The competition among healthcare courses to attract high quality school leavers is becoming increasingly intense. This is particularly challenging in the nursing course which requires the largest recruitment target to meet the workforce demand . Using the Indiana Instrument, most studies to date have primarily focused on school students about the differences in attitudes between ‘ideal career’ and ‘nursing as a career’ [25, 27]. By applying the parallel scales concept of the Indiana Instrument, we developed and tested the HCC-NCC instrument in order to compare the influences of healthcare career choice and perception of nursing as a career choice among the healthcare students.
The content validity of the HCC-NCC instrument was achieved through a combination of literature review, findings from a previous qualitative study, and experts’ validation. Inclusion of a total of 12 experts from a variety of settings including education institutions, hospitals and the Ministry of Health provided a wide perspective of the tool. Based on the experts’ validation, the CVI achieved Lynn’s (1986) criterion for content validity . Additionally, a pilot test with 30 non-experts, established the face validity.
The construct validity of the HCC-NCC instrument was assessed in a factor analysis by using a principal component analysis. Factor analysis was justified with Bartlett’s test of sphericity, while the calculated Kaiser-Meyer-Olkin measure of sampling adequacy indicated that there was adequate sample for factor analysis . Modifications to the instruments were made following the factor analysis to remove items that were found to be weak or unrelated. Finally, all included items possessed factor loadings of >0.4 and accounted for 59 and 64% of the variance for the HCC and NCC scales respectively. The factor analysis extracted six factors corresponding with five out of the six career factors that emerged from the findings of a qualitative study .
The “personal interest” subscale, refers to the students’ personal interest in their chosen professions. According to Holland’s theory of “Career Typology,” individuals choose career environments that best fit their personality and interest . Several studies have shown that students pursuing healthcare careers tend to have similar interests [5, 7, 39]. A personal interest in their chosen professions based on notions of altruism, opportunity to interact with others, as well as an interest for science-related subjects were expressed among the healthcare students in a previous study .
The second factor, “prior healthcare exposure”, reflects how healthcare related experiences could influence their choice of a healthcare career, both positively and negatively. The influence in the developmental stage on career choice, spanning from school years to young adulthood, has long been established by a vocational psychologist [40, 41]. The exposure of students to healthcare-related work, including observing a healthcare professional at work has shown to draw students into a healthcare career [42, 43].
The third factor, “self-efficacy”, refers to a set of self-beliefs about one’s personal competence to perform the actions required to produce outcomes in particular domains . Applying the social cognitive career theory, the links between self-efficacy and career choice has been well-established by Lent et al. . Academic ability which often reflects intelligence serves as an important indicator for an individual to evaluate one’s self-efficacy to an academic related career choice. Nursing is often perceived as a course for students with low academic ability which could have deterred academically-abled students from joining the course .
The factor, “job prospects”, considers the practical aspects of a healthcare career that could influence the career choice. This includes a desire for job opportunity, job stability, and good income. Healthcare careers are often highly regarded for the ease of getting a job and job stability [10, 11]. Nursing is however often perceived as a poorly paid job .
The factor, “perceived nature of work”, relates to how students’ perceived the characteristics of the healthcare careers that influenced their choice of career. The characteristics associated with nursing work, including the involvement of too much hard work , and ‘dirty’ work  have deterred students from joining the nursing profession.
The final factor, “social influences”, includes social status, gender-type and significant others that have been found to have a significant impact on the students’ career decision-making process. Social influences by significant others was found to affect the career aspirations of Asian students more significantly than the Western students [47, 48].
The concurrent validity of the HCC-NCC instrument was examined by correlating with the Indiana Instrument, both of which were administered at the same time. The Indiana Instrument is one of the most widely used tool for determining the difference between the ideal career and a nursing career with tested reliability and validity . A significant strong positive correlation was found between these two scales, confirming the concurrent validity of the HCC_NCC instrument.
Besides evidence to support the validity of the HCC-NCC scales, the study demonstrated a satisfactory internal consistency as reflected by the Cronbach’s alpha of 0.71 to 0.89 for both scales and its subscale, and the high correlation between the items with their respective subscales. The stability of the HCC-NCC instrument was also demonstrated.
In comparison to the existing 17-parallel items Indiana Instrument, the 35-parallel items HCC-NCC instrument offer a more comprehensive comparison of career choice influences. The instrument has many potential applications for future use. The instrument provides a comparison of factors influencing healthcare career choice and perception of nursing as a career. Such comparison can highlight the differences between career influences in non-nursing careers and a nursing career which has the potential to identify specific strategies to enhance nursing recruitment. Each of the parallel scales can also be used as a stand-alone scale. While the HCC scale can be used for identifying factors influencing healthcare career choice, the NCC scale can be used for examining factors influencing nursing as a career choice. Findings obtained from the instrument may aid in the development of recruitment programmes. The effectiveness of the recruitment interventions can be evaluated using this instrument in a pretest-posttest study or in randomised-controlled trials. Future studies may consider adapting the HCC scale for graduating students to examine influences of career choice on healthcare sub-specialities.
Convenience sampling was used to recruit participants in this study, which may lead to potential biasness such as under-representation of different targeted groups within the sample. Future studies with a larger sample size and random sampling may lend added support to the validity and reliability of the instrument. While an acceptable test- retest reliability is achieved, it could be strengthened through a larger sample size of participants attempting the retest after two weeks.