Factors influencing student nurses career choices after preceptorship in a five-year junior nursing college in Taiwan

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1 Nurse Education Today (2008) 28, Nurse Education Today intl.elsevierhealth.com/journals/nedt Factors influencing student nurses career choices after preceptorship in a five-year junior nursing college in Taiwan Whei-Mei Shih *, Shu-Hui Chuang Chang-Gung Institute of Technology, Doctoral student in National Taipei College of Nursing and Job Placement, Room 1117, 261 Wen-Hua 1st Road, Kwei-Shan, Tao-Yuan 33333, Taiwan KEYWORDS Clinical practice; Preceptorship; Nursing education Summary This study was conducted to explore the influence factors of a preceptorship in career choices following student nurses graduations. A total number of 326 student nurses in their fifth year of junior nursing college were selected as participants. A validated and reliable questionnaire was used in this study. Data were analyzed by the Statistical Package for the Social Science (SPSS) for windows for percentage, mean, standard deviation, and Pearson s correlation. The results showed that: (1) the first five factors influencing student nurses career choices were good unit environment, nurse s professional role, self-professional knowledge deficiency, nurse s professional knowledge, and patient s and family s good feedback; (2) the correlation between the chosen field of practice and willingness to work after graduation showed a strong relationship in all areas. Notably, the preceptorship had an impact on student nurses selecting a nursing career. These results can give nurse educators guidance in preparing student nurses as they enter the work force. c 2007 Published by Elsevier Ltd. Introduction Nursing education is often described as idealistic. When a new graduate enters a health care institution, she or he is faced with a situation in which the idealized role conflicts with the actual working role * Corresponding author. Tel.: x5704; fax: address: jeanshih@gw.cgit.edu.tw (W.-M. Shih). of professional nurses. The new graduate experiences frustration when unable to fulfill personal and organizational practice expectations. Reality shock results. Hospital accreditation statistics from the Department of Health in Taiwan reveal that the average turnover rate of nurses in Taiwan is 15%. Some hospitals turnover rates were as high as 40% (Department of Health, 1992). There have been no further statistics from the government since that time. Causes of nurses leaving the workforce were work pressure, mal-adaptation, /$ - see front matter c 2007 Published by Elsevier Ltd. doi: /j.nedt

2 Factors influencing student nurses career choices 495 inability to work at night, and frequent shift changes (Chen, 1996; Wang, 1997; Yin and An, 1991). Most of the nurses in the hospital affiliated with this nursing school graduated from junior nursing colleges in Taiwan (89%). Wang (1997) research showed that 47.4% of nurses in Taiwan who left the workforce had been college students. Nurse administrators from health care institutions complained that new graduates were unable to immediately function as competent professional nurses. A great deal of literature from the United States and Canada suggests that a preceptorship can decrease a new graduate s reality shock and also help new staff adapt to clinical situations and the role of professional nursing (Dobbs, 1988; Itano et al., 1987; Laschinger and MacMaster, 1992; Letizia and Jenrich, 1998; McGregor, 1999). In Taiwan, Junior High School graduates who enter and complete a five-year junior nursing college program will be able to take the NCLEX-RN exam. This program is equivalent to an associate degree in the United States. To the best of our knowledge, only one Baccalaureate nursing program implemented preceptorship in 1992 in Taiwan, but relevant research was rare. No other junior nursing college put a preceptorship into practice. There is no research regarding the effect of nursing students selecting a nursing career after their preceptorship. Literature review Nursing is a science. Its main task is to care for human beings. Therefore, through nursing education, students put nursing theory into practice. This is called learning by doing. In most nursing education programs, nursing practice plays an important role in the nursing education. The only way to ensure better quality of nursing is to apply theory with practice. Within an educational setting, preceptorship is generally defined as an intense, one-to-one, reality-based, clinical rotation for a student nurse whose learning experiences are coordinated and supervised by a staff nurse. The preceptor guides the role of students in a clinical practice. He or she serves as a role model, resource person, consultant, and supervisor for the student (Itano et al., 1987; Kaviani and Stillwell, 2000; Lockwood-Rayermann, 2003; Myrick and Yonge, 2002; Ohrling and Hallberg, 2000). The preceptor can also reduce the risk of the student s learning challenges. This empowers the students by learning through practice and by enhancing critical thinking ability (Kaviani and Stillwell, 2000; Myrick and Yonge, 2004; Ohrling and Hallberg, 2000; Ohrling and Hallberg, 2001). Dobbs (1988) used Corwin s Nursing Role Conception Scale to assess 103 generic Baccalaureate nursing students (BSN) immediately prior to and after their final clinical course. A preceptorship experience found a significant decrease in perceived role deprivation (P < 0.01) and a significant increase in the work-centered role models (P < 0.01). The authors concluded that the preceptorship experience contributed to lessening the degree of reality shock experienced by nurses entering the work force. Scheetz (1989) compared clinical competencies of BSN students who participated in a summer preceptorship experience with those who worked as nursing assistants in non-teaching clinical settings. Students in the preceptorship program demonstrated significantly greater increases in clinical competencies such as problem-solving, application of theory to practice, and psychomotor skills. The authors suggest that preceptorship experiences are effective means of increasing clinical competence of BSN students and may reduce orientation needs for new graduates entering the system. In Laschinger s study (1992), Kolb s theory of experiential learning was used as a framework to study 50 Baccalaureate nursing students perceptions of the contributions of a senior preceptorship experience to the development of adaptive competencies. The preceptorship experience was perceived to have had a significant impact on senior students adaptive competency development and played a role in improving the person-environment fit for newcomers to the profession. Collins research (1993) showed 90% of the nursing students felt they were well prepared to accept the responsibility and accountability for the nursing care they provided. Communication skills were felt to be effective with health care team members during their preceptorship. Eighty-nine percent of the responses rated: (1) an increased ability to organize and provide care to a group of clients, (2) setting priorities in relation to staff and patient care needs, and (3) utilizing problem-solving strategies as helpful or very helpful. According to Mills et al. (2000), a study toward preparing Baccalaureate students for transition to the workforce showed that students developed an in-depth knowledge and clinical skills in a selected area of clinical practice. Potential employers had an opportunity to observe students in a pre-employment setting and to evaluate the fit of skills and personal attributes to the specific situation. This emphasis on a selected course model offers advan-

3 496 W.-M. Shih, S.-H. Chuang tages to students transitioning into the workforce, to employers, and ultimately to clients served. Freiburger (2001, 2002) found that benefits of the preceptorship for nursing students included increased confidence, a sense of comfort, improved organizational skills, more information about procedures and IVs, knowledge about different types of clinical settings, improved communication skills, and gained experience in caring for a larger number of patients. Students who participated in the preceptor program expressed feelings of increased self-confidence and improved levels of competence. Recruitment and retention were clear benefits of preceptorship programs to healthcare facilities (Hughes et al., 1993; Itano et al., 1987; Olson et al., 2001; Shih et al., 2000). Some hospitals used this as a recruitment tool. One study stated that 65% of the students participating in a preceptorship program returned to the same facility after graduation (Hughes et al., 1993). Another study reported the benefits to hospitals with a preceptorship program resulted in: (1) decreased orientation time, (2) less turnover in staff (50% by year two), and (3) lower recruitment costs (Hayes, 2001; Olson et al., 2001). In the study by Shih et al. (2000), the benefits to the hospital of students returning to their previous nursing practice units were: (1) no need to adapt to the environment and/or co-workers again, (2) ease in training these students rather than new graduates who had not been trained there, (3) students self-discipline was higher when compared to new graduates who were not trained there, and (4) the preceptorship was a bridge from school life to clinical settings. There are many factors associated with a career decision. Lai s study (2006) revealed that: (1) students with a greater clinical ability tended to have a stronger intention of become nurses, (2) student nurses considering nursing as a career perceived less stress, and (3) students with a positive attitude towards nursing as their career choice perceived more support than those who did not. Overall, preceptorship implemented in the final year of school is an asset for nursing students. Students view the preceptorship relationship as an opportunity to tie together the loose ends of their education (Lunday et al., 1999). Through this program, nursing students can increase clinical competencies and their confidence so as to better transition into the workforce. Therefore, it is imperative that nurse educators know the factors influencing student nurses career choices in order to better assist students in career planning. Purpose After their last nursing practicum of the educational year, college student nurses were encouraged to join the workforce. This study explored factors influencing students career choices for work after preceptorship. The results of the study can be considered a reference for student nurse s career planning in the future. Method Program design In the traditional clinical nursing practice in Taiwan, the instructor student ratio varied between eight and ten students per instructor. This meant that very little actual teaching time could be spent with each student during each clinical practice shift. Preceptorship is an individualized teaching learning method where each student is assigned to a specific preceptor for a certain period of time. He or she can experience day-to-day practice with a role model and resource person who is immediately available within the clinical setting. (Myrick and Yonge, 2002; Myrick, 1988; Shamian and Inhaber, 1985). The purposes of this school instituting the preceptorship were mainly to have a distinguishing feature, which set them apart from other nursing schools, and to cultivate their students so they might better compete in the workforce. Before starting the program, faculty contacted the coordinator of nursing education in a hospital and met with each head unit nurse in order to orient preceptors, the coordinator, and head nurses to the school s curriculum. They explained the purpose of the course and shared expectations about the preceptor s role. Copies of the course syllabus, preceptor guidelines, and clinical objectives were given at this time. All students participated in a 10-week preceptorship, earning six credits, plus two credits for classroom seminars. This took place during their final year of school. Students were given a choice of their preferred clinical areas of practice for this experience and then the school administrative department arranged appropriate placements with the contracted hospital. Most students chose a setting because they thought they needed that particular type of clinical experience and/or they planned to work in that area of nursing after graduation. Students were assigned to work one-to-one with nurses in selected clinical settings. They were

4 Factors influencing student nurses career choices 497 placed on the same rotation as their preceptor, in order to facilitate their understanding of the nurse s role on three different shifts. The minimum clinical time for this experience was 320 h (usually 32 h per week). Students created their own learning contracts with input from their faculty advisors and preceptors. The conditions of these contracts were congruent with the overall course objectives for the experience, so as to avoid student s frustration when the theory could not be applied to clinical practice. Faculty members served as resources for both students and preceptors, but clinical contact with students was minimal during the 10-week experience. This strategy was employed to provide students with a sense of independence in the execution of their upcoming roles as beginning practicing nurses. According to Davis and Barham s research (1989), implementation of preceptorship near students graduation had a better result in resolving student s clinical ability. This was also the reason why the program was placed in students final year of school. The staff nurse preceptors were selected by each unit s head nurse and considered to be good practitioners and role models. Each had at least three years of experience as an RN, excellent communication skills, good coping ability, a willingness to share knowledge and experience, etc. The primary responsibility of the preceptor was to facilitate the student s learning. They acted as nurse facilitators who functioned as teachers, observers, and evaluators. They also acted as a liaison for the students on the unit and within the hospital by explaining the program to other staff members and working with head nurses and coordinators to arrange certain learning experiences. The faculty held a series of training courses for preceptors regarding students background, nursing processes, teaching and learning abilities, communication skills, and student appraisal skills. The main responsibilities of the faculty members were to facilitate, monitor, and evaluate student learning. Faculty roles were similar to those of the preceptors, but their focus was broader. Faculty members expected and encouraged students to use course information, especially the core lectures, in the clinical area and to discuss reality shock experiences, case studies, and clinical related issues in the seminar. Samples and method Table 1 Salient sample characteristics (N = 301) Characteristics n % Willingness to work before preceptorship Very low Low Medium High Very high Units of preceptorship Medicine Surgery (including operating room) Obstetrics Pediatrics Critical care Willingness to work after preceptorship Very low Low Medium High Very high The study was conducted in a nursing college (fiveyear program) located in the northern part of Taiwan. A total number of 326 convenient samples were collected from a five-year junior nursing college after their 10-week preceptorship. Students were informed in writing about the study purpose and were assured of confidentiality and anonymity. The questionnaire was distributed at the end of the evaluation meeting. The instrument used was a researcher-designed, self-administered questionnaire given after a literature review. Answers were on a five-point scale: strongly agree (5), agree (4), no comment (3), disagree (2), and strongly disagree (1). Two nurse educators evaluated content validity. The content validity index (CVI) value was Reliability was measured using Cronbach s alpha, a cross-sectional approach that estimates internal consistency among items included in the scale. For the 11 items of the scale, Cronbach s alpha was 0.85 indicating acceptable value for a well-developed instrument. Twenty-five incomplete questionnaires were eliminated leaving 301 valid questionnaires. These were analyzed using SPSS for windows 9.0 (see Table 1). Findings and discussion Profile of the samples The demographics for the students participating in this research study showed that samples were relatively homogeneous regarding sex, race, and age. All of the subjects were female and single, and ran-

5 498 W.-M. Shih, S.-H. Chuang ged in age from 18 to 21 years. The mean age for these students was 19.3 years. Out of 301 students, 65 (21.6%) students were in medicine units, 106 (35.2%) in surgical units (including the operating room), 41 (13.6%) in obstetric and gynecologic units, 34 (11.3%) in pediatric units and 55 (18.3%) in critical care units. In order to have better understanding about students willingness to work before and after preceptorship, two questions were raised before starting the questionnaire. The result showed that before preceptorship student nurses willingness to work was as follows: very low 35 (11.6%), low 44 (14.6%), medium 149 (49.5%), high 54 (17.9%), very high 19 (6.4%). Student nurses willingness to work after preceptorship was as follows: very low 18 (6.0%), low 31 (10.3%), medium 116 (38.5%), high 91 (30.2%), very high 45 (15.0%). Positive influence factors for students career choices Descriptive statistics are presented in Table 2 showing factors influencing students career choices. The highest scores of the first five factors were: good unit environment (3.72), nurse s professional role (3.70), self-professional knowledge deficiency (3.67), nurse s professional knowledge (3.65), and patient s and family s good feedback (3.64). Students felt a good unit environment was the most important factor influencing nursing students career choices. Since the school and the contracted hospital were under the same enterprise, the school got full support from the hospital in terms of facilities, equipment, and manpower. Also, 76% of the nursing staff graduated from this school, so students gained recognition from them and were treated nicely. The students felt comfortable working in this hospital. During their work with preceptors and dealing with patients, students recognized the professionalism of nursing. They also felt a self-professional knowledge deficiency and realized a need to work harder to improve it. From this program, students felt a sense of accomplishment and satisfaction from patient and family feedback. This also was an asset that increased their willingness to work in clinical settings. The Pearson correlation coefficients of factors influencing students career choices after preceptorship revealed that all the factors were interrelated with the exception of the work shift. Since nurses in Taiwan are required to rotate by working three different shifts, student nurses were also required to do so. It was not surprising that shift change was an expectation in the nursing profession. Therefore, this factor did not influence their choices to work in clinical settings. The correlation between an area of practice and the willingness to work after graduation showed a strong relationship in all areas from highest to lowest: pediatrics (r 2 = 0.725, P < ), critical care (r 2 = 0.636, P < ), medicine (r 2 = 0.551, Table 3 Area of practice and willingness to work after graduation (N-301) Area of practice N r 2 Rating Medicine a 3 Surgery a 5 Obstetrics and gynecology a 4 Pediatrics a 1 Critical care a 2 a P < Table 2 Descriptive statistics of factors influencing students career choices (N = 301) Factors Mean SD Rating r 1. Nurse s attitude a 2. Nurse s professional knowledge a 3. Head nurse s attitude a 4. Nurse s role a 5. Patient s and family s attitudes a 6. Faculty attitude a 7. Unit environment a 8. Shift Workload b 10. Clinical situation (CPR, patient died) b 11. Self-professional knowledge deficiency b Rating scale: 1 = Strongly disagree, 2 = Disagree, 3 = No comment, 4 = Agree, 5 = Strongly agree. a P < b P < 0.05.

6 Factors influencing student nurses career choices 499 P < ), obstetrics and gynecology (r 2 = 0.531, P < ), and surgery (r 2 = 0.510, P < ) (Table 3). Because students chose their preferred clinical units and the school administrative department also gave full support in placing these students in their unit of choice, they felt they would be more willing to work in that area in the future. Positive self-satisfaction and program evaluation When approached, students expressed interest in this program. They felt the program was a valuable and unusual experience when compared to other nursing schools in Taiwan. They also felt they had a higher competitive edge than students graduating from other nursing schools. The intention to work in the same specialized field after graduation was 3.71 with 28 (9.3%) no intention, 22 (7.3%) less intention, 41 (13.6%) no comments, 130 (43.2%) intention, and 80 (26.6%) high intention. Most students felt this was a good program. After this training they had a better understanding of what the real world was like and how they could be better prepared before entering the workforce. This also could reduce reality shock. Conclusion and recommendation The research of Robinson et al. (1999), demonstrated benefits of collaboration between universities and hospital staff in developing preceptorship programs. Currently, both the contract hospital and the nursing students participating in this preceptorship were all positive about the program. Nursing administrators from hospitals where these graduate students had worked expressed that these new graduates had better adaptation ability and shorter orientation time than other new graduates. Therefore, hospitals welcomed these nursing students in their institutions. These nursing students felt the program could reduce stress and increase competition in the job market. Under the global budget of the health department of the government in Taiwan, hospital administrators monitored their budget very closely. Some hospitals even cut down orientation time of new graduates from four weeks to two weeks and increased the ratio of patient to nurse (from 10:1 to 12:1, on day shift in the Med/Surg unit). Therefore, nursing administrators in hospitals expected new staff to work as experienced staff nurses as soon as possible. As shown in the literature review, preceptorship decreased role deprivation, increased work-centered role models, increased clinical competencies, and increased confidence. There was more advantage than disadvantage. The purpose of this research study was to identify influencing factors of preceptorship toward career choice after students graduation. As of 1990, it is one of the few studies in Taiwan related to preceptorship. There are still only a few nursing schools implementing this preceptorship program. The findings revealed that students had a positive attitude toward working as a nurse after preceptorship. Students had a better understanding about a nurse s role, a nurse s workload, the expected three shift changes, clinical situations, etc. It indicated that a good clinical practice experience and a good educational system would influence a students willingness to join the workforce. It was also very important that the school have a good relationship with the contract hospital. With this, hospital staff would have an increased desire to support students in the learning of practical knowledge. Since the school and the hospital were under the same enterprise, samples were limited to this hospital. There was no comparison between this hospital and any other hospital. A follow-up of employment rate and students clinical performance as new staff nurses can be done in future research. References Chen, M., A study of the factors related to nurses intention to quit work in a medical center. Veteran General Hospital Nursing 13 (1), (Chinese). Collins, P., Hilde, E., Shriver, C., A five-year evaluation of BSN students in a nursing management preceptorship. Journal of Nursing Education 32 (7), Davis, L., Barham, P., Get the most from your preceptorship program. Nursing Outlook 37, Department of Health, Executive Yuan, ROC Nurses retention policy and measures, annual report (Chinese). Dobbs, K., The senior preceptorship as a method for anticipatory socialization of Baccalaureate nursing students. Journal of Nursing Education 27 (4), Freiburger, O.A., A tribute to clinical preceptors: developing a preceptor program for nursing students. Journal of Nurses in Staff Development 17 (6), Freiburger, O.A., Clinical issue. Preceptor programs: increasing student self-confidence and competency. Nurse Educator 27 (2), Hayes, E.F., Factors that facilitate or hinder mentoring in the nurse practitioner preceptor/student relationship. Clinical Excellence for Nurse Practitioners 5 (2), Hughes, R., Cummings, H., Allen, R., The nurse extern practicum: a new partnership between education and

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