Choosing a Career in Community Health Nursing: Perspectives of Undergraduate Nursing Students

Background: There has been an increasing shift in patient care from the acute hospital setting to the community. Nurses play an essential role as part of the community health care workforce; however, only a limited number of baccalaureate nursing students tend to choose a career in community health nursing after graduation. There is currently a gap in knowledge surrounding nursing students’ perception of a career in Community Health Nursing and the issues influencing their career choice upon graduation. Purpose: To explore issues that influence career choice in community health nursing from the perspective of baccalaureate nursing students. Research Methodology: The study was guided by a descriptive qualitative research approach. Individual semi-guided interviews and focus groups were conducted with eleven nursing students and a group of key stakeholders to share their thoughts on pursuing a career in community health nursing and the factors that enabled or hindered their decision making. Thematic analysis of the interview and focus group data generated relevant themes. Findings: Two major themes were represented in the study: 1) societal trends and expectations, and 2) issues influencing career choice in community health nursing. Discussion and Implications: The personal and contextual factors influencing the perceptions and attitudes of students towards pursuing community health nursing are discussed. Existing literature was integrated into the discussion of the many factors that both motivated and hindered baccalaureate nursing students from pursuing community health nursing. The underrepresentation of new graduates in community health nursing calls for directed efforts by community health nursing organizations and the university to improve the situation. Discussions surrounding COVID19 and community health nursing are also discussed. surrounding


Introduction
Increasingly, client care has shifted from the acute hospital setting to the community as a result of multiple factors including aging population needing specialty care and the growing number of people living with chronic illnesses requiring monitoring. Community health nurses are well-positioned to lead efforts to address these shifting demographics in health care. Community health nursing builds on the generic practice expectations of Registered Nurses and identifies the practice principles and variations specific to communities in Canada [1]. Community health nurses "value caring, principles of primary healthcare, multiple ways of knowing, individual and community partnerships, empowerment and social justice" [1]. Community Health Nursing (CHN) is facing challenges in the education, recruitment, and retention of nurses [2]. This is even more problematic in the context of Covid-19 pandemic where timely and effective public health education is essential to flatten the curve of the pandemic and maintain some level of normalcy [3]. As evident in this new reality, there is significant need for skilled public health nurses to filter through the dearth of information in social media and other information platforms and provide the public with clear and concise messaging. There is an even growing need for community health nurses to be present in the community to assist with chronic diseases. We have moved to a world of telehealth, utilizing virtual visits. Nurses in community health can serve as a closer link between provider and client and reporting findings that deviate from the norm in a timely manner. Although the demand for community health nurses is growing, the training and preparation to meet this demand is not; students are not receiving adequate training to prepare them for practice in the field of community health nursing [2]. The Canadian Institute for Health Information's highlights from the 2019 pan-Canadian statistics on regulated nurses reports 15.6% work in community health sector [4]. While CHN trends has historically attracted older nurses [5], the number of younger nurses choosing CHN as a career is steadily improving [6]. The 1997-2007 National Community Health study identified community health nurses on average as being older than the rest of the nursing professionals and fewer younger nurses were entering community health nursing [5]. Similarly, Etowa, et al. assert that community health nursing workforce is growing closer and closer to retirement, and it is imperative to retain existing CHN workforce and to recruit more community health nurses [2]. To achieve this, it is necessary to create an atmosphere that fosters the commitment of nurses currently working in community health nursing and appeal to students who may choose a career in community health settings. While the word "client" is used to refer to the consumers of CHN, the word "patient" is used interchangeably especially when taken direct quotation from study participants.

History of Community Health Nursing
Historically, community health nurses have made significant contributions to the development of the health system in Canada over the last century. To begin, the roots of a formalized system of community health nursing in Canada date back to 1896, when Lady Ishbel Aberdeen identified emerging health and social needs and provided innovative services to help meet those needs [7]. In the late 1890s in Canada, there was a desperate need for doctors, nurses, and hospitals in remote areas and developing towns and cities where people were dying due to the lack of health services. To resolve this issue, Lady Aberdeen formed the Victorian Order of Nurses to travel to these areas and provide care [7]. Another influential community health-nursing leader was Janet Neilson, who became the first visiting nurse in Toronto in 1907. She cared for clients with Tuberculosis in their homes, school, and work areas. She also taught families how to care for their sick loved ones [7]. Provincial governments recognized the important role of nurses to help meet the needs of their communities and the first provincial public health nursing service was established in Manitoba in 1916 by five nurses. British Columbia, Alberta, and Saskatchewan were among the first provinces to appoint a public health nurse. The focus in these western provinces were child health stations in rural areas and the major cities as well as conducting home care nursing [8,9]. In the 1930s, maternal death was the second most common cause of death of women of childbearing age. Many children were dying before age one [10]. Through home visits, public health nurses in Ontario played a major role in educating new parents on healthy lifestyle choices and how to care for their new babies [10].
Worldwide, there is a growing burden of chronic disease. Chronic or Non-Communicable Diseases (NCDs) have become a leading cause of mortality worldwide and are responsible for 63% of all deaths yearly [11]. Chronic disease accounts for about 88% of total deaths in Canada [12]. In addition, Public Health Agency of Canada asserts that 51.6% of Canadians over the age of 20 are living with chronic disease, 14.8% are living with 2 or more chronic disease [13]. This increasing prevalence of chronic disease has profound burden on society. To address this burden of chronic disease in a cost-effective manner that is beneficial both to the health care system and to clients and their families, many health systems globally are shifting care from hospital to community settings [14]. This shift has been accompanied with technological advancement that leverage health data and enable community-based care to improve outcomes and reduce costs [14]. These include innovative health care programs such as the creation of community care clinics and outpatient clinics (where day surgeries and additional treatments or diagnostic testing are offered outside the hospital), have led to a reduction in hospital stays and an increased need for community health nurses.
Traditional workplaces have shifted to include diverse settings such as community health centers, schools, street clinics, youth centers, shelters, and nursing outposts. Also, the presence of diverse partners in these multiple health care settings has helped to address the health needs of specific populations [15]. For these community-based care models to be effective, a robust community health-nursing workforce needs to be maintained. As Etowa, et al., asserts, "community health nurses are educators, seasoned collaborators, skilled communicators, and critical thinkers, and their intimate knowledge of health in communities equip them with the skills necessary to close health equity gaps through more visible leadership roles at decision-making tables" (p.28) [7]. Their community-centric practice and advocacy work are essential in the delivery of community based effective and low-cost care for health care consumers. Thus, the need for more resources to strengthen community health nursing.
The research question that guided this study was: "What are Baccalaureate nursing students' perceptions on pursing community health nursing as a career?" The paper begins with the study purpose and objectives, followed by the research methodology and major findings. The major findings: societal trends, expectations and issues influencing career choice in community health nursing are presented and supported with narratives from the study participants. These findings are situated within existing literature. The paper concludes with lessons learned and key take away messages of the study including implications for nursing education and practice.

Literature Review
A literature review was conducted to obtain information relating to the perceptions of nursing students in relation to pursuing community health nursing as a career. This literature review was performed and divided into four main categories: the key challenges surrounding community health nursing, community health nursing curriculum in Canada, the preconceptions of nursing students about community health nursing clinical practicum and global recruitment and retention issues in community health nursing. There were a variety of electronic databases used to find various sources of literature included PubMed, CINAHL, PSYCINFO, and MEDLINE (OVID). Search terms and phrases included: community health nursing, public health nursing, nursing students, career choice, and decision making. Organizations such as Community Health Nurses Association of Canada and Canadian Association of Nursing Schools were also used as primary sources for information, as well as reviewing the reference lists of the articles used in the literature review.

Purpose
The paper describes the findings of a study that examined the reasons behind undergraduate nursing students' perspectives in choosing a career in community health nursing. To unpack and shed light on the reasons behind the limited number of undergraduate nursing students who choose a career in community health nursing, this paper presents the findings of a research study which has illuminated the societal trends and expectations as well as other issues influencing career choice in community health nursing. It explicates the reason for students' low interest in community health nursing and calls for serious dialogue on the issue among community health stakeholders, health care leaders and nurse educators. Community health care is an affordable type of care that is needed in Canada [16,17], given the country's aging population and the growing number of people living with chronic illnesses and requiring long-term special care in communities. This is even more critical in the current Covid-19 context. Evidence suggests that novice nurses are scarce in the community health-nursing field. Nurses are an essential component of the community health care workforce; however, limited numbers of nursing students choose to pursue a career in community health nursing upon graduation [2]. Although there is a growing need for community health nurses, students show no particular enthusiasm in embracing community health nursing as a career.

Research Design
Sandelowski's approach to qualitative descriptive design was utilized in this study. Qualitative descriptive study is the research approach of choice when straight descriptions of phenomena are desired to obtain straight answers to questions relevant to both health practitioners and policy makers [18]. Qualitative descriptive design is useful for describing phenomena or events in their everyday terms and it requires the researcher to stay close to his or her data [18]. It is often used in the exploration of topics where little is known. Thus, qualitative description is very well suited for this study given the limited available literature on the perceptions of baccalaureate nursing students on community health nursing as a career upon graduation in Canada. This section of the paper describes the sampling technique employed.
The primary sources of data were In-Depth Individual Interviews (IDIs) of undergraduate nursing students and Focus Group Discussion (FGDs) with nursing students, local nursing leaders, and community stakeholders. Eleven students participated in the in-depth individual interviews and two FGDs were conducted which consisted of 10 participants in each group. Semi-structured interviews were conducted using open-ended questions. Probe questions were used to encourage participants to elaborate on ideas and to disclose more detailed and meaningful information. Examples of probing questions are: "Can you tell me more?" or "How did that make you feel?" First and fourth year students were asked the same questions in the interview guide to generate information on any trends or changes over time as the students enter university and progress to their final year.  There were two focus groups that took place. Participants included students who participated in the interview process of the study, as well as members from community health nursing networks and organizations. Participants provided comments and feedback on the preliminary findings of the study, and it was the findings that helped guide the focus group discussion. This focus group provided a forum-type environment for participants to comment and provide feedback on preliminary findings presented. The focus group discussions were tailored in a manner to ensure everyone had the opportunity to contribute to the discussion, allowing for a range of views and opinions to be expressed and discussed.
The student participants were all females aged 18-23, representing two race/ethnicities (Caucasian, and Asian) enrolled into a 4-year basic Bachelor of Science in the Nursing program. There were first and fourth year baccalaureate nursing students who were recruited through the study 'poster' posted at strategic locations on campus. The researcher did not have any relationship to the students. Purposeful sampling technique was used to obtain rich data and ensure maximal variation or heterogeneity of the sample [19]. Purposeful sampling refers to the deliberate search for participants who are knowledgeable about the phenomenon of study, able to articulate the issues and are willing to share information [20,21]. Snowball sampling technique was also used to recruit participants over a period of nine weeks. Snowball sampling technique refers to use of existing research participants to recruit new participants [20]. Participants were recruited and interviewed over a period of nine weeks. All interviews and focus group discussions were recorded and transcribed verbatim. Six steps thematic analysis framework was used to guide the data analysis and interpretation. Analysis began with familiarization of the data. The audio recordings were reviewed, and data transcripts re-read several times to familiarize the researcher with the data and identify preliminary observations. Next, began the coding process, where data was analyzed and labels (codes) were generated and applied to data that was relevant to both research question and topic at hand. The next step included analyzing the codes and searching for common patterns in search for themes. Preliminary themes were created and again analyzed, which allowed for new themes to emerge and some of the initial themes to become subthemes. Next began the process of defining and naming each of the themes. Theme names were created in order to portray and capture a vivid story of participants. In vivo codes were used to create the title for some of the themes and sub themes. Random transcripts were provided to the researcher's supervisor to ensure the coding and analysis process was carried out correctly and matched the final emergent themes and sub themes; thereby establishing trustworthiness of the data. The trustworthiness of data and credibility of the research process were ensured by using Lincoln & Guba criteria, and these include dependability, credibility, transferability, and confirmability [22].
Dependability refers to the replicability of the study, meaning if the study were to be repeated in the same context with the same methods and with the same participants, similar results would be obtained. Dependability of this study was ensured by using data triangulation; this approach ensures validity of the research by using a variety of methods of data collection on the same topic. The multiple methods of data collection used in the study were the focus groups and interviews. In addition to multiple methods, a variety of different kinds of participants were recruited including both first and fourth year students as well as key stakeholders who were members of the University.
Credibility refers to how reliable the study findings are from the perceptions of the participants. To ensure credibility, the researcher position was clarified; worldviews, opinions, comments on past experiences, and personal thoughts were presented. In addition to researcher position, use of thick description was incorporated from the thoughts of participants during the interviews and focus groups. Furthermore, the use of an audit trail enhanced the trustworthiness of the collected data. Thick descriptions of both the data collection and analysis process were provided. These methods will allow readers to reread and develop interpretations derived from data. Also, a detailed log and thick description of the content analysis process were kept in order to go back and confirm the emergent categories and themes.
The use of member checking also ensured credibility. Member checking is the process of verifying the information, findings, and interpretations using the targeted group and receiving their feedback on the information they provided. Lincoln & Guba state member checking is the most critical technique for establishing credibility. Participants were provided with the study results, including analytical themes, interpretations, and conclusions, and were asked for feedback on the results and to assess if representations were adequate [22].
Transferability: refers to the extent the findings of qualitative research can be transferred to other context or settings. Transferability was ensured by using rich and thick description within the study. Such description allows readers to form individual decisions regarding transferability. In other words, readers develop judgments regarding to what degree the findings presented could apply to other settings and contexts [22].
Confirmability refers to the degree to which the results could be confirmed by others. Confirmability guarantees that the study findings are the experiences, words, and ideas of the participants and not of the researcher [23]. This criterion was ensured by acknowledgement of the beliefs and predispositions of the researcher. Confirmability was also ensured by data-triangulation which, as mentioned previously, dictates that multiple data collection methods are used, as well as the use of an audit trail.

Ethics and Protection of Human Rights
The researcher obtained approval from the University Research Ethics Board. This research study strictly followed standard protocol and procedures for research required by the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans.
Consent was obtained prior to engaging in any interviews or focus groups. Important measures were taken to ensure the confidentiality and privacy of participants. For example, pseudonyms were assigned to the study files of participants to prevent the association between the data and collected information and the participants. All study materials were stored in a secured and locked cupboard in the office of the researcher's supervisor at the University. Audio tapes, field notes, transcripts, and research codes with identifying information are each stored separately in a locked cabinet. Participants were reminded that the study was voluntary, and they may leave at any time or agree not to participate. Although the study subject matter is not highly sensitive, study participants were provided contact information for the University student support and counseling services in case they became emotionally distressed or upset during the interview. The potential benefits and risks of the study were reviewed with each student participant prior to each interview. Students were informed that they were unlikely to gain any direct benefits from participating in the study.

Findings
The participants were asked to provide their own definition of community health nursing. There answers varied from one student to the other; however, most participants define CHN as community-centered care rather than care of the individual. Most of the participants described CHN as working in several settings other than "hospital based" settings and included using health promotion as the basis of care.
In this paper, two major themes are addressed. They include societal trends and expectations, and other issues influencing career choice in community health nursing. An overview of these themes and sub-themes is presented in Table 2 below, and more details of each of the themes are then outlined following the 3) personal interests and family oriented lifestyle many students have expressed not wanting to do shift work for the rest of their lives and I think that is a big thing why they would choose a career in community health nursing and a huge factor attracting them to community health nursing later on, when we are older and maybe have settled, have families

4) supportive working environment
In the hospital, you have the support, especially being a new grad...you are just starting out and feel inexperienced, you want to be around people who will be able to help you...
I just find the whole nursing program so oriented and focused on hospital nursing, there are so many more opportunities outside of going to be a floor nurse, some people want to be more than a floor nurse...
Throughout the program, when we were doing all our courses, I was always interested in the preventative end, and I feel like I was not getting that out of my hospital placements…so I knew I needed to go into public health, to be able to teach about prevention.

5) pedagogy of teaching
People went to class but not with interest…they went to class because they needed to do well on the exams I just find the whole nursing program so oriented and focused on hospital nursing, there are so many more opportunities outside of going to be a floor nurse, some people want to be more than a floor nurse...
The positive feedback about pursuing community health nursing was from the clinical instructors who did community, the hospital nurses/teachers I found really tried to sway me...

Theme 1: Societal Trends and Expectations
Prevailing trends and expectations in a society play a major role in decision-making to pursue a nursing career. These societal trends and expectations have been categorized into the four subthemes presented in the table above. Details of these sub-themes will be presented next in the following order: 1) Hospital nursing as the "norm," 2) "ICU or ER nurses are cool," 3) National Council Licensure Examination (NCLEX) preparation and, 4) content and nursing graduate guarantee initiative opportunities.
Hospital nursing as the "norm." refers to the acute care environment most nurses typically work in and how students then desire this as the ideal model of nursing work to follow. Many participants indicated students felt that working in the hospital was the normal trend as opposed to pursuing a career in community health nursing. For example, one participant stated that "most people go into nursing because they want to work in the hospital because that is seen as the 'norm.'" Students tend to follow trends that other nurses set; in this case, most nurses work in the hospital, so this is seen as the setting for 'real' nursing care. Similarly, another student said: "when I think of nursing, I think of the hospital." In describing where her peers wanted to work yet another student participant stated: "I feel like a lot of my friends in the nursing program think that to be a nurse you have to be in the hospital, and they do not really care about community health nursing." Furthermore, a participant added that "I see [the] hospital [environment] as more of a medical side of nursing and that is what I wanted to do when I got into nursing; working with the sick as opposed to working with the healthy." In contrast, one student suggested that the interests in hospital nursing is motivated by other factors and some students who initially choose this kind of nursing may eventually leave that work environment. She recalled, "it is interesting because people are so quick to choose to consolidate in the hospital since it is a trend, but [then] realize that it is not for them and want to make a switch." Another participant suggested that the focus of nursing was slowly reverting back to community health nursing. She said: I think that everything is going towards community health nursing because if you invest in community health nursing now, you are not spending the money later on and I think the government is finally starting to realize that, so they are putting more money into public health nursing and public health nursing initiatives.
"ICU [Intensive care unit) or ER [Emergency] nurses are cool" as a sub-theme of social trends" refers to the nursing specialty areas that tend to be most popular career choices for students or new nurses. Participants suggested that there is a huge "technical focus" in nursing in the fast-paced areas where they can accomplish a variety of procedures. New graduates are attracted to these areas of nursing. One participant mentioned that "in the 1900s, public health nursing was so popular. So, the focus on what is 'cool and sexy' in nursing has changed, and it is not public health nursing anymore." Similarly, another participant added: ICU or ER nurses are cool…ICU nurses are great, and they do all these IVs [intravenous infusions] and all these cool procedures. Students want to be doing work similar to ICU or ER nurses. These are the areas of nursing currently drawing increasing attention from students and new graduates.
National Council Licensure Examination (NCLEX) preparation and content: This sub-theme highlights the role the United States examination board plays in Canadian nursing students career choice. Some participants explained this nursing licensure exam plays a part in where students decide to consolidate. Consolidation is a four-month clinical practicum experience that students decide to work in prior to the completion of their degree. This four-month practicum is not part of all schools of nursing across Canada, only some schools integrate this practicum into the curriculum. One participant indicated that: "students believe [that] because we have to prepare for the NCLEX now, we need to consolidate in the hospital so we can get more of this information to help with the exam." This sentiment of consolidating in hospital settings suggests that the perceived exam content relates to medications or hospital and client scenarios, and that student could do well on such exams having hospital experience as opposed to a community health nursing background. Participants explained that students from previous years give others advice on how to prepare for the nursing licensure exam. They explained that "we [they would] hear from the upper years that if you want to do well on the NCL, consolidate in a general medical or surgical area." Nursing graduate guarantee initiative opportunities, this sub-theme involves how the new programs supporting students' transition to the workplace upon graduation are available in abundance in hospital settings. The Nursing Graduate Guarantee Initiative allows new graduate nursing students to receive a sixmonth paid mentorship with a preceptor in an area of nursing of their choice. One participant explained that "if you consolidate in a general medicine or surgery area, you are most likely to get hired through the Nursing Graduate Initiative program." This idea suggests that students tend to consolidate in areas where they know they will be able to get hired through the Nursing Graduate Guarantee Initiative program and that such positions are fewer in community health nursing settings.

One interesting comment made by a participant was:
Now that we have started our consolidation, there are some students who are currently consolidating in the hospital and… contacting other students to find out about doing the Nursing Graduate Guarantee Initiative in Public Health. It is interesting because people are so quick to choose to consolidate in the hospital since it is a trend, but [then] realize that it is not for them and want to make a switch.
This could suggest that students are deciding to consolidate in a hospital-based setting based on current trend, however, after spending weeks in consolidation, the students realize it may not be the best practice setting for them.

Theme 2: Issues Influencing Career Choice in Community Health Nursing
In addition to the societal trends and expectations outlined above, there were several motivators and barriers influencing students' decision to pursue a career in community health nursing. This section describes the motivators and barriers influencing career choice under the following five sub-themes: 1) the nature of nursing work: community vs. acute care, 2) job accessibility and incentives, 3) family-oriented lifestyle and personal interests, 4) supportive working environment, and 5) pedagogy of teaching.
The nature of nursing work: community vs. acute care. This subtheme refers to all the characteristics of the nursing job, including the description, tasks, and type of work. The nature of nursing work has a major impact on career choice, both as facilitators as well as barriers. Participants provided examples surrounding the pace of work, holistic care, community health nursing skills, hospital nursing skills, teaching as a skill, as well as professional growth and development. The speed of nursing tasks was a barrier for choosing community health nursing as some students described community health nursing as a slowpaced environment and "uninteresting." One participant explained that "community was so boring and slow, it didn't compare to the hospital, where you are always on your toes, always moving." When asked about what attracted them to hospital-based nursing, another participant indicated that "working in the hospital, with your client workload, you have your work cut out for you; you kind of have an idea of what to expect in your shift." On the other hand, many participants explained that they enjoyed the "slow-pace" in community health nursing. One participant explained when describing nursing work in a hospitalbased setting: I realized I get overwhelmed by the acuity in the hospital. One patient is crying. One patient had IV antibiotics due an hour ago. One patient is going for a procedure…that is too much going on, too stressful, I cannot concentrate or do any critical thinking.
Another participant explained that "I find my peers think community health as easier in a sense because it's weekday work with holidays and no shifts, less stress." While another participant went on to say that "what I like more about community is there is less acuity, so I find it is not as stressful." When describing her community health-nursing placement, a participant mentioned: "I found when I started my community placement, it [was] very low stress…. I [felt] like the hospital, especially the patient nurse ratio, it seems like high stress on several floors." Other participants suggested that working in community health nursing enabled them to spend time speaking with clients. One participant described a scenario when taking care of a client with a lot of pain in a home setting and assessing pain management: The client told me he was taking the Tylenol here and there…I told him he could take the Tylenol every four hours regularly even if there is no pain, to keep the pain under control, and also take ibuprofen….If I was in the hospital, I would just give the Tylenol and ibuprofen...I do not even have time always to explain [why]. It appeals to me to be a guest in a client's home.
One participant touched on the fact that "[her] patients liked it more when I was just there and talking to them, rather than giving them something and leaving the room. I liked the aspect of just being there, but I couldn't be there when I have three or four patients." The participant further described the value of spending quality time with clients: I see a difference in the kind of care that you give when you have less patients, I do best with one on one and the patient gets more quality care out of it, if you have 6 patients on a night shift, you cannot provide the same kind of care as if you had only one patient.
Another participant added: "working in community health nursing is less stressful, maybe more laid back, but definitely a very important aspect to how healthcare works." When speaking of the nature of the environment in community health nursing, one participant stated: What really got me interested was the way you can organize your own schedule, that is what I noticed different about the hospital and different in community, being someone who is very organized, I like to work independently, and I found that as much as I like people and the hospital setting, you are very much on their time…versus in the community, you can have x number of patients and you're organizing your own time…and that really suited my personality.
Holistic care and professional growth. Some participants indicated that while working in community health nursing with clients, nurses better assess and evaluate their needs. One participant explained that "it's easier to see someone holistically. You can see the environment, see what they are doing…maybe someone is really stressed. You may say it is related to the illness, but really it's about her son being caught by police smoking pot." Another participant added that "people are more open to you when working with them in their community." This idea suggests that individuals feel more comfortable confiding in nurses when they are working in their environment and building a positive rapport with them.
Professional growth allows you to advance your skills and expertise and work to your fullest potential. One participant mentioned how she enjoyed the flexibility and variety within community health nursing. When describing her practicum experience, she stated: There is so much variety in community health nursing… especially in public health. You can move around internally and it's just amazing…I found in hospital you go into a unit, and you would kind of work with one general population, unless it is a split unit, but you know you would choose obstetrics or pediatrics and you would kind of stick with that…. In community, especially in Public Health…I loved every department, and you can overlap… me being in one department, I was still able to volunteer to do injections and other clinics.
Community health nursing skills vs. hospital skills. All the participants touched on the use of nursing skills and the major role it plays in pursuing a career in community health nursing. One participant explained that "originally when I went into nursing I thought of the hospital, doing injections and different procedures and working with patients." Another participant added that "I know a lot of people are interested in getting their nursing skills and that is another reason people are not starting off in community health nursing." When describing her complex care practicum, one participant stated: I was in cardiac surgery and I had a good experience, I inserted IVs, I did blood work…. Some of my friends did not have that opportunity, so I think maybe if I had not gotten as much skills-based as I did during my complex care practicum…I would have pursued hospital-based career.
The statement this participant provides suggests that if students felt they did not have the chance to practice these 'handson skills' or develop the experience they needed, they would probably look towards medicine or surgery as a career choice. Another participant stated that, "the big thing is you are going into community, you will lose your skills…I never really cared about that. If I want to go into community later, does it actually matter, for my end goal?" On the other hand, many explained that there were skills involved in community health nursing, which were not necessarily hands-on skills and "much harder to acquire." One participant stated: In community health nursing, you are also acquiring an entirely different set of skills, things like communication and program development, those are much harder skills to acquire, you cannot really follow your textbook and learn how to do that, that is something that takes time.

Another participant explained:
It [is] a different kind of hands-on skills we use in community health nursing, like presentations, working within groups, a lot of teaching/health promotion, interventions…it is a set of skills that we need and use, it's just different from 'hands-on' skills.
Yet another participant added that "I was not really into learning all the 'hands-on' nursing skills that are out there…skills [are] not nursing." One participant when describing home health care mentioned: You can do IV antibiotics through PICC line, start peripheral IVs, chemo symptom management, evaluate diet, also you can make calls to the physician to make changes to orders…maybe students do not know you can practice all these 'hands-on skills' in home health care because it was never discussed in class. All these statements suggest that 'hands-on' nursing skills is a very subjective term and nursing skills are actuality found in any area of nursing.
Teaching as a skill. The ability to have time to teach in community health nursing was seen as a motivator to pursue community health nursing for many participants. One participant explained when describing her maternal health practicum: There was an element of the maternity clinical I really enjoyed and that was the teaching…You go to be a teacher as well as a healer, so going into community health, a lot of it was prevention, bringing information to a community that is not sick yet…and I love community health nursing for that.

Another participant added:
I was very passionate about obstetrics, and I found when I was doing teaching, it was my favorite part, and unfortunately, I found there was not enough time to do the teaching in the hospital and that frustrated me and I heard community health/public health you do a lot of teaching and that was what I liked about nursing.
Yet another participant noted further that: Throughout the program, when we were doing all our courses, I was always interested in the preventative end, and I feel like I was not getting that out of my hospital placements…so I knew I needed to go into public health, to be able to teach about prevention.
Job accessibility and incentives. Participants described job accessibility and salary as playing a role in decision-making for career choices. Participants suggested that some students made decisions for the future based on what is currently available in the job market. One participant explained that "students do not want to go into community health nursing…they want to go to an area of nursing where they can get a job right away. Everyone knows hospital jobs are easily accessible and easy to get to postgraduation." Another participant added "I am currently searching for jobs in community health nursing, and I am not finding much jobs … this could be a negative aspect not drawing people, since there are no jobs in community health nursing." When asked how she will make a career choice, one participant stated that "I think the biggest thing is as soon as I graduate what types of jobs are available? Where can I work? Because I am not starting off with tons of experience, so whatever I can get, I will take." One participant added that "a lot of students feel that if they go into a medicine or surgery area, they will have a safe set job right afterwards." The sentiment of this participant suggests that students are making career choices upon graduation based upon the type of jobs that are available.
Salary and appropriate incentives play a major role as deciding factors when it comes to making career choices. One participant stated that "I think the wages in community health nursing may be less than hospital …people want to start working right away, start making money and be able to do things, pay off student loans, or purchase a car." While another participant added: "hospital tends to pay more and provide different sign on bonuses or better benefits." Personal interests and family-oriented lifestyle. Personal interest was another driving factor in decision-making for future career choices. One participant explained that "whatever my interests are will be a huge factor for career choice … if I like oncology, I will go into that or say I really enjoy pediatrics...that's how I will make my decision." When speaking of what attracts her to community health nursing, one participant explained: To be honest, I always thought I would do ICU, like hospital nursing…I always wanted to do that. What swayed me was I did a research project in third year, I got a taste for research, a kind of a different area of nursing, that I did not know existed…So I started looking into what I really enjoyed. I started looking into other areas of nursing that were similar to research, I started looking into public health…It touched on research in a sense that you needed to have a good foundation for whatever intervention you are going to do.
Alongside personal interests, participants also indicated that choosing a career that was in line with their future family goals played a role in the decision-making process. One participant stated: I worked shift work during the summer…It was difficult at times, but it also had its advantages…but the type of schedule you can have in community is very appealing…especially as a woman and knowing that you want to eventually have a family, it would be ideal.
Another participant added that "many students …expressed not wanting to do shift work for the rest of their lives and I think that is a big thing why they would choose a career in community health nursing and a huge factor attracting them to community health nursing later on, when they are older and maybe have settled and have families." Supportive working environment. Another deciding factor in pursuing a career was the work environment, this served both as a facilitator and barrier in choosing community health nursing. One participant explained that "in the hospital you have the support, especially being a new grad…you are just starting out and feel inexperienced. You want to be around people who will be able to help you out." While another participant described: I just like working with people that I can actually communicate with…in the hospital some people may be really sick to the point where it is really hard for them to communicate and so I like that aspect of communicating with them.
Another participant added that "I like the hospital and all my placements there…but I love the idea of going into homes or the community setting, just a different environment…. I think in general, when you think hospital…it is not a very happy place." When asked about what in community health nursing was appealing, one participant stated: Everything that is community health nursing is more much more interesting and appealing to me personally. I like working at the hospital and I can do it, but I find it more rewarding seeing the changes that community health nurses have on people. Even something simple as the community health nurses immunizing children and how much of a change that has made in our society and the health of our population. …It is something so simple that I feel people forget about, but it has made such a large impact and I think that a lot of the things [community health nurses] are doing are making a large impact but it just does not seem like it right away.
Pedagogy of teaching. The participants expressed the art of teaching and delivery of course material as having a major impact on decision making when it comes to pursuing community health nursing. The concepts of 1) delivery of theory course, 2) curriculum development and clinical refinement, 3) early exposure, and 4) access to role models, and will be used to describe the impact teaching has on the decision-making process. These themes Delivery of theory course. When asked if the theory course has an impact on future career choice, one participant expressed that "I think it definitely does, if you have a good professor, you would also feel motivated to learn and enjoy learning the subject. Also, when someone is passionate about what they are teaching you also become passionate about what you are learning." Other participants suggested the theory, professor, as well as delivery methods had an impact on fostering interest in community health nursing amongst graduating students. One participant explained "students had extremely really negative views about it…but I am kind of in the middle, because I feel like the professor meant well, but the prof was pretty much the reason I think that community health nursing is just a laughing thing among my graduating class." Another participant continued this sentiment as she explained that "the questions that the prof asked, no one really felt like they were extremely relevant to community health nursing. A lot of people left the course and felt like 'I don't feel like I've learnt anything about community health nursing.'" One participant added: We had a terrible experience with our theory course professor, exams were not relevant to teaching, exams were very specific situations to what you would find in the news, it was not a global image of community health nursing…It was just a very bad course, so we had a really bad experience with the course so people would say things like 'all I learnt is that I am never going into community'…'community is stupid'…'I hate community'.
Other participants described exams within the theory course and felt "that there was no context to community health nursing and students would ask 'why am I learning about this.'" Some went on to say that they "were not exposed to enough areas in community health nursing" or "it was only from the perspective of the prof and what he had his interest in." When describing the course content, a participant explained that "the class was not really geared on the roles of community health nursing or what you can do in community health nursing. It was very much focused on socioeconomic factors, determinants of health, research." Another suggested that "people went to class but not with interest…they went to class because they needed to do well on the exams." This implied that exam material was possibly only available by attending the theory classes and students felt that was "a way to eliminate absenteeism." One participant explained: There was actually this one time nobody went to [community health nursing theory] class and a prof came to yell at us about the importance of going to class and necessary for our class requirements, after that more and more people also started going to class.
When speaking about the community health nursing class atmosphere, a participant described: You would be sitting in that class, and you would look at everyone's computer and they would be on Facebook or browsing the internet or whatever else they are doing…and no one really gave that teacher any respect, and I felt bad at times because I think the prof meant well but the prof did not convey the information well and people didn't care about it or have an interest in it.
Curriculum development and clinical refinement. In regard to fostering awareness and increasing interest in community health nursing, participants had much to say in relation to curriculum development and clinical refinement. When reflecting on the fouryear nursing program, one participant expressed that "I just find the whole nursing program so oriented and focused on hospital nursing. There are so many more opportunities outside of going to be a floor nurse…I wish the university would focus more on community health nursing." Another participant expressed that "the care you receive in the hospital isn't like the end-all beall and community health nursing affects people's well-being too". She further suggested that other courses could incorporate community health nursing components into their curricula (i.e., maternal health). When referring to course content one participant expressed that "there was a lot of American content in the course, and I feel like that it would be better to incorporate more Canadian context to our theory course." Many participants suggested making major changes to clinical practicum placements could have an impact on decision making in career choices. One participant suggested that "I thought revising the placement…make a huge impact on people's interest in it because I like community health nursing and I did not like that placement very much." While another participant stated, "by fourth year, you expect that you are just going to be doing more, it would have been more interesting to work with the community health nurses, not be like sitting at a desk and stuff." Participants felt having community health nursing preceptors take students into the field and allowing them to play the role of community health nurses could make changes and inform the choice of students on pursing community health nursing as a career. One participant mentioned that: Clinical placement is a huge thing to get people motivated into what they are learning and nursing students are not like other students, where they are studying in the library 24/7…because you have placements and you have so much hands-on experience in this program and nurses enjoy being with people, so like the people who were on excel spreadsheets for 12 weeks in the community health nursing, we want to be working with people…that's why we went into nursing, students want to interact with people, so placements need to be adjusted…and placements need to be more nursing oriented.
Another participant added that "we need to find clinical placements that are more engaging and can have an impact on our learning experience…not just placed in any type of clinical placement for the sake of doing clinical." When describing ways to make changes to clinical practicum, a participant explained: Perhaps even splitting up the days we go to clinical, instead of every Thursday, maybe there would be more placements opportunities on other days, like I know the program I was in was also offered on Wednesdays but because there was no placement that day, there were only 2 students in this program, so it is very limited. I am sure there would have been many more people that could have enjoyed it, maybe even have some kind of rotation that students have the opportunity to change placements throughout the semester and see different areas in community health nursing, which I know, would probably be very difficult. Nonetheless, participants felt revamping clinical placement opportunities is vital in order to foster interest in the students during the nursing program.
Early Exposure: Participants suggested they could benefit from having early exposure to community health nursing within the nursing program. One participant explained in regard to fostering awareness in nursing students: I think the university should start with awareness in the beginning of the program; we should be presented with the different jobs and specialties within nursing. There are so many jobs and different things you can do with the nursing degree, even in community health nursing, so I think if this is presented earlier on students will have awareness and it could attract appeal and students could have interest in it right from the start.
Another participant expressed that "I did not know community health nursing existed until third, maybe even fourth year…community health nursing does not have to be a fourth-year course." While another participant suggested "I think that when they decided to teach the theory [within the curriculum] it has an impact, because we were not exposed to [community health nursing] until fourth year, so people had already decided based on previous placements what their interests were." Another participant suggested "I think it would be most beneficial to have the theory or placement earlier on, maybe second or third year because students would have a better idea of what community health nursing is and possibly have more interest in community health nursing." One participant added: When you think of the different areas of Nursing, community health nursing is not one of the first ones that come to my mind at all. So, letting us know straight from the beginning of our nursing program and introducing us to community health nursing could create more interests in students in the long run.
A participant explained that perhaps more people could have possibly wanted to pursue community health nursing, at least for consolidation; the timing, however, of choosing consolidation fell just after a week or two after the start of the community health nursing clinical. She explained: I think that because we had to pick our consolidation in September, we were not exposed to community health nursing enough to be able to decide whether we would want to pursue community health nursing for consolidation, I think it would benefit [us] if we were exposed to it earlier in the program.
One participant also touched on the amount of exposure to community health nursing. She stated: Maybe we need to have more than one term of community health nursing, maybe we could do community health nursing rotations twice within our undergrad program, I know that would involve a lot of shuffling of current course sequence, but I think early, and sufficient exposure is necessary.
Having the opportunity to fully understand community health nursing and its principles and having the time to appreciate this area of nursing could be achieved by changing the theory course from a final fourth year course. All participants expressed that early exposure could have a major impact on both their learning experience as well as clinical experience. The timing of the course within the curriculum as a final fourth year course did not seem well situated as described by participants.
Access to role models. Another important factor informing the decisions of student is that of role models. One participant explained that "many of the perceptions of community health nursing come from the people higher up…like the professors, clinical instructors…those are the type of people that give the most influence in choices and where to go." When trying to make a decision about career choices, one participant said: I would tell my clinical preceptor [where I want to work] because they always ask, 'where do you want to go' and I would tell them community health nursing, they would tell me 'why would you do that, you are not going to get your nursing skills'… even other faculty members would tell you that.
Another participant expressed that "the positive feedback about pursuing community health nursing was from the clinical instructors who did community, the hospital nurses and teachers I found really tried to sway me or to change my mind." This reality could suggest that some of the stigma arising from pursuing community health nursing is not originating from peers alone; nurses working in other areas also contribute to these ideologies. When describing her experience of speaking with a clinical instructor about her goals, a participant stated: I had a favorite clinical instructor and I remember approaching her and she was really encouraging me to go into a certain area of hospital and I really respected her and looked up to her, I remember the last day during our evaluation, I opened up to her and told her I wanted to do community and she told me 'well you would be really good in hospital…you know if you go into community you can never really come back'…so I was discouraged about that.
Another participant went on to describe the influence clinical instructors and preceptors had on her decision-making: [Clinical instructors and preceptors] say 'you are good in this…maybe you should choose a career in this…and by the time the community health nursing placement comes around, the students' thoughts have already been formed to a certain way…it is too late by then. This statement this student provided suggests that the opinion of a role model is quite influential on the decision-making of students, alongside the timing of the clinical placement, as mentioned in the previous section. When speaking about finally making her decision to pursue community health nursing for both consolidation as well as a future career, one participant explained: The school [NAME OF INSTITUTION REMOVED] actually has really good connections; we have a liaison nurse here and I got through the school the ability to talk to people, even though I found a lot of stigma surrounding community health nursing from faculty and staff, they were willing to give me resources to talk to people. I met over the phone with public health nurses; I think I spoke to five different departments, to different nurses-School Age Health Program, Healthy Learning, Health Baby Healthy Mothers Program…they got me in contact with nurses working in those areas and I got to talk to them. I asked, 'What do you do?' 'What were the challenges of your job?' 'What are the advantages, your daily work routine and description?'…it was really helpful.
In regard to ways of increasing awareness and motivation to pursue community health nursing, many participants thought it beneficial to incorporate more guest lecturers during the theory course. One participant stated: I think having a guest speaker come in and talk to us and say this is really what community health nursing is all about and this is what my day looks like…I think that it would inform a better understanding of community health nursing by having guest lecturer come in from different areas in community health nursing to show us what exists outside hospital nursing.

Another participant explained:
Attending the theory class, you did not really get to see what community health nursing really is and then with placement you also do not get to see what community health nursing is, so people totally do not know what to expect, so I feel more opportunities to learn about the reality of community health nursing would be good from actual community health nurses.
Yet another participant suggested ways of fostering interest amongst undergraduate students in community health nursing: Bring in people who are actually working in community health nursing, bring a nurse working with Healthy baby, Healthy Mothers Program to talk about her experience, bring in a nurse from the Mental Health Outreach Program or bring in a Communicable Disease nurse…One thing I would have to say about this teacher that he did well is he brought in a nurse from the Needle Exchange Program that worked on the van and worked with giving out needles and after that class people were like 'I want to do that job, I want to do what she does'. That was the only class people were so involved in, so if you want to change the minds of the students, bring in more guest speakers who are actually community health nurses, there are so many areas in community health nursing, they can come in and tell their own stories, describe what they actually do.
When discussing the Nursing Job Fair held at the University that provides nursing students the opportunity to see what nursing employment opportunities exist, one participant suggested: I think it's a good opportunity for community health nursing to be there and represent the type of jobs you can have, so when second-or third-year students go, they could have that early contact. I do not remember any community health nurses being there when I went in second year.

Discussion
The results of this qualitative study have illuminated the voices of nursing students in terms of factors that influenced their decision to choose or not to choose a career in community health nursing. These include perceptions, skills, attitudes, and knowledge that baccalaureate students have in relation to pursuing community health nursing as a career. Students show an overwhelming interest in hospital nursing, but they are less keen to become community health nurses. According to Betony and Yarwood, this in part may be due to the heavy focus on hospital-based nursing in current nursing programs and the lack of suitable community-based practicum sites, which leads to students not being well prepared and knowledgeable of the field of community health nursing [24]. There is a need for nursing educational programs to place more emphasis on competencies that are core to community health nursing, including decision-making, quality improvement, and leadership competencies. Curriculum development will ensure students are being taught the essentials and elements of community health nursing. Nursing leaders in community health nursing need to be involved in curriculum development/planning. The Community Health Nurses of Canada (CHNC) have recently updated the Standards of Practice for Community Health Nursing through scoping review of literature, focus groups and modified Delphi Method [1]. These standards include key indicators such as 1). Professional responsibility and accountability, 2) prevention and health protection, 3) health maintenance, restoration, and palliation, 4) professional relationships, 5) capacity building, 6) health equity, 7) evidence informed practice, and 8) professional responsibility and accountability. Using these standards as a framework for curriculum development and to guide exposure of undergraduate nursing students to the full scope of community health nursing practice may increase their knowledge of the field. As highlighted in Etowa, et al. undergraduate nursing students have very limited understanding of the full scope of community health nursing practice [2]. While one could make the case that J Community Med Public Health, an open access journal ISSN: 2577-2228 community health nurses have an equally demanding job as nurses in hospital settings, nursing students described community health nursing, as not 'real nursing" and an area of work better suited for older nurses [2]. This is congruent with Van lersel, et al. who found that some students described community health nursing as challenging and meaningful work due to the variety of caregiving roles and the opportunity to work independently [25]. Van lersel, et al. found that 71.2% of first-year nursing students prefer the general hospital and only 5.4% in community care. These students viewed community care as a 'low-status-field' for the care of the elderly with few opportunities for advancement [25]. Familiarization of undergraduate students with the CHNC standards of practice will ensure that upon graduation, they have a well-grounded of the field and more students may be motivated to pursue a career in community health nursing.
Undergraduate nursing students need to be introduced to some of the 36 core competencies a public health practice [13]. Some of the core competencies include but are not limited to: 1) implementing a policy or program or taking appropriate action to address a specific public health issue, 2) using skills such as team building, negotiating and conflict management and group facilitation to build partnerships, 3) interpreting information for professional, non-professional and community audiences, and 4) determining the meaning of information considering the current ethical, political, scientific, socio-cultural and economic contexts. These core competencies are clearly beyond the scope of entry-level community health nurses. However, within the nursing profession, there is recognition that all new nurses entering into clinical practice need a minimal set of competencies related to public and population health needs for all Canadian communities. These competencies have been articulated by the Canadian Association of Schools of Nursing [26]. The entry-to-practice public health nursing competencies include five domains that all undergraduate nursing students are expected to exhibit upon completion of their nursing program. The five domains include: 1) public health sciences in nursing practice; 2) population and community health assessment and analysis; 3) population health planning, implementation, and evaluation; 4) partnerships, collaboration and advocacy; and 5) communication in public health nursing. Within each domain are three to six indicators on which nursing students can be measured to determine whether they have met minimal levels of competency [26]. Emphasis on community and public health competencies is not to say that clinical nursing in acute care settings and the skills nurses in acute care settings possess do not have value. The focus, however, should not entirely revolve around "hands on" nursing. Keleher, et al. stated that nursing education has focused on preparing graduates for work in acute care settings [27]. The Institute of Medicine reiterated similar statements and added the ways in which nurses were educated during the 20th century are not adequate for dealing with the realities of health care in the 21st century [28]. More education of nursing students about public health crisis such as the current Covid-19 pandemic is an imperative for nursing education programs and policy makers [29]. Similar opinions were echoed in this current study as participants revealed parallel opinions expressing that the nursing program is designed in a way to prepare graduates for an acute care nurse position.
In addition to curriculum content, how we teach undergraduate nursing students (pedagogy of teaching) was also identified as having negative influence on students' career choice in community health nursing. Faculty members, clinical preceptors, instructors, and other nurses play a major role in helping motivate student as they make the difficult decision of choosing a career in nursing. There is a need for nursing educators to bring creativity to the teaching environment including role models as guest lectures to bring different perspectives to students, drawing upon their own personal experiences, perspectives, expertise, and knowledge. Guest speakers have the potential to enhance the learning experience of students and can serve as a great tool for inspiration. There is great importance associated with bringing creativity to the classroom environment [30]. Participants also stated that having access to role models could have a positive influence on students' decisions to pursue community health nursing as a career. This idea is supported by Gibson who explained that role models as vital in the decision-making process when persons explore career options [31]. Other studies have also shown a relationship between the influence of role models and career indecision [32], career aspirations [33], and career choice [34]. Wright et al. surveyed 146 medical students from McGill University to explore the relationship between clinical role models during medical school and the choice of clinical field for residency training [35]. They found that the choice of residency training of students was strongly influenced by their role model. This correlation is supportive of what participants in the current study suggested on how role models could help foster interest in community health nursing amongst undergraduate students. In addition, that the timing of the community health-nursing course and practicum served as a barrier for students to pursue community health nursing. While CHN is currently being taught in the 4th year, perhaps the key values and principles of CHN should be emphasized in earlier years of the program under the umbrella of the social determinants of health. Community health nursing, which is currently taught in fourth year, could be offered in the first year of the program. This will take into consideration students need to appreciate and integrate the knowledge learned in earlier years into the remainder of the program. Branstetter, et al. studied whether introducing radiology in first year of medical school had an impact on the attitudes or knowledge of medical students on the principles of radiology [36]. Their findings suggested that early exposure to radiology in the first year of medical school improved overall impressions of radiology as a specialty and increased interests in choosing radiology as a career. It is possible that early exposure of students to community health nursing could have a positive impact on the interest of students and their subsequent decision to pursue a career in this field.
Nursing leaders in administrative roles also play important role in creating a conducive quality practice environment to support nurses' practices, the education of students and the conduct of research, which ultimately positively affect the quality of health care [37]. Based on their results of their study of undergraduate nursing students, Lai, et al. urge educators and administrators to reconsider the way-nursing students are educated, in order to enhance students' interest in choosing nursing as a career [38]. Similarly, Shih and Chuang found that student nurses' career choices were influenced by work environment, nurse's professional role, self-professional knowledge deficiency, nurse's professional knowledge, and patient's and family's good feedback [39]. While these studies refer to nursing as a profession, they all highlight the issues that are problematic for the nursing students in our study, which focused on community health nursing.
Technology is another factor influencing students' preference for hospital work setting. Currently, the focus is a more technical and technologically enhanced aspect, including working in hospital-based environments and in areas such as ICU and ER, where nurses are working in fast-paced environments with all sorts of unique and highly specialized equipment. Stevens et al. studied the interest of students in pursuing mental health nursing, which revealed that nursing students continue to graduate believing that work in areas associated with the manipulation of technology and specialized equipment are high status and rewarding areas of the nursing profession [40]. Similarly, Van Iersel, et al. systematic review found that students prefer hospitals as a place of work, because of the acute nature and technologically advanced level of care available [25]. On the hand, the students in their study found community health nursing to be unattractive due to its chronic care profile, with limited technical skill, untrained workers, and a high workload [41]. Kiger explored the image of nursing among Scottish nursing students and found that their view of nursing was that the medical-surgical environment represented 'real' nursing. This image is still an ongoing view of nursing, as suggested by the current study's findings. There could be a social pressure for some nurses, upon graduation, to follow the trend and work in a hospital-based environment, where all nurses want to work in. Social pressure causes people to change their perception of reality and leads them to conform to a situation that may be different from what they originally desired. Krumholtz, et al. explained that one category influencing career decisions is environmental conditions and events; these factors are outside the control of any individual and usually a result of social, economic, political or cultural factors [42]. Smith explained the reasons why medical students did not choose to do their residency training in internal medicine [43]. As a residency and clerkship director, Smith had the chance to speak with several medical students and found one who chose internal medicine because he felt obligated to do so to avoid letting his classmates down. Other students reported feeling a sense of peer pressure against choosing medical fields involving primary care and felt embarrassed to let their peers know of their interest. This situation is similar to the findings of this study, where participants suggested that many may have had an interest in community health nursing, but emphasis is placed on hospital nursing as the "norm". Peer pressure may also be a factor in relation to the licensing examinations. For example, students' choice of clinical placements was driven by information from their peers. They selected areas like medicine and surgery for their four-month consolidation placement in order to succeed on the nursing board exam, the National Council Licensure Examination (NCLEX) based on feedback from senior nursing students.
Finally, personal interest also plays a major role on the decisions about career choice of the students. Ko, et al. explored the factors that influenced the career choices among 118 medical students, residents and physicians, and found that personal interests and previous experiences were identified as the most influential aspect in career choice [44]. Also, students believed that a career in community health nursing would allow for a family-oriented lifestyle. Similarly, participants in this study expressed how a career in community health nursing would be more appealing, as the hours of work would be more convenient for someone with a family, because it would be a typical "9-5 to job with no weekends, no shift work." While most students in Van Iersel, et al. study preferred hospital work, a few students found mental health and elderly care as appealing [25]. Students' personal interest was also identified as a dominant factor influencing career choices of students by Sharif et al. [45].
The participants sampled in the study were in their first and fourth year in the program. As students progress through the program, their idea of where they would like to work upon graduation changes due to their experience in different clinical practicum. Early introduction to CHN and another practicum towards the end of the fourth year of the nursing program could help guide their decision in choosing CHN as a career.

Implications for Nursing Research
Globally recruitment and retention issues for community health nursing have been reported in several countries [2,46,47], including the United States and Australia. In the United States, Moon, et al. implemented a project to increase the number of students choosing a career in public health [47]. They indicated a need to foster interest in community health nursing because nursing care has shifted and is now concentrated on populationfocused care rather than acute care. In their study, they observed that in the prior year, only 2 students had indicated interest in pursuing community health nursing, the following year after implementation of the project, 40% of students indicated an interest in a career in community health nursing. Their study suggested through adequate focus on public health nursing in the curriculum, as well as, strategically planned and managed clinical placements, a remarkable interest in public health nursing careers can be achieved. The findings from the current study are similar to what was reported in Moon, et al. study regarding the need for proper education and revision of the nursing curriculum to place equal importance on all areas of nursing specialization [47]. Recommendations suggested in this study can be replicated nationally and internationally to assist in fostering interest in community health nursing among new graduates.

Implications for Nursing Education
Students who participated in the community health nursing study expressed feeling unsatisfied with their clinical learning experiences. Some participants reported being put in placements without a nurse as a clinical preceptor to guide them along the way and others perceived that they were doing non-nursing tasks. In both cases, participants perceived these realities of their clinical placements as preventing them from enacting the role of an actual community health nurse. The issue is that they are often sent to nursing placements with little surveillance and asked to design a project geared at creating an intervention to solve a specific community or population health issue without ever interacting with clients. Students are not always able to apply any value to their role, as they do not feel valued in their placements. Walker, et al. conducted a study in Australia that revealed that positive role models, belonging, peer support, critical thinking abilities and confidence all play a role in how nursing students construct their nursing identity [48]. For most of the participants in this study having a sense of belonging and positive role models to assist them along the way and show them that they are part of the team are ways to help build their nursing identity. Due to preconceived ideas and opinions students have before entering the community health nursing clinical placement, there is a critical need to create clinical placements that allow students to properly enact the role of community health nurses and work alongside experienced community health nurses for a conducive and long lasting positive clinical experience.
The other issue that needs to be taking very seriously is the timing and amount of exposure of the community health nursing clinical practicum. Students are exposed to community health nursing in the final year of the program, first semester, 8 hours a day, once a week for a period of 12 weeks. Participants suggested early exposure as one of the factors that could foster interest in community health nursing amongst undergraduate nurses. Having two semesters or more of community health nursing or changing the timing of the community health nursing theory and clinical courses may boost students' ability to fully capture the principles and foundations of community health nursing while securing its core competencies into their clinical practices. Whether community health nursing is introduced in the first, second or third year of nursing, the findings suggest that having the course in the final year could have negative impacts on pursuing this CHN as a career. Other ways to help prepare nursing students for practicum and for them to properly integrate theory into practice is simulation. Simulation is an evidence-based practice that has a positive impact on nursing students' confidence, satisfaction and learning experiences [49]. Chircop and Cobbett implemented a computer based virtual simulation in a community health nursing clinical. Students felt that the virtual simulation allowed them to achieved course objectives and enhance their learning experience [50]. The authors suggest the use of a combination of both virtual simulations and agency/neighborhood placements to have a positive impact on the clinical experience and allow them to practice their skills.
Besides changes that are needed in the way clinical placements are done, change in curricula is also vital. Participants suggested lack of interest in their community health nursing theory course for several reasons including the style of teaching, the course delivery method and exam contents. It is possible that students lack the ability to align theory to practice and because of their preconceived notions about community health nursing are unable to open their minds to efforts to enlighten them about the linkages between community health nursing theory and community health nursing practice. Perhaps it is because their placements do not allow them to do so, or they do not understand the principles of community health nursing and therefore are not able to apply them to their community health nursing clinical practicum. The latter would be corrected by lengthening exposure to community health nursing, whether it is two terms or revamping the entire nursing curriculum so that other courses within the nursing program incorporate concepts such as the principles of primary health care and how those principles are essential elements to all aspects of nursing practice not just community health nursing. One participant suggested that the entire nursing program is geared towards hospital nursing. Perhaps it is time to change the schools nursing curriculum to include more emphasis on primary health care and preventive healthcare models and move away from a hospital-based sick care model of health care. Some nursing programs have traditional curriculums designed to instruct the student nurse to gain the nursing and clinical knowledge needed to pass licensure examinations and to care for the health needs of client populations [51].
Nurses entering the profession in the future could benefit from a nursing undergraduate program that integrates a primary Volume  health care model into the curriculum to prepare them for the challenges that global health care reform initiatives pose for nurses and other health care providers working in healthcare delivery. It is also vital for community health nursing leaders to take on teaching nursing students as future nurses as a professional obligation; there needs to be a more active and intentional role of community health nursing leaders in the delivery of theory course material, as well as, in clinical practice placements to optimize learning opportunities for nursing students.
The Canadian Association of Schools of Nursing (CASN) began a project to develop core competencies to be integrated into baccalaureate nursing programs [52]. The competencies were grouped into 5 separate domains which include 1) Public health sciences in nursing practice, 2) Population and community health assessment and analysis 3) Population health planning, implementation, and evaluation, 4) Partnerships, collaboration and advocacy, 5) communication in public health nursing. Integrating these core competencies, including indicators will enhance the education delivery and the skills required to practice in the public health arena. Assignments and tasks associated with community health should focus on these key domains and concepts to promote a better understanding of public health nursing [53].
Canadian Association of School of Nursing has further developed guidelines in order to ensure quality community health nursing clinical placements. These guidelines were developed in consultation with community health nursing educators, managers and practitioners from across Canada [26]. The guidelines include essential and preferred recommendations in five categories: 1) Community Health Nursing Identity, 2) Community Health Nursing Scope of Practice, 3) Competent Well-Prepared Preceptor, 4) Supportive Environment for Student Learning and 5) Community-Academic Partnership. These guidelines will help ensure that baccalaureate graduates of Canadian schools of nursing are well prepared to meet the Canadian Community Health Nursing Standards of Practice at an entry-to-practice level [26].

Implications for Nursing Practice
Findings from this study suggest that nurses play a vital role in preparing students to enter the nursing profession. It is important to foster community health nursing as a fulfilling career and an attractive environment for graduate nurses as it plays a vital role in the future of healthcare delivery in Canada.
Stigma and stereotypes surrounding the community health nursing persist and are influencing the choices of students related to pursuing careers in community health nursing. Community health nursing educators, leaders and workers are cognizant of the perceptions of the students. CHN needs to be reinforced as a valuable profession. All nurses must come together as one discipline and have respect for the different kinds of work nurses do entirely. For each nursing specialty to be given due respect, one must remember their own journey to becoming a nurse and the paths they took to bring them where they are today. It is not helpful to young students who are eager to begin a career in nursing while feeling afraid to explore all the opportunities available to new nurses, due to negative perceptions on certain specialties. People need to become educated and aware of the role of community health nurses and the value that community health nursing has for the achievement of optimal health for individuals, families, communities and neighborhoods [54].

Implications for Organizational Policy
The voice of community health nursing needs to be heard. Students in our study suggested that community health nurses are scarce during the nursing job fairs hosted by the university. This underrepresentation of community health nursing should change; community health nursing organizations and the university should make conscientious efforts to provide students with knowledge and information surrounding the roles of community health nurses and the opportunities for nursing students and new nurses in community health nursing settings. Representatives from community health nursing organizations could provide insight into the type of tasks they perform, the challenges encountered in their work settings and the benefits of their profession. Having role models to explain their own personal experience has been demonstrated to produce a positive experience on the nursing identity and is an important factor on students' decision-making process for choosing a career path.
Another step, which may be more difficult to achieve, would be the flexibility in wages, sign on bonuses, lucrative benefit packages and other monetary methods to attract new nurses to community health nursing. This study's findings suggested that salary is a factor in making a career choice among undergraduate students.
Looking into creating more positions in the Nursing Graduate Guarantee Initiative within several different community health nursing environments would also be of interest to students and beneficial to community health nursing and community health nursing organizations. The NGGI is a program that is only available in Ontario that provides new graduates with an employment opportunity that mentorship and preceptorship available. Participants did mention that they were aware of Nursing Graduate Initiative positions available in community health nursing settings; however, they are quite limited and highly competitive. The types of jobs nurses can have in community health nursing are countless, so perhaps looking at more creative and exciting employment opportunities would be beneficial in the long run.
Many participants wanted to go into a hospital-based setting post-graduation because they felt they would have the Volume  necessary support from fellow nurses in those settings. It would also be beneficial if community health nursing organizations and/ or employers offered mentorship programs that would allow new graduates to have the support they need in the first six months to one year after starting a new job.

Limitations of Study
Most participants in the study had a strong interest in pursuing community health nursing, which could be the reason for their participation. Though they were able to provide insights on reasons why they would pursue community health nursing as a career option, they also provided much insight into what their peers who had no interest in community health nursing were saying about community health nursing. This could be seen as a limitation of the study as some participants reporting perceptions about community health nursing that did not come from them directly but from what their peers were saying. It would have been of interest to have more participants who did not have a strong interest in community health nursing weigh in on the findings of this study.
The participants in this study were only women; it would have been of interest to obtain the perspectives of male nursing students and to see if there were any gender-based differences when it comes to career choice among nursing students interested in community health.
Also, this study is based on a single sample from a single cohort at the same University. Though the results were comparative to international studies, it would have been of interest to have the perspective of students from other cohorts at the same University or from other Universities either provincial or national to allow for temporal and geographical comparisons. Comparing the impact of different curriculums on the perceptions of students to community health nursing would be of interest. This is a limitation as it is reflective of one single sample and not different perspectives of nursing students across Ontario or Canada or nursing students that are not in their first or final year of their nursing program.

Conclusion
With demographic changes, growing cost of acute care, aging population and the number of people living with chronic illnesses and needing special care, there is global need for community health nurses. In order to meet these demands, there needs to be major changes in community health nursing education and practice in the 21st century. Making community health nursing an attractive field of nursing is the responsibility of current nurses, faculty members, community health members and community health organizations to be able to provide the care the population will require. As this study and the supporting literature has shown, there are misconceptions about what community health nurses do among nursing students and this has led to the lack of interest in the field among students. It is imperative for nursing leaders in educational and research institutions as well as in community organization to develop programs to motivate nursing students for a career in community health nursing. The attractive aspects of community health nursing such as the independent practice that is central in this kind of nursing needs to be highlighted in educational programs, curriculum content and clinical practicum need to be tailored to address the issues identified in this study including when and how students are exposed to the full scope of community health nursing practice. This is critical to promoting community health nursing as an important area of nursing practice. Community health nursing is a rewarding field of nursing where populations, communities and clients are the focus of care; nurses need to understand the impact they could have on people lives when serving as community health nursing leaders.