How Nurses Views Themselves in Turkey : A Qualitative SWOT Analysis

C l i n M e d International Library Citation: Abay H, Kaplan S, Sahin S, Pinar G (2016) How Nurses Views Themselves in Turkey: A Qualitative SWOT Analysis. Int Arch Nurs Health Care 2:036 Received: December 09, 2015: Accepted: February 16, 2016: Published: February 21, 2016 Copyright: © 2016 Abay H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abay et al. Int Arch Nurs Health Care 2016, 2:036


Introduction
Lifetime gets longer today owing to the developments in science and technology and the desire of spending this time in high-quality increases health care requirements of individuals [1].The nursing profession, which emerged to meet health care requirements and inequality in personnel distribution (rural-urban), deficiency in magnet hospital number, inability to understand the significance of institution culture and organization for employee satisfaction, deficiency in branching out, deficiency in professional nursing and administration, administrative communication problems, inadequacy in qualification and quantification of nurses, increase in the need to nurse work power, experiencing problems in appointments despite of nurse deficiency and unemployment problems (Figure 1) [14,15].
The future nursing's strengthening as a profession with its own identity will depend on knowing what, how and why nurses perform certain functions.To achieve professional definition, nursing needs to outline, recognise, verify and build relationships between aspects falling within its scope of competence [6].Thus firstly it have to analyze the current situation of nursing and have to identify strengths, weaknesses, opportunities and threats of nursing in Turkey.Strengthening of weak aspects will add power to nursing profession by turning threats to opportunities.Illustrating their power and opportunities to nurses will lead to their belief for success and improve their motivation [6].In addition to there is no study encountered with SWOT analysis current situation of nursing in Turkey.

Purpose
Based on this situation, the study was conducted to analyze the strengths, weaknesses, opportunities and threats that define the current situation of nursing in Turkey and to develop suggestions.

Research question
What are the strengths, weaknesses, opportunities and threats of nursing in Turkey?

Research type
The study is a qualitative research conducted on May 21, 2015.Qualitative research is used to examine subjective human experience by using non-statistical methods of analysis [16].It is associated with naturalistic inquiry which explores the complex experience of human beings [17].Qualitative research can generate information that can help nurses by informing clinical decisions.Qualitative nursing research focuses on patients and/or health professionals' experiences.Through this approach the reality of people's experiences and lives are not over simplified and subsumed into a number or a statistic [18].
SWOT analysis was performed among key informants in the study.This method was previously used in the research to analyze nursing in Europe and different profession in Kuwait [6,19].SWOT is a simple framework that points to the importance of external and internal forces for the purpose of understanding the sources of competitive advantage [20].This tool helps look at the organization's or situation's current performance (strengths and weaknesses) and the organization's future (opportunities and threats) by accounting for the factors that exist in the external environment.SWOT is a powerful and sometimes highly successful technique that can be applied to individuals, groups, teams, organizations, or even plans [21].SWOT helps decide whether the main problems facing an organization revolve around a need to revise strategy, a need to improve strategy implementation, or both [22].

Participants
The study population consists of all students who receive education in Nursing Doctorate Program at Yildirim Beyazit University.The sample population is very variable in qualitative research.It can vary from one individual to small groups [16].The study was consisted of the 12 students attending.Samples were selected based on maximum variability sampling.Our purpose was to generate a small sample relatively and to reflect variability in this sample at a maximum level.
The participants' age average was 32.5 ± 0.6 (min = 27, max = 48).Profession year average was determined to be 12.5 ± 6.6 (min = 6, max = 29).One of the participants was an individual in charge of a clinic at the University Hospital, one of them was an administrative in a private hospital, one of them was an oncology nurse at the training research hospital, and nine of them were serving as academician.

Ethical Considerations
The permit was received from the concerned institution to do the research.Before the data were collected in the research, the participants were informed about the purpose of the study and written approvals of the participants were received.

Instruments
The data in the study were collected by instruments include

Data Analysis
The thematic analysis method was used for data evaluation.Thematic analysis emphasizes pinpointing, examining, and recording patterns (or "themes") within data [24].Themes are patterns across data sets that are important to the description of a phenomenon and are associated to a specific research question [25].The themes become the categories for analysis [26].Thematic analysis is performed through the process of coding in six phases to create established, meaningful patterns.These phases are: familiarization with data, generating initial codes, searching for themes among codes, reviewing themes, defining and naming themes, and producing the final report [24].
The data were read over and over again in our study.The points compiled were grouped by theme for each of the 4 categories in the SWOT analysis.The categories were the strengths, weaknesses, opportunities and threats to the nursing profession in Turkey.

Results
Four main themes were determined at the end of the thematic analysis.

Theme 1 -Strengths of nursing profession
In the first main theme is "strengths of nursing profession", subthemes are"strengths of nursing profession education" and "other strengths of nursing profession" in the study.The participants indicated strengthsof nursing profession education as"presence of a license education according to EU criteria", "presence of many numbers of license programs offering nursing education", "absence of a nursing education at high school level legally", "presence of graduate level education programs", "presence of educated instructors" and "nurses having rich theoretical knowledge".In addition, the participants presented opinion about the other strengthsof nursing profession as"nurses have legal rights and laws", "existence of a professional association", "presence of high number of nurses", "an increase in the number of scientific researches and applications in nursing field" and "joining of men to the profession" (Table 1).

Theme 2 -Weaknesses of nursing profession
In the second main theme is "weaknesses of nursing profession", subthemes are "weaknesses of working conditions of nursing profession" and "other weaknesses of nursing profession" in the study.The participants stated the weaknesses about the working conditions of nursing profession as "Inadequate number of nurses working actively although the number of existing nurses working at the hospital is sufficient", "doing overtime", "working for inadequate and unequal wages", "failing to refer to nurse opinion in reaching decisions about the nurses", "lack of an encouraging setting", "insufficient autonomy", "role loss and chaos in the duty, authority and responsibilities of nurses," "perception of physicians as an authority", "absence of the provision of the services of nurses in the performance system", "inadequate worker safety" and "unfavorable effect of shift working system on living quality".In addition, the participants presented opinion about the other weaknesses of nursing profession as "inability to put professional norms and standards into practice," "nonsupport of specialization by the state or still failing to give specialized nurse appointments", "prevalence of authority acceptance and submission to authority by nurses", "inadequate professional awareness", "insufficient organization and conflicts between organizations", "insufficient strategic workforce planning", "appointment of persons in professions other than nursing to health institutions' nursing administrations", "unwillingness to political participation" (Table 1).

Theme 3 -Opportunities directed to nursing profession
In the third main theme is "opportunitiesdirected to nursing profession", subthemes are "job finding opportunities in nursing profession" and "other opportunities directed to nursing profession" in the study.The participants stated the job finding opportunities in nursing profession as "great need for nurses in the society", "increasing in the number of patients", "continuous need for health services", "great job finding opportunity" opportunity to find job in Europe and America in case some conditions are provided" and "very large working field".In addition, the participants expressed opinion on the other opportunities in nursing profession as follows, "an opportunity to do academic career", "presence of opportunities for doing research and a wide research area", "problem solution and practical thinking ability gaining enabled by nursing profession" and "spiritual satisfaction provided by nursing profession" (Table 1).

Theme 4 -Threats against nursing profession
In the fourth main theme is "threats against nursing profession", subthemes are "workers' health" and "other threats against nursing profession" in the study.The participants indicated that nursing profession is perceived as a threat to especially workers' health with the expressions as, "high risk of catching occupational illnesses or contagious diseases", "frequent experience of stress and depression", "high rate of exhaustion experience" and "frequent experience of sleep deprivation, wearing and biological arrhythmia".At the same time, as other threats against nursing profession, they stated "exposure to mobbing", "high anxiety of malpractice and making mistakes", "other health professional (doctors, emergency medicine technicians, etc.)", "nursing aides" and "appointment of men who join nursing profession in administrative duties mostly" (Table 1).

Discussion
The ageing population and accelerated scientific and technical development means nursing professionals and customers become more analytical and demand advanced and bold nursing care that is founded on new knowledge, skills, attitudes, know-how and savoir faire.These developments have increased the necessity to professionalism in nursing occupation in Turkey.In the present study, where the strengths, weaknesses, opportunities and threats that define the current situation of nursing in Turkey were analyzed.In the study of Manzano-García and Ayala-Calvo, it was emphasized that showing the nurses their power and opportunities formed their belief for success and improved their motivation [6].
In the present study, basing nursing education at the license level was put forward among the strong aspects of nursing in Turkey.In Turkey, which is in the process of EU membership, the period of nursing license program which post-graduation high school became, at least, four years based on 4600 hours of theoretical and practical education and all nursing license programs were integrated starting from February 2, 2008 [13,35].In our study, presence of a license education according to EU criteria was determined as the strength of nursing profession.This situation is critical for the acceptance of equivalents of nursing license diplomas received in Turkey, in the EU member countries.As the need for quality nursing care and the developments in science and technology increased, an amendment was made in the Nursing Law in 2007 in Turkey, and a condition was placed for basing nursing profession, having different educational levels as associate degree and license, on license education [27].License level nursing education in Turkey started in 1955, and in 2013, nursing education was given total of 118 universities [28,29].However, because of the inadequate number of nurses in Turkey, a provisional article was added to the Nursing Law, and student acceptance to the vocational nursing school continued.When Health Statistics Annual is examined, it stands out that the number of nurses who graduated from vocational nursing schools (8.874) is greater than the number of nurses who graduated from nursing license programs(6.281)[30].When high school graduate nurses and licensed graduates are compared, it is thought that they will not show the same professional knowledge, ability and professionalism [31][32][33][34].In this regard, it was decided in 2014 that those who graduated from nursing programs based on high school education were granted "nurse aide" title [27].In the present study, nurse aides were seen as a threat because they lower service quality, increase malpractice risk, and their duty definitions are absent.
It is crucial that the students receive education in the guidance of an instructor in a private learning environment for gaining knowledge, ability and attitude in nursing education [3].It is observed that the number of students attending nursing license programs in 2013 in Turkey was 38.112, and the number of instructors (professor, associate professor, research assistant) was 574.At the same time, the number of students per instructor was 66.4 [30].Moreover, it is observed that the number of students per instructor in higher education institutions training nurses during 2003-2013 increased gradually [35].Although this situation reveals the lack of instructors giving nursing license education quantitatively, in our study, the participants thinks that skilled instructors work in nursing department of universities.
In our study, presence of post-graduate program was assessed as the other strength of nursing profession education.Post-graduate education in nursing in Turkey started in 1968, and the doctorate program commenced in 1972 [36].Today, there are nursing programs in many universities offering post-graduate education as master's and doctorate.Although an increase of these programs enables specialization in the nursing profession, it improves occupational knowledge strength of nurses.Hence, nurses gain professionalism and competence, and they can carry out proof-based nursing applications as being aware of their responsibilities and independent functions as a team member.In the Nursing Education in Turkey Report, the number of master's students who graduated from nursing colleges during the past ten years was 461, and the number of doctorate students was 126 [28].It is thought that this number in 2004 reached thousands in master's and three hundred in doctorate [37].Although specialization in the nursing profession still continuous, specialist nurse appointments referred to in the Nursing Law of 2010 have not been assigned yet [15,38].When the United States of America (USA) example is scrutinized about the specialization on women's health nursing in nursing profession, specialized nursing education on women's health field in the USA takes place in two different categories as post-graduate certificate and post-graduate diploma (a diploma received at the end of a post-graduate program) [39].The nurses who complete post-graduate certificate program are given the title of "Registered Nurse".Specialized nursing title in women's health field is granted after the completion of a postgraduate program in nursing that lasts at least two years after the license education.Although the educational content is similar, the titles and authorities of the nurses who graduate from the certificate program and post-graduate program differ from each other due to the differences in the credits of the taken class, educational period (six months or one year in certificate programs, and at least two years in post-graduate programs) and their responsibilities.Although the roles of the women's health nurses with a certificate are more limited, the roles of specialized women's health nurses are more diverse [40].In our study, the inability of nurses who are graduates of master's and doctorate to work according to their specialty fields, the state nonsupporting specialization or failure to appoint specialized nurses still were evaluated among the weaknesses of the profession.
Nursing is identified with sacrifice present in the beneficial and healing role and nature of women.Therefore, in many societies, it is regarded as a women's occupation [41,42].Acceptance of the inappropriateness of men for care-giving role originating social gender patterns and believes prevented entering of men to the nursing profession and this situation was supported in the first Nursing Law as well [43,44].This situation was changed in 2007 in the Nursing Law and 2010 by the Decree of Supreme Court, and the condition of being a woman in nursing profession was annulled [45,46].In our study, joining of men in the occupation was determined as the strength of nursing profession, but appointment of men, who joined nursing profession, in administrative duties mostly stands out as a threat directed to nursing profession.
In our study, it was determined that considerable number of nurses made strength nursing profession, but an insufficient number of actively working nurses made weak nursing profession.When Turkish Ministry of Health data are examined, as of 2013, it is known that there are 149.012nurses working actively in the entire health sector in Turkey, and there are 252 nurses per 100.000persons [30,36].It is remarkable that this number is 869/100.000 in upperincome group countries, 836/100.000 in the EU, 805/100.00 in the World Health Organization European Region, and 880/100.000 in the Organization for Economic Cooperation and Development (OECD) countries [30,47].Based on these data, it can be stated that the number of nurses per the population of Turkey is quite small.Hence, doing overtime indicated as the weakness of nursing profession supports the situation, in the study.Therefore, inadequate strategic workforce planning indicated the weakness of nursing profession needs to be strengthened.
Workers' health and high rate of anxiety about malpractice and making mistakes were determined the most important points in threats against nursing profession, in our study.When the conducted studies are scrutinized, it stands out that nurses in Turkey experience physical fatigue and occupational wear, the tendency to chronic illnesses and increase the rate of making mistakes because of doing overtime [48][49][50][51].It may be discussed that these problems experienced in nursing profession affect the quality of provided care.Therefore, to prevent this situation, it is important that nurses settle a proactive approach and owing to this, the adaptation of the patients to treatment, their motivation, perceiving themselves as valuable and feeling themselves safe is achieved.
This study has three limitations.First, the study is local, but the participants served as a nurse at a different statue in different cities of Turkey.In addition, among the participants, there were nurses and academicians at the doctorate level who had critical thinking skill.Therefore, it is thought that the participants could evaluate nursing profession in Turkey with a wide perspective.Second, we did not use a previously validated questionnaire for data collection.This is because there were no previous SWOT analysis with Turkish nurses.Since there were no male students in the study sample group, the study consists of women perspective and this is evaluated as another limitation of the study.

Conclusion and Suggestions
A qualitative research was made in the study by SWOT analysis.According to the acquired data, it was determined that there were opportunities in the nursing profession under the rapidly changing conditions and that there were different problems and threats and restructuring was needed for this.Although there are many developments in nursing profession, (globalization, inter-country student programs such as Erasmus and Bologna, improvement of educational movement and collaboration, harmonization of class contents, increase in the number of scientific projects, proof-based studies and periodicals, reflection of innovative applications to clinic, opening of new employment areas-assignment of nurses in social service institutions as case managers, working with expert nurses in inter-institutional coordination, life coach) there are strengths of nursing profession.In this context, suggestions of the study are indicated in Table 2.It is suggested that future studies are planned rather at the national level in a large population and to reflect male nurses' perspective.

•
Doing overtime • Working for insufficient and unequal wages • Failing to refer to nurse opinion in reaching decisions about the nurses • Lack of encouraging setting • Insufficient autonomy • Role loss and chaos in the duty, authority and responsibilities of nurses • Perception of physicians as anauthority • absence of the provision of the services of nurses in the performance system • Inadequate worker safety • Unfavorable effect of shift working system on living quality • Non-ergonomic working conditions and being obliged to work with missing materials Other Weaknesses Of Nursing Profession • Inequalities in educational levels of nurses • Insufficient foreign language knowledge • Weak researching aspects of nurses and lack of support of administration on this matter • Resistance to innovation and change • Insufficient reflection of theoretical information on the application and presence of differences in application • Opinion differences among instructors • Instructors do not go to the clinic, therefore there is no unison and harmony between theory and application • Inability to put professional norms and standards into practice • Nurses are not supported by their colleagues in educational field • Nonsupport of specialization by the state or still failing to give specialized nurse appointments • Prevalence of authority acceptance and submission to authority by nurses • Inadequate professional awareness • Inadequate organization and conflicts between organizations • Inadequate strategic work force planning • Appointment of persons in professions other than nursing to health institutions' nursing administrations • Unwillingness to political participation III.Theme: Opportunities Directed to Nursing Profession Job Finding Opportunitiesin Nursing Profession • Great need for nurses in the society • Increasing number of patients • Continuous need for health services • Great work finding opportunity • Opportunity to work in Europe and America if certain conditions are provided • Very large working field • Perceiving or serving as a life coach Other Opportunities Directed to Nursing Profession • An opportunity to do academic career • Presence of opportunities for doing research and wide research area • Problem solution and practical thinking ability gaining enabled by nursing profession • Patients share their situation with nurses most easily • Spiritual satisfaction provided by nursing profession • Existence of an opinion as «a nurse is necessary for each home » • Presenting doctor examination opportunity for our kin the best way IV.Theme: Threats Against Nursing Profession Workers' Health • High risk of catching occupational illnesses or contagious diseases • Frequent experience of stress and depression • High rate of exhaustion experience • Frequent experience of sleep deprivation, wear and biological arrhythmia • Lack of life guarantee Other Threats Against Nursing Profession • Exposure to mobbing • High anxiety of malpractice and making mistakes

Table 2 :
Suggestions of the study Suggestions for Strengthening of Nursing Education • Formation of clinic simulation-based educational opportunities in nursing education • Presenting an opportunity for multidisciplinary team work • Turning nursing colleges to faculties, providing campus setting, rearrangement of faculties according to their substructure need, and presenting equal education opportunity • Supporting students to participate in scientific studies, in congresses and conferences before graduation • In addition to increasing student placement in licensed nursing programs of universities, increasing academic personnel number • Building nursing profession on a scientific ground • Basing nursing applications to studies based on concepts and proofs • Specialization in the profession Suggestions for Improvement of the Working Conditions of Nursing Profession • Establishment of mobbing centers at hospitals • Organization of training on enabling and improving worker safety • The arrangement of work hours • Support of taking leave that is the legal right of nurses by the administration • Updating of legal rights and duty definitions based on the developments in the nursing profession • Removing ethical and legal conflicts • Developing nursing recording systems • Making nursing services visible • Enabling cost effectiveness of nursing care • Adoption of a performance system consisting of nursing applications by institutions • In addition to legal developments in malpractice matter, development of policies and strategies, and at the same time increasing the results of wider scale researches on the matter • Giving orientation training to nurses who just start working • Supporting right strike use and supporting the righteous persons in promotions without gender discrimination • Usage of award systems • Doing strategic workforce planning by considering the number of actively working nurses Suggestions for Strengthening of Nurses Professionally • Improving professional awareness by inner service training offered to nurses • Organization of awareness development-improvement programs on legal rights matter • Evaluation of professional competence at regular intervals • Organization of personal development seminars in institutions regularly • Supporting leadership characteristics of nurses • Use of nurse classification systems such as "The North American Nursing Diagnosis Association-NANDA", "Nursing Interventions Classification-NIC", "Nursing Outcomes Classification-NOC" for nursing diagnoses, nursing initiatives, and nursing results regarding standard language use • Adoption of professional ethics codes • Use of professional standards • Nurses being aware of their authorities • Serving as a mediator • Receiving supervision training and serving as a supervisor • Supporting nurses, who are attending postgraduate education, by hospital administration • Receiving consultancy from the nursing departments of universities in decisions related to the nursing profession • Associations being in collaboration in the matter of assignment of specialization appointments • Preparation of projects with an introduction purpose and usage of media in this context ISSN: 2469-5823 Abay et al.Int Arch Nurs Health Care 2016, 2:036

Table 1 :
Opinions of the participants on nursing profession based on SWOT analysis

Theme: Weaknesses of Nursing Profession Weaknesses of Working Conditions of Nursing Profession
• Inadequate number of actively working nurses although the number of nurses working at the hospital is adequate At the end of the training, interviews were held with the participants by an expert mentor by using S-CIF and brainstorming technique.The group interview was recorded by researchers.
• Appointment of men who join nursing profession in administrative duties mostly • Accusation although they don't deserve it, and being ignored and not caring • Inability to postpone work, mandatory service continuance, emergency and imperativeness of doing the work • Increasing rate of work load • Inability of nurses to participate in decisions about nursing and making of these decisions by different occupation groups • Undertaking roles of other workers • Page 4 of 7 • ISSN: 2469-5823 Abay et al.Int Arch Nurs Health Care 2016, 2:036 participants were answered.