What motivates people to commence a graduate entry nursing programme: a mixed method scoping review

The aim of this scoping review is to describe the evidence on the motivations of graduates who enrol in GEN programmes. The question of the review is: What are the motivations of graduates who enrol in GEN programmes?

Types of participants included individuals seeking to enrol or who were enrolled in a graduate entry nursing programme. Key concepts included motivations, enablers and barriers. The contexts included anywhere applicants for a graduate entry nursing programme may be found such as tertiary education providers. The types of publications included peer-reviewed journal publications of quantitative, qualitative and mixed-methods primary research studies. No date nor language limiters were applied. Due to the large number of irrelevant studies from the veterinary science programmes, a ‘human/humans’ limiter was applied.

Studies were excluded where: 1) learners were entering undergraduate nursing degree programmes; 2) studies only presented academic or theoretical perceptions; 3) studies only presented learners experiences of a programme.

The search of electronic databases included Cumulative Index to Nursing and Allied Health Literature (CINAHL), Emcare, ERIC, Medline and Scopus. Two reviewers independently screened all titles and abstracts, and full-text studies, for inclusion according to the pre-determined inclusion and exclusion criteria. The search strategy for Scopus is provided in Supplementary File 1. The search terms included the following keywords and associated index terms: nurs* AND “graduate entry”, “direct entry”, “G msn”, “MSN entry”, MNSc, “second degree”, “accelerated master*” AND motivat*, enabl*, barrier*, facilitat*, perception*, perceive*, aspiration*, attitude*.

To achieve consistency among reviewers, the first two included studies were independently screened (according to the inclusion and exclusion criteria) by both reviewers (RM and RJ) and the process and results discussed before continuing with the review. Thereafter, the two reviewers independently screened the titles and abstracts of the studies identified in the search followed by full text screening of those potentially meeting the inclusion criteria. Disagreements on study inclusion were resolved through discussion and consensus, consultation with a third reviewer was not required.

Data from eligible studies were extracted independently by the two reviewers according to predetermined extraction fields entered into Covidence™. The fields included: 1) study characteristics such as date, location, population, research design, research objective/s and question/s, research measures; and 2) study findings such population demographics and outcomes. Consensus was reached through discussion.

Database searches yielded 491 articles, with one further additional record from reference list searches. Following removal of duplicates, 268 publications remained, following title and abstract screening, 28 full text articles were assessed for eligibility. Six articles met the selection criteria and were included. A flow chart of the search screening process is illustrated in Fig. 1.

In the title and abstract screening, records were largely deemed irrelevant due to wrong population or phenomenon. During full text screening, 11 articles were excluded as they investigated the wrong phenomenon, four for wrong student population, and three were not research reports. Four studies were excluded because either the GEN students were not identifiable in the findings or GEN student motivations were not reported.

All quality assessments, including reviewer judgements, comments and consensus are reported in supplementary file 2. Of the four qualitative studies [18‐21] the grounded theory study of Neill [20] was assessed as lowest risk of bias, meeting eight out of ten criteria. Participant voices were assessed as well represented across all four studies, however the position of the researcher within each study was not mentioned and only one study addressed the potential influence of the researcher on their findings [21]. Just one of the four qualitative studies reported philosophical perspectives or research methodology [20].

For the quantitative studies, the longitudinal study of DeWitty [22] provided insufficient data to determine adequacy of sample size, included no discussion of drop-outs, and did not address the small sample in some sub-groups in their analysis. All other criteria (6 out of 9) for their study were assessed as low risk of bias. McKenna and Vanderheide’s [23] cross-sectional survey was assessed as low risk of bias for six out of eight criteria. The two criteria assessed as high risk of bias were, firstly, they did not use validated measures (e.g., job satisfaction), and secondly, they did not follow conventions for reporting both means and standard deviations.

The six included studies were conducted in New Zealand (n = 2), in the United States of America (n = 2), and Australia (n = 2), between the years 2011 and 2019, and were predominantly studies of qualitative descriptive design published in five nursing journals (see Table 1).

The objectives and design of each of the six included studies are now described in further detail, highlighting the aspects within each study that particularly inform the motivations to enrol in a GEN programme. DeWitty et al’s [22] longitudinal survey involved the collection of quantitative and qualitative survey data at three time points (n = 3335) across 130 schools of nursing in 41 states and the District of Columbia in the USA. These schools of nursing were part of a scholarship program (New Careers in Nursing) in which scholarships were awarded to second-degree accelerated nursing students. In terms of measuring students’ motivations for enrolling in a GEN programme, within the survey, students were asked to rate the benefits of the scholarship on a 5-point Likert scale. In terms of exploring their motivations, students were asked for their reasons for pursuing a nursing degree.

Both New Zealand studies investigated the same cohort of males enrolled in the GEN programmes at the authors’ tertiary education institutions. Harding et al. [18] sought to describe the reasons underpinning men’s enrolment in the first three intakes of the first graduate entry nursing programme in New Zealand, Jamieson et al. [19] extended this work, seeking to describe these male nursing students’ understanding of the gender stereotypes associated with nursing. In terms of questions specifically related to motivation to enrol in a GEN program, for Harding et al. [18], students were asked “Can you tell me about your decision to enrol in fast track graduate entry nursing program at this time”, “Do you think your life stage has influenced your decision to enrol in this course?”, and more broadly, “Can you tell me about your decision to become a nurse?”, “Did you actively seek a ‘non-traditional male career? Can you tell me about this?”, and “At this stage have you given any thought to your potential career as a nurse? For example: What area would you like to work in and why?”. Jamieson et al. [19] extended on Harding et al’s [18] analysis of the questions, “Did you actively seek a ‘non-traditional male career? Can you tell me about this?”

The fourth study, McKenna and Vanderheide [23] examined the characteristics of individuals in the first two cohorts undertaking the Master of Nursing Practice at the authors’ university, including demographic details, previous education, and rationale for pursuing change of career, in order to better understand their learning needs. In terms of investigating motivations, McKenna and Vanderheide [23] explored the reasons surrounding students’ application for entry to the course.

The fifth study, Neill’s [20] grounded theory study examined the experiences of GEN students at an Australian university. There were three stages of the study, the first stage particularly related to the motivations of students enrolling in a GEN programme where the investigator sought “To describe the decision to pursue nursing” with open-ended semi-structured questions such as “What initially attracted you to nursing?”

The final included study, Raines [21], analysed the pre-written stories of prospective GEN programme students seeking admission to a Southeast United States university. Their stories described the factors that influenced their decision to pursue nursing as a second career. Inductive content analysis was used to analyse the stories in relation to the research question, “What are the factors leading to a decision to study nursing?”

Of the six included studies, five reported qualitative data [18‐22], and two reported quantitative data [22, 23]. The findings of Harding et al. [18] and Jamieson et al. [19] appeared to report the qualitative analysis of different questions asked of the same study participants, thus both studies were included. Firstly, the qualitative and quantitative findings are reported, then finally the narrative synthesis.

The qualitative findings are presented in Table 2.

DeWitty et al. [22] identified five themes related to the benefits of receiving a scholarship: (a) financial; (b) lower stress; (c) goal attainment; (d) focus on school; and (e) program opportunities. Their participants reported reasons for making this transitional career shift, such as: a desire to help others through a nursing career, fulfilling a long-term desire to become a nurse, and flexibility of career pathways in nursing. For programme length, one of DeWitty et al’s [22] participants stated “The most positive aspect of the program was being able to receive a quality education in only 14 months. Being able to get my degree and start my career so soon will mean a much better life for my family and higher personal satisfaction as well.” [22] (p. S9). For financial benefits, “Without the scholarship, I would not have been able to finish my first semester in nursing school. It helped me tremendously with paying for tuition, books, and lab fees. Thank you so much!” [22] (p. S10). For lower stress “The New Careers in Nursing scholarship allowed me to further my career without the added stress that was very taxing on my family of three. This program is great and ultimately saved me! Without it, I would have struggled more in school.” [22] (p. S10).

Harding et al. [18] found two primary themes. First, ‘in search of a satisfying career’ with the associated sub-themes: was at a loss; fulfilment through working with and helping people; and a career with options. One participant stated “... basically just never really had anything you’d call a career.” [18] (p. 259). The second theme ‘the time was right’ was underpinned by two subthemes: The right time of life; and, the right course. For one participant:

In the subtheme ‘the right course’, participants identified that they were attracted to the shorter timeframe, the academic challenge and that it built upon their previous education, for example, one participant reported “the fact that it was shorter definitely appealed” and he “wanted to get to that quickly … there was definitely a financial element there … and it would help me stand out a bit.” [18] (p.261).

Jamieson et al. [19] found the participants were aware of two potent gender scripts with respect to nursing: (1) a dominant stereotype of nursing as women’s work, an associated devaluing of nursing work, and the gender typing of some areas of nursing as being more male appropriate; and (2) the stereotyping of men who are nurses as homosexual. More specific to motivations, the authors reported two further themes: (3) being disquieted by stereotypes that negatively characterise their career choice; and (4) that of resisting the stereotype, as all the participants spoke of their non-subscription to the script of normative masculinity. For one participant:

Then:

Neill [20] identified four categories, three particularly related to motivations: long-term interest, caring, and desire for change. For long-term interest, participants expressed “I had been interested in nursing since childhood” [20] (p.91), and “Nursing has always been in the back of my mind to do one day – had to find the time” [20] (p.91). For caring, participants expressed “I wanted a job caring for people and families” [20] (p.91), and “Seeing what nurses actual [ly] did really fuelled my interest” [20] (p.91). For desire for change, participants expressed “At mid-life I just wanted to care for people in my daily work to find meaning” [20] (p.91), and “My career had absolutely no elements of caring or sense of community contribution” [20] (p.91).

Raines [21] identified ‘What I bring to nursing’, ‘Seeking satisfying work’, and ‘Missing pieces’. For ‘What I bring to nursing’, participants expressed both skills and experiences they had developed in their previous work roles and educational programmes, such as “My communication skills will make me proficient in treating patients and their families” [21] (p.9). For ‘Seeking satisfying work’, participants expressed feeling satisfied and seeing what nurses do as satisfying, such as “I want to feel satisfied at the end of the day, knowing that my work made a difference.” [21] (p.10). For ‘Missing pieces’, participants expressed feelings of responsibility to help others and a desire for more knowledge, such as “Nursing is a career path in which I will be able to pursue my greater responsibility to humanity” and “Becoming a nurse will provide me with knowledge and resources to pursue a deeper level of caring for families” [21] (p.10).

The two studies reporting quantitative data were DeWitty et al. [22] and McKenna and Vanderheide [23]. These data are presented in Table 3.

DeWitty et al’s [22] longitudinal survey found for some students, receipt of a scholarship served as the deciding factor in their decision to enrol in the nursing program. Almost one third of participants reported the scholarships eased their financial burden, and allowed them addtional time to study, because they did not need to work as many hours. Receiving a scholarhsip also gave students confidence and motivation to succeed in nursing. DeWitty et al.’s [22] analysis of the open-ended questions enabled these responses to be further unpacked, as reported in the qualitative findings above. The quantitative results are presented in Table 3.

McKenna and Vanderheide [23] surveyed students (n = 79) and found the most common motivator was the availability of family support, and an eagerness to qualify. Other reasons included the length of the course, the accelerated design of the course, the location, and because the university offered it. Six students selected other, but did not elaborate. Just less than half of the participants (46%) had considered nursing as a career for a year or less and 39% for 2 years or longer.

The thematic analysis identified four themes: finding meaning and purpose through altruism and caring; seeking a satisfying career; looking for a change in direction; reduced financial burden.

The review title was not registered with The Joanna Briggs Institute due to their limitations on the types of bodies that are able to register reviews. The protocol was not registered with PROSPERO due to their limitations to systematic review registration only. Given the potential influence of the researchers on the exploration, analysis and interpretation of the data, two independent reviewers were used at significant stages of the narrative synthesis (analysis, interpretation) and a sample of the analysis is provided as supplementary materials (see Supplementary File 3) to enable readers to make their own judgements regarding decisions made during the research process.