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Predictive factors of occupational stress among nurses during the COVID-19 pandemic: a cross-sectional study in Kashan, Iran

• Zahra Ghaderi   ORCID: orcid.org/0009-0000-8414-7867 1 ,
• Zahra Tagharrobi   ORCID: orcid.org/0000-0003-1704-7510 2 ,
• Zahra Sooki   ORCID: orcid.org/0000-0003-3895-7409 2 &
• Khadijeh Sharifi   ORCID: orcid.org/0000-0002-7531-5440 2  

BMC Nursing volume  23 , Article number:  313 ( 2024 ) Cite this article

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Considering the severe and sudden changes in the job conditions of nurses during the covid-19 pandemic, the increase in job tensions during this critical period and its consequences on the quantity and quality of nursing care, this study aims to investigate the job stress of nurses during the covid-19 pandemic and its predictors in Iran.

This cross-sectional study was conducted on 400 nurses in ‘Kashan’, Iran, who were randomly selected using stratified sampling. Data were collected using two questionnaires on occupational stress and potential related factors. The data were analyzed in SPSS version 16.

The results showed that the occupational stress of nurses in Iran was at a medium to high level with a mean and standard deviation of 103.773 ± 15.742 (scale of 34–136). Factors such as satisfaction with physical health, quality of work life, satisfaction with the availability of facilities, sense of coherence, education level, work experience, job burnout, male gender, being native, and workplace were predictors of occupational stress and explained 23.3% of the variance in occupational stress score. The highest contribution was related to satisfaction with physical health.

Considering the consequences of occupational stress for nurses, it is crucial for health and nursing authorities to take these factors into consideration in policy-making and planning.

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Occupational stress is an emotional, cognitive, behavioral, and psychological response to the harmful aspects of the work environment [ 1 ]. It occurs when the expectations from an individual exceed their abilities and capabilities [ 2 ]. Nurses, due to the nature of their profession, are constantly exposed to various occupational stressors. The level of occupational stress was reported to be 124.06 ± 32.58 (scale of 46–201) in Chaudhari et al.‘s (2018) study in India [ 3 ], 66.2% in Baye et al.‘s (2020) study in Ethiopia [ 4 ], and 109.06 ± 16.22 (scale of 175 − 35) in Ghadirzadeh and Adib-Hajbaghery’s (2017) study in Iran [ 5 ].

With the onset of the COVID-19 pandemic, nurses experienced unprecedented levels of occupational stress due to being at the forefront of the fight against this unknown disease with high mortality rates. Among these stresses were shortages of medical facilities and equipment [ 6 ], wearing heavy protective clothing and masks for long periods [ 7 ], extremely high work pressure, long working hours, cancellation of many personal and recreational programs, being away from family, limited close contact with family and friends, and concern about transmitting the disease to loved ones [ 2 , 8 ]. Some studies reported nurses’ occupational stress during the COVID-19 pandemic in different amount; in Saudi Arabia 6.92 ± 2.91 (scale of 0–10) [ 9 ], in Jordan 94.59 ± 6.08 (scale of 34–136) [ 10 ], in China 91.42 ± 26.09 (scale of 35–140) [ 2 ], in Egypt 193.55 ± 44.94 (scale of 57–228) [ 11 ], and in Iran 72% [ 12 ].

During the COVID-19 pandemic, nurses experienced significant job-related stress, which resulted in various negative consequences such as reduced efficiency, decreased attention and focus, impaired decision-making skills, increased absenteeism, decreased organizational commitment, reduced job satisfaction [ 13 ], an increased tendency to quit [ 14 ] and burnout [ 15 ], a higher likelihood of clinical errors and decreased quality of nursing care [ 4 ].

Studies on factors related to occupational stress indicate various contradictory factors. Some studies have shown a significant statistical relationship between occupational stress and marital status [ 16 ], gender, workplace, work experience [ 17 , 18 ], work overload [ 19 ], shift work, mental health [ 17 ], education level [ 5 , 20 ], number of children [ 21 ], role ambiguity, job change, job satisfaction, spiritual health [ 22 ], quit job, quality of work life [ 14 ], job burnout, resilience [ 23 ], and sense of coherence [ 24 ].

Some studies have not shown a significant statistical relationship between occupational stress and age, marital status [ 17 , 21 ], coworker support [ 19 ], education level, patient safety [ 16 ], gender, work experience [ 21 ], work shifts, job position, income [ 5 ], workplace, overtime hours, and number of children [ 20 ].

Considering the consequences of nurses’ occupational stress and the impact of the environment and structure on the level of stress and changes in working conditions during pandemics such as COVID-19, and the contradictions in previous studies regarding related factors, this study was conducted.

Study design

This cross-sectional study was conducted between August and September 2022 (Simultaneously with one of the peak of COVID-19 in ‘Kashan’, Iran) in hospitals affiliated to ‘Kashan’ University of Medical Sciences in Iran.

Sampling method

The study population included all nurses who were employed in seven hospitals affiliated to ‘Kashan’ University of Medical Sciences in Iran. To determine the sample size, a previous study by Farhadi et al. (2013) was consulted, which reported occupational stress using the Taft and Anderson questionnaire as 121.36 ± 19.88 [ 25 ]. Based on formula number one and considering the accuracy of one tenth of a standard deviation, the sample size was estimated to be 383 individuals. However, considering potential attrition, 400 individuals were selected for the study using stratified random sampling based on hospital wards in all seven hospitals.

Formula number 1

Inclusion and exclusion criteria

The inclusion criteria for participants were being employed in clinical activities in hospital wards (inpatient departments), having at least one year of work experience in clinical settings, willingness to participate in the study, not having any known psychological disorders (self-reported), and having a university degree in nursing. The exclusion criteria were dropping out of the study during questionnaire completion and providing incomplete responses to the questionnaires.

The data collection tools consisted of two questionnaires: The Personal and Occupational Characteristics Questionnaire and “the Gary Toft and Anderson’s Job stress Questionnaire” Especially for nurses.

The first questionnaire, a 36-item questionnaire on personal and occupational characteristics, was developed by the researcher based on a review of the literature. The qualitative content validity of this questionnaire was confirmed by six faculty members from the Nursing and Midwifery department at ‘Kashan’ University of Medical Sciences in Iran. The questionnaire was consisted of two sections: personal characteristics (17 questions) and occupational characteristics (19 questions). Personal characteristics included gender, marital status, age, education level, family income, number of children, ethnicity, regular exercise, sleep and nutrition status, religious beliefs and adherence, history of COVID-19 infection, history of COVID-19 infection in family members, family and friend support and satisfaction with physical and mental health. The occupational characteristics section included workplace, clinical work experience, experience working in COVID-19 wards and temporary COVID-19 wards (inpatient and temporary hospitalization departments for COVID-19 patients), amount of overtime work per month, dominant work shift, quality of work life, interest in nursing profession, job satisfaction, satisfaction with staffing levels in each shift, job burnout, work-family conflict, satisfaction with salary and wages, physician’s behavior and performance towards oneself, colleagues’ behavior and performance towards oneself, satisfaction with behavior and performance of head nurse towards oneself, nursing office officials’ behavior and performance towards oneself, patient feedback, and satisfaction with availability of medical equipment and facilities.

The second questionnaire was the Gary Taft and Anderson Nursing Stress Scale, which consisted of 34 questions in 7 domains [ 26 ]. Responses to the items were rated on a Likert scale as not-stressful (1 point), rarely stressful (2 points), sometimes-stressful (3 points), and always-stressful (4 points). The total score ranged from 34 to 136, with higher scores indicating greater levels of stress. The reliability and validity of this questionnaire have been established in the Iranian population, with a Cronbach’s alpha coefficient of 0.77 reported by Salemi et al. (2017) [ 27 ]. In the current study, both Cronbach’s alpha and McDonald’s omega were calculated to be 0.934.

Data collection method

The first author visited the nursing offices of each of the seven hospital and obtained permission to conduct the research. A list of all departments where nurses were clinically active, along with the number and names of nurses employed in those departments, was obtained. Nurses were randomly selected from each department based on the inclusion criteria and desired sample size. The researcher visited each department at the beginning of each shift, explained the research, and obtained written and verbal consent from eligible nurses. Necessary explanations on how to complete the questionnaires were provided, and the questionnaires were collected at the end of the shift. In cases where the questionnaire was not completed on the scheduled date, an agreement was made with the nurse regarding the delivery time. Each nurse was assigned a unique code.

Data analysis

Data analysis was performed using SPSS software version 16. Measures of central tendency and dispersion were used to describe quantitative variables, while absolute and relative frequencies were used for categorical variables. Skewness and kurtosis indices were used to test for normality of quantitative data, with a range of ± 2 considered as normal.

The collected data were analyzed in two stages. In the first stage, univariate tests were used to examine the relationship between each potential categorical factor. Independent t-tests were used for dichotomous factors, and one-way analysis of variance (ANOVA) or non-parametric equivalent (Kruskal-Wallis) was used for non-normal data. Pearson correlation coefficient was used for quantitative factors. In the second stage, multiple stepwise linear regression analysis was conducted to investigate the precise role of potential factors in determining variations in the occupational stress score, while removing the confounding effect of other factors. Variables that were significant in the univariate analysis (with a P-value < 0.2) were included in the multiple regression analysis. A significance level of less than 0.05 was considered in all analyses.

Missing data for the item “satisfaction with the behavior and performance of the head nurse” were replaced with the mean score. Additionally, missing data for the item “satisfaction with the performance of the head nurse” (for nurses who had served as head nurses for a long time) were also replaced with the mean score.

The questionnaires were distributed among 400 nurses working in the hospitals affiliated to ‘Kashan’ University of Medical Sciences, and all the questionnaires were analyzed. Overall, 76% of the participants were female, 83.3% were married, and 84.8% had a bachelor’s degree. The mean age of the participants was 34.41 ± 7.17 years, and the mean work experience was 10.29 ± 6.86 years. The mean level of interest in nursing profession, satisfaction with the behavior of nursing office officials, and satisfaction with salary and benefits were approximately 7.43, 5.85, and 3.61 (scale of 0–10), respectively. The mean score of nursing stress among the participants was 103.773 ± 15.742 (scale of 34–136). The results of the Univariate analysis showed that there was a statistically significant relationship between age, gender, education, employment status, being native, number of children, regular exercise, nutritional status, workplace, job position, work experience in the COVID-19 ward, work experience in the temporary COVID-19 ward, work-family conflict, support from friends, satisfaction with the number of personnel in each shift, job satisfaction, quality of work life, job burnout, satisfaction with physical and mental health, satisfaction with the behavior of physicians, satisfaction with the behavior of colleagues, satisfaction with the behavior of nursing office officials, satisfaction with feedback from patients, satisfaction with the availability of facilities and equipment, and sense of coherence with nursing stress (Tables  1 and 2 ).

The multiple linear regression model showed that the simultaneous presence of 10 variables in the model was significant in predicting nursing occupational stress. Satisfaction with physical health, quality of work life, satisfaction with facilities and equipment, and sense of coherence had a negative effect on occupational stress. Education level, work experience, and job burnout had a positive effect on nursing occupational stress. Being male and native were associated with lower levels of occupational stress. Workplace was also a significant factor affecting occupational stress (P-value < 0.001, F = 11.848). Additionally, this analysis showed that 23.3% of the variance in nursing occupational stress scores was explained by these 10 variables, with the greatest contribution coming from satisfaction with physical health (R2 = 0.078) (Table  3 ).

The present study aimed to investigate the predictors of nursing occupational stress. The findings showed that the mean total score of nursing occupational stress was 103.773 ± 15.742 (scale of 34 to 136), indicating a higher-than-average level of occupational stress among nurses during the COVID-19 pandemic. The results of the study by Zhan et al. (2020) were consistent with the present study, showing moderate to high levels of occupational stress among Chinese nurses during the pandemic [ 2 ]. Tayyib and Alsulami (2020) also reported higher than average levels of occupational stress among nurses in Saudi Arabia during this period [ 9 ]. The findings of the study by Alkhawaldeh et al. (2020) in Jordan showed moderate levels of occupational stress among nurses during this outbreak [ 10 ]. However, Said and El-Shafei (2021) reported high levels of nursing occupational stress in Egypt [ 11 ]. Nursing occupational stress has been consistently found to be moderate to higher than average and in fact, it has been worthy of attention in all studies during the COVID-19 pandemic. Differences may be influenced by variations in shift work and workload, societal expectations, workplace stressors, amount of rest and free time, time spent with family, friends, and engaging in group and physical activities [ 28 , 29 , 30 ], as well as the number of pandemic-related deaths in the region and availability of medical and protective equipment [ 6 ].

The results also show that nursing occupational stress has a significant relationship with gender, education level, employment status, native status, regular exercise, nutrition status, workplace, job position, experience in COVID-19 ward, experience in temporary COVID-19 hospitalization ward, work-family conflict and social support, age, number of children, satisfaction with staffing levels in each shift, work satisfaction, quality of work life, job burnout, satisfaction with physical and mental health, behavior of physicians, behavior of colleagues, the behavior of nursing office officials, satisfaction with patient feedback, availability of facilities and equipment, and sense of coherence.

The results of the multivariate analysis showed that satisfaction with physical health, quality of work life, availability of facilities, sense of coherence, education level, work experience, job burnout, male gender, native status, and workplace were influential factors on nursing occupational stress. Additionally, the multivariate analysis indicated that 23.3% of the variance in nursing occupational stress scores could be explained by the 10 aforementioned variables, with the greatest contribution coming from satisfaction with physical health. Consistent with the findings of this study, Hendy et al. (2021) reported that during the pandemic, factors predicting nursing occupational stress in Egypt included workplace, education level, participation in COVID-19-related training courses, fear of infection, fear of transmitting the disease to family members, unavailability of protective equipment, performance of officials, nurse shortage, and the stigma of COVID-19 [ 31 ].

The results of the study by Zhan et al. (2020) in China also showed a significant correlation between nursing occupational stress levels and daily working hours, number of night shifts per week, work experience, and education level [ 2 ]. Jamali et al. (2012) in Mashhad, Iran also reported that nursing occupational stress was related to gender, education level, and the level of nurse’s awareness [ 32 ].

The most influential factor on the level of nursing occupational stress in this study was satisfaction with physical health status. Several studies in this field have indicated that physical health is a significant source of stress for nurses. Moreover, working in an environment that does not prioritize their well-being can have a detrimental effect on their physical health, as evidenced by research conducted prior to the COVID-19 outbreak. Unfortunately, the pandemic has only served to exacerbate and intensify this pre-existing issue [ 32 , 33 ]. The findings of the Melnyk study (2022) indicated that during the pandemic, only 25% of nurses had good physical health status, and more than 50% of them reported that COVID-19 pandemic impacted their physical health negatively [ 34 ], which can lead to increased occupational stress, absenteeism, and a decrease in the quantity and quality of nursing care.

Study strengths and limitations

The present study has several strengths, including a relatively large sample size, stratified sampling, and the use of multivariate analysis alongside univariate analysis. However, there are limitations to consider. For instance, some variables, such as work-family conflict, were measured using only one question.

Conclusions and implication

In the multiple linear regression model, 10 variables including satisfaction with physical health, work-life quality, satisfaction with facilities, sense of coherence, education level, work experience, job burnout, gender (male), being native, and workplace explained 23.3% of the variance in nurses’ occupational stress score, with the greatest contribution coming from satisfaction with physical health. Given that healthcare systems worldwide faced challenges during the COVID-19 pandemic, and there were sudden and significant changes in nurses’ work conditions, and also in order to prepare for crises and problems that threaten the life of humanity it is essential for researchers to investigate occupational stress and related factors among nurses during the pandemic to enable health system officials and planners to implement appropriate interventions to improve working conditions.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

This article is based on a master’s thesis in psychiatric nursing. The researchers would like to express their gratitude and appreciation to the Research and Technology Vice Chancellorship of ‘Kashan’ university of medical science (‘KAUMS’) and the nurses who participated in the study.

‘This research was funded by KAUMS’.

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ZG gathered the data, ZT analyzed and interpreted the patient data, KS supervised the project, ZS and KS validated the process of project. All authors read and approved the final manuscript.

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Correspondence to Khadijeh Sharifi .

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The necessary permits and approvals for this study were obtained from the Research Deputy and Ethics Committee of ‘Kashan’ - Iran (with numbers ‘40128’ dated ‘22/03/1401’ and IR. ‘KAUMS.NUHEPM’ ‘.1401.026’, respectively) in accordance with the Declaration of Helsinki. Participants were provided with information about the research and its objectives, the confidentiality of the obtained information, their right to withdraw from the study, and their access to the study findings. Verbal and written informed consent were obtained from all participants.

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Ghaderi, Z., Tagharrobi, Z., Sooki, Z. et al. Predictive factors of occupational stress among nurses during the COVID-19 pandemic: a cross-sectional study in Kashan, Iran. BMC Nurs 23 , 313 (2024). https://doi.org/10.1186/s12912-024-01967-0

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Nurses’ and nursing students’ reasons for entering the profession: content analysis of open-ended questions

Lisa mckenna.

1 La Trobe University, Melbourne, Australia

Ian Ruddy Mambu

2 Universitas Pelita Harapan, Tangerang, Indonesia

Christine L. Sommers

Sonia reisenhofer.

3 Bairnsdale Regional Health Service, Bairnsdale, Australia

Julie McCaughan

4 Siloam Hospitals, Tangerang, Indonesia

Associated Data

The datasets generated and/or analysed during the current study are not publicly available due to ethical approval conditions but are available from the corresponding author on reasonable request.

Global nursing shortages require effective recruitment strategies and understanding of individuals’ motivations to enter the profession. These can be complex and bound by numerous factors such as gender and culture. While much research around this has been conducted, little has been undertaken in non-Western cultures where motivations could be different.

To explore Indonesian nurses’ and nursing students’ motivations for entering the nursing profession.

Online survey with closed and open-ended questions drawn from two different studies. This paper reports findings from one similar open-ended question.

As part of two larger surveys, nurses from 13 hospitals across one private health care group and nursing students with clinical experienced enrolled in a baccalaureate nursing program in Indonesia were asked the question, Why do you want to be a nurse? Responses were translated into English and back-translated into Indonesian prior to being subjected to summative content analysis.

In total, 1351 nurses and 400 students provided responses to the question, representing 98.72% and 99.70% respectively of those completing the survey. Both groups were primarily influenced by desire to serve others and God, personal calling and influence of family members and others. Nurses identified a desire to work in the health field and with the sick, in a noble and caring profession.

Conclusions

Nurses and nursing students were motivated by traditional perspectives on nursing. These should be considered in future recruitment activities. However, more research is needed to understand how these factors influence career choice.

Nurses have been identified as crucial to global achievement of Sustainable Development Goals (SDGs) and play a strong role in health policy, achievement of health targets [ 1 ]. However, global workforce shortages, along with an ageing nursing population [ 1 ] and COVID-19 related burnout further impacting retention [ 2 ], mean that strategies for recruitment into the nursing profession are paramount to meet community health care needs. While more than sufficient numbers of graduate nurses are being produced in Indonesia, 54.1% of nurses are located in urban areas, mostly in Java Island, while the other 45.9% are in rural areas with reported chronic shortages in some areas of the country, especially among communities in Eastern Indonesia [ 3 ]. The need for public education to improve the professional image of nursing has been advocated as one means for promoting recruitment of new nurses into the profession [ 4 ].

Understanding why individuals seek a career in nursing is important in facilitating the targeting of recruitment strategies. Some studies have reported on individual motivations to enter nursing courses, largely from western countries. In Italy, Messineo et al. [ 5 ] found that first year nursing students entered their courses with high levels of empathy and altruistic and prosocial motivations. However, there is also evidence that this declines over the duration of nursing studies [ 6 ]. Crick et al. [ 7 ] found that new nursing students in the United Kingdom were motivated to enter the course due to a desire to care for others. In a study of graduate entry nursing students in Australia, McKenna et al. [ 8 ] identified that previous exposure to nurses, either personally or family, played an important role in their decisions to enter the course, along with desire to care for others.

In a systematic review of 29 papers, Wu et al. [ 9 ] examined motivations of healthcare students influencing career choice, identifying a range of both intrinsic and extrinsic factors. They found that altruism through a desire to help others was strong among nursing students, particularly for those who were sick and in need of care. Job security and social status of nursing were considered important, while financial remuneration was not considered as important as for other health professions. Influence of family was mixed in nursing, with some families seeing nursing as having low pay and status, while having family members in the profession was positively influential.

The introduction of the Indonesian Nursing Act in 2014 saw rapid development in the nurse education system and nursing practice with introduction of curriculum standards and accreditation, national competency examination, and nurse registration across the country [ 10 ]. Four-year bachelor or three-year diploma courses can be undertaken to become professional or vocational nurses respectively. Furthermore, there has been recent growth in postgraduate and doctoral programs across the country [ 11 ]. Few previous studies could be sourced exploring why individuals are motivated (seek) to enter the nursing profession in Indonesia. In one study, 20 nursing diploma students participated in focus groups exploring their reasons for choosing to study nursing. Findings identified wanting to help family and others, being inspired by nurses, wanting to improve the image of nursing, influence of family and parents, and work opportunities all influenced choices [ 12 ]. In another study of 57 students in a bachelor degree nursing program, the majority entered the program because they were interested in the nursing profession or wanted to become nurses [ 13 ]. Around a third of students were motivated by their parents to enter the program. Previous studies regarding motivation among existing qualified nurses could not be sourced. Hence, this study sought to explore why Indonesian nurses and nursing students pursued nursing careers.

Data were drawn from two concurrent studies involving online questionnaires, the first focusing on Indonesian registered nurses’ training needs [ 14 ] and the second, on Indonesian nursing students’ experiences of their clinical learning environment [ 15 ]. In each study, participants were asked the same open-ended question: Why do you want to be a nurse? The responses to that question comprise the focus of this paper. Prior to commencement of data collection, approvals were obtained from ethics committees at La Trobe University (ID: S17-155) and Universitas Pelita Harapan (No.005/MRIN-EC/ECL/III/2018). In the original studies, inclusion criteria for the nurses were currently working at the private hospital with a 3-year nursing diploma level qualification or above. Inclusion criteria for nursing students were those who had completed a clinical placement in the private hospital, were enrolled as a nursing student in the university, and were 18 years of age or older. There were no specific exclusion criteria.

Links to the online Qualtrics surveys were provided in participant information materials. These were circulated via internal email and WhatsApp groups to a convenience sample of 2093 eligible registered nurses from 13 sites of an Indonesian private health care group across Jakarta, Sumatra, Sulawesi and Bali and Nusa Tenggara Timur and 796 students from one nursing degree program. Participants provided informed consent using a survey link in the study information provided and participation was voluntary and anonymous. In total, 406 s- and third-year students and 1355 nurses completed the open-ended question forming the basis of this paper.

Responses to the question from both datasets were translated from Indonesian into English and back-translated by two researchers to ensure original meanings were retained [ 16 ]. Data were then subjected to summative content analysis [ 17 ]. Key words were initially identified and coded within Microsoft Excel by two members of the research team. Codes were then manually collated into categories of like terms, quantified utilising frequency counts. Overarching themes were then identified from categories.

In total, 400 students and 1351 nurses provided responses to the question, representing response rates of 98.52% and 99.70% respectively. Among the student group, the average age was 20 years and 84% were female. In the registered nurse group, 80.8% were female and years of experience were relatively evenly distributed from less than one to more than 10 years. Of these, 39% had been in the profession for longer than five years, that is, before introduction of the Indonesian Nursing Act. From the analysis, seven categories and five themes emerged from the student data (Table  1 ) and eight categories and four themes from the nurse data (Table  2 ). Substantial overlap was evident across the two groups and rankings.

Student data (n = 400)

Nurse data (n = 1351)

Overwhelmingly, having an impact on others’ lives was key to both groups through helping or serving others or own family ranked highest for both groups, reported by 50.00% of students and 44.93% of nurses. Students also wanted to be a blessing to others , while nurses valued the interaction with people that is a fundamental part of nursing practice.

For both groups, factors around decision to enter nursing ranked second. Many described having a calling to nursing, while others described this in terms of a ‘childhood dream’, or for ‘personal reward or satisfaction’. Influence of family, others or circumstances played an important part for students and nurses, while a number of nurses described having no reason or choice around entering nursing. Service to God/religious response was also noted to have been the motivation for some students (9.50%); however, it is important to note that these students were enrolled in a faith-based university, so this could be expected. Attraction to the Profession of nursing was also identified as an important factor for both groups. Students expressed a desire to be a part of, or improve, the profession, while many nurses identified a desire to work in the health field or with the sick. For nurses, the status of the profession as noble and caring was a strong factor.

Finally, financial reasons were identified by a small number of participants in both groups who identified commencing their nursing education as they received an offer of a scholarship.

With a predicted continued global nursing shortage, targeted successful strategies need to be introduced to recruit into the profession. Understanding motivations for entering nursing courses can assist with the development of appropriate recruitment strategies and may also inform future retention strategies to keep nurses within the profession. Hence, this study sought to understand why nurses and nursing students in Indonesia chose to enter the profession. Prior to this study, little was known about such motivations in Indonesia, and outside of western countries.

A desire to impact others’ lives was the strongest reported influence for both nurses and nursing students in this study. This was seen as wanting to serve others, and desire to work with the sick. Altruism has long been identified as a reason why individuals choose nursing careers. However, Carter [ 18 ] cautions against simplifying such motivations just to this aspect, where “gender, culture and class and individual dispositions” (p.703) play an important role in the complex make-up of a nursing professional. These views may also change as students progress in their courses. A longitudinal study of nursing students in The Netherlands found that even though many students entered their courses with altruistic and empathic predispositions, their perceptions towards nursing changed to being more professional and focused on their role, knowledge and skills [ 6 ]. Conversely, this was not reflected in the current study where nurses still displayed strong altruistic characteristics beyond graduation from their nursing courses. This suggests that the caring aspect of nursing and ability to make a difference to people’s lives should be emphasised in recruitment to the profession. Additional research in the Indonesian context is needed to better understand the influences on nurses’ personal dispositions and whether these change over time.

Nurses and nursing students in this study both described a personal calling into nursing. Calling, itself, has been described as complex in nursing, and having changed from a traditional perspective based in religion and femininity, to a more contemporary conceptualisation focused on care provision, the profession and self-fulfilment [ 19 ]. In this study, a more traditional focus emerged with both focus on serving community and service to God. This may be, in part, related to the fact that the study was undertaken in a faith-based university and health care group. Being a strong faith-based country, this may be a particularly important consideration in Indonesia and would benefit from further research with other groups across the country. The importance of inclusion of this concept in recruitment into nursing in the country could be further explored. In a recent study in Indonesia, the concept of calling and reason for entering nursing played a role in student success in a nursing program [ 20 ]. The importance of understanding values is particularly pertinent in nursing recruitment strategies with a recent mandate in the United Kingdom for values-based recruitment of healthcare students aligning with those of the National Health Service [ 21 ].

The influence of families and others was a factor in this study for pursuing a nursing career. In Indonesia, families have been shown to play an important role in career pathways, particularly in family businesses [ 22 ]. However, the literature is mixed on whether this is an important factor for nursing. In their review, Wu et al. [ 9 ] identified that some studies identified parents as not being supportive of their children entering the nursing profession because of low pay and status, a view reflected elsewhere [ 23 ]. Despite this, families have been found to be a strong influencing factor influencing choice of nursing career in some studies [ 8 , 24 , 25 ]. Having family members or friends who are nurses or had experienced time in hospitals were identified as influencing factors in one study [ 8 ]. In a study conducted in the United States, Woods-Giscombe et al. [ 25 ] recommended including family members into recruitment processes into nursing, particularly for recruitment of students from underrepresented groups. This suggests that recruitment strategies should not only be directed towards potential students, but their families as well.

While career stability and vocational reasons have been identified by other researchers as guiding factors in pursuing nursing careers [ 8 , 18 ], these aspects were not identified by nurses and nursing students in this study. It is possible that cultural aspects may play a role. In a Norwegian study, nursing students from immigrant backgrounds were found to be more motivated by salary, status, and work flexibility than non-immigrants [ 26 ]. Findings from the current study suggest that such considerations might not be primary considerations for Indonesian nurses and students and that more research is needed to explore this aspect further.

Media representations have been identified in a number of studies as influencing decisions to pursue nursing careers. In one Australian study, hospital dramas on television as well as print and television news played a role in influencing graduate entry students to pursue nursing education [ 8 ]. In another Australian study focused on television representation of the nursing profession, nursing students perceived nurses to be negatively represented in comparison to doctors who were positively portrayed. They recognised that medical programs could provide some recruitment value [ 27 ]. However, a role of media influencing career choice was not identified in this study. Whether or not this plays some role in assisting career decisions for Indonesian students could also be examined further.

There are some acknowledged limitations to this study. The sample was drawn from one faith-based university and hospital group. While the study population was large and drawn from a number of locations, findings may be different in other Indonesian nurse populations across the diverse cultural groups in the country. Furthermore, data were only collected using one open-ended survey question. Further research that explores these concepts in greater depth would be highly valuable.

With global nursing shortages, there is an ongoing need for effective recruitment strategies into the profession. This makes it vital to understand motivations of those entering the profession to facilitate recruitment approaches. However, motivations may vary according to a wide range of intrinsic and extrinsic factors. This study identified that Indonesian nurses and nursing students were largely motivated by a need to serve others and God, personal calling, and the influence of family. As a strong faith-based country, this is likely to be an important consideration in future nursing recruitment. However, further research is needed across more communities to ensure that other motivating factors can be identified and incorporated into successful recruitment strategies. Further research is also needed to understand if these concepts play a role in nursing students successfully completing a program and entering the nursing profession.

Acknowledgements

The authors are grateful to all the nurses and nursing students for their contributions to the study.

Author Contribution

All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE): (1) substantial contributions to conception and design (LM, CS, SR, IM, JC), acquisition of data, or analysis (LM, CS, IM) and interpretation (LM, CS, IM) of data; (2) drafting the article or revising it critically for important intellectual content (LM, CS).

This study was supported by a La Trobe Asia Research Grant Program grant and the Universitas Pelita Harapan Research and Community Service Grant Program.

Data Availability

Declarations.

The study was approved by Human Research Ethics Committees at La Trobe University (ID: S17-155) and Universitas Pelita Harapan (No.005/MRIN-EC/ECL/III/2018). All data collection was in accordance with relevant guidelines and regulations. Participants provided informed consent for this study using the survey link in study information provided.

Not applicable.

The authors have no competing interests to declare.

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