The effect of uniform wearing and candle lighting ceremony on nursing students’ perspective on the profession – a qualitative study

Introduction and aim. The aim of this study was to investigate the effect of the Uniform Wearing Ceremony and the Candle Lighting on nursing students’ perceptions of the profession. Material and methods. A qualitative, phenomenological method was used to design the study. The standardised criteria for reporting qualitative research with 32 elements were used for the research. The study was conducted with 60 students who volunteered to participate in the study by not selecting a sample of first year nursing students from a university in Northern Turkey. Interviews were conducted 3 times for approximately 20-40 minutes. Results. In this study, the rate of students who perceived the Uniform Wearing Ceremony as positive was as high as (n=42), the rate of those who thought that the uniform had an effect on the image of the nursing profession was 88.3%, and the rate of those who considered nursing as a respected profession was (23%). Conclusion. Nursing students who participated in the study stated that the effect of the Uniform Wearing Ceremony and the Candle Lighting Ceremony positively influenced their perception of the profession and that the uniform had an impact on the image of the nursing profession.


Introduction
Nursing is generally perceived by society as a white uniformed profession, the epitome of love, compassion and kindness. 1,2As an indispensable member of the health care team, nursing has important responsibilities such as the protection and promotion of health and the healing of illness. 1 These responsibilities highlight the importance of nursing education.The educational process aims to ensure that the student nurse has a positive outlook on the profession, is open to development and has a modern professional nursing identity. 2e first steps towards entering the profession and becoming a professional are taken during the student years and continue throughout professional life. 3For nursing students, the perception of the profession begins with the perspective of the environment in which they live and continues to develop and mature throughout the educational process. 4,5][8] Nightingale emphasised the importance of nursing education, drawing attention to the importance of formal education by opening the first nursing school and emphasising the importance of training qualified nurses to meet the ever-changing health needs of society. 9,10he literature states that nursing began in the mid-19th century under the leadership of Florence Nightingale during the Crimean War. 9,11Florence Nightingale was a manager, educator and statistician who took reformist initiatives in nursing care to improve hospital conditions and the wounded around the world. 10Florence Nightingale introduced nursing reform initiatives to improve hospital conditions and wounded people in all countries of the world. 10She was a manager, educator and statistician who dedicated nursing to the care of human life in a practical and scientific way. 11uring the Crimean War, the gas lamp carried by Nightingale helped to spread goodness, love and help from Istanbul to the whole world. 12.This lamp, which has been carried at graduation ceremonies and other academic rituals in educational institutions since 1920, is still used today as a symbol of the nursing profession. 16In the lighting ceremonies held in our country, Safiye Hüseyin (Elbi), who is considered the Florance Nightingale of the Turks and the pioneer of modern nursing, is commemorated along with F. Nightingale, and first-year students experience this justified pride as they take their first step into the profession.
Nursing is the only profession in which the ritual of candle lighting is performed.The Candle Lighting Ceremony is a blessed time in every nurse's life. 17The representative candlelight symbolises the effort to help others and not to feel alone in times of pain and suffering, as well as knowledge that dispels ignorance, enlightenment, experience, hope, love and comfort. 17,18he 'Uniform Wearing Ceremony' , which was performed together with the 'Candle Lighting Ceremony' ritual in the first year of nursing, has begun to become a ritual adopted by various health professions.It is practised by various health professions, including dentistry, pharmacy, medicine, physiotherapy and nursing. 19he Uniform Wearing Ceremony is a symbol of transformation that marks the transition from a vocational student to a health professional. 20In a review of studies conducted abroad, it is stated that this ceremony is a welcome greeting to students who are members of the health profession, and the essence of the ceremony emphasises humanism, excellence and compassion. 21These ceremonies are recognised as a practice that increases professional commitment to a profession and acceptance of professional values. 22In addition, it is stated that the Uniform Wearing Ceremony contributes to students experiencing a sense of pride and shows what professional appearance and presentation means for nursing. 19evertheless, controversial opinions about the Uniform Wearing Ceremony persist. 19In the literature review on nursing symbols and rituals, some authors state that these ceremonies have no meaning or purpose today, and suggest that these ceremonies should not be discarded, but should be reconnected with the values of contemporary professional nursing. 23raditional ceremonies reflect the emotional impact and moral significance of professional commitment.However, there are those who argue that it would be better for students to take the oath as an honourable students, promising to abide by the academic rules of the school and fulfil the duties they have undertaken, rather than in the name of the symbols and rituals of a profession they know nothing about. 24nother view was that it was not possible for the uniform ceremony to represent both a welcome to the profession and professional advancement, arguing that it was not understood why nursing needed a 'Uniform Wearing Ceremony' to remind students that they should have compassion and empathy when nursing has a long history of caring.It was also pointed out that this could lead to role confusion with other health professionals. 25t is stated that it is important for nursing students to recognise, love and consciously choose their profession in terms of professionalism and quality health service delivery. 26ooking at the studies, there are mostly studies with medical and pharmacy students with the Uniform Wearing Ceremony, but there is limited research on the Candle Lighting Ceremony with nursing students. 22,27

Aim
The purpose of this study was to determine the professional perceptions of the Uniform Wearing and The Candle Lighting Ceremony from the perspective of nursing students.

Ethics approval
Ethical permission for the study was obtained from Tokat Gaziosmanpaşa University Scientific Research and Publication Ethics with permission number 01-42 dated 27.05.2022.Prior to this permission, written research permission was also obtained from the School of Nursing Students where the study would be conducted.Participants were informed verbally and the Declaration of Helsinki was read to each participant.Informed consent was signed.
The effect of uniform wearing and candle lighting ceremony on nursing students' perspective on the profession -a qualitative study

Study design
A qualitative, phenomenological method was used in the design of the study.This method was chosen to elicit nursing students' opinions about the impact of the uniform and light ceremony on nursing students' views of the profession, which is the aim of the study.Consolidated criteria for reporting qualitative research with 32 elements were used for the study. 28

Population and sample
First-year nursing students at a university in northern Turkey were included in the study.All first year students constitute the population of the study and also the sample.There are 60 nursing students in the study (Fig. 1).As part of the research, the students were asked questions about what the Uniform Wearing and Candle Lighting Ceremony, which has professional themes, made them think about the nursing profession.All 60 students were basically interviewed 3 times.At the end of the basic interviews within the sample (simultaneously), the data reached saturation.The criterion of data saturation was therefore met.

Data collection
Two separate forms were designed for the purpose of the study and according to the sample.A basic form consisting of 8 questions including age, gender, marital status, place of residence, whether anyone in the family works as a nurse, reasons why students prefer nursing, whether the uniform has an effect on the image of the nursing profession, and whether they like the nursing uniform they will wear in the clinic.The other form (form 2, 8 questions) is the second form that contains open-ended interview questions to obtain the data of the qualitative research to be conducted.Form 2, developed as part of the research, was designed to assess the nursing students' thoughts about the profession after the Uniform Wearing and Candle Lighting Ceremony (Table 1).Form 2, which was designed to collect the research data in a scientific manner and in accordance with the phenomenological design, was created by taking the opinions of three different experts who have studies in the same methodology in the field.Within the framework of the research, the 2nd interview plan was made with the data obtained after the 1st interview with the nursing students.According to the data obtained in the 2nd interview, the 3rd interview plan was made and the data reached saturation.Consent for the study was obtained from the student participants and recorded in writing.The interviews were conducted in a calm, quiet, well-ventilated environment where the interviewer could answer the questions well.The interviews were conducted in a suitable classroom of a faculty where the nursing department is located and lasted approximately 20-40 minutes.The flow chart of the research process is shown in Figure 2.

Information about the uniform wearing and candle lighting ceremony
All first year nursing students attended the ceremony in their uniforms.A selected nursing student gave a speech about their feelings and thoughts about the ceremony.Then, one by one, the students were called up to the stage and received their lights from the lantern in the hands of a nursing instructor.The ceremony ended with the recitation of the nursing oath.

Rigor
Four main criteria were identified in the study to ensure details in terms of reliability, confirmability and transferability. 29To ensure reliability, the researcher tried to maintain a long-term relationship with the nursing students who participated in the study and to establish a friendly and trusting relationship with them.The researcher has a long and significant experience in nursing education.The researcher explained to the nursing students that they could express themselves freely and that every opinion was very valuable/important.All interviews were carried out by two experienced researchers.During data analysis, repeated listening, comparisons and repetition of questions helped to ensure the reliability of the findings.Three different experts experienced in qualitative research were involved in the coding and theme development process in a controlled and comparative way.In addition, the Consolidated Criteria for Qualitative Research Reporting checklist was used to ensure that the study report was transparent and reliable. 28Preliminary interviews were conducted prior to the study and experts were consulted on an ongoing basis.This increased the validity and reliability of the research.However, as with all qualitative studies, not all statements can be included in the data transfer, so an attempt has been made to present the most important and generally reflective data.What was your first reaction when you heard that the ceremony was going to take place?

Do you think the ceremony of Uniform Wearing and Candle
Lighting is necessary for the nursing profession?

Perceptions of the nursing profession and the impact of professional ceremonies
Do you think that the perception of the nursing profession and the ceremony performed are related?
How did you feel about your profession during the ceremony?
How did you feel after the ceremony?

Perception of relationship between nursing profession and uniform
What do you think the nursing uniform means for the profession?

Data analysis
The data obtained from the interviews were analysed using the content analysis method.The qualitative content analysis method is a method that aims to describe and evaluate the phenomena that appear on the subject by dividing them into main topics and themes. 30The data were listened to, written, read and evaluated several times by the researcher.The first codes were developed as part of this evaluation.After the coding process, which was carried out by reading the data in a controlled and comparative way, the researcher developed themes. 31The themes were not predetermined but were derived from the data obtained.No computerised algorithms were used in the qualitative data analysis process.

Results
This study was carried out to investigate student nurses' perspectives on the nursing profession from the students' point of view during the Uniform Wearing and Candle Lighting Ceremony.Of the 60 participants in this study, 38 (63.3%) were female and 34 (56.6%) were aged 18-20 years (Table 2).
23% of the students stated that they chose nursing because they considered it to be a respectable profession.88.3% of nursing students reported that the uniform had an effect on the image of nursing (Table 2).

What is your reason for choosing nursing?
Because my parents wanted it.

19
Because I can be easily appointed 12  20   Because I can make good money 14  23   Because I see it as a respectable profession.

The effect of professional ceremonies on students' thoughts
This section presents data on the impact of professional ceremonies on students' thoughts.

The effect of ceremonies on students' ideas and thoughts about the profession
Although it was seen that the students generally had the same opinion about the Uniform Wearing and the Candle Lighting Ceremony in relation to the nursing profession, it was seen that 18 of the students (n=18) thought that the Candle Lighting Ceremony was "not suitable for our culture".The effect of the uniform on students' perception of the profession This section presents the students' data on how the uniform affects their perceptions of the nursing profession and how important it is to the profession, regardless of the ceremonies.

The effect of the uniform on students' perceptions of the nursing profession ''The nurse's uniform is important as far as I know. Because before we went to the clinic, even before our uniforms were sewn, our teachers told us that a uniform should never be worn outside the clinic (on the way home or in the street). I think this is wrong in many ways. The uniform is not worn everywhere. It also gives you a lot of responsibility in the clinic. It made me feel that I would be doing a very important job and that I should never be separated from equality. '' (Male -43th Student) ''I think a nurse should choose her uniform very carefully and carefully. I think the uniform is like a flag that describes all the duties of a profession... It increases respect and responsibility. In the past, when I saw nurses wearing these uniforms, all I could think of was that they would give me an injection and hurt me. Now I can't wait to learn and practice. '' (Female -34th Student)
The main themes and subcategories developed in the study are presented in Table 3.

Main topics Subcategories
The impact of professional ceremonies on students' thinking The impact of ceremonies on students' ideas and thoughts about the profession

The effect of professional ceremonies on students' perceptions of the nursing profession
The impact of the Candle Lighting Ceremony on students' professional perceptions The impact of the Uniform Wearing Ceremony on students' professional perceptions

The impact of uniforms on students' perceptions of the profession
The effect of uniform on students' perceptions of the nursing profession

Discussion
This study was undertaken to investigate the effect of the Uniform Wearing and Candle Lighting Ceremony on nursing students' views of the profession.Of the 60 participants in this study, 38 (63.3%) were female and 34 (56.6%) were aged 18-20 years.
Traditions have the power to convey important beliefs and values held by professional disciplines. 23,32Professional rituals are activities that can increase students' desire to learn, create a sense of belonging, and transform the classroom from an individualistic space into a community. 33It is known that professional ceremonies have been important since ancient times as a "welcoming" ritual to grasp the basic philosophy of the profession and to adhere to basic ethical rules. 34There are other studies in the literature that explain the impact of professional ceremonies on the ideas and thoughts of participating students.In a study of 77 nursing students who participated in the Uniform Wearing Ceremony, it was reported that the ceremony was valued by the participants, that it was perceived as a symbolic transition into professional nursing education, and that such ceremonies should be continued. 19Another study reported that the "Welcome to the Profession" ceremony and the uniform worn at the ceremonies, conducted with 69 participants consisting of third and fourth year nursing students, improved the sense of professional identity in 92.6% of the third year students who wore the uniform and 76.5% of the fourth year students who did not wear the uniform. 34An author who participated in the passing of the Candle Lighting Ceremony for medical students reported that all participants were deeply moved, satisfied and praised the ceremony in a small sample in which he, as an outside observer, asked the students after the ceremony what they thought of the ceremony. 22n the White Coat Ceremony for pharmacy students, it was reported that the majority of participants saw the White Coat Ceremony as a welcome to the profession (46%), while a smaller proportion saw the ceremony as a way to develop the student's professional identity (12%). 35According to the findings of this study, based on the students' statements about the ceremony, although the participants generally reported positive statements, some students (n=18) also reported that the 'Candle Lighting' ceremony was not suitable for our culture.The fact that the students who felt that it was not appropriate to our culture may be due to the fact that they come from different traditions and that they had not previously received information about this ceremony from their environment and the media.
Professional ceremonies are activities that prepare the ground for student nurses to form a professional identity and to take pride in their profession. 36The Candle Lighting Ceremony is one of the activities that enables students to understand the characteristics of the nursing profession and to embrace their profession.The Candle Lighting that students receive during the ceremony also represents the ethical commitment that will continue throughout their careers. 18There are studies in the literature that explain the effect of professional and Candle Lighting Ceremonies on students' perceptions of the nursing profession.In Canada, it was reported that 92.6% of third-year nursing students and 76.5% of fourth-year nursing students made positive statements that the ceremony had improved (or would improve) their sense of professional identity. 34In another similar study in Canada, it was reported that first-year nursing students embraced the nursing oath ceremony and had the opportunity to emotionally experience their professional identity. 32nother study of nursing students in the United States reported that the proportion of those who considered professional ceremonies to be a very important step in entering the nursing profession was over 96%, and the proportion of those who said that they should feel happy, proud, honoured, excited, nervous/anxious, important, respectful, and attentive to relationships when entering the profession was 97%. 19In a study of 78 pharmacy students in Australia, it was reported that 56% of participants felt positive about the White Coat Ceremony and thought that these ceremonies would contribute to their professional identity in the future. 35Similarly, this study found that most students were excited by the Candle Lighting Ceremony and their professional perceptions were positive.This finding suggests that the meaning and significance of the ceremony is sufficiently accepted and valued by nursing students.
7][38] This study found that student nurses often used uniform and professionalism together.Students attribute meanings such as 'taking the first step towards becoming a professional' to the Uniform Wearing Ceremony and they view it positively.There are other studies in the literature that support the findings of this study and explain the professionalisation effect of the Uniform Wearing Ceremony on the participating students.In a study conducted in Brazil, it was found that uniforms are important in the formation of professional image and identity in nursing schools.In the same study, students stated that they liked wearing the uniform, that they felt pride and honour, that the uniform was a symbolic representation of professionalism, and that the uniform gave them responsibility. 38 similar study conducted in the United Arab Emirates reported that uniforms had a positive effect on student nurses' image as healthcare professionals.39 Another study conducted in Canada reported that wearing a uniform had a positive effect on students' sense of professionalism, with 100% of third year students and 79.4% of fourth year students agreeing that the uniform improved or would improve their sense of professional identity.34 Another study conducted in Brazil reported that student nurses felt that the uniform they wore to graduation ceremonies played an important role during their professional education.40 The literature provides mixed results.In a study of nursing students in Australia, a small number of students (n=2) reported that wearing a uniform was a source of motivation during their training.35 The uniform is an important element of nonverbal communication that plays a crucial role in establishing and maintaining therapeutic relationships. 41While the nurse's uniform influences perceptions of the nursing profession, it also contributes significantly to the image of nursing.42 When we review the literature, we find studies showing that the effect of the uniform on perceptions of the profession among nursing students is quite low.In a study of nursing students in our country, it was reported that 6.3% of students and 9.8% of nurses in another study of working nurses preferred nursing because they liked their uniforms.43,44 In a study conducted with fourteen graduate nursing students in the UK to investigate the effect of uniform on self-image and professional identity, it was reported that some participants expressed that they were proud to wear their nursing uniforms, on the contrary, one male participant was not proud to wear his uniform and another male participant did not want to be seen in his uniform as it would easily be associated with the nursing profession.36 In this study, 88.3% of the students responded positively to the question "Do you think the uniform affects the image of the nursing profession in our country?"and 68.3% of the students responded positively to the question "Do you like the uniform you will wear in the clinic during your training?"(Table 2).Whilst the results of this study suggest that students are affected by the uniform and see it as a symbol of professionalism, the positive evaluation of the effect of the uniform on the image of the profession can be interpreted as a pleasing situation for the nursing profession.
When we reviewed the literature, it was reported that students who reported having nurses in their family or relatives had positive perceptions of the nursing profession.In another similar study, 45.3% of students who had a relative who was a nurse and 46.9% of those who had prior knowledge of the profession had prior interest and knowledge of the profession. 6,8In this study, the fact that none of the students had a nurse in their family and the lack of scores from this group suggests that the participants may have chosen the nursing profession voluntarily and entered the profession with interest.
In the development of a profession, people's perspective on the profession, choosing a profession and adapting to the profession, getting professional satisfaction, having a positive view and attitude towards the profession have a great impact 45 In this study, it was found that the percentage of participants who came because they liked the profession was as low as 15%.
Similarly, in a study conducted with first-year nursing students, it was found that 59.8% of the students did not choose this field voluntarily. 46][49] Perception is a belief or opinion that people use to interpret events.Perception plays a key role in shaping an individual's career. 50Studies investigating nursing students' perceptions of the profession in different countries have produced mixed results.In a study of first year nursing students, 75% of students had a positive perception of the profession prior to choosing a specialty, while only 1% had a negative perception. 51Another study found that male students had a more positive image of the nursing profession than female students and that the majority of students agreed that nursing was a respectable profession. 52In a study conducted on nursing students and working nurses in Iran, it was found that 72.6% of nurses and 65.4% of students had a positive attitude towards the profession. 53A study conducted in Iran among 394 nursing students and working nurses found that 72.6% of the nurses and 65.4% of the students had a positive attitude towards their profession, while about one third of both groups of participants had a neutral or negative attitude towards their profession. 7imilarly, in a study conducted with nursing staff and nursing students in Egypt, it was found that students who voluntarily chose the profession had higher perceptions of the professional image. 54lso noteworthy in the literature are the results of several studies that found nursing students' perceptions of the image of nursing to be low.A study of 28 nursing students in Colombia reported that students had a negative perception of the image of the nursing profession. 55t was found that 43.0% of nursing students had a moderately positive image, perception and attitude towards the nursing profession before their arrival and 44.5% of nursing students after their arrival. 8In this study, 23% of the participants stated that they considered nursing to be a respected and preferred profession.According to the results of this study, the students' perception of the profession is very low compared to the findings from abroad.This finding suggests that choosing a profession without sufficient knowledge about the profession or choosing a profession unwillingly may be one of the important factors underlying low professional perceptions.
Choosing nursing as a career is a serious and important decision. 56In order for nursing to progress and improve its status in Turkey, students who will enter the profession should love their profession, perceive their profession positively, and see the future of their profession and their own future as promising. 49

Conclusion
The fact that the students identified the Uniform Wearing And Candle Lighting Ceremony with the concept of professionalism shows that the ceremony was embraced by the students and that they were aware of the responsibility they were taking on by wearing the uniform.This suggests that these ceremonies build confidence in the students and that they see themselves as nursing professionals.The positive perception and image of the nursing profession that students gain from the ceremonies will encourage them to choose the nursing profession and will also make them proud of their profession.
In our country, the status of nursing in society needs to be improved.It is important to introduce the nursing profession so that people who will choose the nursing profession will know more about the nursing profession.It should be ensured that such ceremonies are widely spread in our country and are visible in the media.This will increase the visibility and attractiveness of the nursing profession.An improved image of nursing in society will contribute to a more conscious choice of the profession by students.

Fig. 1 .
Fig. 1.Flow chart of the study

Table 1 .
Semi-structured open-ended questions used in the interview

Table 2 .
Descriptive characteristics of participants

Do you like the uniform you will wear in the clinic during your training?
When our names were read out one by one with all my friends, it was a great honour for me to be one of them.With the nurse's uniform I wore for the first time, it was as if we were saying to the professionals from different fields who were watching us at the ceremony, "We will develop and improve your health"...
''I felt very important and like a real nurse.During the ceremony, I also wanted to research the theoretical nurses I had heard about from my professors.Hearing that it is a very labour-intensive profession brought me closer to the profession." (Female -11th student) ''The effect of the Candle Lighting Ceremony on students' professional perceptions ''I had heard about the woman with the lamp because my cousin was a nurse.But I didn't know it was such a powerful story in the profession.Especially during the Lighting Ceremony, I felt that our teacher had paved the way for us.I also felt a great sense of responsibility.To be honest, this sense of responsibility was not what I had thought before.During the Uniform Wearing Ceremony I felt like a professional, as if I already had the spirit to become a nurse.'' (Female -8th Student) ''The Uniform Wearing Ceremony is a ceremony that must be held in all future years because the student walks like a nurse during the ceremony.Honestly, when my name was