Factors Influencing Students Choice of Pursuing Nursing Education in Nepal

Nursing is a caring and helpful profession and the unique function of the nurse is to assist the individual, sick or well. Although nursing, as an education and a career, is on a rising trend in Nepal, there is paucity of data regarding the factors that influence choosing it. So, a cross sectional study was carried out purposively among first year nursing students who were just enrolled to study nursing in different nursing colleges in Kathmandu Valley, Nepal. Structured questionnaires were distributed among 336 nursing students. Major source of inspiration to pursue nursing were their parents. The main reasons to choose nursing are to learn new things and to secure job. Major factors which contributed getting enrolled into nursing was an opportunity to care and help needy people (µ±σ=3.8±.39) and an attraction towards possibilities of working abroad in the future (µ±σ=3.4±.59). Besides, the students also felt that nursing was a noble and respectable profession where they could learn newer technologies with a better advancement. About 45.8% agreed that nursing was a profession with relatively lesser earnings and almost 40.5% disagreed that the cost of nursing education was within their payable range.It is recommended that nurses should be well paid and the vacant positions need to be fulfilled in time in both government and private sectors to motivate young students. In addition, it is time to bring advancement in their career by initiating and expanding further courses in nursing education and practice like nurse practitioner, specialization degrees and PhD inside the country.


INTRODUCTION
Nursing is a helping and caring profession. According to the American Nursing Association, nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human individuals and advocacy in the care of individuals, families, communities and populations. 1 Nursing is an integral part of the health care delivery. Nurses are the 'frontline' worker in health system and their contribution is essential in meeting sustainable development goals. 2 Nursing is widely regarded as a noble profession in the society because of the core value it promotes in its practice. 3 Nurses practice as a care provider in many specialities according to their role and responsibilities focusing on patients need. Nursing education has been advanced with many specializations. 4,5 Worldwide there is an increasing evidence of imbalance in the global nursing work force supply and demand. 2 Due to advance technology and innovation in health sector nursing care has become highly demanded & has important role in health services. The demand of qualified and skilled nurses has become challenged. Because of increased prevalence of non-communicable diseases, there is demand of increased support of professional nurses in the developed as well as developing countries. 6 Currently there are two pathways to pursue nursing education in Nepal-proficiency level certificate nursing (PCL) conducted by different institutions with affiliation solely to council for technical education and vocational training (CTEVT); and Bachelor of Science (BSc) in nursing run under different universities. The minimum educational qualification required for enrolment in PCL is completion of high school and for BSc nursing is the completion of +2 in sciences. Before joining a job as a nurse, the students need to clear the licence exam conducted by Nepal nursing council after completion of these courses.
Choosing a nursing profession, there are many factors that influence a person's decision including their prospect of lifelong success. 7 Understanding the career decision of students is an essential component of recruitment and retention strategies. With increasing job opportunities in the nation and international level in various medical field has proved that why students choose as a career. One enters the nursing profession at a young age; the age which corresponds to long term career development and future orientation. 8 Over the last few years there has been a dramatically increase in demand for enrolment at nursing colleges. The number of training applicants has been increasing every year and almost 20-30% of the total nursing workforce trained in Nepal was working outside the country. 9 Nursing is increasingly seen as an attractive career choice for young Nepali women. 10 Therefore, it is important to assess the factors influencing perusing nursing among students entering in both the nursing programs. Limited research was undertaken in Nepal with students entering nursing programmes. So, this study helped to explore the factors influencing students' choice of pursuing nursing education in Nepal.
According to literature, multitude of factors like socio-demographic factors and student's perceptions of nursing as a career can affects nursing students' career choice. 11 Similarly, studies suggests that for young students to choose a career, the process of decision making is a complex multi-faceted which in turn is influenced by predisposing factors such as family, gender, culture and society as well as their ability. Such studies were conducted in Ireland, Hong Kong, Egypt and Sweden. [12][13][14][15][16]

MATERIALS AND METHODS
A cross sectional, descriptive study was conducted using purposive sampling technique. The specific objectives were to explore the sociodemographic profiles of the newly enrolled nursing students and the different factors that would influence pursuing nursing education among nursing students. This study was carried out in selected nursing colleges located inside Kathmandu valley. The target population were the undergraduate students: proficiency certificate level (PCL) or Bachelor of Science in nursing (BSc Nursing). The colleges were selected as per the feasibility of the researcher.

Study Population and Sample size:
The students studying in the first year of nursing and were in the first six months of their course were included in the study. Students of BSc nursing at six different nursing colleges affiliated to three universities (Kathmandu University-1, Purbanchal University-4 and Tribhuvan University-1) and of PCL nursing at five different nursing colleges running under council for technical education and vocational training (CTEVT) were included in the study. Total number of students in the BSc and PCL levels were 165 and 190 respectively. Three students from BSc and sixteen students from PCL were not available at the time of study. Therefore, a total of 336 students (162 from BSc and 174 from PCL) were included for final analysis.

Data collection:
Pretesting was done to evaluate the practicability and feasibility of the study in about 10% (n=30) of sample size among nursing students of Nepal Medical College. Data collection was done over a period of six months between September 2016 and February 2017. The questionnaire was distributed among the participants in the presence of the investigator and the response was collected on the same day.
Ethical clearance: Ethical clearance was obtained from the institutional review committee (IRC) of Nepal Medical College and verbal permission and consent was taken from the selected nursing colleges and the participants before initiation of the study. Anonymity was maintained by not mentioning the name of the colleges and by giving the code number to the participants. Those students who were not present at the time of data collection were excluded from the study.
Instrument for data collection: Student nurses' perceptions towards nursing were collected by the self-reported questionnaire constructed by the researchers themselves.In this study, factors were measured under three subheadings-main reasons to study nursing, source of inspiration to study nursing and the student nurses' image towards nursing. Here, image towards nursing is considered as the factors motivating to pursue nursing course. Here, the highest score on certain statements was considered as the strongest influential factors to choose nursing. There were altogether eight statements related to perceived impression towards nursing and the rating ranged from strongly disagree as -1, disagree-2, agree-3 and strongly agree-4. Out of total 8 statements 2 and 4 were negative statements and hence reverse coding was done: strongly disagree -4, disagree -3, agree-2, strongly agree-1.

RESULTS
Sociodemographic Characteristics: Out of 336 respondents, 51.7% (174) were from PCL and 48.3% (162) were from BSc nursing course. The mean age of the respondents in two groups      Table 1). Out of total participants in the PCL level, six had already lost their father and three had lost their mothers. Regular job, business and working abroad were the major occupation of the father of the respondents in both groups. However, majority of the nursing respondents' mother were worked as homemaker (Table 2 and 3).

Reasons for Choosing Nursing:
Majority of the respondents mentioned that the main reason for choosing nursing as a career were eager to learn new things (88.7%), job security (87.5%), and for better earning (81%) by choosing this field ( Table 4).

Source of inspiration to study Nursing:
Majority of the participants mentioned they were inspired by their parents (60.4%) followed by the siblings (20.5%), close relatives (5.7%), friends (4.8%) and the grand-parents (3.9%) to get enrolled into the field. Only, 18.8% percent reported that they were self-motivated to pursue into the field (Table 5).
Perception (Image) towards nursing: About 83% of the students strongly agreed that the nursing is a caring and helpful profession. Forty five percent agreed that nursing is profession with relatively lesser income. Majority of the students agreed that it is a recognizable and respectful profession. About 18% strongly disagreed and forty percent disagreed that the cost of nursing is within their payable range. Table 6 illustrates that majority (56.3%) of the first year nursing students agreed nursing as a stressful and demanding profession and 66.1% agreed that there is advancement in nursing career and in nursing education. Similarly, the percentage of first year nursing students who strongly agreed and agreed that they would be able to work abroad in the future by choosing nursing as their career were 48.8% and 47.6% respectively. Here the strongest factor to pursue nursing among first year nursing students is the caring and helpful nature of nursing profession. The highest mean (µ±σ=3.8±.39) score obtained in the statement "nursing is caring and helpful profession." The second highest score ((µ±σ=3.4±.59) obtained in the statement that they can work around the world.Student has chosen nursing despite they knew that there is low payment in nursing. Probably, they were looking at the bright side of nursing profession as they perceived nursing as a career where they can work around the world.

DISCUSSION
With the growing dimensions of the field, the extraordinarily satisfying nursing profession is becoming more challenging day by day. So, the selection of the field as a long-term career requires certain criteria to be set not only by the policy makers and educators but also the students who get enrolled into the course. To be both successful and happy in nursing, it demands to have certain personal qualities, expectations and attributes among the nursing students from the time of their joining. To uplift the overall quality of the profession, it

Shrestha et al
is always important to assess and identify the factors that would influence the persuading of nursing as a career among students. Therefore, this study was conducted to explore the factors that influenced selecting nursing as a career among first year nursing students in different nursing colleges of Kathmandu valley in Nepal.
The minimum age of the nursing student at the time of enrolment was 15 years with the mean age of 18 years. More than two thirds of the students enrolled were below the age of 18 years. This shows that students join nursing courses at relatively younger age in Nepal. There has not been a clear age requirement for enrolment in proficiency level certificate and bachelor in nursing programme. 17,18 Setting the minimum age for enrolment in nursing would help to maintain the uniformity in terms of maturity among the students as this field is a sensitive one where the students require to face sensitive issues during taking care of the patients that would help to minimize the rate of dropping down from the profession during or after the completion of the course. The minimum age required for entering into any field of nursing in India is 17 years respectively. 19 In this study, majority of the respondents were from caste groups of Janajati, Brahmin and Chhetri, which is similar to a study done in eastern part of Nepal. 20 However, there seems to have minimum enrolment of students from dalit (Kami, Damai), disadvantaged non-Dalit (Yadav) and religious minorities (muslims). This may be because of relatively lower literacy rate among Dalit woman (45.5%) in comparison to national literacy rate of woman being 57.53% in Nepal. Furthermore, it can be related to the fact that proportion of Dalit girls completing high school, that is the minimum education criteria required to get enrolled in nursing, is relatively less in Nepal. 21 Awareness and internalization of the sensitive issues related to the nursing education among parents of the prospective students might play a major role to broaden the scope of nursing education and profession. Majority of the parents of the respondents in this study had an education level up to SLC, which seems to be better than the studies done in other parts of the world, where the parents of the nursing students were either illiterate or had completed only up to primary level. 8 Majority of the nursing student agreed that main reasons behind choosing nursing are to learn new things and the perceived assurance for future job. This is similar to the findings of the study conducted in Turkey were majority of the students chose the nursing as it is easy to get the job in this field. 22 This is in support of the several other studies conducted in Athens, Jordan, Cyprus, where students selected to study nursing based on their belief that they would be easily employed once graduated. [23][24][25] The major source of inspiration to pursue nursing was parents. It is surprising to see that only few were inspired by self. This may be because that the expenses for the whole course had been managed by either the government (for scholarship seats) or from the parents. This is contradictory to the studies from India which showed majority of the students were self-motivated. 8 Majority of the students have chosen nursing as they perceived nursing as a caring and helpful profession. This is in harmony with several other studies conducted in India, Athens, Poland, and Malaysia. 8,23,26,27 Majority of the students have feelings that they will be able to work around and this seemed to be the second important factor for choosing nursing in context of Nepal. This is in agreement to study from Poland. 26 Majority of the nursing students intend to go abroad after completion of their nursing course. 8,28 On a survey conducted among bachelor of science in nursing student in Nepal where majority of them had plan to go abroad for job or study and the choice of country was USA. 29 Though student choose nursing for opportunity for employment a majority still mentioned that it is lowly paid profession. This is similar to the study from Cyprus where very few agreed that salaries are high in nursing. 30 This is clearly evident by the migration of thousands Nepalese nurses to another country from Nepal every year. 31 The main reasons for the migration were occupational security, better payment and for higher education. [32][33][34] The others reasons to enter in nursing may be that majority felt that nursing is not difficult for them. Besides this students perceived that they have advancement in nursing career or nursing education. Similarly, they described nursing as recognizable and respectful profession.
The most important thing here is that majority felt that they chose nursing despite the fact that this is lowly paid profession. In other hand majority pursued nursing because they will be able to work around the world.This may conclude that they entered in this field in order to grasp the opportunity to work around the world. This can result in draining of the nursing manpower from Nepal to other countries. This could lead to the shortage of qualified and skillful future nurses in the country. Even the survey conducted by International Labour Organizations showed that almost half of the nursing students planned to move abroad for better salary and for further studies. 35 The findings of this study may not be generalized to whole Nepal as this study is only confined to the Kathmandu Valley. Similar type of study can be conducted covering whole Nepal. The positive findings in this study may be because that they have already enrolled in the field.

ACKNOWLEDGEMENT
The author would like to thank the authorities of different colleges for granting permission to conduct the study. Our sincere thanks goes to all the participants and grateful to all who helped in the accomplishment of this report.