Choosing a Nursing Career During a Global Health Event

Background:

Although in the past, the decision to enter the nursing profession was mainly due to intrinsic motives, more recent generations present additional extrinsic career choice motives. The motivation of choosing a nursing career may be affected by global health events, such as COVID-19.

Purpose:

To examine the motivation for choosing a nursing career during COVID-19.

Methods:

A repeated cross-sectional study was conducted among 211 first-year nursing students at a university in Israel. A questionnaire was distributed during 2020 and 2021. Linear regression evaluated the motives that predict choosing a nursing career during COVID-19.

Results:

Intrinsic motives were the leading motives for choosing a nursing career in a univariate analysis. A multivariate linear model revealed that choosing a nursing career during the pandemic was associated with extrinsic motives (β= .265, P < .001). Intrinsic motives did not predict choosing a nursing career during COVID-19.

Conclusion:

Reassessment of motives among candidates may help the efforts of faculty and nursing to recruit and retain nurses in the profession.

Career choice may be one of the most important decisions made during one's life span, and it is influenced by many factors. Tendency toward career choice is developed mainly during childhood and adolescence and is influenced by gender role orientation, personality, educational experiences, and parental and peer interactions.1 Exploring why people enter the nursing profession reveals a number of reasons. Wu et al2 in their systematic review revealed 4 groups of factors influencing career choice among health care students: sociodemographic (gender and socioeconomic status); interpersonal factors (influence of family members and individuals in the profession); intrinsic factors (a desire to care for others and a personal interest in health care); and extrinsic factors (such as financial remuneration, job security, and professional prestige).

In the past, the decision to enter the nursing profession was mainly due to the traditional intrinsic perception of nursing as a virtuous profession: altruistic, noble, caring, and compassionate.3,4 More recent generations present additional extrinsic career choice motives. For example, McLaughlin et al5 found that motivation in nursing students is no longer simply a desire to care but also the opportunity for self-development in the nursing profession. In a large cohort study performed in Sweden, “wanting to care for and help others” was the second reason for choosing nursing studies (among approximately 75% of participants). The main reason students had chosen nursing education was due to “the wide range of possible work tasks and areas” (80%).6

In this study, we refer to self-determination theory (SDT)—a theory of motivation that has recently been applied to health education.7,8 The SDT approach to human motivation highlights the importance of 3 universal psychological needs: autonomy, competence, and relatedness, needs that when satisfied may enable a person to experience a sense of well-being.9 Self-determination theory distinguishes between autonomous intrinsic motivators in life (eg, personal growth, community involvement) and some more extrinsic motivators (eg, wealth, prestige, self-image). People will seek goals that take into consideration the satisfaction of their basic needs.10

Career choice is influenced by both intrinsic and extrinsic motivators.11,12 Messineo et al studied the motivation for choosing nursing studies in the University of Palermo, within the theoretical framework of SDT. Using thematic analysis, the results show that nursing students' motivations can be organized according to the influence of extrinsic and intrinsic autonomous forms of motivation. The most frequent reasons were the desire to help others, and considering the nursing profession as a mission or a vocation, while the second most frequent motivation was related to job opportunities.7

Ben Natan and Becker13 specified the career choice motivations that influence individuals' choices such as helping others, interest, appreciation and self-fulfillment, challenge and excitement, creativity and responsibility, social assistance, and professional status. They stated that people motivated by a desire to help others, rather than by personal interest or challenges, are predisposed to choose a nursing career.13 Other studies support the notion that intrinsic rather than extrinsic motives are the leading factors for choosing a nursing career and revealed additional extrinsic motives of career choice, for example, employment security, flexible hours, high salary, promotion and responsibility, comfortable work conditions, short training, and the ability to work and study at the same time.14–18

Exposure to significant health events in the private and public environment may also contribute to decisions regarding career choice. Di Giulio et al19 found that compared with business students, students of health professions were significantly more exposed to severe personal illness, a relative's illness, death, or addiction, before beginning their professional studies. In March 2011, a large earthquake, tsunami, and nuclear explosion damaged northeastern Japan. A qualitative study that explored the reactions and interpretations of adolescents living in areas affected by the disaster revealed an association between childhood adversity and career choices. The researchers believe that exposure to trauma builds a source of resilience, as among these young people they found an optimistic future orientation and motivation to become a physician.20

There is also preliminary evidence that COVID-19 has influenced medical and nursing career choices. First, health care professions became more popular during the pandemic. For example, Zhang et al21 observed an increased preference for medical studies following the COVID-19 outbreak among high school students and their parents. Bai et al22 also reported an increase in the choice of nursing as a future career in China, from 50.9% before the COVID-19 pandemic to 62.7% after the onset of the pandemic. Second, COVID-19 has influenced career development within the health care profession. In a recent survey conducted among medical students at the University of Pennsylvania during the pandemic, the participants were asked whether they think that COVID-19 will affect their future choices in their medical career. Twenty percent of the students think that COVID-19 will affect their choice of specialty. In another study among a group of nursing students (n = 58), almost all students had decided to quit the nursing profession after graduating from university during the COVID-19 pandemic.23 However, some evidence exists that COVID-19 has had no influence on health care career choice, such as a study of 72 students in undergraduate and graduate-level medical laboratory science programs at a university in the United States that showed that for most students, the pandemic did not influence their decision to pursue this career.24

The global shortage of nurses is growing, and the number of required nursing graduates increases each year. In Israel, the number of nurses is already low, with 5 nurses per 1000 population, compared with the Organization for Economic Cooperation and Development (Israel) average of 9.4.25 Educators, policy makers, and health care professionals need to be aware of candidates' and graduates' career choice motivations and expectations to improve processes of nurses' recruitment and retention in the profession. The current COVID-19 pandemic may change the perceptions of both preservice and in-service public health professionals. The objective of this study was to evaluate the motivation for choosing nursing studies during COVID-19 as an example of a global health event among first-year nursing students, within the theoretical framework of SDT.

Methods

Setting, Study Design, and Sample

A repeated cross-sectional survey study was conducted at the Department of Nursing, School of Health Professions, at Ben-Gurion University of the Negev University, Israel. Participants were first-year undergraduate nursing students who were recruited to the study at 2 points in time during the first month of the academic year, in October 2020 and in October 2021, using a convenience sampling method. A minimum sample size of 194 participants was required for this study based on α= .05, power = 0.20, and an expected correlation coefficient of at least 0.20.26

Research Variables and Measurements

Participants completed a self-reported questionnaire to assess the outcome variable COVID-19 influence for choosing the profession, and the explanatory variables—intrinsic and extrinsic motives for choosing the profession. Participants also completed a demographic and socioeconomic characteristics questionnaire.

The extent to which the participants chose nursing studies due to the COVID-19 pandemic was measured using 5 items created by the researchers (eg, “I chose to learn a healthcare profession following COVID-19” and “I chose to learn a therapeutic profession following COVID-19”). Participants rated their agreement with the items on a 5-point Likert scale from 1 = totally disagree to 5 = totally agree. A mean score was calculated to create the variable. For added consistency, this part was repeated in 5 questions, each question dealing with a slightly different part.

Motives for choosing the profession were assessed using a list of 16 statements addressing the motives of health profession career choice adopted from a valid questionnaire by Romem and Anson.27 Participants rated each item on a 5-point Likert scale from 1 = totally disagree to 5 = totally agree. The original tool was organized under 5 themes (characteristics of the profession; socioeconomic status; childhood dream and personal inclination; previous familiarity with the profession; and family and social network support). In the current study, we organized the motives under 2 categories of intrinsic and extrinsic motives: 9 items were combined under 1 category (α= .50) and are referred to as intrinsic motives (eg, statements referring to the characteristics of the profession, childhood dream, and personal inclination). The other 7 items were combined under a different category (α= .62) and are referred to as extrinsic motives (eg, items relating to socioeconomic status, such as job security and prestige and family and social network support as motives for choosing the profession).

Data Collection

Data were collected during the COVID-19 pandemic, during the first month of 2 academic years: October 2020 and October 2021. An online anonymous questionnaire was distributed using electronic survey software. The Ethics Committee of the Faculty of Health Sciences at Ben-Gurion University of the Negev approved the study protocol (approval no. 45-2020). Participants' consent was obtained online, using a question of agreement to participate in the study at the beginning of the study questionnaire. Filling out the questionnaire was possible only if participants had checked “yes” for this question.

Data Analysis

Data were analyzed using IBM SPSS Statistics software (version 26, Armonk, New York). Descriptive analysis included means and standard deviations for interval variables and frequencies and proportions for categorical variables. Univariate analysis included independent t test, paired t test and Pearson correlation. Multivariate analysis included linear regression for the predictors of “COVID-19 motivation.” The statistical significance level was set at α value of less than .05.

Results

Out of 280 students who began their academic studies at the Department of Nursing in 2020 and 2021, 211 students completed the study questionnaire (compliance rate of 75.4%). No differences were found in sample characteristics between 2020 and 2021. Participants were mostly women born in Israel. Supplemental Digital Content Table, available at: http://links.lww.com/NE/B301, presents the sample characteristics and study variables distributions.

We refer to the 2 points in the time of data collection as 1 comparable sample, after comparing the means of motives and COVID-19 motivation between participants in 2020 and participants in 2021. Three significant differences were found between the study years: “financial security” (t = 2.84, P = .005) and “enabling geographical mobility” (t = 2.20, P = .029), which were rated higher in 2020, and “previous familiarity with military service,” which was rated higher in 2021 (t =−2.25, P = .025). No other differences were noted.

Although examining the means of each item separately, the 4 higher rated motives were (1) helping others, (2) diversity of work options, (3) work with people, and (4) natural tendencies, all of which are recognized as intrinsic motives (Table 1).

Table 1. Descriptive Analysis of Nursing Career Choice Motives.

Motive Type	Motive	Mean	SD	Minimum	Maximum
Intrinsic motives	Helping others	4.89	0.312	4	5
	Diversity of work options	4.70	0.534	2	5
	Work with people	4.64	0.527	3	5
	Natural tendencies	4.39	0.655	2	5
	Fits me the most	3.96	1.037	1	5
	Previous acquaintance with a nurse	3.21	1.547	1	5
	Childhood dream	2.98	1.163	1	5
	Familiarity as a patient	2.66	1.423	1	5
	Familiarity from military service	2.22	1.431	1	5
Extrinsic motives	Potential for professional promotion	4.35	0.691	2	5
	Family support	4.29	0.946	1	5
	Friends support	4.18	0.972	1	5
	Geographic flexibility	4.09	0.898	2	5
	Professional prestige	3.97	0.931	1	5
	Financial security	3.70	0.987	1	5
	Financial constraints	1.74	0.918	1	5

Table 2 presents the α coefficients of the motivational constructs (ie, intrinsic, extrinsic, and COVID-19) and the mean, SD, and correlations between main study variables. COVID-19 motivation to choose nursing as a career was significantly lower than both intrinsic motivation and extrinsic motivation (t =−33.34, P < .001, confidence interval [CI]: −1.78 to −1.58; t =−32.10, P < .001, CI: <1.70 to −1.50, respectively). Intrinsic motivation rated higher than extrinsic motivation (t = 2.26, P = .02, CI: 0.01-0.14). Pearson correlations presented in Table 2 reveal weak positive association between COVID-19 motivation and both intrinsic motivation and extrinsic motivation (r = 0.209, P < .01; r = 0.310, P < .01, respectively). A positive correlation was also observed between intrinsic motivation and extrinsic motivation (r = 0.381, P < .01).

Table 2. Constructs Reliability, Descriptive Statistics, and Correlation Coefficients of Study Variables.

	Alpha	Mean (SD)	Intrinsic	Extrinsic	COVID-19
Intrinsic	.50	3.8 (0.44)	1
Extrinsic	.62	3.76 (0.50)	0.381a	1
Covid-19	.69	2.13 (0.72)	0.209a	0.310a	1

^aP < .01.

Multivariate linear regression for the variables that predict COVID-19 motivation of career choice is depicted in Table 3. The model was significant (F = 8.09, P < .001) and explained 14% of the variance in the motivation to choose the nursing profession following COVID-19. The model reveals that extrinsic motivation predicted COVID-19 motivation (β= 3.664, P < .001) but intrinsic motivation did not do so (β= 1.371, P = .172). Another significant predictor was religion, indicating that non-Jewish participants were less likely to choose the profession due to COVID-19 (β=−2.491, P = .014).

Table 3. Linear Regression for Prediction of Choosing Nursing Career During Covid-19^a.

	B	Standard Error	β	t	P
Constant	0.492	0.491		1.001	.318
Intrinsic motivation	0.158	0.115	.098	1.371	.172
Extrinsic motivation	0.376	0.103	.265	3.664	<.001
Religion (Jewish vs non-Jewish)	−0.413	0.166	−.167	−2.491	.014
Gender (male vs female)	0.017	0.161	.007	0.107	.915
R 2	0.14
F (P)	8.09 (<.001)

^aDependent variable: choosing nursing career during COVID-19.

Discussion

COVID-19 has changed the world in many ways, and this includes the world of employment. This study aimed to explore changes in the motivation of students to choose the nursing profession during the pandemic period that represent a global health event. The results of this study indicate that during COVID-19, extrinsic motives but not intrinsic motives contributed to the decision to study nursing among the research participants. The leading extrinsic motives were either intrapersonal, for example, perception of nursing as a profession with the promotion opportunities and the geographic flexibility it enables, or interpersonal, for example, family and friends supporting the decision to study nursing. The trend in candidates' motivation to choose a nursing career from purely intrinsic motives toward a combination of intrinsic and extrinsic motives has been noted previously, prior to the COVID-19 pandemic,5–7

There is limited literature about the influence of global health events on nursing career choice.20 The COVID-19 pandemic is unique in that it lasted for an extended period and affected almost every location and population around the world. A few studies have shown an increase in demand for nursing studies during the COVID-19 pandemic.21,22 However, to the best of our knowledge, this is the first study that explores changes in motivation for nursing career choice during the pandemic. The fact that choosing nursing due to the pandemic is associated with extrinsic motives seems to support the trend seen in recent years of moving from intrinsic-based to mixed-based motives for choosing a nursing career.5–7 That is, people in the new world of work may enter the profession due to extrinsic factors as well.28,29 Another explanation may be the fact that COVID-19 has affected the stability of many other professions (eg, education, sales, and high-tech), causing people to look for a profession such as nursing. It will be important to follow those who were highly influenced by COVID-19 in their decision to become nurses in order to record their job experiences over time, for example, job satisfaction, burnout, worksite change frequency, and leaving rates.

The higher average of the intrinsic motives in our study indicates that intrinsic motives are still dominant in the process of nursing career choice. This is encouraging, especially in light of the numerous adverse effects of the COVID-19 epidemic on almost all areas of life. The effect of COVID-19 on motivation for choosing the nursing profession was positive. The widespread recognition and appreciation that the medical profession received during the peak periods of the pandemic, as demonstrated by the applause for staff on the balconies,30 increased the prestige of the medical profession and interest in relevant fields of study. In Israel, only a slight intention to leave the profession was noted during the pandemic.31 Furthermore, there was an increase in demand for nursing studies according to the local press,32,33 and the Ministry of Health published an increase in the ratio of nurses per 1000 during this period.34 In fact, it can be cautiously claimed that the extrinsic motives that lead people to choose nursing career following COVID-19 were added to the intrinsic motives, which resulted in positive effect on the nursing career choice.

Two extrinsic motives were higher in 2020 compared with 2021: the financial motive and the geographical motive. The authors believe that at the start of the pandemic, uncertainty and anxiety about the future, particularly in terms of a source of employment and income, were higher. It is worth examining the influence of these 2 motives during periods when there is no global health disaster.

This study has several limitations. The cross-sectional design enabled correlational inference but not a causal effect. Because of the convenience sampling method, there is subrepresentation of important groups such as minorities and male gender populations that are currently growing within the nursing profession in Israel. In addition, data were collected in a single academic setting, may be subject to a specific acceptance policy of the setting, and to a specific nature of the learners, thus limiting generalizability. The study was conducted among individuals who already enrolled in the nursing program, thus excluding those who were not accepted to the program. The results may also be influenced by the country in which the study was conducted, due to local pandemic influence and country policies during COVID-19.

Conclusions

As previous global health events, COVID-19 has brought about numerous environmental and social changes, and it also seems to have affected people's motivation to choose a nursing career. High extrinsic/non–self-determined motivation encourages new students in their choice of a nursing career following COVID-19, more than intrinsic self-determined motivation. This finding emphasizes the need for managers and health-related stakeholders to adopt strategies that address individuals' expectations and motivations, in order to encourage them to join the health system. Such strategies could include increasing opportunities for professional development in nursing, advertising on social media to raise the prestige and the options of the nursing profession, which would be particularly suited to the current generation that is highly influenced by content on various media.

In light of the steep increase in personnel shortage and leaving trends, gaining a true understanding of people's motivation to join the nursing profession is essential both for the recruitment of new students and for the retention of veteran professionals for the long term. Understanding current trends in motivation to join the nursing profession can contribute to the efforts to increase enrolment, enhance work satisfaction, and decrease the intention to leave the profession. Such efforts are needed now more than ever to help overcome the health professional shortage. It is important to continue this research to include additional subgroups among prelicensure nursing students (eg, participants in programs such as a fast track for academics, male students) and to explore strategies that may address these motives.