Nursing Image Among Pre-Nursing Students: A Mixed-Methods Systematic Review with Future Directions on Recruitment Strategies.

AIM: To synthesize existing evidence to inform targeted recruitment strategies and interventions. BACKGROUND: The ongoing global shortage of nurses presents a significant threat to healthcare delivery. Addressing this requires an understanding of why pre-nursing students choose to or avoid nursing as a career. A key deterrent is the profession's negative image, often associated with "dirty work." However, current literature lacks a comprehensive view of the factors shaping these perceptions. METHODS: Nine databases were searched from inception to October 2024. Eligible studies included quantitative, qualitative, and mixed-methods designs focusing on pre-nursing students' perceptions of nursing image. A five-stage framework analysis structured the findings, and Bronfenbrenner's social-ecological model categorized factors at individual, interpersonal, and societal levels. The JBI Convergent Integrated Method integrated qualitative findings and qualitized quantitative evidence according to these levels. RESULTS: Thirty-two studies (9034 participants) from 14 countries were included. Individual-level factors included gender stereotypes, knowledge of the profession, perceived work attributes, and intrinsic motivation. Interpersonal-level factors included the role of family, peers, and exposure to nursing professionals. Societal-level factors included media portrayals, sociocultural norms, and targeted recruitment interventions. CONCLUSION: Factors converge across levels, and passive visibility alone is insufficient to shift entrenched views. Post-COVID "hero" narratives may increase visibility but also reinforce associations with fatigue and difficult working conditions. Improving pre-nursing students' perceptions of nursing image requires sustained, coordinated, multilevel recruitment strategies. IMPLICATIONS FOR NURSING: Educators and healthcare institutions may consider strategies that challenge gender stereotypes, engage parents and peers, provide structured exposure to nursing roles, and strengthen leadership-focused media portrayals. IMPLICATIONS FOR HEALTH POLICY: Recruitment strategies should be supported by policy and aligned with efforts to address structural conditions that shape nursing image, with the ultimate goal of strengthening the future nursing workforce and as part of workforce planning.