Demographics
Of the 273 first-year students who filled in the questionnaire at T0, 239 (87.5%) were female and 34 (12.4%) male. Mean age was 19.8 years (SD = 2.7, range 16–44). Of the 273, 225 (82.4%) had completed general secondary education, 43 (15.8%) had completed secondary vocational education, and 5 (1.8%) had completed higher education. The number of students born in the Netherlands was 252 (92,3%). Many students had, in some way, experience with community care: 44.0% had family or friends working in the field, 18.3% (had) worked themselves in some form of community care, and 35.2% had, either themselves or a close family member, received home care (note: an overlap in positive response to these three items is possible). The students’ demographics correspond approximately with a larger sample (n = 1058) in a multicentre study in the Netherlands [6] and, therefore, can be considered to be typical for Dutch nursing bachelor programmes. However, as this University of Applied Sciences is located in the multicultural environment of a large Dutch city, the number of students born in the Netherlands in the present sample is somewhat lower (92.3% versus larger sample 95.8%).
Placement preferences at cohort level
On the question: “If you were to begin your practice placement next week, where would you choose to do it?”, the majority of the students chose a general hospital in year 1 (79.8%), and this remains the most popular during the four years of study. Mental healthcare is the second popular area at T0 (12.8%), decreasing to 8.8% at T3. Community care is the least popular area at T0 (2.6%), fluctuates during the four timepoints but increases between T0 and T3, to almost the same level as mental healthcare at T3 (8.2%). This changed the rank order of preference for community care from 6 at T0 to 3 at T3 [Table 1].
Table 1
Description of students’ placement preferences at T0-3.
| T0 (n = 273) % (n)* | T1 (n = 188) % (n)* | T2 (n = 166) % (n)* | T3 (n = 170) % (n)* |
General hospital | 79.9 (218) | 75.0 (141) | 78.9 (131) | 76.5 (130) |
Mental healthcare | 12.8 (35) | 8.0 (15) | 11.4 (19) | 8.8 (15) |
Medical rehabilitation | 4.8 (13) | 3.7 (7) | 3.0 (5) | 3.5 (6) |
Care for mentally disabled | 3.3 (9) | 4.8 (9) | 1.8 (3) | 2.9 (5) |
Elderly Care | 2.9 (8) | 1.1 (2) | .06 (1) | .06 (1) |
Community Care | 2.6 (7) | 8.5 (16) | 3.6 (6) | 8.2 (14) |
* Some students mentioned more than one option, which caused a total score at T0, T1 and T3 of > 100%. Based on the assumption that they did not read the instructions well, and preferred more than one field, this information was not excluded. |
Perceptions of community care at cohort level
The description of students’ perceptions of community care at T0-T3 (SCOPE, total scale and subscales, range 1–10 [Table 2]) shows a slight increase of the mean in the total scale and the three subscales between T0 and T1, but an overall small decline between T0 and T3 (total scale 6.66 vs 6.21, respectively), with the lowest score and the largest decline in the placement scale (6.23 vs 5.51, resp.).
At the level of the separate items, it is noticeable that the item means, specifically in the affective component scale and the profession scale, mutually differ substantially [see Table 2 in bold]. In the affective component scale, the items ‘important’ (T0-3 resp. 8.48–8.58), ‘meaningful’ (8.60–8.60) and ‘good’ (8.44–8.14) have a relatively high score, while items representing a more personal attraction, such as ‘attractive’ (5.26–4.86) and ‘fun’ (5.89–5.73) score lower. The results in the profession scale show that students expect to provide care mainly to elderly patients (8.81–8.62) while carrying a lot of responsibility (8.20–8.51) in a poor occupational work environment (5.84–4.15) with little collaboration (5.57–4.48). Students also see community nursing as a low status job (5.36–5.21) with few opportunities for advancement (5.72–5.33).
The longitudinal description at item level shows that, in the affective component scale, the mean in each item after T0 hardly fluctuates over time. In the placement scale, a decline after T0 is visible, specifically in the two items ‘contact with mentor’ and ‘time to evaluate with mentor’ (mean difference 1.89 resp. 1.23, and score at T3 4.46 resp. 4.92). In the profession scale, a slight increase from T0-T3 is found in items that seem to represent two larger areas. The first is ‘contacts’, represented in the items ‘enjoyable relationships with patients’ (7.68–7.77) and ‘contact with family/kin’ (7.70–7.90). The second has a more negative connotation as it appears to relate to ‘workload’, with the items ‘physically demanding work’ (6.85–7.20), ‘work pressure’ (6.87–7.40), ‘responsibility’ (8.20–8.51) and ‘freedom of action’ (7.16–7.84). All other items decline between T0 and T3, except ‘possible health improvement’ with a very slight increase [Table 2].
Table 2
Description of students’ perceptions of community care at T0-T3
(SCOPE: total scale, subscales, and per item)
Perceptions: range 1–10 in mean (SD) with mean values < 5.5 and > 8 in bold | T0 (n = 273) | Missing at T0 | T1 (n = 188) | Missing at T1 | T2 (n = 166) | Missing at T2 | T3 (n = 170) | Missing at T3 |
SCOPE: total scale (33 items) | 6.66 (0.94) | 0 | 6.68 (1.07) | 1 | 6.14 (1.12) | 0 | 6.21 (1.08) | 0 |
Affective component scale (11 items) | 6.64 (1.21) | 2 | 6.72 (1.24) | 1 | 6.44 (1.40) | 0 | 6.55 (1.25) | 0 |
Placement scale (5 items) | 6.23 (1.54) | 7 | 6.37 (1.50) | 5 | 5.41 (1.64) | 0 | 5.51 (1.58) | 3 |
Profession scale (17 items) | 6.80 (0.96) | 1 | 6.98 (0.99) | 2 | 6.56 (0.93) | 0 | 6.57 (0.92) | 0 |
Affective component scale | | | | | | | | |
Dull - interesting | 5.86 (2.18) | 3 | 6.21 (2.04) | 1 | 5.82 (2.08) | 0 | 5.81 (2.17) | 0 |
Boring – fascinating | 6.24 (2.04) | 6 | 6.13 (2.09) | 2 | 5.65 (2.10) | 0 | 5.75 (2.11) | 1 |
Unpleasant – pleasant | 6.18 (1.79) | 5 | 6.25 (1.73) | 3 | 5.95 (2.04) | 1 | 6.07 (1.98) | 1 |
Annoying – agreeable | 6.03 (1.61) | 4 | 6.27 (1.61) | 2 | 5.85 (1.95) | 0 | 5.97 (1.80) | 0 |
Uncomfortable – comfortable | 5.87 (1.67) | 5 | 5.97 (1.68) | 3 | 5.78 (1.87) | 0 | 5.65 (2.02) | 1 |
Old fashioned – modern | 6.21 (1.80) | 6 | 6.61 (2.17) | 1 | 6.46 (1.88) | 2 | 6.87 (1.91) | 1 |
Unimportant – important | 8.48 (1.84) | 4 | 8.25 (1.74) | 2 | 8.28 (1.86) | 0 | 8.58 (1.61) | 2 |
Bad – good | 8.44 (1.60) | 3 | 8.21 (1.55) | 3 | 8.15 (1.68) | 1 | 8.14 (1.73) | 1 |
Useless – meaningful | 8.60 (1.52) | 3 | 8.27 (1.76) | 2 | 8.36 (1.55) | 0 | 8.60 (1.65) | 1 |
Unattractive – attractive | 5.26 (2.18) | 6 | 5.62 (2.24) | 1 | 4.91 (2.33) | 3 | 4.86 (2.29) | 0 |
Stupid – fun | 5.89 (2.10) | 3 | 6.12 (2.03) | 2 | 5.61 (2.20) | 0 | 5.73 (2.27) | 0 |
Placement scale* | | | | | | | | |
Very little – much variety in the caregiving | 5.88 (2.46) | 22 | 6.85 (2.31) | 7 | 5.58 (2.48) | 2 | 5.79 (2.42) | 9 |
Very little – much contact with mentor | 6.35 (2.12) | 30 | 5.63 (2.15) | 13 | 4.73 (2.07) | 8 | 4.46 (2.04) | 13 |
Very few – many opportunities to learn new things | 6.90 (2.00) | 19 | 6.81 (2.03) | 7 | 5.56 (2.13) | 3 | 5.96 (2.16) | 5 |
My mentor will have very little – much time to evaluate | 6.15 (1.84) | 52 | 5.92 (2.00) | 16 | 5.16 (2.10) | 11 | 4.92 (2.18) | 17 |
No – many possibilities to plan own learning activities | 6.00 (1.92) | 61 | 6.53 (2.15) | 17 | 6.15 (2.08) | 10 | 6.13 (2.11) | 12 |
Profession scale* | | | | | | | | |
Very few – may enjoyable relationships with patients | 7.68 (1.57) | 14 | 7.54 (1.61) | 5 | 7.64 (1.52) | 1 | 7.77 (1.63) | 3 |
Very little – much physically demanding work | 6.85 (1.59) | 14 | 7.09 (1.58) | 5 | 7.06 (1.85) | 2 | 7.20 (1.73) | 2 |
Very little – much collaboration with colleagues | 5.57 (2.42) | 10 | 5.42 (2.25) | 4 | 4.50 (2.20) | 4 | 4.48 (2.03) | 2 |
Very little – much collaboration with other disciplines | 6.44 (2.02) | 23 | 7.53 (1.94) | 4 | 6.07 (2.17) | 2 | 6.12 (2.16) | 6 |
Very few – many technical skills needed | 7.58 (1.89) | 4 | 6.91 (1.98) | 5 | 5.96 (1.84) | 0 | 6.30 (1.85) | 4 |
Very little – a lot of freedom of action | 7.16 (1.72) | 18 | 7.98 (1.55) | 5 | 7.75 (1.60) | 3 | 7.84 (1.73) | 5 |
Very little – a lot of variety in the caregiving | 5.99 (2.04) | 15 | 7.03 (1.98) | 3 | 5.93 (2.06) | 0 | 5.85 (2.02) | 7 |
A poor – good occupational work environment | 5.84 (1.80) | 61 | 5.04 (1.89) | 17 | 4.59 (2.03) | 9 | 4.15 (1.96) | 8 |
Very little – plenty of individual responsibility | 8.20 (1.32) | 8 | 8.48 (1.54) | 2 | 8.58 (1.34) | 0 | 8.51 (1.20) | 2 |
No – continual feelings of work pressure | 6.87 (1.67) | 21 | 7.16 (1.74) | 6 | 7.29 (2.00) | 2 | 7.40 (1.53) | 4 |
Very few – plenty of complex patient care needs | 6.22 (1.93) | 25 | 6.58 (1.85) | 5 | 5.85 (1.90) | 1 | 6.02 (1.84) | 5 |
Very few – only elderly patients | 8.81 (1.25) | 3 | 8.32 (1.63) | 3 | 8.66 (1.47) | 0 | 8.62 (1.23) | 1 |
Low – high status work | 5.36 (1.81) | 44 | 5.63 (2.00) | 16 | 5.23 (1.80) | 6 | 5.21 (1.81) | 13 |
No – a lot of possible health improvement for the patient | 6.37 (1.62) | 44 | 6.79 (1.69) | 10 | 6.70 (1.71) | 3 | 6.49 (1.79) | 6 |
Very few – many enthusiastic colleagues | 6.64 (1.78) | 47 | 7.10 (1.63) | 12 | 6.34 (1.71) | 11 | 6.29 (1.71) | 18 |
Very few – much contact with family/ kin | 7.70 (1.70) | 13 | 8.02 (1.71) | 5 | 7.67 (1.70) | 2 | 7.90 (1.62) | 6 |
No – many opportunities for advancement | 5.72 (2.29) | 31 | 5.89 (2.21) | 10 | 5.44 (2.17) | 7 | 5.33 (2.23) | 11 |
*The option ‘I don’t know’ (value 11) in the placement and profession scale is excluded in the calculation of the mean and defined as missing, which explains the larger/ fluctuating numbers of missing values in the placement and profession scale. |
Effect of time T0-T3 on students’ perceptions of community care
To measure the effect of time on students’ perceptions of community care (SCOPE, total scale), a linear mixed model analysis (LMMs) was carried out. The type lll F-test for the linear trend of the relation between 'time' and 'perceptions of community care' shows a significant result at the 5% level [F(3, 184.308) = 19.485, p < .001, indicating that the relationship between the two variables varies significantly. The estimated marginal means of nursing students’ perceptions of community care (total scale) are 6.651 for T0, 6.694 for T1, 6.142 for T2 and 6.200 for T3 [Table 3].
Table 3
Mixed model analysis for the effect of time (T0-3) on nursing students' perceptions of community care
| B | SE B | 95% Confidence Interval |
Constant | 6.200 | .079 | 6.044–6.355 |
T0 | .451 | .083 | .287 –.615 |
T1 | .494 | .083 | .331 – .657 |
T2 | − .058 | .076 | − .207 – .092 |
T3 | Ref | 0 | - |
In order to make it easier to interpret the regression coefficient B in the mixed model analysis, a pairwise comparison of the estimated marginal means of students’ perceptions of community care between the timepoints (indicating the slopes) was conducted. These values increase slightly between T0 and T1 and T2 and T3. Between T1 and T2, a significant decline is shown [Table 4].
Table 4
Pairwise comparison of estimated mean differences in students' perceptions of community care at T0-T3
Timepoint I | Timepoint J | Mean difference (I – J)a | p | 95% Confidence Interval |
0 | 1 | − .043 | .618 | − .211 – .126 |
1 | 2 | .552 | < .001* | .372 –.732 |
2 | 3 | − .058 | .447 | − .207 – .092 |
a A negative result in mean difference indicates a positive slope |
*p < .05 |
Zooming in on students with a preference for community care
The following schemes (Figs. 2a and 2b) represent the individual development of students’ placement preferences. The numbers in the vertical lines represent how many students prefer a specific field at each timepoint (T0-3). The arrows show how students move between the timepoints, and the numbers in the arrows how many students take this pathway. The results at individual level show that of the 14 students with a placement preference for community care at T3, only one had such preference at T0 [Figure 2a]. This is identical to the 7 students with a preference for community care at T0, as only 1 remains at T3 [Figure 2b]; the other 6 make other subsequent choices (3 students) or drop out (3 students). Apparently, although the preference for the field in the cohort generally increases from 7 to 14, there is no consistent choice for the field of community care. With regard to the perception of community care, the 14 students preferring community care at T3 have a mean in perceptions (total scale) of 7.66, compared to 6.21 in all students [Table 2].
Placement preferences for community care at individual level
Comparing placement preferences of the 14 students preferring community care at T3 [Figure 2a] with their factual placements at T1, 2 and 3, shows that 6 students at some point during study had a placement in community care (10 or 20 weeks). The same result is visible at other timepoints: of the 16 students preferring community care at T1, 2 had a placement in the field, and at T2 (n = 6) also 2 students. Therefore, no relation between a factual placement in community care and a preference for the field was found.
A preference for the hospital at individual level
The development of placement preferences in students choosing the general hospital at T0 (n = 218) provides a different pattern [Figure 3]. The number of students who drop-out is relatively large, which is, although undesirable, not uncommon in higher education in the Netherlands [42]. However, of the 121 students preferring the hospital at T1, 95 students remain consistent in their choice at all timepoints. Many students choosing a different area once return back to their earlier choice for the hospital at the following timepoint. In the period of graduation (T3), 111 students have a preference for the hospital, compared to 15 students choosing a different area.