Motives for entering nursing in Iran: A qualitative study.

CONTEXT: Choosing a career is an important decision for each individual, which is affected by many different factors. The process of entering nursing, as one of the pivotal healthcare discipline, certainly affects quality of care, and retention of nurses in the profession. AIMS: Exploring factors affecting the students' decision to enter nursing. SETTING AND
DESIGN: This qualitative content analysis was carried at the school of Nursing and Midwifery of Tehran University of medical sciences.
MATERIALS AND METHODS: The semi structured interview method was used to conduct this qualitative study on 11 nursing freshmen in 2010. We transcribed the interviews verbatim and analyzed them using the conventional content analysis approach.
RESULTS: Four main categories, reflecting the factors affecting the participants' decision to enter nursing emerged in this study: Capabilities of the profession, coercion, having an interest in the medical and allied health fields, and receiving positive feedbacks. The participants had tried to gather information about nursing through different sources, including nurses and other health care professionals, counselors and Internet, which almost all the time, yielded to no useful information and sometimes with negative feedback.
CONCLUSIONS: Findings revealed that, unlike other countries, few participants had entered nursing with a real interest in helping and caring for others, and other factors such as having an interest in the medical and allied health fields, coercion, and good employment opportunities were the most important motives. Students' lack of knowledge about the profession deserves special attention. Nursing managers' should try to introduce the reality of nursing to the public and as a result, attract more competent students to the profession.

INTRODUCTION

Choosing a career is an important decision for each individual.[1] The process of choosing a career is associated with a set of personal, situational, and structural factors.[2] In modern societies, this process commences early in childhood and climaxes during last years of high-school period because of the society and family expectations. However, in some countries, (including Iran), this process completes with the university entrance exam (UEE), which is necessary to enter the desired career.[3]

Nurses, as the largest group of healthcare professionals, have a critical role in the healthcare system and thus in promoting individual and social health.[4] It is obvious that the growth and development of nursing largely depends on the ability to recruit new nurses to the profession. However, our knowledge regarding the factors affecting one's decision to choose nursing as his future career is limited.[2]

In other parts of the world, many reasons have been pointed out for choosing nursing as a career. Currently, in the 21st century the most important factor is the desire to help people and care for others.[125] However, concerns like higher income, having a sense of being different because of doing an important work, flexibility of working shifts, and presence of a nurse in the family are other determinants of entering nursing.[16]

Studies in Iran showed that approximately half of the nursing students were not compatible with the characteristics required for entering nursing.[7] Joolaee et al. also reported that only 18% of nursing students had a positive attitude toward the profession and the rest desired to leave or change their profession. These findings entails that factors affecting Iranian students to enter nursing require deep investigation.[8]

In our country, UEE, which is the main way of entering university, aims to assess the applicants’ capability to enter universities and subsequently careers and to select the most appropriate students for a career. However, one similar exam is designed for all students and all study field. Therefore, UEE does not consider special characteristics and preparations needed for each career and students enter a study field based on their performance on UEE and their way of arranging name of the desired fields on a form called the field choice form.[7]

Previously, students who desired to enter nursing had to remain in waiting lists and those who had better performance on general courses were preferred. However, as the number of nurses who leave the profession has increased, the barriers of entering nursing were removed and as a result, even students with poor performance on UEE can enter nursing.[8]

Nursing staff shortage is an important and challenging problem in Iran. Zarea et al. stated that factors affecting nursing shortage in Iran are different from those of other countries and include job dissatisfaction, socio-cultural and organizational factors.[4] Nursing staff shortage in addition to the increasing demand for high-quality care, increasing population growth rate, increasing the number of elderly, and growing need for highly motivated and competent nurses, require the profession and universities to recruit capable and competent students.[9] To start this process, determining the factors affecting the students’ decision to choose nursing as a study field is the initial step. Recognizing the nursing students’ previous background about nursing, their sources of acquiring information about the profession, and factors affecting their decision to choose nursing as their future career can help us to improve our understanding about the process of choosing nursing and determine current vacuums of the nursing system in recruiting competent staffs to nursing.

Recognizing new students’ expectations and perceptions provide an opportunity for the profession to value the future nurses’ viewpoints. Exploring factors affecting the students’ decision to enter nursing in Iran through a qualitative study provides an opportunity for subsequent interventions for enhancing the profession's status and quality of patient care.

MATERIALS AND METHODS

The conventional content analysis approach was applied to perform this qualitative study. Purposeful sampling was employed and samples of nursing freshman students from Tehran University of medical sciences who wish to enter the study were recruited using maximum variation based on gender, socioeconomic class and place of living. Data saturation was obtained after interview with 11 students. Semi structured interviews were performed using an interview guide. We commenced each interview session with the following general question “What happened that you became a nursing student?” and continued using an interview guide containing complementary questions such as “What did you know about nursing? “How did you obtain information about nursing?” and “What sources of information?” After obtaining participants’ oral consent, we tape-recorded the interviews. Each interview session was conducted with keeping the aims of the study in mind. At the end of each interview, we asked the participants to speak about other important issues not included in the interview guide nor did mention by the interviewer. Approximate length of interviews was 20 minutes. We employed the content analysis method for analyzing interviews. All of interviews were transcript verbatim. For managing and retrieval of data, MAXQDA software was used. Data was read line by line and meaning units were identified. They were labeled as a code using reduction, distillation and condensation techniques. The coding process was done according to research objectives and categories were formed. Computer program facilitate the coding process. To ensure credibility of the analysis we asked several participants to check whether the primary codes reflect their opinions (member-checking method). All of them confirmed the codes. Moreover, researcher's colleagues confirmed the analysis in the peer-checking credibility assurance process. To increase the data analysis credibility the researcher communicated with the participant appropriately. Moreover, we employed the maximum-variation sampling strategy, considering variables such as the participants’ age, gender and living place to increase the richness of the gathered data.

RESULTS

Eleven freshman-nursing students from Tehran University of Medical Sciences participated in this study. Three of them were male and eight female. All of them were single. The mean age of participants was 18 years. Eight of them were from Tehran and the rest from other cities. All but one had entered college immediately after high school graduation.

Data analyzing revealed that four main categories including “capabilities of the profession,” “coercion,” “having an interest in the medical and allied health fields,” and “receiving positive feedback” affected our participants’ decision to enter nursing.

The capabilities of the profession consisted of four sub-category including academic characteristics, spiritual values, good employment opportunities, as well as nurses’ practical and theoretical capabilities. Participants considered capabilities of the profession as a serious factor affecting their decision to enter nursing. Good employment opportunities and appropriate overseas employment opportunities were those important capabilities of the profession as mentioned by the participants especially by the male freshmen:

“I went to hospitals and asked nurses. They said nursing is much better than other study fields in terms of its employment opportunities and salary stability. These factors were important for me.” (Participant 1)

“I concluded that nursing is better because of its salaries and income. Employment opportunities are also available. For example, when I was looking at employment announcements, nurse to radiology-technician ratio was 20 to1.” (Participant 5)

“I tried to choose those fields that were beneficial to me and consistent with my goals and as living overseas was possible for me; I wanted to study in a famous university and a study field with good overseas employment and salary opportunities. Studying nursing in University of X had all of these options. Nursing is so honorable overseas.” (Participant 6)

Academic characteristics of nursing such as possibility of graduate education and education in other study fields after graduating in nursing were other influencing factors.

“I wanted to choose a series of other study fields like X and Y; however, when I found that those fields are provided just in the baccalaureate degree I didn't choose them. Graduate education was important to me and nursing provided this opportunity.” (Participant 8)

“I studied veterinary for two years. Then I gave up, took up the UEE once more, and entered the field of nursing because I wanted to study Master of Science of X and also veterinary did not afford such an opportunity to me while nursing did.” (Participant 11)

Spiritual values of the profession, another sub-category of the capabilities of the profession main category, were an important factor affecting freshmen's decision to enter nursing. Believing in after life remuneration and having opportunity to help and care for other people were incentives for some participants to enter nursing.

“From early in high school, when I wanted to choose a field of study, I chose biological sciences because I wanted to enter nursing and as nursing had a caring state I liked it and knew that nurses help people.” (Participant 9)

The last sub-category of the capabilities of the profession main category was the nurses’ practical and theoretical capabilities.

“I think nursing is useful everywhere; for example, one day in a subway station a person had fallen on the ground with a convulsion episode. It was very crowded around him and nobody did anything. I wish I was in higher terms and able to help him.” (Participant 2)

“I knew that nurse's information is very complete and same as physician. I thought having a complete source of health-related knowledge would be very good for my future life”. (Participant 11)

The second main category of the study was the coercion. Being under the pressure of UEE and acquiring a grade lower than what was expected, were among the factors affecting the participants’ entrance to nursing.

“I liked physical therapy but our indoor condition was not very well. I was under a great deal of mental pressure and hence, I could not wait for one more year to enter physical therapy. It was very difficult for me to study day and night for one more year. As a result I was coerced to enter nursing.” (Participant 3)

“I was not much interested in nursing; my goal was a different thing. I wanted to enter medicine, I was very interested in it; however, I could not study very well and hence, my grade on UEE became this. I was compelled to enter nursing.” (Participant 2)

Having an interest in the medical and allied health fields and liking hospital works were among the most important factors affecting our participants’ decision to enter nursing.

“Nursing was among one of those fields I liked. I liked nursing because it was in the medical team. Generally, I liked hospital environment and those fields involved in the treatment process since childhood. Working in a hospital was very important for me; I liked it, whether as a physician or a nurse.” (Participant 10)

“Generally, I liked and was interested in those fields related to the human body and the medical science.” (Participant 2)

The forth-main category of the current study was receiving positive feedback. Although the participants mentioned receiving countless negative feedback hindering them to enter nursing, however they reported receiving positive feedback from family members, healthcare professionals, media and also when searching for gathering information about nursing.

“My aunt recommended nursing to me. She affected me greatly because I trusted her very much. She was both an anesthetic technician and a nurse and hence, her opinion was very important for me.” (Participant 6)

“I watched the “All Saints” TV movie eagerly since its beginning. It started when I was at high school. It affected my attitude toward nursing very much.” (Participant 11)

“One of my relatives was a nursing PhD. He told me that among nursing, anesthetic technician and operating-room technician study fields, nursing provides much more better employment opportunities and is generally much more better in terms of income and status.” (Participant 2)

In addition to the four afore mentioned categories regarding the factors affecting the students’ entrance to nursing, another category in terms of the sources of obtaining information about nursing also emerged in our study. The participants had tried to gather information about nursing through different sources, including nurses and other health care professionals, counselors and Internet, which almost all the time, yielded to no useful information and sometimes negative feedback were generated from educational counselors.

“I searched the web but I couldn't find much information. The retrieved information was very superficial. That information was not comparable with the reality of nursing. It is just after entering nursing that one can understand its reality. Usually the information just said nursing is a sacred job and provided the name of several nursing lessons and nothing much.” (Participant 9)

“I spoke with a counselor who indirectly told me not to choose nursing. He wanted me to choose laboratorial sciences or microbiology fields, which provide the opportunity of post-graduate education and are of high-class.” (Participant 2)

However, few participants had some presuppositions about nursing and hence, did not feel any need for obtaining information about it and did not try for it.

DISCUSSION

In this study, we explored the factors affecting students’ decision to enter nursing. Although we recruited freshman students, participation in university classes may be influenced on their perception and responses.

Findings revealed four main categories including capabilities of the profession, coercion, having an interest in the medical and allied health fields, and receiving positive feedback.

Participants mentioned capabilities of the profession including possibility of graduate education in nursing and education in other study fields, such as medicine and biotechnology, after graduating in nursing as one of their motives for entering nursing. Duffield et al. also reported the stepping-stone as a motive for entering the profession.[10]

Spiritual values, in terms of having an opportunity to help and care for other people, were another aspect of the profession's capabilities. This finding is similar to results of Duffield and O’Brien studies.[510] Participants in these studies reported the desire to help others as an important motive for entering nursing. Findings from a meta-synthesis study conducted by Price also confirmed our findings.[2]

Good employment opportunities of the profession were a pivotal motive for entering nursing especially for the male participants. The possibility of employment and money making immediately after graduation and even during education, while many youths are worried about current prevalence of unemployment in our country, was a tempting factor to enter nursing. Dal et al. also reported this factor as an important incentive for Cyprian students to enter nursing.[1]

Another finding of the study, which is probably exclusive to our country, was entrance to the profession under compulsive conditions. The pressure of UEE coerced the participant to just pass the exam and enter university, which meant no need to study hard for one more year or two. Acquiring a UEE grade lower than what was expected coerced the participants to choose study fields not interested in. Although the participants were not regretful of entering nursing, however their entrance was not based on their interest and awareness rather because of coercion. Other studies did not report such findings.

Having an interest in the medical and allied health fields and liking hospital works were serious influencing factors. Few participants expressed that they really liked studying nursing; however, others had entered nursing as the closest field to medicine because their UEE result was not suitable for entering medicine. On the other hand, in a study conducted in Pakistan, 53% of the participants reported the personal interest as an important motive for entering nursing.[11]

Although not as much prevalent as other factors and negative feedbacks, positive feedbacks were also determinant in the participants’ decision to enter nursing. Our participants repeatedly mentioned the “All Saints” Australian TV serial, which is on Iranian TV for many years, as a determining motive for entering nursing. However, some studies refuted the effect of the media on one's decision to enter nursing.[5]

The presence of healthcare professionals, including nurses, physicians, and dentists, in the participants’ families or among their friends, who had a positive attitude toward nursing and highlighted positive, rather than negative, aspects of nursing was also important in affecting the freshmen's decision to choose nursing as their study field. In some cases, the participants’ family members were an incentive. It is noteworthy that when the participants decided to choose nursing, negative feedbacks were less effective. However, other studies reported the influential effect of parents on the students’ career choosing decision. For example, Miller and Cumming in a systematic review study found that family members, especially mothers, had an important effect on the competent students’ decision regarding their future career. They also reported that these students intended to choose prestigious, high-income study fields, which provide a high-level education. The students were less likely to choose nursing as their future career.[12]

Searching information about the profession, another finding of the study, highlighted the participants’ effort for informed selection of the profession. Participants mentioned searching the World Wide Web, counseling with educational counselor, talking with nurses, and using sources published by the National Exam Center as strategies for gathering information about nursing. Al-kandari and Lew found that 35% of Kuwaiti participants gathered information about nursing from nurses during their hospital visits.[13] Dal et al. also reported that around 67% of the students had gathered rather extensive information about nursing before choosing it as their study field from which around 40% have gathered this information from nurses.[1]

Despite the participants’ data-gathering efforts, unfortunately, the informational sources provided a limited and superficial perspective about nursing to them. Persian electronic databases could not clarify the reality of nursing for the participants and their contents were limited to some description about the nursing curriculum and educational degrees. In this regard, Law and Arthur confirmed that expanding the accessible information about nursing could facilitate the recruitment process.[9]

On the other hand, educational counselors, directly or indirectly, dissuaded the students from entering nursing. King et al. in a study conducted on Australian educational counselors, reported the same findings. The counselors reported that they received few applications from students for acquiring information about nursing and they did not offer nursing as a profession actively. As educational consolers are key informational sources for students in terms of choosing their future career and can greatly affect the students’ attitude toward nursing, paying much more attention to their role is crucial.[14]

CONCLUSION

The results of this study showed that the motives for entering nursing in Iran are not the same as other countries. Most of the studies reported altruistic tendencies and caring for others as the main reasons for entering nursing; however, in Iran although few participants had entered nursing with a real interest in the profession and caring for others, other factors such as having an interest in the medical and allied health fields and coercion were the most important motives. These findings show that factors irreconcilable with the nature of nursing guide students to enter nursing and this issue will produce some concern about recruiting competent students to the profession in future. To alleviate the progressive crisis of nursing staff shortage, healthcare and nursing managers have to improve strategies to attract competent students to the profession. Most of the pre-university students do not have a true image of nursing; therefore, we have to introduce the professional nature of nursing to them through different methods including open-day sessions at the field-choosing season, professional campaigns, serious media works, and educational classes for guidance-and high-school students. We hope that providing correct and comprehensive information would increase the number of competent students attracted to nursing. The importance of this issue in Iran after removing UEE will become more salient. Finally, we recommend a large-scale quantitative study for determining the most important motives for entering nursing in Iran.