The Perceptions Of KwaZulu-Natal Nu rsing Students About The Discipline

Opsomming LR Uys D Soc Sc School of Nursing University of Natal


In lro d u d io n
The question of how the present gen eration of student nurses sees the pro fession, its past and its future, is an im portant one for a num ber of reasons.Firstly the future of the discipline of nurs ing lies in the hands of the current stu dents in nursing colleges and schools.It is this group who will shape, maintain or change the discipline as they take charge of nursing as practitioners, edu cators and administrators.If they are the custodians of the future, they should also be participants in the current debate.Secondly, an understanding of the per ceptions of the incoming generation is essential for nursing education to plan relevant educational programmes.It is easy for educators to believe that they know what students think without explor ing their perceptions empirically.This is a dangerous fallacy, since nurse educa tors have gone through a long profes sional socialisation process, and often Die a rtik e l doe n v e rs la g o o r ' n beskrywende studie wat daarop gerig is om die sienings van verpleegstudente oor die verlede, hede en toekoms van die dissipline te ondersoek.In diepte onderhoude met 12 studente van Kwa Z u lu -N a ta l is op s k rif g e s te l en geanaliseer.Studente het 'n realistiese siening van die dissipline getoon.Hulle waardeer die essensie van die professie, en is p o s itie f o o r hul w erk en hul o p le id in g .H ulle voel e g te r d at verpleegkundiges nie deur andere goed behandel word nie, dat die werksomstandighede swak is, en die kwaliteit van diens dikw els veel te wense oorlaat.H ulle sien d ie h u id ig e rol van die verpleegkundige as meer onafhanklik as tevore, en voorspel dat die verpleeg kundige meer in the gem eenskap sal inbew eeg, m eer g espesialiseerd sal w ord, en m eer e n tre p re n e u ria a l sal optree.Hulle sien die uitdagings van die toekoms in die area van kwaliteit diens, die verbetering van opleiding, erkenning aan die professie, en bestuur, sowel as d ie h a n te rin g van d ie H IV/AID S probleem.
have years of life experience behind them.In some cases, they might have little in common with the students they teach.A lack of understanding of the thinking of students can only lead to teaching/learning experiences which in adequately address the reality of the stu dents.There is the additional motivation that students bring a fresh eye to the professional situation.They know it well enough to make judgements, but have not been socialised into the 'groupthink' of the profession.They therefore give an outsider's inside view of the discipline.This argument links to that of the Stand point Theory, which promotes the idea th a t th e p e rc e p tio n s o f th e m ost marginalized section of any community bring a perspective to the description of that community which is essential and important (Harding, 1991).Students may be seen as such a marginalized group, since they are seen as non-members of the com m unity in many respects, and the lowest in the hierarchy of the profes sion.At the m om ent this group is seldom heard in the discourse about nursing.Most of the writing about nursing is done by senior nurses, either in practice, edu cation or administration.Students sel dom publish in the professional journals.Although nurse educators may be more aware than others of the perceptions of their students about nursing, even this group may give more credence to what they want students to think, rather than what students actually think.Since edu cators are also evaluators, students edit their com m unications to educators to ensure that they comply with what is ex pected.In South Africa, and in many developing countries, student organisa tions are localised or in their infancy, and their voice is seldom or never heard in professional debates.Their perceptions on issues therefore remain hidden.
This research was therefore undertaken to explore the perceptions of South Afri can nursing students on the profession, its immediate past and future and their role in it.

Research Objectives
The research objectives were to: 1. Describe the perceptions of student nurses on the past, present and future of the discipline.2. Identify common themes and predic tions about the future.

M ethodology
This was a qualitative explorative survey, in which in-depth interviews were used to gather information from the respond ents.
A sam ple of five students from three nursing schools was sought from two nursing co lle ge s and one u niversity school.Senior nursing classes (third and fourth year) were approached and were asked to volunteer for the inter views.This was done since the interview took over an hour, and it was thought that non-volunteers would not be willing to give this amount of time.Furthermore, it was felt that volunteers would probably be students who were interested in the topic, and therefore more willing to share their thoughts.The names of all volun teers were taken, and the interviewer then made appointments with each one.The first five interviews were done, and the rest of the students were informed that they would not be needed.Inter views took place over a period of six months.
Five students from each of the colleges were interviewed, but the interviewer was successful in interviewing only two degree students.There were fewer vol unteers from this group, and their busy schedules also made it more difficult to get to see them.The interviewer gave up after the student either missed two appointments, or could not be contacted within a period of two weeks.The final sample therefore consisted of 12 stu dents, five of whom were Indian, six Afri can and one White.The percentage of the different ethnic groups amongst the nursing in South Africa is not known, but the proportion of Africans in the Durban population is 73% and the Indians 16% and this is a fairly representative sample (Datakonsult, 1986).Two of the students were m ale (one degree and one d i ploma), and the rest were female.The breakdown of gender in the nurses cur rently registered in this country is 95% female and 5% male, and again the sam ple is therefore fairly representative with 93% female respondents (SANC, 1997).
The interviews were done by a skilled interviewer with a Masters degree in Psy chology.She used a very brief interview schedule, which included only six very wide, open-ended questions and then probed the answers of respondents fur ther.Questions such as 'What do you think of nursing today?' 'How has nurs ing changed in the last ten years?1 'How do you see the future of nursing?' and 'What is the greatest challenge facing nursing?' were included.Interviews were taped and then transcribed.
Coding was done using five main cat egories, namely nursing today, changes in the recent past, the future of nursing, the image of nursing and the individual s tu d e n t.The last tw o c a te g o rie s emerged from the data, while the first th re e were inherent in the interview schedule.The content under each cat egory was coded by creating sub-categories as they emerged from the data.These su b-ca te g o rie s were later re viewed, and some were joined, so that final four main headings remained.The coding followed the semantic content a n a lysis m od el d e s c rib e d by Fox (1970:198).From interview ten no fur ther sub-categories were added, which suggests that the sa m pling was a d equate for the qualitative survey.The data and its analysis were reviewed in terms of credibility, transferability and dependability (Marshall and Rossman, 1995).In terms of credibility, the inter viewer was not also the coder, which pre vented enmeshment of interviewer with data.It was also increased by having the interviewer add emerging elements of earlier interviews to later interviews, in order to check their persistence.Trans ferability was established by asking stu dents and tutors in other settings to read the results and comment on its validity to themselves.Tutors often said that they experience exactly the same perceptions amongst their own student, while stu dents consistently found their own per ceptions reflected in the data.Depend ability is reflected in that interviews were taped and transcribed, and the transcrip tions and coding was checked by a sec ond person.

Results
The results are discussed under head ing s, w h ich c o m b in e som e o f the themes.Each of the subheadings (in bold) was taken from the interviews, and seems to express the view of respond ents on that sub-category of data.Di rect quotes from the interviews are typed in italic script.The referencing of quotes refers to the respondent number and the transcript page on which the quote ap pears, e.g.10:1 refers to respondent 10 on page 1.The language or grammar of respondents was changed only when the m eaning would not otherwise be clear.It should be rem em bered that English was the second language for most of the respondents.

Nursing Now:
The Positives It's about caring for people.Respond ents see nursing as caring for patients or people, based on science knowledge, so that patients recover and can look after themselves.Some respondents emphasised the preventative role of the nurse, w hile a num ber of them m en tioned the holistic aspect of the nurses' caring, as well as the necessity of con tinuing the care from the hospital to the community.A more individualistic vision of nursing expressed by one of the re spondents was: Nursing is about getting to know people; learning to live with people and learning about their beliefs, their customs and re specting their values in life (10:1).
When discussing the unpleasant tasks inherent in nursing, one respondent ex pressed the view that 'Somebody has to do it, and that it is clearly part of nurs ing, and therefore m ust be accepted (1:1).A nother respondent said that nursing demands A devotion, and you had to be called to nursing: (2:1), again emphasising the demanding character of nursing.Another respondent pointed out that technological advances have made the job of the nurse easier.She gave disposable enemas and improved dressing techniques as examples (3:6).One of the positive things students like and value about nursing is seeing peo ple get well.They also believe that this is one of the things which has improved over the last ten years, with the progno sis for many patients getting better (11:1 and 5:5).
/ think the best feeling is when you see the patient coming in that is totally ill and after you giving them the nursing care and the day o f their discharge, when they are walking away from the hospital, like able to do things for themselves (6:1).
Another positive aspect about nursing is the continuous availability of the nurse for the patient, and her resultant intimate knowledge of the patient (1,10, and 11).
The nurse is always there for the patient in the ward.And also the patient, at times cannot recover physically when his or her emotional status is not well.At times she needs that em otional support and the nurse is always there for her whereas the doctor has not time for that (11:3).

Basically I am satisfied with what I am.
Many of the students expressed a very positive image of themselves as nurses and a bo ut n ursing as a p ro fessio n.Firstly they felt confident and know l edgeable, and believed that they were equipped to act independently.Some of them also linked this idea with being more assertive.

From where I come I felt very restricted. But now, being three years here, I find that I can do that (approach seniors) because I've learnt how to be assertive. I've learnt much more about the profession. It feels very good. It feels good to have a doctor come and ask for an opinion or a doctor comes and asks you for help or your ad vice. It does feel very good when a sis ter has to admit that she's wrong and that you are right (3:6). 'I think being independent will give you more confidence in what you're doing, will give you more pleasure as a person. You're able to deliver better nursing care rather than being told what needs to be done. If someone tells you what is to be done continuously, I think you begin to doubt yourself and that's when you have cracks and breaks in the nursing care. So responsibility plays a big role and it is im portant because you begin to value yourself, you begin to think o f yourself as m aking a d ifferen ce because you've thought o f doing that for the patient and you've made a difference. And I think as well, the nurse's being more independ ent give you more joy in what you do. You know what you're talking about. (4:6).
A num ber of respondents refer to the inherent value of nursing, and the value that participation in this profession be stows on the individual nurse.

From the patient's perspective, when they're ill and they need help, you feel worthwhile, you know. You feel like you've done som ething; you've made som e body's life better by being able to help this person (1:1).
Actually, I think it helps us be more selfconfident and it teaches us to have bet ter relationships with other people.You've got to understand other people's feelings and the way they are thinking and it sort of broadens our knowledge on certain aspects (6:4).

Because working in a hospital you get to see a lot of things and you come to things that you never knew existed in this way and never knew such things could hap pen to people. And I've learnt a lot from it and I really appreciate that I have chosen this profession (7:6).
There is that diversity that is required o f a nurse and I find that it... well, its happi ness, getting this broader knowledge for yourself... (1:3).

Because now I am someone. I'm not only told that I should do this and that -now I have a stand (2:8).
I think the training is fine.Most re spondents mentioned improvements in the education of nurses am ongst the positive changes in the profession.They mentioned: • nurses learn more than they used to (1:2, 6:2, 10:1), • it is possible to gain higher degrees in nursing (2:1), • the increased emphasis on certain sub jects, like pharmacology (8:1), • improved resources, such as libraries • the four year com prehensive pro gramme which prepares them for holis tic and comprehensive care (4:6, 9:1), andwhich shortens the total training pe riod (12:1), • tutors are better prepared academi cally, and m ore know ledgeable (9:2, 10:2), • student involvement in nursing edu ca tion ch an ge s has increased (9:2, 10:2), • the external trappings of higher edu cation, such as academic dress, have • been incorporated into nursing edu cation (9:1).
Summarising the general feeling of stu dents about their training is the follow ing statement from one of the respond ents: I think it has prepared me sufficiently be cause I'm having confidence that I can take good care o f my patients without being supervised (8:10).
The two degree students were in a prob le m -b a s e d , c o m m u n ity -b a s e d p ro gramme, and they both pointed out the extensive theoretical base and the teach ing approach as the positive aspects of the programme.We looked like nuns you know.The changes in nurses' uniform s and the decreased rigidity in this regard is gen erally viewed as a positive change by respondents (8,4,3).One respondent sees it as a sign of a deeper change in the profession, which indicates more freedom for the nurse, even in terms of thinking (8:2).
We don't wear caps anymore!Previously it was very strict.Now there's a bit more leniency like with jewellery, cutex.Its not so strict (4:5).
A number of them, however, still felt that a white uniform and limits on make-up and jew ellery are im portant, because otherwise the trappings 'get in the way' (3:5) and the 'professional' image is spoilt (3:5).
But when you are a nurse, she should look like a nurse (3:6).

Concerns
Nurses feel like they are trodden on.When discussing nursing, the theme of poor relationships between nurses, and the negative effects of the hierarchical bureaucracy, are mentioned most often.One respondent blames the hierarchy, which creates a distance between the to p and th e b o tto m w hich is never bridged (1:1).Another respondent has the following to say on this theme: We always hear senior nurses complain ing about how students behave.......I would say that is bad.They should actu Curationis March 2000 81 ally (take) the time and also start treating like people, not like logs that need to be put there and removed from that place' (2:2).
The matrons come in for a lot of criticism in this regard.More than one respond ent mentions the fact that their health does not seem to be important, and they are made to feel guilty when they are sick (4:4), they are spoken to without any sign of respect (5:2), there is little if any un derstanding for their individual situation (4:4), and they display a critical attitude (7:2,3).The following are typical com ments: But it is not only matrons who are per ceived as not contributing to good rela tionships between nurses.The tendency of nurses to fo rm in -g ro u p s , w hich makes it difficult for students to become part of the work group in a unit, was also mentioned.The groupings are some times based on having worked together for a long time (5:3), and at other times are based on hierarchical level or edu cational level (9:7).Students also have m any p ro b le m s w hen p ra c tic e and theory does not agree (5:2).Respond ents are afraid of speaking out, since they expect victimisation.
7 think that we should be able to speak to the sister and sort o f get them to open up, to be able to accept viewpoints from the students and from people who have ju s t learnt things that they have learnt many years ago' (5:2).
'Although you may know that its not right, you're afraid to say so because o f the fear that If you are placed in that ward again, you'll be victimised by that person' They b e lie v e th a t n u rse s have less m inds A number of respondents felt that there was generally a lack of under sta nd ing of the level of edu catio na l preparation and the com plex role of nurses (12:1), leading to an under-esti mation of nurses.Some commented that they themselves had a limited un derstanding of nursing when they came for training.

I have to say that my opinion o f nurses wasn't too great to begin with and here I am doing nursing. And I find my opinion has changed (1:1).
Patients have told me that they've never known that nurses do this kind of jo b un til they are admitted and they are there and they watch and they see what the nurses to do and stuff.In fact myself, before I had com e into nursing I had never thought that it would be (so) diffi cult.I mean it is not easy.(6:4).
Others commented on the perceptions of the general public, that were either out-dated (4:3) or limited (7:2).Nursing is often perceived as a dirty job done by inferior people.(12:7).

think the public, there's still a lack of knowledge o f the profession o f nurses. Because they still regard us as just carry ing the bedpans or just cleaning up the patient if he messes (4:3).
A doctor is always someone who is up there.Ja.So generally, they are taking us as not that up.We are down there.(8:7).
This negative perception about nursing is sometimes also found amongst other members of the health professions, no tably doctors.Students refer specifically to rudeness (12:3, 10:5, 7:3, 8:8), a su perior attitude (12:3, 3:3, 8:8).One re spondent expressed her frustration with the attitude of doctors as follows: I will not be taken as something... not in telligent as such.We need intelligent people and we are intelligent.And I think it was not going be right in life for all of us become doctors or become lawyers or become whatever you think about.But for the work progress, you need one to support the other.And you should not think that you are more intelligent ju s t because you are a doctor, you had the chance o f getting that status.You need the support o f everybody.I mean, every body should be of value to you ' (12:3).
It is better now.Some respondents felt that the perceptions of doctors about nursing have improved recently (10, 7, 2).One such respondent explained possible causes for this change: I don't know if at all its because nowa days doctors are not only the sons or daughters of doctors.But now, also doc tors are admitted from the lower classes.So respect is growing, the respect for another, for a nurse and respect for a doctor, because that is my brother (2:8).
Another respondent ascribed the im provement to a more multi-disciplinary approach in health professional educa tion (9:6), and a more assertive style of nurses (9:7, 5:3, 3:4).Respondents ex pressed the feeling that nurses have more confidence and freedom to ex press their own opinions (2:1), and that the gap between them and other pro fessions has narrowed.This narrowing was ascribed to the fact that nurses also have degrees (12:4), and that they work more independently, especially in com munity settings.
The way we are taught now, we are be ing told that we are all equal.I/Ve work parallel to each other and once some body becomes rude to me, aich!I... can not be rude to that person, but I decide to keep quiet and then if he does it again, then I give it back to that person!' (9:7).
Respondents point out that registered nurses may support the negative stere otypes and subservient roles for nurses in their dealings with doctors (5:3).One respondent states emphatically that the attitude of others towards nurses will not improve before nurses themselves re spect themselves more:

But first o f all, I think we need to start re specting it (the profession o f nursing) ourselves (4:3).
N ot g o o d q ua lity as such.Respondents expressed concern about the quality of care given to patients.One of the main factors which they said caused less than optimal care is the over-emphasis on 'pa perwork1 .Respondents link this over emphasis on paper-work to a loss of fo cus on the patient and the essential na ture of nursing.It is often a documenta tion, technology, and routine dominated activity.(3, 4, 7).
Although we might be there to nurse the patient, there are times that I think we worry more about the admin part than the patient himself.We do give about 50% care and 50% (admin).I think it should be more like 80% care and 20% admin (7:2).Also you find that its not like the Florence Nightingale aspect.I think she said you have to treat the patient instead o f the ill ness.Now its more like we have to treat the illness and then the patient comes second.Its not like on an individual ba sis or person-person.Its like person, patient and then p ap er com es in b e tween, or technology, you don't have that touch with the patient anymore.(4:1) Its more computer orientated, the care, where there's not so much bedside nurs ing.Its more like sitting in the duty room and observing the patient from there, and having all the observations done on the computer.(6:3).
Another factor is a lack of resources.This includes physical resources, such as linen, human resources, and commu nity resources (9:9).Owing to the short age of staff only the most basic and usu ally physical care is given (3:9).
Our patients they come here from low socio-econom ic standards and even if we try to give the resources we have, they become exhausted.In hospital... we are short of many things: bed linen, some pillows for support...And because there are too many patients and we cannot now nurse patients up to our satisfaction be cause you nurse this patient, that one also needs your attention, and that one, at the same time.And you end up doing routine nursing care, just doing the rou tine.

And you don't have time to sit down with the patient and go into detail about what is the problem, how you can solve it. You end up getting the same patient com ing back to be adm itted because now the source of infection, or the source o f the problem that was causing illness, is at home there (12:2).
The working situation is awful.Stu dents repeatedly mentioned the condi tions under which they work, as well as the form al conditions of service, in a negative way.They site the unpopular hours they work without additional com pensation (6:5), and the high risk of pick ing up a contagious disease (8:10).
Nurses are being exposed to lots o f dis eases, for instance AIDS, Ja, we are chal lenged in diseases and those diseases which are mostly incurable.(8:10).
Improve the salaries first, and then ben efits.You know, like be covered in case o f contracting the various hazards, life hazards that we encounter in the field of nursing.You're n ot even covered for touching the blood of someone who is HIV positive.You're just told that you are provided with gloves -and what if those gloves are broken?And it feels like most o f these can be improved, and you can get covered, and things like that; maybe I can be interested in going on (2: 5-6).
While some of the respondents felt that the workload of students has improved over the last ten years (12:2), others do not agree.They feel the hours are too long (5: 4-5) and the work too demand ing (13:3).Even when working so hard, the percep tion is that rewards are scarce.Promo tion takes long to come, and it takes a life-time to get to the top.
The hierarchy o f nursing is too long.I mean, many people reach higher status in nursing only at a very late stage in their lives.You find that one will be promoted to a matron's position at 55 years of age maybe and within a few years that per son is retiring.Most people say, 'Whats the use then?' (12:4).
The salaries of nurses were raised by a number of respondents.Some said as students they had no com plaints, but that in general nurses were leaving nurs ing because the salaries were too low (8:6).One commented on the fact that enrolled nurses did much of the work of the registered category, and did not get paid accordingly (3:12).

Present And fu tu re
PAST: Handmaiden of the doctor.A number of respondents referred to this role as one very much in evidence in the past, but no longer acceptable.Nurses were also general cleaners and little more than servants in the past (3:3), but such servant duties have now fallen away.The change is seen to be the re sult of advances in technology, which extended the role of the nurse, as well as increased education, which lead to a change in attitude (1,4,6).
B e fo re it was lik e n urses w ere the handmaidens o f doctors: to do as the doctor says; open the packs before the doctor gets there.(4:3).

PRESENT: We have our own scope of practice.
Currently respondents see the role of the nurse as a well-educated per son with an extended role (8:1).When they describe what the nurse does cur rently, they mention a comprehensive approach w hich includes prevention (4:1) and a holistic approach to patients (4:1) as well as the context of their ill ness.They also mention their independ ent decision making as professionals ( 7).
You Nursing is on a much more independent basis now, where its a profession on its own.You're allowed to think independ ently, plan accurately -independently at the same time.Its more technologically advanced (3:6).

FUTURE: A community professional.
A num ber of students saw the future of nursing as being mainly in the comm u nity.They saw an increased focus on prevention, with a major responsibility for this aspect falling on community health workers.They expected fewer patients in hospitals, and more nurses in com munities.This was often linked with practising independently (8, 7, 3, 2, 1, and 10).
Perhaps having your own clinic, and be ing a primary health care sister.That all comes with your experience and your further studies.Because the community is like the start o f everything.I think that if we place the emphasis there, we'll be reducing the patients that are coming in to hospital (7: 4-5).
And more home visits.That would be like community-based because we said that prevention is the most important thing.
Taking part in the community itself.Be ing part o f the community.Not so hospi tal based or in a surgery all the time (3:8).
A specialist In future a greater diver sity within the profession will make spe c ia lis a tio n in c re a s in g ly necessary.
Nurses feel that they have more choice within the profession (2:8, 10:4).Re spondents see the specialist nurse as a very welcome and eagerly awaited de velopment in the profession (8:6, 6:1).
So by then (20 years hence) perhaps we will be able to do more.There's also things like anaesthetic nursing and also cardiac nursing.(9: 11-12).
The respondents see the future nurse as increasing even further in scope (2:1, 8:6).The right to prescribe is often men tioned in this regard, as is assisting in surgical procedures, and even doing som e surgery them selves.A nother m entioned the p o s s ib ility of nurses opening hospitals or nursing homes (8:8, 9:4).
We're doing pharmacology.So maybe in a few years time, nurses will be allowed to prescribe for their patients, as they are taking care o f their patients (8:6).

Challenges For The fu tu re
Quality of care.As indicated above, respondents were not completely satis fied with the quality of care currently given by nurses.Two of the respond ents saw the improvement and then the maintenance of nursing standards as the biggest challenge facing nursing.
The biggest challenge, the performance o f the nurses in their field, that is very challenging.If the nurse fails to take good care o f the patients, the blame will be put on her (8:10).
Its for nurses to improve skills.The nursing should go into the general stream o f education so that we are going to get all the facilities that are there used by the students (9:8).
Respondents repeatedly pointed out that their four year post-matric study did not mean as much as that of other health professionals such as radiographers (9:8), pharmacists and physiotherapists (1:1), not only in terms of status, but also in terms of rewards.

Recognition.
Although respondents were generally satisfied with their edu cation, they also emphasised that nurses need more knowledge, and that in cer tain ways the education should change.One of the points made was that there should be greater articulation between nursing training and that of other pro fessions, so that more movement is pos sible (9: 9-10).Recognition of nursing diplom a training towards a degree in nursing was also mentioned (10:3).
So if nursing can be, if someone want to go and do medicine, at least she may be credited for those four years that she was doing here (8:2).
Another area of recognition respondents mentioned was the issue of legal restric tions on their practice, which did not rec ognise their potential role and actual educational preparation (3:18).
Nurses, they have the knowledge their knowledge base is increasing, but there are still those great limitations as to what you're allowed to do.Protocols in the hospital and the law and that sort o f thing.We need more recognition for the type of jo b we do, more recognition fo r that knowledge that you actually have (1: 3-4).
A third aspect around the subtheme of recognition is that nurses should get more incentives towards further study, and more recognition for achievement.
They should build up interest in young nurses to continue nursing so that nurs ing can progress forward.There's noth ing that can discourage a person like just working hard and then anyway, after it all, I won't get a thing (12:6).I d o n 't kn o w th a t I'm s a tis fie d w ith m anagem ent.Over and above the poor human relationships seen as inherent in nursing service management today, re spondents also expressed concerns about other aspects of management.
The preparation of managers is a con cern expressed by more than one re spondent.One said that experience is essential in a manager, while another described the poor preparation of future m anagers which left senior positions empty or inadequately filled.

So, no matter how educated you are, if you... don't have experience, you still go down (2:2).
And then an inexperienced person gets into that status o f being a matron.And then that lowers the standard because this person is not experienced.Some times the space will remain vacant for some time because there is actually no body qualifying to enter that position (12:4).
HIV o f course.A number of respond ents mentioned HIV/AIDS as one of the g re ate st ch allen ge s fa cing nursing.They talk about the lack of solutions to this problem, and the immensity of it. (11:6).

Getting rid o f the fear that you are going to get AIDS. Learning to treat them as being normal (4:9). Most people are in danger and I just can't imagine what co uld happen if nurses becom e infected in greater numbers.
Because then itll be a disaster (10:6).

Discussion
To assess the awareness of the students of topical issues, their perceptions were compared to the topics making head lines in the South African publication, Nursing News in 1997 (when this study was done).There were some remark able similarities and differences.The themes which students address under 'nurses feel like they are trodden on1 , 'the working situation is awful' and I don't know that I'm satisfied with m anage ment', are also addressed in the journal under the following broad headings: * nursing organisations and member benefits (July, November) * caring and ethics in nursing (April, June, July) * medico-legal and labour relation issues (August, September, November) The focus which the students see in their future vision of 'the community profes sional' is reflected in the Nursing News under Primary Health Care (February, June).The workplace problems were also ad dressed by m ore than one research study published in the same year, show ing the fear and anxiety engendered by the high level of infectious diseases n ursed by s tu d e n ts (N aude and Mokoena, 1997), the disempowerment felt by nurses through current manage ment practices (Jooste, 1997), and the effects of community violence on nurses (Gcaba, 1997).Major topics in the journal which were not mentioned by students, were * substance abuse (January, February, June, November) * Tuberculosis (May, July).At the same time, there were a number of topics students addressed, particu larly HIV/AIDS, which were alm ost ig nored at that time in the journal.
The past and current roles described by respondents show great similarities with those discussed in the literature in the 1990's.The greater autonomy which re spondents describe, echoes that de scribed by Cronenwett (1995) and Elliott (1995).The health education and com munity based roles seen by respondents as future roles, are described by authors such as Wass and Backhouse (1996).Clinical specialists and advanced prac titioners have recently been much dis cussed (Morgan and Trolinger, 1994;El-Sherif, 1995) and this topic is gaining in ternational recognition as a major need for development in nursing.Less atten tion has been paid in the literature to the entrepreneurial role of the nurse as de scribed by respondents.Although there is some mention of nurse-run institutions, it seemed to have more to do with the independent role than with an entrepre neurial approach.The relatively positive and confident at titude of students as reflected in 'basi cally I am satisfied with what I am' and 'I think the training is fine', contrasts with the perception of Khoza, a tutor in Uni versity School, published in the same year.She made the statement that many newly qualified nurses do not feel com petent or confident in their new role (1997).The anxiety of newly qualified nurses m ight go up as they enter the work setting as registered nurses, rather than while they are senior students in the relatively protected educational environ ment.

Conclusion
In conclusion it was interesting to find out what the future plans of these re sp ondents were.O nly one of them planned to leave nursing, and will take any well paid job outside of nursing.Three have no specific plans, but see them selves as m aking an im pact (2), getting more knowledge (12) and work ing more with prevention than cure (4).One wants work in a counselling capac ity (9), one in a hospital (11), one in a community health centre (5), and one in a research setting (1).Only one has al ready decided which speciality she is interested in, and that is operating room nursing (6).
On the whole the responses reflect an idealistic view of nursing tempered by a realistic knowledge of the difficulties en countered in the pra ctical situation.There is no question that these students speak about nursing from experience, but still they have retained a positive and expanding vision of the future of the pro fession.They were able to articulate not only this vision, but also their concerns.Coupled with their feeling of competence and confidence, one can expect that this generation of students will make a posi tive contribution to the profession.
We have work and come back from work dog tired and this tends ... decrease my interest in nursing.If maybe we are short-staffed and now we have to do the work o f two people; you have double your job and do the job for this one and that one.Because of the job, people have to work long hours and some o f them just get off sick.So the moment they get off sick, you that are in the ward, you have to work harder and anyway what makes people go off sick the workload.They just get too tired (12:3).
're the one who has to identify the problems and you're the one who has to make the initial step once you've identi fied the problem because there isn't al ways a doctor around.(1:2).