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Prestige of disciplines within the field of nursing: a cross-sectional study

Human Resources for Health volume 22, Article number: 72 (2024) Cite this article

Abstract

Background

Considering the global shortage of nurses, leaders in the field must understand the strengths and weaknesses of various nursing specialties in order to retain professionals within the field. Occupational prestige reflects the perceived contribution of an occupation ‘to society’, and measures its desirability, benefit and values. Understanding how experienced nurses view the prestige of nursing specialties may help to explain why some specialties are more desirable than others. We conducted a cross-sectional study to examine the prestige of nursing specialties among nurses taking post-graduate in-training courses.

Methods

The study questionnaire examined nurses’ perceived prestige of nine nursing specialties, the perceived extent of autonomy and authority, the unique knowledge and clinical skills required for each specialty, and participants' demographic and professional characteristics.

Results

A total of 101 nurses (90% females, mean age 35.4 ± 9.39 years) completed the questionnaire. Intensive care (4.67 ± 0.59) and neonatal intensive care (4.57 ± 0.74) were perceived as having the highest prestige, whereas physical activity consultation (2.67 ± 0.98) and sleep consultation (2.71 ± 0.92) were perceived as having the lowest prestige. These specialties were also perceived as requiring the most and least unique knowledge and clinical skills, respectively. In contrast, authority and autonomy were ranked highest in breastfeeding consultation (4.50 ± 0.81), followed by intensive care (4.10 ± 0.87), while congestive heart failure received the lowest score (3.48 ± 0.84). Principal component analysis showed that higher prestige is attributed to acute care specialties, while chronic care specialties or ones involving consultation have lower prestige.

Conclusions

Nursing specialties with lower scores should be rebranded to encourage nurses to enter these fields.

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Introduction

Career choices in nursing are often reported from the perspective of nursing students who gain insights from clinical experiences in various clinics as part of their study obligations, influencing their career decisions upon graduation [1,2,3,4]. However, examining nursing from the viewpoint of different generations, particularly nurses already in practice, offers intriguing insights into their perspectives on different nursing specialties as career decisions continue after career selection has occurred [5].

Most Israeli nurses (68%) work in hospitals or inpatient facilities. About two-thirds of the nurses are employed in hospitals, and the rest work in the community [6], compared to about three-quarters who worked in hospitals about a decade ago [7].

The Israeli nursing workforce is a critical component of the healthcare system. It relies on nurses to provide essential services in hospitals, clinics, community health centers, and long-term care facilities. Like other countries around the world [8], it suffers from a shortage of nurses, especially in specialty nursing areas such as geriatric and mental health nursing [9], due to an aging nursing workforce approaching retirement, a limited numbers of nursing graduates choosing to specialize in these areas, and difficulties in retaining nurses in high-stress and demanding specialties [10].

In Israel, nurses’ salary level depends on factors such as experience, qualifications and position in the organization, as well as on whether they work in the community or in hospital settings [11]. Nurses who work in shifts or are on standby get additional pay. However, according to the nurses’ collective agreement, the completion of advanced training courses is not reflected in their salary [12].

The Israeli Nursing Administration is responsible for the development, construction, and running of the advanced clinical training system. It offers registered nurses advanced continuing education courses (in-service training) in various clinical areas according to the policies of the Ministry of Health and in line with the needs of the healthcare system. The aim of this training is to teach nurses to make clinical decisions, solve problems, promote health, and assure that nurses provide professional, safe, and quality care based on knowledge and skills in the various care metrics. Typically, nurses enrolled in these courses already have work experience, with many being mid-career professionals who understand the realities associated with what is deemed prestigious within the field.

Considering the global shortage of nurses [13], leaders in the field must understand the strengths and weaknesses of various nursing specialties in order to retain professionals within the field. When considering what constitutes a desirable nursing specialty, factors such as autonomy, authority, knowledge, and clinical skills come into play. Consequently, these perspectives can inform interventions aimed at retaining nurses who may be contemplating entering different fields or leaving the profession altogether.

Occupational prestige is a sociological category formed by a collective subjective consensus on occupational status assessed by elements such as dignity, respect, and esteem [14]. It reflects an occupation’s contribution ‘to society’, and measures its desirability, benefit, and values. Therefore, it is a cultural phenomenon that captures the social standing given to those holding a specific occupation [15, 16], in addition to other attributes such as power, income level, and education [17,18,19]. Adler and Kraus [20] evaluated prestige in terms of standard of living, power and influence over other people, level of qualifications required, value to society, initiative and autonomy, and social standing. These authors asserted that the knowledge and skills required for an occupation serve as the most reliable predictors of its prestige. They also reported that education carries more weight than income in predicting prestige in Israel, while education and income have equal weights on prestige in the United States [20].

Nezlin [21] has identified six dimensions that influence the prestige of occupations: autonomy, authority, the level of professionalism and professional training required, the requirement for unique knowledge, the interaction with more prestigious professionals, and the patient’s status.

The literature on the prestige of nursing specialties is scarce. Understanding how experienced nurses view the prestige of nursing specialties may help to explain why some specialties are more desirable than others. In this study, we examined nurses’ self-perceived prestige of nine nursing specialties among students taking advanced nursing courses at a nursing academy in Israel. We also evaluated the dimensions affecting the prestige of these specialties.

Methods

Study design

This cross-sectional study was conducted among 114 nurses taking 4 advanced in-service nursing courses in intensive care nursing (n = 26), midwifery (n = 25), breastfeeding consultation (n = 26) and clinical instruction (n = 37) at an academic nursing school in Israel in 2018. The students were asked to participate in the study at the beginning of the courses and were assured anonymity. Participants were excluded if they did not provide a completed questionnaire.

The study was approved by the institutional ethics committee (approval number 0002–18). All participants provided their informed consent to participate in the study.

Research tools and data collection

The study instrument was based on validated questionnaires [20, 21]. It included three sections: in the first section, the participants were asked to rank the prestige of nine nursing specialties on a scale ranging from 1 (very low) to 5 (very high). These specialties were chosen from among 26 nursing specialties in Israel because they represent different aspects of nursing practice. In the second section, the participants were asked to rank on a scale of 1 (very low) to 5 (very high) the perceived extent of (a) autonomy and authority (i.e., the degree of independence that the nurse has in making decisions regarding the patient), (b) unique knowledge, and (c) clinical skills (i.e., the degree to which the practice in the field requires higher professional training than is customary in other fields of nursing) required for each specialty. The third section of the questionnaire included questions on participants' demographics and professional characteristics (Supplementary File).

The participants completed the questionnaires at the end of the course. Only complete questionnaires were included in the analysis.

Statistical analysis

The data were analyzed using SPSS version 25.0 (IBM Corp. Armonk, NY, USA).

Continuous variables were summarized as mean and standard deviation (SD), and categorical variables were summarized as number and percentage.

Four factor analyses were performed for the ratings of the specialties in general prestige, autonomy and authority, special knowledge. and clinical skills. Then, to identify common characteristics that affect the prestige of nursing specialties, we conducted a principal component analysis.

Results

Among the 114 nurses who participated in the advanced in-training courses, 101 nurses (mean age 35.4, SD  9.39 years, 90% females) completed the questionnaires and were included in the analysis (88.6% response rate). All nurses had a bachelor’s degree and 41.8% of them had previously taken an advanced in-service nursing course. The mean seniority in nursing was 9.8 (SD 7.71) years. Most nurses (74%) reported working in hospitals, 19% reported working in the community, and the rest were distributed among other specialties.

The specialties with the highest mean prestige were intensive care (mean 4.67, SD 0.59) and neonatal intensive care (mean 4.57, SD 0.74). The specialties with the lowest mean prestige were physical activity consultation (mean 2.67, SD 0.98) and sleep consultation (mean 2.71, SD 0.92) (Table 1). These specialties were also perceived as requiring the most and least unique knowledge and clinical skills, respectively (Table 1). In contrast, breastfeeding consultation was ranked the highest regarding the extent of autonomy and authority allowed in this specialty (mean 4.50, SD 0.81), followed by intensive care (mean 4.10, SD 0.87), whereas congestive heart failure (mean 3.48, SD 0.84) and nephrology (mean 3.61, SD 0.84) were ranked the lowest (Table 1).

Table 1 Perceived prestige and levels of authority, knowledge and clinical skills required for each nursing specialty
Full size table

To identify the characteristics that determine the prestige of an in-service training course, we conducted a principal component analysis. By employing the orthogonal rotation method (Varimax), three factors were extracted using principal component analysis, which accounted for 70.1% of the total variance. The factors were labeled as follows: factor 1 (acute care), factor 2 (chronic care), and factor 3 (consultation). The factor loadings were strong and statistically significant for each item. The factors’ ranges were 0.71–0.87 for factor 1, 0.61–0.78 for factor 2, and 0.69–0.86 for factor 3.

Cronbach's alpha was 0.79, 0.67, and 0.77 for factors 1, 2, and 3, respectively, indicating a high internal consistency. Analysis of the rotated component matrix (Table 2) showed that the courses can be classified as acute care (intensive care, neonatal intensive care), chronic care (congestive heart failure, nephrology, geriatric care) and consultation (breastfeeding consultation, sleep consultation and physical activity consultation).

Table 2 Classification of courses by rotated component matrix
Full size table

Plotting the mean scores given to the specialties under each classification clearly showed that specialties dealing with acute care have the highest prestige while those dealing with consultation have the lowest prestige (Fig. 1). Acute care specialties also had the highest perceived unique knowledge and clinical skills, while autonomy and authority were perceived to be lower in these specialties compared to consultation specialties. Although the prestige of consultation was lowest among the three areas, its perceived autonomy and authority were higher than those of both the acute and chronic care specialties.

Fig. 1
figure 1

Perceived prestige and its indices by care area. Bars depict mean perceived scores given to the advanced in-service training courses in each care area

Full size image

Discussion

Our analysis shows that nurses taking advanced in-service clinical training courses attribute higher prestige to acute care specialties, while chronic care specialties, or those involving consultation, have lower prestige. Acute care specialties were also perceived to have the greatest need for unique knowledge and clinical skills, while autonomy and authority in these specialties were perceived to be lower than those of consultation specialties. Nevertheless, although the prestige of consultation was lowest among the three types of specialties, its perceived autonomy and authority were higher than those of both acute and chronic care specialties. Thus, the dimensions comprising prestige were not always consistent with the perceived prestige of the care area and its related specialties. Our results corroborate the findings of a previous study performed in 1998–2004 among Israeli baccalaureate nursing students who ranked critical care as the clinical area with the greatest social prestige, followed by maternity, emergency medicine, surgical, and pediatric nursing. Gerontological, community, and psychiatric nursing were ranked as the least prestigious in that study [22]. Our findings that nurses attribute higher prestige to acute care specialties agree with Norredam and Album [23], who reviewed prestige hierarchies of medical specialties and disease in papers published over 55 years. Higher levels of prestige were associated with high-technology, specialized, biomedical fields, and hands-on (active) specialities practiced on the upper body organs of middle-aged and young individuals. Australian medical students also ranked surgery, intensive care, and internal medicine as the most prestigious fields, wheras occupational, non-specialist hospital medicine, and public health were considered the least prestigious [24].

The prestige of nursing specialties may also be deduced from the preferred work environments among nurses. Nursing students in Ghana ranked pediatric nursing, critical care nursing, and obstetric nursing/midwifery the highest as future career options, while gerontological nursing was ranked the lowest. Interestingly, in that study, public health nursing was also ranked highly [25]. Kloster and Hoie [26] found that only 7% of Norwegian students choose to pursue a career in community nursing upon completing their nursing education. Likewise, 71.2% of first-year students from six universities in the Netherlands favored working in general hospitals, while only 5.4% selected community care [27]. In a survey among 281 Israeli final-year nursing students, most expressed a preference for working in a hospital rather than working in the community. The particularly favored departments such as surgery, emergency medicine, and pediatrics, which they regarded as closely related to medicine [1]. Research has consistently shown that mental health nursing is one of the least preferred job choices among nurses [3]. In a study that examined the factors that influence the perceived occupational status of nursing home nurses, it appeared that some nurses were unable to derive satisfaction and pride from their nursing skills due to the perceived routine nature of their skills practice. These skills are important for managing and stabilizing residents’ complex multi-morbidities [28]. It is interesting to note that a Scandinavian study involving 600 registered nurses has found that geriatric rehabilitation nursing was considered a specialty that demanded both knowledge and professional skills [29]. These differences may be attributed to different cultural attitudes and perceptions of the public, nurses, and even the healthcare system towards nursing and its specialties in different countries, including the responsibilities and privileges given to nurses.

While both chronic care and acute care advanced in-service clinical training courses have a duration of 1 year, we have found that nurses perceive chronic care specialties as requiring less knowledge and clinical skills than acute care specialties.

Indeed, it has been suggested that in Western culture, health is primarily influenced by technology, science, and medical interventions aimed at treating and curing disease; consequently, medical specialties that focus on these practices and knowledge are considered more important than those that deal with the ongoing care of patients with chronic conditions [30, 31]. Lakanmaa et al. [32] proposed that critically ill patients necessitate complex care and attention from a team of very proficient healthcare professionals, including nurses, who therefore require particular knowledge, skills, and experience. In contrast, our findings show that nurses perceive they have less autonomy when working in acute care specialties. This is in agreement with a study conducted in Cyprus, in which nurses who worked in intensive care units with higher acuity, (i.e., patients with more severe illnesses) tended to report lower levels of autonomy, collaboration and satisfaction with care decisions compared to nurses in intensive care units with lower acuity. This was explained by the less complex and more repetitive clinical decision-making in units with lower acuity, which allowed nurses to sense increased autonomy [33].

The study’s limitations include its cross-sectional design, which reflects a single point in time. Additionally, the study may have been subject to a selection bias, as the study sample included nurses who participated in 4 out of 26 advanced in-service training courses offered by the Ministry of Health during a single year in one nursing academy in Israel. As approximately 3000 nurses complete advanced in-service training courses each year across Israel [6], our study population represents 3% of these nurses; therefore, although the results may not be generalizable to the entire nursing community in Israel, the demographic and professional characteristics of the nurses in our study were similar to those of the entire population of nurses working in Israel: 90% of nurses who participated in the study were female vs. 85% among the Israeli nursing workforce in 2021; 41.8% of nurses who participated in the study previously took an advanced in-service nursing course compared to 47% of nurses in the entire nursing workforce; and 74% of nurses in our study sample reported working in hospitals vs. approximately two-thirds of nurses in the Israeli population [6]. An additional limitation that may have affected the study findings are extreme responding, whereby participants may have chosen the most extreme options on the scale, which may have led to lower of higher self-perceived prestige of specific specialties than what is actually believed by the participants. Additional limitations are confirmation bias since the participants could be convinced that acute care is better, and social desirability bias due to the tendency to answer questions in a manner that will be viewed favorably by others. However, the participants were assured anonymity prior to completing the survey. Last, in the current study, we have only evaluated nurses’ self-prestige of 9 of 26 nursing specialties; however, the nine specialties chosen for this study represent different aspects of nursing and as such may be generalized to the perceived prestige of other specialties.

Implications for research and practice

The study’s findings suggest that training programs should emphasize the importance of knowledge and skills in all nursing specialties, not just acute care, assuming it is not already done so across all training programs. This can help improve the perception of autonomy and authority in chronic care specialties and ensure that nurses are well-equipped to provide high-quality care across different settings. Further research should analyze the contents of advanced in-training courses to identify those requiring curriculum changes to better emphasize the importance of knowledge and skills. In addition, policies that promote diversity and recognition of various nursing specialties, including chronic care, gerontological nursing, and mental health nursing, should be encouraged. This could help address the perceived differences in prestige and knowledge associated with different specialties. Policies should aim to create a supportive environment that values all nursing specialties equally and respects the unique contributions of nurses in different areas of practice.

Strategies to promote the value and importance of specialties perceived as less prestigious should be utilized in order to provide incentives for working in these areas and to offer professional development opportunities.

In terms of research, additional components of prestige should be explored in order to deepen our understanding of the perception of this concept in relation to nursing. Longitudinal studies to track changes in perceptions of nursing specialties over time and monitor factors influencing nurses' choices throughout their career should be planned. This can help identify trends, challenges, and opportunities for improving the overall perception and status of nursing specialties.

By implementing these recommendations, policymakers, educators, and healthcare organizations can work towards creating a more inclusive, supportive, and well-rounded nursing workforce that values all specialties equally and provides opportunities for professional growth and development across diverse healthcare settings.

Conclusions

Acute care nursing specialties are perceived by Israeli nurses as more prestigious, compared to chronic care and consultation specialties. As the Ministry of Health Nursing Administration offers courses according to the needs of the health system, understanding the perceived hierarchy of nursing specialties among nurses may help to plan interventions to increase the prestige of specific specialties and to encourage nurses to enter these fields in order to curb nurse shortages in chronic care fields such as geriatric and mental health nursing.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

SD:

Standard deviation

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Acknowledgements

The authors thank Kelly Saporta-Sorozon, PhD, for the statistical analysis and Sharon Furman-Assaf, PhD, for assisting in the preparation of the manuscript.

Funding

The study was supported by Barzilai University Medical Center.

Author information

Authors and Affiliations

  1. School of Nursing, Ein Kerem Campus, Hadassah Hebrew University Medical Center, Jerusalem, Israel

    Nurit Zusman

  2. Sabar Health - Home Hospice and Palliative Care, Even Yehuda, Israel

    Yael Dvori

  3. Nursing Administration, Hadassah Hebrew University Medical Center, Jerusalem, Israel

    Julie Benbenishty

  4. Nursing School, Centers of Training in Nursing, Barzilai University Medical Center, Ashkelon, Israel

    Miri Geva

  5. Nursing Administration, Soroka University Medical Center, Beersheba, Israel

    Raya Tashlizky Madar

  6. Department of Nursing, Ben-Gurion University of the Negev, Beersheba, Israel

    Raya Tashlizky Madar

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  1. Nurit Zusman
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Contributions

NZ: conceptualization (lead); writing—original draft (lead); writing—review and editing (equal). YD: writing—original draft (supporting); writing—review and editing (equal). JB: writing—original draft (supporting); writing—review and editing (equal). MG: writing—review and editing (equal). RTM: conceptualization (supporting); funding acquisition; writing—original draft (supporting); writing—review and editing (equal).

Corresponding author

Correspondence to Nurit Zusman.

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Ethics approval and consent to participate

The study was approved by the institutional ethics committee (approval number 0002–18) and all participants signed an informed consent.

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The authors declare no competing interests.

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Zusman, N., Dvori, Y., Benbenishty, J. et al. Prestige of disciplines within the field of nursing: a cross-sectional study. Hum Resour Health 22, 72 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12960-024-00953-6

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Human Resources for Health

ISSN: 1478-4491