Introduction

Individuals trained in healthcare occupations are expected to be in high demand in the coming years. The outlook for healthcare professions exceeds that of the average for all occupations, with projected growth of 18% in employment between 2016 and 2026 [1]. This growth is a result of the rising rates of chronic conditions, focus on primary and preventive care, and aging baby boomers [1]. In order to recruit and prepare enough students to fulfill these highly needed roles, colleges and universities should be attuned to the motivating factors of students in these fields. Understanding such factors may be important in presenting opportunities and experiences that will encourage and motivate students to pursue and find satisfaction in needed occupations. Aside from recruiting students into nursing, retaining students in the profession may be equally if not more challenging due to long hours, stressful work, and job-related fatigue.2 This paper explores what aspects of nursing curriculum and practical experiences motivated students to remain in a nursing program.

Current State of the Nursing Profession

To avoid a shortage, 1.1 million new registered nurses are needed by 2022 [2]. There are numerous opportunities for nurses; however, there are also several challenges associated with the nursing profession, including the aging of the baby boomer generation, physician shortages, retirement of working Registered Nurses (RNs), and healthcare reform [3,4]. Newer nurses are leaving bedside nursing to advance their degrees or to take specialty positions adding to the already existing nursing shortage [4]. These challenges lead to long hours and strenuous work, which can result in job dissatisfaction and burnout [2]. Furthermore, the Institute of Medicine’s new recommendations that 80% of registered nurses be trained at the Bachelor’s degree level puts increasing demands on an already strained workforce [5].

Current State of Nursing School Retention

The first year of nursing education experiences the highest attrition rates due to students being unprepared for college or having life-events that made college too challenging an option according to Andrew, et al. [6]. A study conducted in the Netherlands found the first two years of nursing school to be the most influential on retention [7]. While increased academic tenure led to enhanced attitudes toward education, skill development, and the role of nurses, one unintended outcome was a decline in empathy [7]. In contrast to most clinically-based health professions, nursing students are subject to coursework and clinical rotations at the undergraduate level [8]. Due to the stress and anxiety resulting from the rigorous coursework of nursing school, research shows the need for stress management interventions early in the academic process [9]. Furthermore, the introduction of self-care techniques (i.e., exercise, focusing on holistic practice of health, and taking breaks) in nursing school may carryforward to the profession and assist in stress management, combat compassion fatigue, and improve care delivery [8].

Nursing Motivation

The concept of motivation is highly researched among many professions with a plethora of literature on the nursing profession. Some of the general motivations for selecting a career in nursing include altruism, self-validation, sense of achievement, and having a family member in the healthcare industry. More generalized literature analyzes motivation in the form of intrinsic and extrinsic motivators. The most common theme threaded throughout the literature on nursing student motivation is altruism, also commonly coded in the literature as possessing a caring nature [10-13], a desire to serve or help others [14,15], and an experience caring for a loved one [16]. This theme was prevalent throughout the literature as a result of the nature of the nursing profession, which is to help others [12,17]. Researchers found that nursing students’ perceptions of the profession were associated with caring and the innate desire some people have to help other people [11,12]. Furthermore, altruism is often considered to be one serving as the Good Samaritan [13].

McLaughlin, et al. found that altruism was significant in student motivation to select nursing [10]. Having an active role in the care delivered to patients and the feeling of helping the patient recover were also motivating factors for nursing students [12]. Wittlock and Leonard’s findings indicate that a number of respondents were motivated to choose nursing as a result of caring for an ill family member [16]. Notably, respondents who found it difficult to care for others ended up dropping the nursing major [16]. Another study found that along with financial factors, stress among nursing students can significantly impact motivation [18]. O’Brien, et al. discovered that student motivation to select a nursing career was not deterred by how the media influences society’s view of the nursing profession [11].

Another common theme in the literature on nursing motivation is self-validation or sense of achievement [10,12]. Self-validation refers to the appreciation and recognition nurses receive from their patients, specifically being thanked for their work, ability to upgrade a skill set, and recruitment of staff [12]. A sense of achievement refers to the contribution and role of nursing in the patient’s recovery and overall wellness. McLaughlin, et al. established that nursing students were motivated by self-development, which includes income, job security, ability to travel, being on a team and providing team-based care, and job satisfaction [10]. Finally, positive feedback from family and friends and the presence of role models motivated nursing students to continue to pursue a nursing career [10].

Purpose

The purpose of this study was to determine what factors within the educational experience motivated undergraduate nursing students to continue on their current career path. This study fills this gap by conducting a qualitative analysis of current nursing students’ motivations for remaining in the nursing program at two distinct intervals: sophomore year (before clinical experience) and senior year (after clinical experience). By understanding what motivates current nursing students, we can develop solutions to improve retention in nursing programs.

Materials and Methods

Data Collection and Sample

A convenience sample of sophomore and senior nursing students were invited to participate in this study during the fall semester. These intervals were initially selected to measure students’ motivation pre- and post-clinical experience. The current curriculum has nursing students starting clinical rotations during the spring semester of sophomore year. Researchers attended two nursing classes to recruit students to participate in the study (one for sophomores and one for seniors since all students in each cohort would be in attendance during these two selected courses).

To prevent coercion to complete the survey, the research team delegated the recruitment of nursing students to the student research assistants on the study. Students were assured by the student research assistants that they would not be penalized for not participating in the study. To encourage participation, nursing students were incentivized using a random drawing for a $50 gift card. Nursing students completed a 27-question electronic survey regarding their motivation for selecting the nursing major, motivation for staying in the nursing program, empathy measured using the Jefferson Scale of Empathy, and basic demographics. The results presented in this manuscript are a small subset of the data obtained from this study. The main research question for this paper is “what motivates nursing students to continue on their current career path?”

The final data set contained responses from 142 nursing students: 76 seniors and 66 sophomores. Sixty-five percent of the sample was aged 19-21, 85% were female, a quarter were first generation college students, and 42% had a family member working in the health care industry (Table 1).

Analysis

Motivation to stay in the nursing program was measured by the open-ended question, “In as much detail as possible, describe a situation during coursework or internship/clinical that motivated you to continue on your current career path?” The following definition of motivation was also providing: “Motivation is what allows a student to pursue their ambitions.” Using content analysis, two members of the research team independently coded each of the study participants’ responses. Inductive content analysis was selected to analyze the data [19]. Each student response was analyzed using conventional coding methods; the codes were derived from the text responses and not from common models of theories in the literature [20]. After each student response was coded, the researchers reanalyzed the codes and grouped codes into general themes [19]. Once the general themes were devised, each theme was tallied to provide a quantitative assessment of the qualitative codes.

There were two major location-based categories in the data where motivation occurred: classroom and clinical setting. If the motivation occurred in a healthcare facility, the location was classified as “Clinical.” If the motivation occurred during or as a result of coursework, the location was classified as “Class.” If the student did not response to the question, the motivation was classified as “Blank.” Five themes emerged from the data on clinical motivations: clinical experience, patient experience, self-validation, altruism, and clinical competence. Due to the small number of responses for class, only one theme occurred: engaged professors.

Results

Almost half (45.39%) of the nursing students reported an event associated with their clinical rotation as a motivation to stay on their current career path, while 5.67% expressed a motivation associated with class and 48.94% left the question blank (Table 2). For those whose motivation stemmed from or occurred during the clinical, 95% were seniors. For motivation from class, 66.67% were sophomores. Nearly 86% of sophomores, compared to 17.33% of seniors, left the question blank (Table 3).

Motivation from Clinical Experience

The most prevalent theme identified by nursing students was the clinical experience. Of those included in the sample, 22% of nursing students explicitly indicated that their clinical experience motivated them to continue on their current career path. This theme includes any mention of the facility, preceptor, or reference to performing an internship or clinical rotation. (Clinical experience does not include specific examples of patient encounters, self-validation, or clinical accomplishments. Though related, these concepts were captured in separate themes to be discussed later.) One nursing student commented “At my internship my preceptor was very friendly and knowledgeable. She reminded my how much I want to do this, and that if she can do it, I can do it” [Student #6]. Other comments vaguely alluded to time spent on a particular unit, such as “shadowing in the ER made me very excited for my future” [Student #7]; “Clinical experience on the labor and delivery unit” [Student #8]; “Working on the [obstetrics] floor at [xxx] and [pediatric] floor at [xxx] has solidified my desire to work as a nurse” [Student #9]; and “There was a time when I shadowed a pediatrician and saw how much nurses do for their patients and how much patients actually care about nurses” [Student #10]. Another student commented on the experience working with great nurses: “My internship this past summer motivated me to become the best nurse possible, because I witnessed so many not so great nurses on my unit” [Student #11]. Additionally, a nursing student discussed his/her interaction with other providers: “At my clinical site, there is a NP there that is amazing at her job and was always so willing to talk to the students and teach them and did not talk down to us. This has motivated me to be the best nurse I can and be understanding and not talk down to people” [Student #12]. Finally, “watching excellent nurses in their practice gave me the motivation to continue in nursing” [Student #13].

Seventeen percent of nursing students cited patient experiences as a common motivation for continuing in the major. Patient experience refers to a specific encounter that motivated the student to continue his or her education in nursing.

One Nursing Student Stated

During my pediatric clinical at [xxx] Hospital, I was motivated to continue my current career path by being able to care for children and help to improve their health. Children are more fragile and being able to care for them is very rewarding because not only are you caring just for them you are caring for their families. Parents are always in the child’s room with them and they need support and comfort as well. I like to think that I can bring this to the child and the family members. This is something that has made me feel like I really want to work with kids [Student #14].

Another student explained his or her motivation came from working “In [the] community learning about all the problems the people with a lack of health care face; and in [pediatrics] trying to have empathy for the family of a newborn who used drugs throughout the pregnancy, but is showing that they want to get better for their kid” [Student #15]. One nursing student broadly stated, “seeing the impact we can make on these patients and families not only physically but mentally is absolutely incredible” [Student #16]. Another nursing student commented, “when you are able to get through to a patient and make their time at the hospital better in some way, even if it’s the smallest way, makes it worth it” [Student #17]. Finally, students commented on continued motivation through the development relationships with their patients: “during my internship/clinical, I have taken care of patients that have showed me what the meaning of life is. I have taken care of people that will forever change the way I will work as a nurse” [Student #18] and “during my internship I formed relationships with patients and families that motivated me to want to finish my degree and start working ASAP and make a difference in their lives each day I care for them” [Student #20].

Self-validation was found to be a motivating factor among 17% of nursing students. Self-validation pertains to a student recalling a particular instance when a patient expressed gratitude or appreciation for the student and/or the care that was delivered by the student, which served as a source of motivation.

One Nursing Student Described a Patient Encounter

During clinical, I had a patient who was neglected because she had a lot of needs. Just taking some time to meet all her needs at once and go above and beyond satisfied her and she was truly grateful for the care I provided. She told me I would make an excellent nurse one day and this reaffirmed my decision to continue on this career path [Student #21].

Another nursing student recalled “I had a patient at clinical thank me for simply rubbing her back while she was in pain. She explained how much it helped her and it made me realize that even the smallest gestures as a nurse can be fulfilling” [Student #22]. Similarly, another student stated, “During clinical I had a patient who expressed so much gratitude for my care. They told me that my smile and presence had made their hospital stay so much better. This experience made me realize that what I do actually is making a difference in [people’s] lives” [Student #23].

A Nursing Student Expressed

I had a patient tell me he was so negative and was refusing treatment but when [I] came along he said my positivity and the connection I made with him changed his whole view of being in the hospital. He said he was now willing to participate and be more positive, and to me that is motivation in itself. The fact that I am able to help someone by having a positive attitude really motivates me to want to do more/ better [Student #24].

Finally, a nursing student recalls a specific patient experience and expression of gratitude that motivated him or her to continue in the nursing field:

When I was at clinical I had a patient who was going down for surgery on her arm. She was an 8-year-old girl and she was very quiet and nervous. I went down and helped perform preoperative care to her and remained with her throughout the procedure. When she heard word that I would be going into the OR with her she sighed with relief and told her mom and me that she felt so much safer and happy knowing I would be by her side the entire time and that I would be there when she woke up. After her procedure her and her mother came up to me and thanked me for being such a good nurse to her and making her feel comfortable and relieving some of her stress. It confirmed all the reasons I do my job [Student #25].

The fourth theme, reported among 11% of the sample, was altruism. Altruism refers to the desire to help and care for others, give back, and make a difference. A majority of the nursing students’ comments regarding altruism related to their interactions with patients. One nursing student commented, “…Seeing how much these nurses love their patients in some of the hardest times of their lives and providing them comfort and support is what motivates me to continue in the current career path I have choose” [Student #1].

A Nursing Student Reflected on a Specific Patient Experience

When I had a child [patient] in respiratory distress, I was so motivated and so focused. I saw a passion in myself that I had not seen before in adults. I had always cared and did my best, but this was different. I felt like I was really making a difference, and I was performing to the best of my clinical abilities. I felt like a real nurse, not just a nursing student [Student #2].

Two nursing students expressed altruism through their clinical experiences: “seeing all of the sick patients who I have cared for over the years makes me want to help more and more. We need nurses, as there is a shortage, and I want to be a good nurse who helps people feel better, even when they are sick” [Student #3] and “I saw how many lives I have changed and how much good I can do” [Student #19].

One Nursing Student Remarked

I entered this profession because I have a desire to help people. During [my medical-surgical clinical rotation] I had several patients [who] made me want to continue this career. For example, many of my patients had terrible infections that made them very sick and the nursing care provided to them is the only thing that will get them better. I’ve had patients that are elder and just need someone to listen to them and talk with them about the little things in life and that is what makes nursing so special, the power to turn someone’s situation around simply by being kind and listening while providing quality care (Student #4).

Finally, a nursing student commented “When I was at [xxx] and seeing neglect and abuse it made me want to care for these patients” (Student #5).

The final theme of clinical competence was recorded in 7% of the responses. Clinical competence refers to the student’s successful completion of a clinical task in the hospital setting or the application of educational material in the clinical setting. Some nursing students commented “I have given CPR to a child that was successful, it felt amazing to be [a part] of saving someone’s life” [Student #26], “when I started my first IV on the first try, it really showed me that I do have the ability to help a person” [Student #27], “learning new things and feeling competent in what I’m doing at clinical sites” [Student #28], and “I was motivated when I correctly diagnosed a new onset of crackles and reported it to the nurse” [Student #29]. Additionally, one nursing student stated that his or her motivation came from “…becoming better in my clinical skills throughout the years has motivated me… to become a nurse. Being able to succeed in clinical and in my courses shows me that I will be able to make it as a nurse in the real world and will continue to love my job” [Student #30].

Motivation from Class

Due to the limited number of responses with a class-based motivation, the only theme in this category is engaged professors, which received a 6% response rate. One student stated “Having professors and instructors that motivated me to do better. These professors lead by example in the classroom and outside of the classroom. They did this by teaching me and setting high expectations for their students. They also cared about my life” [Student #31]. Another student commented “after my first ever simulation, both of my professors complimented me on my performance and it gave me the confidence boost I needed to keep going” [Student #32]. Two students commented about their professors’ passion for nursing: “Seeing the success of my professors and their passion for nursing” [Student #33]; “Hearing instructor’s personal stories about being in the field, from their vast experience, really made me inspired to keep working hard through my first sophomore semester” [Student #34].

Across both the clinical and classroom, no students voiced any negative experiences or expressed a lack of motivation to continue in the nursing program.

Discussion

Students were intrinsically motivated to continue on their current career path through factors related to job-attitude, including self-validation, clinical accomplishments, and altruism. These intrinsic motivators were found to be more salient among our sample of college students compared to external factors. This is a significant finding as it could serve as a way for organizations to motivate nurses to continue in the profession. One of the common themes found among nursing students was altruism. Nursing students are drawn to the nature of their chosen profession, which entails a hands-on, direct approach to helping others and making a difference. Through their comments, students recognize the altruistic nature of the healthcare industry by expressing motivation to help patients.

Self-validation, clinical competence, and patient experience were three commonly reported themes. Students were motivated by the positive reinforcement they received from patients, a patient encounter, or successful completion of a nursing task or skill during their clinical rotation. Creating more opportunities for nursing students to interact with patients and practice their skills in a clinical setting could enhance the retention and motivation of nursing students. With the current state of the nursing profession, creating opportunities for patient experiences earlier in the nursing program or even at the high school level could increase enrollment and retention of students in nursing programs.

The alternative to intrinsic motivation is extrinsic, which in this study includes variables that pertain to the organization, work environment, and interpersonal relationships. The clinical experience provides students with a limited and superficial view of these organizations. Seventeen percent of nursing students reported motivators related to the organization, work environment, and preceptors at the organization in which they completed their practice experience. However, a true measure of these extrinsic motivators may not be accurately assessed until students become more immersed in and committed to an organization. One method of exposing students to the operations of an organization or unit within an organization would be to change the approach to education by requiring an internship, practicum, or clinical observation earlier in nursing school. Another option would be mandated volunteer hours in various organizations. These solutions could improve student retention in nursing programs and help students select a specific discipline or type of organization under the broad umbrella of potential practice locations. Furthermore, having earlier access to patients, via observation or volunteer opportunities, could inform students of the true nature of the nursing profession and motivate them to continue on their projected path.

The unanticipated finding in this study was that nearly half of the sample (48.94%) did not respond to the open-ended question. Eighty-one percent of this group were sophomores. Since, at the time of this survey, the sophomores had no formal clinical rotation, one assumption is that sophomore students are not motivated by coursework and/or do not identify their nursing classes as a motivator. When analyzing the responses of seniors only, 79% of the comments indicated clinical motivators compared to 4% class, and 17% blank, compared to the respective 5%, 9%, and 86% responses by sophomores (Table 4). These results stress the importance and timing of the clinical rotation. The curriculum is such that sophomore students do not have clinical rotations until spring semester, only coursework the first year and a half. One study concluded that their 21% attrition was a result of problems within the nursing program and due to students’ personal problems [7]. Receiving good grades and self-validation from professors may intrinsically motivate students to want to continue in a major whereas, receiving poor grades and struggling to comprehend the coursework may increase a student’s disengagement and ultimately lead to withdrawal from the major. With the nursing shorting entering unprecedented levels, retention of nursing students is a major goal, not only of nursing programs, but policymakers and healthcare organizations as well (Table 5).

Conclusions

Understanding student motivation for continuing in a major is critical for retention within programs and ultimately future job satisfaction within the profession. Differentiating between intrinsic and extrinsic motivators provides academic programs with the opportunity to make the most beneficial changes to positively influence retention not only in the program but also within the profession after graduation. Finally, understanding where and when in the curriculum motivation peaks could aid nursing programs in their efforts to improve retention and graduation rates. Future studies will analyze the role of early clinical rotations on nursing school retention and students’ motivation.

References

1. Bureau of Labor Statistics (2018) Healthcare Occupations.
2. American Nurses Association. Workforce.
3. Buerhaus PI, Skinner LE, Auerbach DI, Staiger DO (2017) Four Challenges Facing the Nursing Workforce in the United States. Journal of Nursing Regulation 8: 40-46.
4. Rosseter R (2017) The Voice of the Academic Nurse Fact Sheet: Nursing Shortage. American Association of Colleges of Nursing.
5. Institutes of Medicine (2010) The Future of Nursing. Focus on Education. Report Brief.
6. Andrew S, Salamonson Y, Weaver R, Smith A, O’Reilly R, et al. (2008) Hate the course or hate to go: semester differences in first year nursing attrition. Nurse Education Today 28: 865-872.
7. Ten Hoeve Y, Castelein S, Jansen WS, Jansen GJ, Roodbol PF (2017) Nursing students' changing orientation and attitudes towards nursing during education: A two-year longitudinal study. Nurse Education Today 48: 19-24.
8. Crary P (2013) Beliefs, Behaviors, and Health of Undergraduate Nursing Students. Holistic Nursing Practice 27: 74–88.
9. Turner K, McCarthy VL (2017) Stress and anxiety among nursing students: A review of intervention strategies in literature between 2009 and 2015. Nurse Education in Practice 22: 21-29.
10. McLaughlin K, Moutray M, Moore C (2010) Career motivation in nursing students and the perceived influence of significant others. Journal of Advanced Nursing 66: 404-412.
11. O’Brien F, Mooney M, Glacken M (2008) Impressions of nursing before exposure to the field. Journal of Clinical Nursing 17:1843-1850.
12. Newton JM, Kelly CM, Kremser AK, Jolly B, Billett S (2009) The motivations to nurse: an exploration of factors amongst undergraduate students, registered nurses and nurse managers. Journal of Nursing Management 17: 392-400.
13. Timmins F, King C, de Vries JM, Johnson M, Cullen J, et al. (2018) Altruism, Honesty and religiosity in nursing students. Journal of Clinical Nursing 27: 3687-3698.
14. Beck CT (2000) The Experience of Choosing Nursing as a Career. Journal of Nursing Education 39: 320-322.
15. Price SL, Hall LM, Angus JE, Peter E (2013) Choosing nursing as a career: a narrative analysis of millennia nurses’ career choice of virtue. Nursing Inquiry 20: 305-316.
16. Whittock M, Leonard L (2003) Stepping outside the stereotype. A pilot study of the motivations and experiences of males in the nursing profession. Journal of Nursing Management 11: 242-249.
17. Kersten J, Bakewell K, Meyer D (1991) Motivating Factors in the Student’s Choice of Nursing as a Career. Journal of Nursing Education 30: 30-33.
18. Volkert D, Candela L, Bernacki M (2018) Student motivation, stressors, and intent to leave nursing doctoral study: A national study using path analysis. Nurse Education Today 61: 210-215.
19. Elo S, Kyngas H (2008) The Qualitative Content Analysis Process. Journal of Advanced Nursing 62: 107-115.
20. Hsieh HF, Shannon SE (2005) Three Approaches to Qualitative Content Analysis. Qualitative Health Research 15: 1277-1288.