PERCEPTIONS OF STUDENT NURSES OF THEIR CAREER PROGRESSION OPPORTUNITIES BY CATHERINE NKHOMA submitted in accordance with the requirements for the degree of Master in Nursing at the University of the Witwatersrand June 2022 ii DECLARATION I Catherine Nkhoma, Student number 2252336 declare that Perceptions of student nurses of their career progression opportunities at the University of the Witwatersrand in Johannesburg, South Africa was done by me. All references used have been acknowledged. It is the first time that this Research Report has been submitted to any University. Signature……………………… Date ……………………… 23rd June 2022 iii ACKNOWLEDGEMENTS I would like to thank the almighty God for giving me this opportunity to complete the Master of Nursing Education dissertation which has made me to move one step ahead. The grace which has been stowed upon me during this dissertation period is beyond human imagination. The vote of thanks should also go to my beloved supervisor Dr Lizelle Crous who has been on my side and working tirelessly from the start of the proposal to the end of the thesis. Your expertise and unending feedback helped me to not give up and to remain stronger day by day in critical thinking so that I could move to the next level. Let me not forget to thank Dr Sue Armstrong who is my mentor and has been supporting me in different ways so that my work is completed and is of high quality as well. I salute you Dr Sue Armstrong. Finally, I would like to thank my soulmate Dr Richard Nkhoma for the wisdom and counselling whenever I felt it was hopeless and wanted to give up. Thank you for being there for me and always being the supportive husband. May you receive my gratitude. iv TABLE OF CONTENTS DECLARATION ................................................................................................................ ii ACKNOWLEDGEMENTS ............................................................................................... iii ABSTRACT ...................................................................................................................... vii 1 CHAPTER 1: OVERVIEW OF THE STUDY .................................................... 1 1.1 Introduction .......................................................................................................... 1 1.2 Background .......................................................................................................... 1 1.3 Problem Statement ............................................................................................... 2 1.4 Research Question ................................................................................................ 3 1.5 Objective of the Study .......................................................................................... 3 1.6 Significance of the Study ..................................................................................... 3 1.7 Definitions ............................................................................................................ 3 1.7.1 Student Nurses ...................................................................................................... 4 1.7.2 Career Progression ................................................................................................ 4 1.7.3 Career Opportunities ............................................................................................. 5 1.7.4 Retention of Nurses .............................................................................................. 5 1.8 Methodology ........................................................................................................ 5 1.9 Chapters Outline ................................................................................................... 6 1.10 Summary .............................................................................................................. 6 2 CHAPTER 2: LITERATURE REVIEW .............................................................. 7 2.1 Introduction .......................................................................................................... 7 2.2 Nursing Profession ............................................................................................... 7 2.2.1 Career progression opportunities for nurses ......................................................... 7 2.2.2 Career progression opportunities for nurses in South Africa ............................. 10 2.3 Nursing Students’ Perception of Possible Career Progression ........................... 11 2.4 Summary ............................................................................................................ 12 3 CHAPTER 3: RESEARCH METHODOLOGY ................................................ 13 3.1 Introduction ........................................................................................................ 13 3.2 Research Design ................................................................................................. 13 v 3.3 Research Methods .............................................................................................. 13 3.4 Research Setting ................................................................................................. 14 3.5 Population........................................................................................................... 14 3.6 Sample and Sampling Methods .......................................................................... 14 3.6.1 Inclusion criteria ................................................................................................. 14 3.6.2 Exclusion criteria ................................................................................................ 15 3.7 Data Collection ................................................................................................... 15 3.7.1 Validation of the interview guide ....................................................................... 16 3.7.2 Development of the interview guide ................................................................... 17 3.7.3 Face validity ........................................................................................................ 17 3.7.4 Pilot study ........................................................................................................... 17 3.7.5 Theoretical data saturation .................................................................................. 18 3.8 Data Analysis ..................................................................................................... 18 3.8.1 Familiarisation with data .................................................................................... 18 3.8.2 Generating initial codes ...................................................................................... 18 3.8.3 Searching for themes .......................................................................................... 19 3.8.4 Reviewing themes ............................................................................................... 19 3.8.5 Defining and naming themes .............................................................................. 19 3.8.6 Report writing ..................................................................................................... 19 3.9 Measures to Promote Quality and Trustworthiness ........................................... 19 3.9.1 Credibility ........................................................................................................... 20 3.9.2 Transferability ..................................................................................................... 20 3.9.3 Dependability ...................................................................................................... 20 3.9.4 Confirmability ..................................................................................................... 21 3.10 Ethical Considerations ........................................................................................ 21 3.11 Summary ............................................................................................................ 22 4 CHAPTER 4: FINDINGS AND DISCUSSIONS .............................................. 23 4.1 Introduction ........................................................................................................ 23 4.2 Findings and Discussions from the Study .......................................................... 23 4.3 Theme 1: Career Opportunities after Graduation ............................................... 23 vi 4.3.1 Sub-theme 1.1: Signs of career progression ....................................................... 24 4.3.2 Sub-theme 1.2: Signs of career stagnation ......................................................... 24 4.4 Theme 2: Support for Career Progression .......................................................... 26 4.4.1 Positive support or lack of it ............................................................................... 26 4.5 Theme 3: Barriers to Career Progression ........................................................... 28 4.5.1 Causes of lack of career progression and solutions ............................................ 29 4.6 Discussion of the Findings ................................................................................. 30 4.7 Summary ............................................................................................................ 32 5 CHAPTER 5: LIMITATIONS, CONCLUSIONS AND RECOMMENDATIONS 33 5.1 Introduction ........................................................................................................ 33 5.2 Summary of the Main Findings .......................................................................... 33 5.3 Limitations of the Study ..................................................................................... 33 5.4 Recommendations of the Study.......................................................................... 34 5.5 Conclusion .......................................................................................................... 35 6 REFERENCES ................................................................................................... 37 ANNEXURE A: INTERVIEW GUIDE ........................................................................... 44 ANNEXURE B: PARTICIPANT CONSENT SHEET .................................................... 45 ANNEXURE C: CONSENT FORM FOR AUDIO RECORDING OF STUDY PARTICIPATION ............................................................................................................ 46 ANNEXURE D: REQUEST TO CONDUCT RESEARCH AT THE INSTITUTION AND CLEARANCE FROM HOD AND DEPUTY UNIVERSITY REGISTRAR ........ 47 ANNEXURE E:ETHICAL CLEARANCE OBTAINED FROM THE UNIVERSITY OF THE WITWATERSRAND HUMAN RESEARCH ETHICS COMMITTEE (MEDICAL) AND VICE CHANCELLOR ............................................................................................ 50 ANNEXURE F: ENGLISH PROOF-READING CERTIFICATEError! Bookmark not defined. vii ABSTRACT Aim: This research aims at exploring the perceptions of student nurses towards their career progression opportunities that are available to them. The probability of a student pursuing and remaining in the nursing profession is influenced by the student's view of the profession. Background: This study is all about how the student nurses perceive their opportunities as they progress in their career. In this report, the researcher looked at the perception of the nursing career by undergraduate students. The findings from this research will help to understand the perceptions that student nurses have about their career, career plans and their understanding of progression once they have completed their training. Once this is known, it would help nursing educators on how to prepare for working life realities of nurses, thereby minimising the connection between this and the students’ expectations. Methodology: Semi-structured interviews were used for gathering data in this study as part of a qualitative research approach. Thirteen (n = 13) participants from the study population, (N = 90) nursing students at a university in Gauteng, South Africa, were invited to take part in the study. All thirteen interviews were conducted upon which theoretical data saturation was reached at interview number ten. Due to the Covid-19 restrictions and students being taught remotely interviews were conducted using an electronic meeting platform familiar with the students namely ZOOM. The interviews were transcribed verbatim and analysis was done using thematic analysis approach. Findings: Three themes were generated and were categorised as: (i) Careers opportunities after graduation, (ii) Support for career progression and (iii) Barriers to career progression. Conclusion: The study’s major goal was to find out student nurses’ perceptions when it comes to career progression. The study used a qualitative research method and managed to achieve this goal. Participants mentioned what career progression is all about, they highlighted the career opportunities available to them, what they consider to be barriers to career progression as well as what they thought is the support they would need to promote career progression. 1 1 CHAPTER 1: OVERVIEW OF THE STUDY 1.1 Introduction This chapter gives an overview of the study which describes the process that has been taken by the researcher to explore the perceptions of student nurses about their career progression. The section begins with the background to the study followed by highlighting the following subsections: research problem statement, research question, research objectives, significance of this research and will end with an illustration of an overview of the research plan. 1.2 Background This study is all about how the student nurses perceive their opportunities as they progress in their career. In her thesis, Tsakissiris (2015) claimed that a student's view of the nursing profession influences his or her likelihood of following a nursing career. In this regard, she concluded that an individual is attracted to pursue a career in an industry if the industry can provide the desired place of work incentives and image that an individual thinks valuable, depending on the personal preferences, sociocultural factors, and prior educational qualification and work experiences. The student nurses have not yet developed in their career, and they are not yet exposed to different opportunities, but they have plans regarding the growth of their career once they graduate from their studies (Rognstad et al., 2004, van Iersel et al., 2016 and Sela-Vilensky et al., 2020). Student nurses are exposed to the profession through their clinical placements in hospitals, community-based settings or even through social interactions (Motsaanaka et al., 2020). Based on their interaction or exposure to the profession, students form their own opinion about the career opportunities within the profession, but also about the profession. The information, true or not, they obtain through their interaction with other nurses, and from their own experiences within clinical settings might influence their decisions about their own career pathway within nursing or not (Marcinowicz et al., 2016). Student nurses join the profession for various reasons ranging from wanting to care for people and be of service, for others who see nursing as a steppingstone into the healthcare environment and for others wanting to seize leadership opportunities that a nursing career has to offer (Wilkes et al., 2014). Nurses ought to know that there are many career paths that one would opt to pursue depending on the requirements after graduation. There are three possible career paths in nursing, (Fusilero 2 et al., 2008), which one can consider pursuing in their pursuit for progression which are: (i) clinical, (ii) education and (iii) management. Management can also cut across clinical and education. More also, there is an area of research that can be considered but mostly it is part of these three. There are many ways that one can take in order to qualify for the advancement such as attaining an additional qualification by going back to school or attending specialty courses in the chosen area. One also has to note that depending on the organisation that they have joined, they may find that they have opportunities to advance depending on the setup of the organisation according to (Yang et al., 2015). There are many reasons that motivate one to want to progress with their career such as (i) job satisfaction which has been cited as an important factor for nurse advancement and turnover in the articles by (Vitali et al., 2020) and (Collins et al., 2000), (ii) new roles also play a part in motivating some to want to advance in their career (Collins et al., 2000), and (iii) the possibility of earning more once one is promoted, even though this is not cited by many as the motivating factor, propels some to want to advance with their career. The las point can be viewed from the point that most organisations, if not all, have a salary structure which is commensurate with the position that one holds (Motsosi & Rispel, 2012). In this report, the researcher looked at the perception of undergraduate students of career progression in nursing. The findings from this research will help to understand the perceptions that student nurses have about their career, career plans and their understanding of progression once they have completed their training. Once this is known, it would help nursing educators on how to prepare for working life realities of nurses, thereby minimising the disconnection between this and the students’ expectations. 1.3 Problem Statement Limited or no literature is available, specifically addressing the topic under study, in South Africa. Students’ motivation for embarking on a career in nursing is influenced by various reasons (Wilkes, et. al., 2014). What is interesting to note from research conducted by Mkhize and Nzimande (2007) showing that 87.6% of their study participants chose nursing as their career of choice, however, in another study by Rispel et. al., (2019) found that only 47.6% of nursing professionals remain in the profession after qualifying as a nurse. 3 It is unclear what are the factors influencing the decision of nurses to remain in the profession, especially with the reporting of shortages of nurses globally. Literature addressing this notion of why nurses leave the profession and how it influences students to embark on a career in nursing is limited, especially within the South African context. It would therefore be valuable to understand what student nurses perceive their career progression opportunities are in an attempt to retain professional nurses in the profession. 1.4 Research Question • What are the perceptions of student nurses regarding opportunities for career progression in the nursing profession? 1.5 Objective of the Study The objective of the study: • Is to explore the perceptions of student nurses regarding opportunities for career progression in the nursing profession. 1.6 Significance of the Study The study is significant because it deepens the understanding of nursing students’ perceptions of career progression within the nursing profession. This knowledge will assist in determining the gap between the students’ perceptions and the working life realities of nurses. In addition, the study will contribute to the practice of nursing education by highlighting the need for career guidance and development as an intervention to promote the retention of nurses within the nursing profession. The workplace, therefore, will understand the needs of nurses who stay in the Nursing Education Institutions so that the institutions can adjust their marketing strategy to attract more students to study nursing and develop programmes in various specialities that offer progression and work opportunities. 1.7 Definitions The definitions being provided are based on the title of this study in order to set the context of focus of the study. 4 1.7.1 Student Nurses In this context, student nurses are those enrolled in an R425 legacy programme undergraduate bachelor of nursing at one of the universities in South Africa and they will formulate the sample of the study. These student nurses can be in any year of study from year 2nd year to year 4th year since the duration of the programme is 4 years. The first years have been enrolled into a new programme as the legacy programme was phased out from year 2020. 1.7.2 Career Progression The word career progression has “career” and “progression” as separate standalone words. Career in this case shall refer to the nursing profession with a nurse as a person behind this career. A nurse is regarded as a hands-on health professional who provides focused and highly personalized care. Nursing is challenging but at the same time it is a rewarding career that provides significant opportunities to help others and make a difference in the world (Price & Reichert, 2017). Progression wise, there's also ample room to achieve even higher levels of education and to advance into many different roles (Cleveland et al., 2019). The interpretation of this statement is that when one is moving forward or grow skills in their career or use skill set that one has to succeed is considered progression. Many nurses wish to advance their education and to grow in their profession, by becoming advanced practice registered nurses, community or public health nurses, nursing and healthcare administrators, nurse educators, and healthcare policymakers (Godsey et al., 2020). Progression has multiple meanings as it may mean that when one moves or advances vertically into leadership or management positions through promotions. From (Cleveland et al., 2019), it can be seen that progression does not always mean that one has to get a promotion in order to be considered as progressing but you can also consider getting more responsibilities than what one has previously. Some other forms of progression would be taking up new challenges, moving to another section or another job, and also gaining more training. Sheikhi et al. (2016) emphasise the fact that nurses have to be given new roles and challenges to flourish and develop in their profession such as promotion. Promotions act as incentives, motivations and morale boosters which also instils some sense of confidence in employees (Singh et al., 2015; Weller, 2008). Depending on the organisational set-up, nurses are expected to progress, depending on the skills and experience required for such positions as charge nurse, head nurse, supervisor, and the senior nurse manager or matron. The expectation of everyone is to see clear guidelines 5 being used for such progressions such as personal development, work experience, level of skills (Sheikhi et al., 2016). 1.7.3 Career Opportunities This phase is in two parts which are “career” and “opportunities”. From Collins dictionary, career is a profession that someone does for a very long period or throughout their life after acquiring a skill. Opportunity, is defined as a situation in which it is possible to someone to do what they want. In this context, career opportunities will be the possible paths or jobs that one would take throughout their entire life after graduation and that would become part of their occupation. 1.7.4 Retention of Nurses Retention is the ability of an organisation to provide an excellent working environment so that workers don’t frequently leave the organisation for greener pastures. There are so many factors that contribute to the retention of workers and in this case, we will be talking about the retention of nurses. Archana and Rashmi (2017) concluded that factors which influence the retention of the nurses among others are, empowerment, autonomy, the provision of challenges, a sense of community within an organization, the education and peer development, working environment, the flexible working shift, and an adequate financial reimbursement. Mokoka et al. (2011) said that nurses in South Africa, are not highly retained due to failure of the organisations to meet the needs of nurses according to several factors. In this report, it says that 90 percent of the nurses’ decision to stay is related to renumeration, safety, security, equipment, management, staff, and patients. Since student nurses are exposed to such information when they are placed in clinical placements, it might affect their perception negatively about their career prospects. On the other hand, hiring institutions or employers should be aware of the factors of retention of employees as student nurses working in their establishments will come to know. 1.8 Methodology In this research, semi-structured interviews were used for gathering data as part of a qualitative research approach. The analysis was done using thematic analysis approach. There are three themes were generated which will be expanded under discussion and the results sections. The study’s major goal was to find out student nurses’ perceptions when it comes to career progression. It will also be shown that participants know what career progression is all about 6 and the career opportunities available to them. Methodology will be covered in more details in chapter 3 and will include ethical consideration and trustworthiness sections. 1.9 Chapters Outline Table 1.1 below provides a brief outline of the chapters included in the report. Table 1-1: Outline of chapters Chapter Description Chapter 1 Overview of the Research Study Chapter 2 Literature Review Chapter 3 Methodology Employed in the Research Study Chapter 4 Presenting the Research Findings Chapter 5 Summary of the main findings, study of the limitations and recommendations, and conclusion 1.10 Summary Chapter 1 provided an overview of the research study with emphasis on the background of the study, the objective of the study and the significance of the study. Most of the concepts that were initiated in this chapter, will be expanded further in the subsequent chapters. The next chapter (Chapter 2) provides a discussion on the literature around the topic. 7 2 CHAPTER 2: LITERATURE REVIEW 2.1 Introduction Chapter 2 will be providing a description of the literature around the topic of the career progression of nurses. Different perceptions were discussed in this chapter with support from scholarly articles. 2.2 Nursing Profession There are different definitions when it comes to nursing, and they are mainly dependent on the locality of the practicing nurse. Nursing, according to the South African Nursing Council (SANC) (Nursing Act 33 of 2005), is a caring profession in which a person registered under section 31 supports, takes care and treats a healthcare user in order to maintain their wellbeing, and if they fail to do so, they still stake care of the patient so that they live comfortably up to the time that they die with dignity. Nursing as a profession relies on experience and understanding in order for one to discharge their duties effectively. Because of this, nursing institutions of higher learning such as universities and colleges must build the required skills in students and the necessary competencies to easily overcome global challenges (James & Ella, 2016). The global understanding of nursing is that health and well-being problems transcend geographic and national boundaries; it is competence and cultural awareness: having empathy, respect and understanding for the different population groups; it is the drive to work together for equal opportunities in health (Edmonson et al., 2017). This viewpoint informs nursing research, teaching, and practice, as well as their implementation in the real world, both locally and worldwide, by combining common values and a sense of belonging to a shared cultural and social domain. 2.2.1 Career progression opportunities for nurses Globally, there are similarities in how nursing is practiced as shown by the ease of migration of nurses from one country to another (Kingma, 2001; Li et al., 2014). Nursing is a regulated profession and forms an integral part of the entire healthcare system. Nursing is concerned with the promotion of health, prevention of illness, and care of patients be it physically or mentally including the disabled people and dying people. It covers individuals, families, and groups of people of all ages in all healthcare and other community settings (Hertz & Santy-Tomlinson, 8 2018). It is worth noting that there are some minor differences between various categories of nurses in different countries such as United States of America, United Kingdom and Australia. There are a number of career paths for nurses apart from the general nursing in medical and surgical units, and emergency, or intensive care unit (ICU) nursing. Nurses are exposed to technology which has made them evolve and explore more about nursing by using evidence- based practice (Powell-Cope et al., 2008; Ahmad et al., 2018). There are different specialities all of which can work independently after obtaining a master’s or a PhD degree such as among others: 1) Neonatal nurse is a nurse who works in critical care units and is responsible for the treatment of children who may be at risk of complications and require specialist care. 2) Nurse midwife is a nurse who specialises in pregnancy, prenatal care, childbirth, and postpartum recovery. 3) Clinical nurse is a nurse who specialises in infant care, older adult care, critical or emergency care, particular disease management such as diabetes or cardiovascular disease, rehabilitation, mental health, pain management and wound care. 4) Infection control or prevention nurse is a nurse whose function it is to identify, survey, and manage infections, diseases, and viruses. 5) Dialysis nurse is a nurse who is trained to operate a dialysis machine that is used to clean patient's blood. They also monitor patients' vital signs before and after dialysis, as well as providing instruction on drugs and do follow-ups. 6) Family nurse practitioner is a nurse who evaluates, examines, and treats patients at all stages of life, from birth to old age, with a special focus on primary care. 7) Public health nurse is a nurse who works with communities, educating people on health and safety issues and assisting them with access to healthcare. 8) Nurse anaesthetist is a nurse who during surgical procedures and recuperation, delivers anaesthetic and pain medicine, monitors patients' vital signs, makes modifications, and administers anaesthesia and pain medication. 9) Nurse educator is a nurse who is engaged in teaching nursing to students in institutions of higher learning as well as offering continuing education and refresher courses for nursing practitioners. 9 10) Psychiatric mental health nurse is a nurse who assesses, diagnoses, and treats patients with mental disorders. 11) Trauma nurse is a nurse who assists in the treatment of patients with problems that are potentially fatal, severe, and life altering conditions, and 12) Oncology nurse is a cancer care nurse who manages patients and symptoms in various stages of the disease. (Keeling, 2015; Raines & Taglaireni, 2008). Figure 1: Career progression example as proposed by SingHealth as found on https://www.singhealthacademy.edu.sg/NOH21/Pages/Nursing-Career-Tracks.aspx There are different career pathways in nursing that one can specialise in namely: education, management, clinical, informatics and research just to mention but a few (Hamric et al., 2019). In each career pathway, one can progress from one level to the next. In any context that is chosen nurses are supposed to be registered with their respective nurse’s council. For example, one can opt to go into nursing education and the following is the possible career progression pathway: Tutor/Associate Lecturer → Lecturer → Senior Lecturer → Associate Professor → 10 Professor, depending on the setup. In other countries, such as Singapore, the career progression is well spelt out as shown in Figure 1. It should be borne in mind that these career progression paths are dependent on an establishment, additional qualification, and experience (Oyetunde & Oluwafunke, 2015). 2.2.2 Career progression opportunities for nurses in South Africa Similarly, in South Africa, one can specialise in the following areas after being registered with the SANC as a Registered Nurse with their nursing degree or diploma, master’s degree or postgraduate diploma according to the SANC website: critical care, trauma, education, management, flight/transport nurse and advanced nurse practitioner, among others. Furthermore, in South Africa, midwifery is part of the qualification of nursing which is not the same as in other countries where one has to do a separate qualification for midwifery. According to the South African Nursing Act 33 of 2005 there is no difference between the registered nurses who upgrade to master’s level to become nurse practitioners and work independently and globally where master’s education level in nursing is also regarded as a nurse practitioner. It is often said that nurses are like an oiled machine that keeps the healthcare system running. It is regarded as a calling for those who want to pursue this career path as it is demanding and requires someone with passion for others. It is a noble profession. Their contributions are visible in each and every hospital, clinic, or any health establishment (Breakey et al., 2015). Nurses are most probably the largest number of health practitioners who are often employed in the health sector. The World Health Organisation (WHO) puts this number at 50 percent. According to the SANC, the nursing profession is divided into two, namely: (i) non-clinical nurses who are into health services management and nursing education and (ii) clinical nurses who provide direct patient care (https://www.sanc.co.za/education-and-training/). Although the antecedents of career progression are the same for South African nurses, the outcomes are sometimes different. This is collaborated by Oosthuizen and Ehlers (2007) and later by Labonté et al. (2015) who said that inadequate remuneration, poor working environments, heavy workloads, lack of professional development and career progression chances, among other factors, impact South African nurses' decision to relocate. Notably, Oosthuizen and Ehlers (2007) found that 70.1 percent of the respondents, cited inadequate 11 career advancement as the main motivation for wanting to migrate. They make a recommendation that systems should be developed to meet the nurses needs for personal growth, career advancement and achievement. In 14 years, nothing has changed as South African nurses are still migrating due to perceived slow progression in their careers. The recommendations made by Oosthuizen and Ehlers (2007) have not been implemented. Bidwell (2014) explains that South African nurses prefer to migrate to the developed world whenever they see that they are not progressing in their careers. 2.3 Nursing Students’ Perception of Possible Career Progression Literature seems to suggest that student nurses’ perceptions of their future career progression changes as they advance in their university education. Ward et al. (2003) and Bjørk et al. (2014) found that student nurses who were in the early phase of their university education had positive perceptions of their future career prospects and this assertion was collaborated by Duah, 2015. It is inevitable that the nursing students’ expectations of their future career progression is very different from those of the practicing nurses. McKenna et al. (2010) suggested that these expectations change as the practicing nurses as students get nearer to graduation. This change mostly results from clinical placements. Thus, clinical placements provide nursing students with the opportunity to reflect on their career choice and most important the influence in determining whether nursing is the right career for them. Clinical placement, which happens in the later years of university education, has a mixed influence on student nurses’ perceptions of their future career progression prospects. Abbey et al. (2006) and Bjørk et al. (2014) suggested that places where the student nurses do their clinical placement influences their perceptions regarding their future career progression. They found that students who were placed in the old age homes had negative perceptions about their future career progression. This was because these student nurses interacted with practitioners who had little or no qualification. On the positive side, clinical placement enables the student nurses to plan for their future careers. For example, McKenna et al. (2010) and Abbey et al. (2006) found that student nurses who were exposed to community nursing think that they will start their careers in acute nursing and later on move to community nursing when they want to start families. The student nurses thought that they could use the knowledge and the experience gained in acute nursing later if they were to shift to community nursing. 12 2.4 Summary Chapter 2 provided an overview of the literature study that showed the global context of nursing versus the local context. It also showed the available career paths in nursing if one wants to progress with nursing from one level to the next globally as well as the career paths that are available locally. Of importance was the highlight that, just like any other career, nursing also has its own challenges. Therefore, the challenges facing nursing in this chapter have been explained. Chapter 3 will provide a discussion on the research methodology that was used. 13 3 CHAPTER 3: RESEARCH METHODOLOGY 3.1 Introduction The study technique covered the following subheadings in this chapter: research design, research setting, population and sample, data collection, tool validation (interview guide), interview process, data analysis, trustworthiness, and lastly ethical issues. 3.2 Research Design A qualitative research design was employed in this study. The researcher considered this approach as appropriate based on the nature of information to be gathered to answer the research question. Qualitative research that was used was inductive based which means that the themes identified are strongly linked to the data that was collected (Nowell et al., 2017). According to Braun and Clarke (2006), this method is evidence-based and is a holistic form of research that provides for a complete knowledge of an individual's views and experiences without being influenced by the researcher's personal interests or experiences. The aim of this study was to uncover the understanding of how student nurses perceive their future career progression. This aligns with the qualitative approach to the research design (Tenny et al., 2021). The researcher also considered this approach as appropriate based on the nature of information to be gathered to answer the research question. 3.3 Research Methods The researcher employed a qualitative approach using semi-structured interviews to elicit data to answer the research question. Semi-structured interviews are considered to be an effective method for data collection, according to DeJonckheere & Vaughn (2019), when the researcher wants: (1) to collect qualitative, open-ended data; (2) to explore participant thoughts, feelings, and beliefs about a particular topic; and (3) to delve deeply into personal and sometimes sensitive issues. This study targeted undergraduate nursing degree students at a purposefully selected university in Gauteng. This institution was chosen for convenience because the researcher had easy access to the students through the Department of Nursing Education, which facilitated the process of selecting participants for the study. 14 3.4 Research Setting This study focused on undergraduate nursing students registered for the academic year 2021 at a purposefully selected university in Gauteng. This institution was chosen for convenience because as a fellow postgraduate student in the department, the researcher had easy access to the undergraduate students through the Department of Nursing Education. 3.5 Population In this study, student nurses were the target population, as they are in the process of starting their nursing career. These students qualify, upon graduation, as professional nurses since their bachelor’s degree in nursing is required for one to be registered with SANC. Others that qualify for registration with SANC are spelt out in section 2.2.2. There are 21 university nursing department in South Africa that offer nursing degree programmes of which the research setting was one. At the purposefully selected university in Gauteng the study population consisted of second, third-, and fourth-year students as they have been exposed to nursing for at least a year. In 2021 the student numbers consisted of 25 students in their fourth year, 27 students in their third year and 38 students in their second year. The study population therefore was N = 90. 3.6 Sample and Sampling Methods Total sample was used – where all second to fourth year students were invited to participate in the study via email. Thirteen (n=13) students indicated their willingness to participate, and interviews were scheduled at a time convenient for them. The first years were not considered. because of lack of clinical experience. 3.6.1 Inclusion criteria • Students who have enrolled for the Bachelor of Nursing degree in the year 2021 and are in either second, third or fourth year of study. • Students who should have at least six months exposure to the clinical environment due to the Covid regulations students’ clinical training were adapted to include more simulation during the earlier months of 2020. The usual placement of students in the 15 clinical environments normalised by November of 2020, which would allow for engagement with professional nurses. 3.6.2 Exclusion criteria • Any students who may not have been in the clinical environment within the last six months (have to be in the clinical environment between November 2020 and May 2021) to be able to draw on their experiences. Some students opted to extend their training due to Covid-19 and did not return to clinical practice placements in 2020, which would impact on how they would reflect on their experiences. 3.7 Data Collection Data collection was conducted on an electronic platform namely ZOOM. The researcher chose to use a semi-structured interview method of data collection which refers to a specific predefined set of questions as can be seen in Annexure A but does not strictly follow the formalised list of questions based on the explanation from Whiting (2008) and Galleta (2013). The interviews were scheduled based on the availability of students and their scheduling which was based on the sequence of responses indicating their availability. One on one interviews were conducted with the willing participants as this allowed flexibility for the participants to give more insights into the topic under discussion (DeJonckheere & Vaughn, 2019). Each interview was audio recorded and notes were taken by the researcher who was the interviewer. Probing questions were used as follow-up questions to get clarification of the interviewee’s responses. Data gathering was based on the personal views of the student nurses as this research was about their perceptions. Furthermore, there was no interruptions to class attendance as the research was carefully planned to avoid any interruptions. However, consideration was given to collect data during normal operating hours. Thirteen students responded to the invitation indicating their willingness to participate. These students were interviewed between 23 May and 3 June 2021. A summary of the participants, interview duration, and dates are presented in Table 3.1. 16 Table 3-1: A summary of interview information detailing interview dates and durations Date of Interview Interview Duration 1 26 May 2021 32 minutes 2 27 May 2021 40 minutes 3 30 May 2021 19:30 minutes 4 27 May 2021 21:54 minutes 5 27 May 2021 20 minutes 6 23 May 2021 18 minutes 7 23 May 2021 30 minutes 8 2 June 2021 24 minutes 9 2 June 2021 29 minutes 10 2 June 2021 32:45 minutes 11 3 June 2021 31 minutes 12 3 June 2021 22 minutes 13 3 June 2021 26 minutes 3.7.1 Validation of the interview guide The interviewer is aware that data errors could be found through different sources such as from a participant or from the mode of interview. Systemic errors could happen during data collection due to socially accepted answers which the participants could have or could be using since they grew up in the community. It was noted by Terre Blanche et al. (2012) that the habit of answering the well-known answers by the community are always there so the researcher took precaution measures during the interviews and were observed to reduce such errors so that the study could produce a truthful report. Table 3.2 below explains how the researcher sorted the errors which could have disturbed the process of data collection. 17 Table 3-2: Table showing validity of the data and correction process Errors How errors were corrected Unavailability of Zoom app on the student phone It was downloaded by the participants Unreliable internet Waited until it was reconnected Volume problem from background noise Sorted it by using headsets Lack of data Only interviewed when students have access to internet 3.7.2 Development of the interview guide Development of the questionnaire was based on the construct of perception, which in itself cannot be measured, but questions were structured to solicit information that led to the understanding of student nurses’ perceptions. 3.7.3 Face validity Face validity was used, even though it is a discouraged validity method to evaluate the readability and clarity (Brink et al., 2018) of the questionnaire used by this researcher. As suggested by Connell et al. (2018) this validity method was used as it is still considered important by other researchers. The interview guide was sent to two working classmates and a senior lecturer for review who provided invaluable feedback. The interview guide was reviewed, and minor changes were made to the questions based on the response. 3.7.4 Pilot study Before starting the main data collection, a pilot study was conducted by approaching three undergraduate nursing students from the same institution who met the inclusion criteria. Their information is not part of the main study. The pilot study was conducted to test the feasibility of the study to identify any possible shortcomings in the study which can be corrected and adjusted prior to the main study (van Teijlingen & Hundley, 2002; Malmqvist et al., 2019). The pilot study assisted the researcher to know such hindrances as well as network problems for the area since it could prevent the process of data collection to work smoothly. Further to this, the pilot study gave this researcher an opportunity to practice interview skills in an online environment. According to Brink et al. (2018) the costs can be avoided during the actual study due to the pilot study and it really showed that it was worth doing the pilot study. 18 3.7.5 Theoretical data saturation Saunders et al. (2018) describe the term data saturation as commonly taken to indicate that, on the basis of the data that has been collected or analysed hitherto, that further data collection and/or analysis are unnecessary. They further suggested that theoretical data saturation is a point in the data collection and analysis where if you proceed, you do not learn more about the topic under study. In other words, if the collected data keeps on repeating on what has been said before, it means that there is no longer new information that is coming through. 3.8 Data Analysis The data analysis started immediately after the first interview was conducted. Data collected was transcribed verbatim and was analysed using thematic analysis. Thematic data analysis focuses on identifying and describing implicit and explicit ideas present in a particular qualitative data and representing them as themes (Guest et al., 2012). There are several variations in how thematic data analysis is conducted (Maguire et al., 2017). The researcher followed the six steps approach that is outlined by Braun and Clarke (2006). 3.8.1 Familiarisation with data During this phase, the researcher familiarised herself with the collected data by scrutinising the collected data and to make the sense of the gathered information. To achieve this, the researcher read and re-read the transcripts of the 13 interviews that represented the diversity of experiences. 3.8.2 Generating initial codes During familiarisation, codes were generated to assist in organising data relative to each code. The first cycle of coding was applied to the transcripts from the first ten interviews that were conducted. The initial cycle codes were purely descriptive in nature. The second cycle coding created higher order analytic codes from the descriptive codes, which was followed by the first cycle coding. Through clustering, the higher order analytic codes were evolved into encompassing themes and subthemes. Overarching themes and subthemes were renamed to make them more compatible with the research topic. (Andersson et al., 2012). The generated codes are given in Chapter 4. 19 3.8.3 Searching for themes During this phase, the researcher sorted the codes that were generated into meaningful themes bearing in mind that not all codes could fit together into a theme. In this study, all codes that were generated were used. The researcher used matrix coding, comparison charts, and organizational charts to undertake thematic synthesis, which included within-case and cross- case comparisons. The researcher was able to find linkages between the subthemes thanks to the thematic synthesis. The thematic synthesis allowed the researcher to discover relationships between the subthemes. During this phase, the researcher named all the themes and gave them a meaningful description and highlighted what was interesting under the theme. If the themes were not making sense, they were refined until they were clear. 3.8.4 Reviewing themes During this phase, the generated themes were reviewed thoroughly. The code-theme relationship was thoroughly analysed to see if there were any misfits or to see if they overlap. The aim was to only remain with themes that are distinct and clearly identifiable. 3.8.5 Defining and naming themes Themes that are making a meaningful contribution to the data at hand were carried forward to produce and be arranged in a coherent manner to produce the final report addressing the topic of the study, the objectives, and the research questions. The researcher compared the themes’ description to the collected data to make sure there was correlation. 3.8.6 Report writing After obtaining the full set of themes, the researcher re-read the interview transcripts to identify data extracts that demonstrate prevalence of the identified themes. The researcher also wrote a narrative of the findings, emphasising the coherence of the identified themes, the data extracts, and the narratives. 3.9 Measures to Promote Quality and Trustworthiness According to Lincoln and Guba (1985), trustworthiness is the term that is used to assess the validity of the information as it measures the objectivity of the outcome to avoid the appearance of the results having come from the researcher and not the interviewees. For the confirmation of trustworthiness to pass the test, all four criterions; namely credibility, transferability, 20 dependability, and confirmability must be put to the test as per Shenton (2004) and Gunawan (2015). These criteria, according to Shenton (2004), must be met for a qualitative research study to be academically sound and compelling. As a result, these approaches of determining trustworthiness were used in this study. 3.9.1 Credibility According to Setati and Nkosi (2017), credibility is defined as "any efforts that raise the possibility of credible findings being produced in order to assure credibility." Checking the saturation of the data, peer debriefing, and member checking were all employed in this study (Moon et al., 2016). In terms of peer-debriefing, the researcher asked a fellow master’s student to review the research design, to anonymise interview transcripts and the themes uncovered in the study. This was done to verify that the researcher’s interpretation of the findings was consistent to the collected data. For member checking, the researcher asked the participants to verify if the themes developed represented the ideas that they wanted to convey in the interviews. 3.9.2 Transferability It can be summarised from Shenton (2004) and Gunawan’s (2015) study that transferability is the extent through which the research findings can be generalised and applied or transferred to other similar scenarios or settings. This was checked to see if the findings can be applied to other nursing students in similar setting of learning. Although the findings of the study could not be generalised, the researcher provided a thick description of the study’s settings, participants and the research design that was used (Moon et al., 2016). This would enable readers to judge for themselves if the findings of this study would be applicable to their contexts. 3.9.3 Dependability Since this report is for qualification, the issue of dependability can be demonstrated by the fact that it has undergone extensive review by the supervisor. The revisions will formulate part of the audit trail. 21 3.9.4 Confirmability The researcher used a reflective journal (an aide-memoir) to document everything and kept all manuscripts used. The memoire was used so that the researcher can reflect on what has been written and kept on reviewing it so that only thoughts of the participants reflect in the final findings and not from the researcher. This helped the researcher to remain objective. These will be kept for five years to ensure an audit trail. 3.10 Ethical Considerations This research involved student nurses and the researcher obtained authorisation from the ethics committee. The guidelines fulfilled the principles as outlined in the book by Easterby-Smith et al. (2012). They outlined ethical principles that should be met, including ensuring that no harm is done to research participants, respecting the dignity of research participants, obtaining informed consent from research participants, protecting research subjects' privacy, ensuring the confidentiality of research data, protecting the anonymity of individuals or organizations, and avoiding manipulation about the nature or goals of the research. In order to satisfy these guidelines, the following was used as per the University of the Witwatersrand’s guidelines: • Consent from the participants to participate in the interview was obtained (see Annexure B). • Consent from the participants was obtained to be audio recorded (see Annexure C). Participants were also given information emails pertaining to the study. • Permission was received from the Head of the Nursing Department and the University registrar to conduct research on students (see Annexure D). Responses from the Head of Department and the Deputy University Registrar are included in the Annex. • The University of the Witwatersrand Human Research Ethics Committee (Medical) gave their approval (see Annexure E). • The participants were volunteers, and they were reminded that they might withdraw their interest at any time if they were uncomfortable with the interview. The participants were told that if they opted out in the middle of the proceeding, the data collected up to that point would still be incorporated in the analysis. • Before the interview began, all participants were told verbally of the objectives of the study and they all signed the consent of the study. They were also told that if they were 22 uncomfortable with any of the questions, the researcher was going to skip and move on to the next question. Each participant was asked if they were comfortable to have the conversation recorded as per consent form • The study was of minimal ethical risk and the foreseen minimal risk was minimal comfort due to questions. No difficult questions that would traumatise participant were asked. None of the anticipated ethical risk events happened. 3.11 Summary In this chapter, qualitative research design using semi-structured interviews for data collection were discussed as it was perceived to be the appropriate approach. Other elements discussed and addressed were the sample preparations, data analysis and ethical issues. Chapter 4 discusses findings based on the collected data. 23 4 CHAPTER 4: FINDINGS AND DISCUSSIONS 4.1 Introduction In the previous chapter, the methodology that was followed in conducting this study was discussed. In this chapter the findings and interpretation of the data will be discussed and presented. 4.2 Findings and Discussions from the Study Thematic analysis of the interview transcripts resulted in the identification of three main themes namely: careers after graduation, support for career progression, and barriers to career progression. These themes which highlight nursing students’ perceptions of crucial aspects of career progression and their underlying codes are presented in Table 4.1 below. They are explored further in the sections below. Table 4-1: Themes and their underlying codes that emerged after the theming analysis stage Theme Sub-themes Codes 1 Career opportunities after graduation Signs of career progression Increased responsibility Further studies – and become APN Signs of career stagnation Lack of job satisfaction Lack of independent practice Migrate Change of career No movement in career 2 Support for career progression Positive support or lack of it Further studies Work incentives Recognition Good working conditions Permanent job offers Policies and regulations Ability to work independently 3 Barriers to career progression Causes of lack of career progression and solutions Lack of training Temp staff / relief staff job offers Lack of information Lack of support and resources Poor working condition 4.3 Theme 1: Career Opportunities after Graduation The nursing students believed that once they started working after graduation, they would be able to see if their careers were progressing or not. The general feeling was that there are signs 24 that one can pick up which would alert a person to the viability of one’s career in nursing. The analysis revealed two categories of signs, signs of career progress and signs of career stagnation and these two became sub-themes. Therefore, this theme covers two sub-themes, namely: signs of career progression and career stagnation. 4.3.1 Sub-theme 1.1: Signs of career progression Under this theme, there were two codes that were identified which were: (i) increased responsibility and (ii) further studies and (iii) become an advanced practice nurse (APN) or advanced nurse/midwife specialist. These were the two codes that were chosen based on the definition found in section 1.7 of career progression that it includes more responsibilities and attainment of additional qualifications. Codes that were identified from the interviews are shown in Table 4.1 above and ranges from a level of responsibility to response and to perceived stagnation. As for increased levels of responsibility, participant 1 during the interview, said that: … having a business or some top of a service where you say that I have got 20 nurses or 5 nurses and we go to these people’s houses and we monitor them, we help them, it only looks like a community nurse but it’s more of a specialty you know full specific diseases … The second code that was developed, as earlier mentioned, was further studies – and become an APN. Most of the participants suggested that increasing autonomy as reflecting in being able to work independently is a good indicator of a career on the rise. Participant 1 explained the importance of being able to work independently to the realisation of her potential as a nurse. … I want to stay in a rural area with old people so having someone who works independently as nurse practitioner you will be able to help other people with basic care needs, when you don’t have capacity there are other people that you can refer to so for me that’ really something that I would really have loved to pursue … 4.3.2 Sub-theme 1.2: Signs of career stagnation This sub-theme has five codes, namely: (i) lack of job satisfaction, (ii) lack of independent practice, (iii) migrate, (iv) change of career and (v) no movement in career as can be seen in Table 4.1 above. The reverse of career progression is career stagnation i.e., this means that one 25 does not see any progress in their career at all. The participants were able to identify that if they see the mentioned signs under the codes, one will know that nothing is moving in their career. It is worth noting that although the nursing students highlighted the lack of a salary increase as a sign of career stagnation, however, they did not mention salary increase as an indicator of career progression. Perhaps this is a reflection of the findings of Ryan (2019) that showed that most nursing students who chose nursing were not motivated by money but rather by the desire to help people. Participant 1 expressed the stagnation in terms of what prevents someone from progressing in the following manner: …yeah, it can be a barrier in that way, unlike if they allow me to work with them and give me time to progress with my education, that would help me achieve my career plans…. and I see barriers in terms of opportunities to further the studies, because I am interested in certain fields that I will have to move out of the country for. Despite this, it is clear from the findings that the students viewed the lack of salary increases as a sign of career stagnation. Participant 8 explained the association between inadequate salary increases and nurses leaving the profession. … They can do better hey, they can increase salary and make salary nice because some people are leaving nursing too because of salary is not that great hey. It could be motivating and making sure that they take something … Inadequate renumeration increases were not the only indicator of perceived career stagnation. The nursing students associated the lack of time for other activities such as time for further studies and family responsibilities as an indicator of career stagnation. It seems that the students understood that early in their careers, they would have to devote more time to their work but as they progressed, they would be rewarded by having more time to attend to other pursuits. One participant, participant 7, elucidated the perceived link between time-off for further studies and career progression. … If they can allow me to work with them and give me time to progress with my education, that would help me to achieve the career plans … Another student mentioned that not being given time off for further studies would be frustrating. 26 … Placed at work environment that doesn’t really allow me to study or there is not much time in everything so that’s when I have to make decision of working temporary as opposed to full-time … It is evident form the interviews that students associated being given time off for further studies as either evidence of career progression or as its antecedent. Perhaps, this is a reflection of the qualification linked structure of nursing registration. The students might have also seen during their clinical placement that nurses with higher qualifications had higher positions and more autonomy. For example, most senior nursing managers have a minimum of a first degree (McKenna et al. 2010). Some participants mentioned the issue of international migration if they don’t progress or wanting to change career if they see that they are meeting challenges in their career. Participant 9 said that: … I think if it gets to a point where I am not getting a job then migration will be the only option left because it’s not like nursing is not in demand under in other places… 4.4 Theme 2: Support for Career Progression This theme addresses codes related to support participants which are viewed as important facilitators in career progression but also what would happen if these support structures were not in place. In this theme, participants’ perception is that there should be support rendered for one to advance in their career. There was one sub-theme that came out of this theme, namely: positive support or a lack of it 4.4.1 Positive support or lack of it This sub-theme has six codes, namely: (i) work incentives, (ii) recognition, (iii) good working conditions, (iv) permanent job offers, (v) policies and regulations and (vi) ability to work independently as can be seen in Table 4.1 above. The participants suggested that having a permanent job is crucial for career progression. Having a permanent job enables one to grow because you have access to company funded training, and more access to career support. On the other hand, if you are on a short-term contract, or locum, then your relationship with your employer is transactional. Participant 8 explained that if you are permanently employed, you don’t have always to be thinking of looking for a job again. 27 … They should also try accommodating that they get permanent employment or something that is more long term rather than after community service you are back looking for the job again, that would really help if the employer can do that … Aligned with this issue of having a permanent job is a need for good working conditions. Participant 10 explained that the employers such as the Department of Health, need to devote their resources to the betterment of their employees. … They should use resources for the betterment of the employees in terms of salary increment to prevent the nurse’s sour attitude towards Department of health … Participant 6 added: … I think employers should be good role model to your employees by giving positive feedback … Lastly, the participants expressed the need for information for different career paths should be made readily available through career guidance either at the university or places of work. Participant 10 elaborates: … The universities should clearly indicate what they offer, not necessarily just nursing but actual category like dispensary type of nursing courses. Instead of just using colleague informants, they should actually have proper advertisement with enough information on where and when to find such information … The participants did not indicate what to do if their career is progressing well. However, most of the participants suggested that they would take some action in response to career stagnation. Some indicated that they would continue with further studies. It must be noted that pursuing further studies was not only in response to perceived career stagnation but was generally desired by the student nurses. There seemed to be a general consensus that having a postgraduate qualification in nursing is a good thing. For example, participant 7, clearly stated that they want to have a master’s degree if given a chance. As quoted below: … I gonna continue studying by getting my master’s in education and management because I wanna help other people like I wanna want to advise the nurses if I can put that way … 28 It appears that the desire for further qualification is influenced by the desire to work independently. It seems that the participants did not know that according to the Nursing Act, Nursing Practitioners are independent and autonomous. Participant 1 mentioned that it is preferable to work as a midwife because they have some independence: … I think when you are a degree nurse you have the knowledge and have capacity to be really a much more supportive person than somebody who do basic things, you can really do so much because in this country we have midwives that work independently although I know that they struggle with having back up gynaecologist too or willing to. If something goes wrong call me … The study found that participants would be contemplating migrating or leaving nursing for other professions if they don’t find job opportunities if South Africa. For instance, participant 8 earlier suggested that people are leaving nursing because of the lack of salary increases. Participant 10 extends this narrative and suggests that nurses might migrate overseas. … I would consider working here if working condition improves, furthermore the working environment should be as great as overseas, always innovative in cases where you have limited resources, thinking on spot, and using what is available to progress with the work … This study collaborates Bidwell (2017) and Oosthuizen’s (2007) findings that most South African nurses who migrate overseas, do so to find work after becoming frustrated by the lack of work incentives or after not finding any headway in career progression. 4.5 Theme 3: Barriers to Career Progression The third theme overlaps a bit with the lack of support mentioned in the second theme, however, additional codes fit naturally into this theme as listed in Table 4.1 above. The participants perceived that there are barriers to career progression. There was one sub-theme that came out of this, namely causes of lack of career progression and solutions. For lack of information, participant 4 expresses it as follows: …Even next year with community service, I don’t know if am actually going to be placed in Gauteng province… 29 Participant 9 expressed expected support from the employers if one wants to progress with training as follows: …I think they need to understand that sometimes, that people want to study further so people need so in such cases so people need to be allowed to actually study further we do understand that at some point there may be a shortage of stuff… As for support, it is interesting to note that participants not only expected support from places of work but also from family members or from peers as expressed by participant 12 below: …I think a few things, obviously to have that support is very important, from my family, my peers, the people who immediately surround me… 4.5.1 Causes of lack of career progression and solutions This sub-theme has five codes, namely: (i) lack of training, (ii) temp staff / relief staff job offers, (iii) lack of information, (iv) lack of support and resource and (v) poor working conditions as can be seen in Table 4.1 above. The participants had a lot to say about contextual factors that might hinder their career progress in nursing. They spoke of things that are in the community at large and in the various workplaces. Participant 6 suggested that communities must be taught to support nurses at the very least not to spread negative things about the nursing profession as this might be demotivating to those who want to join the profession as well as practicing nurses. This was captured in the following quote: … So many times, we read negative things about nurses which makes nurses backward instead of progressing. I think it’s very important to teach other people on what nurses do because they think nurses are there for bed pan only to change people’s perception towards nurses … In addition, the participants spoke of the need for policies that would allow nurses to work independently and have more autonomy. Participant 7 articulated this need for policy change. … If they can improve policies by allowing nurses to work independently. That they are not under anyone and that they are able to practice independently … 30 The participants spoke of the need for nurses to be incentivised by minimising the workload that they have. This also aligns with strategies to fill vacancies as the need for this is shown by the long queues that are prevalent in most clinics and hospitals. Student 7 elaborates: … I think they should create job vacancies so that the unemployed nurses would work because in healthcare facilities, there are long queues that reveals that its sign that nurses are few which gives burden to other nurses too … 4.6 Discussion of the Findings The findings from the study indicated that there is a clear understanding of the student nurses under the topic of progression. The students were able to know that there are opportunities that are there after graduation, that there is support if one wants to progress in their chosen path but also that there are barriers that would prevent one from progressing in their chosen career path. Moran et al. (2011) summarised that progression is about career success and that is not only about material accomplishments (objective) but is also subjective i.e., taking into consideration personal preference such as reduced working hours. Their research was done on career progression of nurse executives in Australia. They further said that career progression means different things to different people, what one considers as a successful career may be attributed to personal ambitions. This is also what was observed in this research that the participants displayed both subjective and objective understanding of career progression. It’s no secret that there is a shortage of nurses out there. Every effort has to be made to return as many nurses as possible to the profession. Eley et al. (2013) discusses that career progression in nursing affects turnover with many nurses thinking of or actually doing a career switch because of the lack of progression. Their research was on career progression of Queensland nurses in Australia. The researcher also observed from the participants in this study that if they do not see development, they may consider changing occupations. Another factor observed in the research by Eley et al. (2013) was that nurses who go for further studies were satisfied with their career progression and career prospects than those who did not. This is also one of the areas that was clearly mentioned in this research that the perception of most participants highlighted further studies as one of the supports they would need to have to progress in their careers. 31 According to Sheikhi et al. (2016), nurses typically consider career advancement and promotion after accumulating knowledge and technical skills. Their research was on the skills required for career advancement of Iranian nurses. This corresponds to the nurses' perception in this study that they are considering career advancement soon after graduation. According to Sheikhi et al. (2016)'s research, staff promotion inspires people and helps them establish a sense of worth. They also indicated that when nurses grow in their careers, they feel a stronger sense of commitment and responsibility for their work. The second theme delt with was support for career progression. Obviously, everyone would want to progress in their careers at some point. It makes sense to want to know available career paths after graduation as well as what it takes to progress in the chosen path. For one to advance in the ladder of progression, there are so many avenues that can be considered. People advance in their career either based on experience or competencies after acquiring a certain skill set through promotions or additional education (Sheikhi et al., 2016). Sheikhi et al., (2016) mentioned that the entry point to most nursing jobs is the attainment of technical competency and afterwards, the promotion of nurses depends on their technical, interpersonal, and organizational skills plus one’s performance from the previous assignment among other requirements. Each level that one attains, there are different requirements as there is no one size fits all kind of requirements. These are some of the things that participants might wish to know before they get their hopes up. Their perception is mainly on the perceived support that they wish to be given to progress in their career. Their perception is based on what a qualified nurse would want i.e., to have in the form of company support and not what an employer would want so that it is balanced. This in itself is not wrong as the impact of work support has proven to stimulate qualified nurses to offer job satisfaction and also to help with staff retention (Yang, et al., 2015). Yang, et al., 2015 explored the linkage between work support and organisation career growth of Chinese nurses against the turnover. The final theme is all about barriers to career progression. The findings of the perception of the participants in this case are in line with what is found in literature. In the article by Eley et al. (2013), it was found that there was a lack of support to advance knowledge; a lack of opportunities for promotion; a number of career options; and costs associated with advancement were the barriers to career progression. In this article, it is also found that nurses were thinking of switching careers because of lack of advancement in their careers. 32 This research has highlighted the perception of student nurses to career progression opportunities which were discussed under three themes, namely, a career after graduation which shows their understanding of career prospects after graduation, support for career progression which in their perception is what is needed for one to easily advance in their career and barriers to career progression which are factors that would prohibit one to progress well in their chosen career path. Since the information gathered in this research came from students, the results can be used to draft appropriate interventions. The researcher has suggested some of the interventions under the recommendations section that can be found below. 4.7 Summary Based on the definition of progression highlighted under the discussion above, this chapter was laid progressively to indicate that after graduation, there are potential career opportunities that one could venture into and that there are tell-tale signs of career progress. Similarly, there are tell-tale signs of career stagnation that would indicate no movement. Besides this, there are some employees who would have loved the companies to provide the means that would enable them to easily progress in their careers. Conversely, there are barriers that would prevent one from moving forward to the next level in their career pursuits. The perception of students on career progression showed that they are aware of the career opportunities and career progressions that lie ahead of them. The only challenge is the flow of information and perceived lack of support for them to make informed choices. 33 5 CHAPTER 5: LIMITATIONS, CONCLUSIONS AND RECOMMENDATIONS 5.1 Introduction This chapter highlights the main conclusions taken from the results, limitations of the research and recommendations for career progression shall be discussed in this chapter. 5.2 Summary of the Main Findings This research wanted to answer the research question: What are the perceptions of student nurses regarding opportunities for career progression in the nursing profession? There were three themes that were generated which were categorised as: (i) Career opportunities after graduation, (ii) Support for career progression and (iii) Barriers to career progression. The following are the main lessons that are learnt from this research: • The participants indicated that signs of career progression are when one is able to see increased responsibility and where one is able to go for further studies that would result in working as an advanced nurse practitioner, where he or she is empowered and working where critical thinking is cherished. • The participants highlighted that when there is career stagnation, there will be no increase in renumeration, there will be a lot of frustration, a lack of independent practice and also when one is not finding employment. • The participants also suggested that there are some environments that would cause one not to progress well with their career such as a lack of support, stringent policies or regulations and a lack of workplace incentives. • Finally, the participants mentioned that for one to progress well, there should be enough support and incentives such as refresher training, or permanent job offers as one cannot plan well if one works for short term contracts as well as good working conditions. 5.3 Limitations of the Study • The researcher used classmates for the review of the interview guide and this may be taken as a limitation in terms of experience. • The researcher had a sample from those who were interviewed during the pandemic period when the nursing education practice was not normal. Students were not placed 34 in the clinical environment and had limited socialisation with other nurses. Further the nurses’ perceptions of their profession might have been different prior to Covid and due to the pandemic, their perceptions might have been influenced. However, this does not mean that the findings are not significant or valuable but rather that the readers should take this into account when considering whether the findings are relevant to their context. • The scope of study limited to data collection to only one institution. It is suggested, therefore, that the study be replicated using a quantitative questionnaire to include as many nursing departments as possible. • Because of the number, second year students were interviewed as part of the population. Their contribution might not be substantial considering their experience. • The researcher was limited in terms of movement and access to full spectrum of questionnaire development rigor because of COVID. This led to, for example, using classmates for review. 5.4 Recommendations of the Study It was the envisioned that this study would provide useful information to the concerned stakeholders to improve the nursing programme by listening to the perceptions of their students regarding career progression that would guide the students to take the right path, sustain motivation, arouse more enthusiasm, and retain them in their chosen career. Therefore, the researcher would like to present the following recommendations as proposed by the participants. Recommendations for Nursing Education • Career guidance – There is a need for the consideration of a personalised career guidance beyond the current setup or normal guidance that should be based on what one wishes to pursue after graduation such as information on wound care nurses etc. • Further, the nurses’ perception of their profession might have been different prior to Covid and due to the pandemic, their perceptions might have been influenced. There is a need for research to cover the influence of the Covid-19 pandemic on nursing education. • Further studies may be directed to the workplace to determine progression opportunities. 35 Recommendations for Nursing Practice • This researcher saw that there is a disconnection between what the policy says about nurses who practice autonomy and what the students perceive as to what is happening on the ground. In view of this, there is a need to bridge the gap between the policy that is found in the Nursing Act and reality. There should be research done on uncovering the extent of this knowledge gap and how to close it. Recommendations for Nursing Research • As it is likely that the Covid-19 pandemic influenced the perceptions of nurses on career progression, there is need for research to be done to cover the perception of nurses’ post Covid-19 pandemic. • There could be research to: o Quantify the number of nurses leaving the profession in South Africa for other professions. o Quantify the number of nurses migrating to other countries because of a lack of progression. o Find correlation between career guidance and the retention of nurses within the profession. o Find an effective career guidance strategy to attract students to the profession. o Find out whether the promotion of speciality training retains nurses in SA or does it enable international migration? 5.5 Conclusion This study highlights opportunities and barriers to career progression as perceived by student nurses. Issues mentioned by participants can help, if interventions are put in place by the Nursing Department and other stakeholders, so as to change the negative mindset that they have. Nurses can benefit in their career with enough resources and good polices for nursing. Support from employers, stakeholders and the education sector are essential for their success. There is need to emphasise the benefits and the challenges of a nursing career in the context of current realities of nursing. Employers and the education sector should explore ways for supporting nurses to progress so as to encourage the retention of nurses within South Africa. 36 The participants were able to mention what career progression is all about, they highlighted the signs of career progression, the hindrances to career progression as well as what they thought are things to consider to promote career progression. 37 6 REFERENCES 1. Abbey, J., Abbey, B., Bridges, P., Elder, R., Lemcke, P., Liddle, J., & Thornton, R. 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