The objective of this study was to investigate how baccalaureate nursing students’ perceptions towards community care and placement preferences develop during a more community care-oriented curriculum, and which curriculum elements have the potential to positively influence students’ perceptions of community care.
First, the development of students’ perceptions while progressing through the four-year curriculum (between T0 and T3) show an overall slight decrease (6.651 at T0 vs. 6.200 at T3, range 1–10), indicating that the curriculum as a whole did not have a positive effect. The higher score at T1 (6.694) could be the result of the theme week on community care [D in Fig. 1], which is a relatively intensive and ‘powerful’ intervention. However, this effect does not last. The longitudinal picture of students’ placement preferences also shows that the curriculum in period A/years 1 and 2 did not have the intended effect of students choosing the ‘paved way to community care’ in period B/years 3 and 4, indicated by the ‘dip’ at T2 in the preference for the field [Table 1]. Also, in Fig. 2b, the field of community care at T2 is empty. These results correspond with existing literature on the effect of specific courses/programs on students’ perceptions of working with elderly [29, 43–45] and in community care/primary care [24, 46], not only with regard to the positive, but also the short-term effect.
Second, despite the lack of more positive perceptions in the whole cohort, the proportion of students with a preference for a placement in community care increases substantially between T0 and T3 (2.6% vs. 8.2%). This in contrast with all the other fields experiencing, to a greater or lesser extent, reduced attention. This result ties in with Pfarrwallers et al.’s conclusion that a longitudinal approach is the only effective strategy to stimulate student interest . On the other hand, the results here do not provide an obvious explanation for the increased interest for community care, due to the fluctuation of students with a preference for the field during the four-year curriculum (7-16-6-14) and the fact that the 14 graduates mainly are different persons than the 7 with a community care preference at T0. However, the fact that these 14 students with a preference for community care have a higher score on perceptions than the whole cohort (7.66 vs. 6.21), indicates that placement preference and positive perceptions go ‘hand in hand’, which is in line with existing literature [7, 16].
Third, no impact of a factual placement in community care on students’ intention to work in the field is visible in this cohort. This contrasts with several studies, where students who participated in a placement were more likely to intend to work in community care [7, 10, 22, 47], and with the last placement being crucial . With regard to placement experiences in this student cohort, it seems noteworthy that the items in the placement scale on ‘contact with mentor’ and ‘time to evaluate’ [Table 2] have a low score at T0, but even lower at the end (<5). This raises doubts about the quality of students’ experiences in community care, even more so while they see clinical nurse commitment [49, 50], a qualified and motivated mentoring nurse [5, 20, 38], and a feeling of appreciation and connection with the staff  as important for their placement. In contrast, stress and fatigue in staff appears to be a hindrance to feeling part of a team, which negatively effects students’ valuation . It is possible that the nursing students during the placement period are confronted with the consequences of labour market problems, leading to a negative vicious circle of shortages causing more shortages, when students experience a high workload and other related problems and, hence, make other career choices.
Fourth, the visualisation schemes indicate that many first-year students are undecided about their career, as their placement preferences fluctuate considerably in the subsequent years of study, a phenomenon earlier described in studies in Norway  and Australia . Nevertheless, it should be noted that in this study, this applies to a minor extent to students with a preference for the hospital.
Finally, and in contrast with the placement preferences, students’ perceptions of community care seem to be quite stable. The data in Table 2 show that, although the items differ mutually, from a longitudinal perspective the changes per item are limited. Also, the results at T3 correspond with data collected from students graduating in 2015, 2016 and 2017 from an earlier study . Difficult issues are visible hindering a positive outlook on community care, such as having much responsibility while working alone with little guidance, a low status, and few opportunities for advancement. Despite the transforming healthcare delivery environment, the status quo of the hospital being ’the place to be’ seems difficult to modify.
These insights underline the importance of a close collaboration between educational institutions and community care organisations, as it is a growing challenge to offer good placements in a tightening labour market. Also, as students do not look forward to the high responsibility they have to bear in this more autonomous role, it may be worthwhile investing time and effort in designing a curriculum that attracts more mature students. Older students appear to have more positive perceptions of placements outside traditional settings [10, 20], and they see workplace support as less important . This curriculum should, on the one hand, contain the same themes with regard to extramural caregiving, but, on the other, establish strong ties with the students, for example in a part-time baccalaureate programme for vocational trained nurses, or a dual track, combining workplace learning with learning in educational institutions. More maturity might make it easier to tackle the high responsibility that is seen as a major impediment by the younger students in the full-time programme. It could even be that more mature students see aspects as autonomy and freedom of action as desired features the hospital cannot offer them.
Strengths and limitations
Strengths of this study are its high response rate compared to many other studies, and the holistic/ broad longitudinal approach of the curriculum-redesign. Another strength is that a longitudinal study on placement preferences with quantitative data at the individual level is uncommon. Some methodological problems limit the findings and interpretations of this study. The sample was drawn from one cohort in a single institution, and nursing curricula mutually differ, which limits the general applicability of the findings. Second, the small number of students in the ‘community care pathway’ was a limitation for some statistical procedures. Third, the repeated data collections may be considered as an intervention as well, and it is not easy to properly assess the impact on students of being ‘under scrutiny’.
Implications for further research
Some issues with regard to students’ preferences for healthcare areas, and directly related, career choice, need further exploration. Little is known about the exact moment at which the definitive choice for an area for the future career takes place, and under what influences. These questions could be explored in a retrospective qualitative study with graduating students. Also, as the evidence on the positive effect of maturity on a preference for working outside traditional settings is limited, this topic needs further exploration.