Nurse Education Today 52 (2017) 66–72

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Career choice and perceptions of nursing among healthcare students in

higher educational institutions
Sok Ying Liaw a,⁎, Ling Ting Wu a, Yeow Leng Chow a, Siriwan Lim a, Khoon Kiat Tan b
a
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
b
School of Health Sciences, Nanyang Polytechnic, Singapore

a r t i c l e i n f o a b s t r a c t

Article history: Background: Due to the ageing population and competition from other healthcare courses, a greater demand in
Received 3 October 2016 the healthcare workforce has made it challenging for educational institutions to attract school leavers to enter
Received in revised form 26 January 2017 nursing courses. Understanding the considerations of students who have chosen non-nursing healthcare courses
Accepted 8 February 2017 and their perceptions of nursing can help identify specific strategies to enhance the attractiveness of nursing
course. This study aims to examine the differences between healthcare career choices and perceptions of nursing
Keywords:
as a career choice among first-year non-nursing healthcare students.
Career choice
Healthcare course
Method: A descriptive survey design was conducted at the beginning of the healthcare courses of seven
Nursing enrolment healthcare groups and from four higher educational institutions in Singapore. A total of 451 students responded,
Nursing recruitment yielding an overall response rate of 52.7%. The online survey was administered using a valid and reliable 35-item
Influential factor parallel scale, known as the Healthcare Career Choice and Nursing Career Choice.
Results: The participants perceived prior healthcare exposure as the most influential factor and self-efficacy as the
least influential factor when choosing nursing as a career. In comparison to their own healthcare career choices,
nursing was perceived to have greater gender stigma and, as nurses, they would be less likely to achieve higher
qualifications and career advancements, and they would be less likely to enjoy fulfilling careers. They also per-
ceived that they would be less likely to gain their parents' support to pursue nursing and to make their parents
proud.
Conclusions: This study provides educators and policy-makers with vital information to develop key strategies to
improve nursing enrolment in educational institutions. These strategies include early exposure to nursing as a
rewarding career during school years, addressing the issue of gender stigma, and promoting information on
the career and educational advancement of a registered nurse to parents of school leavers.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction establishing more healthcare training institutions and increasing stu-

According to the World Health Organization (WHO) (2014), the
global shortage of healthcare workers will reach 12.9 million by 2035.
With the current global ageing population, it is estimated that by
2030, the number of people who are 65 years and older will increase
to one billion worldwide (Mukherji et al., 2015). Internationally, and
particularly in Singapore, healthcare systems are expected to face a
shortage of trained healthcare workforce from rapid expansion of the
healthcare infrastructure to meet the increased ageing population. As
such, there is a need to expand the healthcare education pipeline by
⁎ Corresponding author at: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of
Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11
10 Medical Drive, 117597, Singapore.
E-mail addresses: nurliaw@nus.edu.sg (S.Y. Liaw), nurwlt@nus.edu.sg (L.T. Wu),
nurcyl@nus.edu.sg (Y.L. Chow), siriwan_lim@nuhs.edu.sg (S. Lim),
tankhoonkiat@gmail.com (K.K. Tan).
dent enrolment for healthcare courses (Betlehema et al., 2009). Howev-
er, among the healthcare courses, nursing has not been perceived as a
popular course by the students. It faces greater challenge and competi-
tion in attracting school leavers who are interested in healthcare
courses (Neilson and Jones, 2012).
With the demands of healthcare courses, there is an increasing inter-
est to explore the motivations of students who take up a career in
healthcare. A systematic review conducted by Wu et al. (2015) identi-
fied several factors that influence career choice among healthcare stu-
dents. A personal interest in healthcare was identified to be a more
influential factor in choosing medicine when compared against dentist-
ry and pharmacy. This factor was also influential for nursing (Rashid et
al., 2013; Tanalp et al., 2012). The interest for choosing nursing was
often founded on altruism (Halperin and Mashiach-Eizenberg, 2013).
Monetary reward was an important consideration for students who
chose pharmacy and dentistry when compared with other healthcare
courses as revealed in several international studies (Hayes and

http://dx.doi.org/10.1016/j.nedt.2017.02.008
0260-6917/© 2017 Elsevier Ltd. All rights reserved.
 S.Y. Liaw et al. / Nurse Education Today 52 (2017) 66–72
Shakya, 2013; Tanalp et al., 2012). Unlike medicine and pharmacy,
healthcare students who chose nursing may have done so for job secu-
rity, but the findings for dentistry students were less consistent (Rashid
et al., 2013; Tanalp et al., 2012). To dentistry students, job autonomy
was important as the opportunity to be self-employed was a major con-
sideration (Tanalp et al., 2012). The effect of parents' expectations on
healthcare career choices was inconclusive. Wu et al. (2015) suggested
that parental influence might be important in Asia. Law and Arthur
(2003), for example, described how family influenced students to join
nursing courses in Hong Kong. In the United Kingdom (UK), however,
a qualitative study advocated that parents discouraged their children
from entry into nursing (Norman, 2015).
Although both nursing and non-nursing healthcare careers were
able to fulfil an individual altruistic desire (Hayes and Shakya, 2013;
McLaughlin et al., 2010), nursing was found to be the least attractive
of all healthcare courses. Nursing was perceived to be for students
with less satisfactory academic results (Neilson and Lauder, 2008) and
was unsuitable to warrant a university degree (Ogunyewo et al.,
2014). Nursing was also perceived as having lesser responsibilities and
decision-making rights (Duffield and O'Brien-Pallas, 2003), often hav-
ing to do ‘dirty’ work (Hadley et al., 2007), and involving stressful
tasks on handling distressed patients and their family members. A nurs-
ing career was reported by school-aged students to match their ideal ca-
reers in terms of busyness, caring for others, hard work, and job security
(Palumbo et al., 2008), but falls short of their ideal careers in terms of
appreciation, autonomy, financial remuneration, and respect (Cohen
et al., 2004).
In Singapore, registered nursing education is offered in higher edu-
cational institutions, including polytechnics and university. While poly-
technics offer a diploma in nursing to school leavers with a General
Certificate of Education Ordinary Level (GCE ‘O’ Level), universities
offer a nursing degree to college school leavers with a GCE Advanced
Level. Polytechnics have the highest enrolment target for nursing
courses with approximately 1200 each year to fulfil the nursing man-
power needs of the nation. Given the availability of the vast range of
healthcare related diploma courses (e.g. dental hygiene, healthcare
management, pharmaceutical science, psychology, and social work) of-
fered in Singapore's four polytechnics, the nursing courses face chal-
lenges in reaching its huge enrolment target as well as attracting high
quality school leavers (Liaw et al., 2016a; Neilson and Jones, 2012).
Among the healthcare diploma courses, nursing has the lowest entry re-
quirements based on GCE ‘O’ Level.
It is important to find out the career choices of students who en-
rolled in various healthcare courses and examine why these other
healthcare courses students did not choose nursing as their preferred
career choice (Natan and Becker, 2010). An earlier qualitative study
on 59 healthcare students identified six factors that influenced their
healthcare career choices (HCCs) (Liaw et al., 2016a). These factors
were utilised to construct an instrument with parallel scales to compare
the influences of HCC with the perception of nursing as a career choice
(Liaw et al., 2016b). In this study, using the newly developed instru-
ment, we aim to conduct a quantitative study to examine the differences
between HCCs and perceptions of nursing as a career choice among
first-year non-nursing healthcare students. This comparative under-
standing of career choice influences can provide valuable information
for educators and policy-makers to consider specific strategies to im-
prove nursing recruitment.
2. Methods
2.1. Study Design and Sample
A descriptive survey study was conducted between April to June
2016 during the first two months of entry to diploma courses. The sam-
pling frame included the entire target population. All 855 first-year stu-
dents undertaking non-nursing healthcare courses in four tertiary
67
educational institutions were invited to participate in this study. These
healthcare courses included heath management, pharmaceutical sci-
ences, dental hygiene therapy, psychology, and social work. Four hun-
dred and fifty-one students completed the survey.
2.2. Data Collection and Instrument
Following approval from the Institutional Review Boards of two
higher educational institutions, email invitations were sent to the
school directors of the four tertiary educational institutions to seek
their support and permission to conduct the study. Recruitment posters
and a weblink to the online questionnaire were then disseminated to
the potential students through collaborators in the institutions. The stu-
dents were informed about the study purpose via a participation infor-
mation sheet that is available in the weblink. The students were assured
that their participation was voluntary and anonymity would be
maintained.
The instrument was a newly developed and self-administered ques-
tionnaire known as the Healthcare Career Choice and Nursing Career
Choice (HCC-NCC) parallel scale. It comprises two scales with 35 paral-
lel items in each scale to enable comparison between the influences of
HCC and the perception of nursing as a career choice. The HCC-NCC par-
allel scale measures the items on a 5-point Likert scale, from 1 “strongly
disagree” to 5 “strongly agree”, and includes six subscales: personal in-
terest, prior healthcare exposure, self-efficacy, job prospect, perceived
nature of work, and social influences. Table 1 states the descriptions of
each subscale. The scale was carefully constructed and tested for psy-
chometric properties in a previous study. The scale's content validity
was established by a panel of 12 healthcare experts from a variety of
healthcare settings, including hospitals, educational institutions, and
the Ministry of Health. The content validity index (CVI) was 0.78 for
the HCC scale and 1.0 for the NCC scale. Construct validity was tested
using exploratory factor analysis which revealed 35-parallel items in a
six-factor solution and explained 59% and 64% of the variance for the
HCC and NCC scales, respectively (Liaw et al., 2016b). Concurrent valid-
ity was examined by correlating the HCC-NCC parallel scale with an
established Indiana Instrument developed by May et al. (1991). A signif-
icant strong positive correlation (r = 0.76, p b 0.001) was found be-
tween these two scales. Internal consistency in this study was high
with Cronbach's alphas of 0.93 for the HCC scale and 0.96 for the NCC
scale. Test-retest reliability was acceptable with an intraclass correlation
coefficients of 0.63 for the HCC scale and 0.60 for the NCC scale (Liaw et
al., 2016b).
Table 1
Descriptions of subscales find in Healthcare Career Choice and Nursing Career Choice
questionnaire.
Subscales Descriptions
Personal interest Refers to the students' personal interest (i.e., altruism, interest
for science-related subject) in their chosen professions
Prior healthcare Reflects how healthcare related experiences (i.e., observing a
exposure healthcare professional at work) could influence their choice
of a healthcare career
Self-efficacy Refers to a set of self-beliefs about one's personal competence
(i.e., academic ability) to a career choice
Job prospects Considers the practical aspects (i.e., job opportunity, job
stability, good income) of a healthcare career that could
influence the career choice
Perceived nature Relates to how students' perceived the characteristics aspects
of work (i.e., autonomy, hands-on skills) of the healthcare careers that
influenced their choice of career
Social influences Includes social status, gender-type and significant others that
would have significant impact on the students' career
decision-making process
68 S.Y. Liaw et al. / Nurse Education Today 52 (2017) 66–72

2.3. Data Analysis Table 3

Demographic characteristics of the participants.

Statistical Package for the Social Sciences (SPSS) was used to analyse Demographics n (%)
the data. Descriptive statistics were computed for demographic vari- Age (years)
ables. Paired t-test was performed to compare the differences between 16–19 395 (87.6)
influences of each participant's HCC and nursing as a career choice. 20–25 56 (12.4)
Gender
Male 108 (23.9)
3. Results Female 342 (75.8)
Nationality
3.1. Demographics Characteristics (Singaporean)
Yes 412 (91.4)
No 39 (8.6)
A total of 451 students responded to the survey, yielding an overall Ethnic group
response rate of 52.7% (Table 2). Table 3 indicates the demographic Chinese 313 (69.4)
characteristics of the participants. The average age of the participants Malay 73 (16.2)
was 17 years (SD ± 1.7), with a range between 16 and 25 years. The ma- Indian 45 (10.0)
Others 20 (4.4)
jority of them were female (n = 342, 75.8%), Singaporean (n = 412,
Education
91.4%), Chinese (n = 313, 69.4%), secondary or college school leavers GCE N/O/A levels 402 (89.1)
with a GCE (n = 402, 89.1%), and had enrolled in a pharmaceutical sci- ITE/Diploma 49 (10.9)
ence course (n = 236, 52.3%). Only about 30% (n = 133) of the partic- Courses
Dental Hygiene 17 (3.8)
ipants indicated that they sought career advice from significant others.
Healthcare management 98 (21.7)
Pharmaceutical science 236 (52.3)
3.2. Most and Least Influential Reasons for HCC and NCC Psychology 46 (10.2)
Social work 54 (12.0)
Career advice from significant others
Table 4 shows the five highest-scored items identified by the partic- Yes 133 (29.7)
ipants as influential in making their HCCs. These items were: (1) making No 317 (70.3)
a difference in someone's life, (2) a desire for a fulfilling career, (3) a de-
GCE N level - General Certificate of Education Normal (Academic) Level.
sire to help others, (4) contributing to the society, and (5) wanting par- GCE O level - General Certificate of Education Ordinary Level.
ents to be proud. Most of these items were under the subscale of GCE A level - General Certificate of Education Advanced Level.
“personal interest” and were also among the highest-scored items in ITE-Institute of Technical Education.
NCC.
No consistency was reported between the lowest-scored items in
the HCC and NCC scales, except for one item in “inspired by social interest of contributing to the society and interacting with people but
media”. Most of the lowest-scored items rated by the participants on less likely influence by the desire for a fulfilling career.
the HCC scale were related to the factor “prior healthcare exposure”.
On the contrary, most of the lowest-scored items rated by the partici- 3.3.2. Prior Healthcare Exposure
pants on the NCC scale were from the factor “self-efficacy”. The mean scores for all the items within the factor “prior healthcare
exposure” were reported to be significantly higher in the NCC scale than
3.3. Differences between HCC and NCC in the HCC scale. Nursing as a career was perceived as more likely to be
influenced by prior healthcare exposure, which include taking care of a
Table 5 represents the differences in mean scores between the HCC sick family member, being taken care of by a healthcare professional,
and NCC scales for the six factors and items. The means scores for the participating in related school co-curricular activities, observing
factors “prior healthcare exposure,” “nature of work”, and “social influ- healthcare professionals at work, hearing about the profession from sig-
ences” were significantly higher in the NCC scale than in the HCC scale. nificant others, and doing voluntary work in healthcare settings.
No significant difference between HCC and NCC was reported in the
mean scores for the factors “personal interest”, “self-efficacy”, and “job 3.3.3. Self-Efficacy
prospect”. The item “able to make diagnoses” was reported to have a significant
lower mean scores in the NCC scale than in the HCC scale, suggesting
3.3.1. Personal Interest that the consideration of the ability to make diagnoses has more influ-
The items “contribute to the society” and “enjoy interacting with ence on HCC than nursing as a career choice.
people” were rated significantly higher in the NCC scale than in the
HCC scale whereas the item “desire for a fulfilling career” was rated sig- 3.3.4. Nature of Work
nificantly lower in the NCC scale than in the HCC scale. In other words, in The mean scores for the items “more hands-on job”, “challenging
comparison to their own career choices, nursing as a career choice was job”, and “demanding job” were reported to be significantly higher in
perceived by the participants as more likely influenced by the personal the NCC scale than in the HCC scale. These findings indicated that nurs-
ing as a career was being perceived as more hands-on, which is chal-
Table 2
lenging and demanding when compared to the participants' career
Participants' response rates. choices. In addition, the greatest disparity between the NCC and HCC
scales was the item “do not mind attending to others hygiene needs”.
Response received
The participants had chosen a career that did not need to perform this
Courses No. of students n(%)
hygiene task.
Dental hygiene 20 17 (85.0)
Healthcare management 260 98 (37.7)
Pharmaceutical science 365 236 (64.7) 3.3.5. Job Prospect
Psychology 140 46 (32.9) The mean scores for the item “never be unemployed” was signifi-
Social work 70 54 (76.1) cantly higher in the NCC scale than in the HCC scale whereas the
Overall 855 451 (52.7)
mean scores for the items “opportunities for career advancement” and
 S.Y. Liaw et al. / Nurse Education Today 52 (2017) 66–72 69

Table 4
Highest and lowest mean scores items (top five) for HCC and NCC.

HCC M SD NCC M SD

Highest scored items

I want to make a difference in someone's life. 4.19 ±0.85 Nurses want to make a difference in someone's life. 4.26 ±0.80
I desire for a fulfilling career. 4.15 ±0.83 Nurses can contribute to society. 4.17 ±0.78
I desire to help others. 4.12 ±0.83 Nurses desire to help others. 4.10 ±0.83
I can contribute to the society. 4.01 ±0.83 Nursing is a hands-on job. 4.08 ±0.87
I want my parents to be proud of me. 4.01 ±1.00 Nursing is a challenging job. 4.08 ±0.95

Lowest scored items

In my school co-curriculum activities 2.26 ±1.27 Nurses want to choose a course that is more deserving of their good grades. 3.16 ±1.04
In being taken care of by healthcare professional 2.68 ±1.29 Nurses have high income. 3.20 ±0.94
Doing voluntary work in healthcare settings 2.79 ±1.13 The social media has inspired them to take up nursing. 3.23 ±0.98
The social media has inspired me 2.80 ±1.13 Nurses can make autonomous decisions at work. 3.26 ±0.94
In taking care of a sick family member 2.91 ±1.30 Nurses are able to make diagnosis. 3.31 ±1.01

“chance for achieving higher qualification” were significantly lower in
the NCC scale than in the HCC scale. In comparison to the participants'
career choices, nursing was perceived as a more employable job but,
as a career, it was less likely to provide opportunities for advancement
and to attain a higher qualification.
3.3.6. Social Influences
The items “well respected”, “good public image”, “inspired by social
media”, “peers encouraged of the choice”, and “peers will look up to me”
were rated significantly higher by the participants in the NCC scale than
in the HCC scale. In contrast, the items “no gender stigma”, “parents are

Table 5
Differences between healthcare career choice (HCC) and nursing as a career choice (NCC) scores.

HCC NCC
t-score
Domain/item M SD M SD

Personal interest 20.25 ±3.40 20.45 ±3.55 −1.226

1 Desire to help others 4.12 ±0.83 4.1 ±0.83 0.498
2 Contribute to the society 4.01 ±0.83 4.17 ±0.78 −4.081**
3 Desire a fulfilling career 4.15 ±0.83 3.9 ±0.88 5.192**
4 Enjoying interacting with people 3.77 ±0.95 4.02 ±0.84 −4.847**
5 Want to make a difference in someone's life 4.19 ±0.85 4.26 ±0.80 −1.685

Prior healthcare exposure 16.88 ±5.20 20.99 ±4.36 −17.610**

6 Experience in taking care of a sick family member 2.91 ±1.3 3.57 ±0.96 −11.438**
7 Experience in being taken care of by a healthcare professional 2.68 ±1.29 3.37 ±1.03 −11.400**
8 Experience in my school co-curricular activities 2.26 ±1.27 3.34 ±1.01 −16.805**
9 Experience in observing healthcare professionals at work 3.01 ±1.29 3.46 ±0.96 −7.354**
10 Experience in hearing about the profession from significant others 3.23 ±1.17 3.58 ±0.85 −6.150**
11 Experience in doing voluntary work in healthcare settings 2.79 ±1.13 3.67 ±0.89 −15.369**

Self-efficacy 13 ±3.29 13.01 ±3.35 −0.71

12 Reflects well on academic ability 3.23 ±1.08 3.28 ±1.04 −0.914
13 Choose a course that is more deserving of grades 3.06 ±1.15 3.16 ±1.04 −3.297
14 Make autonomous decisions at work 3.19 ±0.90 3.26 ±0.94 −1.37
15 Able to make diagnosis 3.52 ±1.07 3.31 ±1.01 3.519**

Nature of work 17.33 ±3.62 19.91 ±3.75 −14.505**

16 Highly skilled occupation 3.68 ±0.96 3.7 ±0.98 −0.425
17 More hands on job 3.72 ±0.95 4.08 ±0.87 −7.282**
18 Challenging job 3.37 ±1.01 4.08 ±0.95 −12.818**
19 Demanding job 3.28 ±1.03 4 ±0.98 −13.224**
20 Do not mind attending to other's hygiene needs 3.29 ±1.03 4.06 ±0.94 −14.321**

Job prospects 24.64 ±5.45 25.08 ±5.09 −1.742

21 Ensures a stable job 3.82 ±0.98 3.91 ±0.88 −1.88
22 Never be unemployed 3.27 ±1.14 3.81 ±1.00 −9.491**
23 Ensures high income 3.24 ±1.08 3.2 ±0.94 −0.757
24 Ensures a good standard of living 3.45 ±0.96 3.48 ±0.90 −0.503
25 Provides a chance to work overseas 3.39 ±1.07 3.48 ±0.96 −1.713
26 Provides many opportunities for career advancement 3.71 ±0.92 3.61 ±0.91 2.011**
27 Provides a chance to achieve higher qualifications 3.75 ±0.90 3.57 ±0.92 3.518**

Social influences 26.86 ±5.76 28.02 ±6.05 −4.479**

28 Well respected 3.26 ±1.01 3.67 ±1.01 −7.618**
29 Good public image 3.29 ±1.02 3.64 ±0.93 −6.775**
30 Inspired by social media 2.8 ±1.13 3.23 ±0.98 −8.141**
31 No gender stigma in the career 3.51 ±1.05 3.32 ±1.20 3.133*
32 Parents are supportive 3.93 ±0.96 3.58 ±0.91 6.689**
33 Want parents to be proud 4.01 ±1.00 3.71 ±0.89 6.306**
34 Peers encouraged of the choice 3.11 ±1.15 3.39 ±0.96 −5.672**
35 Peers will look up to me/nurses 2.96 ±1.14 3.47 ±0.98 −9.525**

Significant at ** p b 0.001, * p b 0.05.

70 S.Y. Liaw et al. / Nurse Education Today 52 (2017) 66–72
supportive”, and “want parents to be proud” were rated significantly
lower by the participants in the NCC scale than in the HCC scale. In
other words, in comparison to their own career choices, the participants
perceived nursing to have stronger respect and support from peers and
the public but less so from their parents and that their parents would be
less proud of their choices. Nursing was also perceived as more likely to
suffer from gender stigma.
4. Discussion
A personal interest in their chosen healthcare careers based on in-
trinsic values such as the desire to help others and wanting to make a
difference in someone's life was rated by the Singaporean healthcare
students as a strong motivating factor. This finding is consistent with
several international studies that identified personal interest as a strong
intrinsic factor which influences career choices among healthcare stu-
dents in the UK, Ireland, Nepal, Israel, and the Arab world (Crossley
and Mubarik, 2002; Halperin and Mashiach-Eizenberg, 2013; Hayes
and Shakya, 2013; McLaughlin et al., 2010). Holland (1966) supported
this by stating that individuals choose a career based on their personal-
ity profiles and interests.
Prior exposure to healthcare work was perceived by the healthcare
students as a strong influencing factor for choosing nursing as career
but not for their chosen healthcare careers. In our findings, the greatest
differences on prior healthcare exposure reported were in relation to
their school co-curriculum activities and doing voluntary work in
healthcare settings. The influence of prior experience in healthcare for
choosing a nursing career has been reported by previous studies con-
ducted in the United States and the UK (Larsen et al., 2003;
McLaughlin et al., 2010). Nursing courses are attracting more older stu-
dents who have prior working experiences than younger school leavers
(Pool et al., 2013). While this is good because the students are more ma-
ture and more certain of what they want, it may be a human resource
waste that young school leavers spend valuable time exploring other
options first. If they can make informed career choices at a younger
age, it will benefit them, nursing, and the society as a whole. The expo-
sure to healthcare through the participation of school co-curriculum ac-
tivities, such as Saint John's Ambulance and The Red Cross, and
community involvement programmes in healthcare settings seems to
have important influences in students' career preferences for nursing.
Thus, exposure to healthcare related work through school activities
should be promoted to influence students in considering nursing as a
career.
Self-efficacy was perceived as the least influential factor for consid-
ering nursing as a career choice. In this study, self-efficacy relates to a
student's belief of their academic and intellectual ability to their career
choice. As a result of the huge nursing intake, students who are accepted
into the nursing course range from excellent performers in their GCE ‘O’
Level examinations to those with lower academic abilities. Nursing
course has been perceived as an easy course to get into and, to some,
it was perceived as a ‘dumping’ course for students who did not achieve
sufficient academic grades to enter their preferred career choices (Liaw
et al., 2016b). Qualitative studies conducted in the UK and Singapore
suggested that the perception of nursing for low academically inclined
students could have deterred academically-abled students from apply-
ing for a nursing course (Liaw et al., 2016b; Neilson and Lauder,
2008). In contrast, the requirement of good academic performance to
study nursing was perceived by students from Kuwait, Nigeria, and
Hong Kong (Al-Kandari and Lew, 2005; Law and Arthur, 2003;
Ogunyewo et al., 2014). As a low academic entry requirement of nursing
course seems to reflect low intellectual requirement expected of nurses,
there is a need for Singapore educational institutions to review the ad-
mission criteria and strategies for selecting and recruiting nursing
students.
In our findings, healthcare students perceived that their chosen ca-
reers offered opportunities to make diagnoses while nursing as a career
choice does not, possibly because they perceived nursing as a more
hands-on job. This study supported previous findings in that the general
public views the role of a nurse as one who mainly follows doctors' or-
ders and performs physical tasks (Seago et al., 2006; Williamson, 2012).
In Singapore, non-nursing healthcare courses prepare individuals to be-
come assistants or allied health therapists (e.g. oral hygiene therapists,
psychology students, and social work associates). Given that a diploma
nursing course in Singapore will lead to the role of a registered nurse,
our findings identified the lack of understanding on the role of a regis-
tered nurse among non-nursing students. A possible reason for this
lack of understanding could be due to the diverse nursing workforce
in Singapore such as registered nurses, enrolled nurses, and healthcare
assistants who put on similar corporate uniforms. Thus, the image of a
registered nurse needs to be recognisable from the rest and as a homo-
geneous group in the whole country to promote a distinct registered
nurse image. In addition, the specific role of a registered nurse which in-
volves developing nursing diagnoses and care plans for patients, and su-
pervising the work of non-registered nurses, needs to be highlighted.
The participants perceived their chosen careers as more fulfilling
than nursing as a career choice. A plausible explanation for this could
be the lack of understanding on the rewarding nature of nursing work.
Thus, there is a need to consider how to promote nursing as a fulfilling
career among school leavers. In addition, the non-nursing healthcare
students in our study reported a significant disparity between their
healthcare career choices and nursing as a career in terms of the nature
of work. The perception of nursing as a more challenging and demand-
ing job, and the need to attend to others' hygiene needs, may have de-
terred these students from choosing nursing as a career. While
acknowledging the challenges and demands of nursing work, the
value, dignity, and rewards that could be experienced from nursing
work, including meeting someone's personal hygiene, should be
highlighted to associate the value of the nature of work and the sense
of job fulfilment.
In the area of job prospect, healthcare students recognised that nurs-
ing as a career choice enjoys a better employment opportunity despite
lesser opportunities for educational and career advancements. These
students appeared to have limited information on the availability of
higher nursing education ranging from an advanced diploma to a doc-
toral degree to prepare nurses for nursing specialities and different ca-
reer pathways. Despite the established career pathways in Singapore
nursing, our findings revealed that many people are still unfamiliar
with the roles of advanced nurse practitioner, researcher, educator,
and manager.
In comparison to their own career choices, nursing as a career choice
was perceived by the students as more likely suffer from gender stigma.
This finding is not unexpected as the social construction of nursing
being female dominant is known to inhibit men from entering the nurs-
ing profession. The stereotypical image of a male nurse as one of being a
homosexual, effeminate, or a sexual deviant poses challenges for male
students to consider a career in this profession (Bronner et al., 2003;
McMillan et al., 2006). Grounded in Gottfredson (1981), gender-type
and occupational status have been testified as important variables in
influencing the career aspirations of students. Family members and par-
ents play an important role in shaping their attitudes toward occupa-
tional status and gender-type (Leung et al., 2011).
Gaining parents' support and making them proud of their career
choices were indicated by the students as significantly more important
influential reasons for their career choices than for choosing nursing as a
career. The effect of parental influences could be explained by the col-
lectivist culture of Singapore whereby an individual student may tend
to make a career decision that will meet their parents' expectations
rather than to satisfy their own interest (Sawitri et al., 2014). These find-
ings also highlighted the strong influence that Singaporean parents
might have on their children's career choices. In a study conducted in
Hong Kong, the effect of parents' influences was found to be significant-
ly associated with students' considerations of nursing as a career (Law
 S.Y. Liaw et al. / Nurse Education Today 52 (2017) 66–72
and Arthur, 2003). Asian parents from other countries, including China
and Taiwan, have also reported to have high career expectations in
their children (Hou and Leung, 2011; Wang and Heppner, 2002). With
the perception of nursing as a low prestige and female-dominated occu-
pation, parental objection may play a significant influence in their
children's decisions of entering a nursing course, especially for male
students.
4.1. Limitations
The findings of this study, though obtained from four tertiary educa-
tional institutions in Singapore, may not be transferable to other coun-
tries with different social and cultural issues. However, these findings
have international significance as the nursing workforce issue is a global
problem complicated by a worldwide ageing trend. A few items embed-
ded in the HCC-NCC parallel scale can be either positively or negatively
worded items. However, these items were positively worded based on
the previous psychometric testing outcome. Another method bias is
the social desirability effect whereby participants may tend to respond
to the questionnaire in a socially and culturally acceptable manner.
However, the disparity in the HCC and NCC scales probably indicate
that socially desirable responses may not be apparent in this study.
5. Conclusions
This study examined the differences between the influences of cho-
sen HCCs and nursing as a career choice among non-nursing healthcare
students in higher educational institutions. This comparative under-
standing of career choice influences has provided valuable implications
for educational institutions and policy-making planners to consider
strategies to enhance nursing enrolment among school leavers. As the
greater demand for the nursing workforce is a global problem, these
strategies may have international implications since the recruitment
of school leavers for nursing courses is challenging.
Firstly, the exposure of nursing as a rewarding career should be pro-
vided in the early stages of life, especially in school. Policy leaders can
promote this by encouraging schools to incorporate caregiving
programmes into early school curriculums or co-curricular activities
and to reflect on the value of these activities.
Secondly, the perception that nursing courses are for students with
lesser academic and intellectual abilities should be corrected by the
entry requirements of diploma nursing courses. One way is to reduce
the emphasis of academic results and employ other selection ap-
proaches such as emotional intelligence tests to recruit students with
appropriate attributes.
Thirdly, a concerted effort is needed from policy leaders, educators,
and researchers to address gender stigma and promote gender diversity
in the nursing workforce. Given that roughly half of the population is
male, recruiting men into nursing can significantly fulfil the nursing
shortage. Future studies to explore the challenges faced by Singaporean
male student nurses may provide valuable insights for more specific re-
cruitment strategies targeted on male students.
Fourthly, there is a need to promote public awareness on the differ-
ent levels of nurses and recognise the problem-solving abilities and
leadership role of a registered nurse. This publicity should also include
the career advancements of a registered nurse (e.g. advanced nurse
practitioner, educator and managers) and nursing education progres-
sion from a diploma to a doctoral degree.
Finally, the publicity approach should target parents to help them
better understand the roles and career advancement opportunities in
nursing. As parents are increasingly active influencers of their children's
career decisions, it is vital to develop innovative strategies to engage
parents in the career decision-making processes of their children. Fu-
ture studies could further examine the effect of parental expectations
on healthcare students' career choices, particularly the career choices
of nursing students.
71
Conflict of interest
No conflict of interest has been declared by the authors.
Acknowledgement
This study was funded by Ministry of Health (MOH) Health Services
Research Grant (HSRG11MAY023). We would like to thank the
healthcare students from higher education institutions for participating
in the research study. We also thank the NUHS Medical Publications
Support Unit (PSU) for providing editing services for this manuscript.
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