NURSING STUDENTS’ FUTURE EMPLOYMENT PREFERENCES AND THE REAL DEMANDS OF PATIENTS USING THE HEALTH SERVICES. A QUALITATIVE STUDY ON A GROUP OF FINAL-YEAR STUDENTS AT THE UNIVERSITY OF PADUA

Increasing life expectancy and the growing number of chronic diseases have changed the kind of patients who need to be assisted. This paper presents a qualitative study conducted with a group of nursing students near graduation, aimed at describing and discussing vocational preferences and desirable healthcare settings for future employment.


Introduction
The increase in life expectancy as well as the growing number of patients suffering from chronic diseases require the development of a specific nurse's profile with clinical skills and vocational motivations suitable for this care target (Mazhindu et al. 2016). If, after graduation, students acquire adequate theoretical and clinical knowledge as well as critical-thinking skills, they will be able to express an elevated level of professional performance (Rothwell, Sensenig 2002;Spencer, Spencer 1995;Marañón, Pera 2015;Ames 1992).
Recent studies have underlined that a nurse's vocational motivation seems to be linked to a self-realization need expressed as a caring attitude towards fragile subjects (Mackintosh 2007;Miers et al. 2007;Williams et al. 1997).
Nevertheless, students have different caring targets in mind. Indeed, a significant percentage of them tend to focus their employment expectancies on specific clinical areas that are more preferred than others: critical rather than general medicine, paediatric rather than the elderly (Rognstad et al. 2004;Storen, Hanssen 2011). This could be due to students' development of a professional overview influenced by some trivialized and simplified patterns that might even involve the image of patients (perhaps influenced by unrealistic television series). These distortions are incoherent with the complexities of caring for ill children, and critical or terminal patients (Gurses et al. 2009;Aujoulat et al. 2006;Brewster 1982). On the other hand, these patterns seem inadequate to respond to the real needs of a healthcare that is more and more oriented to assisting an increasing number of chronic patients and, implicitly, to caring for them at home (Italian Law. 38/2010).
This kind of motivational structure may subject nursing students to frustration in their vocational project; moreover, future nurses may be unable to meet the real needs of their patients. A frustrated subject may be potentially exposed to great psychophysical stress and, consequently, suffer from some secondary traumatic stress disorder that can elicit a shirking of professional responsibility, emotional distance, and the activation of defence mechanisms. These elements can all provoke professional burn-out (Schwam 1998;Kearney et al. 2009;Conrad, Kellar-Guenther 2006).
The aim of the present study is to qualitatively describe vocational preferences and desirable future employment areas in a group of nursing students near graduation. The description will focus particularly on speculation concerning the coherence between students' preferences and the complexity of patients' healthcare needs.

Methods
A qualitative study was conducted with a group of nursing students near graduation at Padua University. The study was conducted using a bottom-up approach, and within a phenomenological perspective (Reinharz 1983;Berger, Luckmann 1966). The researchers' intention was to go beyond a quantitative description of students' choices to reach a hermeneutic comprehension regarding their desires and subjective perception.
Semi-structured interviews were realized individually with each student. The interview protocol was based on Happell's paper (2000). During the interviews, the students' personal data was collected, while the protocol included some specific questions useful to explore students' motivations regarding their desire to become a nurse and their preferred clinical areas for future employment. Clinical areas proposed to the students were: Paediatrics, Critical/ A&E, Surgery, General Medicine, Geriatrics, Mental Health, and Home Care.
The interviews were recorded in their entirety and transcribed. Data were analysed using Atlas.ti, 7.1.8.

Results
The study was conducted in September 2013. 37 students near graduation were involved (8 males and 29 females; the mean age (±DS) was: 25.6±5.9 years.
Considering students' reasons linked to the choice of this university course, test analyses led to the identification of 10 different motivations. Some of them seemed similar for most of the subjects involved. Others, instead, were only mentioned by a few students (Fig. 1). One of the most frequent motivations described concerns the need to find a satisfying strategy to express solidarity. A substantial number of students talked about the desire to receive gratitude from patients and therefore to feel that they were useful.
Frequently, students reported knowing other nurses, especially among their family members and friends. Another frequent motivation that they referred to was having had experience of social volunteering. This reason was often linked to a clear declaration of feeling pleasure when involved in a work activity with both technical and relational dimensions.
In many cases, students referred to an innate vocation, without any possible rational explanation; a sort of desire (that seems to have emerged during childhood or adolescence) to work in a healthcare setting, especially in a hospital.
Few students reported having chosen this Degree Course to have a guaranteed job, occasionally as a fresh start after a layoff in later life.
Instead, not a few students admitted that their choice was induced by a failure to pass the test for a medical or physiotherapist's degree. Nevertheless, in all these cases, they admitted their satisfaction concerning their Nursing Degree.
Other motivations, reported by only one or two students, were linked to a passion for some bio-scientific subjects of the nursing degree curriculum, or the human body as an object of interest.
Regarding preferred clinical areas for future employment, the students were clearly influenced by the positive experiences that they had had during their internships. Students frequently referred to a particular emotional context or a skilful and charismatic clinical tutor making the difference. Other reasons were also identified, distinguished by preferred healthcare areas as follows.
Five out of 37 students chose the Paediatrics Area: they expressed two preferences, for Paediatrics and Maternity units (Fig. 2). Three students chose the maternity unit because of their desire to assist new mothers in learning to care for their baby, and because of a natural aptitude to socializing with other women. Lastly, because in this area there were no chronic patients.
Those who chose the Paediatric unit explained their choice simply with the statement, «I love children, even better if new-born». Moreover, they discussed the complexity of caring for an ill child, since professionals are more emotionally engaged, this might contribute to letting them feel useful to young patients as well as their parents.
There was another interesting result: the students who chose the Paediatric and Maternity units underlined that these areas are less exposed to the risk of having to cope with death, pain, or a therapy failure compared to other areas (e.g.: Geriatrics or General Medicine).
Three units were chosen as being in the 'critical area': Coronary Intensive Unit, Intensive Care Unit, and A&E. This sector was chosen by many students: 11 out of 37 (Fig. 3). Regarding the reasons linked to this choice, the students reported that working in this sector represented a chance to cope with a variety of situations, pathologies, and different patients and, in addition, might be an opportunity to acquire (or reinforce) new knowledge and skills. They affirmed that in this sector nurses could play an active role in managing the critical situation and working with the medical team. From the students' point of view, these elements all seemed to contribute to a more detailed nurse profile.
Above all, in the intensive units, students mentioned the inclusive relationship they could establish with a sedated patient who, in this way, seemed to be utterly dependent on their care.
The situation characterized by A&E, the chance to save patients' lives and the adrenaline-filled condition deriving from this idea, clearly represented some salient motivations for these students.
Five students chose the surgical area; the Surgical Ward and the Operating Theatre were the two units they pointed to (Fig. 4).
The first motivation reported concerned the chance to obtain more information, knowledge, and skills linked to the acquisition of more responsibilities.
The students preferred the operating theatre where they could experience direct work on patients, linked to the chance to satisfy their interest in the human body (as a tangible object to be handled). In this healthcare setting the relationship with the doctors seems to have been perceived at the same level. Certain stereotypes, derived from television medical dramas, emerged from the students' accounts. Additionally, they stated that these areas let them avoid emotional involvement with the patients.
Seven students chose General Medicine (5) and Geriatric Area (2); results are described together because they present some analogies. Many clinical units have been pointed out by students (Fig. 5). Students stated that they preferred these contexts because they offer many chances to establish a continuative, holistic, and deep relationship with the patient. This area was considered a good setting for initial employment, because it let new graduate nurses learn the basics of their job in a safe condition. Even in this area, nevertheless, one student reported fear of patients dying.
Only one student chose the Home Care Area. His motivation was linked to the opportunity to establish with the patients and their family a caring alliance and a human relationship; this would let him become a reference point for them. In this way, he expected to receive significant payback for his efforts.
Four students chose the oncological area. They indicated the Oncology, Chemotherapy, and Ambulatory Units, and the Hospice (Fig. 6). These students told us about the opportunity to play − as a nurse − a complete role in terms of caring for a patient who needs human attention. Almost all said that taking care of a dying patient during his or her last days seemed to be a virtuous professional aim. One of them mentioned some personal grief that influenced his choice; this personal experience may have significantly contributed to his future professional preferences. It is possible to reflect on the extent of his elaboration of grief.
Students seemed to perceive the oncology patient as a complex person and, for this reason, someone who could stimulate their professional learning. This complexity, indeed, and the great need for care of these patients let students imagine − or expect? − to receive significant feedback (in terms of self-esteem and self-efficacy), not com-parable to other areas. Students involved in this study seemed not to be sufficiently aware of the risk of emotional involvement. Very few reflections on this theme were recorded.
Four students chose the Mental Health Area. Everyone indicated the Dependency Service (Fig. 7). These students mentioned the operative and autonomous role that nurses can play in this context. Besides this, patients suffering from drug addiction seemed to be particularly stimulating for these students, since they were described as complex and unpredictable but, at the same time, captivating and capable of great payback. Additionally, the continuity of the assistance allows nurses to take care of these patients more through a human relationship than a technical approach.

Discussion and final remarks
The choices and preferences that moved these students near graduation were coherent with other previous studies (Williams et al. 1997). They were keen (except for few cases) to stand caring for a patient, even if suffering from a chronic condition. Despite this, the analysis of the students' answers concerning the explanation of their future professional preferences, revealed some inappropriate − or unrealistic − ideas. Students seemed not to have a clear awareness regarding their future job in the various healthcare areas. Firstly, a sort of instinctive love for children drove some students towards the maternity or paediatric sector and let us hypothesize a desire for maternage -'mothering', rather than a real understanding of the complexity of paediatric patients (Happell 2000).
In other cases, choosing a specific sector seemed to be a way to avoid suffering, death, or patients' pain: all these elements could compromise the need for security and control that many of these students expressed directly or indirectly (Rosenbloom et al. 1999). On the other hand, those who chose the oncological context seemed to express a heroic will, but perhaps they were seeking a social payback that they perceived as necessary for their self-esteem. The security they mentioned in coping with the risk of human involvement in a patient's history of pain, is indeed incoherent with their youth and the competences they may have acquired a few months before taking their degree. In fact, solidarity (like the main professional motivations) appears linked to a major risk of exposure to burn-out ( Joinson 1992;Crumpei, Dafinoiu 2012).
Lastly, the students' desire (frequently expressed) to work in a critical setting was very meaningful: they wished for a job that would give them the chance to be, continually, in an adrenaline-filled condition, to help a critical patient utterly dependent on their skills. This dependence concerned both the patient's therapeutic needs and (even more significantly for the students) his or her life. This attitude may have derived from a prolonged adolescent desire for power and control (Barone 1990Rosenbloom et al. 1999, alternatively, it could be an attention-seeking behaviour. Moreover, it could be coming from the current social and cultural context characterized by a hyper-stimulating environment which might induce them to need continuous stimuli at every moment of their life (even from a professional point of view) (Griffiths 2000).
Considering the preferences and desires expressed by the students involved in this study, there is little space for the concrete needs of the patient. It is not simply arguing what level of awareness these students near graduation possess regarding patients' human needs, or about their skills and competence (or limits) in caring for them (Cowin 2001).
The results of the present study let us partially confirm our initial hypothesis; generally, it was indeed possible to identify in these students a limited consideration of the concrete opportunities for employment and a poor awareness of the real complexity of both their job and patient's needs. These distortions, within a few years, might expose them to some dangerous consequences concerning their own identity as well as their emotional wellbeing (Yoder 2010;Stamm 1999;Fingley 1995). This risk appears increased by a clear absence in their portfolio of competences in some meta-cognitive skills that could protect them from any disturbances or vicarious traumas (Yassen 1995). These are some serious educational gaps that must be bridged by some specific paths to help them comprehend and integrate into their vocational wishes a more realistic idea of patients, as well as a clear idea of the nursing profession (a difficult job, full of professional, emotional, and personal obstacles). The literature appears rich in suggestions regarding training strategies fit for this student target: there are some didactic strategies by which it appears possible to lead students to integrate their -prevalently − rational thinking with a more contemplative one (Heiddeger 1966;Hixon 1978). In this way, they would able to care for a patient while thinking about his or her wellbeing (which only the patient can describe − Mottura 1986), avoiding wasting their good intentions and vocational motivation on role profiles which, in the present healthcare systems, are less and less requested.