1. Introduction

Nursing is as old as human life itself; however, the shortage of nurses is not a recent phenomenon, nor one restricted to a specific geographical location. The profession said to have long suffered from public stereotyping and from being closely associated with femininity and powerlessness. The time has never been better for nurses to reach out to the public to change certain perceptions about nursing. Various people have different understandings of the nursing profession based on prior events in their lives since perceptions are subjective ^[33].

The Saudi Arabian government has committed enormous resources to improving health care, with the ultimate goal of providing free and accessible healthcare services for every Saudi national and expatriate working within the public sector ^[6]. With rapid change in the national health care system in KSA, the notable increase in the number of hospital beds and an increase in health care facilities in both the government and private sectors, Saudi Arabia are encountering a significant shortage of qualified Saudi nurses. Whereas it identifies the inadequacies of Saudi nursing in many critical areas ^[7]. Despite continued efforts to increase the number of Saudi nurses, by 2010, expatriate nurses still constituted 74% of the total nursing workforce in Saudi Arabia. The total nursing workforce of expatriates and Saudi nurses in all health sectors is 129792 and Saudi nurses represent 31.8 percent of the total workforce ^[32].

In addition, Gazzaz ^[19] added that; in Saudi Arabia, recruitment and retention of nurses appear faced with challenges; it reported that the majority of young women do not view nursing as socially appropriate career choice. Most Saudi families do not consider nursing as an honorable occupational choice for their own children. Therefore, prevailing negative images and perceived low status of nursing have contributed to the high stress level of participants. Saudis of both genders will not choose the nursing profession as an ideal future career because of long working hours; night shifts; negative perceptions of community and family members; working with the opposite gender especially for female nurses and concerns about not getting married as some men may not like their wives working as nurses ^[3].

Students often have misconceptions regarding the reality of nursing and the opportunities available to nurses that sometimes result in poor choices related to pursuing nursing as a career Lundberg et al., ^[27]. Hence, the image of both nurses and nursing as a profession are vital in the successful recruitment and retention of staff in the health care industry ^[12].

Many strategies currently needed to address a profound Nursing shortage that is threatening to health care quality. One of them is to increase the interest of young adolescent in the Nursing profession. Perceptions of higher secondary school students about nursing are important because they offer strategic clues towards successful recruitment of the next generation of nurses. They are the one part of the society and therefore the great impact of the society what they think and believe about nursing profession ^[33].

Consequently, Perceptions of advanced secondary school students of nursing are important to attract more individuals to the profession, a positive image of nursing needs engendered by nurse education and the general community. Attitudes, beliefs, and values are highly subjective areas, usually based upon perception and not fact. Perceptions held by the public about the nursing profession greatly influence the personal and public image of nursing. The role of gender in the choice of a career is an extremely important concept, because men constitute nearly half of the potential recruitment pool. Noticing a male nurse ridiculed would deter boys to think of a nursing career ^[24].

The conceptual framework presented here describes a four-stage process that used during career decision making. This study focuses on three of the six factors involved in career decision-making career image, career preference, and career accessibility.

In this conceptual framework, career decision-making is viewed as a four-stage process involving six factors: self-concept, career image, career preference, career accessibility, range of acceptable careers, and career choice. Students progressively narrow their career choices as they pass through each decision-making stage. The six factors are believed to hold varying degrees of importance (Gottfredson, 1981). The two most important factors, self-concept and career image, are explored in the first stage. Students’ progress to the next stage, which involves an examination of career preference and career accessibility. This leads them to stage three, where they consider their range of acceptable careers. Gradually, students thus build perceptions of careers until they arrive at the final stage, career choice. The following is an overview of each factor and its relevance to the conceptual framework.

1. Career Image

2. Career Preference

3. Career Accessibility

4. Range of Acceptable Careers

5. Career Choice.

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Figure 1. Adaptation of Gottfredson’s (1981). “Occupational Aspirations Model”. Circumscription and compromisc: A derelopmental theory of occupational aspirations. Journal of Counselling Psychology, 28(6), 545-578

Aim of this study was to describe preparatory Students’ perception for Nursing Profession and The Impact on their career choice in Qassim University in KSA.

• Does the preparatory students’ perception for the nursing profession affects their career choice in Qassim University in KSA?

• Do the students' personal characteristics have an impact on their perception for the nursing profession?

2. Methodology

A descriptive cross sectional survey used to accomplish this study and to answer research questions.

All preparatory premedical students' male and female present at the time of the study recruited to describe preparatory students’ perception for the nursing profession and the impact on their career choice at Qassim University in KSA within Academic year 2013-2014.

Probability sample including all preparatory premedical students' male and female in Qassim University in KSA present at the time of the study recruited to describe preparatory students’ perception for the nursing profession and the impact on their career choice at Qassim University in KSA within Academic year 2013-2014 within 4 months. Whereas male numbers equal 260 students and Female numbers equal 253 students.

Sample criteria should specify between 18 to 20 years old male and female their age groups.

Pilot study was carried out after the development of the tools on 10% of the preparatory premedical students' to test applicability of the tools then necessary modifications were done according to the finding results of the pilot study and expertise opinions. Otherwise, these students were then excluded from the sample of research work to assure the stability of answers.

The study conducted at the classes of the premedical preparatory year at the Qassim University male and female sections in KSA.

Data collected between January 2014 and April 2014 through self-Administered questionnaire. The instrument used in this study was a modified version of the Career Questionnaire designed by Kohler and Edwards ^[25]. Questionnaire modified by researchers after pilot study and modified some vague questions.

Which consists of three parts; first one socio demographic data as age, sex and GPA; second part assessed nursing image; third part assessed information regarding nursing profession.

Nursing image parts were in Likert scale, approximately 50% of the items were positive and 50% were negative. Based on the conceptual framework, the Likert scale questions were grouped into the categories of career image, preference, and accessibility and identified as positive or negative

Responses to the Likert scale questions that contained statements exhibiting a positive perception of nursing were coded using the following ordinal scale: 1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree and 5 = strongly agree. Responses to questions portraying a negative perception were reverse coded. An overall score obtained by summing the response values of the 41 items that coded using the Likert scale. Thus, high scores represented a positive perception of nursing as a career choice, whereas low scores represented a negative perception. The possible range of values for the total score was 41 to 205. Scores also obtained for each of the three sub-categories.

Ethical approval from the dean and coordinator preparatory year obtained. The aim of the research explained to the students. After clarifying the procedures of the study, a verbal consent from every student to participate in the study obtained. Participants informed about their right to refuse participation and to withdraw at any time without giving reasons and with no consequences. Total confidentiality of any given information assured.

The statistical analysis was done using appropriate statistical methods. i.e. percentage, range, arithmetic mean (X), standard deviation (SD), F test to compare mean of study variables. Data were analyzed using the Statistical Package for Social Sciences (SPSS) windows version 16. A P value of 0.05 or less was considered as statistically significant.

3. Results

Table 1 shows that maximum age of students was 22 years old while minimum age was 17 years old with mean (18.59±0.71). It shows that nearly half of them (50.7%) were male. Regarding GPA it shows that nearly one third of them (32.4% and 30.2%) had excellent and very good respectively.

Regarding career image, Table 2 shows the majority of students (83.3%, 84% and 82.1%) agreed that nursing is a profession and technical occupation and nurses don't get paid well. Nearly two-thirds of them (64.7% and 68.6%) agreed nurses make many important decisions and nurses spend most of time socializing with doctors. While nearly two-thirds (65.5% and 63%) disagreed that nurses are kind and compassionate, nurses equal to physicians and most nurses are mean and don't care.

Table 1. basic information of studied sample

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Regarding Career preference Table 3 shows that most of students (79%) agreed nurses make high salaries and nearly two-thirds (62.2%, 62% and 60.6%) agreed that nurses have to take responsibility for the people, nurses have many opportunities for advancement and nursing is a low-level skill occupation respectively. More than half of them (54.8%, 54.2%, 53% and 55.2%) agreed all nurses must have a university degree to practice nursing, nursing is stimulating and challenging work, Nurses have high standards of behavior and nurses work under stress. While nearly two-thirds (67.8% and 58.1%) disagreed nursing requires a high degree of skill and nurses work too hard respectively.

Regarding career accessibility Table 4 shows that the majority of students (81.5%) agreed that nurses have to take hard courses in school. Nearly half of them (59.8%, 47.4% and 48.3%) agreed anyone can afford to go to nursing school, it costs a lot to go to nursing school and it takes too long to be a nurse. While nearly half (58.3%) disagreed that only women should be nurses.

Table 2. Mean, standard deviation and level of Career Image among studied sample

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Table 3. Mean, standard deviation and level of Career preference among studied sample

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Table 4. Mean, standard deviation and level of Career Accessibility among studied sample

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Regarding career choice Table 5 shows nearly three quarters of students had an acceptable image regarding Career preference and more than half of them had acceptable image regarding total career choice. More than half of them (53.4% and 50.9%) had an unacceptable image regarding career image and career accessibility.

Table 5. Mean, standard deviation and level of Career choice among studied sample

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Table 6 shows nearly two thirds of students (66.1%) did not consider nursing as their career choice. Nearly two thirds of them (64.5%) their sources of views about nursing from knowing someone who is a nurse. Nearly one third of them (39.2%) one or both parents is/are nurses and more than half of them (53%) had family members other than parents are in healthcare.

Table 6. Factors Affecting Career Choice Among Studied Sample

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Table 7. Relation between mean of levels of career choice, sex, career choose, family health care member and GPA

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Table 7 shows that male student had better career image than female students whereas mean (2.97± 0.32 and 2.85 ± 0.32) respectively with highly statistically significant difference (p > 0.000) while female students had better career preference and career accessibility than male students whereas mean (3.14± 0.37 and3.24± 0.40, 2.78± 0.66 and 2.91± 0.63) respectively with statistically significant difference (p = 0.003). Also it shows that students who have not family health care member had better career choice than students who have family health care member whereas mean (2.94±0.21 and 3.01±0.20) respectively with statistically significant difference (p > 0.05). In addition it shows that student who had satisfactory GPA had better career image than other students with statistically significant difference (p > 0.05). The students who get good GPA had better career accessibility than other students with statistically significant difference (p > 0.05).

4. Discussion

Student perceptions about the field of nursing may have the largest impact on their decisions to seek opportunities to learn more about the profession. Therefore, Saudi health decision-makers need to increase the positive attitude on the nature and encouraging characteristics of modern nursing and its increasing respect as a skillful career for high school students.

The findings of the study revealed that participant's age were between 17 to 22 years and half of them were male. In the same line Al Jarrah ^[4] reported (69.1%) of the subjects were males and about one-third (30.9. %) of them were females. More than half are in the age group 18-20 years.

Regarding career image the majority of students agreed that nursing is a profession and technical occupation and nurses not paid well. In a study carried out by Gazzaz ^[18] about Saudi Nurses’ Perceptions of Nursing as an Occupational Choice, she found that most participants (interns, staff nurses and senior nurses) cited in-service education and on-job training as factors influencing their decision to stay or leave a particular organization. They perceived opportunities for continuous education and advanced training as important aspects of their motivation, satisfaction and retention. For them, on-job education and training are opportunities which enhance their professional knowledge and practices. However, on-the-job services seemed to vary considerably across the different hospitals and sectors. Compared to their counterparts at the other-government sector, staff nurses and senior nurses working at the government hospitals sounded more frustrated and disappointed for having less opportunities for attending such services. Also, Khowaja ^[23]; Jan, & Sikander ^[21] added more than half of the undergraduates were interested to join teaching after completion of graduation, which may highlight their need to get rid of bad social image of bedside nurse, and it is self-satisfactory to them known as a teacher instead of a bedside nurse.

In addition, our findings indicated that nearly two thirds disagreed that nurses are kind and compassionate people, nurses are equal to physicians and most nurses are mean and do not care. Our findings are contrary with some previous research studies ^{[28, 36, 39]}. Overall majority of the students perceived that nursing is a profession to serve humanity, earn blessings of the people; which also may provide an opportunity for personal growth, bright prospective in abroad and their by an economic security.

Regarding Career preference, the findings reflected that most of students agreed nurses make high salaries and nearly two thirds agreed nurses have to take responsibility for the people they take care of, nurses have many opportunities for advancement and nursing is a low-level skill occupation respectively. Similarly, Al Jarrah ^[4] reported that More than one-third of the study subjects did join the faculty of nursing due to financial reasons/availability of work. This is also supported by AbdlKarim et al., ^[2] in Egypt and Buerhaus et al., ^[14], (U.S.A); Chauvette et al ^[15]. They found their subjects haven chosen nursing as it represented a good opportunity for them to work. Sand-Jecklin & Schaffer, ^[41] added that students most frequently reported choosing nursing because of the availability of career opportunities, jobs security, salary, and interest in nursing.

In addition, our findings reflected that more than half of them agreed all nurses must have a university degree to practice nursing, nursing is stimulating and challenging work, Nurses have high standards of behavior and nurses work under a lot of stress. In this context Oulton ^[35] referred that nurses play a central role in delivering health care. Nurses advocate for health promotion, educate patients and the public on the prevention of illness and injury, provide care and assist in cure, participate in rehabilitation, and provide support. No other health care professional has such a broad and far-reaching role. Additionally, nurses' roles have expanded significantly to include a number of tasks previously performed by a physician’s ^[16]. While Al-Mahmoud ^[10] stated many students considered the heavy workload facing students, the theory part of the study and the difficulty of studying in English language, as important contributing factors in student dropout. This is consistent with the finding of Al Kandari and Ajao ^[9] study in Kuwait, where heavy student workload and focus on the theoretical part of nursing considered barriers to retention.

Regarding career accessibility, our results revealed that the majority of students agreed nurses take hard courses in school. According, Lamadah & Sayed ^[26] indicated that Nursing education in Saudi Arabia has, for a number of years, been either diploma and associate degree programmes managed by the Ministry of Health, or BSN programmes managed by Ministry of Higher Education. Considering either an upgrade or integration of the former programmes with the latter would require careful and long-term planning that takes into account experiences from other countries. In addition, different educational systems in nursing leads to overlapping in job description among different levels.

Nearly half of the studied sample agreed that anyone can afford to go to nursing school, it costs a lot of money to go to nursing school and it takes too long to learn to be a nurse. In this line ^[11] recommended that the status of nursing in Saudi Arabia should be enhanced in order to make it a worthwhile career. The education sector should reconsider the length of nursing training (5 years compared with 3 years in many developed countries) while maintaining competent and safe practice. Reducing the financial burden on the nursing student through provision of additional financial support would encourage more students. In particular, nurses should be paid a full salary during the intern year as currently occurs with medical students.

Additionally, the findings reflected that nearly half disagreed that only women should be nurses. This result supported by Lamadah & Sayed ^[26] indicated that gender-mixing, long working hours and rotating shifts which render nursing as socially unacceptable occupational choice. With the current shortage in nursing, hospital nurses are usually working longer hours with extra load of patients. The long hours and rotating shifts which characterize a career in nursing were frequently cited as major deterrents to the uptake of nursing by Saudi female school students. Additionally, Al-Mahmoud ^[10] who revealed that The highest mean disagreement was with negative statement “Nursing is not an appropriate profession for Saudi women”, with over half the respondents strongly disagreement with the statement.

Regarding career choice, our findings referred that nearly three quarters of students had an acceptable image regarding career preference and more than half of them had acceptable image regarding total career choice. In the same context, Al-Kandari and Lew ^[8] reflected that the nursing profession respected in Kuwaiti society. This is contrary to an earlier study ^[9] which showed that Kuwaiti nursing students equated nursing to a servant’s job. This different perception represents a positive change, which needs followed up with active recruitment aimed at high school students. The nature of some nursing functions (e.g., caring for sick and dying patients, handling blood and bodily waste) has been cited as negatively affecting the image of nursing. In addition, only 5% of the 54 students who said they might consider nursing as a future career stated that service to the community was the motivating factor for their choice ^{[25, 40]}. While Al-Sa'd ^[5] added that some students are interested in nursing but afraid and hesitant. A fraid from society and its perception, afraid of failure and regrets, hesitant to take risks and to experience difficulties. Society looks at nurses with some suspicion and disrespect so that girls are afraid of joining nursing even if they like it. Some girls had to terminate their study in order to get married because their husbands and their families do not accept nursing as a profession. Some families do not like women to work nights and to work late or long hours or to work weekends. They see nurses as an assistance of doctors.

Nearly two thirds of participants their sources of views about nursing from knowing someone who is a nurse. These results supported by El Sharkawy and El Hadad, ^[17] who studied "factors affecting students’ choice of nursing as a career in Egypt and Syria". They found that the family members had the significant impact on the choice of nursing as a career. The study of Kelly et al. ^[22] in Chicago reported that family members were the most encouraging forces to their entering nursing and was the main source of moral support during the years of schooling. These findings confirmed, as the positive family reaction to joining, the faculty of nursing represents 92.6% of the subjects in this study. Heath ^[20] stated that young students may be applying to nursing programs as a response to parents’ dream instead of their own and the majority of the subjects had a family member or a friend in the nursing profession. Tawash et al ^[43] & EL-Sharkawy et al ^[17] that showed parents and friends were very powerful motivators for them to join nursing. This may be due to the clinical environment increasing interaction between the students and the medical staff. This study also showed that the family member opinion has the greatest negative effect and the lowest positive effect in the change in the image of nursing. Working conditions was the second reason for the negative influence among the study subjects. This may be due to uncomfortable working environment, exposure to hazards whether physical or emotional, lack of facilities and resources, and the gap between theories taught and the actual practices in governmental hospitals ^[1].

Our findings revealed the students who have not family health care member had better career choice than students who have family health care member. In the contrast, Al Jarrah ^[4] stated that More than one-fifth of the study subjects reported an advice from a family member was the main reason for joining the profession. Sand and Schaffer ^[41] indicated that few students identified the media as influencing their own perceptions of nursing; however, many identified the media as influential in the public’s perceptions. Comparison of student perceptions of the influences on the public’s view and Public Valuing subscale scores demonstrated that students perceived the media as a negative influence on public perception. Al-Kandari and Lew ^[8] reflected that the students’ sources of information about the nursing profession varied. The primary source of information was hospital visits (35%), followed by television (27%) and journals (18%). Friends and school scored equally (9%), and radio was the least used source of information (2%). The majority (81%) indicated they would not consider nursing as a career.

Patidar et al., ^[36] explored that most of the nursing students were not interested to change their profession this contrary with Pelletier et al. ^[37]. reported that more than half of the undergraduates were interested to join teaching after completion of graduation which may highlight their need to get rid of bad social image of bed side nurse and it is self satisfactory to them to be known as a teacher instead of a bed side nurse. Our findings supported by Rognstad & Aasland ^[39]. While contrast with Chauvette&Alexander ^[15] reported that majority of the outgoing nursing students were not having any family member or relative in nursing profession. It indirectly suggests that those who are already in this profession do not want their children or relatives in to the nursing profession.

Shukri ^[42], added that in Jordan, found that students’ families, especially mothers, encouraged both their daughters and their sons to study nursing which eventually affected positively the nationalization in Jordan where only 4-6% of their nurses are expatriates.

While, Jan & Sikander ^[21] indicated that only 5.4% students had definitely yes response while 46% students had definitely not to consider nursing as a career choice. Thus, the highest numbers of students were not willing to choose nursing as a career. This is similar to earlier reports.

Al Jarrah ^[4] the study indicated that the associate nursing students in Jordan generally have positive perceptions about the image of the nursing profession. The findings related to the students’ perception are statistically significant. This finding is consistent with many studies in Belgium ^[39], Egypt ^{[2, 13]}, Bahrain, ^[43], and in India ^[38].

Al-Kandari and Lew ^[8] the students’ reasons for considering or not considering nursing as a career. These reasons determined whether nursing was a future career choice for them. Nearly 90% of respondents indicated that they might consider nursing as a career because it is a “nice profession.” However, many respondents would not consider nursing as a future career because they “do not like nursing” (60%), it is “physically exhausting” (30%), or it requires “contact with men” (23%).

Our findings showed that male student had better career image than female students did while female students had better career preference and career accessibility than male students did. In the same line Al-Mahmoud ^[10], male students were significantly less likely than females to consider that the hour's nurses work are too long. The reason for the gender differences in aspirations might be that many sectors, especially MOH, encourage male nurses to take managerial posts after six months of joining the workforce. These findings are consistent with those of Nasrabadi et al. ^[34] in Iran, which revealed that the social structure contributes to the rapid promotion of males to management and faculty positions that afford more respect and prestige and higher pay. However, whilst this low anticipated, retention in clinical nursing of male students could have a negative impact on the Saudisation of the nursing workforce; it might have a positive effect in reducing the high dependency on expatriates in managerial posts. At the same time, Saudi men who choose nursing also face criticism from family and friends. According, Miller et al. ^[30] reported a Saudi male nurse as saying that his mother refused to tell her friends that her son is a nurse. When he observed working in the hospital his mother claimed that he was a doctor.

The study results reflected that students who had satisfactory GPA had better career image than other students did. In addition, the students who get good GPA had better career accessibility than other students did. Al-Omar 2004 supported that high school students (males and females) have scored very low on the intention of becoming a nurse.

5. Recommendation

The study recommends conducting further studies on the perception of the nursing students in KSA. According to this study, the opinions of family members about nursing have influenced career decision making of their children, and so it is necessary to plan recruitment. Therefore, it is recommended to; nursing students must be motivate to work initially on bedside nursing and Government and authorities must proactive and pay a due attention to prevent brain drain in nursing.

There is also a need to increase awareness about nursing, beginning at the primary school level. Nursing institutions, in collaboration with the nursing division of the Ministry of Health in KSA, should organize outreach programs to schools. Such programs should include lectures about different career pathways and educational growth of the nursing profession, and provide colorful publicity materials through school libraries and career counselors.

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