Introduction

Although the nursing profession has historically been dominated by females, involvement of men in the nursing field dates back to the 11^th century [1]. Despite this, men were secluded from caring for the sick. The founder of modern nursing, Florence Nightingale, accepted only lady nurses [1, 2]. This development contributed to stereotyping nursing as a feminine profession. The trend was reversed after the second World War when men were then formally accepted to be educated as nurses [2, 3]. Nowadays, despite many men entering the profession worldwide [4], the dominance of females has continued into the 21st century as shown by various studies. For instance, it was reported that the proportion of male nurses was 5.6% in 2005 in Canada [5], 10% in 2003 in the United Kingdom [6] and 25% in 2000 in Jordan [7]. It means that gender has an impact on the nursing career choices. This is in line with a researcher who asserted that the gender of an individual can be a factor in career choice [8].

Parents, families, guardians, guidance teachers and career advisors in western countries play a significant role in career choices of their children by influencing them either positively or negatively [9, 10]. Similarly, in South Africa, a study found out that family, self-learners and teachers were significant factors in determining children’s careers; and it was recommended that parents and teachers should not force but rather should support and guide their children in making the right career choice [11]. Further, the study researchers emphasised that schools should provide career guidance programmes because career guidance made a significant impact on an individual’s career choice. This calls for informed career choice and decision making on the part of the prospective professional. In nursing, for example, Cohen advocates for an accurate and up-to-date information about nursing to be communicated to prospective nursing students [12]. This would help them make an informed career choice; and that the task of choosing a career is seen to be part of the individual’s developmental process [8].

Benefits of making an informed career choice upon joining any profession cannot be over emphasised. Informed career choice prepares an individual psychologically for the profession in question. It gives an opportunity to clarify career/personal aspirations and/or misconceptions, if any, and prevents an unnecessary career change from taking place upon registering at a university [11]. This is what was called anticipatory sociology [13]. This is in-line with what another writer emphasised; that university students including nursing students should have enough knowledge and insight about their career choices as it is one of the most crucial decisions an individual makes in his/her lifetime [14].

Contrary to this, findings of a qualitative study undertaken by the first author of this article in Malawi in 2014, that focused on gender mainstreaming in nursing education, revealed that the majority of male student nurses did not make informed career choices prior to joining the nursing profession [15]. As a result, the male students faced a lot of challenges during and after training [15]. For instance, some participants experienced reduced motivation shortly after joining the nursing career while others opted for career change. Such challenges could hinder the growth of the nursing profession. One major contributing factor to the challenges faced by nurses, especially male nurses, is lack of career guidance to the prospective nursing students [16, 17]. In an effort to address this factor, an information tool (in the form of a brochure) titled, “A career in nursing and midwifery in Malawi,” was developed. Development of the brochure was based on recommendations made by the study participants in the 2014 study in Malawi [15].

Malawi is one of the countries in the sub-Saharan countries located south of the equator. It is bordered to the north and northeast by the United Republic of Tanzania, to the east, south and southeast by the People’s Republic of Mozambique and to the west and northwest by the Republic of Zambia [18]. The country educates both male and female nurse midwives at professional and technical levels. Education of male nurse midwives in Malawi began in 1985 at the University of Malawi [19]. Gradually, enrolment of men into nursing within the country spread to all nursing and midwifery colleges. Due to other factors, such as, Malawi being a patriarchal culture, men still remain a minority in the country. The trend is similar regionally and globally, though culture may not be a factor in other countries. Use of career guidance tools in form of a brochure could help recruit and retain prospective nurse midwives.

This paper describes how the brochure was validated using the Nominal Group Technique (NGT) as expounded by Varga-Atkins [20]. The aim of the NGT used in this study was to evaluate the outlook and content of the brochure, thereby increasing ownership of the brochure by Malawian nurse midwives. It is hoped that principles of the NGT as described in the article could be of benefit to other researchers in future.

The Table 1 below captures some important issues covered in the brochure.

Description of the nominal group technique

There are a number of group–based research techniques which researchers use to determine peoples’ views on services and other specific issues [21, 22]. The techniques include focus group discussions, brainstorming, the Delphi technique and the nominal group technique. The nominal group technique has more advantages than the rest [23]. For example, the technique ensures the group achieves consensus and action planning on a chosen topic [20, 23].

Researcher bias is minimised because participants are directly involved during both data collection and analysis [21]. Each group participant is given an equal voice since the process encourages individual input in a non-judgemental environment [23]. In addition, feedback in terms of results can be given to group members immediately. In cases where senior and junior personnel belong to the same group, they all interact or operate at the same level without some being intimidated [20].

The technique was first developed by Delbecq, Van de Ven and Gustafson in 1975 to facilitate effective group decision-making in social psychological research [23]. Since then, the technique has been applied by many researchers among many fields as a research method or evaluation method [23]. However, a number of modifications from the original technique have been introduced by various researchers based on the specific issues being addressed [20].

Some of the studies that have utilized the nominal group technique have been conducted in radiography [24], education [25], social service and physiotherapy [23].

According to the technique, participants take part in a highly structured face-to-face meeting of a small number of people, such as 5–9 participants. Group sizes may vary, however, as some researchers choose to use larger group sizes [20, 23, 25].

The nominal group technique has five stages during the validation process, namely: introduction, silent generation of ideas, sharing of ideas, group discussions and voting/ranking stage [20, 23, 25]. The stages are expounded in the methodology section when explaining the validation exercise.

Despite having a number of advantages, there are a few guidelines to be followed when applying the technique. The guidelines are considered to be disadvantages [23]. They include the need to formulate clear and stimulating question/s which will help address the issues at hand. Participants should know the issue/s to be addressed so as to contribute effectively and represent their profession adequately. The facilitator should have explicit knowledge of the issue/s being addressed. Finally, the facilitator should have skills in implementing the group technique.

Methodology

The development of the brochure and the validation exercise were part of the multiple methods employed by the first author in a mixed methods study undertaken during doctoral studies. Appropriate ethical principles were employed. These ensured safeguarding of study participants’ rights. Therefore, prior to conducting the study, approval was sought from the appropriate authorities as follows: The Postgraduate committee for Faculty of Health Sciences and Human Research Ethics Committee at the University of Witwatersrand in South Africa – certificate Number M130805; The Ministry of Health Ethics Committee in Malawi – certificate Number NHSR 1235.

Permission to access institutions in Malawi where data were collected was sourced from the institutional heads. Study participants were requested to submit written consent.

The sample comprised student nurses (n = 37) in four purposively selected nursing colleges from a population of N = 849. The colleges represented university, government, and faith-based nursing colleges. Inclusion criteria of study participants included; willingness to participate in a NGT for approximately 1½ to 2 hours, being above 18-years of age and written informed consent. The study participants met the researcher in an agreed designated place on the college premises. Each group was gender balanced. There were 6–8 students per group.

A pilot study on the NGT was carried out at one of the nursing colleges with eight student nurses. The number comprised four females and four men. The aim of the pilot study was, firstly, to assess the extent to which answers of the set questions could provide the information required to validate the brochure. Secondly, the pilot study was to help the facilitator familiarise herself with the process of undertaking a NGT with students prior to undertaking the main data collection exercise. The findings from the pilot study did not form part of the main study.

The exercise took place in one of the classrooms at each college. The venue provided a conducive environment, which enabled participants to sit in a semi-circle to encourage participation. Each participant was encouraged to contribute freely in a non-judgemental manner.

Results

Discussion

The aim of this study was to validate the brochure by evaluating the content contained in it as a career guidance material. Specifically, participants were required to assess the general appearance and content of the brochure and provide objective feedback based on strengths, weaknesses and areas requiring improvements. The NGT proved to be effective and user friendly in validating the brochure. The results revealed that the design was well conceived with a layout that managed to give clear and relevant information about nursing and midwifery. The information included challenges that may be faced upon joining nursing. Though some participants in three of the five groups indicated that the brochure was gender-sensitive, two of the five groups suggested that pictures needed to be improved by adding some more pictures of males thereby improving gender sensitivity.

The majority of the groups (four of the five), found the brochure to be relevant and motivating to prospective nurse midwives. This finding is critical considering that the brochure is aimed at complementing information on career guidance and counselling for nursing students in general and male nursing students in particular. By participating in the validation exercise and suggesting areas that needed improvement, the nursing students demonstrated interest in the brochure thereby endorsing it for use in career guidance and for use in counselling prospective nursing students especially male students.

Use of appropriate career guidance materials for students making career choices is critical and should not be underrated. Malawian culture is to a large extent patriarchal. The fact that nursing and midwifery is still regarded as a feminine profession means that prospective male nurse midwives may require comprehensive career guidance prior to choosing the female-dominated profession. Such guidance could help ensure adequate psychological preparation as well as the ability to adjust to a female-dominated social environment. The guidance information would enhance the ability of the prospective nursing and midwifery students to make informed decisions prior to joining the career [26], thereby preventing career change during course of training or after [11]. This is because informed career choice help in averting wrong career choice [27].

The brochure, validated in this study, considered some factors that could influence an individual’s career choice. For example, the brochure contained career guidance information relevant to prospective professionals. The brochure, if used as a means of mass media could be an important information resource during career guidance activities. This could influence school leavers in their choice of a career in nursing [28, 29]. Thus, the brochure could be used as a career guidance material thereby helping some prospective male nurse midwives make an informed career choice in the female dominated profession.

Conclusion

Using the nominal group technique, the validation process has revealed that the content and appearance of the brochure are satisfactory. The brochure is appropriate, acceptable and useful for prospective nurse midwifery students in Malawi. On the other hand, it was recommended that the brochure be enriched with pictures depicting male nurses at work so as to be gender sensitive.

Finally, the authors recommend use of the NGT, compared to other group-based research techniques, considering the benefits the NGT offers.