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Career choice and perceptions of nursing among healthcare students in higher educational institutions
Career choice and perceptions of nursing among healthcare students in higher educational institutions Sok Ying Liaw, Ling Ting Wu, Yeow Leng Chow, Siriwan Lim, Khoon Kiat Tan PII: DOI: Reference:
S0260-6917(17)30031-X doi:10.1016/j.nedt.2017.02.008 YNEDT 3491
To appear in:
Nurse Education Today
Received date: Revised date: Accepted date:
3 October 2016 26 January 2017 8 February 2017
Please cite this article as: Liaw, Sok Ying, Wu, Ling Ting, Chow, Yeow Leng, Lim, Siriwan, Tan, Khoon Kiat, Career choice and perceptions of nursing among healthcare students in higher educational institutions, Nurse Education Today (2017), doi:10.1016/j.nedt.2017.02.008
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ACCEPTED MANUSCRIPT TITLE PAGE
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Title: Career choice and perceptions of nursing among healthcare students in higher educational institutions
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Word Count: 5082
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Authors’ names and affiliation:
1. Corresponding Author: Sok Ying Liaw, RN, PhD in Medical Education, Assistant Professor, Alice
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Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. Email:[email protected]; Mailing address: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore. Level 2, Clinical
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Research Centre, Block MD11 10 Medical Drive, Singapore 117597 2. Ling Ting Wu, RN, BSc (Nursing), Research Assistant, Alice Lee Centre for Nursing Studies, Loo
Lin
School
of
National
University
of
Singapore,
Singapore.
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Email:[email protected]
Medicine,
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Yong
3. Yeow Leng Chow, RN, PhD in Health Sciences, Alice Lee Centre for Nursing Studies, Yong Loo
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Lin School of Medicine, National University of Singapore, Singapore. Email: [email protected]; 4. Siriwan Lim, RN, Master of Health Science, Alice Lee Centre for Nursing Studies, Yong Loo Lin School
of
Medicine,
National
University
of
Singapore,
Singapore.
Email:
[email protected];
5. Khoon Kiat Tan, RN, PhD in Health Sciences, Senior Lecturer, School of Health Sciences, Nanyang Polytechnic, Singapore. Email: [email protected] Acknowledgement: This study was funded by Ministry of Health (MOH) Health Services Research Grant. We would like to thank the healthcare students from higher education institutions for participating in the research study. We also thank the NUHS Medical Publications Support Unit (PSU) for providing editing services for this manuscript. Conflict of interest: No conflict of interest has been declared by the authors.
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ACCEPTED MANUSCRIPT TITLE: Career choice and perceptions of nursing among healthcare students in higher educational
institutions
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ABSTRACT
Background: Due to the ageing population and competition from other healthcare courses, a greater
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demand in the healthcare workforce has made it challenging for educational institutions to attract school
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leavers to enter nursing courses. Understanding the considerations of students who have chosen nonnursing healthcare courses and their perceptions of nursing can help identify specific strategies to
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enhance the attractiveness of nursing course. This study aims to examine the differences between healthcare career choices and perceptions of nursing as a career choice among first-year non-nursing
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healthcare students.
Method: A descriptive survey design was conducted at the beginning of the healthcare courses of seven
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healthcare groups and from four higher educational institutions in Singapore. A total of 451 students
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responded, yielding an overall response rate of 52.7%. The online survey was administered using a valid and reliable 35-item parallel scale, known as the Healthcare Career Choice and Nursing Career Choice.
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Results: The participants perceived prior healthcare exposure as the most influential factor and selfefficacy as the least influential factor when choosing nursing as a career. In comparison to their own healthcare career choices, nursing was perceived to have greater gender stigma and, as nurses, they would be less likely to achieve higher qualifications and career advancements, and they would be less likely to enjoy fulfilling careers. They also perceived that they would be less likely to gain their parents’ support to pursue nursing and to make their parents proud. Conclusions: This study provides educators and policy-makers with vital information to develop key strategies to improve nursing enrolment in educational institutions. These strategies include early exposure to nursing as a rewarding career during school years, addressing the issue of gender stigma, and promoting information on the career and educational advancement of a registered nurse to parents of school leavers. Keywords: career choice, healthcare course, nursing enrolment, nursing recruitment, influential factor
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ACCEPTED MANUSCRIPT INTRODUCTION According to the World Health Organisation (WHO) (2014), the global shortage of healthcare workers will
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reach 12.9 million by 2035. With the current global aging population, it is estimated that by 2030, the number of people who are 65 years and older will increase to one billion worldwide (Mukherji et al., 2015).
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Internationally, and particularly in Singapore, healthcare systems are expected to face a shortage of
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trained healthcare workforce from rapid expansion of the healthcare infrastructure to meet the increased ageing population. As such, there is a need to expand the healthcare education pipeline by establishing
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more healthcare training institutions and increasing student enrolment for healthcare courses (Betlehema et al., 2009). However, among the healthcare courses, nursing has not been perceived as a popular
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course by the students. It faces greater challenge and competition in attracting school leavers who are interested in healthcare courses (Neilson & Jones 2012). With the demands of healthcare courses, there is an increasing interest to explore the motivations
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of students who take up a career in healthcare. A systematic review conducted by Wu et al. (2015)
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identified several factors that influence career choice among healthcare students. A personal interest in
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healthcare was identified to be a more influential factor in choosing medicine when compared against dentistry and pharmacy. This factor was also influential for nursing (Rashid et al., 2013; Tanalp et al., 2012). The interest for choosing nursing was often founded on altruism (Halperin & Mashiach-Eizenberg, 2013). Monetary reward was an important consideration for students who chose pharmacy and dentistry when compared with other healthcare courses as revealed in several international studies (Hayes & Shakya, 2013; Tanalp et al., 2012). Unlike medicine and pharmacy, healthcare students who chose nursing may have done so for job security, but the findings for dentistry students were less consistent (Rashid et al, 2013; Tanalp et al., 2012). To dentistry students, job autonomy was important as the opportunity to be self-employed was a major consideration (Tanalp et al., 2012). The effect of parents’ expectations on healthcare career choices was inconclusive. Wu et al. (2015) suggested that parental influence might be important in Asia. Law and Arthur (2003), for example, described how family influenced students to join nursing courses in Hong Kong. In the United Kingdom (UK), however, a
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ACCEPTED MANUSCRIPT qualitative study advocated that parents discouraged their children from entry into nursing (Norman, 2015). Although both nursing and non-nursing healthcare careers were able to fulfil an individual
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altruistic desire (Hayes & Shakya, 2013; McLaughlin et al., 2010), nursing was found to be the least
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attractive of all healthcare courses. Nursing was perceived to be for students with less satisfactory academic results (Neilson & Lauder, 2008) and was unsuitable to warrant a university degree (Ogunyewo
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et al., 2014). Nursing was also perceived as having lesser responsibilities and decision-making rights
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(Duffield & O’Brien-Pallas, 2003), often having to do ‘dirty’ work (Hadley et al., 2007), and involving stressful tasks on handling distressed patients and their family members. A nursing career was reported
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by school-aged students to match their ideal careers in terms of busyness, caring for others, hard work, and job security (Palumbo et al., 2008), but falls short of their ideal careers in terms of appreciation, autonomy, financial remuneration, and respect (Cohen et al., 2004).
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In Singapore, registered nursing education is offered in higher educational institutions, including
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polytechnics and university. While polytechnics offer a diploma in nursing to school leavers with a
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General Certificate of Education Ordinary Level (GCE ‘O’ Level), universities offers a nursing degree to college school leavers with a GCE Advanced Level. Polytechnics have the highest enrolment target for nursing courses with approximately 1,200 each year to fulfil the nursing manpower needs of the nation. Given the availability of the vast range of healthcare related diploma courses (e.g. dental hygiene, healthcare management, pharmaceutical science, psychology, and social work) offered in Singapore’s four polytechnics, the nursing courses face challenges in reaching its huge enrolment target as well as attracting high quality school leavers (Liaw et al., 2016; Neilson & Jones, 2012). Among the healthcare diploma courses, nursing has the lowest entry requirements based on GCE ‘O’ Level. It is important to find out the career choices of students who enrolled in various healthcare courses and examine why these other healthcare courses students did not choose nursing as their preferred career choice (Natan & Becker, 2010). An earlier qualitative study on 59 healthcare students identified six factors that influenced their healthcare career choices (HCCs) (Liaw et al., 2016a). These factors were utilised to construct an instrument with parallel scales to compare the influences of HCC with the perception of nursing as a career choice (Liaw et al., 2016b). In this study, using the newly developed
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ACCEPTED MANUSCRIPT instrument, we aim to conduct a quantitative study to examine the differences between HCCs and perceptions of nursing as a career choice among first-year non-nursing healthcare students. This comparative understanding of career choice influences can provide valuable information for educators
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and policy-makers to consider specific strategies to improve nursing recruitment.
METHODS
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Study design and sample
A descriptive survey study was conducted between April to June 2016 during the first two months of entry
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to diploma courses. The sampling frame included the entire target population. All 855 first-year students undertaking non-nursing healthcare courses in four tertiary educational institutions were invited to
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participate in this study. These healthcare courses included heath management, pharmaceutical
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completed the survey.
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sciences, dental hygiene therapy, psychology, and social work. Four hundred and fifty-one students
Data collection and instrument
Following approval from the Institutional Review Boards of two higher educational institutions, email invitations were sent to the school directors of the four tertiary educational institutions to seek their support and permission to conduct the study. Recruitment posters and a weblink to the online questionnaire were then disseminated to the potential students through collaborators in the institutions. The students were informed about the study purpose via a participation information sheet that is available in the weblink. The students were assured that their participation was voluntary and anonymity would be maintained. The instrument was a newly developed and self-administered questionnaire known as the HCC and Nursing Career Choice (HCC-NCC) parallel scale. It comprises of two scales with 35 parallel items in each scale to enable comparison between the influences of HCC and the perception of nursing as a career choice. The HCC-NCC parallel scale measures the items on a 5-point Likert scale, from 1 “strongly
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ACCEPTED MANUSCRIPT disagree” to 5 “strongly agree”, and includes six subscales: personal interest, prior healthcare exposure, self-efficacy, job prospect, perceived nature of work, and social influences. Table 1 states the descriptions of each subscale. The scale was carefully constructed and tested for psychometric properties in a
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previous study. The scale’s content validity was established by a panel of 12 healthcare experts from a
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variety of healthcare settings, including hospitals, educational institutions, and the Ministry of Health. The content validity index (CVI) was 0.78 for the HCC scale and 1.0 for the NCC scale. Construct validity was
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tested using exploratory factor analysis which revealed 35-parallel items in a six-factor solution and
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explained 59% and 64% of the variance for the HCC and NCC scales, respectively (Liaw et al., 2016). Concurrent validity was examined by correlating the HCC-NCC parallel scale with an established Indiana
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Instrument developed by May (1991). A significant strong positive correlation (r=0.76, p<0.001) was found between these two scales. Internal consistency in this study was high with Cronbach’s alphas of 0.93 for the HCC scale and 0.96 for the NCC scale. Test-retest reliability was acceptable with an intraclass
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correlation coefficients of 0.63 for the HCC scale and 0.60 for the NCC scale (Liaw et al., 2016).
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Data analysis
Statistical Package for the Social Sciences (SPSS) was used to analyse the data. Descriptive statistics were computed for demographic variables. Independent t-test was performed to compare the differences between influences of each participant’s HCC and nursing as a career choice.
RESULTS Demographics characteristics A total of 451 students responded to the survey, yielding an overall response rate of 52.7% (Table 2). Table 3 indicates the demographic characteristics of the participants. The average age of the participants was 17 years (SD±1.7), with a range between 16 and 25 years. The majority of them were female (n=342, 75.8%), Singaporean (n=412, 91.4%), Chinese (n=313, 69.4%), secondary or college school leavers with
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ACCEPTED MANUSCRIPT a GCE (n=402, 89.1%), and had enrolled in a pharmaceutical science course (n=236, 52.3%). Only about 30% (n=133) of the participants indicated that they sought career advice from significant others.
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Most and least influential reasons for HCC and NCC
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Table 4 shows the five highest-scored items identified by the participants as influential in making their HCCs. These items were: (1) making a difference in someone’s life, (2) a desire for a fulfilling career, (3)
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a desire to help others, (4) contributing to the society, and (5) wanting parents to be proud. Most of these
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items were under the subscale of “personal interest” and were also among the highest-scored items in NCC.
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No consistency was reported between the lowest-scored items in the HCC and NCC scales, except for one item in “inspired by social media”. Most of the lowest-scored items rated by the participants on the HCC scale were related to the factor “prior healthcare exposure”. On the contrary, most of the
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lowest-scored items rated by the participants on the NCC scale were from the factor “self-efficacy”.
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Differences between HCC and NCC
Table 5 represents the differences in mean scores between the HCC and NCC scales for the six factors and items. The means scores for the factors “prior healthcare exposure,” “nature of work”, and “social influences” were significantly higher in the NCC scale than in the HCC scale. No significant difference between HCC and NCC was reported in the mean scores for the factors “personal interest”, “selfefficacy”, and “job prospect”.
Personal interest The items “contribute to the society” and “enjoy interacting with people” were rated significantly higher in the NCC scale than in the HCC scale whereas the item “desire for a fulfilling career” was rated significantly lower in the NCC scale than in the HCC scale. In other words, in comparison to their own career choices, nursing as a career choice was perceived by the participants as more likely influenced by the personal interest of contributing to the society and interacting with people but less likely influence by the desire for a fulfilling career.
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ACCEPTED MANUSCRIPT Prior healthcare exposure The mean scores for all the items within the factor “prior healthcare exposure” were reported to be significantly higher in the NCC scale than in the HCC scale. Nursing as a career was perceived as more
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likely to be influenced by prior healthcare exposure, which include taking care of a sick family member,
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being taken care of by a healthcare professional, participating in related school co-curricular activities, observing healthcare professionals at work, hearing about the profession from significant others, and
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doing voluntary work in healthcare settings.
Self-efficacy
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The item “able to make diagnoses” was reported to have a significant lower mean scores in the NCC scale than in the HCC scale, suggesting that the consideration of the ability to make diagnoses has more
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Nature of work
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influence on HCC than nursing as a career choice.
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The mean scores for the items “more hands-on job”, “challenging job”, and “demanding job” were reported to be significantly higher in the NCC scale than in the HCC scale. These findings indicated that nursing as a career was being perceived as more hands-on, which is challenging and demanding when compared to the participants’ career choices. In addition, the greatest disparity between the NCC and HCC scales was the item “do not mind attending to others hygiene needs”. The participants had chosen a career that did not need to perform this hygiene task.
Job prospect The mean scores for the item “never be unemployed” was significantly higher in the NCC scale than in the HCC scale whereas the mean scores for the items “opportunities for career advancement” and “chance for achieving higher qualification” were significantly lower in the NCC scale than in the HCC scale. In comparison to the participants’ career choices, nursing was perceived as a more employable job but, as a career, it was less likely to provide opportunities for advancement and to attain a higher qualification.
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ACCEPTED MANUSCRIPT Social influences The items “well respected”, “good public image”, “inspired by social media”, “peers encouraged of the choice”, and “peers will look up to me” were rated significantly higher by the participants in the NCC scale
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than in the HCC scale. In contrast, the items “no gender stigma”, “parents are supportive”, and “want
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parents to be proud” were rated significantly lower by the participants in the NCC scale than in the HCC scale. In other words, in comparison to their own career choices, the participants perceived nursing to
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have stronger respect and support from peers and the public but less so from their parents and that their
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parents would be less proud of their choices. Nursing was also perceived as more likely to suffer from
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gender stigma.
DISCUSSION
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A personal interest in their chosen healthcare careers based on intrinsic values such as the desire to help
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others and wanting to make a difference in someone’s life was rated by the Singaporean healthcare
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students as a strong motivating factor. This finding is consistent with several international studies that identified personal interest as a strong intrinsic factor which influences career choices among healthcare students in the UK, Ireland, Nepal, Israel, and Arab (Crossley & Mubarik, 2002; Halperin & MashiachEizenberg, 2013; Hayes & Shakya, 2013; McLaughlin et al., 2010). Holland’s theory of career typology (1966) supported this by stating that individuals choose a career based on their personality profiles and interests.
Prior exposure to healthcare work was perceived by the healthcare students as a strong influencing factor for choosing nursing as career but not for their chosen healthcare careers. In our findings, the greatest differences on prior healthcare exposure reported were in relation to their school cocurriculum activities and doing voluntary work in healthcare settings. The influence of prior experience in healthcare for choosing a nursing career has been reported by previous studies conducted in the United States and the UK (Larsen et al., 2003; McLaughlin et al.,2010). Nursing courses are attracting more older students who have prior working experiences than younger school leavers (Pool et al., 2013). While
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ACCEPTED MANUSCRIPT this is good because the students are more mature and more certain of what they want, it may be a human resource waste that young school leavers spend valuable time exploring other options first. If they can make informed career choices at a younger age, it will benefit them, nursing, and the society as a
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whole. The exposure to healthcare through the participation of school co-curriculum activities, such as
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Saint John’s Ambulance and The Red Cross, and community involvement programmes in healthcare settings seems to have important influences in students’ career preferences for nursing. Thus, exposure
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to healthcare related work through school activities should be promoted to influence students in
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considering nursing as a career.
Self-efficacy was perceived as the least influential factor for considering nursing as a career
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choice. In this study, self-efficacy relates to a student’s belief of their academic and intellectual ability to their career choice. As a result of the huge nursing intake, students who are accepted into the nursing course range from excellent performers in their GCE ‘O’ Level examinations to those with lower academic
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abilities. Nursing course has been perceived as an easy course to get into and, to some, it was perceived
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as a ‘dumping’ course for students who did not achieve sufficient academic grades to enter their preferred
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career choices (Liaw et al., 2016b). Qualitative studies conducted in the UK and Singapore suggested that the perception of nursing for low academically inclined students could have deterred academicallyabled students from applying for a nursing course (Liaw et al., 2016b; Neilson & Lauder, 2008). In contrast, the requirement of good academic performance to study nursing was perceived by students from Kuwait, Nigeria, and Hong Kong (Al-Kandari & Lew, 2005; Law & Arthur, 2003; Ogunyewo et al., 2014). As a low academic entry requirement of nursing course seems to reflect low intellectual requirement expected of nurses, there is a need for Singapore educational institutions to review the admission criteria and strategies for selecting and recruiting nursing students. In our findings, healthcare students perceived that their chosen careers offered opportunities to make diagnoses while nursing as a career choice does not, possibly because they perceived nursing as a more hands-on job. This study supported previous findings in that the general public views the role of a nurse as one who mainly follows doctors’ orders and performs physical tasks (Seago et al., 2006; Williamson, 2012). In Singapore, non-nursing healthcare courses prepare individuals to become assistants or allied health therapists (e.g. oral hygiene therapists, psychology students, and social work
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ACCEPTED MANUSCRIPT associates). Given that a diploma nursing course in Singapore will lead to the role of a registered nurse, our findings identified the lack of understanding on the role of a registered nurse among non-nursing students. A possible reason for this lack of understanding could be due to the diverse nursing workforce
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in Singapore such as registered nurses, enrolled nurses, and healthcare assistants who put on similar
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corporate uniforms. Thus, the image of a registered nurse needs to be recognisable from the rest and as a homogeneous group in the whole country to promote a distinct registered nurse image. In addition, the
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specific role of a registered nurse which involves developing nursing diagnoses and care plans for
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patients, and supervising the work of non-registered nurses, needs to be highlighted. The participants perceived their chosen careers as more fulfilling than nursing as a career choice.
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A plausible explanation for this could be the lack of understanding on the rewarding nature of nursing work. Thus, there is a need to consider how to promote nursing as a fulfilling career among school leavers. In addition, the non-nursing healthcare students in our study reported a significant disparity
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between their healthcare career choices and nursing as a career in terms of the nature of work. The
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perception of nursing as a more challenging and demanding job, and the need to attend to others’
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hygiene needs, may have deterred these students from choosing nursing as a career. While acknowledging the challenges and demands of nursing work, the value, dignity, and rewards that could be experienced from nursing work, including meeting someone’s personal hygiene, should be highlighted to associate the value of the nature of work and the sense of job fulfilment. In the area of job prospect, healthcare students recognised that nursing as a career choice enjoys a better employment opportunity despite lesser opportunities for educational and career advancements. These students appeared to have limited information on the availability of higher nursing education ranging from an advanced diploma to a doctoral degree to prepare nurses for nursing specialities and different career pathways. Despite the established career pathways in Singapore nursing, our findings revealed that many people are still unfamiliar with the roles of advanced nurse practitioner, researcher, educator, and manager. In comparison to their own career choices, nursing as a career choice was perceived by the students as more likely suffer from gender stigma. This finding is not unexpected as the social construction of nursing being female dominant is known to inhibit men from entering the nursing
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ACCEPTED MANUSCRIPT profession. The stereotypical image of a male nurse as one of being a homosexual, effeminate, or a sexual deviant poses challenges for male students to consider a career in this profession (Bronner et al., 2003; McMillan et al., 2006). Grounded in Gottfredson’s theory of career aspiration (1981), gender-type
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and occupational status have been testified as important variables in influencing the career aspirations of
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students. Family members and parents play an important role in shaping their attitudes toward occupational status and gender-type (Leung et al., 2011).
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Gaining parents’ support and making them proud of their career choices were indicated by the
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students as significantly more important influential reasons for their career choices than for choosing nursing as a career. The effect of parental influences could be explained by the collectivist culture of
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Singapore whereby an individual student may tend to make a career decision that will meet their parents’ expectations rather than to satisfy their own interest (Sawitri et al., 2014). These findings also highlighted the strong influence that Singaporean parents might have on their children’s career choices. In a study
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conducted in Hong Kong, the effect of parents’ influences was found to be significantly associated with
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students’ considerations of nursing as a career (Law & Arthur, 2003). Asian parents from other countries,
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including China and Taiwan, have also reported to have high career expectations in their children (Hou & Leung, 2011; Wang & Heppner, 2002). With the perception of nursing as a low prestige and femaledominated occupation, parental objection may play a significant influence in their children’s decisions of entering a nursing course, especially for male students.
Limitations
The findings of this study, though obtained from four tertiary educational institutions in Singapore, may not be transferable to other countries with different social and cultural issues. However, these findings have international significance as the nursing workforce issue is a global problem complicated by a worldwide ageing trend. A few items embedded in the HCC-NCC parallel scale can be either positively or negatively worded items. However, these items were positively worded based on the previous psychometric testing outcome. Another method bias is the social desirability effect whereby participants may tend to respond to the questionnaire in a socially and culturally acceptable manner. However, the
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ACCEPTED MANUSCRIPT disparity in the HCC and NCC scales probably indicate that socially desirable responses may not be
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apparent in this study.
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CONCLUSIONS
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This study examined the differences between the influences of chosen HCCs and nursing as a career choice among non-nursing healthcare students in higher educational institutions. This comparative
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understanding of career choice influences has provided valuable implications for educational institutions and policy-making planners to consider strategies to enhance nursing enrolment among school leavers.
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As the greater demand for the nursing workforce is a global problem, these strategies may have international implications since the recruitment of school leavers for nursing courses is challenging.
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Firstly, the exposure of nursing as a rewarding career should be provided in the early stages of life,
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especially in school. Policy leaders can promote this by encouraging schools to incorporate caregiving programmes into early school curriculums or co-curricular activities and to reflect on the value of these
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activities.
Secondly, the perception that nursing courses are for students with lesser academic and intellectual abilities should be corrected by the entry requirements of diploma nursing courses. One way is to reduce the emphasis of academic results and employ other selection approaches such as emotional intelligence tests to recruit students with appropriate attributes. Thirdly, a concerted effort is needed from policy leaders, educators, and researchers to address gender stigma and promote gender diversity in the nursing workforce. Given that roughly half of the population is male, recruiting men into nursing can significantly fulfil the nursing shortage. Future studies to explore the challenges faced by Singaporean male student nurses may provide valuable insights for more specific recruitment strategies targeted on male students. Fourthly, there is a need to promote public awareness on the different levels of nurses and recognise the problem-solving abilities and leadership role of a registered nurse. This publicity should
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ACCEPTED MANUSCRIPT also include the career advancements of a registered nurse (e.g. advanced nurse practitioner, educator and managers) and nursing education progression from a diploma to a doctoral degree. Finally, the publicity approach should target parents to help them better understand the roles and
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career advancement opportunities in nursing. As parents are increasingly active influencers of their
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children’s career decisions, it is vital to develop innovative strategies to engage parents in the career decision-making processes of their children. Future studies could further examine the effect of parental
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expectations on healthcare students’ career choices, particularly the career choices of nursing students.
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Centre for Nursing Studies, National University of Singapore, SG. Leung, S.A., Hou, Z.J., Gati, I., Li, X., 2011. Effects of parental expectations and cultural-values orientation on career decision-making difficulties of Chinese University students. Journal of Vocational Behaviour. 78(1), 11-20.
May, F.E., Champion, V., Austin, J.K., 1991. Public values and beliefs toward nursing as a career. Journal of Nursing Education. 30, 303–310. McLaughlin, K., Moutray, M., Moore, C., 2010. Career motivation in nursing students and the perceived influence of significant others. Journal of Advanced Nursing. 66(4), 404-412. McMillan, J., Morgan, S.A., Ament, P., 2006. Acceptance of male registered nurses by female registered nurses. Journal of Nursing Scholarship. 38(1):100-106. Mukherji, A., Roychoudhury, S., Ghosh, P., & Brown, S., 2015. Estimating Health Demand for an Aging Population: A Flexible and Robust Bayesian Joint Model. Journal of Applied Econometrics. 31(6), 1140-1158.
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ACCEPTED MANUSCRIPT Natan, M. B., Becker, F., 2010. Israelis’ perceived motivation for choosing nursing career. Nurse Education Today 30, 308-313. Neilson, G.R., Lauder, W., 2008. What do high academic achieving school pupils really think about a
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career in nursing: analysis of the narrative from paradigmatic case interviews. Nurse Education Today.
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28(6), 680-690.
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Neilson, G.R. & Jones, M.C. (2012) What predicts the selection of nursing as a career choice in 5 and 6
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year school students? Nurse Education Today, 32, 588-593.
th
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Norman, K.M., 2015. The image of community nursing: Implications for future student nurse recruitment. British Journal of Community Nursing. 20(1), 12-18.
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Ogunyewo, O.A., Afemikhe, J.A., Ajio, D.K., Olanlesi_aliu, A., 2014. Adolescents' perception of career choice of nursing among selected secondary schools in Jos, Nigeria. Journal of Nursing and Midwifery. 7(2),21-29.
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Palumbo, M.V., Rambur, B., McIntosh, B., Naud, S., 2008. Perceptions of an ideal career versus
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perceptions of six health careers. Nursing Outlook. 37(1),8-14.
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Pool, I., Poell, R., ten Cate, O., 2013. Nurses’ and managers’ perceptions of continuing professional development for older and younger nurses: a focus group study. International Journal of Nursing Studies. 50(1):34-43.
Rashid, H., Manoharan, A., Abufanas, S., Gallagher, J.E., 2013. Motivation for a career in dentistry: the views of dental students in the United Arab Emirates. International Dental Journal. 63(5), 259–265. Sawitri, D.R., Creed, P.A., Zimmer-Gembeck, M.J., 2014. Parental influences and adolescent career behaviours in a collectivist cultural setting. International Journal for Educational and Vocational Guidance. 14(2), 161-180. Seago, J.A., Williamson, A., Atwood, C., 2006. Longitudinal analyses of nurse staffing and patient outcomes: more about failure to rescue. Journal of Nursing Administration. 36, 13-21. Tanalp, J., Ilguy, D., Dikbas, I., Oktay, I., 2012. Demographic profile and future expectations of students enrolled in a Turkish private dental school. Journal of Dental Education. 76(6), 800–809. Wang, L., Heppner, P.P., 2002. Assessing the impact of parental expectations and psychological distress on Taiwanese college students. The Counselling Psychologist. 30,582–608.
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ACCEPTED MANUSCRIPT Williamson, C.L., 2012. Hispanic female undergraduates’ perception of nursing as a career choice: A phenomenological study. (D.H.A.), University of Phoenix. http://libproxy1.nus.edu.sg/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=
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109859848&site=ehost-live (Accessed 15 Dec 2015).
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World Health Organization. 2014. Global health workforce shortage to reach 12.9 million in coming
shortage/en/index.html (Accessed 2 February 2014).
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decades. http://www.who.int/mediacentre/news/releases/2013/health-workforce-
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Wu, L.T., Low, M.M.J., Tan, K.K., Lopez, V., Liaw, S.Y., 2015. Why not nursing? A systematic review of factors influencing career choice among healthcare students. International Nursing Review 62, 547-
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Table 1: Descriptions of subscales find in Healthcare Career Choice and Nursing Career Choice questionnaire
Descriptions
Personal interest
Refers to the students’ personal interest (i.e., altruism, interest for science-related subject) in their chosen professions.
Prior healthcare exposure
Reflects how healthcare related experiences (i.e., observing a healthcare professional at work) could influence their choice of a healthcare career.
Self-efficacy
Refers to a set of self-beliefs about one’s personal competence (i.e., academic abiliy) to a career choice.
Job prospects
Considers the practical aspects (i.e., job opportunity, job stability, good income) of a healthcare career that could influence the career choice.
Perceived nature of work
Relates to how students’ perceived the characteristics aspects (i.e., autonomy, hands-on skills) of the healthcare careers that influenced their choice of career.
Social influences
Includes social status, gender-type and significant others that would have significant impact on the students’ career decision-making process.
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Subscales
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ACCEPTED MANUSCRIPT Table 2: Participant’s Response Rate No. of students
Response received n(%)
Dental Hygiene
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17 (85.0)
Healthcare management
260
Pharmaceutical Science
365
Psychology
140
Social work
70
Overall
855
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Courses
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98 (37.7)
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236 (64.7)
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46 (32.9) 54 (76.1) 451 (52.7)
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Table 3: Demographic characteristics of the participants
16-19
395 (87.6)
20-25
56 (12.4)
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Gender Male
108 (23.9)
Female
342 (75.8)
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Nationality (Singaporean) Yes
412 (91.4) 39 (8.6)
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No Ethnic group Chinese
313 (69.4) 73 (16.2)
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Malay Others Education
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GCE N/O/A levels
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Indian
ITE/Diploma Courses
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N (%)
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Demographics Age (years)
45 (10.0) 20 (4.4) 402 (89.1) 49 (10.9)
Dental Hygiene
17 (3.8)
Healthcare management
98 (21.7)
Pharmaceutical Science
236 (52.3)
Psychology
46 (10.2)
Social work
54 (12.0)
Career advice from significant others Yes
133 (29.7)
No
317 (70.3)
GCE N level- General Certificate of Education Normal (Academic) Level GCE O level- General Certificate of Education Ordinary Level GCE A level- General Certificate of Education Advanced Level ITE-Institute of Technical Education
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SD
4.19
±0.85
I desire for a fulfilling career
4.15
±0.83
I desire to help others I can contribute to the society I want my parents to be proud of me
4.12 4.01
±0.83 ±0.83
Nurses want to make a difference in someone's life Nurses can contribute to society Nurses desire to help others Nursing is a hands-on job
4.01
±1.00
Lowest scored items
±1.29
2.79
In taking care of a sick family member
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2.68
2.80
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The social media has inspired me
±1.27
2.91
SD
4.26
±0.80
4.17
±0.78
4.10 4.08
±0.83 ±0.87
Nursing is a challenging job
4.08
±0.95
Nurses want to choose a course that is more deserving of their good grades
3.16
±1.04
Nurses have high income
3.20
±0.94
3.23
±0.98
3.26
±0.94
3.31
±1.01
The social media has inspired them to take up nursing Nurses can make autonomous decisions at work Nurses are able to make diagnosis
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In being taken care of by healthcare professional Doing voluntary work in healthcare settings
2.26
±1.13
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In my school co-curriculum activities
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Highest scored Items I want to make a difference in someone's life
NCC
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HCC
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Table 4: Highest and lowest mean scores items (top five) for HCC and NCC
±1.13 ±1.30
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Table 5: Differences between healthcare career choice (HCC) and nursing as a career choice (NCC) scores
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ACCEPTED MANUSCRIPT Highlights More opportunities should be created for exposure of nursing in the early school years
The role and career advancement of a registered nurse need to be promoted
There is a need to address the issue of gender stigma
The publicity approach on nursing recruitment should target on parents
The perception of nursing courses for students with lesser academic abilities should be corrected
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S0260-6917(17)30031-X doi:10.1016/j.nedt.2017.02.008 YNEDT 3491
To appear in:
Nurse Education Today
Received date: Revised date: Accepted date:
3 October 2016 26 January 2017 8 February 2017
Please cite this article as: Liaw, Sok Ying, Wu, Ling Ting, Chow, Yeow Leng, Lim, Siriwan, Tan, Khoon Kiat, Career choice and perceptions of nursing among healthcare students in higher educational institutions, Nurse Education Today (2017), doi:10.1016/j.nedt.2017.02.008
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE PAGE
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Title: Career choice and perceptions of nursing among healthcare students in higher educational institutions
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Word Count: 5082
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Authors’ names and affiliation:
1. Corresponding Author: Sok Ying Liaw, RN, PhD in Medical Education, Assistant Professor, Alice
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Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. Email:[email protected]; Mailing address: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore. Level 2, Clinical
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Research Centre, Block MD11 10 Medical Drive, Singapore 117597 2. Ling Ting Wu, RN, BSc (Nursing), Research Assistant, Alice Lee Centre for Nursing Studies, Loo
Lin
School
of
National
University
of
Singapore,
Singapore.
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Email:[email protected]
Medicine,
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Yong
3. Yeow Leng Chow, RN, PhD in Health Sciences, Alice Lee Centre for Nursing Studies, Yong Loo
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Lin School of Medicine, National University of Singapore, Singapore. Email: [email protected]; 4. Siriwan Lim, RN, Master of Health Science, Alice Lee Centre for Nursing Studies, Yong Loo Lin School
of
Medicine,
National
University
of
Singapore,
Singapore.
Email:
[email protected];
5. Khoon Kiat Tan, RN, PhD in Health Sciences, Senior Lecturer, School of Health Sciences, Nanyang Polytechnic, Singapore. Email: [email protected] Acknowledgement: This study was funded by Ministry of Health (MOH) Health Services Research Grant. We would like to thank the healthcare students from higher education institutions for participating in the research study. We also thank the NUHS Medical Publications Support Unit (PSU) for providing editing services for this manuscript. Conflict of interest: No conflict of interest has been declared by the authors.
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ACCEPTED MANUSCRIPT TITLE: Career choice and perceptions of nursing among healthcare students in higher educational
institutions
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ABSTRACT
Background: Due to the ageing population and competition from other healthcare courses, a greater
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demand in the healthcare workforce has made it challenging for educational institutions to attract school
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leavers to enter nursing courses. Understanding the considerations of students who have chosen nonnursing healthcare courses and their perceptions of nursing can help identify specific strategies to
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enhance the attractiveness of nursing course. This study aims to examine the differences between healthcare career choices and perceptions of nursing as a career choice among first-year non-nursing
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healthcare students.
Method: A descriptive survey design was conducted at the beginning of the healthcare courses of seven
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healthcare groups and from four higher educational institutions in Singapore. A total of 451 students
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responded, yielding an overall response rate of 52.7%. The online survey was administered using a valid and reliable 35-item parallel scale, known as the Healthcare Career Choice and Nursing Career Choice.
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Results: The participants perceived prior healthcare exposure as the most influential factor and selfefficacy as the least influential factor when choosing nursing as a career. In comparison to their own healthcare career choices, nursing was perceived to have greater gender stigma and, as nurses, they would be less likely to achieve higher qualifications and career advancements, and they would be less likely to enjoy fulfilling careers. They also perceived that they would be less likely to gain their parents’ support to pursue nursing and to make their parents proud. Conclusions: This study provides educators and policy-makers with vital information to develop key strategies to improve nursing enrolment in educational institutions. These strategies include early exposure to nursing as a rewarding career during school years, addressing the issue of gender stigma, and promoting information on the career and educational advancement of a registered nurse to parents of school leavers. Keywords: career choice, healthcare course, nursing enrolment, nursing recruitment, influential factor
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ACCEPTED MANUSCRIPT INTRODUCTION According to the World Health Organisation (WHO) (2014), the global shortage of healthcare workers will
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reach 12.9 million by 2035. With the current global aging population, it is estimated that by 2030, the number of people who are 65 years and older will increase to one billion worldwide (Mukherji et al., 2015).
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Internationally, and particularly in Singapore, healthcare systems are expected to face a shortage of
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trained healthcare workforce from rapid expansion of the healthcare infrastructure to meet the increased ageing population. As such, there is a need to expand the healthcare education pipeline by establishing
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more healthcare training institutions and increasing student enrolment for healthcare courses (Betlehema et al., 2009). However, among the healthcare courses, nursing has not been perceived as a popular
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course by the students. It faces greater challenge and competition in attracting school leavers who are interested in healthcare courses (Neilson & Jones 2012). With the demands of healthcare courses, there is an increasing interest to explore the motivations
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of students who take up a career in healthcare. A systematic review conducted by Wu et al. (2015)
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identified several factors that influence career choice among healthcare students. A personal interest in
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healthcare was identified to be a more influential factor in choosing medicine when compared against dentistry and pharmacy. This factor was also influential for nursing (Rashid et al., 2013; Tanalp et al., 2012). The interest for choosing nursing was often founded on altruism (Halperin & Mashiach-Eizenberg, 2013). Monetary reward was an important consideration for students who chose pharmacy and dentistry when compared with other healthcare courses as revealed in several international studies (Hayes & Shakya, 2013; Tanalp et al., 2012). Unlike medicine and pharmacy, healthcare students who chose nursing may have done so for job security, but the findings for dentistry students were less consistent (Rashid et al, 2013; Tanalp et al., 2012). To dentistry students, job autonomy was important as the opportunity to be self-employed was a major consideration (Tanalp et al., 2012). The effect of parents’ expectations on healthcare career choices was inconclusive. Wu et al. (2015) suggested that parental influence might be important in Asia. Law and Arthur (2003), for example, described how family influenced students to join nursing courses in Hong Kong. In the United Kingdom (UK), however, a
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ACCEPTED MANUSCRIPT qualitative study advocated that parents discouraged their children from entry into nursing (Norman, 2015). Although both nursing and non-nursing healthcare careers were able to fulfil an individual
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altruistic desire (Hayes & Shakya, 2013; McLaughlin et al., 2010), nursing was found to be the least
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attractive of all healthcare courses. Nursing was perceived to be for students with less satisfactory academic results (Neilson & Lauder, 2008) and was unsuitable to warrant a university degree (Ogunyewo
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et al., 2014). Nursing was also perceived as having lesser responsibilities and decision-making rights
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(Duffield & O’Brien-Pallas, 2003), often having to do ‘dirty’ work (Hadley et al., 2007), and involving stressful tasks on handling distressed patients and their family members. A nursing career was reported
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by school-aged students to match their ideal careers in terms of busyness, caring for others, hard work, and job security (Palumbo et al., 2008), but falls short of their ideal careers in terms of appreciation, autonomy, financial remuneration, and respect (Cohen et al., 2004).
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In Singapore, registered nursing education is offered in higher educational institutions, including
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polytechnics and university. While polytechnics offer a diploma in nursing to school leavers with a
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General Certificate of Education Ordinary Level (GCE ‘O’ Level), universities offers a nursing degree to college school leavers with a GCE Advanced Level. Polytechnics have the highest enrolment target for nursing courses with approximately 1,200 each year to fulfil the nursing manpower needs of the nation. Given the availability of the vast range of healthcare related diploma courses (e.g. dental hygiene, healthcare management, pharmaceutical science, psychology, and social work) offered in Singapore’s four polytechnics, the nursing courses face challenges in reaching its huge enrolment target as well as attracting high quality school leavers (Liaw et al., 2016; Neilson & Jones, 2012). Among the healthcare diploma courses, nursing has the lowest entry requirements based on GCE ‘O’ Level. It is important to find out the career choices of students who enrolled in various healthcare courses and examine why these other healthcare courses students did not choose nursing as their preferred career choice (Natan & Becker, 2010). An earlier qualitative study on 59 healthcare students identified six factors that influenced their healthcare career choices (HCCs) (Liaw et al., 2016a). These factors were utilised to construct an instrument with parallel scales to compare the influences of HCC with the perception of nursing as a career choice (Liaw et al., 2016b). In this study, using the newly developed
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ACCEPTED MANUSCRIPT instrument, we aim to conduct a quantitative study to examine the differences between HCCs and perceptions of nursing as a career choice among first-year non-nursing healthcare students. This comparative understanding of career choice influences can provide valuable information for educators
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and policy-makers to consider specific strategies to improve nursing recruitment.
METHODS
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Study design and sample
A descriptive survey study was conducted between April to June 2016 during the first two months of entry
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to diploma courses. The sampling frame included the entire target population. All 855 first-year students undertaking non-nursing healthcare courses in four tertiary educational institutions were invited to
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participate in this study. These healthcare courses included heath management, pharmaceutical
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completed the survey.
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sciences, dental hygiene therapy, psychology, and social work. Four hundred and fifty-one students
Data collection and instrument
Following approval from the Institutional Review Boards of two higher educational institutions, email invitations were sent to the school directors of the four tertiary educational institutions to seek their support and permission to conduct the study. Recruitment posters and a weblink to the online questionnaire were then disseminated to the potential students through collaborators in the institutions. The students were informed about the study purpose via a participation information sheet that is available in the weblink. The students were assured that their participation was voluntary and anonymity would be maintained. The instrument was a newly developed and self-administered questionnaire known as the HCC and Nursing Career Choice (HCC-NCC) parallel scale. It comprises of two scales with 35 parallel items in each scale to enable comparison between the influences of HCC and the perception of nursing as a career choice. The HCC-NCC parallel scale measures the items on a 5-point Likert scale, from 1 “strongly
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ACCEPTED MANUSCRIPT disagree” to 5 “strongly agree”, and includes six subscales: personal interest, prior healthcare exposure, self-efficacy, job prospect, perceived nature of work, and social influences. Table 1 states the descriptions of each subscale. The scale was carefully constructed and tested for psychometric properties in a
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previous study. The scale’s content validity was established by a panel of 12 healthcare experts from a
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variety of healthcare settings, including hospitals, educational institutions, and the Ministry of Health. The content validity index (CVI) was 0.78 for the HCC scale and 1.0 for the NCC scale. Construct validity was
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tested using exploratory factor analysis which revealed 35-parallel items in a six-factor solution and
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explained 59% and 64% of the variance for the HCC and NCC scales, respectively (Liaw et al., 2016). Concurrent validity was examined by correlating the HCC-NCC parallel scale with an established Indiana
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Instrument developed by May (1991). A significant strong positive correlation (r=0.76, p<0.001) was found between these two scales. Internal consistency in this study was high with Cronbach’s alphas of 0.93 for the HCC scale and 0.96 for the NCC scale. Test-retest reliability was acceptable with an intraclass
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correlation coefficients of 0.63 for the HCC scale and 0.60 for the NCC scale (Liaw et al., 2016).
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Data analysis
Statistical Package for the Social Sciences (SPSS) was used to analyse the data. Descriptive statistics were computed for demographic variables. Independent t-test was performed to compare the differences between influences of each participant’s HCC and nursing as a career choice.
RESULTS Demographics characteristics A total of 451 students responded to the survey, yielding an overall response rate of 52.7% (Table 2). Table 3 indicates the demographic characteristics of the participants. The average age of the participants was 17 years (SD±1.7), with a range between 16 and 25 years. The majority of them were female (n=342, 75.8%), Singaporean (n=412, 91.4%), Chinese (n=313, 69.4%), secondary or college school leavers with
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ACCEPTED MANUSCRIPT a GCE (n=402, 89.1%), and had enrolled in a pharmaceutical science course (n=236, 52.3%). Only about 30% (n=133) of the participants indicated that they sought career advice from significant others.
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Most and least influential reasons for HCC and NCC
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Table 4 shows the five highest-scored items identified by the participants as influential in making their HCCs. These items were: (1) making a difference in someone’s life, (2) a desire for a fulfilling career, (3)
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a desire to help others, (4) contributing to the society, and (5) wanting parents to be proud. Most of these
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items were under the subscale of “personal interest” and were also among the highest-scored items in NCC.
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No consistency was reported between the lowest-scored items in the HCC and NCC scales, except for one item in “inspired by social media”. Most of the lowest-scored items rated by the participants on the HCC scale were related to the factor “prior healthcare exposure”. On the contrary, most of the
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lowest-scored items rated by the participants on the NCC scale were from the factor “self-efficacy”.
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Differences between HCC and NCC
Table 5 represents the differences in mean scores between the HCC and NCC scales for the six factors and items. The means scores for the factors “prior healthcare exposure,” “nature of work”, and “social influences” were significantly higher in the NCC scale than in the HCC scale. No significant difference between HCC and NCC was reported in the mean scores for the factors “personal interest”, “selfefficacy”, and “job prospect”.
Personal interest The items “contribute to the society” and “enjoy interacting with people” were rated significantly higher in the NCC scale than in the HCC scale whereas the item “desire for a fulfilling career” was rated significantly lower in the NCC scale than in the HCC scale. In other words, in comparison to their own career choices, nursing as a career choice was perceived by the participants as more likely influenced by the personal interest of contributing to the society and interacting with people but less likely influence by the desire for a fulfilling career.
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ACCEPTED MANUSCRIPT Prior healthcare exposure The mean scores for all the items within the factor “prior healthcare exposure” were reported to be significantly higher in the NCC scale than in the HCC scale. Nursing as a career was perceived as more
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likely to be influenced by prior healthcare exposure, which include taking care of a sick family member,
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being taken care of by a healthcare professional, participating in related school co-curricular activities, observing healthcare professionals at work, hearing about the profession from significant others, and
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doing voluntary work in healthcare settings.
Self-efficacy
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The item “able to make diagnoses” was reported to have a significant lower mean scores in the NCC scale than in the HCC scale, suggesting that the consideration of the ability to make diagnoses has more
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Nature of work
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influence on HCC than nursing as a career choice.
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The mean scores for the items “more hands-on job”, “challenging job”, and “demanding job” were reported to be significantly higher in the NCC scale than in the HCC scale. These findings indicated that nursing as a career was being perceived as more hands-on, which is challenging and demanding when compared to the participants’ career choices. In addition, the greatest disparity between the NCC and HCC scales was the item “do not mind attending to others hygiene needs”. The participants had chosen a career that did not need to perform this hygiene task.
Job prospect The mean scores for the item “never be unemployed” was significantly higher in the NCC scale than in the HCC scale whereas the mean scores for the items “opportunities for career advancement” and “chance for achieving higher qualification” were significantly lower in the NCC scale than in the HCC scale. In comparison to the participants’ career choices, nursing was perceived as a more employable job but, as a career, it was less likely to provide opportunities for advancement and to attain a higher qualification.
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ACCEPTED MANUSCRIPT Social influences The items “well respected”, “good public image”, “inspired by social media”, “peers encouraged of the choice”, and “peers will look up to me” were rated significantly higher by the participants in the NCC scale
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than in the HCC scale. In contrast, the items “no gender stigma”, “parents are supportive”, and “want
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parents to be proud” were rated significantly lower by the participants in the NCC scale than in the HCC scale. In other words, in comparison to their own career choices, the participants perceived nursing to
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have stronger respect and support from peers and the public but less so from their parents and that their
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parents would be less proud of their choices. Nursing was also perceived as more likely to suffer from
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gender stigma.
DISCUSSION
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A personal interest in their chosen healthcare careers based on intrinsic values such as the desire to help
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others and wanting to make a difference in someone’s life was rated by the Singaporean healthcare
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students as a strong motivating factor. This finding is consistent with several international studies that identified personal interest as a strong intrinsic factor which influences career choices among healthcare students in the UK, Ireland, Nepal, Israel, and Arab (Crossley & Mubarik, 2002; Halperin & MashiachEizenberg, 2013; Hayes & Shakya, 2013; McLaughlin et al., 2010). Holland’s theory of career typology (1966) supported this by stating that individuals choose a career based on their personality profiles and interests.
Prior exposure to healthcare work was perceived by the healthcare students as a strong influencing factor for choosing nursing as career but not for their chosen healthcare careers. In our findings, the greatest differences on prior healthcare exposure reported were in relation to their school cocurriculum activities and doing voluntary work in healthcare settings. The influence of prior experience in healthcare for choosing a nursing career has been reported by previous studies conducted in the United States and the UK (Larsen et al., 2003; McLaughlin et al.,2010). Nursing courses are attracting more older students who have prior working experiences than younger school leavers (Pool et al., 2013). While
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ACCEPTED MANUSCRIPT this is good because the students are more mature and more certain of what they want, it may be a human resource waste that young school leavers spend valuable time exploring other options first. If they can make informed career choices at a younger age, it will benefit them, nursing, and the society as a
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whole. The exposure to healthcare through the participation of school co-curriculum activities, such as
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Saint John’s Ambulance and The Red Cross, and community involvement programmes in healthcare settings seems to have important influences in students’ career preferences for nursing. Thus, exposure
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to healthcare related work through school activities should be promoted to influence students in
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considering nursing as a career.
Self-efficacy was perceived as the least influential factor for considering nursing as a career
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choice. In this study, self-efficacy relates to a student’s belief of their academic and intellectual ability to their career choice. As a result of the huge nursing intake, students who are accepted into the nursing course range from excellent performers in their GCE ‘O’ Level examinations to those with lower academic
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abilities. Nursing course has been perceived as an easy course to get into and, to some, it was perceived
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as a ‘dumping’ course for students who did not achieve sufficient academic grades to enter their preferred
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career choices (Liaw et al., 2016b). Qualitative studies conducted in the UK and Singapore suggested that the perception of nursing for low academically inclined students could have deterred academicallyabled students from applying for a nursing course (Liaw et al., 2016b; Neilson & Lauder, 2008). In contrast, the requirement of good academic performance to study nursing was perceived by students from Kuwait, Nigeria, and Hong Kong (Al-Kandari & Lew, 2005; Law & Arthur, 2003; Ogunyewo et al., 2014). As a low academic entry requirement of nursing course seems to reflect low intellectual requirement expected of nurses, there is a need for Singapore educational institutions to review the admission criteria and strategies for selecting and recruiting nursing students. In our findings, healthcare students perceived that their chosen careers offered opportunities to make diagnoses while nursing as a career choice does not, possibly because they perceived nursing as a more hands-on job. This study supported previous findings in that the general public views the role of a nurse as one who mainly follows doctors’ orders and performs physical tasks (Seago et al., 2006; Williamson, 2012). In Singapore, non-nursing healthcare courses prepare individuals to become assistants or allied health therapists (e.g. oral hygiene therapists, psychology students, and social work
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in Singapore such as registered nurses, enrolled nurses, and healthcare assistants who put on similar
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corporate uniforms. Thus, the image of a registered nurse needs to be recognisable from the rest and as a homogeneous group in the whole country to promote a distinct registered nurse image. In addition, the
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specific role of a registered nurse which involves developing nursing diagnoses and care plans for
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patients, and supervising the work of non-registered nurses, needs to be highlighted. The participants perceived their chosen careers as more fulfilling than nursing as a career choice.
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A plausible explanation for this could be the lack of understanding on the rewarding nature of nursing work. Thus, there is a need to consider how to promote nursing as a fulfilling career among school leavers. In addition, the non-nursing healthcare students in our study reported a significant disparity
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between their healthcare career choices and nursing as a career in terms of the nature of work. The
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perception of nursing as a more challenging and demanding job, and the need to attend to others’
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hygiene needs, may have deterred these students from choosing nursing as a career. While acknowledging the challenges and demands of nursing work, the value, dignity, and rewards that could be experienced from nursing work, including meeting someone’s personal hygiene, should be highlighted to associate the value of the nature of work and the sense of job fulfilment. In the area of job prospect, healthcare students recognised that nursing as a career choice enjoys a better employment opportunity despite lesser opportunities for educational and career advancements. These students appeared to have limited information on the availability of higher nursing education ranging from an advanced diploma to a doctoral degree to prepare nurses for nursing specialities and different career pathways. Despite the established career pathways in Singapore nursing, our findings revealed that many people are still unfamiliar with the roles of advanced nurse practitioner, researcher, educator, and manager. In comparison to their own career choices, nursing as a career choice was perceived by the students as more likely suffer from gender stigma. This finding is not unexpected as the social construction of nursing being female dominant is known to inhibit men from entering the nursing
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ACCEPTED MANUSCRIPT profession. The stereotypical image of a male nurse as one of being a homosexual, effeminate, or a sexual deviant poses challenges for male students to consider a career in this profession (Bronner et al., 2003; McMillan et al., 2006). Grounded in Gottfredson’s theory of career aspiration (1981), gender-type
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and occupational status have been testified as important variables in influencing the career aspirations of
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students. Family members and parents play an important role in shaping their attitudes toward occupational status and gender-type (Leung et al., 2011).
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Gaining parents’ support and making them proud of their career choices were indicated by the
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students as significantly more important influential reasons for their career choices than for choosing nursing as a career. The effect of parental influences could be explained by the collectivist culture of
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Singapore whereby an individual student may tend to make a career decision that will meet their parents’ expectations rather than to satisfy their own interest (Sawitri et al., 2014). These findings also highlighted the strong influence that Singaporean parents might have on their children’s career choices. In a study
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conducted in Hong Kong, the effect of parents’ influences was found to be significantly associated with
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students’ considerations of nursing as a career (Law & Arthur, 2003). Asian parents from other countries,
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including China and Taiwan, have also reported to have high career expectations in their children (Hou & Leung, 2011; Wang & Heppner, 2002). With the perception of nursing as a low prestige and femaledominated occupation, parental objection may play a significant influence in their children’s decisions of entering a nursing course, especially for male students.
Limitations
The findings of this study, though obtained from four tertiary educational institutions in Singapore, may not be transferable to other countries with different social and cultural issues. However, these findings have international significance as the nursing workforce issue is a global problem complicated by a worldwide ageing trend. A few items embedded in the HCC-NCC parallel scale can be either positively or negatively worded items. However, these items were positively worded based on the previous psychometric testing outcome. Another method bias is the social desirability effect whereby participants may tend to respond to the questionnaire in a socially and culturally acceptable manner. However, the
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ACCEPTED MANUSCRIPT disparity in the HCC and NCC scales probably indicate that socially desirable responses may not be
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apparent in this study.
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CONCLUSIONS
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This study examined the differences between the influences of chosen HCCs and nursing as a career choice among non-nursing healthcare students in higher educational institutions. This comparative
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understanding of career choice influences has provided valuable implications for educational institutions and policy-making planners to consider strategies to enhance nursing enrolment among school leavers.
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As the greater demand for the nursing workforce is a global problem, these strategies may have international implications since the recruitment of school leavers for nursing courses is challenging.
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Firstly, the exposure of nursing as a rewarding career should be provided in the early stages of life,
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especially in school. Policy leaders can promote this by encouraging schools to incorporate caregiving programmes into early school curriculums or co-curricular activities and to reflect on the value of these
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activities.
Secondly, the perception that nursing courses are for students with lesser academic and intellectual abilities should be corrected by the entry requirements of diploma nursing courses. One way is to reduce the emphasis of academic results and employ other selection approaches such as emotional intelligence tests to recruit students with appropriate attributes. Thirdly, a concerted effort is needed from policy leaders, educators, and researchers to address gender stigma and promote gender diversity in the nursing workforce. Given that roughly half of the population is male, recruiting men into nursing can significantly fulfil the nursing shortage. Future studies to explore the challenges faced by Singaporean male student nurses may provide valuable insights for more specific recruitment strategies targeted on male students. Fourthly, there is a need to promote public awareness on the different levels of nurses and recognise the problem-solving abilities and leadership role of a registered nurse. This publicity should
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ACCEPTED MANUSCRIPT also include the career advancements of a registered nurse (e.g. advanced nurse practitioner, educator and managers) and nursing education progression from a diploma to a doctoral degree. Finally, the publicity approach should target parents to help them better understand the roles and
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career advancement opportunities in nursing. As parents are increasingly active influencers of their
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children’s career decisions, it is vital to develop innovative strategies to engage parents in the career decision-making processes of their children. Future studies could further examine the effect of parental
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expectations on healthcare students’ career choices, particularly the career choices of nursing students.
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ACCEPTED MANUSCRIPT REFERENCES Al-Kandari, F.H., Lew, I., 2005. Kuwaiti high school students' perceptions of nursing as a profession:
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healthcare education: The Hungarian experience. Nurse Education Today. 29, 240-245.
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Bronner, G., Peretz, C., Ehrenfeld, M., 2003. Sexual harassment of nurses and nursing students. Journal of Advanced Nursing. 42(6), 637-644.
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Cohen, J.A., Palumbo, M.V, Rambur, B., Mongeon, J., 2004. Middle school students' perceptions of an ideal career and a career in nursing. Journal of Professional Nursing. 20(3), 202-210.
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Crossley, M.L, Mubarik, A., 2002. A comparative investigation of dental and medical student's motivation towards career choice. British Dental Journal, 193(8), 471-473. Duffield, C., O’Brien-Pallas, L., 2003. The causes and consequences of nursing shortages: A helicopter
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view of the research. Australian Health Review. 26(1),192-199.
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Gan, K.Y., 2012. MOH 2012 Committee of supply speech Healthcare 2020: Improving accessibility,
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quality and affordability for tomorrow's challenges. http://www.moh.gov.sg/content/moh_web/home/pressRoom/speeches_d/2012/moh_2012_committeeo fsupplyspeechhealthcare2020improvingaccessibi.html. (Accessed 24 Aug 2015). Gottfredson, L.S., 1981. Circumscription and compromise: a developmental theory of occupational aspirations. Journal of Counselling Psychology. 28, 545-579. Hadley, M.B., Blum, L.S., Mujaddid, S., Parveen, S., Nuremowla, S., Haque, M.E., et al., 2007. Why Bangladeshi nurses avoid ‘nursing’: Social and structural factors on hospital wards in Bangladesh. Social Science & Medicine. 64(4),1166-1177. Halperin, O., Mashiach-Eizenberg, M., 2013. Becoming a nurse – a study of career choice and professional adaptation among Israeli Jewish and Arab nursing students: a quantitative research study. Nurse Education Today. 34(10), 1330–1334. Hayes, B.W., Shakya, R., 2013. Career choices and what influences Nepali medical students and young doctors: a cross-sectional study. Human Resources for Health. 11(5), 1–12.
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Hou, Z.J., Leung, A., 2011. Vocational aspirations of Chinese high school students and their parents'
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Larsen, J.T., Norris, C.J., Cacioppo, J.T., 2003. The affect matrix: A single-item measure of positive and negative affect (Unpublished manuscript), Texas Tech University, Lubbock.
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Law, W., Arthur, D., 2003. What factors influence Hong Kong school students in their choice of a career in
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Liaw, S.Y., Wu, L.T., Holroyd, E., Wang, W., Lopez, V., Lim, S., Chow, Y.L., 2016a. Why not nursing?
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Liaw, S.Y., Wu, L.T., Lopez, V., Chow, Y.L., Lim, S., Holroyd, E., Tan, T.T., Wang, W., 2016b.
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Development and psychometric testing of parallel scales to compare career choice influences and
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perceptions of nursing among healthcare students. (Manuscript submitted for publication). Alice Lee
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Centre for Nursing Studies, National University of Singapore, SG. Leung, S.A., Hou, Z.J., Gati, I., Li, X., 2011. Effects of parental expectations and cultural-values orientation on career decision-making difficulties of Chinese University students. Journal of Vocational Behaviour. 78(1), 11-20.
May, F.E., Champion, V., Austin, J.K., 1991. Public values and beliefs toward nursing as a career. Journal of Nursing Education. 30, 303–310. McLaughlin, K., Moutray, M., Moore, C., 2010. Career motivation in nursing students and the perceived influence of significant others. Journal of Advanced Nursing. 66(4), 404-412. McMillan, J., Morgan, S.A., Ament, P., 2006. Acceptance of male registered nurses by female registered nurses. Journal of Nursing Scholarship. 38(1):100-106. Mukherji, A., Roychoudhury, S., Ghosh, P., & Brown, S., 2015. Estimating Health Demand for an Aging Population: A Flexible and Robust Bayesian Joint Model. Journal of Applied Econometrics. 31(6), 1140-1158.
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Rashid, H., Manoharan, A., Abufanas, S., Gallagher, J.E., 2013. Motivation for a career in dentistry: the views of dental students in the United Arab Emirates. International Dental Journal. 63(5), 259–265. Sawitri, D.R., Creed, P.A., Zimmer-Gembeck, M.J., 2014. Parental influences and adolescent career behaviours in a collectivist cultural setting. International Journal for Educational and Vocational Guidance. 14(2), 161-180. Seago, J.A., Williamson, A., Atwood, C., 2006. Longitudinal analyses of nurse staffing and patient outcomes: more about failure to rescue. Journal of Nursing Administration. 36, 13-21. Tanalp, J., Ilguy, D., Dikbas, I., Oktay, I., 2012. Demographic profile and future expectations of students enrolled in a Turkish private dental school. Journal of Dental Education. 76(6), 800–809. Wang, L., Heppner, P.P., 2002. Assessing the impact of parental expectations and psychological distress on Taiwanese college students. The Counselling Psychologist. 30,582–608.
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decades. http://www.who.int/mediacentre/news/releases/2013/health-workforce-
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Wu, L.T., Low, M.M.J., Tan, K.K., Lopez, V., Liaw, S.Y., 2015. Why not nursing? A systematic review of factors influencing career choice among healthcare students. International Nursing Review 62, 547-
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Table 1: Descriptions of subscales find in Healthcare Career Choice and Nursing Career Choice questionnaire
Descriptions
Personal interest
Refers to the students’ personal interest (i.e., altruism, interest for science-related subject) in their chosen professions.
Prior healthcare exposure
Reflects how healthcare related experiences (i.e., observing a healthcare professional at work) could influence their choice of a healthcare career.
Self-efficacy
Refers to a set of self-beliefs about one’s personal competence (i.e., academic abiliy) to a career choice.
Job prospects
Considers the practical aspects (i.e., job opportunity, job stability, good income) of a healthcare career that could influence the career choice.
Perceived nature of work
Relates to how students’ perceived the characteristics aspects (i.e., autonomy, hands-on skills) of the healthcare careers that influenced their choice of career.
Social influences
Includes social status, gender-type and significant others that would have significant impact on the students’ career decision-making process.
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Subscales
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Response received n(%)
Dental Hygiene
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17 (85.0)
Healthcare management
260
Pharmaceutical Science
365
Psychology
140
Social work
70
Overall
855
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Courses
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98 (37.7)
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236 (64.7)
20
46 (32.9) 54 (76.1) 451 (52.7)
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Table 3: Demographic characteristics of the participants
16-19
395 (87.6)
20-25
56 (12.4)
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Gender Male
108 (23.9)
Female
342 (75.8)
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Nationality (Singaporean) Yes
412 (91.4) 39 (8.6)
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No Ethnic group Chinese
313 (69.4) 73 (16.2)
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Malay Others Education
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GCE N/O/A levels
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Indian
ITE/Diploma Courses
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N (%)
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Demographics Age (years)
45 (10.0) 20 (4.4) 402 (89.1) 49 (10.9)
Dental Hygiene
17 (3.8)
Healthcare management
98 (21.7)
Pharmaceutical Science
236 (52.3)
Psychology
46 (10.2)
Social work
54 (12.0)
Career advice from significant others Yes
133 (29.7)
No
317 (70.3)
GCE N level- General Certificate of Education Normal (Academic) Level GCE O level- General Certificate of Education Ordinary Level GCE A level- General Certificate of Education Advanced Level ITE-Institute of Technical Education
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SD
4.19
±0.85
I desire for a fulfilling career
4.15
±0.83
I desire to help others I can contribute to the society I want my parents to be proud of me
4.12 4.01
±0.83 ±0.83
Nurses want to make a difference in someone's life Nurses can contribute to society Nurses desire to help others Nursing is a hands-on job
4.01
±1.00
Lowest scored items
±1.29
2.79
In taking care of a sick family member
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2.68
2.80
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The social media has inspired me
±1.27
2.91
SD
4.26
±0.80
4.17
±0.78
4.10 4.08
±0.83 ±0.87
Nursing is a challenging job
4.08
±0.95
Nurses want to choose a course that is more deserving of their good grades
3.16
±1.04
Nurses have high income
3.20
±0.94
3.23
±0.98
3.26
±0.94
3.31
±1.01
The social media has inspired them to take up nursing Nurses can make autonomous decisions at work Nurses are able to make diagnosis
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In being taken care of by healthcare professional Doing voluntary work in healthcare settings
2.26
±1.13
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In my school co-curriculum activities
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Highest scored Items I want to make a difference in someone's life
NCC
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HCC
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Table 4: Highest and lowest mean scores items (top five) for HCC and NCC
±1.13 ±1.30
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Table 5: Differences between healthcare career choice (HCC) and nursing as a career choice (NCC) scores
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ACCEPTED MANUSCRIPT Highlights More opportunities should be created for exposure of nursing in the early school years
The role and career advancement of a registered nurse need to be promoted
There is a need to address the issue of gender stigma
The publicity approach on nursing recruitment should target on parents
The perception of nursing courses for students with lesser academic abilities should be corrected
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