Introduction
The nursing profession is continuously evolving to meet the diverse healthcare needs that people demand [1]. It is crucial that nursing students, who will eventually perform this profession, graduate with the necessary qualifications to provide high-quality care that meets the current demands of healthcare services [2]. The process of nursing education presents a significant opportunity to build a strong nursing workforce, encourage nurses’ involvement in decision-making processes, develop leadership and management roles in nurses, and enhance their nursing skills. Therefore, it is necessary to evaluate nursing students’ gains during their education and implement additional interventions in cases where the desired development is not achieved.
Ensuring and maintaining the quality of nursing education helps students understand the value of the nursing profession and recognize the importance of professionalism in nursing practice and education [3]. Some studies on the examination of nursing students’ perceptions of the concept of nursing have shown that students’ perceptions can be either positive [4, 5] or negative [6], depending on their school year or the department where they do the clinical practice. For this reason, it is important to assess the perceptions of first-year students, who have just been introduced to the nursing profession, about nursing and professional communication. In Türkiye, undergraduate nursing students are generally introduced to the concept of nursing through the “introduction to nursing” course in the first semester of the first year. They begin to acquire knowledge, skills, and experience through the “fundamentals of nursing” course, which allows them to enter the nursing field. Subsequently, they start clinical practice and try to transfer the knowledge, concepts, skills, and experiences they gained at university to the clinical environment. Developing positive perceptions of the profession as early as the first year may be an important step in the process of gaining professional identity.
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A metaphor is an effective linguistic tool that helps us understand an individual’s insights, feelings, and thoughts about any concept [7]. Therefore, an examination of metaphors can help discover how nursing-related concepts are perceived and what they evoke in students’ minds. Moreover, during the nursing education process, students practicing the profession provide an objective, unbiased, and realistic perspective based on their personal experiences [5]. Nursing education integrates both theoretical and practical elements to help students acquire the necessary knowledge, skills, and attitudes [8, 9]. The practical component, often referred to as clinical practice, makes up the fundamentals of undergraduate nursing programs. Clinical practice allows students to learn in a laboratory setting and adopt the role models created by academic nurses in hospital settings, which are their natural environments [10]. In this sense, clinical practice acts as a bridge between school and clinical field. During this transition from theoretical learning to clinical practice, nursing students often encounter discrepancies between their expectations and the real hospital environment, a phenomenon known as “reality shock” [11].
In clinical practice, nursing students face various challenges and stress factors, such as adapting to clinical routines, feeling isolated, fearing making mistakes, and dealing with communication issues with both instructors and clinical staff [12, 13]. Throughout this experience, they observe nurses, collaborate with them, and witness their interactions with patients firsthand. During this process, nursing students begin to gain some insights into the concepts they have been theoretically trained in.
Examining the metaphorical perceptions of nursing students during their first clinical practices will provide insights into how they internalize the concept of nursing and how they experience professional communication. It will also offer valuable information for enhancing the quality of education and supporting the development of students’ professional identities. Thus, strengthening both the theoretical and practical aspects of nursing education will create the potential to contribute to the provision of high-quality patient care.
This study aimed to examine nursing students’ experiences, professional communication, and perceptions of nursing through a metaphorical lens during their clinical practices.
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Method
Design
A descriptive qualitatve phenomenological research design, one of the qualitative research methods, was employed. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [14].
Research questions
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What metaphors do nursing students use regarding the concept of nursing?
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What metaphors do nursing students use regarding professional communication?
Sample selection
The population of the study consisted of first-year nursing students doing Cappadocia University simulation-based practice laboratory during the 2023–2024 academic year (N = 45). The purposive sampling method was used. First-year nursing students were invited to participate in the study and all agreed to participate (n = 45).
The inclusion criteria for participation in the study were as follows: (i) enrollment as a first-year student, (ii) fluency in Turkish, and (iii) first-time engagement in clinical practice. The students that have previously completed the clinical practice period were not included in the study.
Data collection
The data collection process involved the exploration of metaphors a commonly used method to describe and understand experiences and perceptions. The purpose of this approach was to gain in-depth knowledge about how individuals perceived the concepts of professional communication and nursing through metaphors and the meanings they attributed to these metaphors [15]. The data were collected using a “student information form” and a “metaphor form,” both developed by the researchers based on the literature [7, 14]. The student information form consisted of seven questions designed to assess students’ gender, age, marital status, whether they had chosen the profession willingly, factors influencing their career choice, whether they liked the profession, and their self-assessment of communication skills. The metaphor form explained the concept of metaphor, provided examples to concretize the concept, and asked students to complete some sentences such as “Nursing is like. because.” and “Professional communication is like. because.”
Participants were given the metaphor form and instructed to complete it fully by creating metaphors that reflected their thoughts on the concepts of nursing and professional communication. No further guidance was provided on creating the metaphors. The form included information about the purpose of the study, how the data would be used, and an explanation of the metaphor concept. Students were given 15 min to reflect on the concepts of nursing and professional communication and to create their own metaphors. These forms, which were filled out by the students, served as the primary data source for the study. Data were collected face to face in the simulation-based learning practice laboratory at Cappadocia University between June 17 and 21, 2024.
Data analysis
The sociodemographic data of the participants were analyzed on the Statistical Package for the Social Sciences (SPSS) software. Descriptive analyses were used to evaluate the quantitative data related to participants’ characteristics. The analysis and evaluation of the metaphors created by nursing students for the concepts of nursing and professional communication were carried out in five stages, following the qualitative data analysis approach called “Metaphor Analysis”. This analysis method is inspired by Moser (2000) and drawing upon various sources for methodological guidance [16‐18]. The codes obtained from the data were visualized as a code cloud on a website (https://wordart.com/create).
The steps followed in the metaphor analysis are outlined below:
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Coding and ordering stage
At this stage, the metaphors produced by the students were reviewed by both researchers. The metaphors were listed, and a temporary file was created. Metaphors related to the concept of nursing were coded with labels, such as “tree of life,” “street lamp,” and “spine.” Metaphors related to professional communication were coded with labels such as “garden” and “rudder.” Forms containing expressions that could not be accepted as metaphors (n = 3) were excluded from the analysis.
Example metaphor image review stage
The metaphors created by the students were listed with color markings, and the raw data were examined. “Example metaphors”, such as …., representing each metaphor were selected.
Category development stage
At this stage, valid metaphors such as …., were examined in terms of common characteristics. The valid metaphors were analyzed based on their topics, origins, and relationships, and were categorized accordingly. Each metaphor was associated with a theme related to the common features of the concepts of nursing and professional communication and then was analyzed and categorized under different conceptual categories.
Validity and reliability stage
Establishing validity in qualitative studies requires presenting the research process in detail. Therefore, the data analysis was explained in detail. The authors conducted the data analysis independently for the metaphor analysis, and coding was done by both researchers. After discussing the findings and reaching a consensus, uncertainties were resolved, and expert opinions were obtained from three faculty members specialized in nursing. The metaphors and categories were finalized based on expert feedback. As part of the data analysis process, example metaphor expressions were reviewed and presented in the findings section as quotes from the students’ statements. The metaphors and categories were transferred to a computer file, and frequency (f) values were calculated. Intercoder reliability was estimated using Miles and Huberman’s (1994) formula and was found to be 92% [19]. Since this value exceeded the 70% threshold, the reliability of the study was considered satisfactory.
Ethical considerations
Before the study was initiated, the approval of the Cappadocia University Non-Invasive Research Ethics Committee was obtained (Decision No: 24.11, Date: 10.06.2024). After receiving ethical approval, participants were informed about the research, and their informed consent was obtained on the data collection date. Participation in the study was voluntary. Students were informed by the researchers prior to the interviews that they had additional opportunities to consent or withdraw from the study. Data collection documents were numbered, participants’ anonymity was ensured, and the documents were stored in a locked cabinet at Cappadocia University.
Findings
All the participants in the study were first-year nursing students with an average age of 19.88 ± 0.96 years. Of the nursing students, 66.7% had chosen the nursing program willingly, and 57.1% had preferred the program due to job opportunities (Table 1). Metaphorical data in the study were reported under two main headings: the concept of nursing and the concept of professional communication (Table 2).
Table 1
Distribution of participants’ descriptive characteristics
Variables | Mean ± SD | |
|---|---|---|
Age | 19.88 ± 0.96 | |
Whether the nursing program was chosen willingly | ||
Yes | 28 | 66.7 |
No | 14 | 33.3 |
Factors for choosing the profession | ||
Family effect | 8 | 19.0 |
Knowledge of the profession | 10 | 23.8 |
Job opportunities | 24 | 57.1 |
Liking the nursing profession | ||
Yes | 37 | 88.1 |
No | 5 | 11.9 |
How would you rate your communication skills? | ||
Good | 19 | 45.2 |
Moderate | 22 | 52.4 |
Poor | 1 | 2.4 |
Table 2
Categories created from the metaphors developed by the students about the concept of professional communication and nursing profession
Nursing Profession | Professional Communication | |||||
|---|---|---|---|---|---|---|
Category | Metaphors | Frequency | Category | Metaphors | Frequency | |
Indispensability of the nursing profession | Tree of life, life, pacemaker, national economy, cotton thread sun, money | 7 | Sensitivity in Professional Communication | Garden, conflict, book (2), bird | 5 | |
Guiding aspect of nursing profession | Rainbow, family (3), street lamp, light, medicine, compass, mother (8) | 16 | Self-development in Professional Communication | Notebook, glass of water, work of art, sea, rudder, book | 6 | |
The art aspect of nursing profession | Drawing, painting, doing sports | 3 | Achieving Reality in Professional Communication | Tree branches, wave at sea, navigation, flashlight | 4 | |
Autonomy of the nursing profession | Heaven-Hell, rose, spine(2), water (4), river | 9 | Respect in Professional Communication | Family communication (3), computer, trust, blind | 6 | |
Total | 35 | The Indispensability of Professional Communication | Foundation of the building, light, love, knot, water, food, eating, heart, giving water to a dry tree | 8 | ||
Common Language in Professional Communication | Pomegranate, rosary, politics | 3 | ||||
Total | 32 | |||||
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The concept of nursing
Upon examining the metaphors created by the participants regarding the concept of nursing, four categories emerged: the indispensability of the nursing profession, the guiding aspects of the nursing profession, the artistic aspect of the nursing profession, and the autonomy of the nursing profession. The metaphors related to the concept of nursing are shown in the word cloud (Fig. 1).
Fig. 1
Word cloud of metaphors created about the concept of nursing profession
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Category 1: the indispensability of the nursing profession
The defining feature of the metaphors in this category was that nursing students perceived the nursing profession as indispensable. The metaphors students used were associated with concepts in their lives that were irreplaceable and of critical importance. Examples of metaphorical expressions created by students for this category are provided below:
“The nursing profession is like the national economy because the country and society would collapse without it.” (S2).
“The nursing profession is like a pacemaker because living without it is impossible.” (S5).
Category 2: the guiding aspects of the nursing profession
In this category, students used metaphorical expressions that emphasized the guiding aspects of the nursing profession in human life. Through the metaphors, they described nursing care as a tool that touches the patient’s life. Examples of the metaphorical expressions created by students under this category are presented below:
“The nursing profession is like a compass because if you don’t know where you’re going, the path you choose doesn’t matter.” (S4).
“The nursing profession is like a streetlamp because it lights up the darkness.” (S13).
Category 3: the artistic aspects of the nursing profession
The defining feature of the metaphors in this category was that students described nursing as a profession that utilizes personal creativity and individual styles. Examples of metaphorical expressions created by students for this category are provided below:
“The nursing profession is like painting because what you imagine becomes a reality.” (S17).
“The nursing profession is like coloring because it requires prolonged effort but is satisfying in the end.” (S21).
Category 4: the autonomy of the nursing profession
In this category, students described nursing as a profession having decision-making power. They used expressions that emphasized the nurses’ ability to achieve professional autonomy through their decision-making potential. Examples of the metaphorical expressions created by students for this category are provided below:
“The nursing profession is like heaven and hell because the outcome depends on the nurse’s choices.” (S43).
“The nursing profession is like a river; just as the water in a river flows continuously, new knowledge and developments also keep flowing endlessly.” (S18).
The concept of professional communication
As a result of the analysis of the participants’ expressions regarding professional communication, six categories were elicited: sensitivity in professional communication, self-improvement in professional communication, reaching the truth in professional communication, respect in professional communication, the indispensability of professional communication, and common language in professional communication. The metaphors related to the concept of professional communication are shown in the word cloud (Fig. 2).
Fig. 2
Word cloud of metaphors created about the concept of professional communication
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Category 1: sensitivity in professional communication
In this category, students used expressions that emphasized the importance of professional communication, which served a specific purpose and was under the nurse’s control, through feeling, understanding, and awareness. Examples of metaphorical expressions created by students for this category are presented below:
“Professional communication is like a garden because it is in our hands to protect, clean, and maintain it.” (S1).
“Professional communication is like a book because if you don’t read it, you won’t know what’s inside.” (S11).
Category 2: self-improvement in professional communication
In this category, students used expressions emphasizing the importance of developing communication skills by nurses and deepening understanding to achieve the goals of professional communication. Examples of metaphorical expressions created by students for this category are provided below:
“Professional communication is like a rudder because if you use it well, you can solve everything.” (S24).
“Professional communication is like a glass of water because every drop adds knowledge.” (S30).
“Professional communication is like a work of art because it gains meaning when you appreciate and look at it.” (S31).
Category 3: reaching the truth in professional communication
In this category, students described professional communication as a way of reaching accurate information. Examples of metaphorical expressions created by students for this category are provided below:
“Professional communication is like a wave in the sea because it brings new things to the shore and reveals them.” (S8).
“Professional communication is like navigation because it takes you to the right place.” (S14).
“Professional communication is like a flashlight because it reveals everything along with communication.” (S25).
Category 4: respect in professional communication
In this category, students described professional communication as acknowledging the other person’s existence and making him/her feel important and valuable. Examples of metaphorical expressions created by students for this category are provided below:
“Professional communication is like family communication because it is shaped by respect and love.” (S28).
“Professional communication is like a computer because just as the speed of a computer does not vary from person to person, nor does professional communication in nursing.” (S4).
“Professional communication is like a bridge because it connects people.” (S29).
Category 5: the indispensability of professional communication
In this category, students described professional communication as a necessity for carrying out the nursing process and facilitating interactions between members of the nursing profession. Examples of metaphorical expressions created by students for this category are provided below:
“Professional communication is like the foundation of a building because a building cannot stand without it.” (S9).
“Professional communication is like love because it is a part of life.” (S16).
“Professional communication is like a tight knot because if communication is not strong, the knot will come undone.” (S17).
“Professional communication is like watering a dry tree because a tree that doesn’t get water won’t bear fruit.” (S42).
Category 6: common language in professional communication
In this category, students emphasized that although nurses had different characteristics, they could achieve mutual understanding by using written and verbal communication techniques through professional communication. Examples of metaphorical expressions created by students for this category are provided below:
“Professional communication is like a pomegranate because from the outside, it looks like one thing, but when you open it, you see different ideas inside that come together at a common point.” (S43).
“Professional communication is like politics because you need to know what to say and where to say it.” (S18).
“Professional communication is like prayer beads because if they get tangled, they break.” (S20).
Discussion
This study revealed nursing students’ metaphorical perceptions of professional communication and the concept of nursing in clinical practice. The findings emphasized significant characteristics of the nursing profession, such as its indispensability, guidance, artistic aspects, and autonomy, while highlighting categories like sensitivity in professional communication, self-improvement, pursuit of truth, respect, the indispensability of communication, and the necessity for a common language. Nursing students created metaphors related to the nursing profession, such as mother, family, water, and painting, thereby fostering a positive outlook toward the concept of nursing. Similarly, other studies in the literature indicated that nursing students had a favorable view of the nursing profession [5, 7, 21].
Under the category of the indispensability of the nursing profession, it was observed that students perceived nursing as a critical element for human life. The nursing profession has always had a vital importance in addressing the changing needs of individuals and patient care from the past to the present [15]. Particularly, with the global impact of the pandemic, the indispensability of the nursing profession has become more pronounced, leading to an increase in its visibility [20]. The literature contains numerous studies that emphasize the indispensability of the nursing profession [5, 7, 22, 23]. The research findings align with existing literature, suggesting that nursing students begin to internalize the concept of nursing during their first clinical practice training. Students stated that the nursing profession played a guiding role, presenting nursing as an element that guides patient care. Nurses utilize guidance, counseling, and direction roles under changing conditions, in various environments, and during crises [24‐26]. The emphasis placed by students on the guiding aspect of nursing may stem from their observations of nurses’ communication with patients, patient education, treatment processes, and other nursing practices during clinical practice training.
Students also used metaphors about professional communication, such as garden, rudder, navigation, intra-family communication, the foundation of a building, and pomegranate. All these metaphors demonstrate that nursing students hold a positive perspective on professional communication, which is essential for the nursing profession. Nurses maintain nursing care through continuous communication and interaction with other professional groups and colleagues [10]. Therefore, it is crucial to equip nursing students with professional communication skills during their education, and it is expected that students enhance and experience their communication skills during clinical practice training [12]. The metaphors created by nursing students under the categories of sensitivity, self-improvement, and pursuit of truth in professional communication indicated that they viewed communication as a critical tool for both personal and professional development. This situation aligns with studies highlighting the importance of developing communication skills during clinical practice for nursing students [9, 27, 28].
The metaphors nursing students used regarding sensitivity in professional communication were similar to those in the study conducted by Işık et al. (2023), which emphasized the need for nursing students to develop empathy and sensitivity skills [7]. Given the metaphors created by nursing students about professional communication, it has been emphasized that for professional communication to be maintained effectively, nurses must continue to develop themselves, establish trust-based and respectful communication between nurse-patient and nurse-nurse, and utilize a common language within a professional framework. The concepts highlighted by nursing students in the current study are also mentioned in a review about competency expected from nursing students by Purabdollah et al. (2023) [29]. The perceptions of nursing students regarding professional communication were consistent with the competencies expected from nursing graduates [8]. This suggests that nursing students gain experiences that help them understand the importance of professional communication during clinical practices.
Strengths and limitations of the study
One of the significant strengths of this study was the innovative use of metaphors to examine nursing students’ perceptions of professional communication and the concept of nursing. This method provided qualitative insights that allowed for a deeper understanding of students’ emotional connections to their professional identities and roles. The metaphorical content analysis conducted with well-defined categories enhanced the reliability of the data. Although the sample size was limited to a single university, it increased the internal validity of the study as it encompassed the entire population of first-year students. Furthermore, the phenomenological design facilitated eliciting students’ experiences during their first clinical applications, proving beneficial in understanding their early thoughts and emotional responses.
The high inter-coder reliability rate (92%) further solidified the consistency of data analysis. On the other hand, the study had several limitations. For example, it focused on a single academic institution, which was likely to restrict the generalizability of the findings. The cultural and educational context of Cappadocia University may not have fully reflected the experiences of nursing students from other regions or institutions. Additionally, since the study was based on self-reported data, there was a possibility of social desirability bias, where students may have provided socially acceptable responses.
Implications for future applications and research
The findings of this study underline the importance of metaphorical and reflective thinking in the teaching of professional communication and identity in nursing education. These insights can be utilized in the design of educational programs that encompass the guiding, autonomous, and artistic dimensions of nursing, as well as its practical and clinical aspects. Curricula that prioritize communication skills can help nursing students recognize the vital role of professional communication in daily practices through simulations or role-playing activities at the university’s simulation-based learning environment.
Conclusion
This study further underscores the critical role of nursing education in shaping students’ perceptions of professional identity and roles. Clinical practices represent a significant learning process where nursing students transform their theoretical knowledge into practice and embody their professional roles. The challenges faced by students during this process and the coping strategies they use significantly contribute to their professional development.
Nursing students’ metaphorical perceptions of their first clinical applications provide profound insights into how they experience professional communication and the nursing profession. These metaphors hold great importance in understanding the challenges faced, skills acquired, and emotional responses encountered by students in their professional development processes. The use of metaphors to comprehend nursing students’ perceptions of professional communication and the concept of nursing offers an opportunity to conduct an in-depth analysis of the student perspective. This innovation facilitates the exploration of students’ professional identities and emotional ties.
Nursing students’ metaphorical perceptions of sensitivity, self-improvement, and the pursuit of truth in professional communication reveal that the nursing profession encompasses not only technical knowledge but also emotional and ethical dimensions. This situation reiterates the necessity of clinical experiences in nursing education. Nursing educators can better guide students’ clinical experiences by considering these metaphorical perceptions and strengthen their professional commitment.
The findings of this study highlight the necessity of integrating metaphorical and reflective thinking approaches into nursing education. These approaches can be utilized to deepen students’ understanding of professional identity and the multidimensional nature of the nursing profession. Nursing curricula should emphasize not only the development of technical skills but also the enhancement of emotional intelligence, ethical reasoning, and professional communication skills.
Future research should explore how metaphorical perceptions evolve over the course of nursing education and how targeted interventions can further enhance students’ professional identity development.
Acknowledgements
We would like to thank the nursing students who participated in the study for their contributions.
Declarations
Ethics approval and consent to participate
Ethics committee approval was obtained from Cappadocia University Non-Interventional Ethics Committee before the study was initiated (decision number: 24.11 and date: 10.06.2024). After ethics committee approval was obtained, participants were informed about the research on the planned data collection date and their informed consent was obtained. Participation in the study was voluntary.
Consent for publication
Not Applicable.
Competing interests
The authors declare no competing interests.
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