measures included the analysis of written descriptions of intent and experience from prospects, and individual and group interviews. Neither method of selection was exposed in greater detail in marketing materials. A few programs offered students comprehensive lists of necessary behaviours and characteristics for work as professional nurses – these lists were intended to inform the prospective student of nursing realities. Documents allowed prospects to reflect their personal suitability for the profession of nursing, and strongly encouraged them, if necessary, to consider strategies to negotiate areas of personal weakness or disability. Incoming nursing students were required to be immunized, First Aid and CPR certified, and screened for criminal record prior to entering nursing programs. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 63 This study’s findings revealed differences in understanding across Canada, of the process wherein a prospective nursing becomes a professional nurse. This resulted in a variety of methods used throughout nursing education to produce professional nurses. Nursing students were ‘fostered’ and ‘developed’ in programs of Eastern Canada, were ‘disciplined’ in the Central region and ‘educated’ Northern Canada, were ‘promoted in the Prairie region, and ‘engaged’ and ‘encouraged’ in the West. Although curricular emphasis was placed upon community and public health trajectory of nursing, the predominant setting of skill consolidation for nursing students was represented by institutional, medical care facilities and medical, technology-focussed nursing laboratories located at educational facilities. This study observed that marketing materials stressed core nursing, natural science, French or English languages, and mathematics coursework as educational foundations of Baccalaureate nursing students, while promoting to a lesser degree the role of social science and humanities in nursing education. Coursework was reported to be taught through a variety of teaching modalities throughout Canada (i.e. lecture, online, groupwork, independent study, and practicum experience). Methods of education involving technology were most heavily promoted in the Central, West and Prairie regions, whereas education in Northern and remote regions of Canada focussed most upon intercultural and community practice experiences. Regional differences were noted across the Canadian image of nursing in dialectical differences of the language used to describe nursing; in the Central region, where practice environments were most diverse in choice, word-choice used to describe nursing became increasingly academic, standardized and technical. Whereas, in the regions surrounding the CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 64 language describing nursing and education were increasingly oriented toward social diversity, community, wholistic practice and justice. This study found that little explicit emphasis was made to encourage the need for commitment and persistence throughout nursing education and practice. Marketing materials most often employed slogans which emphasized the benefits of professional nursing practice and encouraged participation in nursing education, with sparse mention of persistent or committed attitudes and behaviours of nursing professionals. Conclusion The image of nursing presented online to prospects of Canadian Baccalaureate nursing programs, is neither static nor indiscrete. Professional nursing is characterized by caring, medical and psychosocial expertise, a specific clinical skill set, physical action and intellectual activity. Findings from this study show that nursing is a profession of both challenge and opportunity - one that demands much of its professionals, and simultaneously provides reward. Nursing is practiced by a variety of individuals, in community with each other, and in collaboration with clients, patients, families, groups and communities, as well as those other health disciplines. This research has revealed nursing depicted in various settings, Canada-wide and beyond -from bustling urban critical care units to remote out-post health service stations, in the air and underground as occupational health and safety officers of industry, on the streets of our cities serving those without homes, and in long-term care facilities, working with those with chronic health challenges. Whether incoming students are committed to the profession, learning or those whom nursing professional serves, commitment behaviour is only partially explicated as a necessary CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS characteristic of incoming nursing students. Of the ninety programs studied, thirty one made explicit statements of the commitments of professional nurses. The following chapter will discuss the implications of the findings of this study in relation to the foci of current nursing marketing activities in Canada, and current trends in student recruitment, retention and attrition. 65 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 66 Chapter Five Introduction No single paragraph or photograph can adequately capture the entirety of professional nursing in Canada. Collected together, many pictures of nurses and nursing serve to inform and draw the prospective student, laying foundational images of professional nursing that Baccalaureate nursing education will either confirm or challenge. In this chapter, salient findings of the current study are addressed against the background of current literature – illuminating the current representation of nursing in promotional materials used by Baccalaureate nursing programs in Canada, and addressing current gaps in knowledge. The Honesty of the Image The variety of pictures and descriptions of Nursing provided in online marketing materials of Canadian Baccalaureate Nursing programs represents the variety within the nursing profession across this broad and diverse nation, at a time of great professional growth and changing social needs. Professionally, we have made dramatic movement away from perspectives of nursing that were subservient and professionally limited – nursing has made great strides in asserting itself as an academic, research discipline since establishing itself in Canadian universities in the 1990’s (Pringle, 2006). Canadian healthcare systems have undergone dramatic reforms in service provision, which in turn affects the environment where nursing care is provided, and the manner of care provision by registered nurses. As the age of the Canadian population reaches late adulthood, the care needs of the majority of the population puts increased pressure upon ill-fitting care facilities (i.e. tertiary care facilities) to meet their needs – overburdening acute facilities with exacerbations of chronic illnesses better suited to preventative and palliative management. Acute care institutions become increasingly CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 67 specialized, delivering urgent and emergent care, necessitating an increased emphasis on primary healthcare, community and public health, home care, chronic and long-term care that support Canadian’s in health and wellness, and through management of chronic disease. In order to address care needs and financial restraints, mixed nursing staff (including practical nurses and personal care aids) provide nursing and personal care to clients and patients in collaboration with registered nursing staff. This division of care calls for a revitalized image of nursing in Canada, as tasks traditionally performed by registered nurses are now provided by other health professionals, and allows registered nurses to take on roles and tasks which utilize their Baccalaureate education. Marketing’s utilization for the promotion of nursing has brought on concern for the honesty of the collective image of nursing in Canada of marketing initiatives in previous studies related to perspectives on nursing image, and realism in nursing marketing initiatives (Kirby, 2009; Morris, 2010). Nursing has acted upon the need to confront a poor image: subservient, hand-maidens who unthinkingly carried out the wishes and whims of higher professionals, and rebellious, work-hardened matrons (a woman’s work), a paradoxical interest in represent the positive attributes of nursing in its image developed (Kirby, 2002; Tamlyn, 2005). Investigations of nursing student’s perceptions of their chosen profession including, Grainger et al.’s study of Canadian Baccalaureate nursing students, and O’Brien et al.’s study of Irish pre-entry nursing students indicated that incongruity between perceptions of and actual nursing practice (2006; 2008). Reorienting themselves to a different image of nursing during the demands of Baccalaureate nursing education was found to be a challenge to Canadian nursing students (Grainger, et al, 2006). CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 68 The variety of nursing characteristics and actions described in the findings of the current study aid Canadian Baccalaureate Nursing marketing initiatives by preparing prospective students for the breadth of the profession, and point toward the diversity and dramatic changes that are occurring in current nursing practice and are projected to take place in the future. Honest description of the practice of nursing is derived from realities of nursing education and practices, and requires explanations of nursing’s goals, actions, attributes, demands and requirements, challenges and rewards. Communication theory asserts that individual points of an image create a pattern which connotes a message (Burgoon, et al., 2003; Littlejohn, et al., 2008), and so the Canadian image of nursing is a collection of smaller, regional descriptions and illustrations of nursing analyzed in this study. The current study’s concern is for the ‘fullness’ of the image of nursing as an indicator of promotional honesty – expecting each unique Baccalaureate program to represent nursing as a comprehensive part of the whole nursing, in Canada. This ‘fullness’ includes describing the current realities of nursing - rooting nursing deep within its rich history and disciplinary knowledge, and revealing the profession’s aspirations. This ‘fullness’ also comprises description of nurses as whole persons: of intellect, body, emotion and spirit, and those they care for as whole persons as well – who are individuals part of larger communities. ‘Fullness’ describes nurses for their roles, behaviours, actions, commitments, unique knowledge, working environment and perspective of the people and communities they nurse within. ‘Fullness’ describes a profession which engages persons at every stage of their life (Potter, et al., 2006a). Describing nursing, fully and honesty, indicates the integrity, or as Hughes would state, the “quality” (2000) of the profession, of nursing education and the marketing practices of Baccalaureate nursing programs in Canada. A full and CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 69 honest representation provides prospective nursing students with an accurate and consistent image of nursing to decide upon and work toward throughout nursing education. The current literature reviewed served as a backdrop, against which nursing promotional materials were compared against at every level of honesty: accuracy, internal consistency and external consistency. In this study, findings revealed that Canadian Baccalaureate nursing programs varied in their disclosure of nursing description and photographic representations of nursing. The findings of the current study revealed that nursing was not represented honestly, in the online marketing materials provided by Canadian Baccalaureate nursing programs. The collected promotional materials of each nursing program provided accurate photograph, film and written representations of current nursing education and practice realities – they were not however, ‘full’. Canada-wide very little of historical nursing was presented in marketing materials, and often these descriptions cast nursing history negatively in a non-progressive manner; this is indicative of residual positivistic ideology influencing professional nursing. Continuing in the positivistic trend, nursing programs in Canada reflected a nursing image of the future, bright and technological. Written descriptions, photographs and film, emphasized positive attributes of professional nursing (i.e. altruism, making a difference, advocacy, financial & professional security, opportunities for advancement, international need for nurses), and the use of technology in nursing. Written descriptions were most likely to describe nursing in relation to the deep professional relationships nurses make with patients, clients, families and communities. Photographs and films represented the same, and featured nursing students and professionals in clean, new, technologically-resourced nursing laboratories and practice settings – interacting with a predominantly young, healthy clientele. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 70 Accuracy. According to findings of the current study, variety and opportunity were the dominant characteristics of a nursing career to be emphasized across Canada by Baccalaureate Nursing programs. These characteristics are similarly utilized in the promotion of nursing practice by the CNA (2010). In interviews with nurses and nursing students themselves, nursing was described as a profession of choice, opportunity and growth – one student interviewed stated enthusiastically, “Nursing is the most respected profession in the world”. The dominance of these positive traits is consistent with previous findings by Hayes, whose study of three nursing programs in Ontario highlighted the strengths of nursing for promotion of the profession and programs (2007). Hayes’ findings also reveal a consistency of key representations of nursing, and perspectives of the profession by nursing students. In Dunnion et al., nursing was understood by nursing students as a career of variety, financial and job security by nursing students (2010). This mirrors the current study’s findings, where these characteristics were intentionally highlighted for the purpose of marketing Canadian Baccalaureate nursing programs. Internal consistency. Of the ninety Baccalaureate nursing programs analyzed in this study, very few revealed a full image of nursing; these few were not limited to one region of Canada. Marketing materials rarely presented nursing as an historical profession, and predominantly focussed upon marketing the professional and technological advancement of nursing practice and education. Programs of the Prairie and Eastern regions were most likely to promote nursing in a historical context. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 71 Most marketing materials selected a theme describing the nursing program, and marketing slogans and information was utilized consistently to build upon that theme - for instance, one common program theme was empowerment, thus slogans were motivational, information regarding nursing programs focussed upon supportive resources for nursing students, and in written and film interviews, nursing students expressed overcoming challenges in nursing education with support. Similarly, marketing materials also tended to focus upon one aspect of nursing practice or nursing education or practice. For instance, one program simply outlined the academic criteria, program outline and course titles for Baccalaureate nursing students on a single webpage. Other websites focussed upon distinct roles of nursing – these programs were most likely to use futureoriented language, challenging prospects to ‘make a difference’ in nursing and society. These same programs were often vague in offering explanations of where prospects might find employment in nursing following graduations – often characterizing nursing and healthcare as a place of ‘constant change’. A large amount of information provided in marketing materials did not qualify as a full image of nursing. Some nursing program websites offered a series of webpages and or institutional or academic documents to prospective students, covering a vast array of nursing education and professional information. These documents were plain, sterile, and systematically thorough, but lacked in giving the prospect the unique perspective of nursing with which to help interpret this information. Marketing materials were internally consistent to program theme or bias, but not to a full image of nursing. External consistency. Nurses were described, photographed and filmed in online marketing materials of Baccalaureate nursing programs, as healthy and young; the majority of those featured were CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 72 Caucasian. The media images presented predominantly female individuals as nurses or nursing students; this is an accurate reflection of demographic characteristics. While only 6.2% of nurses in Canada were male in 2009 (CNA, 2011a), the findings of this study revealed almost 20% of individual student nurses and nursing professionals featured in media representations marketing the profession to prospects to be male. Consistent with findings of the literature review, nurses in the current study were often photographed and filmed in areas depicting healthy, young children and less frequently in photograph or film with geriatric populations. Most patients, clients, families and groups, appeared in photograph and film images in good health, whether in the context of medical care or at home, in community (Escober, et al., 2007). The current study revealed strikingly similar symbols of nursing employed in Canadian Baccalaureate nursing promotional materials as to those found in previous literature. Stethoscopes and needled syringes occurred as symbols which connoted nursing was consistent with Bosco, et al.’s elicited illustrations of nursing and nurses by nursing students (2001). Nurses were depicted at the bed-side, in clinical settings – wearing nursing uniforms, nametags, white shoes and smiles upon their faces; these nurses were positioned close to patients in the hospital bed. The current study confirmed a neat and modest appearance and being dressed in a plain or patterned nursing uniform continued associated to nurses and nursing students who appeared in photographic, film and written representations of nurses – helping to distinguish nurses from other healthcare professionals, patients and clients. Nursing as a bed-side, clinical profession still dominates much of the promoted understanding of nursing practice by Baccalaureate nursing programs according to the findings of this study – this accurately reflects current practice realities, for 87.9% of employed nurses in CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 73 2009 reported providing direct patient care (CNA, 2011a). One surprising finding in this study was the negative projection of some bedside activities from Baccalaureate nursing programs. Several programs conveyed the perspective that nursing was not “traditional”, that bedside nursing was a thing of the past, and that traditional nursing action: emptying bedpans, changing linens, were passé in professional nursing practice. In the studied online marketing materials, phrases such as these were often found in the context of promoting the technological advancement of nursing education and nursing practice. The use of technology was widely promoted by Baccalaureate nursing programs across Canada in written materials, and many images portrayed nursing labs outfitted with computers, electronic monitors and assessment tools (i.e. blood pressure cuffs, electronic thermometers) and a variety of simulation equipment (i.e. mannequins, virtual clinical programs). Phrases used to connote technological advancement and education progress in nursing education and practice, included “state-of-the-art”, “cutting edge”, and “advanced” by many programs across Canada in the current study. In contrast to this were phrases which described the “heart” of the nursing profession, the “art of nursing”, and of needing a demeanour of softness, to care for those who are experiencing illness. In the context of this study, professional nursing and baccalaureate nursing education are at odds to define who nurses are, what they do presently and will do in the future. Promotional materials described the diversity of nursing roles with heavy emphasis upon nursing’s position of leadership – roles that dealt with healthy and young populations were represented more prominently in online marketing materials of Canadian Baccalaureate nursing programs. Reflective of current reforms in healthcare and changes in nursing practice, many programs referred to nursing roles existing beyond institutional, clinical contexts. Many CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 74 programs specifically noted primary and public health environments as important employment areas which were well suited to meet the present and projected future needs of Canada’s various populations. In a manner of addressing the need of incoming nursing students to understand fully the implications of professional nursing, three Western region nursing program websites in the current study not only offered access to the “Requisite Skills and Abilities” document drafted by the provincial College (College of Registered Nurses of British Columbia, 2007), but one also indicated students were required to read and sign a copy of this as an indication of their understanding of and commitment to the standards of Nursing practice before admission to the program. One program in the Eastern region made summary of requisite skills and abilities, and made available a link to a similar professional College document for prospective students. Commitment in the Image Expectation of commitment, and commitment behaviour were presented to prospective students sporadically across the country by Baccalaureate nursing program marketing materials, and were presented in manners ranging from explicit to implicit. Programs of the Western region were most explicit in their representations of nursing as a profession requiring career commitment. Nurses were more likely to be described as dedicated, dependable, hard-working, willing, strong in online marketing materials of Canadian Baccalaureate nursing programs, than committed, perhaps because of the connotations of obligation inherent of the term commitment (Merriam-Webster, 2011a). Commitment is perhaps an uncomfortable word for an incoming generation of nursing students – particularly a generation that has been marketed the profession of nursing upon the premise of its reward. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 75 Persistence in the Image Nursing as a career of challenge was consistent the image promoted to prospective students of Canadian Baccalaureate nursing programs – particularly a challenge which reaped tangible reward (i.e. payment, travel, status). The slogan expressing the most ‘persistence’ that was utilized by a Canadian program was, “You can do it!” in the context of a description of nursing practice – sharing with prospects that ‘yes, nursing may be difficult, but you can do it’. Professional nurses were often described by their marks of resilience: dependability, willingness, and stamina, but little mention of the transformation it would take to come to those places of extraordinary personal and professional strength was observed in the study. A film representation provided the most comprehensive picture of continuation through nursing education toward professional practice. A nursing student, with a confident appearance, was followed through various periods of education until employment as a registered nurse. The film showed this student persisting through time; it did not include any circumstances of struggle or difficulty for the nurse, which might have been encouraging for prospective students to be exposed prior to entering professional nursing education. Conclusion The comprehensive image of nursing observed and analyzed in this study, depicts a profession and a nation in transition. The overall image of nursing in Canada presented to prospective students of Canadian Baccalaureate nursing programs is broad, forthright, and thorough, but not altogether honest or full; individual programs across Canada however vary in the honesty of their representations of nursing, and the level and manner by which they express commitment and persistence as invaluable characteristics for professional nursing practice. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 76 Regionally, the greater number of programs influenced the comprehensiveness of the nursing image, but none captured nursing as fully as the national image. Such is the challenge of Baccalaureate nursing programs, to confidently express the unique attributes of nursing in particular regions of Canada and share the diversity of the profession to prospective students, while not compromising the fullness of the image of Canadian nursing. The following chapter will outline recommendations to be considered by governing Canadian nursing associations and colleges, nursing employers, and individual nursing Baccalaureate nursing programs to consider as they continue their presentation of nursing to prospective students, and confront challenges of recruitment and retention. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 77 Chapter Six Introduction This study aimed to capture the current image portrayed by Canadian Baccalaureate nursing programs in their online marketing materials, paying particular attention to the honesty (i.e. accuracy, and internal and external consistency) of the image portrayed. It also aimed to investigate the character of this presented nursing for indicators of persistence and commitment. Persistence and commitment are two critical characteristics involved in student perpetuation through post-secondary education (Tinto, 1987), and throughout this study sensitivity to these concepts in analyzing and interpreting findings was maintained. This study provides current findings of the image of nursing according to online Baccalaureate marketing materials and reveals gaps in our current representation of nursing in promotional materials that demand attention. This chapter will explain conclusions derived from the findings of the current study, in relation to previous research. It will also provide recommendations for Canadian nursing’s individual practitioners, educators, administrators and governing bodies to actively engage in presenting an honest, comprehensive image of nursing to prospective students of Baccalaureate programs. Conclusions This study is the first to provide a comprehensive image of professional nursing and nurses, presented in online marketing materials to prospective students of Baccalaureate nursing programs in Canada. Several conclusions can be made regarding the national image of nursing. Findings from this study reveal a national representation of nursing which is in part accurate against recent releases by Canadian Nursing Association of demographic and practice CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 78 statistics. Collected together, marketing materials of individual Baccalaureate nursing programs describe the breadth of nursing in Canada. This study reveals however that this is not done with consistency throughout the country, and program marketing materials present messages that tend heavily toward themes or single attributes of nursing education or practice – very few mention attributes commitment or persistence in the promoted image of the professional nurse. Previous concerns found in the literature of image dissonance are founded, as this study has illustrated that there are a variety of contrasting characteristics of nursing represented in the current image. These dissimilar representations of professional nursing, such as describing the profession as an art, juxtaposed with the demand for nurses with technological knowledge, are presented to prospects on Baccalaureate program websites in brief, with little framework provided to aid prospective students to interpret these images, in a way that engages the fullness of nursing reality with confidence in nursing skills to prepare them for their professional careers. Furthermore, though many Canadian Baccalaureate nursing program websites boasted a profession of variety, fewer went on to explain the diversity of nursing practice (i.e., different practice tasks, roles and settings) in a balanced manner. While in the context of this study the variety of nursing was observable Canada-wide, it would be unlikely that individual prospective students would study the online marketing materials of all Canadian programs (let alone perhaps those of their region) to gain a comprehensive understanding of the professional path they might embark upon. Recommendations From the perspective of this study, Baccalaureate nursing programs across Canada provide a unique image of nursing and within distinct regions of Canada similarities can be observed. To improve the comprehensive national image of nursing, individual nursing CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 79 programs from across Canada would benefit from networking their perspectives on and representations of professional nursing with one another. This is not to say that one, entirely static image of nursing by Canadian Baccalaureate nursing programs is possible – but it does connote an effort on the part of nursing education, to present an honest image of nursing that is not simply lucrative for an individual institution, but for the whole of Canadian nursing. Another recommendation from this study includes the choice of terminology utilized to convey image of nursing. While nursing must present a strong image, robust enough to prevail through future generations of professional growth and healthcare change, care also should be taken not to disvalue current and past nursing work, but rather honour and respect them. To make statements inconsiderate of the efforts of the entire nursing workforce, past and present – to promote solely “advancement”, is to encourage division amongst different generations of nurses, when in the face of great challenge and change we must promote collegiality. To heavily promote only one role or attribute of nurses or nursing is to do harm to the whole. The structure of the message influences the response of the receiver (Littlejohn, et al., 2008): the certain image of nursing put forth by educational institutions is both potent and interactive to the prospective student, while considering career options, as has been illustrated in the literature, as in Tinto’s literature on student departure (1987). The goals of marketing (geared to students-as-consumers to purchase nursing education as a product), however, must not overpower the honesty of the image: care must be taken in the endeavour to present nursing to potential practitioners. Most programs stated that registered nurses were “prepared” individuals, and most went on to explain the use of nursing skills to provide some measure of patient care: assessment, planning, intervention, and evaluation of action (Potter, Wood, Ross-Kerr, Gilbert, Stephen & CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 80 Day, 2006b). What only some programs mentioned, was the confidence gained and preparedness experienced by students to become successful nursing professionals. This might be an important connection missed when engaging prospective students considering nursing, for after being exposed to realistic descriptions and media of professional nursing and potentially documents outlining the abilities and skills required, many may feel at the outset of their nursing education considerably overwhelmed. As illumined in Dunnion et al. and Hoke, the number of career options today for Canadians is staggering (2010;2006). The number of stable, lucrative careers available to prospects, whose image presents with a more appealing return on prosperity for effort exerted are prevalent against the varied images of nursing put forth by Canadian Baccalaureate nursing programs. It is commendable for nursing to describe itself for all that it is – the reward, the difficult, the unpleasant and the seemly inexpressible satisfaction. It may also be the prerogative of nursing to cultivate a culture that does not despise or fear challenge and change, but that is inspired by the equipping offered by nursing education and practice to engage in a fullness of human experience. This study indicates the need for further research into the image of nurses described in Francophone contexts. Through this current research, the researcher began to identify specific and commonly presented characteristics of nursing that were put forth by the nursing education programs studied, for instance the perspective of apprenticeship as a model of nursing education, the use of “formation” language to express nursing education, and the emphasis of Francophone marketing materials upon the professional and scientific aspects of professional nursing education and practice. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 81 Insofar as nursing marketing materials were found on institutional, departmental and program websites, did the researcher observe the difference in the nature and comprehensiveness of the presentation. Further study into the types of online marketing material development with the character of the product produced is necessary. This is consistent with findings similarly noted by Hughes, in her investigation of nursing education and marketing quality (2000). While online representation of nurses and nursing marketed by Canadian Baccalaureate education websites is a considerable part of the effort of marketing of professional nursing practice to prospects, further study into other means of marketing should be analyzed for their contribution to the national image of nursing by Baccalaureate nursing programs. These would include print materials, prospective student events hosted by college and university Faculties of Nursing, and organizations and facilities where professional nurses are employed. A cohesive online image of nursing practice loses credibility and potency if it is found to be in conflict with other representations of nursing from the same program, institution or within the same Canadian region. With Tinto’s admonishment to emphasize the relationship of student fit with institution and program of study (1987), individual nursing administrators and educators, and collectively through organizations such as the Canadian Association for Schools of Nursing have the opportunity to actively engage in the process of describing and reflecting the image of nursing through promotional materials for Baccalaureate nursing programs. The efforts of both nurses and marketers are necessary to present an honest image of committed, persistent nursing practice for the generation of nurses who will carry on nursing from here. Nursing utilizes (and should continue to) marketing for its usefulness in promoting the profession (Crow, et al., 2009; Dominiak, 2004; Hughes, 2000; Morris, 2010); Nill and CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 82 Schibrowsky’s review of ethics related marketing literature reveals how lessened attention has been placed upon marketing well - with integrity (2007). This has impacted ethos of the theoretical frameworks of marketing that are taken up by professions such as nursing, that focus upon maintaining the consumption of the consumer regardless of the implications of that consumption on consumer, societal or environmental health. Abela and Murphy too defined the need for values to impact our marketing, as they looked toward a manner of marketing which demands integrity of the marketer for the interest, protection and service of the consumer, as a means to alleviate current inaccuracies and inconsistencies of current marketing practices (2008). Action first begins with motivated intention – a similar process to the one taken up by individuals to become registered nurses, must be re-enacted in the honest promotion of nursing. Former president of the Canadian Nurses Association, Dr. Deborah Tamlyn, encouraged in a 2005 article in the Canadian Nurse on the pressing significance of presenting the image of nursing, “I believe the time is right for each nurse to act – individually and collectively – to create a more positive social image for our profession. If we want to be perceived as knowledgeable, flexible, collaborative and self-confident, we need to pay attention to our appearance, presentation, attitudes and behaviours. First impressions count.” (p 26) The collective, comprehensive image this study offers compelling impetus to improve current online marketing of Baccalaureate nursing, and provides a national glimpse of nursing to utilize for reflection. Across Canada: may nurses integrate their work with their words, ideas and wisdom to share with those who are considering nursing as their prospective career. Honest nursing image is the responsibility of all nurses, individually and collectively. This study finds several consistencies in marketing nursing across Canada, while also CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 83 representing professional and demographic diversity. This research recommends collaboration between governing provincial and territorial Colleges of Nursing and nursing associations in uniting the image of professional nurses, nursing education and practice from Coast-to-Coast and providing guidelines to nursing programs to encourage full and honest representation of nursing. Another recommendation arising from this study is that the Canadian Association of Schools of Nursing (CASN), as the accrediting body for Canadian Baccalaureate Nursing education, takes measures to assess the methods and character of the image of nursing in marketing materials utilized by Canadian nursing programs. Further still, this research suggests that national bodies such as CASN, as well as the Canadian Nursing Association provide leadership in promoting a the full, honest image of nursing through guidelines development for Baccalaureate nursing education programs, which focus upon the marketing of nursing in Canada. Program marketing materials might be considered for their accuracy, their consistency within materials to provide a cohesive, full image of nursing that contributes to the external consistency of the image of nursing promoted across Canada. Enacting the recommendations of this study – developing and marketing an ‘honest’ image of nursing, characterized by the need for commitment and persistence, to prospective students of Canadian Baccalaureate nursing programs will set Canadian nurses apart professionally and internationally as people who strive to mark every part of nursing practice with excellence and integrity. We are a profession of character, commitment and care. We are a profession that endures challenge, struggle amidst the social and physical environments where we are employed. Nurses are dealt profound responsibility; we stand for accountability for our knowledge and actions – and through all of this, we persist and bring nursing to Canadians. We CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS must also persist in bringing an image of nursing, honest and full to prospects of our Canadian Baccalaureate nursing programs. 84 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 85 References Abela, A.V., Murphy, P.E. (2008). Marketing with integrity: ethics and the service-dominant logic for marketing. Journal of the Academy of Marketing Science, 63, 39-53. Angus Reid Global Strategies. (2009, Sep 1). High respect for nurses in Canada, US and UK. Available at http://www.angusreid.com/polls/37056/high_respect_for_nurses_in_canada_us_and_uk/. Bosco, A., Ward, C., Styles, I. (2005). Looking to the future: Nursing as a career goal. 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University of Chicago Press: Chicago, IL. Tinto, V. (1993) in Hayes, L. (2007). Recruitment strategies for baccalaureate nursing students in Ontario. Journal of Nursing Education, 46 (6), 261 –268. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 91 Appendix A Programs for Analysis CASN-accredited institutions of baccalaureate nursing education (2006, accessed November 9, 2010) by province/territory, study number Canadian Province Study Institution/Website Number Prince Edward 1. Island University of PEI www.upei.ca/nursing/ (1) Nova Scotia 2. (3) Cape Breton University www.accb.ns.ca/academics/nursing 3. Dalhousie University www.dal.ca 4. St. Francis Xavier University www.stfx.ca Newfoundland 5. (3) Centre for Nursing Studies Health Care Corporation of St. John’s www.cns.nf.ca 6. Memorial University of Newfoundland www.mun.ca/nursing 7. Western Regional School of Nursing www.swgc.mun.ca/ New Brunswick 8. University of Moncton CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS (2) www.umoncton.ca 9. University of New Brunswick www.unb.ca Nunavut 10. (1) Northwest Nunavut Arctic College www.nac.nu.ca 11. Territories Aurora College www.auroracollege.nt.ca (1) Quebec 12. (9) McGill University www.mcgill.ca 13. Université de Laval www.fsi.ulaval.ca 14. Université de Montréal www.scinf.umontreal.ca 15. Université de Sherbrooke www.usherbrooke.ca 16. Université de Quebec à Abitibi-Témiscamingue www.uqat.ca 17. Université du Quebec à Chicoutimi www.uqac.ca 18. Université du Quebec Outouais www.uqo.ca 19. Université du Quebec à Rimouski 92 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS www.uqar.ca 20. Université du Quebec à Trois-Rivières www.uqtr.ca Ontario 21. (35) Algonquin College www.algonquincollege.com 22. Boréal Collège www.borealc.on.ca 23. Brock University www.brocku.ca 24. Cambrian College of Applied Arts & Technology www.cambrianc.on.ca 25. Canadore College www.canadorec.on.ca 26. Centennial College www.centennialcollege.ca 27. Conestoga College www.conestogac.on.ca 28. Confederation College www.confederationc.on.ca 29. Durham College www.durhamc.on.ca 30. Fanshawe College www.fanshawec.ca 93 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 31. Fleming College www.flemingc.on.ca 32. George Brown College www.gbrownc.on.ca 33. Georgian College of Applied Arts & Technology (AAT) www.georgianc.on.ca 34. Humber College of Applied Arts & Technology www.humberc.on.ca 35. La Cité Collégiale www.lacitec.on.ca 36. Lakehead University www.lakeheadu.ca 37. Lambton College www.lambtonc.on.ca 38. Laurentian University www.laurentian.ca 39. Loyalist College of Applied Arts & Technology www.loyalistc.on.ca 40. McMaster University www.mcmaster.ca 41. Mohawk College www.mohawkcollege.ca 42. Nipissing University 94 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS www.nipissingu.ca 43. Northern College www.northernc.on.ca 44. Queen’s University www.queensu.ca 45. Ryerson University www.ryerson.ca 46. Sault College of Applied Arts & Technology www.saultc.on.ca 47. Seneca College www.senecac.on.ca 48. St. Clair College www.stclaircollege.ca 49. St. Lawrence College www.stlawrencecollege.ca 50. Trent University www.trentu.ca 51. University of Ontario Institute of Technology www.uoit.ca 52. University of Ottawa www.uottawa.ca 53. University of Toronto www.bloomburg.nursing.utoronto.ca 95 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 54. University of Western Ontario www.uwo.ca 55. University of Windsor www.uwindsor.ca/nursing 56. York University www.yorku.ca Manitoba 57. (4) Brandon University www.brandonu.ca 58. Red River College of Applied Arts, Science & Technology (AAST) www.rrc.mb.ca 59. University College of the North http://www.ucn.ca/ 60. University of Manitoba www.umanitoba.ca Saskatchewan 61. (3) First Nations University of Canada www.firstnationsuniversity.ca 62. Saskatchewan Institute of Applied Science & Technology (SIAST) www.siast.sk.ca 63. University of Saskatchewan http://www.usask.ca/nursing/ Alberta 64. Athabasca University* 96 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS (10)* www.athabascau.ca 65. Grande Prairie Regional College www.gprc.ab.ca 66. Grant MacEwan University www.macewan.ca 67. Keyano College www.keyano.ca 68. Lethbridge Community College www.lethbridgecollege.ca 69. Medicine Hat College www.mhc.ab.ca 70. Mount Royal University www.mtroyal.ca 71. Red Deer College www.rdc.ab.ca 72. University of Alberta www.ualberta.ca 73. University of Calgary www.ucalgary.ca 74. University of Lethbridge www.uleth.ca British Columbia (17) 75. British Columbia Institute of Technology (BCIT) www.bcit.ca 97 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 76. Camosun College www.camosun.bc.ca 77. College of New Caledonia www.cnc.bc.ca 78. College of the Rockies www.cotr.bc.ca 79. Douglas College www.douglas.bc.ca 80. Kwantlen Polytechnic University www.kwantlen.bc.ca 81. Langara College www.langara.bc.ca 82. Malaspina University-College www.mala.bc.ca 83. North Island College www.nic.bc.ca 84. Selkirk College www.selkirk.bc.ca 85. Thompson Rivers University www.tru.ca 86. Trinity Western University www.twu.ca 87. University of British Columbia 98 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS www.nursing.ubc.ca 88. University of British Columbia Okanagan www.ubc.ca/okanagan 89. University of Northern British Columbia www.unbc.ca 90. University of Victoria www.uvic.ca 91. University of the Fraser Valley www.ufv.ca TOTAL 90 PROGRAMS * program suspended as of 15 March 2007 99 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 100 Appendix B Data Collection Excel Spreadsheet Guiding Questions: What are the prevalent physical and affective characteristics of nursing marketed to prospective students of Canadian baccalaureate nursing programs? What characteristics of the prospective student are emphasized? What is the character of the relationship described between prospective student and professional nursing? University/College Program Study Number University Affiliation Program URL Program Title Number of Pages/Links Print Images Descriptive Images Film Images Centre for Nursing Studies St. Health Care Cape Francis Corporation University Breton Dalhousie Xavier of St. of PEI University University University John’s 1 2 3 4 5 … CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS Appendix C Code Book for Analysis A. Characteristics of the Nurse B. Dress Code C. Environment D. Nursing Actions E. Goals of Nursing F. Nursing Roles G. Characteristics of the Discipline H. Characteristics of Nursing Education I. Criteria for Nursing J. Nursing values K. Slogans L. Commitment 101 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 102 Appendix D Program Photographs Photo 1. Example of stethoscope: instrument and icon of nursing ( www.langara.bc.ca). Photo 2. Example of client/patient-oriented body posture and gentle use of touch, with smiling faces and deliberate eye contact (University of Lethbridge, www.uleth.ca ). Photo 3. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 103 Example of disciplined posture for the performance of aseptic nursing techniques (University of Alberta, www.ualberta.ca). Photo 4. Example of positivistic, professional relationships with nurses, characterized by gestures and expressions of happiness (Douglas College, www.douglas.bc.ca). Photo 5. Smiling, male and female nurses in scrubs, surrounding a smiling, bed-bound patient (George Brown College, www.gbrownc.on.ca). CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 104 Photo 6. Nurse with healthy infant, relaxed and happy posture (Kwantlen Polytechnic University, www.kwantlen.bc.ca). Photo 7. Nursing students manage acute illness of simulator child, with focussed attention, and deliberate intervention (Lakehead University, www.lakeheadu.ca). CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 105 Photo 8. Example of clinical technology in nursing environment, intravenous pump education (McMaster University, www.mcmaster.ca). Photo 9. Nursing students happily study (University of Manitoba, www.umanitoba.ca). Photo 10. Example of use of grasp by professional nurses (Ryerson University, www.ryerson.ca). CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS Photo 11. Communication among colleagues in medical setting (Université de Sherbrooke, www.usherbrooke.ca). Photo 12. Nursing students focussed (Trinity Western University, www.twu.ca). Photo 13. Nurses in focussed monitoring (University of Calgary, www.ucalgary.ca). 106 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 107 Photo14. Precision in psychomotor skill (University of the Fraser Valley, www.ufv.ca). Photo15. Keenly observant nurses (Université de Montréal, www.scinf.umontreal.ca). Photo 16. Intentional use of therapeutic touch by nurse (Université de Montréal, www.scinf.umontreal.ca). CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 108 Photo 17. Nursing care in home setting; blood pressure monitoring (Ryerson University, www.ryerson.ca). Photo 18. Photograph representing Palliative nursing (La Cité Collégiale, www.lacitec.on.ca). Photo 19. CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS Canadian nurse pictured in Bangladesh as part of refugee assistance effort (University of Calgary, www.ucalgary.ca). Photo 20. Marketing image of nurses, modelling poses of subtle sensuality (Department of Nursing Education: Nursing Education, Grande Prairie Regional College, www.gprc.ab.ca). Photo 21. Painting found on School of Nursing home page, presenting various images of nursing (University of Victoria, www.uvic.ca). 109 CANADIAN NURSING IMAGE TO PROSPECTIVE STUDENTS 110