INTRODUCTION

The International Council of Nursing states that "the training of the Bachelor's Degree in Nursing prepares and trains to carry out the promotion of health, the prevention of illness and to know how to provide the necessary care to people with physical, mental and disabled illnesses from a newborn to an elderly person, and to know how to adapt them to all levels of care in the community"¹. It should also be noted that the Bachelor's Degree in Nursing is one of the most requested university degrees in our country ².

Despite the wide range of fields, settings and areas covered by nursing, as well as the diversity of the population to which nurses can provide care, many studies have reported that many nursing students show more preference for some clinical areas, as well as feeling a special rejection for others^3)(4)(5. Thus certain areas such as geriatric nursing^6)(7)(8, psychiatric-mental health nursing^9,10 or community nursing¹¹ have been reported as areas of low preference by nursing students when choosing a field in which to carry out their professional work.

Multiple and varied reasons have been reported for this disparity of preferences among students: intrinsic factors (gender and age), experience in clinical practice, the complexity of the care to be provided, individual culture, the influence of certain stereotypes associated with certain roles or discriminatory biases, etc ^{3)(4)(5)(8)(12)(13)(14}.

It has also been studied that, as students' training progresses, interest and decisions regarding these preferences may change¹⁵, and can be modified, for example, by certain interventions, such as increasing the number of clinical practices in an area or service, the inclusion of specific content for particular areas in the curriculum or the implementation of specific programmes^5)(6)(16)(17.

In the present context of the lack of nurses in the world and in our country¹⁸, this topic may have important consequences for healthcare systems, since many of the areas that require a high number of nurses for their correct functioning are not very attractive to nursing students^5,18.

For this reason, the study of which subject areas arouse the greatest interest in nursing students is relevant, as this information allows us to detect the clinical areas with the least preference and demand on the part of students, allowing the design and implementation of strategies to mitigate the possible existing imbalance.

After reviewing the literature, no studies have been found that have addressed this theme in our country, so the present study was proposed with the aim of identifying the employment preferences of nursing students at the University of La Laguna (Canary Islands-Spain) once they have completed their undergraduate studies, according to clinical-thematic areas.

MATERIAL AND METHODS

A descriptive cross-sectional observational study with an analytical component was carried out.

The study population consisted of students enrolled in the 3rd and 4th year of the Degree in Nursing at the University of La Laguna in the academic year 2021/2022. For the selection of the sample, a non-probabilistic convenience sample was applied among the students enrolled in the Degree in Nursing. No exclusion criteria were considered for this study.

No prior sample calculation was made, since the aim was to include the total study population (144 students enrolled in 3rd year/142 students enrolled in 4th year), with an estimated total study population of 286 students (n=286).

The following variables were considered: age, gender, previous healthcare work experience, nationality, marital status, number of children, university campus (Tenerife and La Palma university campuses), course enrolled, intention to access the specialised training programme (specialist nurse in residence programme), postgraduate training (Official Master's Degree) or doctorate and ten areas of work preference. These areas were: Paediatric Nursing, Obstetric-Gynaecological Nursing (Midwife), Mental Health-Psychiatric Nursing, Emergency and Urgent Nursing, Operating Room and Anaesthesia Nursing, General Nursing, Intensive and Critical Care Nursing, Family and Community Nursing, Geriatric Nursing and Other areas (teaching-management-research).

The data collection instrument used was an online questionnaire of the authors' own design, inspired by the one used in the study by Matarese M et al⁵. The first part, designed "ad hoc", collected the sociodemographic variables to be studied, and the intentions of accessing the specialised training programme, postgraduate training or doctorate. The second part collected the preferences by areas, where the preference for each area was scored on a Likert scale from 1 to 5 points, where 1 = not at all desired and 5 = very much desired.

To assess the comprehensibility, and to detect possible problems in the administration of the instrument, a pre-test of the questionnaire was first carried out with 10 students of the Nursing Degree from another university (University of Las Palmas de Gran Canaria), and the questionnaire was also evaluated by two professors from that university.

The questionnaire was made available to participants through the use of a secure digital forms platform (Google Form^®). Dissemination was carried out by means of an invitation through the students' university's corporate emails, and was available from 14 January 2022 until 6 February 2022.

The data collected through the questionnaires were captured in an Excel^® spreadsheet and transferred to a matrix of the IBM SPSS^® v19 programme for analysis.

Initially, a descriptive analysis of all the variables was carried out, reflecting them by frequencies and percentages in the qualitative variables and by means of the mean, standard deviation and maximum-minimum values in the quantitative variables. Subsequently, a bivariate inferential analysis was carried out to establish possible associations between different variables and the students' areas of preference. Pearson's X² or Fisher's statistic was used for the comparison of qualitative variables and the Student's t-test for the comparison of means for quantitative variables (the Kolmogorov-Smirnov test demonstrated the symmetry of the distribution of the data). Statistical significance was set at α <= 0.05 for this study.

For each association studied, effect sizes were calculated according to the Hedges formula¹⁹. Effect sizes between 0.2-0.5 were considered as "small", between 0.5-0.8 as "moderate" and above 0.8 as "large".

Permission was sought from the University of La Laguna Faculty of Health Sciences (positive opinion), and from the Research Ethics Committee of the province of Tenerife. The Ethics Committee did not consider it necessary to evaluate the submitted project, but gave its approval to carry it out by official communication.

The students who participated were informed of the purpose of the study and the voluntary nature of the study, guaranteeing the anonymity and confidentiality of the data of each participant, respecting the Organic Law on Personal Data Protection and Guarantee of Digital Rights (3/2018 of 5 December). It was understood that by voluntarily submitting the form, each student gave their consent.

RESULTS

A total of 153 students (n= 153) with a mean age of 24.25±7.63 years finally participated in the study (Response rate=53.50%). Of the participants, 77.1% (118) were female and 22.9% (35) were male. 98.7% were of Spanish nationality compared to 1.3% (2) who were not. Regarding marital status, 91.5% (140) were single, 7.2% (11) were married, and 1.3% (2) were separated/divorced. 7.8% (12) of the students had children and 92.2% (141) had no children. Regarding work experience, 19.0% (29) had previous health work experience and 81.0% (124) did not.

Of the total sample, 54.9% (84) belonged to the Tenerife Campus, while 45.1% (69) were assigned to the La Palma Campus. Regarding the year of enrolment, 49.0% (75) were from the 3rd year, while 51.0% (69) belonged to the 4th year.

Regarding the intention to pursue a nursing speciality, 33.3% (51) responded affirmatively, 37.9% (58) responded negatively, while 28.8% (44) responded Don't know/No answer. Regarding the intention to undertake postgraduate training, 52.9% (81) answered in the affirmative, 19.0% (29) answered in the negative and 28.1% (43) did not know/no answer. Regarding the intention to pursue a doctoral programme, 17.0% (26) said yes, 43.80% (67) said no and 39.2% (60) said don't know/no answer.

Table 1 shows the frequencies and percentages of the variables considered according to the campus to which the participants were affiliated, in addition to the intentions to pursue a nursing speciality, postgraduate studies and doctorate, with no statistically significant differences being found between the groups.

Table 1. Frequencies and percentages of the variables considered according to the centre to which the participants were affiliated. 

A= Fisher's statistic

B=X² of Pearson

With regard to the students' preferences, Table 2 shows the floor percentage, ceiling percentage, mean and standard deviation of each of the scores for the areas considered. The area with the highest score and preference was the area of "Emergency and Urgent Nursing" (Mean=3.04±1.05), while the least preferred area was "Other areas" (Mean=1.10±1.22).

Table 2. Floor-ceiling percentage, mean and standard deviation for each of the scores of the areas considered. 

Possible associations of the variables collected with respect to the 10 areas were explored. The variables considered for this analysis were: Year (Year 3 vs Year 4), Gender (Male vs Female), Children (Yes vs No), Previous Healthcare Work Experience (Yes vs No) and University Campus (Campus 1 vs Campus 2). Table 3 shows all the means and standard deviations of the groups for each of the areas, as well as the p-values and effect sizes obtained for each of the inferences studied for each association.

Table 3. Group means and standard deviations for each of the areas, p-values and effect sizes obtained for each of the inferences. 

^*Statistically significant value p ≤ 0.05 (Student's t-value)

-Data presented as Mean (Standard Deviation)

-Effect sizes according to g Hedges; 0.2-0.5 small effects, between 0.5-0.8 moderate effects and above 0.8 large effects.

DISCUSSION

As in the rest of the international literature consulted, the results obtained show that there are substantial differences in the preferences of undergraduate nursing students in relation to certain clinical areas.

The area of Emergency and Urgent Care obtained the highest mean score among final year students, this being the area that students indicated as the most preferred, similar to what has been reported in other studies^5)(12)(20. Other results obtained are consistent with the literature, such as that women prefer to work more with children and in obstetrics^3)(4)(5, and that students who have children prefer not to work in paediatrics compared to those who do^5-6, in both cases with moderate effect sizes.

Likewise, it is confirmed that areas such as Geriatric Nursing and Mental Health and Psychiatric Nursing are areas that generate rejection among students. This is in line with the existing literature, which reveals that these are consistently reported as unattractive professional fields. Studies describe that students perceive them as areas where the functions are routine, unchallenging and uninteresting, as well as constantly facing suffering and death^{5)(6)(7)(14)(15)(21}.

It is paradoxical how students choose geriatrics as one of the least preferred areas for their professional career, but opt for one of the most favoured, emergency care, when it is estimated that a high percentage of the demand for emergency care is attribuTable to the attention of the geriatric population^5)(6)(22)(23.

Other areas identified as unattractive were Operating Theatre Nursing and Anaesthesia (this result being contrary to what is reflected in other studies^5-7) and the so-called "Other areas". For this study, this last category included areas not related to direct patient care (teaching, management and research), but the results obtained for this category should be assessed with caution, since the activities included in this item are not exclusive to this area, as nurses can perform these roles in any of the other areas considered. In fact, ideally, all nurses should integrate these role-activities along with the purely caring role in their professional development²⁴.

Although it has been pointed out that the possibility of doing a doctorate has provided an opportunity for Spanish nurses to advance in the development of their research role²⁵, the results obtained in our sample indicate that the percentage of students who plan to do a doctorate is very low (17.0%).

In contrast to other studies carried out in other countries with different models of nursing professional organisation, this study also investigated students' intentions to pursue a speciality. In Spain, the development of the nursing speciality model has been exponential in recent years, which has led to an increase in the quality of care provided by Spanish nurses²⁶; however, only approximately 30% of the students who completed the survey responded that they intended to pursue a nursing speciality, although there were a significant number of undecided respondents. This result is surprising, considering that, in order to work in our country in certain areas (such as in the field of obstetrics-midwifery) it is essential to have a speciality, while in others (such as paediatrics or family and community nursing), although it is not yet a necessary condition, it is expected to be so in the future²⁶.

We wanted to explore the possible relationship between locations and preferred areas. Although some differences were found (in " Emergency and Urgent Nursing" and "Other Areas"), it can be said that the results obtained in this respect were homogeneous, which can be interpreted positively, as it facilitates a possible reorganisation and joint planning of the educational plan.

This research has some limitations. The sample was composed only of students from a single university and may not be representative of the Spanish nursing student population. These results should be confirmed in new studies evaluating the entire population of Spanish nursing students in order to ensure the external validity of these results.

Another limitation emanates from the type of sampling, since although the response rate has been moderate, those students who did not participate may have had different preferences, and this could affect the internal validity of the results obtained.

Finally, one limitation is related to the data collection questionnaire, as a non-validated questionnaire was used, although a pre-test was carried out in the target population to minimise this problem. In addition, the other similar studies did not use validated instruments either^{5)(6)(12)(15)(20}, as none currently exist, probably due to the disparity of training environments for nurses in each country, which makes it difficult to develop a single tool.

As a strength we can note that, to the best of our knowledge, this study is the first to examine the preferences of nursing students by clinical areas in our country. The results obtained may encourage the teaching departments that offer nursing degree courses to investigate which are the most preferred areas of the students in their environment.

CONCLUSIONS

The study of which are the preferred areas of professional performance for nursing students is important, because it can potentially have an impact on the organisation and planning of nursing resources in health systems. This topic needs to be further explored in Spain, as it is a pending issue to know why some areas of work are more attractive and popular than others. This aspect should be a priority for universities, centres and schools that provide undergraduate training in nursing, as this data is necessary to establish strategies, teaching policies and curricula to ensure that those areas that are less attractive become so. Precisely many of these clinical areas that are not very attractive to students require a large number of nurses to attend to the care needs of the community. The present study offers a first approach to this theme in our country.