Nursing students plan after graduation: A qualitative study.

BACKGROUND: Identifying nursing students' plan after graduation is necessary to maintain the profession in line with their nursing education. This study was conducted to explore the career plans of diploma nursing students after graduation and factors influencing their plans.
MATERIALS AND METHODS: This was a qualitative descriptive study using focus group discussion, conducted in Academy of Nursing of Belitung, Indonesia. Twenty diploma nursing students at the beginning of their 1st year of study were recruited. Data were analyzed using content analysis model.
RESULTS: The plan of diploma nursing students after graduation: becoming a civil servant and its influencing factors (fixed and higher salary, fair remuneration and incentives, and retirement fund); becoming a bedside nurse and its influencing factors (helping others and gaining experiences); and continuing higher education in nursing and its influencing factors (recognition as professional nurse, financial support, family responsibilities, and location of nursing schools).
CONCLUSION: It is suggested that nurse educators should change the mindset of the students not to focus only becoming a civil servant, and the government should open bachelor program in nursing in Belitung and provide educational support for those who would like to continue studying nursing.

Introduction

Questions about what I am going to be in 5 or 10 years and how to get there are often proposed by nursing students, as their first career decision to identify a plan on which to act just after college graduation.[1] A career plan means a process of becoming aware of self, opportunities, constraints, choice, and consequences; identifying career-related goals, timing, and sequence of steps to attain the goals.[23] However, career plan might be influenced by circumstance, and that is why considered to be flexible.[1]

For nursing students, although they have neither the knowledge nor the confidence to navigate a highly dynamic labor market and career development,[4] nursing graduates will definitely find jobs as nurses. Besides, pursuing higher education may be another choice to develop their competences in a specific field.[5] However, new graduates may have different plans for their future career.[6] Turkish study reported that the majority of the students want to work as an academician at the university or in management at a hospital,[1] whereas Palese et al.[6] study with 923 students found that majority of students (64.2%) intend to search for a nursing position in their home country, 15.8% of them have intention to work abroad, and 8.9% of them intend to continue nursing education. However, it could be though choices for new graduates in Indonesia.

Indonesia is considered as the largest number of nursing schools in Association of Southeast Asian Nations countries and increased every year. The expansion of the number of nursing schools is from 409 nursing schools in 2004 to 733 schools in 2014.[7] It is approximately >34,000 nurses produced per year,[89] and currently there are 250 million of Indonesian society is served by 309,017 nurses (50 nurses per 100,000 population),[10] which is a great number to fulfill the need of Indonesian society to improve their health conditions.[11] However, in fact, the total absorptive capacity by public and private health sector still remains low, which are able to absorb 5000–6000 nurses or 82% of unemployment rate of the total number of nurses per year.[1213] Therefore, there are many nurses do not get the right place to work or uncertain placement. This unemployment ratio may push graduates to emigrate to another country or leave nursing professions.[14] Thus, based on this information, this study aims to explore the career plans of nursing students after graduation and factors influencing their plans.

Materials and Methods

Design

This study employed a descriptive qualitative design to explore the nursing career plans of diploma students after graduation. Using a qualitative research design was in congruence with the purpose of this study.

Setting

This study was conducted at Academy of Nursing of Belitung (Akademi Keperawatan Pemerintah Kabupaten Belitung), Bangka Belitung Province, Indonesia. This institution offers a diploma nursing program that consists of 3-year program.

Participants

The study sample consisted of twenty nursing students in the first semester of their 1st year of nursing. All of participants were born in Belitung, Indonesia. Their ages ranged from 19 years to 22 years. There were 8 male students and 12 female students. The samples were selected using convenience sampling during the study in the Academy of Nursing of Belitung. The total number of the nursing students in the first semester of the 1st year was sixty students; however, the other forty students were in hospitals and laboratory for nursing practice.

Data collection

Ethical clearance was sought and obtained for this study from the Government Institution of Society Protection in Belitung (Ethical Research Committee), Bangka Belitung Province, Indonesia, Kesatuan Bangsa Perlindungan Masyarakat (Kesbanglinmas) in Indonesian terms with Number 070/219.a/BKBPPB/2015 and permission from Academy of Nursing of Belitung. Students were recruited and informed about the aim of the study and were assured that participation in the study was voluntary. The researchers guaranteed the confidentiality of their data and also ensured them that their information would be published anonymously. Participants’ names were not used in the presentation of the results. In the end, the researchers asked the participants to read and sign the informed consent form. Data were collected between July 2015 and October 2015. Focus group discussion (FGD) was performed to twenty nursing students divided into two groups. Each group consisted of ten persons. The reason to divide the group was to enable an effective interaction among the participants. FGD ranged from 45 to 120 min per se ssion in Indonesian or Belitung language and audiotaped to ensure that the totalities of the spoken words were captured. The participants in this study were initially asked with the open-ended questions. “What is your plan after graduation?” and continued until the data reached saturation. There was no a pilot test for the question. The interview was conducted by the first researcher who understands Belitung language comprehensively.

Data analysis

Data were analyzed by content analysis model using Colaizzi's method of data analysis with the following steps: (1) Each transcript was read and reread to obtain a general sense about the whole content, (2) significant statements for each transcript that pertain in this study were extracted, (3) meanings were formulated from these significant statements, (4) the formulated meanings were sorted into themes, (5) the findings of the study were integrated into an exhausted description of the phenomenon in this study, (6) the fundamental structure of the phenomenon was described, and (7) validation of the findings was sought from the research participants to compare the researcher's descriptive results with their experiences.[151617] To ensure trustworthiness, peer-checking method was used to establish the credibility of the analysis process. The peer review was done by an experienced researcher to compare and contrast on the data quality and interpretations. Dependability was achieved through a researcher audit and notes that documented all methodological issues and decisions. Although the interviewer or principle investigators were mostly Indonesian nurses, bracketing was ensured by discussing among researchers about personal biases and experiences with the research topic.

Results

Findings emerged from FGD data using seven-step method of qualitative data analysis. Three themes emerged from the data. These were:

Becoming a civil servant and its influencing factors

Becoming a bedside nurse and its influencing factors

Continuing higher education in nursing and its influencing factors.

Those themes are illustrated below with exemplars from the participants’ stories using pseudonyms for the participants.

Theme 1: Becoming a civil servant and its influencing factors

More than half of students agreed that they choose to be civil servant or government employee after graduation although they need to take the examination for many times. Participants express this in the following statement:

“… Yes to be a civil servant is the first priority, although I fail many times during the test, I will not give up, I need to test again and again…” (F1).

“… I think I am the same, everyone would like to be a civil servant. We can see our future if becoming government employee…” (F5).

“… I will be a contracted nurse or one or 2 years if I fail the test while waiting for the next test to be government employee…” (F2).

Factors influencing students plan to be civil servant

Three factors were identified that influence student plan to be a civil servant, and participants expressed these factors include:

Fixed and higher salary

Most of the participants agreed that their reason to be government employee is the fixed and higher salary, like participants said:

“…To be a government employee is good, we can get fixed salary every month…” (F19).

“…Fixed money per month is really helpful, this salary is also higher compared to the salary of contracted nurses and salary in the private hospitals…” (F8).

Fair remuneration and incentive

More than a half of participants agreed that fair remuneration and incentive are the influencing factors of their plan. Participants express this in the following statements:

“…If I become a government employee, I will get another compensation from remuneration system beside my salary…” (F19).

“…If I work in night shifts, I get more money, the good thing form remuneration. Incentive is also available for those who work hard…” (F20).

Retirement fund

All participants agreed that getting a pension fund is the reason to choose a government employee as their future career. Participants in the following statement express this:

“… Becoming government employee will get a retirement fund. I will also get insurance. However I need to work for long term…” (F6).

“…I am not worried if I am getting older, I will get pension fund…” (F9).

Theme 2: To be a bedside nurse

More than half of nurses agreed that, after graduation, they want to be a bedside nurse, both in clinical and community setting. Participants express this in the following statement:

“… Whether working in public or private, it doesn’t matter. Becoming a bedside nurse I think it's my first choice…” (F6).

“… I’ve been thinking seriously about nursing practice in a rural area in the community, like in Tanjung Binga or Membalong or any other islands in Belitung…” (F3).

“…When I graduate I want to work in NICU or pediatrics as a bedside nurse…” (F13).

“…My decision is I would like to work as a nurse, have thought about ICU lately…” (F15).

Factors influencing students plan to be bedside nurses

There were two factors identified as the reasons the students want to be bedside nurses include “helping other people” and “gaining experiences.” It is great to know that the students want to use what they had learned in college for the purpose of helping others in need and passing knowledge on to others. Participants expressed these in the following statements:

“… Becoming a bedside nurse I think it's my first choice, so I can really apply my knowledge to other people in direct way…”[16]

“…I may work as a nurse first to look for some experiences in clinic, after that I might think something else…” (F8).

“…The fact that ICU nurses can make a big difference in a patient's life in just a short amount of time, I want to be a part of that…” (F14).

Theme 3: Continuing higher education in nursing

More than half of participants agreed that they are hoping to pursue a higher degree after they complete their current program. They want to attend graduate school after completing their diploma studies like participants said:

“… I want to continue study at least bachelor degree, because I think diploma degree is not enough…” (F1).

“…I plan to graduate next year with a Diploma Degree in Nursing, then work on a BSN degree right after graduation…” (F5).

“…I plan to continue on for my BSN as soon as I graduate and go to work…” (F9).

Factors influencing students’ plan to continue education

There were four factors identified from the data, namely:

Recognition as a professional nurse

Recognition as a professional nurse is the factor that influences students to continue higher education in this study like participants said:

“… I want to be a professional nurse so that's why I need to continue study. As Indonesian nursing act said that diploma nurse is technical nurse, not a professional nurse…” (F15).

Financial support

Although some nurses would like to continue studying nursing, some of them have a financial problem as their barrier. They hope the government will support them, like participants said:

“… I plan to continue BSN in nursing, but I have no money. Anyway, I will apply scholarship to the government. Hopefully I can get support…” (F5).

Family responsibilities

Family factor is considered as an inhibiting factor to continue education, especially for those who are married, like participants said:

“… I can continue studying if my husband allow me to…” (F17).

“… It's rather difficult to study again because I need to take care my wife and my children…” (F18).

Location of nursing schools

Participants also mentioned that location is the influencing factor to continue education. Most of them are not able to go outside the city to study. Participants expressed this in the following statements:

“… If we need to go out from Belitung, I think it's difficult. We hope BNS program will be opened in Belitung, so we can study here…” (F20).

“…If bachelor program is in Belitung, it will be great, so we don’t need to leave the family and do not spend much money…” (F13).

Discussion

This study was conducted qualitatively to explore the career plans of diploma nursing students after graduation. There had been three themes emerged: (1) becoming a civil servant and its influencing factors, (2) becoming a bedside nurse and its influencing factors, and (3) continuing higher education and its influencing factors.

The theme “becoming a civil servant and its influencing factors” indicated that students prefer to be a government employee in the future, rather than working in the private sectors or starting their own business. In Indonesia, especially in Belitung, most of people tend to respect those who are government employees, which is why their orientation or target is becoming a civil servant. The required educational background to be civil servant or Pegawai Negeri Sipil (in Indonesian term) is at least diploma level.[18] Those who would like to be a civil servant should join the qualification and competency test, and it is held every year by the government of Indonesia. However, to be a government employee is not easy, high competition among nurses could not be avoided due to lack of government employee vacancies, which is based on the formation and the need of hospitals in Indonesia. In fact, the number of civil servants in Indonesia is equivalent to only about 1.8% of the total population.[819] As a consequence, the number of jobless nurses will be increased per year if they still insist to be a civil servant. Thus, the mindset to be civil servant, however, needs to be changed.

The concept of entrepreneurship in nursing could be the answer for this situation, which all nurses start their own businesses, to apply their knowledge and skills in the work and put into building of their own companies, services, practices, and firms such as nursing center, nursing home care, and supreme health service. These kinds of businesses are also supported by Indonesian Nursing Act No 38 year 2014, which all nurses are able to open their independent nursing practice.[20] However, to deal with a high number of nurses who do not get the right place to work, government of Indonesia also needs to open more job opportunities.

Findings of this study also revealed the factors influencing students plan to be civil servant, namely fixed and higher salary, fair remuneration and incentive, and retirement fund. These factors could be the benefits of becoming a government employee. These results are in line with the previous studies stated that fixed salaries or incentives for government employees are fair at every level based on nurse education and past job experiences. This avoids any kind of discrimination among the employees.[21] In addition, government employees will also get lifelong benefits such as lifelong health care, pensions, housing facilities as well as provident funds.[21] Similar with Ellickson and Logsdon[22] found that the attention to be government employee influenced by perceptions of satisfaction with promotional opportunities, pay, and fringe benefits. Overall, the students desire to stay in a comfortable environment.[6]

The theme “becoming a bedside nurse and its influencing factors” remains positive. Generally, students like to be in academic part (education) or management position after graduation.[123] Students in this study also mentioned that it does not matter they work in public or private sectors. Thus, for this reason, the students who would like to be bedside nurses to responsible for direct nursing care can help dealing with nursing shortage in Indonesia, and it may prevent them from developing wrong expectations and goals in their career planning. However, this result is not in line with Yildirim's study found that more than half of the nursing student are not including direct patient care in their career planning.[1] Followed by Rognstad et al. determined that nursing students were less interested in giving care and help to others.[24]

Factors influencing student plan to be a bedside nurse in this research included helping other people and gaining experiences. It is line with the literature stated that the main source of inspiration to be a nurse comes from an innate desire to help people[25] although students have a lack of knowledge to navigate the complexity of the nursing labor market.[4] However, in this study, students seem having another plan after 2 or 3 years of working experiences in doing direct nursing care. It is questioned whether they intend to stay in nursing profession or not because they may be influenced by circumstance and considered to be flexible.[1] Literature revealed that the intention to stay of nurses is influenced by job satisfaction driven by internal and external factors.[26]

The theme “continuing higher education in nursing and its influencing factors” indicated that students realize that diploma nurses might not be enough to answer the complexity of health problems today. This is why some of the students mentioned that they want to be a professional nurse as a reason to continue education, which is at least bachelor degree considered as the first level of professional nurse. However, diploma nurse is considered as a technical nurse.[20]

The other factors influencing students plan to continue education in this study included the financial support factor. Literature indicated that lack of financial support was reported as a major barrier not participating in continuing education programs.[272829] Besides, family is another barrier in this study, which is similar with the previous studies that showed families responsibilities as a factor deterring to continue education.[2829] It is difficult for nurses to study while they have to take care of family and children. The last factor is the location of the nursing school. It is consistent with the findings of the previous study that mentioned that geographical barrier is to continue education.[30] Teaching approach like E-learning should be addressed for the development and progression in nursing career pathways.[30] However, continuing education is a vital component for the nursing profession to provide state of the art and science in nursing.[27]

Conclusion

This study explored the career plans of diploma nursing students. FGDs revealed that becoming a civil servant remains the predominant plan after graduation, which is influenced by fixing and higher salaries, fair remuneration and incentives, and retirement fund. In this study also found that students plan to be bedside nurses without thinking, they need to be in public or private. This plan is influenced by their intention to help others and gain more experiences in nursing. This study also revealed that continuing education in nursing is the students’ plan after graduation, which is positive to understand more about professional nursing. However, there are some barriers encountered to continue the study, such as financial support, family matter, and the location of the school. Thus, these findings suggest that:

To change the mindset of nursing students not to focus more on becoming civil servant

The concept of nursing entrepreneurship should be addressed in the nursing curriculum

Government might need to absorb more nurses to get the certain jobs and provide more job opportunities

Government should provide financial supports for nurses who would like to continue education

Providing bachelor program in nursing in Belitung and Distance Learning program such as E-learning might need to be considered to facilitate diploma holder nurses.

Financial support and sponsorship

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of interest

There are no conflicts of interest.