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Vol.8, No.1 April 2002
Contents

The Influence of Education on the Career Preferences
of Undergraduate Nursing Students

Author

Associate Professor Brenda Happell
RN., B.A. (Hons), Dip Ed., Ph.D.
Director
Centre for Psychiatric Nursing Research and Practice
School of Postgraduate Nursing
University of Melbourne
Level 1, 723 Swanston Street
Carlton VIC 3010 Australia
Phone (03) 8344 0769 | Fax (03) 9347 4172
Email: b.happell@nursin g.unimelb.edu.au

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Abstract

The introduction of comprehensive nursing education programs reflected the intention to prepare graduates for practice at beginning level in all nursing settings. Research from both Australia and oversees suggests that students entering nursing programs already hold strong views about the desirability or otherwise of nursing specialty areas. The limited available research suggests that these views do not alter significantly as a consequence of undergraduate nursing education. The current study discusses the results of a longitudinal study investigating the career preferences of undergraduate nursing students and the extent to which they are influenced by the education program. Statistically significant changes were evident between the two phases of the study, however the highly technical specialties and the working with children and babies remain the most popular choices. Psychiatric nursing, aged care and community health continued to be the least popular choices. These findings suggest that undergraduate nursing education requires a radical review in order to project a more egalitarian view of nursing specialties.

KEY WORDS: Attitudes, Career Preferences, Comprehensive Nursing Education, Nursing Students, Nursing Practice Undergraduate

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Introduction

The transfer of nursing education from hospitals to the higher education was completed almost a decade ago. Perhaps now is the appropriate time to reflect on the changes that have occurred and the extent to which the vision has been realised. Amongst other goals, the transfer was intended to herald a greater unification of the nursing profession. Education programs leading to initial registration as a nurse were to be comprehensive in nature. Specialist undergraduate nursing programs in areas including psychiatry, intellectual disability and geriatric nursing were discontinued.

The new programs were intended to prepare " registered nurses for generalist practice with beginning level of competence in primary, secondary and tertiary health care in all settings were nursing care is required (Royal College of Australia et al, Appendix 2.3, p.3). This would suggest that a marked change in the existing general nursing programs would be required, not only to promote the clinical thinking and problem solving capacity of future registered nurses, but to extend the perimeters of nursing practice beyond the walls of the acute medical-surgical hospital.

With so much importance placed on the comprehensive nature of nursing education, the absence of widespread critical review of this aspect of nursing education has been a notable omission. While the extent to which Australian courses are truly comprehensive has been questioned, such claims have tended to be made on behalf of the less popular nursing specialities such as psychiatric nursing (Farrell & Carr 1996, Happell, 1997, Stevens & Dulhunty 1992, 1997) and geriatric nursing (Stevens & Crouch, 1995, 1998). These authors have reviewed undergraduate curricula to demonstrate the underrepresentation of their particular specialty within courses which continue to be medical-surgical dominated.

Research results might have alerted the pioneers of comprehensive education to the strong likelihood that the bias towards acute medical-surgical nursing would persist following the relocation of nursing education in the higher education sector. The United States experience suggests that students and registered nurses strongly favour medical-surgical nursing as the field to pursue their nursing career. (Arnswald 1987; Campbell 1971; Caroselli-Karinja et al 1988; Carter 1986; Delora & Moses 1969; Fielding 1986; Gunter 1971; Knowles & Faan 1985; Peplau 1989; Philipase, Tate & Jacobs 1991; Reif & Estes 1982; ; Stickney 1985; Wright 1988; Zukerberg 1991). Psychiatric nursing and aged care in particular were identified as unpopular areas for career focus.

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Stevens and Dulhunty (1992; 1997) and Stevens and Crouch (1995; 1998) undertook the pioneering Australian work in the area of career preferences. The findings of their research supported the popularity of medical-surgical and the highly technical areas of nursing. Working with children was another area where students indicated a desire to pursue their nursing career. Aged care, psychiatric/mental health nursing and community health nursing were again found to be unpopular areas (Stevens & Dulhunty 1992;1994).

The advantage of the Stevens and Dulhunty (1992; 1994) and Stevens and Crouch (1995; 1998) research is that it enabled a comparison of the career choices of students between the commencement and the completion of their educational program. In doing so it provided the opportunity to comprehend the impact of education on the manner in which new nursing graduates view the desirability of various areas of specialty practice. It was evident that student nurses favored the highly technical areas of nursing and working with children. These findings were supported by a similar study conducted in Victoria (Happell 1999).

The capacity of nursing education to influence these preconceived ideas and produce more positive attitudes to the areas of nursing practice which tend to be less popular has been more thoroughly researched. Again this work has commonly been conducted in the areas of psychiatric nursing and aged care. Exposure to the theory and practice of psychiatric nursing was found to produce more positive attitudes towards the care of the mentally ill (Bairan & Farnsworth 1989; Collister 1983; Hafner & Proctor 1991; McLaughlin & Chalmers 1989; Proctor & Hafner 1993; Rushworth & Happell 1998). A very different pattern emerged in the aged care area, where the research tends to suggest that undergraduate students become less interested in aged care as the result of nursing education (Stevens & Crouch 1995).

With so much recent emphasis on workforce planning with a view to meeting the nursing requirements of our health care systems. While research of this kind has been valuable, by focusing primarily on attitudinal change to the clientele, it is not clear the extent to which more positive attitudes will result in more new graduates choosing to work in areas such as aged care and psychiatric nursing. Furthermore, it does little to demonstrate how students conceive of nursing and its many specialty areas, and whether consideration is given to each of these areas as legitimate areas of equal status. The final stage of the Stevens and Crouch (1998), Stevens and Dulhunty (1997) research suggests that this is not the case. At the completion of the undergraduate program psychiatric nursing became only slightly more popular, while aged care actually became less so.

There is clearly a need for further research to examine these issues and provide the opportunity to more thorough evaluate the impact of comprehensive nursing education on the relative desirability of specialty areas of nursing practice. The current study was designed to elicit more information to increase our understanding of why view particular areas of practice are popular while others remain unpopular. A greater understanding of the impact of education on career preferences will be gained through a comparison between the popularity of various areas of nursing specialty between the commencement and completion of the course.

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METHOD

The current study conducted in Victoria, Australia was based upon the research by Stevens and Dulhunty (1992). The career preferences of undergraduate nursing students were measured at the commencement of the course and again immediately prior to course completion. This paper primarily addresses the results obtained at the second stage, with discussion as to how these results demonstrate changes in student attitudes from those they held at the commencement of the course.

Sample

In phase one of this study, a self-administered questionnaire was distributed to 834 students commencing an undergraduate nursing course in Victoria. Seven hundred and ninety three completed questionnaires were returned, securing a return rate of 95%. At phase two of the research 566 questionnaires were distributed with a return rate of 92% (n=521). The high return rate results from the distribution of questionnaires during class time. The lower sample size in the second phase is indicative of the natural attrition rate characteristic of undergraduate nursing education.

Questionnaire.

The questionnaire was based on the instrument developed by Stevens & Dulhunty (1992). Some minor modifications were made to instrument to make it suitable for use in Victoria. A pilot study was conducted with 30 students to ensure the reliability of the adapted instrument. The students were asked to complete the questionnaire and comment on the clarity of each question. The results support the reliability of the instrument with no further modifications required.

The questionnaire was designed to be self-administered and to completed within a short time frame (approximately 10 minutes). The instrument contained three broad sections. Section 1 sought demographic information including age, gender and previous nursing experience. In section 2 students were asked to rank nine areas of nursing practice, with number 1 representing the most popular and number 9 representing the least preferred choice. Section 3 comprised a series of open-ended questions which sought further information regarding the rationale behind the choices made. For example students were asked to provide reasons for their choice of the most preferred and least preferred option.

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Data Analysis.

The data was analysed using SPSS for Windows. Data analysis was overseen by a qualified statistician. The relative popularity of each career preference was demonstrated through calculations of the mean, median and mode. The responses to open-ended questions was analysed thematically. Common themes were identified and coded. The frequencies for each coded response was recorded. The differences between students’ career preferences between the two time periods was measured using the paired samples T-test.

Findings

Demographic profile

Of the 793 participants at phase 1 83.% (n=660) were female, 10% (n=80) are male and 7%(n=53) did not record their gender. Seventy seven percent of participants were aged 23 or less, with fewer than 12% of participants over the age of thirty. Seventy percent of participants had no previous nursing experience. The nursing experience of the remaining 30% included limited periods of work experience, varying years of experience a state enrolled nurse, a psychiatric or mental retardation nurse. An analysis of demographic data at time 2 was similar other than age, which reflected the time period between the two points of data collection.

Stage 1 results

The initial ranking of career preferences demonstrated strong preferences for two main areas of nursing practice. Working with children and midwifery were the two most popular areas, while intensive/critical care and operating theatre were also very popular. Conversely aged care, psychiatric nursing and community health nursing were clearly not popular choices. More detailed information is presented in table 1.

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Table 1. The relative popularity of nursing career choices (Pre-test).

In explaining the reasons for their most preferred and least preferred career preferences, the students revealed strong prejudices regarding the desirability of certain areas of nursing practice over others. Students who ranked working with children or midwifery as the most preferred area presented a positive view of the work environment and clientele. Caring for children and babies was viewed as joyous, fulfilling and worthwhile. The areas of operating theatre and intensive/critical care were viewed as action packed, exciting and interesting, the manipulation of technology was considered highly skilled and highly responsible practice.

The picture students portrayed of working with the elderly or in the area of psychiatric nursing indicated a very negative view of the clientele and the working environment. These areas were considered routine, dull and depressing and in some instances the work was considered to be almost futile with little possibility of recovery or significant improvement. In the case of psychiatric nursing fear of being emotionally and/or physically harmed by, and the perceived inability to cope with mentally ill patients was also common. The image of community health nursing was less negative, however students tended to view this area as less dynamic, and providing less variety in clinical experience than they could expect in a hospital environment.

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Stage 2

An analysis of the results of the second stage suggests that the career preferences of nursing students are not static and have been influenced during the three years of nursing education. The post-test ranking of career choices is presented in table 2

Table 2. The relative popularity of nursing career choices (Post-test).

At this stage the first five career preferences are different to those of the pre-test, with three of the results indicating statistical significance. On closer analysis however it is only the order that differs. Surgical nursing demonstrated the most dramatic ascendancy increased in popularity from a ranking of five at pre-test to becoming clearly the most popular choice, with the difference in mean scores found to be highly significant. Intensive/critical care demonstrated a slight decrease in the mean score, but overtook midwifery to be ranked at number 2. Working with children and midwifery both experienced declines in the mean score. In the case of midwifery this was found to be significant at .045. The main casualty of the top five was operating theatre which declined from a ranking of 3 to 5, with the change in mean highly significant at .000.

At the lower end of the scale significant results were found in the areas of psychiatric nursing and working with the elderly. The popularity of psychiatric nursing demonstrated a significant increase although it continued to be ranked as the second least popular choice. Working with the elderly remained as last preference demonstrated a highly significant decrease in popularity. Overall there were only minor changes in rankings in the lower order, with medical nursing and community health nursing swapping positions at 6 and 7.

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Students’ reasons for the popularity of specific career preferences

Analysis of the qualitative responses was undertaken to ascertain the extent to which the similarities and differences in career preferences at stage 2 are indicative of for example, an altered image or an increased knowledge of nursing. A brief overview of the responses given is provided and supported by indicative quotes from the students.

Surgical Nursing

Students indicated that they find this an interesting, challenging and rewarding area which exposes them to variety in procedures and offers the opportunity to see their patients become well. It was also viewed as an area that would provide the opportunity for students to consolidate the skills learnt in the undergraduate program and provide a solid background for other areas of nursing practice in the future. The following quotes from student responses illustrate some of these issues:

I enjoy the variety that general surgical areas offer. You are able to practice your nursing skills in a wide environment

[surgical nursing] gives good general overall experience which would make me more employable if I wanted to travel or move cities.

I feel more confident in taking care of this type of patient. Most of my clinical placements were in a surgical ward.

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Intensive/Critical care

Responses from students who ranked this area as their most preferred option indicate similar views to those given during the first stage. The intensive/critical care environment is perceived as dynamic, pressured and cutting edge. It provides the opportunity to save lives and calls upon highly developed skills to operate within this area. The following student responses provide illustrate of these views:

I enjoy the knowledge that you have to acquire and use in intensive/critical care.

Interesting, challenging, rewarding. Very advanced nursing – providing patients with optimum level of care.

I enjoy high dependency nursing as it involves the need to broaden my skills to many areas, i.e. emergency nursing. I enjoy learning new "modes of care" continuously.

Working with children

A positive attitude towards the clientele was again the most predominant reason given for a desire to work with children. Students described a love of children and a desire to help them. The idea that this work environment would be challenging, interesting and rewarding was also frequently asserted. As demonstrated by the following quotes:

I love working with children, very entertaining, keeps you going.

Because I can relate to them well. I like being with children due to their nature.

I relate well with children and enjoy caring for them. I feel it would be a satisfying career.

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Midwifery

Students ranking midwifery as their most preferred area continued to demonstrate a highly positive view of the working environment. Childbirth was seen as a joyous occasion that the students would feel privileged to be a part of. A desire to, and belief that they had the skills to, work effectively with babies and children was also commonly stated. The following student quotes illustrate some of these issues:

As a midwife you are allowed to participate in a hugely important aspect of people’s lives and that is a privilege. I also find this area fascinating. There is more scope to be an independent practitioner too.

I worked at the Rosebud Midwifery unit and felt absolutely wonderful. The midwives said I had a way with patients. They responded well to me and I had enormous input to help the mothers.

I feel I can do a great job here. An area I am very keen on. Having had the experience of childbirth gives you different insight.

Operating theatre

The perceived challenging nature of the perioperative environment continued to be highly emphasised. Students viewed this area as exciting, interesting and challenging. In some instances the ability to observe the human body was considered a desirable aspect of this field of work. The following student quotes emphasise the positive aspects attributed to this area of work:

I enjoy theatre as it is an advancing area that requires a large knowledge base.

It is easier on my knees and back and I like the teamwork. More autonomy.

Theatre is fun and always busy. There appears to be more teamwork than any other area and it is challenging.

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Students’ reasons for the unpopularity of specific career preferences

Working with the elderly

Aged care continues to be viewed as a sad and depressing environment, where the work is boring, repetitive and physically taxing. Students frequently expressed frustration at working with elderly people who do not get better. The response that the students had worked in this area before and sought to broaden their experiences through different areas of practice was more common at the second stage of the research. This may reflect the fact that many undergraduate nursing students in Australia obtain part time work in nursing homes to supplement their income during their student years. The following quotes illustrate some of the attitudes of nursing students towards aged care:

I find that the elderly don’t "get better as such", they have more chronic conditions. I feel increased job satisfaction when I see that I have helped in recovery.

I don’t want to put my back out with heavy lifting. I don’t think I could put up with one more story about "their days", 365 days a year.

I’ve hated my clinical placements with the elderly. I think it was a bit boring for me.

I worked in nursing homes during university and would like to do something different.

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Psychiatric Nursing

Psychiatric nursing was one area of practice where there were notable changes in student responses between the pre-test and post-test phase. Fear of and intimidation by the mentally ill has become less frequent as an issue affecting the popularity of this area. The most common response now reflected the view that this area is not sufficiently exciting or rewarding. Insufficient knowledge or understanding of the mentally ill; the belief that they lacked the personal characteristics or qualities to perform in this environment; an image of psychiatric nursing as depressing, sad, stressful and/or demanding place to work; and, a preference for other areas of practice, particularly medical-surgical nursing were other common explanations. Furthermore, the psychiatric nursing unit within the undergraduate program was specifically mentioned in 1% of responses at having a negative impact on interest in this area. A further 10% indicated a negative clinical experience as adversely effecting the image of this specialty. The following quotes demonstrate some of the views of psychiatric nursing held be these students:

I have no interest in psychiatric nursing and find it difficult to relate to the patients.

There is not enough ‘hands on’ nursing work. I feel that I do very little for the patient. Often a cure is not in sight or cannot be attained.

I have completed my psych [sic] nursing and I found that there was little job satisfaction for me, something that I didn’t enjoy.

Psychiatric nursing is the area which interests me the least – I believe it would be very difficult and draining to work with such clients who have psychiatric difficulties regularly.

Too slow and it is talking to people, not much practical.

I did clinical placement in psychiatric nursing and did not enjoy it at all.

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Community health nursing

Community health nursing showed a small increase in popularity which did not prove to be statistically significant. The most common reasons for ranking this area as least preferred had not changed substantially from the pre-test period. These students indicated a desire to work in a hospital environment which they perceived as being faster paced and providing more hands on experience, and providing for more 1:1 contact with patients. As demonstrated in the following quotes:

Boring! Dressings, meds and more dressings. Slow.

I hated the district nursing placement. Showering is not something you do a degree for the privilege of doing.

DISCUSSION

The results of this research suggest that the impact of nursing education on students’ attitudes towards the desirability of specific areas of nursing practice as future career choices is limited. Some statistically significant changes were evident between choices at the commencement and the end of the course, but most of these demonstrated changes in position between what were initially established as the most popular practice areas. Surgical nursing became the most popular choice while there were minor differences in the rankings of intensive/critical care.

The more technologically driven areas of practice emerged to be the most popular by the end of the course (with the exception of operating theatre nursing which dropped from 3 to 5). This supports the findings of Kiger (1993) that on graduation the view of students that medical-surgical nursing is ‘real’ nursing has been strengthened. The work of Stevens and Crouch (1998) and Stevens and Dulhunty (1997) suggests that this translates into medical-surgical and high tech areas being that students tend to. It has been argued that the manipulation of technology brings the nurse closer to the world of medicine, by identifying with the concept of cure as opposed to the concept of care which is assumed to underpin the nursing role (Johnstone 1994; Millen 1989). This view has been supported by Australian research (Wilson & Retsas 1997) which found that acute care and critical care nurses are more likely to highlight factors such as knowledge base, teaching skills, clinical skills and achievement orientation as most important in their work place. Characteristics associated with caring including compassion, empathy and a holistic view of nursing care were less frequently articulated. The latter characteristics were more commonly attributed to nurses employed in the aged care environment, which would further support the view that ‘caring’ is less highly regarded than ‘curing’.

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The privilege of curing over caring provides a significant contribution to explaining the popularity of the technologically driven areas of nursing in comparison to the more care focused areas of aged care, psychiatric nursing and community mental health nursing. The results of the current study support this view. Again the differences in career preferences represented a minor change in the order of the bottom four. Although a highly significant increase in the popularity of psychiatric nursing was evident between the two time periods, psychiatric nursing continues to be ranked at number 8. Working with the elderly not only remained at number 9 but became significantly less popular. The minor changes between medical nursing and community were not found to be statistically significant.

The popularity of midwifery and working with children does not however fit neatly into this mould. While neither area is devoid from the use of technology, the responses from students who listed the two areas as their most preferred rarely referred to technology as a reason for their interest in the specific practice area. Clearly this demonstrates the preference for youth over age generations (Stevens & Crouch, 1995; Stickney, 1985; Wright, 1988; Zukerberg, 1991). The participants in this study clearly demonstrated the view that older people do not get better, and it is more rewarding and fulfilling to contribute to the care of people with a future.

This issue must be viewed as one of serious concern to the nursing profession. It may be stated that all areas of nursing practice are equal but from the results of this research it would appear that some are more equal than others. To continue on the present path is tantamount to saying that the manipulation of technology is more important that the essence of nursing itself.

The most obvious place to address this is in Schools of Nursing. Curricula need to be radically reviewed, not just in terms of revising the content to reflect a more even exposure to areas of nursing practice, but to examine the approaches to teaching that reinforce the image that medical-surgical nursing equates to nursing. The same ethos needs to be reflected by our clinical partners. Students need to view clinical placements in all areas of practice as equally valuable, and if they express their desire to pursue a career in a less popular area such as psychiatric nursing or aged care, this should be respected and no attempts made to deter them. Statements like: "what a smart girl like you?" or "you need to consolidate your skills in a general hospital first" do little to improve the image of the already marginalised specialties. The strength of the nursing professional will rest in no small part in it’s ability to promote itself as a professional of diverse practice and focus, but with the single aim to promote the contributing nursing can make to improving the health outcomes of consumers, across the life span, varying health care needs.

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