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Effects of self-reflection-focused career course on career search efficacy, career maturity, and career adaptability in nursing students: A mixed methods study
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Journal of Professional Nursing journal homepage: www.elsevier.com/locate/jpnu
Effects of self-reflection-focused career course on career search efficacy, career maturity, and career adaptability in nursing students: A mixed methods study Ju Hee Kim, Hye Sook Shin
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College of Nursing Science, Kyung Hee University, 26, Kyunghee-daero, Dongdaemun-gu, Seoul 02447, Republic of Korea
A R T I C LE I N FO
A B S T R A C T
Keywords: Career adaptability Career search efficacy Career maturity Mixed research design Self-reflection
Background: Career education in nursing can affect career search efficacy, career preparation behavior, career maturity, perception of the nursing profession, and decision-making style. Reflection is essential for an in-depth approach to learning, and plays an important role in professional practice as well as in improving learning. Purpose: The aim is to investigate the effects of a self-reflection-focused career course, and what could improve a self-reflection-focused career course. Methods: An explanatory sequential mixed methods design was used. The career search efficacy, career maturity, and career adaptability were measured three times in both the experimental and the control group. After the class ended, a focus group interview was conducted with the students in the experimental group. Results: The quantitative results suggested that the self-reflection focused career course was more effective on career adaptability than the general career course (F = 4.60, p < .001). The qualitative findings supported the quantitative results and also provided new information, in which nursing students became acquainted with themselves through the self-reflection-focused career course, developed a positive mind about nursing, had realized that they were well-connected to nursing care, and that they would prepare the future nurse. Conclusion: The self-reflection-focused career course was effective tools in the career development of nursing students.
Introduction
Schaffer, 2016; Park, 2015; Yilmaz, Ilce, Cicek, Yuzden, & Yigit, 2016).
The undergraduate period is an important phase that explores and shapes one's career, and that serves as a transition from school to the world of work (Super, 1969). Despite its importance, attrition rates in nursing education are around 9–28% worldwide (Buchan, Charlesworth, Gershlick, & Seccombe, 2019; Buchan & Seccombe, 2011; Gaynor et al., 2008; Kukkonen, Suhonen, & Salminen, 2016; National Solution, 2019). Incorrect career selection owing to lack of information about nursing science and difficulties in clinical practice were students' most commonly reported reasons for leaving nursing education (Glossop, 2002; Kukkonen et al., 2016). Even when students have graduated from a nursing college, their negative experiences affect their lives as nurses, and their satisfaction with their job is reduced, and eventually becomes a factor in turnover (Beercroft, Dorey, & Wenten, 2008). To prevent this discontinuation of education and help in the adaptation of nursing students, nursing colleges have run a variety of programs, such as career courses and accelerated programs (Doggrell &
Background and literature review
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Career education is intended to convey career information and assist in career planning for students (Park, 2015). Previous research on career education has proven effective in developing students' career search, career adaptation, and career development (Fouad, Cotter, & Kantamneni, 2009; Lee, Lee, & Yoon, 2015; McDow & Zabrucky, 2015; Reese & Miller, 2006; Ryan, 1999; Scott & Ciani, 2008; Whiston, Sexton, & Lasoff, 1988). In the nursing field, career education is established under the auspices of discipline-based career courses (Park, 2015), career activity (Yilmaz et al., 2016), success strategies improvement courses (Walker, 2016), and career planning (Park, 2012). These educations are implemented in the form of a program or class lasting 8–39 h (Fouad et al., 2009; Lee et al., 2015; Lim et al., 2010; McDow & Zabrucky, 2015; Park, 2012; Park, 2015; Reese & Miller, 2006; Scott & Ciani, 2008; Walker, 2016; Yilmaz et al., 2016). The
Corresponding author. E-mail addresses: [email protected] (J.H. Kim), [email protected] (H.S. Shin).
https://doi.org/10.1016/j.profnurs.2020.03.003 Received 1 October 2019; Received in revised form 4 March 2020; Accepted 11 March 2020 8755-7223/ © 2020 Published by Elsevier Inc.
Please cite this article as: Ju Hee Kim and Hye Sook Shin, Journal of Professional Nursing, https://doi.org/10.1016/j.profnurs.2020.03.003
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of a self-reflection-focused career course on career search efficacy, career maturity, and career adaptability. The qualitative research used a focus group interview design to comprehensively understand the effects of a self-reflection-focused career course and to evaluate the course.
career education are targeted toward either the whole grade of nursing students or only to the fourth-year students, and the contents of career courses are mostly related to the delivery of information on nursing or employment preparation (Lim et al., 2010; Park, 2012; Park, 2015; Yilmaz et al., 2016). Nursing research on career education reported that a career education can affect career search efficacy, career preparation behavior, career maturity, career adaptability, perception of the nursing profession, and decision-making style (Lim et al., 2010; Park, 2012; Park, 2015; Yilmaz et al., 2016). Career search efficacy refers to the degree of the individual's confidence to perform important activities associated with career selection and search (Solberg et al., 1994). Career maturity means an individual's degree of career decision-making and readiness to make occupational choices (Savickas & Porfeli, 2011). Career adaptability means an individual's psychosocial readiness and resources for coping with vocational development tasks, occupational transitions and work trauma (Savickas, 1997). However, the purpose of a career education is not just to convey career information, but to prepare for the profession through self-reflection (Lee et al., 2015; Pai, 2015). Reflection is essential for an indepth approach to learning and plays an important role in professional practice as well as in improving learning (Moon, 1999). Nursing students can reflect on their clinical experience, behavior, decisions, and correction of errors by critical self-reflection (Mezirow, 1990; Pai, 2015; Schaefer & Zygmont, 2003). They are educated through continuous self-reflection training, and when they become nurses, they are able to understand the patient's needs and provide appropriate nursing care (Bagay, 2012; Pai, 2015; Pai, Ko, Eng, & Yen, 2017). Therefore, the contents of the career education should include career learning through self-reflection. Moreover, students have different career needs according to their grades, so career contents need to be structured differently (Maietta, 2013). For example, the program for students before graduation should include information on job readiness, while the program for first year nursing students should include content ranging from self-awareness to exploring career areas. Therefore, providing appropriate career education to first year nursing students may have positive effects on their academic performance over the next four years and may reduce attrition rates (Kukkonen et al., 2016; Lee et al., 2015). And, most studies relate to career education are based on a quantitative research design, so they can only provide limited results measured by instruments, not the in-depth information in afforded by qualitative research; the career education effect measurement is also measured only once before and after the career program, so it is difficult to identify the change pattern of the effects. Meanwhile, mixed methods research is a type of research that combines elements of quantitative and qualitative research approaches (e.g., use of viewpoint, data collection, analysis, inference techniques), so it can provide a breadth and depth of understanding and corroboration of the effects of the career course (Creswell & Clak, 2018).
Participants The present study recruited first year nursing students in nursing college at K university in Korea using convenience sampling. The specific inclusion criteria included students who were taking the career course offered to first year nursing students at K University, whereas the exclusion criteria included those who were not first year nursing students, or those who had previously participated in nursing-related career courses and workshops. Quantitative phase The career course for first year nursing students was divided into two classes that consisted of 40–50 students each. One class was assigned to the experimental group, and the other class was assigned to the control group. In order to recruit subjects, the researcher explained the purpose of the study to the students in the first class, and noted that there was no penalty for not participating in the study. In 2018, the number of nursing students enrolled in the career course was a total of 94 students, and of them, four students were excluded due to non-first year students and experience of nursing career program. A total of 90 subjects were finally selected for the present study with 46 in the experimental group, and 44 in the control group The required total sample size of the experimental research was calculated to be 66 subjects on the assumption of a significance level of 0.05, a power of 0.95, an effect size of 0.2, two groups, three measurement points, a correlation between the points of 0.5, and repeated ANOVA measurements using the G-power 3.1.3 program. Given these conditions, the sample size in this study is sufficient to measure the effects of the self-reflection career course. Qualitative phase The number of samples required for the focus group interview in the present study was determined according to the guide suggested by Krueger and Casey (2015), which states that five–eight individuals per group are appropriate for focus group interviews. In the present study, four focus groups (total 24 students) were conducted, and each group consisted of five–seven students. Ethical consideration The present study was approved by the institutional review board at K University, to which the authors and subjects belong (KHUIRB-17008). After obtaining the approval of the head of department and the dean of the College of Nursing Science, the researchers explained the purpose of the study and the data collection process to students in class, who were assured of guaranteed anonymity and confidentiality.
Aims The present study aimed to investigate the effects of a self-reflection-focused career course developed for first year nursing students on career search self-efficacy, career maturity, and career adaptability, and what could improve a career course through using explanatory sequential mixed methods.
Data collection Development of self-reflection focused career course The career course used in the present study was developed in 2015, and has been offered since 2016 at K university to help first year nursing students' adaptation and assist them to establish their nursing careers. The course development team reviewed the national career development guidelines, Holland's theory, career construction theory, social cognitive career theory, various career education theories, and career-related courses and programs conducted in other fields (Campbell & Holland, 1972; Crites, 1965; National Career Development Association, 2007; Savickas, 2005; Savickas & Hartung, 1996). The contents of the constructed course were reviewed by the Curriculum Committee at the Nursing Science College. In addition, in order to
Methods Design An explanatory sequential mixed methods design (QUAN → qual) was used (Creswell & Clak, 2018) to explore the effects of the self-reflection-focused career course among first year nursing students who entered a nursing school (Fig. 1). The quantitative research used a quasi-experimental pre-post intervention design to identify the effects 2
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Fig. 1. Research flowchart in implementing an explanatory sequential mixed methods design.
Fig. 2. Contents of the self-reflection-focused career course.
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ability to engage in networking activities such as using a network to identify job opportunities. Personal exploration efficacy refers to the ability to explore personal and career values and preferences. Each item is rated on a 10-point scale (ranging from 0 to 9 points); a higher score indicates higher career search efficacy. The reliability of the CSES at the time of its development was Cronbach's alpha = 0.97, and its reliability in the present study was Cronbach's alpha = 0.98. Career maturity was measured using a revised Career Maturity Inventory (CMI), which was originally developed by Crites (1965) and later revised by Savickas and Porfeli (2011). The present study used CMI Form C, and this instrument provided a total score for career choice readiness of three scale scores reflecting adaptability dimensions of concern, curiosity, and confidences (18 items), and a single score reflecting relational style in forming occupational choices (six items). A higher score indicated higher career choice readiness and a more interdependent relational style. The reliability of this test at the time of its development was estimated using Cronbach's alpha = 0.86, and its reliability in the present study was Cronbach's alpha = 0.90. Career adaptability was measured using a Career Adapt-Abilities Inventory (CAI) (international version) developed by Savickas and Porfeli (2012). The CAI has four subscales: concern, control, curiosity, and confidence, and consists of six items for each subscale for a total 24 items. Each item is rated on a 5-point scale, and a higher score indicates higher career adaptation ability. The reliability of the CAI at the time of its development was Cronbach's alpha = 0.92, and its reliability in the present study was Cronbach's alpha = 0.94. CSES, CMI, and CAI were used after the back translation process. The translated tools were checked for content validity by three experts and the content validity index (CVI) values range from 0.92 to 0.99, which signifies that these scales have good content validity. The discriminant validity between variables was appropriate with all correlation coefficients.
reflect the students' opinions in the career courses, the contents of the constructed courses were informed by the feedback received from the nursing students in all grades. The class format used various forms of teaching such as special lectures, presentations after interviewing nursing seniors and facilities, and group discussions. The contents of the career course were as follows: the first part consisted of time to share information on the educational values, mission, scholarship system, and supporting facilities of the university, and to meet with colleagues. The second part consisted of career searching and planning processes. The third part consisted of exploring nursing through interviews with nurses working in various areas of nursing. The fourth part was designed to specifically plan for the nursing field of interest. The career course was conducted for 15 weeks, 1 h per week, and the course was evaluated as pass/fail. In the present study, an experimental intervention strengthened self-reflection training in the existing career course. In the selfreflection career course, the class was focused on discussing rather than unilaterally conveying information to the students. The self-reflection career course reinforced four parts: strengthen self-awareness, strengthen career-information search, strengthen the awareness about nursing, and strengthen with nursing (Fig. 2). For example, students reflect on oneself through taking a Holland's vocational aptitude inventory, painting a life graph, and describing one's strengths and weakness. Holland's vocational aptitude inventory, developed by psychologist John L. Holland, is one of the most popular measures used for assessing career aptitude. Holland's vocational personality theory suggests a career decision method through a hexagonal model called RIASEC (Realistic, Investigative, Artistic, Social, Enterprising, Conventional). Based on a characterization of personality, this test recommends what kind of work environments and occupations suit you best (APA, 1995). A life graph is a tool for self-reflection. Students recall their past, and graph important moments over time. Through the graph, students will know what kind of events occurred during their life, how they viewed them, and how they responded to important moments. At the same time, students will know what they think is important in life (Back & Bourque, 1970). Moreover, parts 3 and 4 were designed to reflect on how nursing can be linked to them, and to discuss the core competencies in nursing.
Qualitative phase: focus group interview Data collection for the focus group interview was undertaken with the experimental group of students July 2018 in a classroom after the completion of the career course. The researcher, who did not run this class, served as a moderator, and two assistant researchers, who did not participate in this study, assisted with the process of interviewing and recording field notes, including on-site requirements. Assistant researchers were present at the interview site and recorded field notes from the beginning to the end of the focus group interview. In the field notes, the name of the study, the date, time, location, and participants of the focus group interview, the names of the moderator, assistant moderators, seating arrangement, and information about the participants were recorded. All of the focus group participants' details were recorded as well as their opinions, quotes from conversations and intonation during the discussion that might be helpful to the analysis process. The desks were arranged in a circle so that the participants could look at each other and talk in a relaxed atmosphere. The interview took about 40–70 min. The focus group interview was recorded using an MP3 or windows media audio recording device, rather than cell phones, laptops, and PC recorders. Before the focus group interview, the researchers gathered, drafted, and reviewed questions based on previous studies on the career course. According to the guide on questioning described by Krueger and Casey (2015), opening questions should be easy for participants to answer quickly and should not be questions of discussion; introductory questions should introduce the topic of discussion and should help participants think briefly about the topic before participating in the discussion; transition questions should move the participants' conversation toward addressing key questions; key questions should be four–six questions on the discussion topic; and closing questions should consist of questions to conclude the discussion. Based on this guide, the present study constructed the following questions. Opening questions: Thank you for your time even though you may
Quantitative phase: experimental study The career course was conducted every Monday for 15 weeks from March 2018 to June 2018. For the data collection from the research, the baseline scores for career search efficacy, career maturity, and career adaptability in the subjects were measured during the first week of class, followed by the first posttest measurement at the eighth week and the second posttest measurement at the 15th week in both the experimental and control groups. The questionnaire instruments consisted of demographic questions, and questions on career search efficacy, career maturity, and career adaptability. We investigated the demographic characteristics of the subjects including gender, age, number of members in family, birth order, living with parents, and presence of health professionals in the family. The Career Search Efficacy was measure by a Career Search Efficacy Scale (CSES), in which developed by Solberg et al. (1994). Career Search Efficacy refers to the degree of confidence, which one has for performing a variety of career search tasks. The CSES was designed for college students, individuals entering the workforce for the first time or reentering it after breaks, and individuals changing jobs, and it has been validated in many populations (Choi and Kim, 2007; Park, 2015). The CSES consists of a total of 35 items with 14 items on job search efficacy, eight items on interviewing efficacy, eight items on networking efficacy, and five items on personal exploration efficacy. Job efficacy refers to the degree of confidence in job search such as identifying employers, dealing with job barriers, and finding information about potential employers. Interviewing efficacy assesses the ability of interviewing such as evaluating job requirements. Networking efficacy means the 4
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Quantitative phase results: effects of self-reflection-focused career course on career search efficacy, career maturity, and career adaptation ability
be busy after class. Each of you is going to introduce yourself. Introductory questions: What do you think of the term “career course?” Transition questions: Think of the first class of the career course. What was your first impression of the class? Key questions:
The present study conducted repeated measured ANOVA on how career search efficacy, career maturity, and career adaptation ability changed between experimental group and control group as the class progressed. The results are shown in Table 2 and Fig. 3. Career search efficacy, career maturity, career adaptability, and satisfaction of nursing increased in both the experimental and control groups as the career course progressed. There were significant differences in career search self-efficacy and career maturity only between groups, and between times. However, career adaptation ability showed significant differences between groups, between times, and in the interaction between groups and times.
- How did/didn't the career course help you in your career development? - Which project do you remember the most from your career course? - What do you think is the biggest advantage of this course? Ending questions: Do you have anything else to add regarding the career course? After the focus group interview was completed, the research team members gathered to debrief and discuss the issues recorded in the field notes, considerations, and points to be emphasized that the team members observed and listened to during the interview.
Qualitative phase findings: students' experience of the career course After the completion of the 15-week career course, a focus group interview was conducted with 24 students who agreed to participate. These participants consisted of 16 female nursing students (66.7%) with a mean score of satisfaction with nursing of 8.58 ± 1.43 points out of a maximum score of 10 points. The results of analyzing the focus group interview data revealed that a total of 89 meaningful statements were extracted, from which four themes and nine sub-themes were derived.
Data analysis The collected data were analyzed using SPSS/WIN 24.0. The homogeneity between experimental and control groups was analyzed using a t-test and χ2 test. The effects of the career course were measured at the first, eighth, and 15th weeks of the course and were analyzed using repeated measure ANOVA. After data collection from the focus group interview was completed, the qualitative research data were analyzed using interview transcripts and the field notes. Inductive and deductive content analysis was performed, taking into account the four main elements of focus group analysis (systematic, verifiable, sequential, and continuous) (Elo & Kyngas, 2008).
1. Getting to know myself (understanding myself through self-reflection) The participants stated that they could reflect on their past and present, and strengths and weaknesses using the life reflection graph and mind maps, and could thus understand themselves more specifically. “I used to think abstractly about who I am and what I plan for the future. Through the task of designing and writing my future, I was able to understand myself better. Also, I was able to establish my future plans more concretely…[omitted]…I could recall that entering the nursing department was not the end, but the beginning, and it was an opportunity for me to make a commitment to achieve the goals.” (Group 2P3)
Results Homogeneity of the experimental and control group The present study used the test for homogeneity for baseline measurement in the experimental and control groups. Results of the test for homogeneity of general characteristics and variables between experimental and control groups as shown in Table 1. There are no significant differences between the two groups in demographic characteristics, career self-search efficacy, career maturity, career adaptability, or satisfaction with nursing.
“It was helpful to write a reflective report on myself. I was able to look back at my life by creating a life reflection curve, and I learned about my strengths and weaknesses through a SWOT analysis. Through this, I was able to see what areas I needed to build up as my strengths and it was good to create my future plans. Thinking about what I would look like in the near future or one year later, I was able to establish my future plan in detail, and it was an opportunity to think about what it will be like when I
Table 1 Homogeneity of general characteristics and variables between experimental and control groups Characteristics
Age (year) Gender Number of members in family Birth order Living with parents Presence of health professional in the family Career search self-efficacy Career maturity Career adaptability Satisfaction with nursing
Categories
Female Male ≦4 >4 First ≥Second Yes No Yes No
Experimental group (n = 46) n (%)/mean ± SD
Control group (n = 44) n (%)/mean ± SD
19.32 ± 1.16 37 (80.4) 9 (19.6) 6 (13.0) 40 (87.0) 20 (43.5) 26 (56.5) 24 (52.2) 22 (47.8) 28 (60.9) 18 (39.1) 6.72 ± 2.17 189.62 ± 12.45 3.12 ± 0.87 7.12 ± 0.78
19.89 ± 1.69 36 (81.8) 8 (18.2) 8 (18.2) 36 (81.8) 18 (40.9) 26 (59.1) 24 (54.5) 20 (45.5) 27 (61.4) 17 (38.6) 6.46 ± 1.80 190.10 ± 19.01 3.29 ± 1.99 7.32 ± 1.70
5
t/χ2 test
p-Value
0.44 3.19
0.756 0.213
1.13
0.566
0.94
0.348
0.78
0.099
1.84
0.123
0.45 12.21 0.19 1.17
0.891 0.234 0.062 0.085
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Table 2 Changes of career search efficacy, career maturity, career adaptability, and satisfaction with nursing in experimental and control group Variables
Pretest (T1)
Posttest 1 (T2)
Posttest 2 (T3)
Mean ± SD
Mean ± SD
Mean ± SD
Career Search Self-Efficacy
Exp. Con.
6.72 ± 2.17 6.46 ± 1.80
7.64 ± 1.53 7.12 ± 0.91
8.96 ± 3.66 8.06 ± 2.06
Career Maturity
Exp. Con.
189.62 ± 12.45 190.10 ± 19.01
201.31 ± 22.11 197.31 ± 51.82
241.73 ± 11.87 222.73 ± 91.12
Career Adaptability
Exp. Con.
3.12 ± 0.87 3.29 ± 1.99
3.45 ± 1.45 3.89 ± 1.34
4.87 ± 3.21 4.47 ± 0.45
Satisfaction with Nursing
Exp. Con.
7.12 ± 0.78 7.32 ± 1.70
7.79 ± 1.11 7.89 ± 0.24
8.12 ± 0.44 8.04 ± 1.09
Group Time Group Group Time Group Group Time Group Group Time Group
∗ time
∗ time
∗ time
∗ time
F
p
9.68 12.71 0.12 21.29 132.15 1.89 7.99 23.88 4.60 12.53 2.25 7.46
0.028 0.002 0.411 < 0.001 < 0.001 0.290 0.033 < 0.001 < 0.001 0.059 0.038 0.041
graduate four years late.” (Group 3P1) 2. Have a positive mindset about nursing The participants stated that they had a positive mindset about nursing, although they had had a slightly negative attitude in the past, and that they had an increased understanding of nursing after self-reflection focused career course. The participants also stated that they had known of nurses' main competencies. Knowing many areas of nursing As the participants were first year student, they did not know what kinds of jobs exist in the nursing field, and what nurses do. They stated that it was good for them to learn about the various fields and tasks of nursing through their seniors. “Through interviews with seniors in various fields, I noticed that the nurses could advance in various areas such as becoming health teachers, having IT-related jobs, and working in healthcare organizations, and I learned that I can take many paths instead of being a nurse after graduation from nursing college. This seemed to be an opportunity to think about what way I would go ahead.” (Group 1P7) “I thought that nurses worked only in hospitals, and it was good to learn about the various paths of nursing that I did not think about before.” (Group 2P3) “I learned that nurses are well-treated because a nurse who had just entered the nursing practice told us about the starting salary and welfare... On television, there are only scenes showing that nurses do just what doctors order, exchange jokes with doctors, or rebuke patients, and I did not know that nurses work so much to take care of patients.” (Group 4P5) Understanding of nursing The participants thought that nursing was a difficult job, but they learned about the value of nursing and received support from their families and those around them through the self-reflection focused career course. Fig. 3. Change patterns of career search self-efficacy (a), career maturity (b), and career adaptability (c).
“At first I felt that the nursing job is very difficult and hard. After the course, I realized that nursing is really an important and necessary job to help people to live.” (Group 3P1) “My parents objected to me becoming a nurse because nursing is hard. As I talked to my parents every week about what I learned at the career 6
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(Group 4P6)
course, my parents changed their mind a lot. Now that my parents are no longer opposed, it is fine with me, too.” (Group 4P3)
Knowing that I am a good fit for nursing The participants had not had the opportunity to seriously think about their career as a nurse. Through the self-reflection focused career course, they got information about the nursing, and realized that they fit well with nursing.
Thinking about the competencies of nurses The participants stated that nurses' core competencies were not only accurate nursing knowledge and skills, but also communication between medical staff/patients, collaboration, professionalism, healthy bodies, health management, time management and humanism.
“It's true that I entered the nursing department because I wanted to be a nurse, but it was really good because it was a course that made me think a lot about whether the career of nurse would really fit my aptitudes and I would do well in the future.” (Group 2P7)
“In interviews with seniors, many seniors emphasized the importance of human relationships. Nurses not only have to communicate with other nurses, but also face many situations where they have to communicate with doctors, patients, and caregivers. Therefore, I think that nurses need the ability to communicate and empathize with others.” (Group 2P6)
“I was able to see how fit I am for nursing when I was taking a Holland test, and it was a precious time to feel that through various activities I have to adjust to something that does not fit me well.” (Group 3P5)
“I think that nurses' physical strength is a very important factor because their body rhythms are broken during shifts, they have leg edema if they keep standing, they do not have enough time to drink water, and operating room nurses have to stand throughout the operation. And, if nurses lose concentration due to a lack of physical strength, they may cause many mistakes, which can be a threat to the health and life of patients.” (Group 4P2)
4. Prepare to become a professional nurse The participants realized that they needed to live more consistently in their current school lives and they planned their life as professional nurses after graduation.
3. Recognized that I was connected to nursing
Planning school life
The participants stated they came to know that they were a good fit for nursing and they gained confidence.
The participants were able to learn that grade management, health care, and a variety of experiences were important in their current studies.
Having a sense of belonging to the nursing college
“I knew vaguely that I should manage my credits well to join the hospital that I wanted to. After hearing stories from the senior today, I think I thought it was too easy. I need to manage my credits better.” (Group 2P1)
As the participants were first year students, and they usually took liberal arts classes, they had not had a chance to learn about colleagues, facilities, missions, and the faculty of nursing colleges. They stated that they felt like a member of a nursing college through the self-reflection focused career course.
“During an interview, a senior said that nurses should have a variety of experiences because they meet various patients. So, before graduation, I would like to be active in club activities and social volunteering activities and meet a lot of people from other fields to build up diverse experiences.” (Group 2P5)
“I came to the nursing department according to my grades. I felt alienated because my fellow students seemed to want to enter the nursing department. However, I felt a great sense of kinship with my seniors who are concerned about the same thing.” (Group 3P5)
Life planning after graduation
“It was difficult to meet nursing professors because I take only liberal arts classes.... [omitted].... I learned that the history of our Nursing Science College goes back about 50 years and I knew nursing professors and the facilities and the location of the Nursing Science College. So now, I think I am a real nursing student.” (Group 4P7)
The participants began to dream about the various career options in the nursing field through the career information and self-awareness that they learned in class. “I will have clinical experience for at least three years after graduation, as the senior said. After that, I would like to go to a country that needs my help and do international volunteer work.” (Group 3P3)
Increased ties to colleagues through the class activities
“I would like to be the first male nurse to be the head of the nursing department at K Medical Center. To do so, I will need to be good at physical and stress management so that I can work for a long time in clinical practice.” (Group 4P6)
The participants were first year students and did not yet know who their friends were. However, they stated that it is good to discuss about nursing with friends and to get acquainted with them on their teamprojects. “I hope we have more discussion time because this kind of discussion time that we had today enabled us to cultivate a sense of closeness with colleagues by sharing opinions, and advising, and discussing with each other.” (Group 1P2)
Discussion The present study was a mixed methods study designed to analyze the effects of a self-reflection focused career course developed for first year nursing students using a combination of experimental quantitative design research and a focus group interview for qualitative analysis. Therefore, the discussion describes both the quantitative and
“It is good for me to have opportunities to get acquainted with others while doing group work with friends at the same nursing department when everything is unfamiliar for the first time.” 7
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qualitative findings based on the main variables. The results of the present study found that as the self-reflectionfocused career course progressed, nursing students' career search efficacy increased significantly, which is similar to the results of many previous studies (Fouad et al., 2009; McDow & Zabrucky, 2015; Park, 2012; Park, 2015; Walker, 2016). In a study by Park (2015) in which a career course was implemented for fourth-year nursing students for 2 h per session over eight weeks, it was reported that upon the completion of the “discipline-based career course” for 16 h, the students' career search efficacy increased. In addition, a study by Walker (2016), in which the “A Bridge to Success” program was conducted for 59 undergraduate nursing students for a total of 22.5 h over three days, reported that upon the completion of the program, the students' self-efficacy increased and their stress decreased. Looking at career search efficacy sub-variables found in the results of the present study, job search, networking, and efficacy of personal exploration significantly increased, whereas interviewing efficacy did not. These results are similar to the results of a study by Park (2012) in which it was found that networking and personal exploration efficacy significantly increased, whereas interviewing efficacy and job search efficacy did not. The reason that interviewing efficacy did not significantly increase in the present study is thought to be because the career course was designed for first-year students and did not include content required for employment, such as writing a resume or conducting mock interviews; thus, interviewing efficacy was not significant. In addition, looking at the qualitative research results, the participants made statements “reflecting my past and present, and my strengths and weaknesses” and “understanding the environment surrounding me” and this suggests that they knew what resources they could use. These qualitative research results are related to career search efficacy, which is associated with exploring personal, occupational values and preferences, and networking, which is associated with identifying job opportunities and seeking help through networks as measured in the quantitative research; this shows that the qualitative research results also support the quantitative research results in the present study. The present study showed that as the career course progressed, the students' career maturity increased. These results are similar to the results of a study by Yilmaz et al. (2016) in which a career planning program was implemented for 105 nursing students for 8 h, and the results of a study by Lim et al. (2010) in which a cognitive behavioral therapy program was conducted for 40 fourth-year nursing students for 8 h over eight weeks. A study by Lim et al. (2010) also reported that after the completion of the program, the perception of nursing profession and career maturity increased in the experimental group compared to the control group. In the qualitative research of the present study, the participants stated that they have a sense of belonging to the nursing college and ties to nursing colleagues, indications that are related to “concern” over career maturity. Concern means the extent to which an individual is oriented to involvement in the process of making career decisions (Savickas & Porfeli, 2011). Moreover, participants stated that they thought about the competencies of nursing, suggesting a development which is related to the “curiosity” of career maturity. Curiosity refers to the extent to which an individual is exploring the world of work and seeking information about occupations and their requirements (Savickas & Porfeli, 2011). Students also stated that they feel they are a good fit for nursing, indicating a “confidence” of career maturity. Confidence means the extent to which an individual has faith in her or his ability to make wise career decisions and realistic occupational choices (Savickas & Porfeli, 2011). In the present study, the concern, curiosity, and confidence of career maturity were increased; these results showed that the quantitative and qualitative research results are in agreement. The results of the present study showed that as the career course progressed, the students' career adaptability increased. This finding is similar to the results of a study by Park (2012), which showed that career adaptability, career search self-efficacy, and career search
behavior increased in fourth-year nursing students who completed a career planning course. In terms of the sub-variables of career adaptability in the present study, the students' concern, curiosity, and confidence increased, but their career control did not. Career control enables individuals to become responsible for shaping themselves and their environments to meet what comes next by using self-discipline, effort, and persistence (Savickas & Porfeli, 2012). The reason why the control area was not found to be significant is because the contents of the career course designed did not contain methods for controlling individuals. In the qualitative research results, the participants stated that they will plan their school life, and future after graduation, suggesting that these are related to career adaptability. In particular, male students said that they were suffering from social prejudice, but they had confidence. These results are in keeping with the increase in confidence among the career adaptability. In addition, the degree of satisfaction with nursing increased in both the experimental and control groups as the career course progressed. In qualitative research, the students stated that improvements to the career course were extended in class time, through the addition of role play, and peer-to-peer interaction. These quantitative and qualitative findings suggested that a career course involving self-reflection was effective in career exploration and first year student development in nursing education. In this study, career search self-efficacy and career maturity were significantly different between groups and between times, but there was no significant difference in the interaction between group and time. On the other hand, career adaptability was significantly different between groups, between times, and in the interaction between group and time. This finding means that the self-reflection career course was more effective on career adaptability than the general career course. Career adaptability is a psychosocial construct that denotes an individual's resources for coping with tasks, transitions, and traumas in their occupational roles, and altering their social integration; these psychosocial constructs can only be developed through self-awareness, such as self-reflection (Savickas, 1997; Savickas & Porfeli, 2012). Therefore, the 15-week self-reflection focused career course may have a significant impact on the career adaptability of nursing students. Limitations and ideas for future research Despite the study's strength, there are several limitations to the present study. The sample size was relatively small, thus it is difficult to generalize the results. Convenience sampling was used, so there may a selection bias and potential threats to the validity of the study. There are two classes of first-year students in our nursing college. In order to minimize the risk to internal validity, we assigned both the classes on the same day. In addition, it was confirmed that there was no difference between the two groups by verifying the homogeneity of various variables before the career course began. The measurements in this study are designed for the career development of college students in general, not nursing students, so there may be limitations in measuring the unique characteristics of nursing students. Therefore, further research is needed to develop career development tools that can specifically reflect the characteristics of nursing students. In this study, the focus group interview was conducted only in the experimental group, so no qualitative comparison between the two groups was possible. Therefore, in future studies, it is necessary to compare both experimental and control groups in qualitative research. We recommend that it is necessary to identify the effects of the self-reflection focused career course over a long period of time, for example during college, in various cultures with larger sample sizes, and to compare the attrition rates of nursing student. Conclusion The present study aimed to investigate the effects of a self-reflection-focused career course designed for first year nursing students using 8
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a mixed methods design that included a quasi-experimental pre-post intervention study and a focus group interview. In conclusion, as the career course progressed, the career search efficacy, career maturity, and career adaptability increased in both the experimental group and the control group; however, the self-reflection focused career course was more effective on career adaptability than the general career course. The qualitative findings supported the quantitative results and also provided new information, in which students became acquainted with themselves through self-reflection-focused career courses, had a positive attitude toward nursing, realized that they are well-connected to nursing care, and consistently prepared the nurse for the future.
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Effects of a university career development course on career decision-making self-efficacy. Journal of Career Assessment, 14(2), 252–266. https:// doi.org/10.1177/1069072705274985. Ryan, N. (1999). Career counseling and career choice goal attainment: A meta-analytically derived model for career counseling practice. Chicago, IL: Loyola University of Chicago1–348. Savickas, M. L. (1997). Adaptability: An integrative construct for life-span, life-space theory. Career Development Quarterly, 45, 247–259. Savickas, M. L. (2005). The theory and practice pf career construction. In S. D. Brown, & R. W. Lent (Eds.). Career development and counseling: Putting theory and research to work (pp. 42–70). Hoboken, NJ: John Wiley & Sons. Savickas, M. L., & Hartung, P. I. (1996). The career development inventory in review: Psychometric and research findings. Journal of Career Assessment, 4, 171–188. Savickas, M. L., & Porfeli, E. (2011). Revision of the career maturity inventory: The adaptability form. 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Solberg, V., Good, G., Nord, D., Holm, C., Hohner, R., Zima, N., ... Heffeman, M. (1994). Assessing career search self-efficacy expectation: Development of the career search efficacy scale. Journal of Career Assessment, 2(2), 111–123. Super, D. E. (1969). Vocational development theory: Persons, positions, and processes. The Counseling Psychologist, 1(1), 2–9. Walker, L. (2016). A bridge to success: A nursing student success strategies improvement course. Journal of Nursing Education, 55(8), 450–453. https://doi.org/10.3928/ 01484834-20160715-05. Whiston, S., Sexton, T., & Lasoff, D. (1988). Career intervention outcome: A replication and extension of Oliver and Spokane. Journal of Counseling Psychology, 45, 150–165. https://doi.org/10.1037/0022-0167.45.2.150. Yilmaz, A., Ilce, A., Cicek, S., Yuzden, G., & Yigit, U. (2016). The effect of a career activity on the student’s perception of the nursing profession and their career plan: A singlegroup experimental study. 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Recommendations for nursing education The present study suggests that the self-reflection focused career course was effective as an education tool in career development for nursing students. In addition, previous research has reported that the self-reflective process can lead to higher nursing competency, positive learning attitude, enhancement of critical thinking in nursing education, as well as improvement of nursing quality for patients' safety (Bagay, 2011; Harris, 2005; Pai, 2015; Pai et al., 2017; Schaub-de Jong, Schonrock-Adema, Dekker, Verkerk, & Cohen-Schotanus, 2011). Thus, nursing educators need to strengthen self-reflection in all nursing education. Funding sources This work was supported by a grant from Kyung Hee University in 2017 [grant numbers 7KHU-20171278]. Declaration of competing interest The authors declare that there are no conflicts of interest. References American Psychological Association (1995). Awards for distinguished professional contributions: John L. Holland, J. L. American Psychologist, 50, 236–238. Back, K. W., & Bourque, L. B. (1970). Life graphs: Aging and cohort effect. Journal of Gerontology, 25(3), 249–255. https://doi.org/10.1093/geronj/25.3.249. Bagay, J. M. (2012). Self-reflection in nursing. Journal of Professional Nursing, 28(2), 130–131. Beercroft, P. C., Dorey, F., & Wenten, M. (2008). Turnover intension in new graduate nurses: A multivariate analysis. Journal of Advanced Nursing, 62(1), 41–52. https:// doi.org/10.1111/j.1365-2648.2007.04570.x. Buchan, J., Charlesworth, A., Gershlick, B., & Seccombe, L. (2019). A critical moment: NHS staffing trends, retention and attrition. Available from The Health Foundationwww.health.org.uk/sites/default/files/upload/publications/2019/A% 20Critical%20Moment_1.pdf. Buchan, J., & Seccombe, I. (2011). A decisive decade: The UK nursing labour market review 2011. Royal College of Nursing. Campbell, D. P., & Holland, J. L. (1972). A merger in vocation interest research: Applying Holland’s theory to Strong’s data. Journal of Vocational Behavior, 2, 353–376. Choi, O. H., & Kim, B. W. (2007). The influence of attachment relationship and style and career search self-efficacy on career development of college students. Korean Journal of Counseling, 8(3), 1063–1084. Creswell, J. W., & Clak, V. L. P. (2018). Designing and conducting mixed methods research (3th ed.). Thousand Oaks, CA: SAGE Publications51–99. Crites, J. O. (1965). Measurement of vocational maturity in adolescence. Psychological Monographs, 79 (Whole No. 595). Doggrell, S. A., & Schaffer, S. (2016). Attrition and success rates of accelerated students in nursing courses: A systematic review. BMC Nursing, 15(1), 24. Elo, S., & Kyngas, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. https://doi.org/10.1111/j.1365-2648.2007.04569.x. Fouad, N., Cotter, E., & Kantamneni, N. (2009). The effectiveness of a career decisionmaking course. Journal of Career Assessment, 17(3), 338–347. https://doi.org/10. 1177/1069072708330678. Gaynor, L., Gaynor, L., Gallasch, T., Yorkston, E., Stewart, S., Bogossian, F., ... Turner, C. (2008). The future nursing workforce in Australia: Baseline data for a prospective study of the profile, attrition rates and graduate outcomes in a contemporary cohort of undergraduates (accessed 04.12.15), Retrieved from http://www.ajan.com.au/ Vol25/AJAN_25_2pdf.
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Contents lists available at ScienceDirect
Journal of Professional Nursing journal homepage: www.elsevier.com/locate/jpnu
Effects of self-reflection-focused career course on career search efficacy, career maturity, and career adaptability in nursing students: A mixed methods study Ju Hee Kim, Hye Sook Shin
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College of Nursing Science, Kyung Hee University, 26, Kyunghee-daero, Dongdaemun-gu, Seoul 02447, Republic of Korea
A R T I C LE I N FO
A B S T R A C T
Keywords: Career adaptability Career search efficacy Career maturity Mixed research design Self-reflection
Background: Career education in nursing can affect career search efficacy, career preparation behavior, career maturity, perception of the nursing profession, and decision-making style. Reflection is essential for an in-depth approach to learning, and plays an important role in professional practice as well as in improving learning. Purpose: The aim is to investigate the effects of a self-reflection-focused career course, and what could improve a self-reflection-focused career course. Methods: An explanatory sequential mixed methods design was used. The career search efficacy, career maturity, and career adaptability were measured three times in both the experimental and the control group. After the class ended, a focus group interview was conducted with the students in the experimental group. Results: The quantitative results suggested that the self-reflection focused career course was more effective on career adaptability than the general career course (F = 4.60, p < .001). The qualitative findings supported the quantitative results and also provided new information, in which nursing students became acquainted with themselves through the self-reflection-focused career course, developed a positive mind about nursing, had realized that they were well-connected to nursing care, and that they would prepare the future nurse. Conclusion: The self-reflection-focused career course was effective tools in the career development of nursing students.
Introduction
Schaffer, 2016; Park, 2015; Yilmaz, Ilce, Cicek, Yuzden, & Yigit, 2016).
The undergraduate period is an important phase that explores and shapes one's career, and that serves as a transition from school to the world of work (Super, 1969). Despite its importance, attrition rates in nursing education are around 9–28% worldwide (Buchan, Charlesworth, Gershlick, & Seccombe, 2019; Buchan & Seccombe, 2011; Gaynor et al., 2008; Kukkonen, Suhonen, & Salminen, 2016; National Solution, 2019). Incorrect career selection owing to lack of information about nursing science and difficulties in clinical practice were students' most commonly reported reasons for leaving nursing education (Glossop, 2002; Kukkonen et al., 2016). Even when students have graduated from a nursing college, their negative experiences affect their lives as nurses, and their satisfaction with their job is reduced, and eventually becomes a factor in turnover (Beercroft, Dorey, & Wenten, 2008). To prevent this discontinuation of education and help in the adaptation of nursing students, nursing colleges have run a variety of programs, such as career courses and accelerated programs (Doggrell &
Background and literature review
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Career education is intended to convey career information and assist in career planning for students (Park, 2015). Previous research on career education has proven effective in developing students' career search, career adaptation, and career development (Fouad, Cotter, & Kantamneni, 2009; Lee, Lee, & Yoon, 2015; McDow & Zabrucky, 2015; Reese & Miller, 2006; Ryan, 1999; Scott & Ciani, 2008; Whiston, Sexton, & Lasoff, 1988). In the nursing field, career education is established under the auspices of discipline-based career courses (Park, 2015), career activity (Yilmaz et al., 2016), success strategies improvement courses (Walker, 2016), and career planning (Park, 2012). These educations are implemented in the form of a program or class lasting 8–39 h (Fouad et al., 2009; Lee et al., 2015; Lim et al., 2010; McDow & Zabrucky, 2015; Park, 2012; Park, 2015; Reese & Miller, 2006; Scott & Ciani, 2008; Walker, 2016; Yilmaz et al., 2016). The
Corresponding author. E-mail addresses: [email protected] (J.H. Kim), [email protected] (H.S. Shin).
https://doi.org/10.1016/j.profnurs.2020.03.003 Received 1 October 2019; Received in revised form 4 March 2020; Accepted 11 March 2020 8755-7223/ © 2020 Published by Elsevier Inc.
Please cite this article as: Ju Hee Kim and Hye Sook Shin, Journal of Professional Nursing, https://doi.org/10.1016/j.profnurs.2020.03.003
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of a self-reflection-focused career course on career search efficacy, career maturity, and career adaptability. The qualitative research used a focus group interview design to comprehensively understand the effects of a self-reflection-focused career course and to evaluate the course.
career education are targeted toward either the whole grade of nursing students or only to the fourth-year students, and the contents of career courses are mostly related to the delivery of information on nursing or employment preparation (Lim et al., 2010; Park, 2012; Park, 2015; Yilmaz et al., 2016). Nursing research on career education reported that a career education can affect career search efficacy, career preparation behavior, career maturity, career adaptability, perception of the nursing profession, and decision-making style (Lim et al., 2010; Park, 2012; Park, 2015; Yilmaz et al., 2016). Career search efficacy refers to the degree of the individual's confidence to perform important activities associated with career selection and search (Solberg et al., 1994). Career maturity means an individual's degree of career decision-making and readiness to make occupational choices (Savickas & Porfeli, 2011). Career adaptability means an individual's psychosocial readiness and resources for coping with vocational development tasks, occupational transitions and work trauma (Savickas, 1997). However, the purpose of a career education is not just to convey career information, but to prepare for the profession through self-reflection (Lee et al., 2015; Pai, 2015). Reflection is essential for an indepth approach to learning and plays an important role in professional practice as well as in improving learning (Moon, 1999). Nursing students can reflect on their clinical experience, behavior, decisions, and correction of errors by critical self-reflection (Mezirow, 1990; Pai, 2015; Schaefer & Zygmont, 2003). They are educated through continuous self-reflection training, and when they become nurses, they are able to understand the patient's needs and provide appropriate nursing care (Bagay, 2012; Pai, 2015; Pai, Ko, Eng, & Yen, 2017). Therefore, the contents of the career education should include career learning through self-reflection. Moreover, students have different career needs according to their grades, so career contents need to be structured differently (Maietta, 2013). For example, the program for students before graduation should include information on job readiness, while the program for first year nursing students should include content ranging from self-awareness to exploring career areas. Therefore, providing appropriate career education to first year nursing students may have positive effects on their academic performance over the next four years and may reduce attrition rates (Kukkonen et al., 2016; Lee et al., 2015). And, most studies relate to career education are based on a quantitative research design, so they can only provide limited results measured by instruments, not the in-depth information in afforded by qualitative research; the career education effect measurement is also measured only once before and after the career program, so it is difficult to identify the change pattern of the effects. Meanwhile, mixed methods research is a type of research that combines elements of quantitative and qualitative research approaches (e.g., use of viewpoint, data collection, analysis, inference techniques), so it can provide a breadth and depth of understanding and corroboration of the effects of the career course (Creswell & Clak, 2018).
Participants The present study recruited first year nursing students in nursing college at K university in Korea using convenience sampling. The specific inclusion criteria included students who were taking the career course offered to first year nursing students at K University, whereas the exclusion criteria included those who were not first year nursing students, or those who had previously participated in nursing-related career courses and workshops. Quantitative phase The career course for first year nursing students was divided into two classes that consisted of 40–50 students each. One class was assigned to the experimental group, and the other class was assigned to the control group. In order to recruit subjects, the researcher explained the purpose of the study to the students in the first class, and noted that there was no penalty for not participating in the study. In 2018, the number of nursing students enrolled in the career course was a total of 94 students, and of them, four students were excluded due to non-first year students and experience of nursing career program. A total of 90 subjects were finally selected for the present study with 46 in the experimental group, and 44 in the control group The required total sample size of the experimental research was calculated to be 66 subjects on the assumption of a significance level of 0.05, a power of 0.95, an effect size of 0.2, two groups, three measurement points, a correlation between the points of 0.5, and repeated ANOVA measurements using the G-power 3.1.3 program. Given these conditions, the sample size in this study is sufficient to measure the effects of the self-reflection career course. Qualitative phase The number of samples required for the focus group interview in the present study was determined according to the guide suggested by Krueger and Casey (2015), which states that five–eight individuals per group are appropriate for focus group interviews. In the present study, four focus groups (total 24 students) were conducted, and each group consisted of five–seven students. Ethical consideration The present study was approved by the institutional review board at K University, to which the authors and subjects belong (KHUIRB-17008). After obtaining the approval of the head of department and the dean of the College of Nursing Science, the researchers explained the purpose of the study and the data collection process to students in class, who were assured of guaranteed anonymity and confidentiality.
Aims The present study aimed to investigate the effects of a self-reflection-focused career course developed for first year nursing students on career search self-efficacy, career maturity, and career adaptability, and what could improve a career course through using explanatory sequential mixed methods.
Data collection Development of self-reflection focused career course The career course used in the present study was developed in 2015, and has been offered since 2016 at K university to help first year nursing students' adaptation and assist them to establish their nursing careers. The course development team reviewed the national career development guidelines, Holland's theory, career construction theory, social cognitive career theory, various career education theories, and career-related courses and programs conducted in other fields (Campbell & Holland, 1972; Crites, 1965; National Career Development Association, 2007; Savickas, 2005; Savickas & Hartung, 1996). The contents of the constructed course were reviewed by the Curriculum Committee at the Nursing Science College. In addition, in order to
Methods Design An explanatory sequential mixed methods design (QUAN → qual) was used (Creswell & Clak, 2018) to explore the effects of the self-reflection-focused career course among first year nursing students who entered a nursing school (Fig. 1). The quantitative research used a quasi-experimental pre-post intervention design to identify the effects 2
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Fig. 1. Research flowchart in implementing an explanatory sequential mixed methods design.
Fig. 2. Contents of the self-reflection-focused career course.
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ability to engage in networking activities such as using a network to identify job opportunities. Personal exploration efficacy refers to the ability to explore personal and career values and preferences. Each item is rated on a 10-point scale (ranging from 0 to 9 points); a higher score indicates higher career search efficacy. The reliability of the CSES at the time of its development was Cronbach's alpha = 0.97, and its reliability in the present study was Cronbach's alpha = 0.98. Career maturity was measured using a revised Career Maturity Inventory (CMI), which was originally developed by Crites (1965) and later revised by Savickas and Porfeli (2011). The present study used CMI Form C, and this instrument provided a total score for career choice readiness of three scale scores reflecting adaptability dimensions of concern, curiosity, and confidences (18 items), and a single score reflecting relational style in forming occupational choices (six items). A higher score indicated higher career choice readiness and a more interdependent relational style. The reliability of this test at the time of its development was estimated using Cronbach's alpha = 0.86, and its reliability in the present study was Cronbach's alpha = 0.90. Career adaptability was measured using a Career Adapt-Abilities Inventory (CAI) (international version) developed by Savickas and Porfeli (2012). The CAI has four subscales: concern, control, curiosity, and confidence, and consists of six items for each subscale for a total 24 items. Each item is rated on a 5-point scale, and a higher score indicates higher career adaptation ability. The reliability of the CAI at the time of its development was Cronbach's alpha = 0.92, and its reliability in the present study was Cronbach's alpha = 0.94. CSES, CMI, and CAI were used after the back translation process. The translated tools were checked for content validity by three experts and the content validity index (CVI) values range from 0.92 to 0.99, which signifies that these scales have good content validity. The discriminant validity between variables was appropriate with all correlation coefficients.
reflect the students' opinions in the career courses, the contents of the constructed courses were informed by the feedback received from the nursing students in all grades. The class format used various forms of teaching such as special lectures, presentations after interviewing nursing seniors and facilities, and group discussions. The contents of the career course were as follows: the first part consisted of time to share information on the educational values, mission, scholarship system, and supporting facilities of the university, and to meet with colleagues. The second part consisted of career searching and planning processes. The third part consisted of exploring nursing through interviews with nurses working in various areas of nursing. The fourth part was designed to specifically plan for the nursing field of interest. The career course was conducted for 15 weeks, 1 h per week, and the course was evaluated as pass/fail. In the present study, an experimental intervention strengthened self-reflection training in the existing career course. In the selfreflection career course, the class was focused on discussing rather than unilaterally conveying information to the students. The self-reflection career course reinforced four parts: strengthen self-awareness, strengthen career-information search, strengthen the awareness about nursing, and strengthen with nursing (Fig. 2). For example, students reflect on oneself through taking a Holland's vocational aptitude inventory, painting a life graph, and describing one's strengths and weakness. Holland's vocational aptitude inventory, developed by psychologist John L. Holland, is one of the most popular measures used for assessing career aptitude. Holland's vocational personality theory suggests a career decision method through a hexagonal model called RIASEC (Realistic, Investigative, Artistic, Social, Enterprising, Conventional). Based on a characterization of personality, this test recommends what kind of work environments and occupations suit you best (APA, 1995). A life graph is a tool for self-reflection. Students recall their past, and graph important moments over time. Through the graph, students will know what kind of events occurred during their life, how they viewed them, and how they responded to important moments. At the same time, students will know what they think is important in life (Back & Bourque, 1970). Moreover, parts 3 and 4 were designed to reflect on how nursing can be linked to them, and to discuss the core competencies in nursing.
Qualitative phase: focus group interview Data collection for the focus group interview was undertaken with the experimental group of students July 2018 in a classroom after the completion of the career course. The researcher, who did not run this class, served as a moderator, and two assistant researchers, who did not participate in this study, assisted with the process of interviewing and recording field notes, including on-site requirements. Assistant researchers were present at the interview site and recorded field notes from the beginning to the end of the focus group interview. In the field notes, the name of the study, the date, time, location, and participants of the focus group interview, the names of the moderator, assistant moderators, seating arrangement, and information about the participants were recorded. All of the focus group participants' details were recorded as well as their opinions, quotes from conversations and intonation during the discussion that might be helpful to the analysis process. The desks were arranged in a circle so that the participants could look at each other and talk in a relaxed atmosphere. The interview took about 40–70 min. The focus group interview was recorded using an MP3 or windows media audio recording device, rather than cell phones, laptops, and PC recorders. Before the focus group interview, the researchers gathered, drafted, and reviewed questions based on previous studies on the career course. According to the guide on questioning described by Krueger and Casey (2015), opening questions should be easy for participants to answer quickly and should not be questions of discussion; introductory questions should introduce the topic of discussion and should help participants think briefly about the topic before participating in the discussion; transition questions should move the participants' conversation toward addressing key questions; key questions should be four–six questions on the discussion topic; and closing questions should consist of questions to conclude the discussion. Based on this guide, the present study constructed the following questions. Opening questions: Thank you for your time even though you may
Quantitative phase: experimental study The career course was conducted every Monday for 15 weeks from March 2018 to June 2018. For the data collection from the research, the baseline scores for career search efficacy, career maturity, and career adaptability in the subjects were measured during the first week of class, followed by the first posttest measurement at the eighth week and the second posttest measurement at the 15th week in both the experimental and control groups. The questionnaire instruments consisted of demographic questions, and questions on career search efficacy, career maturity, and career adaptability. We investigated the demographic characteristics of the subjects including gender, age, number of members in family, birth order, living with parents, and presence of health professionals in the family. The Career Search Efficacy was measure by a Career Search Efficacy Scale (CSES), in which developed by Solberg et al. (1994). Career Search Efficacy refers to the degree of confidence, which one has for performing a variety of career search tasks. The CSES was designed for college students, individuals entering the workforce for the first time or reentering it after breaks, and individuals changing jobs, and it has been validated in many populations (Choi and Kim, 2007; Park, 2015). The CSES consists of a total of 35 items with 14 items on job search efficacy, eight items on interviewing efficacy, eight items on networking efficacy, and five items on personal exploration efficacy. Job efficacy refers to the degree of confidence in job search such as identifying employers, dealing with job barriers, and finding information about potential employers. Interviewing efficacy assesses the ability of interviewing such as evaluating job requirements. Networking efficacy means the 4
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Quantitative phase results: effects of self-reflection-focused career course on career search efficacy, career maturity, and career adaptation ability
be busy after class. Each of you is going to introduce yourself. Introductory questions: What do you think of the term “career course?” Transition questions: Think of the first class of the career course. What was your first impression of the class? Key questions:
The present study conducted repeated measured ANOVA on how career search efficacy, career maturity, and career adaptation ability changed between experimental group and control group as the class progressed. The results are shown in Table 2 and Fig. 3. Career search efficacy, career maturity, career adaptability, and satisfaction of nursing increased in both the experimental and control groups as the career course progressed. There were significant differences in career search self-efficacy and career maturity only between groups, and between times. However, career adaptation ability showed significant differences between groups, between times, and in the interaction between groups and times.
- How did/didn't the career course help you in your career development? - Which project do you remember the most from your career course? - What do you think is the biggest advantage of this course? Ending questions: Do you have anything else to add regarding the career course? After the focus group interview was completed, the research team members gathered to debrief and discuss the issues recorded in the field notes, considerations, and points to be emphasized that the team members observed and listened to during the interview.
Qualitative phase findings: students' experience of the career course After the completion of the 15-week career course, a focus group interview was conducted with 24 students who agreed to participate. These participants consisted of 16 female nursing students (66.7%) with a mean score of satisfaction with nursing of 8.58 ± 1.43 points out of a maximum score of 10 points. The results of analyzing the focus group interview data revealed that a total of 89 meaningful statements were extracted, from which four themes and nine sub-themes were derived.
Data analysis The collected data were analyzed using SPSS/WIN 24.0. The homogeneity between experimental and control groups was analyzed using a t-test and χ2 test. The effects of the career course were measured at the first, eighth, and 15th weeks of the course and were analyzed using repeated measure ANOVA. After data collection from the focus group interview was completed, the qualitative research data were analyzed using interview transcripts and the field notes. Inductive and deductive content analysis was performed, taking into account the four main elements of focus group analysis (systematic, verifiable, sequential, and continuous) (Elo & Kyngas, 2008).
1. Getting to know myself (understanding myself through self-reflection) The participants stated that they could reflect on their past and present, and strengths and weaknesses using the life reflection graph and mind maps, and could thus understand themselves more specifically. “I used to think abstractly about who I am and what I plan for the future. Through the task of designing and writing my future, I was able to understand myself better. Also, I was able to establish my future plans more concretely…[omitted]…I could recall that entering the nursing department was not the end, but the beginning, and it was an opportunity for me to make a commitment to achieve the goals.” (Group 2P3)
Results Homogeneity of the experimental and control group The present study used the test for homogeneity for baseline measurement in the experimental and control groups. Results of the test for homogeneity of general characteristics and variables between experimental and control groups as shown in Table 1. There are no significant differences between the two groups in demographic characteristics, career self-search efficacy, career maturity, career adaptability, or satisfaction with nursing.
“It was helpful to write a reflective report on myself. I was able to look back at my life by creating a life reflection curve, and I learned about my strengths and weaknesses through a SWOT analysis. Through this, I was able to see what areas I needed to build up as my strengths and it was good to create my future plans. Thinking about what I would look like in the near future or one year later, I was able to establish my future plan in detail, and it was an opportunity to think about what it will be like when I
Table 1 Homogeneity of general characteristics and variables between experimental and control groups Characteristics
Age (year) Gender Number of members in family Birth order Living with parents Presence of health professional in the family Career search self-efficacy Career maturity Career adaptability Satisfaction with nursing
Categories
Female Male ≦4 >4 First ≥Second Yes No Yes No
Experimental group (n = 46) n (%)/mean ± SD
Control group (n = 44) n (%)/mean ± SD
19.32 ± 1.16 37 (80.4) 9 (19.6) 6 (13.0) 40 (87.0) 20 (43.5) 26 (56.5) 24 (52.2) 22 (47.8) 28 (60.9) 18 (39.1) 6.72 ± 2.17 189.62 ± 12.45 3.12 ± 0.87 7.12 ± 0.78
19.89 ± 1.69 36 (81.8) 8 (18.2) 8 (18.2) 36 (81.8) 18 (40.9) 26 (59.1) 24 (54.5) 20 (45.5) 27 (61.4) 17 (38.6) 6.46 ± 1.80 190.10 ± 19.01 3.29 ± 1.99 7.32 ± 1.70
5
t/χ2 test
p-Value
0.44 3.19
0.756 0.213
1.13
0.566
0.94
0.348
0.78
0.099
1.84
0.123
0.45 12.21 0.19 1.17
0.891 0.234 0.062 0.085
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Table 2 Changes of career search efficacy, career maturity, career adaptability, and satisfaction with nursing in experimental and control group Variables
Pretest (T1)
Posttest 1 (T2)
Posttest 2 (T3)
Mean ± SD
Mean ± SD
Mean ± SD
Career Search Self-Efficacy
Exp. Con.
6.72 ± 2.17 6.46 ± 1.80
7.64 ± 1.53 7.12 ± 0.91
8.96 ± 3.66 8.06 ± 2.06
Career Maturity
Exp. Con.
189.62 ± 12.45 190.10 ± 19.01
201.31 ± 22.11 197.31 ± 51.82
241.73 ± 11.87 222.73 ± 91.12
Career Adaptability
Exp. Con.
3.12 ± 0.87 3.29 ± 1.99
3.45 ± 1.45 3.89 ± 1.34
4.87 ± 3.21 4.47 ± 0.45
Satisfaction with Nursing
Exp. Con.
7.12 ± 0.78 7.32 ± 1.70
7.79 ± 1.11 7.89 ± 0.24
8.12 ± 0.44 8.04 ± 1.09
Group Time Group Group Time Group Group Time Group Group Time Group
∗ time
∗ time
∗ time
∗ time
F
p
9.68 12.71 0.12 21.29 132.15 1.89 7.99 23.88 4.60 12.53 2.25 7.46
0.028 0.002 0.411 < 0.001 < 0.001 0.290 0.033 < 0.001 < 0.001 0.059 0.038 0.041
graduate four years late.” (Group 3P1) 2. Have a positive mindset about nursing The participants stated that they had a positive mindset about nursing, although they had had a slightly negative attitude in the past, and that they had an increased understanding of nursing after self-reflection focused career course. The participants also stated that they had known of nurses' main competencies. Knowing many areas of nursing As the participants were first year student, they did not know what kinds of jobs exist in the nursing field, and what nurses do. They stated that it was good for them to learn about the various fields and tasks of nursing through their seniors. “Through interviews with seniors in various fields, I noticed that the nurses could advance in various areas such as becoming health teachers, having IT-related jobs, and working in healthcare organizations, and I learned that I can take many paths instead of being a nurse after graduation from nursing college. This seemed to be an opportunity to think about what way I would go ahead.” (Group 1P7) “I thought that nurses worked only in hospitals, and it was good to learn about the various paths of nursing that I did not think about before.” (Group 2P3) “I learned that nurses are well-treated because a nurse who had just entered the nursing practice told us about the starting salary and welfare... On television, there are only scenes showing that nurses do just what doctors order, exchange jokes with doctors, or rebuke patients, and I did not know that nurses work so much to take care of patients.” (Group 4P5) Understanding of nursing The participants thought that nursing was a difficult job, but they learned about the value of nursing and received support from their families and those around them through the self-reflection focused career course. Fig. 3. Change patterns of career search self-efficacy (a), career maturity (b), and career adaptability (c).
“At first I felt that the nursing job is very difficult and hard. After the course, I realized that nursing is really an important and necessary job to help people to live.” (Group 3P1) “My parents objected to me becoming a nurse because nursing is hard. As I talked to my parents every week about what I learned at the career 6
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(Group 4P6)
course, my parents changed their mind a lot. Now that my parents are no longer opposed, it is fine with me, too.” (Group 4P3)
Knowing that I am a good fit for nursing The participants had not had the opportunity to seriously think about their career as a nurse. Through the self-reflection focused career course, they got information about the nursing, and realized that they fit well with nursing.
Thinking about the competencies of nurses The participants stated that nurses' core competencies were not only accurate nursing knowledge and skills, but also communication between medical staff/patients, collaboration, professionalism, healthy bodies, health management, time management and humanism.
“It's true that I entered the nursing department because I wanted to be a nurse, but it was really good because it was a course that made me think a lot about whether the career of nurse would really fit my aptitudes and I would do well in the future.” (Group 2P7)
“In interviews with seniors, many seniors emphasized the importance of human relationships. Nurses not only have to communicate with other nurses, but also face many situations where they have to communicate with doctors, patients, and caregivers. Therefore, I think that nurses need the ability to communicate and empathize with others.” (Group 2P6)
“I was able to see how fit I am for nursing when I was taking a Holland test, and it was a precious time to feel that through various activities I have to adjust to something that does not fit me well.” (Group 3P5)
“I think that nurses' physical strength is a very important factor because their body rhythms are broken during shifts, they have leg edema if they keep standing, they do not have enough time to drink water, and operating room nurses have to stand throughout the operation. And, if nurses lose concentration due to a lack of physical strength, they may cause many mistakes, which can be a threat to the health and life of patients.” (Group 4P2)
4. Prepare to become a professional nurse The participants realized that they needed to live more consistently in their current school lives and they planned their life as professional nurses after graduation.
3. Recognized that I was connected to nursing
Planning school life
The participants stated they came to know that they were a good fit for nursing and they gained confidence.
The participants were able to learn that grade management, health care, and a variety of experiences were important in their current studies.
Having a sense of belonging to the nursing college
“I knew vaguely that I should manage my credits well to join the hospital that I wanted to. After hearing stories from the senior today, I think I thought it was too easy. I need to manage my credits better.” (Group 2P1)
As the participants were first year students, and they usually took liberal arts classes, they had not had a chance to learn about colleagues, facilities, missions, and the faculty of nursing colleges. They stated that they felt like a member of a nursing college through the self-reflection focused career course.
“During an interview, a senior said that nurses should have a variety of experiences because they meet various patients. So, before graduation, I would like to be active in club activities and social volunteering activities and meet a lot of people from other fields to build up diverse experiences.” (Group 2P5)
“I came to the nursing department according to my grades. I felt alienated because my fellow students seemed to want to enter the nursing department. However, I felt a great sense of kinship with my seniors who are concerned about the same thing.” (Group 3P5)
Life planning after graduation
“It was difficult to meet nursing professors because I take only liberal arts classes.... [omitted].... I learned that the history of our Nursing Science College goes back about 50 years and I knew nursing professors and the facilities and the location of the Nursing Science College. So now, I think I am a real nursing student.” (Group 4P7)
The participants began to dream about the various career options in the nursing field through the career information and self-awareness that they learned in class. “I will have clinical experience for at least three years after graduation, as the senior said. After that, I would like to go to a country that needs my help and do international volunteer work.” (Group 3P3)
Increased ties to colleagues through the class activities
“I would like to be the first male nurse to be the head of the nursing department at K Medical Center. To do so, I will need to be good at physical and stress management so that I can work for a long time in clinical practice.” (Group 4P6)
The participants were first year students and did not yet know who their friends were. However, they stated that it is good to discuss about nursing with friends and to get acquainted with them on their teamprojects. “I hope we have more discussion time because this kind of discussion time that we had today enabled us to cultivate a sense of closeness with colleagues by sharing opinions, and advising, and discussing with each other.” (Group 1P2)
Discussion The present study was a mixed methods study designed to analyze the effects of a self-reflection focused career course developed for first year nursing students using a combination of experimental quantitative design research and a focus group interview for qualitative analysis. Therefore, the discussion describes both the quantitative and
“It is good for me to have opportunities to get acquainted with others while doing group work with friends at the same nursing department when everything is unfamiliar for the first time.” 7
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qualitative findings based on the main variables. The results of the present study found that as the self-reflectionfocused career course progressed, nursing students' career search efficacy increased significantly, which is similar to the results of many previous studies (Fouad et al., 2009; McDow & Zabrucky, 2015; Park, 2012; Park, 2015; Walker, 2016). In a study by Park (2015) in which a career course was implemented for fourth-year nursing students for 2 h per session over eight weeks, it was reported that upon the completion of the “discipline-based career course” for 16 h, the students' career search efficacy increased. In addition, a study by Walker (2016), in which the “A Bridge to Success” program was conducted for 59 undergraduate nursing students for a total of 22.5 h over three days, reported that upon the completion of the program, the students' self-efficacy increased and their stress decreased. Looking at career search efficacy sub-variables found in the results of the present study, job search, networking, and efficacy of personal exploration significantly increased, whereas interviewing efficacy did not. These results are similar to the results of a study by Park (2012) in which it was found that networking and personal exploration efficacy significantly increased, whereas interviewing efficacy and job search efficacy did not. The reason that interviewing efficacy did not significantly increase in the present study is thought to be because the career course was designed for first-year students and did not include content required for employment, such as writing a resume or conducting mock interviews; thus, interviewing efficacy was not significant. In addition, looking at the qualitative research results, the participants made statements “reflecting my past and present, and my strengths and weaknesses” and “understanding the environment surrounding me” and this suggests that they knew what resources they could use. These qualitative research results are related to career search efficacy, which is associated with exploring personal, occupational values and preferences, and networking, which is associated with identifying job opportunities and seeking help through networks as measured in the quantitative research; this shows that the qualitative research results also support the quantitative research results in the present study. The present study showed that as the career course progressed, the students' career maturity increased. These results are similar to the results of a study by Yilmaz et al. (2016) in which a career planning program was implemented for 105 nursing students for 8 h, and the results of a study by Lim et al. (2010) in which a cognitive behavioral therapy program was conducted for 40 fourth-year nursing students for 8 h over eight weeks. A study by Lim et al. (2010) also reported that after the completion of the program, the perception of nursing profession and career maturity increased in the experimental group compared to the control group. In the qualitative research of the present study, the participants stated that they have a sense of belonging to the nursing college and ties to nursing colleagues, indications that are related to “concern” over career maturity. Concern means the extent to which an individual is oriented to involvement in the process of making career decisions (Savickas & Porfeli, 2011). Moreover, participants stated that they thought about the competencies of nursing, suggesting a development which is related to the “curiosity” of career maturity. Curiosity refers to the extent to which an individual is exploring the world of work and seeking information about occupations and their requirements (Savickas & Porfeli, 2011). Students also stated that they feel they are a good fit for nursing, indicating a “confidence” of career maturity. Confidence means the extent to which an individual has faith in her or his ability to make wise career decisions and realistic occupational choices (Savickas & Porfeli, 2011). In the present study, the concern, curiosity, and confidence of career maturity were increased; these results showed that the quantitative and qualitative research results are in agreement. The results of the present study showed that as the career course progressed, the students' career adaptability increased. This finding is similar to the results of a study by Park (2012), which showed that career adaptability, career search self-efficacy, and career search
behavior increased in fourth-year nursing students who completed a career planning course. In terms of the sub-variables of career adaptability in the present study, the students' concern, curiosity, and confidence increased, but their career control did not. Career control enables individuals to become responsible for shaping themselves and their environments to meet what comes next by using self-discipline, effort, and persistence (Savickas & Porfeli, 2012). The reason why the control area was not found to be significant is because the contents of the career course designed did not contain methods for controlling individuals. In the qualitative research results, the participants stated that they will plan their school life, and future after graduation, suggesting that these are related to career adaptability. In particular, male students said that they were suffering from social prejudice, but they had confidence. These results are in keeping with the increase in confidence among the career adaptability. In addition, the degree of satisfaction with nursing increased in both the experimental and control groups as the career course progressed. In qualitative research, the students stated that improvements to the career course were extended in class time, through the addition of role play, and peer-to-peer interaction. These quantitative and qualitative findings suggested that a career course involving self-reflection was effective in career exploration and first year student development in nursing education. In this study, career search self-efficacy and career maturity were significantly different between groups and between times, but there was no significant difference in the interaction between group and time. On the other hand, career adaptability was significantly different between groups, between times, and in the interaction between group and time. This finding means that the self-reflection career course was more effective on career adaptability than the general career course. Career adaptability is a psychosocial construct that denotes an individual's resources for coping with tasks, transitions, and traumas in their occupational roles, and altering their social integration; these psychosocial constructs can only be developed through self-awareness, such as self-reflection (Savickas, 1997; Savickas & Porfeli, 2012). Therefore, the 15-week self-reflection focused career course may have a significant impact on the career adaptability of nursing students. Limitations and ideas for future research Despite the study's strength, there are several limitations to the present study. The sample size was relatively small, thus it is difficult to generalize the results. Convenience sampling was used, so there may a selection bias and potential threats to the validity of the study. There are two classes of first-year students in our nursing college. In order to minimize the risk to internal validity, we assigned both the classes on the same day. In addition, it was confirmed that there was no difference between the two groups by verifying the homogeneity of various variables before the career course began. The measurements in this study are designed for the career development of college students in general, not nursing students, so there may be limitations in measuring the unique characteristics of nursing students. Therefore, further research is needed to develop career development tools that can specifically reflect the characteristics of nursing students. In this study, the focus group interview was conducted only in the experimental group, so no qualitative comparison between the two groups was possible. Therefore, in future studies, it is necessary to compare both experimental and control groups in qualitative research. We recommend that it is necessary to identify the effects of the self-reflection focused career course over a long period of time, for example during college, in various cultures with larger sample sizes, and to compare the attrition rates of nursing student. Conclusion The present study aimed to investigate the effects of a self-reflection-focused career course designed for first year nursing students using 8
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a mixed methods design that included a quasi-experimental pre-post intervention study and a focus group interview. In conclusion, as the career course progressed, the career search efficacy, career maturity, and career adaptability increased in both the experimental group and the control group; however, the self-reflection focused career course was more effective on career adaptability than the general career course. The qualitative findings supported the quantitative results and also provided new information, in which students became acquainted with themselves through self-reflection-focused career courses, had a positive attitude toward nursing, realized that they are well-connected to nursing care, and consistently prepared the nurse for the future.
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Recommendations for nursing education The present study suggests that the self-reflection focused career course was effective as an education tool in career development for nursing students. In addition, previous research has reported that the self-reflective process can lead to higher nursing competency, positive learning attitude, enhancement of critical thinking in nursing education, as well as improvement of nursing quality for patients' safety (Bagay, 2011; Harris, 2005; Pai, 2015; Pai et al., 2017; Schaub-de Jong, Schonrock-Adema, Dekker, Verkerk, & Cohen-Schotanus, 2011). Thus, nursing educators need to strengthen self-reflection in all nursing education. Funding sources This work was supported by a grant from Kyung Hee University in 2017 [grant numbers 7KHU-20171278]. Declaration of competing interest The authors declare that there are no conflicts of interest. References American Psychological Association (1995). Awards for distinguished professional contributions: John L. Holland, J. L. American Psychologist, 50, 236–238. Back, K. W., & Bourque, L. B. (1970). Life graphs: Aging and cohort effect. Journal of Gerontology, 25(3), 249–255. https://doi.org/10.1093/geronj/25.3.249. Bagay, J. M. (2012). Self-reflection in nursing. Journal of Professional Nursing, 28(2), 130–131. Beercroft, P. C., Dorey, F., & Wenten, M. (2008). Turnover intension in new graduate nurses: A multivariate analysis. Journal of Advanced Nursing, 62(1), 41–52. https:// doi.org/10.1111/j.1365-2648.2007.04570.x. Buchan, J., Charlesworth, A., Gershlick, B., & Seccombe, L. (2019). A critical moment: NHS staffing trends, retention and attrition. Available from The Health Foundationwww.health.org.uk/sites/default/files/upload/publications/2019/A% 20Critical%20Moment_1.pdf. Buchan, J., & Seccombe, I. (2011). A decisive decade: The UK nursing labour market review 2011. Royal College of Nursing. Campbell, D. P., & Holland, J. L. (1972). A merger in vocation interest research: Applying Holland’s theory to Strong’s data. Journal of Vocational Behavior, 2, 353–376. Choi, O. H., & Kim, B. W. (2007). The influence of attachment relationship and style and career search self-efficacy on career development of college students. Korean Journal of Counseling, 8(3), 1063–1084. Creswell, J. W., & Clak, V. L. P. (2018). Designing and conducting mixed methods research (3th ed.). Thousand Oaks, CA: SAGE Publications51–99. Crites, J. O. (1965). Measurement of vocational maturity in adolescence. Psychological Monographs, 79 (Whole No. 595). Doggrell, S. A., & Schaffer, S. (2016). Attrition and success rates of accelerated students in nursing courses: A systematic review. BMC Nursing, 15(1), 24. Elo, S., & Kyngas, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. https://doi.org/10.1111/j.1365-2648.2007.04569.x. Fouad, N., Cotter, E., & Kantamneni, N. (2009). The effectiveness of a career decisionmaking course. Journal of Career Assessment, 17(3), 338–347. https://doi.org/10. 1177/1069072708330678. Gaynor, L., Gaynor, L., Gallasch, T., Yorkston, E., Stewart, S., Bogossian, F., ... Turner, C. (2008). The future nursing workforce in Australia: Baseline data for a prospective study of the profile, attrition rates and graduate outcomes in a contemporary cohort of undergraduates (accessed 04.12.15), Retrieved from http://www.ajan.com.au/ Vol25/AJAN_25_2pdf.
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