Nursing Proffesion

THE NURSING SHORTAGE: A CASE STUDY OF NURSING STUDENTS’ BELIEFS
AND ATTITUDES TOWARDS VARIOUS MARKETING STRATEGIES DESIGNED
TO RECRUIT ADDITIONAL INDIVIDUALS INTO THE NURSING PROFESSION
by
Carol L. Rewers
A Dissertation Presented in Partial Fulfillment
Of the Requirements for the Degree
Doctor of Philosophy
Capella University
June, 2007
UMI Number: 3264303
Copyright 2007 by
Rewers, Carol L.
All rights reserved.
UMI Microform 3264303

Copyright 2007 by ProQuest Information and Learning Company.
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© Carol L. Rewers, 2007
THE NURSING SHORTAGE: A CASE STUDY OF NURSING STUDENTS’ BELIEFS
AND ATTITUDES TOWARDS VARIOUS MARKETING STRATEGIES DESIGNED
TO RECRUIT ADDITIONAL INDIVIDUALS INTO THE NURSING PROFESSION
by
Carol L. Rewers
has been approved
June 2007
APPROVED:
JOHN KLOCINSKI, Ph.D., Faculty Mentor and Chair
JEAN GORDON, Ph.D., Committee Member
NATHANIEL TYMES, Ph.D., Committee Member
ACCEPTED AND SIGNED:
__________________________________________
JOHN KLOCINSKI, Ph.D.
__________________________________________
Kurt Linberg, Ph.D.
Dean, School of Business & Technology
Abstract
This research study was undertaken to understand several important dimensions
associated with the present nursing shortage, including: the scope, contributory factors,
and, most importantly, identification of marketing strategies that can be used to recruit a
younger, more diversified group of individuals into the nursing profession. A total of 109
members of the Michigan Nursing Student Association (MNSA) participated in this case
study.
The primary research question this study sought to answer is “What marketing
related activities, if any, have influenced nursing students’ decisions to pursue a career in
nursing?” Secondary research questions, included: What type(s) of nursing recruitment
campaigns have students seen, heard, or accessed? What particular individual(s), if any,
have influenced nursing students’ decisions to pursue a career/enroll in a nursing
program. Do student responses to factors that influence their decision to pursue a
career/enroll in a nursing program differ based on age, gender, or ethnicity?
Findings from this exploratory case study suggest differences in the level of
influence that various marketing, societal, and familial items play in regards to students’
decisions to pursue careers in nursing based on gender, race/ethnicity, and age. The most
important lesson learned from this research study is that, what items ultimately influence
a student to pursue a career in nursing, appear to be different, from those marketing
related activities and items designed to initially capture students’ interest in nursing as a
viable career option, and marketing materials that are designed to promote specific
nursing programs.
Dedication
This dissertation is dedicated to my parents who lovingly instilled upon me the value
of hardwork, perseverance, and the importance of an education. To my husband, who
supported and inspired me to continue to pursue my dream throughout the many trials
and tribulations. And to my children, Alexis and Tyler for their relentless patience,
understanding, and willingness to forego some of their important childhood events and
activities that ultimately provided me the opportunity to focus and achieve my life long
dream. Thank you!
iii
Acknowledgments
As with any goal in life, a team effort is required. I would like to acknowledge the
following individual members of my team who have supported me in numerous ways
throughout my journey and have assisted me to realize my dream. First, I would like to
express my sincere appreciation to my mentor, Dr. John Klocinski, who spent many
hours prompting and encouraging me, reviewing my drafts, offering recommendations
and feedback, and for his overall guidance and direction. I would also like to extend a
special thanks to Dr. Jean Gordon and Dr. Nathaniel Tymes for their time and effort in
serving on my dissertation committee and for their willingness to share their knowledge
and expertise.
Additionally, I would like to thank Dr. Bernadette Curry for granting me permission to
modify her survey instrument. Whitney Lewis, President of the Michigan Nursing
Students Association, for her time, effort, and granting me permission to conduct the pilot
test and survey of association members. Kristen Salomonson, Assistant Dean of
Institutional Research and Testing at Ferris State University, for supporting my research
and offering her recommendations regarding web based survey instruments. Amy
Otteson, Research Analyst within the Institutional Research and Testing Center at Ferris
State University, for the many hours she spent in consultation with me over different
aspects of developing and implementing my online survey. And to my brother, Steve
Rewers, for always inquiring, “How’s it going?”
Most of all, I would like to thank my husband, Steve Lyman, who supported,
encouraged, and made many personal sacrifices that enabled me to also achieve my Ph.D.
We did it...Again!
iv
Table of Contents
Acknowledgments iv
List of Tables viii
List of Figures x
CHAPTER 1: INTRODUCTION 1
Introduction to the Problem 1
Industry Overview 4
Background of the Study 6
Nursing Workforce Supply and Demand Forecasts 6
Factors Contributing to the Nursing Shortage 9
Statement of the Problem 12
Purpose of the Study 14
Rationale 14
Research Questions 15
Significance of the Study 16
Definition of Terms 19
Conceptual Framework 22
Assumptions and Limitations 24
Nature of the Study 26
Organization of the Remainder of the Study 26
CHAPTER 2: LITERATURE REVIEW 27
Image of the Nursing Profession 27
v
Students’ perception of nursing as a career 39
Development of Nurse Recruitment Campaign Strategies 45
Key Stakeholder Recommendations 45
Recent Nurse Recruitment Strategies 47
Johnson & Johnson’s Campaign for Nursing’s Future 50
Literature Review Summary 54
CHAPTER 3: METHODOLOGY 56
Introduction 56
Research Design 57
Sample and Population 58
Survey Instrument 60
Data Collection Procedure 62
Data Analysis 64
Validity and Reliability 66
CHAPTER 4: ANALYSIS AND PRESENTATION OF FINDINGS 68
Introduction 68
Data Presentation and Analysis 69
Demographic Analysis 70
Research Question 1 74
vi
CHAPTER 5: SUMMARY, CONCLUSION AND RECOMMENDATIONS 114
Summary 114
Discussion of Research Question 1 117
Conclusion 130
Recommendation 135
REFERENCES 138
APPENDIX A: Web Based Survey Instrument 148
APPENDIX B: Question 11 Write in Comments 154
APPENDIX C: Question 15 Single Item Survey Responses 156
vii
List of Tables
Table 1: Currently in Nursing Program by Type of Nursing Program 70
Table 2: Currently in Nursing Program by Gender 71
Table 3: Gender by Race/Ethnicity 71
Table 4: Gender by Type of Nursing Program 72
Table 5: Age Distribution 72
Table 6: Gender by Age 73
Table 7: Race/Ethnicity 73
Table 8: Race/Ethnicity by Type of Nursing Program 74
Table 9: Level of Influence that Nursing-Related Information/Marketing Activities

had on Student Decision to Pursue a Career/Enroll into a Nursing Program. 76
Table 10: Overall, Cumulative Response Rate to Items Identified as

Either: Influential, Moderately Influential, or Very Influential. 77
Table 11: Comparison of Top 5 Very Influential Marketing Items 79
Table 12: Priority Ranking of Marketing Items 80
Table 13: Overall, Top Five Marking Items 81
Table 14: Student Awareness of Various Marketing Related Campaign Strategies 85
Table 15: Cumulative Awareness of Marketing Item: Personal Contact Category 87
Table 16: Cumulative Awareness of Marketing Item: Visits/Fairs Category 88
Table 17: Cumulative Awareness of Marketing Item: Media Related Category 89
Table 18: Comparison of Media Items Identified as “Not Aware of Use” 90
Table 19: Level of Influence of Family and Friends 91
Table 20: Ordinal Listing of Important Family Members by Gender 93
Table 21: Chi-Square Family/Friends by Gender 95
viii
Table 22: Consolidated Chi-Square Test Statistics for Family/Friends by Gender 96
Table 23: Chi-Square Test Results for Marketing Items 97
Table 24: Consolidated Chi-Square Test Statistics for Marketing Items 98
Table 25: Chi-Square Test Results for Societal Items 99
Table 26: Consolidated Chi-Square Test Statistics for Societal Items 100
Table 27: Chi-Square Statistics for Race/Ethnicity for Relative 103
Table 28: Chi-Square Statistics for Race/Ethnicity Marketing Related Items 104
Table 29: Chi-Square Statistics for Race/Ethnicity’s Societal 105
Table 30: Chi-Square Test Statistics for Race/Ethnicity’s Single Factor 106
Table 31: Chi-Square Statistics for Age Based on Family Member/Friend Responses 108
Table 32: Chi-Square Statistics for Age and Marketing Related Items 109
Table 33: Chi-Square Statistics for Age and Societal Item 111
Table 34: Chi-Square Statistics for Age and Single Items 113
Table 35: Comparison of the Top Five Marketing Items 118
Table 36: Overall, Top 5 Marketing Items Identified as “1st, 2nd, and 3rd Choice 119
Table 37: Top 5 Marketing Strategies Students were “Most Aware of”
and “Influenced By”. 120
Table 38: Listing of the Most Influential Person in Students’ Career Decision 121
Table 39: Summary of Null Hypothesis H1 126
ix
List of Figures
Figure 1: National supply and demand projections for FTE RN’s 9
Figure 2: Continuum of responses to the nursing shortage 23
x
CHAPTER 1. INTRODUCTION
Introduction to the Problem
The nursing profession has historically encountered intermittent problems
recruiting and retaining sufficient numbers of qualified Registered Nurses (R.N.’s) within
their workforce (Janiszewski Goodin, 2003; Ledgister, 2003a; Ledgister, 2003b). A
review of the literature suggests, nursing labor shortages have historically been attributed
to a variety of factors including: economic, workplace, social, and demographic
(Heinrich, 2001; Ledgister, 2003a; Buerhaus et al., 2003). However, recent changes
within the healthcare industry when combined with an outmoded “image” of nursing, and
alternative career options for women has lead to one of the most critical and prolonged
shortages of Registered Nurses in U.S. history (Douglas, Auerbach, & Buerhaus, 2000;
Kany, 2004; Seago, Spetz, Alvarado, Keane, & Grumbach, 2006). The current nursing
shortage, which industry leaders began reporting in 1998, is unusual in the sense that it
has been classified by the federal government as a national security concern (Nelson,
2002).
This research was originally undertaken to understand several important
dimensions associated with the current nursing shortage, including: the scope,
contributory factors, and identification of strategies that could be used to alleviate the
shortage. What has emerged from this exploratory research study is a deeper
understanding of the important role that the “image” of nursing has had, and is continuing
to have, on the present recruitment of future generations of nurses into the profession
(Bridges, 1990; Kalisch & Kalisch, 1987; Kany, 2004).
1
According to Ledgister (2003a), there exist within our society beliefs about the
nursing profession that stems from the early history of nursing in which nursing care was
originally provided by “family members or disreputable women of questionable
backgrounds with little or no training” and is “promulgated today through a number of
media, and tends to misrepresent the working life and responsibilities of the professional
nurse” (p. xi-xii).
Research further suggests these societal beliefs have been capitalized upon and
negatively reinforced by the media during the particular time period when the women’s
movement greatly expanded the number of career options available to women (Kalisch &
Kalisch, 1987; Staiger, Auerbach, & Buerhaus, 2001). The effects from these three
societal factors the negative image of nursing, frequently reinforced by the media, during
and immediately following the women’s movement has resulted in the diminishing
interest of young women in pursuing careers in nursing (Douglas, Auerbach, & Buerhaus,
2000; Kalisch & Kalisch, 1987).
In addition, recent turbulent changes within the healthcare industry forced some
healthcare organizations to adopt cost cutting survival strategies that included the
restructuring and reengineer of nurses’ work. Nurses were continually challenged to do
more with less. Unable to control their work environments, registered nurses became
increasingly disenfranchised with their profession which often led to increase turnover
and premature career exodus of experienced nurses. The combined effect of these societal
and industry factors not only exacerbated the emerging labor shortage, but eventually
culminated into the present nursing crisis.
2
In response, several prominent healthcare organizations have suggested two basic
solutions for resolving the current nursing labor shortage. These basic solutions include
improving nurse recruitment and retention efforts (Kimball & O’Neil, 2002; American
Hospital Association, 2002; Joint Commission on Accreditation of Healthcare
Organization’s, 2002; American Nurses Association, 2002). Although both of these
solutions are equally important, this research will focus solely on recruitment efforts. In
particular, this research will examine the impact that recent collaborative marketing
strategies developed by schools of nursing, hospitals, professional nursing organizations,
and affiliated healthcare partnerships have had on altering the present negative image of
nursing as a less than desirable career. Specifically, this research study has developed
into a descriptive case study to determine what marketing strategies, if any, have been
effective in influencing students’ beliefs, attitudes, and decision’s to pursue a career in
nursing. Results of this research can be used to expand the existing limited body of
knowledge that identify those marketing activities and strategies that are most effective in
recruiting additional individuals into the nursing profession.
The following section provides a brief contextual description of major changes
that have impacted health care organizations during the past several decades and resulting
ramifications these industry changes have had on the current supply and demand for
Registered Nurses. This contextual overview is followed by detailed background
information pertaining to the scope of the nursing shortage, contributory factors, a
statement of the problem, purpose, rationale, research questions, significance, definitions,
conceptual framework, and study assumptions and limitations.
3
Industry Overview
The U.S. healthcare industry has undergone numerous environmental threats and
changes in the past two decades. In the early 1980s, the healthcare industry was fraught
with projections that the need for in-patient health care would plummet. Correspondingly,
cost containment efforts instituted by Medicare, Medicaid, and Health Maintenance
Organizations (HMO’s) shifted the provision of hospital services towards outpatient
settings. It was during this time period that reimbursement for healthcare services
provided by hospitals changed from a retrospective-fee for service to a prospective-
average or fixed cost payment system. In 1983, Medicare implemented the prospective
payment system referred to as Diagnostic Related Groupings (DRG’s). To combat rising
health care costs and encourage operational efficiencies within the healthcare industry;
hospitals were reimbursed based on the average cost of treating patients within a specific
DRG classification, rather than, the actual cost incurred for treating a particular patient.
Hospitals ultimately began losing money on patients that exceeded average DRG length
of stays at a time when operational costs for items such as pharmaceuticals and
technological advances began to skyrocket.
In response to these reimbursement changes and rising costs, hospital mergers,
acquisitions, right sizing, downsizing, redesigning, and, in some cases, closures became
the industry norm throughout the 1990s (Michigan Health & Hospital Association, 2000;
Weinberg, 2003). Still reeling from these turbulent industry changes, demographic
changes within the U.S. population also began to negatively impact healthcare
organizations. As individuals within our society began living longer, the number of
chronic illnesses and severity of these illnesses began placing increasing financial
4
pressures on healthcare organizations and physical and emotional demands on healthcare
workers; in particular, Registered Nurses.
It is well documented that working conditions and job satisfaction for nurses
deteriorated during much of the 1990s (Aiken et al., 2001; Weinberg, 2003; Buerhaus et
al., 2005). During this time period, nursing turnover and career exit rates increased; at a
time, when the number of individuals pursuing careers in the nursing profession
significantly declined (HRSA, 2004).
A review of the literature suggests that healthcare industry leaders began to first
recognize Registered Nurse labor force shortages during 1998. The Bureau of Labor
Statistics has since estimated that by 2010 there will exist within the United States a
deficit of 400,000 licensed Registered Nurses (R.N.). The U.S. Department of Health and
Human Services further predicts that by 2020, the current shortage of Registered Nurses
is projected to reach 1 million nurses; comparable to a nurse vacancy rate of 36% (Dall et
al., 2004).
As noted by Nelson (2002), the federal government has classified the current
nursing shortage as a national security concern. Review of the literature suggests that the
current deficit in the number of nurses available to provide patient care has already begun
to negatively affect patient access and quality of care (Gelinas & Loh, 2004; IOM, 1999;
JCAHO, 2002; Healthgrades, 2003). It has also been suggested that if measures are not
taken to address the current supply of nurses, a serious threat to public safety will be
inevitable (Aiken et al., 2001; Kimball & O’Neil, 2002).
5
Background of the Study
An extensive background literature review was conducted with special emphasis
placed on understanding two important aspects involved with the current nursing labor
shortage; understanding the scope and factors that have influenced the present nursing
shortage. The first aspect, the scope of the nursing shortage, attempts to understand the
federal government’s formula for calculating both the future supply and demand for
Registered Nurses. The second aspect attempts to identify nursing labor force trends or
factors that have contributed to the nursing shortage. Findings from the background
literature review are summarized in the paragraphs below.
Nursing Workforce Supply and Demand Forecasts
The U.S. Department of Health and Human Services, Bureau of Health
Professionals National Center for Health Workforce Analysis utilizes the Registered
Nurse Demand Model (NDM) to estimate the future workforce demand for nurses
(Health Resources and Services Administration, 2002; Fritz, M. 1999; Dall, 2004). The
NDM incorporates elements of both expert testimony and empirical analysis in predicting
the future role of nurses in delivering care.
In forecasting demand, the NDM examines trends in six healthcare delivery
settings: inpatient, outpatient, and emergency departments in general and short-term
hospitals; non-general and long-term hospitals; nursing facilities; and home health
(HRSA, 2002). The NDM also incorporates workload measures into the model.
Measures, such as, inpatient volumes, number of visits by clinical setting, patient
demographics, and staffing intensity are also included in the model. To forecast the future
healthcare demands of the U. S. population, the NDM divides the general population into
6
thirty-two subgroups based on age, sex, and urban or rural location. The model then
compares the demand generated by each of these thirty-two subgroups to current national
per capita healthcare service(s) usage rates based on each of the six delivery settings
described above. The national demand estimates for nurses are then used to develop each
state's NDM forecast (HSRA, 2002).
Precise estimates of the future demand for nurses, based on the NDM model is
difficult to establish. The model utilized by the federal government to estimate future
demand for nurses contains several inherent flaws that call into question the internal and
external validity of the model. The most glaring validity issue consists of using estimates
of future healthcare usage rates in calculating the NDM. An error in accurately
forecasting healthcare usage rates should correspond to an error in predicting future
demand for nurses. Experts unable to develop a more reliable model for predicting future
nurse demands, rely almost exclusively upon the NDM.
Experts also utilize the Nursing Supply Model (NSM) to project the future supply
of nurses’ available (HRSA, 2002). The NSM consist of three relatively simple steps for
calculating the supply of nurses. These three steps include, estimating: (1) nurse
population, (2) current supply of nurses, and (3) full-time and part-time positions reported
by employers. Basically, each of the states submits to the federal government the number
of Registered Nurses in possession of a license to practice nursing within their state on a
given date. This number is referred to as the nurse population. The federal government
then determines the number (supply) of nurses currently practicing within the healthcare
industry. This number includes those nurses currently employed or who have been
7
seeking employment within the profession. The government then utilizes Registered
Nurse vacancy rates, reported by employers, to calculate the NSM (HRSA, 2002).
The U.S. Department of Labor - Bureau of Labor Statistics (BLS) relying upon
the NDM and NSM estimate that by 2010 the United States will have a projected deficit
of 400,000 licensed Registered Nurses (Bureau of Labor Statistics, 2001). According to
the Department of Health and Human Services (DHHS), by 2020 this gap will increase as
the projected deficit of nurses is expected to exceed 1 million (Dall et al., 2004).
Originally, the Bureau of Health Professionals (BHPr) within the Health Resources and
Services Administration (HRSA) estimated the only states that would be unaffected by
the national nursing shortage by 2020 would be Iowa, Kansas, Kentucky, Ohio, and
Vermont. These projections have since been update. The latest projections indicate that
every single state within the United States will be impacted by the nursing labor shortage;
however, the severity will differ by state (Dall et al., 2004).
Figure 1 entitled National Supply and Demand Projections for FTE Registered
Nurses: 2000 to 2020 illustrates this widening gap (Dall et al., 2004). For example,
during 2000, the Bureau of Health Professionals estimated the demand for nurses would
be approximately 2.0 million and the supply 1.89 million; which corresponds to 110,000
full time equivalent (FTE) nurse vacancies (HRSA, 2002).
8
3,000,000
2,500,000
2,000,000
Supply
1,500,000
Demand
1,000,000
500,000
0
2000 2005 2010 2015 2020
Figure 1: National Supply and Demand Projections for FTE Registered Nurses: 2000 to
2020. Source: Department of Health and Human Services, 2004
In 2000, the American Medical Association (AMA) estimated the actual shortage of
nurses had already exceeded those forecasted by either the U.S. Department of Labor -
Bureau of Labor Statistics or the U.S. Department of Health and Human Services -
Bureau of Health Professionals by an estimated 16,000 nurses (AMA, 2002).
Factors Contributing to the Current Nursing Shortage.
The reason supply of Registered Nurses is unable to keep pace with the current
and future demand for nurses has primarily been attributed to the following factors: (1)
traditional image of nursing as being a white, female dominated profession, (2) declining
growth rate in new nurses entering the profession, (3) increase number of nurses leaving
the profession due to dissatisfaction in working conditions and wages, and (4) increase
9
growth in the number of nurses retiring (Seago et al., 2006; Aiken et al., 2002; Heinrich,
2001).
Nursing has historically been recognized as a white, female dominated profession
(Green, 1998). This image of nursing has been corroborated by government labor force
data. According to the U.S. Department of Health and Human Services, there are
approximately 2,915,309 licensed Registered Nurses in the United States (Dall et al.,
2004). In 2004, 94.3 % (or approximately 2,740,390) of all licensed Registered Nurses
were female. An analysis of the Registered Nurse population based on race confirms
there is a disproportionate lack of ethnicity within the nursing profession. According to
the National Sample Survey of Registered Nurses (2004), 88.4% of nurses are White,
4.6% Black, 3.3% Asian or Pacific Islander, 1.8% Hispanic, 0.4 % is American Indian or
Alaskan Native, and 1.5% from two or more racial backgrounds.
The second factor contributing to the nursing shortage has been the steady decline in
the number of young individuals entering the nursing profession during the past several
decades. Some researcher’s suggest the declining interest in nursing careers is attributed
to the negative image of nursing which has, up until recently, been promulgated by the
media and deters women from pursuing careers in nursing, particularly, following the
women’s movement which has allowed women greater access to alternative,
nontraditional career options (Buerhaus et al., 2005; Sax et al., 2004; Staiger et al., 2001;
Douglas et al., 2000; Kalisch & Kalisch, 1987). Evidence of declining interest in nursing
as a career is supported by data collected from the U.S. Department of Health and Human
Services Bureau of Health Professions, National Sample Survey of Registered Nurses
(2004), which shows that in 1980 approximately 40.5% of RNs were under age 35. In
10
2004, the number of RNs under age 35 declined to 16.6% of the Registered Nurse
population. These figures represent a 23.9% decline in young nurses entering the
profession.
A third factor contributing to the current nursing shortage is the increase number
of nurses leaving the profession due to dissatisfaction with working conditions and
wages. Media attention comparable to "Study finds Nurses Dissatisfied" has been
frequently reported on television and in newspapers (CBS, 2001). It is common
knowledge that nurses work in adverse work environments. These adverse working
conditions include: (1) physically and psychologically demanding work, (2) increase
workload, (3) increase patient acuity, (4) mandatory overtime, (5) low pay, (6) increase
exposure to occupational threats of personal violence, and (7) lack of respect and poor
public image (Cohen, 2006; Seago et al., 2006; GAO, 2001; Hart, 2001; U.S. Department
of Health and Human Services, 2000; Irvine & Evans, 1995; and Kalisch & Kalisch,
1987).
The fourth factor contributing to the complexity of the current nursing shortage is the
growth in number of practicing nurses projected to retire. According to the U.S.
Department of Health and Human Services, Bureau of Health Professions National
Sample Survey of Registered Nurses (2004) there has been a steady shift in the nurse
population towards older age groups. According to the Bureau of Health Professionals
(2004) report, the largest group of RNs in 1980 was the 25 to 29 year old age group. In
2004, the age group representing the largest number of nurses was observed in the 45 to
49 year old age group. Registered Nurses, typically, cut back their hours or retire
completely between the ages of 53 to 56 (Thrall, 2005; Sherman, 2006). Currently, the
11
average age of a nurse is 46.8 (HRSA, 2004). By 2020, it is anticipated the majority of
nurses will be in their mid – 50’s, on the verge of retirement with fewer new nurses
entering the profession to “back fill” their positions (Janiszewski Goodin, 2003).
Statement of the Problem
In the past two decades, numerous environmental threats have resulted in changes
within the healthcare industry that have contributed to deteriorating working conditions
and job satisfaction for nurses (Buerhaus et al., 2005; Heinrich, 2001; Aiken et al., 2001).
The once popular image of nursing as a respected, appreciated, and personally rewarding
career option for women has faltered (Ledgister, 2003a; Ledgister, 2003b; Kalisch &
Kalisch, 1987). Presently, nursing is revered as a profession that has endured decades of
organizational abuse in the form of mandatory overtime, increase workload, low pay, and
lack of respect. To make matters worse, since the mid 1960s, nurses have routinely been
depicted by the media in a demeaning and demoralizing manner. The cumulative effects
of these societal and media forces has contributed, in recent decades, to an increase in
nurse turnover and career exit rates that when combined with the decreasing interest by
younger generations of women in nursing careers - has lead to the most critical and
prolonged shortage of Registered Nurses in U.S. history (Kany, 2004; Seago et al., 2006;
Staiger et al., 2001).
In the past, healthcare organizations historically relied upon societal norms which
limited the number of career options available to women to naturally replenish the supply
of nurses available within the workforce. For example, prior to the Women’s Rights
Movement, women were limited to careers in either teaching, secretarial work, or
nursing. Women who expressed an interest in science or medicine, were often directed
12
towards the only career option available to them at that time; nursing. Since the Women’s
Rights Movement, the type of career options available to women has greatly expanded.
Women are now free to choose non-traditional careers; such as, engineer, law, and
medicine. As the number of career options for women have expanded, career interest in
the nursing profession has waned. As observed by Grossman (1989), “the pervasive
image of nursing as a powerless profession with low salaries and poor working
conditions dissuades today’s teenagers who have been described as being more
materialistic and less idealistic than their predecessors…” from pursing careers in nursing
(p.18). The researcher also noted, “…freshmen college students seem less inclined
towards altruistic careers such as nursing and are more interested in high-status
professions…”(Grossman, p.18). Kulp (2001) contends, “…the media offers high school
graduates an image of lives in the high tech, high glamour worlds of information
technology and finance. (Whereas) Nursing careers are routinely portrayed as underpaid,
stressful, demanding, inflexible, and understaffed…” (p. 5).
The combined effect of these societal beliefs and attitudes has led to a paradigm
shift for leaders within the healthcare industry. A paradigm shift away from the past
practice of relying on societal norms that at one time provided a convenient or natural
laborforce supply advantage for recruiting women into the nursing profession; towards a
new paradigm in which healthcare organizations must now actively compete with other
industries and professions to develop and implement marketing strategies designed to
recruit a broader, more diversified group of individuals into the nursing profession.
Results of this exploratory research investigation has revealed there currently
exists a gap within the nursing literature pertaining to what today’s student’s beliefs and
13
attitudes are towards the perceived effectiveness of marketing strategies designed to raise
the public’s awareness of career opportunities within nursing and factors that influence
student decisions to pursue careers in nursing. This research attempts to bridge this gap
by adding to the existing body of knowledge pertaining to what today’s student’s beliefs
and attitudes are towards the perceived effectiveness of various marketing strategies that
may, or may not, have influenced their decision to pursue a career in nursing.
Purpose of the Study
This exploratory research was conducted to 1) understand the scope and main
contributory factors associated with the current nursing shortage, 2) identify key
strategies that have been developed to alleviate the current nursing labor shortage, and 3)
to conduct a case study to understand the impact of marketing influences upon student
perceptions of nursing as a potential career option and decision to enroll in nursing
programs. In particular, this research seeks to understand what type(s) of marketing
activities have most influenced student’s decisions to pursue a career in nursing.
Rationale
Research findings suggest that there exist within most societies a general lack of
public understanding of the role and job responsibilities that should be readily and
positively associated with and promoted by the nursing profession (Hemsley-Brown &
Foskett, 1998). This lack of socio-cultural understanding of the nursing profession has, in
recent decades, lead to a distorted image of nursing as a profession (Buerhaus et al.,
2005). This distorted image of nursing is frequently associated with less than desirable
working conditions that include: long hours, heavy workloads, and low pay (Reilly,
2003). In addition, there exist a public perception that nursing is a vocation; rather than a
14
profession and that there exists a general lack of autonomy, respect, status, and career
mobility (French, Watters, & Matthews, 1994, Stevens & Walker, 1993).
Since 2002, healthcare organizations have begun to adopt aggressive marketing
campaigns in an effort to raise student awareness about careers in nursing. For example,
in February 2002, Johnson & Johnson, Inc. launched a $30 million dollar multiple year,
multi-media, campaign strategy entitled, Campaign for Nursing’s Future. The purpose of
this and similar marketing campaigns is to influence student’s decisions to enroll in
nursing schools. However, limited research exists that recently explore students’ beliefs
and attitudes toward factors that have influenced their decision to pursue careers in
nursing.
This descriptive case study was designed to update and expand the existing body
of knowledge pertaining to factors that influence students’ decisions to pursue careers in
nursing. In particular, this research sought to identify what recent marketing campaign
efforts, if any, have been perceived by students to be effective strategies at improving the
recruitment of younger generations of individuals into nursing programs.
Research Questions
The primary research question this study sought to answer is, (1) What marketing
related activities, if any, have influenced nursing student’s decisions to pursue a career in
nursing? Additional secondary or subsidiary research questions will also be asked of
respondents. These secondary or subsidiary research questions include:
(2) What type(s) of nursing recruitment campaigns have students’ seen, heard, or
accessed?
(3) What particular individual(s), if any, have influenced nursing students’ decisions to
pursue a career/enroll in a nursing program.
15
(4) Do student responses to factors that influence their decision to pursue a career/enroll
in a nursing program differ based on age, gender, or ethnicity?
Significance of the Study
Research conducted by Buerhaus (2003) suggest, recent recruitment strategies
that have been developed to address the present nursing shortage have provided only
temporary, short term, tactical relief for resolving the nursing shortage. These short term
solutions initially relied on recruiting “older, married and foreign-born RNs” to fill
critical nursing vacancies. According to research conducted on behalf of the U.S.
Department of Health and Human Services, Agency for Healthcare Research and Quality
(2004),
The most recent research shows a jump of 100,000 RNs, or 9 percent, in

the hospital RN workforce between 2001 and 2002 because of increased
demand, higher pay, and a weakening economy. However, since almost all
of the increase came from RNs over age 50 who returned to the workforce
and a greater influx of foreign-born RNs, this does not alter the structural
features in the long term: the aging of the nurse population and the
increasing unwillingness of young women to consider nursing as a
profession. (Stanton & Rutherford, p.1)
Additionally, the recruitment of RNs from other countries is inherently operationally,
fiscally, and politically problematic. According to Glabman (2001), the “growing
worldwide shortages of nurses…threatens many countries health systems. A brain drain
of nurses from developing nations immigrating to industrial countries exacerbates an
already bad situation” (p. 14).
Unable to keep pace with demand, healthcare organizations and the nursing
profession have collaborated and adopted aggressive marketing campaign strategies
purposely crafted to expose young students to careers in nursing. The purpose of these
16
multi-media marketing strategies is to raise student awareness about careers in nursing
for the ultimate purpose of influencing student’s decisions to enroll in nursing schools;
thereby, increasing the supply of nurses available within the U.S. laborforce.
Since these marketing campaign strategies have gone into effect, applications into
nursing programs have increased. According to the National League for Nursing (NLN),
baccalaureate, associate, and diploma schools on average reported a 69.7% increase in
the number of nursing school applications during 2004. The American Association of
Colleges of Nursing (AACN) has corroborated these enrollment results; but cautioned,
“…shortage(s) of nursing faculty, funding cuts, inadequate facilities, competition for
students, and a lack of clinical placement opportunities are hampering efforts to attract
and retain more students” (AACN, 2002).
Officials at the American Association of Colleges of Nursing (2002) further
contend, the increase number of nursing school applications signal a positive shift in
recent enrollment trends, but cautiously warn, “…the number of students in the
educational pipeline is still insufficient to meet the projected demand for a million new
and replacement nurses over the next 10 years” (AACN, 2002, p.1).
Recently, the American Association of Colleges of Nursing reported, “…even
though enrollments are up nationally, almost 20 percent of nursing schools experienced
enrollment declines or no growth in 2004. AACN is concerned that a portion of the
reported enrollment growth may reflect only students’ intention to pursue a nursing
degree, rather than an actual increase in the number of students admitted into the nursing
major” (AACN, 2004, p.1).
17
To resolve the present U.S. nursing shortages, researchers have suggested the
underlying root cause of nursing shortages must be recognized, understood, and
addressed. These researchers contend, the underlying cause of most nursing shortages can
be traced to the negative image associated with the nursing profession (Seago, Spetz,
Alvarado, Keane & Grumbach, 2006; Kany, 2004; Buerhaus et al., 2003; Ledgister,
2003a; Heinrich, 2001). In addition, alternative career options and waning interest of
younger, predominately female generations of individuals in nursing careers have only
exacerbated the cyclical nature of registered nurse labor shortages (Buerhaus, 2003).
For example, in 1983, approximately half of the Registered Nurse labor force was
comprised of individuals under age thirty-five. Between 1984 and 2001, recruitment
efforts for RN’s younger than 35 years of age fell 1.4 percent per year and an additional
8.3 percent during 2002 (Buerhaus, 2003). Currently, less than 22 percent of the total
registered nurses practicing within the U.S. are young nurses (Buerhaus, 2004).
If these employment trends continue, the ability of the U.S. healthcare industry to
successfully recruit additional foreign born and older nurses will become more
problematic and eventually decline. In addition, if healthcare industry leaders are not able
to alter the present negative image of nurses and objectively identify, support, and expand
upon strategies that will market the nursing profession as a desirable career to students;
than recent improvements in nursing school enrollment trends will falter and contribute to
the growth of an insufficient supply of nurses in the U.S. workforce.
This case study builds upon, updates, and expands the existing body of
knowledge pertaining to the perceptual opinions and attitudes that students have towards
careers in nursing. In particular, this research seeks to identify what recent marketing
18
efforts, if any, have been perceived by students to be effective strategies at improving the
recruitment of younger generations of individuals into nursing programs.
Failure to identify and adopt marketing strategies that will improve the number of
individuals enrolled in nursing programs will hamper efforts to increase the supply of
registered nurses available, now and in the future, who provide the bulk of patient care
within healthcare organizations. Research further suggests, if the nursing shortage is not
addressed, the minor inconveniences in hospital operations that the public has recently
encountered within some healthcare organizations; could eventually lead, to significant
disruptions in both access and quality of patient care (IOM, 1999; JCAHO, 2002;
Healthgrades, 2003).
Definition of Terms
Contribute: shall mean “to play a significant part in bringing about an end or
result” (Merriam-Webster Dictionary, 2006).
Effective: is defined as “producing a desired effect” (Merriam-Webster
Dictionary, 2006). In this research study, students who respond that television
advertisements, for example, have influenced there decision to pursue a career/enroll into
a nursing program will constitute marketing effectiveness.
Influence: is defined as the “power or capacity of causing an effect in indirect or
intangible ways” (Merriam-Webster Dictionary, 2006).
Marketing: Kotler (2003) defines two types of marketing; social and managerial.
This research will utilize the social definition of marketing which is described as “a
societal process by which individuals and groups obtain what they need and want through
19
creating, offering, and freely exchanging products and services of value with others”
(Kotler, p.9).
Nursing: Nursing has been defined in numerous ways depending upon the
particular historical timeframe or practice setting involved. For example, researchers at
the University of North Carolina have suggested,
The definition of Nursing is always changing. In 1859, Florence

Nightingale, said, “The goal of nursing is to put the patient in the best
condition for nature to act upon him, primarily by altering the
environment.” Many people today still view a nurse’s job as a primary
care taker. But the health field has evolved immensely since 1859. When
Florence Nightingale made her statement, nursing tasks consisted of
housekeeping, meal preparation, and patient hygiene. Today’s nurse does
things that were done by only doctors less than forty years ago; tasks like
taking blood pressure readings, changing dressings, physical
examinations, giving injections, and handling machines and sophisticated
monitors. The responsibilities of a nurse will grow, especially with the
current changes in health care. (University of North Carolina, 2006)
The American Nurses’ Association (2006) has suggested, the nursing professional, be
defined according to the following essential features:
1. Provision of a caring relationship that facilitates health and healing,

2. Attention to the range of human experiences and responses to health and illness
within the physical and social environments,
3. Integration of objective data with knowledge gained from an appreciation of the
patient or group’s subjective experience,
4. Application of scientific knowledge to the processes of diagnosis and treatment
through the use of judgment and critical thinking,
5. Advancement of professional nursing knowledge through scholarly inquiry, and
Influence on social and public policy to promote social justice.
Based on the preceding descriptions, there appears to exist no clearly defined universally
accepted definition of the term nurse. Adding to this definitional confusion, is the fact,
there currently exist three points of career entry for licensed Registered Nurses. These
three points of career entry are described below.
20
1. Associate Degree Nurse (ADN) – a program that requires at least two academic
years of full-time college coursework and awards an associate’s degree in nursing.
2. Diploma Nurse – a hospital based program that requires two to three years of on-
site training after which time a diploma is awarded
3. Bachelor's Degree Nurse (BSN) - a program that requires at least four academic
years of full-time college coursework and awards a bachelor’s degree in nursing.
For the purposes of this research, the American Nurses’ Association (ANA) description
of the term nurse will serve as the conceptual definition. In Nursing’s Agenda For the
Future: A Call to the Nation, the ANA defines a nurse as “the pivotal health care
profession, highly valued for its specialized knowledge, skill and caring in improving the
health status of the public and ensuring safe, effective, quality care” (p.3).
Image of nursing: According to Kalisch & Kalisch (1987), the phrase “image of
nursing” is defined as “the sum of beliefs, ideas, and impressions that people have of
nurses and nursing” (p. 2). The term image is defined as a set of beliefs, ideas, and
impressions a person holds regarding an object (Kotler, 2003).
Stakeholders: Stakeholders can be defined as individuals or groups who can
affect, and are affected by, strategic outcomes (Hitt, Ireland, and Hoskisson, p. 22).
Stereotyping: Stereotyping is a method used by individuals to simplify vast
amounts of information into manageable amounts by drawing generalizations. Robbins
(2003) suggests stereotyping can be best defined as “judging someone on the basis of our
perception of the group to which he or she belongs” (Robbins, p. 128).
Strategy: Harrison & St. John’s (2004) defines strategy as “an organizational plan
of action that is intended to move an organization toward the achievement of its shorter-
21
term goals and, ultimately, toward the achievement of its fundamental purposes” (p.6).
Hitt, Ireland, and Hoskisson (2005) suggest that a particular strategy consists of “an
integrated and coordinated set of commitments and actions designed to exploit core
competencies and gain a competitive advantage (p.7).
Conceptual Framework
This section identifies and elaborates on the conceptual framework that guided
this exploratory research involving the nursing labor shortage. The underlying conceptual
framework used in this research is based on a model originally developed by Kimball and
O’Neil (2002) for the Robert Wood Johnson Foundation entitled, Continuum of
Responses – (to) an Evolving Profession (p.9). The model, illustrated in Figure 2,
identifies four stages that characteristically emerge in response to healthcare industry
actions used to address nursing labor shortages. These four stages include; scramble,
improve, reinvent, and start over. The model suggests that most actions or responses
undertaken to address nursing shortages evolve in a predictable linear fashion over time
(Kimball & O’Neil, p.9).
According to Kimball & O’Neil (2002), once a nursing shortage is recognized,
healthcare industry leaders and key stakeholder groups usually “scramble” to identify the
extent of and reasons for the nursing shortage. During the “scramble” stage, healthcare
industry leaders view nursing personnel as a commodity – dictating hours and working
conditions.
22
Figure 2: Continuum of Responses to the Nursing Shortage. Kimball & O’Neil (2002)
Health Care’s Human Crisis: The American Nursing Shortage, p.9
During the second stage, improvement, collaborating committees are established
to develop strategies that, hopefully, address and alleviate the shortage of nurses. It is
during this second stage that most healthcare industry leaders begin to sincerely
appreciate and recognize the valuable mission critical contributions that nurses provide to
organizations and society. It is during the improvement stage that nurses gain increase
respect and recognition within most health care organizations as internal customers;
verses being viewed as a commodity.
During the third stage, reinvent, nurses are revered as “valuable assets.”
Subsequently, numerous industry and organizational tactics and strategies are
implemented to ensure an adequate supply of nurses’ are available to meet projected
patient care demands. The majority of tactics implemented by organizations during this
phase can be classified into two basic categories or strategies; either the retention or
23
recruitment of nursing staff. For example, tactics that reduce or eliminate mandatory
overtime, establish safe staffing ratios, improve wages and benefits, and provide
mechanisms for the inclusion of nurses in organizational decision-making have been
found to improve the working conditions and overall job satisfaction of nurses (Buerhaus
et al., 2005; Green & Jordan, 2004; and Upenieks, 2005). These tactics can be classified
as retention strategies. Retention strategies are designed to reduce nurse turnover and
career exit rates. Recruitment strategies, on the other hand, are designed to attract new
individuals into the nursing profession.
In the fourth phase, start over, nurses finally reach the professional partnership
stage in which organizational decisions that impact either patient care or working
conditions for nurses are based on the principles of shared governance and which may
eventually lead an organization to pursue magnet status (Green & Jordan, 2004; Porter-
O’Grady, 2003).
Once the supply of nurses is sufficient to meet patient care demands, less
importance is inadvertently placed on supporting nurse recruitment and retention
strategies due to competing organizational threats and priorities (ACHE, 2006). As time
elapses, organizational leaders begin to make decisions based on institutional needs that,
once again, begin to adversely impact nurses. Working conditions steadily deteriorate,
until increase nurse turnover and career exit rates are again observed and associated with
a new nursing shortage - repeating the cyclical nature of registered nurse labor shortages.
Assumptions and Limitations
This research assumes there exists within our society a “negative image” of nurses
that effect students’ decisions to pursue careers in nursing. It is also assumed that
24
strategies can be developed and promoted that can positively influence students decisions
to enroll in nursing programs. The objective of this research is to determine what
particular type(s) of marketing strategy is currently most effective in influencing student
enrollment decisions.
This research utilized a case study design methodology. The most obvious
limitation associated with this particular research design methodology includes the fact
that case studies are not typically generalizable. In addition, the survey instrument
utilized in this case study which was adapted with approval from research originally
conducted by Dr. Bernadette Curry (1994) entitled Societal and marketing influences
upon enrollment into baccalaureate nursing programs was original intended to evaluate
student responses to marketing efforts designed to increase enrollment in only
baccalaureate nursing programs. The reliance solely on baccalaureate nursing programs
was perceived as a research limitation since within the United States there continues to
exist three points of career entry for Registered Nurses: Diploma, Associate Degree, and
Baccalaureate nursing programs.
Subsequently, Dr. Curry’s survey instrument was modified to capture responses
that were more representative and reflective of the greater nursing population.
Adaptations made to Dr. Curry’s original survey instrument may present additional
limitations in that responses to items listed within the survey questions may not be
inclusive of all factors currently influencing students’ decisions to pursue, or not to
pursue, careers in nursing. This research assumes that all students who respond to the
survey questions; will do so, honestly. It is further understood, that the beliefs and
25
attitudes of student respondents that are observed in this case study may not be
representative of students located in other geographical regions of the United States.
Nature of the Study
This exploratory case study provides descriptive data and information. The study
utilizes a web based survey that has been adapted from a pencil and paper survey that was
originally developed by Curry (1992) to understand nursing students’ beliefs and
attitudes towards factors that may have influenced their decision to pursue a career in
nursing. Specifically, the survey was administered to members of the Michigan Nursing
Students Association in an attempt to understand the level of influence that various
marketing strategies have had on students’ decision to enter a career in nursing by
enrolling in a nursing program.
Organization of the Remainder of the Study
Chapter 2 examines the literature pertaining to the theoretical perspective and
importance that “image” has had on the recruitment of individuals into the nursing
profession. The literature review also examines the research involving student
perceptions of nursing as a career and recent marketing strategies designed to alter the
present negative image of nursing as a less than desirable career option.
Chapter 3 describes the design methodology that was used in conducting this
research. Chapter 4 contains the data presentation and analysis. Chapter 5 provides a
discussion of the results and recommendations for future research studies.
26
CHAPTER 2. LITERATURE REVIEW
The two most basic solutions for resolving the current nursing labor shortage
includes improving, concurrently, both recruitment and retention efforts (Cohen, 2006;
Kimball & O’Neil, 2002; American Hospital Association, 2002; Joint Commission on
Accreditation of Healthcare Organization’s, 2002; American Nurses Association, 2002).
This research focuses exclusively on the aspect of recruitment for the purpose of
determining what particular marketing strategies, if any, have been most effective in
influencing students’ beliefs, attitudes, and decisions to pursue a career in nursing. In
order to understanding, assimilate, and analyze the issues related to recruiting students
into the nursing profession, a literature review was undertaken of the following areas: the
image of the nursing profession, student perceptions of nursing as a career, and
examination of recent marketing strategies designed to alter the present negative image of
nursing as a less than desirable career option - to attract a younger, more diversified
workforce.
Image of the Nursing Profession
According to Bridges (1990), the single most important factor impeding the
recruitment of sufficient numbers of individuals into the nursing profession has been the
negative image of nursing. What possible implications could arise from such a negative
image? Kalisch & Kalisch (1987) assert,
…implications of the negative image of nursing and the consequences of a

distorted image of nurses and nursing are serious and far-reaching.
Perhaps one of the most crucial problems is that this poor image affects
the quantity and quality of persons who choose nursing as an occupation.
A public constantly fed a demeaning image of nursing will not perceive
nursing as a desirable profession. This is especially true for young people,
who are very heavy media consumers. (p. 187)
27
Concerns regarding, the image of nursing, is not a new phenomenon. For example, in
1983, the American Academy of Nursing conducted a Delphi Survey of its’ fellowship.
Three areas of critical concern were identified and included, the need to: 1) improve the
public image of nursing, 2) develop public awareness of the unique contributions nursing
makes to healthcare, and 3) create public acceptance of nursing as an independent
profession.
Janiszewski-Goodin (2003) suggests, “Throughout history, stereotypical and
negative portrayals of nurses such as the physician’s handmaiden have continued to
dominate society’s perceptions of the nursing profession” (p. 338). There exists,
according to Ledgister (2003), “A particular view of nursing traditionally held by society
at large (and) stemming from the early history of nursing…” in which nursing care was
originally provided by “family members or disreputable women of questionable
backgrounds with little or no training” and (which) is promulgated today through a
number of media, and tends to misrepresent the working life and responsibilities of the
professional nurse” (p. xi-xii).
According to Ohlen & Segesten (1998), “originally, nursing was viewed as a part
of the female sphere of the family and womanhood, a profession undervalued through the
gender segregation” (p. 723). Ledgister (2003a) observed,
Thus, from the very beginning, nursing was not viewed as an attractive
profession – a perception that has led to recruitment problems lingering on
through the twentieth century. With its submissive and obedient culture,
more suited to the working class female than to society women, it
represented an unattractive working environment especially for those
women not required to be employed. In addition, the women who became
nurses were for the most part from lower classes with little or no social
political influence to make a difference for the profession. (p. xii)
28
Negative societal images of nursing not only exists within the confines of the
United States; but also, transcends other cultures. For example, Foong, Rossiter, and
Chan (1999) interviewed nineteen high school students in Hong Kong regarding their
perceptions of the nursing profession. Research findings suggest, there exist a “clear
ignorance of the roles of nurses” (p. 545). Hong Kong teenagers perceived “that nursing
could be done by anyone without having to be educated or trained”, the “image of
nursing to be poor,” and careers in nursing “far from desirable” (1999). The top ten
reasons identified by study participants for not choosing careers in nursing, include: 1)
want to be a doctor or teacher as the status is higher, 2) low status, 3) wants a good job
for the future, 4) boring and dirty job, 5) low pay, 6) smell in hospital, 7) appearance of
some patients, 8) having to see dead bodies, 9) not caring enough or lacking patience, and
10) simply not interested (Foong, Rossiter, & Chan, p. 546).
French, Watters, & Matthews (1993) conducted semi-structured interviews on
114 Pakistani nurses to understand why the women chose a career in nursing. During the
course of the study, the researchers noted,
Pakistan’s acute shortage of nurses has existed since the country was
founded in 1947 despite actions to improve the status of nursing…nursing
continues to have difficulty attracting sufficient numbers of qualified
applicants and in retaining nurses in the workforce. (French, Watters, &
Matthews, p. 142)
The researchers contend there are multiple factors within the Pakistani culture that
impede women from entering careers in nursing. Two important cultural factors
include: the “low acceptance of a public role for women, and the very nature of
the work (nursing) itself which violates many sociocultural norms governing
29
behaviours of women” within Pakistani culture (French, Watters, & Matthews,
p.141).
Nasrabadi, Lipson, & Emami (2004) research suggest that in some cultures,
“nursing is still striving for acceptance and recognition as a profession (p. 396). The
researchers contend, “In Iran, as in other West and East Asian countries, the image of
nurses has not changed despite advances in nursing practice, education, and research…”
(p.396).
Research conducted by Hallam (2002), in the United Kingdom (UK), also support
the theoretical perspective and importance that “image” has on the nursing profession.
Hallam (2002) observed,
The public image of a profession is an important barometer of the group’s

status in society. Media images play a key role in this respect, projecting
the ideas and values of the group…Images of nurses play a crucial role in
conferring social status on the identity of the profession…Successful
recruitment to any occupational group (in turn) depends on how the group
is valued in society. (p.35)
Current research suggests, that nursing's image is often outdated and incorrect
(Meier, 1999). For example, the public “still see nurses as nice women who empty
bedpans and straighten bed sheets…”or comparable to nurses observed on the television
show "General Hospital" in which nurses are characterized as “spend(ing) most of their
"careers" standing around the telephone, chatting at the nurse's station and saying, "Yes
doctor" when a doctor breezed through the scene” (Meier, p.273).
Researchers contend the four most common stereotypes or mental models
associated with the image of nursing observed in the various forms of media include:
angels of mercy (ministering angles), matronly battleaxes, physician handmaidens, or sex
30
symbols (Salvage, 1982; Bridges, 1990; Kalisch et al., 1982, Kalisch & Kalisch, 1987).
Bridges (1990), for example, describes the ministering angel (angels of mercy) as
compliant, willing, caring, dedicated, selfless, and hardworking. The matronly battleaxe,
on the other hand, is described as an older, overweight, authoritarian nurse who
intimidates younger nurses, physicians, and patients. The image of nurses as physician
handmaidens is frequently characterized as weak, unassertive, submissive, and unskilled.
Nurses have also been portrayed as sex symbols or naughty nurses; depicted by the
media, as always available and sexy. A perfect example of the media abusing and
capitalizing upon the image of nurses as sex symbols can be readily observed in the
1970s television series M*A*S*H which often portrayed nurses; in particular, Hotlips
Houlihan, in demeaning and demoralizing situations.
In the book, The Changing Image of the Nurse, Kalisch & Kalisch (1987)
succinctly captures how the media has taken advantage of the nursing profession by
frequently reinforcing a negative image of nurses to their audience, our society, and
resulting ramifications the media portrayal of these images have had over time on the
nursing profession.
In the majority of media portrayals of nurses from the mid-1960’s to the

present time, an obsession with nurse’s sex lives has dominated all other
thematics elements, and yielded a representation of the nursing profession
which is often blurred and twisted to fit bizarre objectives. In these
portrayals, nurses are depicted as sensual, romantic, hedonistic, frivolous,
irresponsible, and promiscuous. And unfortunately, the more the nurse is
presented as a sex object, the less she is shown being engaged in actual
professional nursing work. (p. 161)
Research involving the image of nursing has been examined according to the
following media modes: motion pictures, prime time television, novels, newspapers, and
31
journals. In the research article, The Image of the Nurse in Motion Pictures, Kalisch &
Kalisch (1982b), evaluated 204 English-speaking motion pictures released between 1930
and 1979 using a content analysis methodological approach. The authors found,
The image of the nursing profession in motion pictures reached its most
positive expression during the 1940’s, actually peaking at the height of
World War II. Since then, a steady erosion of the strong and positive
image of the nursing profession has occurred. A particularly dramatic
decline began in the 1960’s and intensified throughout the 1970’s, as the
nursing profession was denigrated and satirized in many important and
influential films. (Kalisch & Kalisch, p. 606)
Kalisch & Kalisch (1982) further observed the important role that Hollywood films have
on shaping the beliefs of individuals within our society. In particular, the authors
observed,
the media portrayal of nursing certainly…have an impact on the attitudes

of prospective nurses, since the largest proportion of the more than one
billion motion picture admission tickets that are sold each year are
purchased by adolescents. How nurses are being portrayed to a group that
is in the process of making career decisions ought to be a concern of all
nurses. (p. 605)
In the research article, The Nurse as a Sex Object in Motion Pictures 1930 to
1980, Kalisch et al., (1982d), examined 191 motion pictures using content analysis and
Sex Object Index. Of the total 211 nurse roles examined, the researchers found: 27% (57)
of the nurse roles “exhibited little or no characterization of the nurse as a sex object;”
28% (60) of the nurse roles placed “medium emphasis on the nurse as a sex object;” and
45% (94) of the nurse roles included “well developed characterizations of the nurse as a
sex object” (p. 149).
The researchers also observed that nurse characterizations during the 1930 –
1950s seldom included as the “dominant” feature; nurses as sex objects. However, during
32
the 1960 -1970s a significant increase (p<.005) in the Sex Object Index was observed.
For example, the following Sex Object Index variables were found significant: blonde,
attractiveness of her face, voice, figure, body motions, sexual behaviors, grooming, style
of dress, and general behaviors (submissive, vulnerable, feminine, lacking ambition, not
very intelligent) in motion picture portrayals of nurses (Kalisch et al., 1982d).
In The World of Nursing on Prime Time Television, 1950 to 1980 Kalisch,
Kalisch, & Clinton (1982c), utilizing content analysis and the Nurse Character Analysis
Tool, systematically reviewed 320 episodes from 28 different series of shows which aired
during a three decade period on public, prime time television. Research results indicate
the professional work image of nurses reached its’ highest level in 1960. As evidence, the
researchers cited the television show, The Nurses, which aired between 1962 and 1965 on
CBS. The series, according to the researchers, provided the most accurate and positive
portrayal of nurses and contributions that nurses make on behalf of patient care. The
researchers also observed, that “Although more nurses were shown on television in the
1970’s than in any other previous decade, the quality of the projected image fell to an all
time low” (p. 363).
According to Kalisch, Kalisch, & Clinton (1982c), the most common nursing
activities depicted on prime time television during the three decades (1950-1980), in
descending order, included: resource to other health care providers, emotional support for
patients or family, nursing process, administrative, technical care, physical comfort,
menial tasks, expanded role, educational, and scholarly (p. 360).
Kalisch et al. (1982c) concluded, prime time television is the “most pervasive” and
“influential” source of mass media. According to the authors, “80 million U.S. homes
33
have at least one television set, and the average American home uses the television six
hours and 36 minutes a day” (p.358). According to Kalisch, Kalisch, & Clinton (1982),
prime time television represents an important “socializing force" for molding ideas;
further suggesting,
The pervasive impact of the unfavorable portrayal of the nursing

profession on TV not only makes recruitment of future nurses difficult, but
also adversely influences the decision-making process of policy makers
who decide what scarce resources the nursing profession will or will not
have to carry forth its mission to the public. (p.363)
Hereford (2005) explored how baccalaureate-nursing students’ career perceptions
were influenced based on stereotypic images of nurses they observed in the media.
Hereford’s research findings suggest, “fictional images of nursing are harmful to those
individuals who may consider nursing as a career” (p. 187). The researcher’s conclusion
was reached, through in-depth interviews and focus groups with nursing students in the
study which demonstrated the most “persistent stereotypic” image conveyed by the media
was the “sexy or naughty nurse.” The students also reported two newly “emerging”
negative stereotypic images of nurses that include: “dimwitted, lazy nurses” and
“homosexual nurses”.
According to Hereford (2005), the emotional responses of students to the media’s
negative portrayal of nurses varied by gender. For example, male student nurses reported
the following emotions: anger, embarrassment, disappointment, anxiety, humor, and
excitement. In contrast, female student nurses reported the following emotional
responses: anxiety, humor, pride, and excitement (Hereford, p.119).
Hereford observed, that several nursing students reported the media influenced
their perceptions regarding career choice and jobs within nursing. Study subjects also
34
made the salient observation that the newly emerging depiction by the media of male
nurses as homosexual could further deter men, who already perceive nursing as a female
profession, from pursuing a career in nursing. The researcher suggested, that more
“accurate and gender neutral” marketing strategies are needed. According to Hereford,
media images must be based on “real life examples” that show “what the profession of
nursing really does” (p.189).
In the article, An Analysis of the Impact of Authorship on the Image of the Nurse
Presented in Novels, Kalisch & Kalisch (1983) reported using content analysis to
examine 201 novels that were published between 1843 through 1980. The purpose of the
study was to “determine if nurse-authored novels differed from those authored by
physicians or by non-health care providers in the quality of the portrayal of nurses and
nursing” (p. 18). Kalisch & Kalisch (1983) contend,
The values in popular fiction correspond to those in the general culture

because this fiction has a genuine function in the mass society. It
participates in the vital business of creating public images. By embodying
communal values in stereotyped situations and personalities, popular
fiction offers symbolic models of ideal behavior to the members of the
mass society. (p. 18)
Kalisch & Kalisch (1983) research results revealed no significant difference between
nurse and non-nurse authors in terms of the demographic depiction of nurses contained in
novels. Nurse characters were “always female (99%), single (71%), childless (92%),
under 35 years of age (69%), and caucasian (97%)” (p. 19). However, the researchers did
confirm empirically,
Nurse-authored novels depicted nurses as making greater contributions to

the welfare of patients and other persons, being commended more often,
using a greater amount of autonomous judgment, being more nurturant
and empathic, and taking greater satisfaction in their career than any other
35
type of author. Nurse characters developed by nurses also exhibited more
drive, were depicted more powerful and more intelligent, and were shown
in their professional role to a much greater extent. (Kalisch & Kalisch, p.
22)
In 1997 Sigma Theta Tau International, nursing’s honor society, published a
report entitled The Woodhull Study on Nursing and the Media: Health care’s invisible
partner. The Woodhull Study examined 20,000 articles which were contained in 16
different newspapers, magazines, and trade publications during a one month timeframe;
September 1997. Newspapers examined included, for example, USA Today, New York
Times, Chicago Tribune, etc. Magazines sampled, included Business Week, Newsweek,
Time, and US News & World Report. Trade publications included, for example, Modern
Healthcare, Hospitals & Health Network, Healthplan, Business & Health, etc.
Three key research findings emerged from the Woodhull Study’s analysis of the
publications, including the fact: 1) Nurses were only cited 4% of the time in the 2000
health related articles that were identified in the various publications; 2) The few
references to nurses or nursing that did occur were mostly just in passing; and 3) In many
of the stories, nurses and nursing would have been more germane to the story subject
matter than the references selected (p. 9).
The Woodhull Study also identified six (6) strategies for addressing the lack of
nurse inclusion in publications which the study authors commonly refer to as the
“invisibility of nurses”. The strategies, identified by the Woodhull Study, which are most
applicable to this research include:
1. Educate nurses in the use of effective public communication and media

relations models.
36
2. Widely disseminate the findings of the Woodhull Study and replicate
the nursing and the media panels throughout the country as a means to
engage the media and nursing in dialogue.
3. Expand the Woodhull Study model to include a review of how the
broadcast media portray nursing.
4. Using the 1997 Woodhull Study as a benchmark, conduct a follow-up
study to monitor the media and carefully assess the effectiveness of the
above initiatives. (Sigma Theta Tau International, p.13)
Auker (2004), also conducted research involving the image of nursing in printed
media and observed, “there (still) remains an abyss between the reality and what the
discourse in the media is showcasing regarding the (nursing) profession” (p.93). The
researcher utilized two different approaches to examine two types of print media; nursing
journals and U.S. newspapers. Initially, Auker (2004) utilized content analysis to evaluate
30 advertisements contained within three different nursing journals: The American
Journal of Nursing, The Orthopedic Nurse, and Nursing 2003.
The main reason Auker analyzed nursing journals was to determine whether
hospital advertisements that were designed to recruit nurses, mentioned any of the criteria
most commonly associated with “Magnet Hospitals.” Auker, quoting Greene (2003),
noted “The Magnet Hospital Program which recognizes organizations that are preferred
places for nurses to work is quickly moving from an obscure nursing journal subject to
the latest hospital marketing tool” (p. 54). Auker (2004) utilized the following Magnet
Hospital characteristics as the basis for the study’s comparison criteria: strong leaders,
participation in management, autonomy in practicing nursing, flexibility in scheduling,
low nurse/patient ratios, and career advancement opportunities (p.54).
Auker’s research revealed, “Overall the recruitment advertisements in the study
sample did not effectively communicate the Magnet message. In fact, 8 of the 30
37
advertisements did not mention any of the Magnet qualities at all”(p. 57). The vast
majority of hospital advertisements promoted “vacation-like qualities.” The researcher
observed,
These ads are somewhat offensive…as they seem to give nurses little
credit for the critical thinking skills of which they are masters…promoting
the vacation-like qualities of the location suggests that nurses can be
duped into any practice situation, as long as they can get a good tan after
hours … A sound approach to attracting nurses, encouraging prospective
students to choose nursing as a career, and to retain nurses, is for nurses
and hospital administrators to work toward improving nursing situations
so that Magnet qualities are reflected more broadly across the spectrum of
the discipline. In addition, these qualities should be showcased in the
media, in literature used to inform prospective students about nursing, and
in recruitment ads for specific facilities. (Auker, p. 58-59)
Auker (2004) also studied newspapers. The researcher observed, “Newspapers,
read by 60% of Americans, are powerful mechanisms to convey the essence of nursing to
the public” (p.70). Through the process of discourse analysis, which Auker described as
“focusing on the analysis of actual written and spoken texts in an effort to reveal how
both the content and form, or the way that language is expressed, promotes a preferred
reading or understanding of that discourse” (p. 71); the author discovered, that
newspapers or “the press, is not only describing the plight of nurses, it is contributing to
the problem” (p. 83). According to Auker (2004),
Nursing is portrayed by the press as a job that no one wants. Descriptors

of the work evoke images of drudgery and exploitation. The stories are
replete with accounts of long hours, lack of respect, too much
responsibility, and limited support. Pictures are painted of nurses who,
after long shifts of taxing work, are not permitted to go home. Employers
are seen as doing battle for nurses to boost their supply and then watching
them carefully as they threaten to escape the harsh conditions. The
question glares at the public: who would ever want to be a nurse? (p.84)
38
Students’ Perception of Nursing as a Career
Given the negative image associated with the nursing profession, the question
“Who would ever want to be a nurse?” raises a salient point. Researchers have conducted
a number of studies exploring the issue of student’s perceptions of nursing as a career.
For example, Cassells, Redman, & Jackson (1986) surveyed 1804 baccalaureate nursing
students between the years 1984-1985 to determine why the students chose to pursue a
career in nursing. Respondents indicated in descending order of importance the following
reasons for pursing a career in nursing: desire to work in the healthcare field (88.4%),
opportunity to work closely with people (83.3%), availability of jobs in nursing field
(73.7%), diverse positions available in nursing (64.1%), always wanted to be a nurse
(35.4%), opportunity for advancement in nursing positions (33.1%), reputation of nursing
as a professional career (28.7%), nursing skills are marketable (26%), flexibility of hours
(25.1%), good salary (24.8%), scholarship/financial aid available to study nursing (5.7%)
(p. 187).
Grossman, Arnold, Sullivan, Cameron, & Munro (1989), surveyed 300 public and
private high school juniors to determine their perceptions of the nursing profession and
decision to consider a career in nursing. Research results indicated, 17% of the high
school juniors surveyed reported they were “considering” a career in nursing. The high
school students who reported an interest in pursuing nursing as a career had a more
positive view of the profession than respondents who indicated they were not considering
nursing as a career. Female students surveyed had a more favorable opinion of nurses;
than male students. The researchers also observed that a significant relationship existed
between a student having had a nurse as a role model, and the student’s decision to
39
consider a career in nursing (p.21). Based on their findings, Grossman et al., (1989),
concluded, “Now more than ever, nursing has to embark on a large scale public relations
program to improve its negative image because, as this survey indicates, high school
students with low opinions of nursing tend to choose other careers” (p. 21).
Kohler & Edwards (1990) surveyed 306 public high school students’ to
understand students’ perceptions about the education, working conditions, salary, and
status of nurses (p.30). Researcher results indicate that 30% of the respondents classified
nursing as a low status occupation. 70% of the respondents believe nursing is a technical
occupation that takes a considerable amount of money (70%) and knowledge (88%) to
obtain a nursing degree (78%). Of the 306 students surveyed, only 8.6% responded they
were “considering” a career in nursing. Kohler & Edwards (1990) concluded, “Students
perceive nursing education to be too difficult and costly in view of the potential return on
their investment in terms of status or monetary compensation (p. 29). The researchers
also observed the primary source of students’ views towards the nursing profession were
gleamed through the following sources: observing a nursing (33.9%), watching television
(29.5%), knowing a nurse (26.4%), printed media (7.5%), and school (2.7%).
Kersten, Bakewell, & Meyer (1991), surveyed 752 nursing students to determine
what factor(s) influenced their choice of nursing as a career. The motivating factors that
influenced students’ decision to pursue a career in nursing included: nurses (39.9%),
exposure to health care (21.5%), family (18.8%), work experience (16.7%), and
television/media (11.6%). Kersten, et al., (1991) research indicates that nurses serve a
vital function in marketing nursing as a profession and career option. According to the
researchers,
40
Nurses influence an individual’s perception of nursing and subsequently
his/her choice of nursing as a career…every effort to reflect that image as
truthfully and positively as possible…To encourage individuals to enter
the profession would be a way that nurses can help themselves (and the
profession) to maintain steady recruitment of good and qualified
individuals as colleagues. (Kersten et al., p.32)
Mendez & Louis (1991) conducted a comparative survey between two groups of
students; 163 non-nursing and 93 nursing students to determine college students’
opinions of nursing as a career choice. Researcher findings indicate that “only 43.5% of
the non-nursing group (of students) reported being exposed to a nurse role model…(of
which)…64% reported that the nurse role model had no influence on their choice of
nursing as an ideal career” (p. 315). In contrast, 70% of the nursing students reported
exposure to a nursing role model; of which, 60% reported the nurse role model
influenced their choice of careers.
Mendez & Louis (1991) research findings support Grossman et al., (1991) and
Kohler & Edwards (1990) research, that emphasize the important contributions that nurse
role models have on students’ decisions to pursue careers in nursing. Mendez & Louis
(1991) noted,
The nursing shortage is widespread and expected to increase in the coming

years. The recruitment pool is shrinking. The profession must compete
much more intensely than ever before to attract potential nurses….Nurses
need to become positive and highly visible role models in all aspects of
their practice. An intensive public relations campaign with a theme of
“have you taken a look at nursing lately?” is needed to educate the public
about the positive aspects of nursing practice today and into the 21st
century. Nursing must combat the image stressor. (p. 318)
Stevens & Walker (1993) surveyed 641 college-bound high school students to
determine students’ overall knowledge of nursing as a career and reasons why students
either chose or decided not to choose nursing as a career. According to Stevens &
41
Walker, 92.3% of the students surveyed indicated they were not considering nursing as a
career option. The researchers noted, students’ overall knowledge of the nursing
profession was “fairly accurate” in terms of education, wages, and worked hours (p.14).
However, students were not aware that nurses dealt with high-tech equipment (84.1%),
computers (91.8%), directed health programs (85.5%), or held management positions
(81.2%). In addition, only 5.4% of the students felt nurses did important work, was a real
profession (9.9%), believe nursing is a challenging profession (9.4%), or is an important
profession (5.4%). Of the 7.7% of the students considering nursing as a career, the factor
that most influenced their career decision was personal interactions with nurses, followed
by the media. Based on their findings, Stevens & Walker (1993) suggested a dual
approach to recruiting individuals into the nursing profession. This dual approach
includes the responsibility of nurses to act as role models and need to characterize nurses
that are observed in media campaign efforts as “doing important work, being respected,
helping others, and using scientific information” (p.17).
Curry (1994) surveyed 649 nursing students to determine what societal and
marketing factors influenced their decision to pursue a baccalaureate nursing program.
Respondents identified the following societal factors as influencing their decision to
pursue a career in nursing and enrolling in a baccalaureate nursing program: greater
opportunity for career and educational mobility (81%), personal desire for college degree
(80.7%), desire to pursue advanced graduate study (49.8%), status of having
baccalaureate degree in nursing (49.1%), expectation of a higher salary (36.2%),
convenient location of baccalaureate nursing program (31.1%), some limitations for
employment without a degree (27.4%), opportunity to work in non-hospital settings
42
(26.3%), desire for comprehensive liberal arts/scientific background to complement
nursing knowledge (26.1%), and parents’ expectation that you acquire a college degree
(17.3%) (Curry, p.59).
In response to marketing factors that influenced the students’ decision to enroll in
a baccalaureate nursing program, survey respondents indicated the following, in
descending order of importance, as factors influencing their career decision: campus
meeting with nursing dean/representative (18.6%), nursing program brochure (16.1%),
personal contact by student(s) in the program (13.7%), college bulletin/catalogue
(10.9%), open house hosted by nursing program (10%), personal contact by admissions
personnel (9.5%), personal contact by nursing alumni (9.5%), telephone call from nursing
faculty/program representative (9.4%), college view book (6.7%), and letter from nursing
dean (4.6%) (Curry, p.71).
Larsen, McGill, & Palmer (2003) surveyed 495 nursing students to understand
what influenced students’ decisions to become a nurse. The factors that influenced
students’ decision to pursue a career in nursing included: past experience with a loved
one or self being ill and/or hospitalized (71.7%), past health care work experience
(65.6%), family member or friend who was a nurse (65.3), nurse role model (53.3%), and
television/media (21.6). According to Larsen, McGill, & Palmer (2003), the influence of
the media on students’ decisions to become a nurse was “somewhat surprising” and
should not be interpreted as meaning “the nursing profession needs to be less vigilant
about its portrayal in the media (p.172).
Seago, Spetz, Alvarado, Keane, & Grumbach (2006) surveyed 3,253 students in 8
community and 4 state colleges in California that were enrolled in college math and
43
science courses to “assess their perceptions of a career as a nurse in relation to a career as
a physical therapist, high school teacher, or a physician” (p.96). The researchers used the
following job characteristics: good income potential, good job security, prestige and
status, interesting work, work independently, low risk of injury, makes a difference,
flexible hours, not a lot of pressure, and women are better suited to compare the
occupational perceptions of the students. Two thirds of the students agreed that a career
in nursing was interesting, offered good job security, and income potential. However,
nursing was perceived by the college students to be women’s work and a less desirable
career in terms of job independence. The researchers observed,
Healthcare leaders, educators, managers, and recruiters have long

contended that a poor public “image” of the registered nurse contributes to
inadequate numbers of students entering nursing training programs…
(and)…Because of the belief that a poor image is a major organizational
recruitment problem, countless dollars have been spent trying to
rehabilitate the public image of the nurse through media campaigns, job
satisfaction surveys, and various recruitment strategies. (Seago et al., p.97)
Seago, Spetz, Alvarado, Keane, & Grumbach (2006) concluded, “Increasing the
number of nursing school graduates in the United States is a key strategy for
alleviating this nurse shortage” (p. 97). The researchers further suggest, “If one of
the purposes of recruitment is to attract more applicants in the hope that the most
qualified applicants will be admitted and hired, then major marketing and
recruitment efforts may continue to be of value” (p.104).
In summary, the research that has been done to date has primarily focused on
students’ perception of nursing as a career. Few research studies have been conducted to
determine what particular marketing activities are most successful in recruiting students
into the nursing profession. This research attempts to bridge this gap by adding to the
44
existing body of knowledge pertaining to what today’s students beliefs and attitudes are
towards the perceived effectiveness of various marketing strategies that may, or may not,
have influenced their decision to pursue a career in nursing.
Development of Nurse Recruitment Campaign Strategies
As evidenced in the preceding sections, the media has played a pivotal role in
altering the image of nurses and public’s perception of the nursing profession. For
example, during World War I and II, nurses were portrayed by the media as essential to
wartime efforts (Schmidt, 2001). During this time period, nurses were frequently admired
and revered by the media as heroines (Kalisch & Kalisch, 1982b). This positive image of
nurses and nursing has slowly eroded. Since the mid 1960s, the image of nurses’ has been
routinely depicted by the media in a demeaning and demoralizing manner (Kalisch,
Kalisch, & McHugh, 1982; Auker, 2004). A society that has been repeatedly exposed to
negative media images of nurses, particularly during and immediately following the
Women’s Right Movement, will undoubtedly view nursing as an undesirable career and
elect to choose what they perceive is a more desirable career option (Morsch, 2006;
Staiger, Auerbach, & Buerhaus, 2000; Kalisch & Kalisch, 1987).
Key Stakeholder Recommendations
Based on the aforementioned conclusion, several leading healthcare organizations
have responded by highly recommending and encouraging healthcare organizations to
adopt recruitment strategies that alter the present negative image of nurses and nursing
(Kimball & O’Neil, 2002; American Hospital Association, 2002; JCAHO, 2002; ANA,
2002; Sigma Theta Tau International, 1997). For example, in Health Care’s Human
Crisis: The American Nursing Shortage, the Robert Wood Johnson Foundation (2002)
45
suggests the current nursing shortage is quantitatively and qualitatively different from
past shortages and further observed that past solutions will fall short (Kimball & O’Neil,
p.6). The authors also noted that there currently exists a “generation gap.” A gap in
which, younger generations of workers find careers in nursing less appealing. As a result,
healthcare organizations must learn to compete in the “war for talent” with other
industries and professions to develop strategies specifically designed to recruit a younger,
more diversified workforce (Kimball & O’Neil, p. 18).
According to the Robert Wood Johnson Foundation’s report, healthcare
organizations must adopt recruitment strategies that support the following measures: 1)
upgrade the image of nursing, 2) assist the public in understanding the shortage and need
for action, 3) make careers in nursing more appealing to 18 -25 year olds, 4) focus on
recruitment efforts designed to increase the diversity of the nursing workforce, 5) provide
prospective nursing students with better career information, and 6) develop integrative
workforce recruitment and retention strategies (Kimball & O’Neil, p. 6).
In the American Hospital Association (2002) report entitled, In Our Hands: How
Hospital Leaders Can Build a Thriving Workforce the authors expand on the recruitment
strategies mentioned in the preceding report, further suggesting the need to “build
societal support” by “collaborating with others” in order to “broaden the base” or supply
of nurses. In the Joint Commission on Accreditation of Healthcare Organization’s
(JCAHO) report, Health Care at the Crossroads: Strategies for Addressing the Evolving
Nursing Crisis, the authors advocate recruitment strategies that take into consideration
the need to bolster nursing’s educational infrastructure and establish financial incentives
for investing in the nursing profession.
46
In the report entitled, Nursing’s Agenda for the Future: A Call to the Nation, the
American Nurses Association’s (2002) recognized,
…that the skewed image of nurses and nursing, and, perhaps more
fundamentally, the lack of awareness and value for what the nursing
profession contributes in terms of both cost and quality of health care,
were the issues that really needed to be addressed…(Kany, p. 112)
In summary, the Robert Wood Johnson Foundation’s, American Hospital Association’s,
Joint Commission on Accreditation of Healthcare Organization’s, and American Nurses
Association’s reports all emphasize the critical need to develop business strategies that
will alter the present negative image of nurses and nursing if the profession is to compete
in the “war for talent” and successfully recruit additional individuals into the nursing
profession.
Recent Nurse Recruitment Strategies
The development of business strategies specifically designed to promote a more
positive image of the nursing profession as a rewarding, respected, and personally
fulfilling career option for the purpose of increasing the supply of registered nurses
available within our laborforce is a fairly new marketing phenomenon within the
healthcare industry (Greenawalt, 2001). According to Luke, Walston, & Plummer (2005),
Business strategy is a very young field. As a result, not all of the concepts
and approaches to analysis are yet well established or agreed on.
Significantly, the field of healthcare strategy is even less well developed,
arriving in healthcare only in the past decade. Consequently, we have
much to learn about how strategy should be applied in so distinctive and
important an industry as healthcare. (p.3)
For the purposes of this research study, strategy is defined as an “integrated and
coordinated set of commitments and actions designed to exploit core competencies and
gain a competitive advantage” (Hitt, Ireland, & Hoskisson, p.7). The purpose of the
47
strategic management process is to develop a “full set of commitments, decisions, and
actions required for a firm to achieve strategic competitiveness and earn above-average
returns” (Hitt, Ireland, & Hoskisson, p. 5).
In order for healthcare organization’s to carryout their missions’ and achieve the
level of competitive advantage as described in the preceding definitions; sufficient
numbers of highly skilled licensed Registered Nurses, which are healthcare
organization’s front line knowledge workers, must be available in sufficient numbers to
provide patient care 24/7. Failure to recruit sufficient numbers of individuals into the
nursing profession results not only in the disruption of hospital operations; but also,
negatively impacts access and quality of care being provided within these institutions
(Weinberg, 2003; Kimball & O’Neil, 2002).
In the past, healthcare organizations typically relied on local colleges and
universities to independently recruit sufficient numbers of students into nursing programs
to satisfy the local demand for nurses. Graduates of these local nursing programs were in
turn recruited by local healthcare organizations’ via word of mouth, job postings, or local
newspaper advertisements.
As the supply of registered nurses’ began to decrease, healthcare organizations
began adopting more competitive nurse recruitment strategies. For example, many
healthcare organizations began to supplement their traditional methods of local
advertising with more extensive recruitment campaigns that involved a combination of
local, state, regional, and national marketing strategies.
As the nursing shortage became more acute, increase nurse vacancy rates began to
severely affect some healthcare organizations’ abilities to meet patient care needs. As a
48
result, some hospitals began to operationally experience delays in admissions, ambulance
diversions, postponement of elective surgeries, and bed closures due to the lack of
available - Registered Nurses.
These operational issues not only impacted healthcare organizations from a public
relations standpoint; but also, had negative financial ramifications. As a result, healthcare
organizations began to actively seek out and develop more sophisticated and
collaborative recruitment strategies designed to assist colleges and universities recruit
additional individuals into the nursing profession. (Kimmel, 1991).
Sigma Theta Tau International (2006), for example, recommended “implementing
and sustaining a marketing effort that addresses the image of nursing and the recruitment
of qualified students into nursing as a career; and (that) repositions nursing as a highly
versatile profession where young people can learn science and technology, customer
service, critical thinking, and decision-making skills.”
Greenawalt (2001) suggests, “…one of the best ways to improve nursing’s image
as a whole is to combine current recruitment and retention strategies that market nursing”
(p. 27). Greenawalt refers to this marketing technique as “branding”. According to
Greenawalt (2001), healthcare industry leaders should “…step back to evaluate how other
industries (and countries) handle recruitment and retention issues” (p. 26). For example,
recent recruitment efforts within the United Kingdom entitled “Nursing the Future” have
been implemented to promote the following:
[1] To challenge and dispel misconceptions about nursing…

[2] To empower nurses …to publicize what they do.
[3] To encourage nurses…to “sell” or talk up their professions to future
generations.
49
[4] To raise the public voice and profile of nurses…
[5] To encourage more respect for the profession…
(Wallis, p. 14)
Foong, Rossiter, & Chan (1999), further suggest that registered nurses “need to find ways
of publicizing and marketing the positive aspects (of their jobs) with elements of realism
which the general population…could relate to more readily (p. 542).
Johnson & Johnson’s Campaign for Nursing’s Future
One of the most highly publicized national nurse recruitment efforts recently
undertaken within the United States is the Johnson & Johnson’s (J & J) campaign
entitled, Campaign for Nursing’s Future. According to J & J’s Health Care Systems Inc.
2004 Progress Report, the Campaign for Nursing’s Future was launched in February
2002 and is a $30 million dollar multiple year, multi-media campaign strategy designed
to “…creat(e) a positive mood, new momentum, broad goodwill, and growing optimism
among the nursing profession” ( p. 6).
According to the Johnson & Johnson website news release entitled, Nurse
Executives Graduate from Management Education Program Sponsored by J & J and the
Wharton School, the “corporation (J & J) launched a multi-year initiative to work with
nursing leadership to address the nation’s nursing shortage…the efforts and many others
by nursing leadership throughout the country have contributed to major shifts in public
attitudes towards nursing and a turnaround in recruitment into the profession.”
The main purpose of the Johnson & Johnson campaign is to “enhance the image
of the nursing profession, recruit new nurses and nurse educators, and to retain nurses
currently in the system” (p.1). Johnson & Johnson “partnered” with the following
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organizations to promote their marketing campaign: National Student Nurses Association
(NSNAA), the National League for Nursing (NLN), the American Association of
Colleges of Nursing (AACN), the American Nurses Association (ANA), the American
Organization of Nurse Executives (AONE), and Sigma Theta Tau International (p.17).
The Johnson & Johnson’s Campaign for Nursing’s Future utilizes a multifaceted
recruitment campaign strategy that relies on a combination of “elements” to promote the
nursing profession, including:
[1] A national television, print, and web based interactive advertising campaign.
[2] Highly visible public relations & fund raising (student scholarships and grants,
and faculty fellowships) components.
[3] Recruitment materials (brochures, posters, videos, and pins) distributed free of
charge to hospitals, high schools, nursing schools, and nursing organizations.
In addition, Johnson & Johnson has developed a marketing slogan that challenges
individuals to consider careers in nursing. The slogan promotes a new image of nursing,
“Be a Nurse…Join the Ones Who Dare to Care” (J & J Healthcare Systems, Inc. 2002).
The new image of nursing is based on the “careerist” model image of nursing and
emphasizes the following job attributes: “Because I’m a Nurse…I have no limits…I live
my life on my own terms…I am a highly educated professional….that can go
anywhere…I make a difference” (Kalisch & Kalisch, 1982a; J & J Healthcare Systems,
Inc. 2002). According to Kalisch & Kalisch (1982a) the “careerist” model of nursing is
synonymous with “an intelligent, logical, progressive, sophisticated, empathic, and
assertive woman or man who is committed to attaining higher and higher standards of
51
health care for the American Public” (p. 21). J & J’s marketing campaigns show increase
racial and gender diversity among nurses who are represented within their brochures,
posters, and advertisements.
Johnson & Johnson, Inc. has also established and maintains a website solely
devoted to the recruitment of nurses. The website entitled, www.discovernursing.com,
provides individuals with general information on the nursing shortage, career
opportunities in nursing, specific nursing programs, available scholarships, and links to
other important nursing organizations.
The website also promotes and serves as a centralized clearinghouse location for
other creative strategies designed to recruit future nurses. For example, in 2005, J & J’s
Campaign for Nursing’s Future developed the following national television advertising
and nurse recruitment videos: A Nurse’s Touch, Patient Perspectives, Baby Nurse,
Nurse/Jazz, and Recruitment Video which can be ordered free of charge from their
website and used by high school counselors and nursing schools to recruit perspective
students into the nursing profession.
In August 2004, Johnson & Johnson, Inc. also developed “The Nursing Gang” an
interactive web based cartoon featuring four different nursing characters. According to
Smith (2005), “The characters will soon make their television debut in a rhythm and
blues style music video targeting children in grades 4 thru 6…these formative years have
a larger potential to influence career decisions than we may realize” (p.199). The J & J
website also distributes free of charge a 24 page coloring book that can be used by
schools or healthcare organizations to target or actively promote nursing careers amongst
younger children.
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So how effective has recent nurse recruitment strategies, like Johnson &
Johnson’s Campaign for Nursing’s Future, been? According to the University of
California -Los Angeles (UCLA’s) Higher Education Research Institute, which conduct’s
an annual national survey of college freshman, entitled Cooperative Institutional
Research Program (CIRP) “The number of students who have indicated nursing as a
probable career is at a twenty-year high (3.9 percent)…(According to UCLA’s CIRP
survey) there have been steady increases in nursing interest among both men and women
over the last four years…” (Dey et al., p. 2). Can the results of this national survey, CIRP,
which shows an increase in student interest in nursing careers over the last four years; the
timing of which coincides with J & J’s Campaign for Nursing’s Future, be attributed to
any specific marketing strategy or activity?
According to Johnson & Johnson’s, Health Care Systems Inc. 2004 Progress
Report, preliminary results indicate that the Campaign for Nursing’s Future has been
successful at increasing the awareness of students regarding nursing careers. J & J
utilized the following survey indicators to measure and demonstrate how effective their
campaign efforts have been. According to Johnson & Johnson’s, Health Care Systems
Inc. 2004 Progress Report, 46% of young people ages 18-24 recall the advertisements;
24% of the respondents that indicated they were interested in a nursing career reported
the commercials were a factor; 97% of high schools surveyed have used J & J brochures
and materials; 84% of nursing schools that reported using J & J’s campaign materials
reported an increase in nursing school applications and/or enrollment; and more than $5
million has been raised to date for student scholarships, nurse educator fellowships, and
nursing program capacity expansion grants (p. 4).
53
In an effort to objectively determine whether Johnson & Johnson’s nurse
recruitment campaign has been successful, Donelan, Buerhaus, Ulrich, Norman, & Dittus
(2005), surveyed 496 nursing students between April 11 and June 23, 2003. The intent of
the survey was to “measure (the) awareness of (J & J’s) campaign activities, campaign
sponsorship, and the perceived impact of the campaign” (p. 152). The researchers found
that “eight out of ten nursing students” were aware of at least one of J & J’s campaign
activities; 24% of the nursing students named the company on an open-ended question;
and more than 56% identified the company by name from a list of organizations that had
also sponsored television and radio commercials about nursing careers during the past
year” (p. 153). Overall, 81% of the nursing students responded that they had strong
“positive sentiments…that the campaign had a positive impact” on their attitude towards
becoming a nurse” (p. 154).
Literature Review Summary
To counteract the negative image of nurses and nursing that have been frequently
and erroneously portrayed in the media, various stakeholder groups have been working
diligently to develop marketing strategies designed to promote a more positive,
professional, image of the nursing profession. Based on findings from the literature
review, it appears that recent marketing efforts, like Johnson & Johnson’s Inc. national
campaign entitled Campaign for Nursing’s Future, have been successful at recruiting
additional individuals into the nursing laborforce.
However, the lingering question becomes, which marketing efforts or strategies, in
particular, have been most effective in attracting current students into the nursing
profession? As evidenced in the literature review, few research studies have been
54
undertaken that examine nursing students perceptions of the various types of marketing
activities and level of influence that these marketing efforts have had on their decision to
pursue a career in nursing. It is the intent of this study to update and expand the existing,
limited body, of knowledge in this area.
55
CHAPTER 3. METHODOLOGY
Introduction
According to Sackett & Mavor (2004), “good research should begin with
developing a clear statement of the problems to be studied, because the nature of the
policy questions influences and shapes the most appropriate research designs” (p.10). The
stated purpose of this study is to examine the beliefs and attitudes of nursing students’
towards various marketing strategies. The primary research question this study seeks to
answer is,
(1) What marketing related activities, if any, have influenced nursing student’s
decisions to pursue a career in nursing?
Additional secondary or subsidiary research questions were also asked of respondents.
These secondary or subsidiary research questions include:
(2) What type(s) of nursing recruitment campaigns have students seen, heard, or
accessed?
(3) What particular individual(s), if any, have influenced nursing students’

decisions to pursue a career/enroll in a nursing program.
(4) Do student responses to factors that influence their decision to pursue a

Sackett & Mavor (2004) further contend, “While a given research question(s) can be
studied using a variety of approaches and techniques, some research designs in our view
are more promising than others for particular research questions” (p. 10). The following
sections of this chapter describe the research design methodology, sample, instrument,
data collection, data analysis, and validity and reliability testing that has been selected in
order to conduct this research and answer the research questions.
56
Research Design
According to Cooper and Schindler (2003), research design is the “blueprint for
the collection, measurement, and analysis of data. It aids the scientist in the allocation of
his limited resources by posing crucial choices” (p.146). The research design
methodology or “blueprint” that was utilized for conducting this research is based on a
case study approach. According to Marshall & Rossman (1999), “studies focusing on
society and culture, whether a group, a program, or an organization, typically espouse
some form of case study as an overall strategy” (p. 61). O’Sullivan, Rassel, & Berner
(2003) further suggest, case studies provide researchers with the ability to “examine in
some depth persons, decisions, programs or other entities that have a unique
characteristic of interest” (p. 39). Case studies are the preferred research design method if
one wants to learn the details about how or why something happened (O’Sullivan et al.,
p.39).
A case study approach was purposely selected as the research design
methodology for this study because it allowed the researcher to examine in detail the
beliefs and attitudes of a particular group of students, Michigan Nursing Students’
Association, about their perceptions regarding recent marketing efforts that may have
influenced their decision to enroll in a nursing program/pursue a career in nursing. In
particular, this case study utilized a web based survey as the vehicle for data collection.
As observed by Huberman & Miles (2002), the “terms qualitative and case study
are often used interchangeably, case study research (however) can involve qualitative
data only, quantitative only, or both” (p.14). This case study utilized quantitative,
specifically, a combination of descriptive and inferential statistics to examine the beliefs
57
and attitudes of nursing students’ towards various marketing strategies to determine what
particular factor(s), if any, have influenced their decision to pursue a career in nursing.
Sample and Population
Copper & Schindler (2003) define the term population as “the total collection of
elements about which we wish to make some inference” (p.179). This particular case
study seeks to understand what type(s) of marketing strategies may have influenced
nursing students’ decisions to pursue a career in nursing. The particular population of
interest to this research study, therefore, is nursing students. However, as Marshall and
Rossman (1999) observed “Unless a study is quite narrowly construed, researchers
cannot study all relevant circumstances, events, or people intensively and in depth; they
(must) sample” (p. 68).
Sampling is utilized in research when it is “impractical to survey all members of a
population” (Berman, p.16). The procedure for selecting the sample from the study’s
population is referred to as the sampling design and consists of either probability or
nonprobability sampling. Probability sampling is utilized when each individual within a
population has the same chance of being selected for inclusion in the study’s sample. In
nonprobability sampling, individuals are not randomly selected. Instead, samples are
based on either a convenience, purposive, or quota sampling design.
The advantages and disadvantages of probability and nonprobability sampling
designs were both considered. The main advantage of using probability sampling is to
reduce biases and allow researchers to generalize their results. The disadvantages of
probability sampling include labor and financial constraints. Because this case study
seeks to understanding, specifically, nursing students’ beliefs and attitudes;
58
nonprobability sampling of a nursing student population was identified and selected as an
appropriate sampling design best suited for this research study.
The Michigan Nursing Students’ Association was identified as a rich purposive
and convenience nonprobability sampling source. As of August 16, 2006 the Michigan
Nursing Students Association had 1727 members. The Michigan Nursing Students
Association draws its’ membership from 50 public and private colleges and universities
located within the State of Michigan. Members are also drawn from and represent
different geographical areas within the State, including: urban, suburban, rural, and
remote locations. Using case study participants that are from different geographical areas
and nursing schools elicit responses that are more consistent and representative of
students who have been exposed to different types of marketing strategies and potential
variations in the frequency of these advertisements. For example, marketing strategies
that use television advertisements for recruitment might be more prevalent in urban and
suburban geographical locations; and less prevalent in rural and remote areas.
In addition, members of the Michigan Nursing Students Association also include
undergraduate and graduate nursing students. Inclusion of these two groups of nursing
students could potentially reveal differences in student perceptions of marketing
strategies. Graduate students, for example, will yield results from established registered
nurse populations that had already made their decision to pursue a career in nursing prior
to the onslaught of recent marketing campaign efforts; as a posed to undergraduate
nursing students, who made their career decision during the height of the marketing
campaign efforts to recruit individuals into the profession.
59
The President of the Michigan Nursing Students Association, Whitney Lewis, was
contacted regarding participation in the study. On August 26, 2006, the proposed research
study was presented to the Board of Directors of the Michigan Nursing Students
Association. In September 2006, the Michigan Nursing Students Association forwarded a
letter of approval supporting this research proposal, authorizing the pilot testing of the
survey instrument, and granting authorization to access the Michigan Nursing Students
Associations’ website to post the web based survey instrument to their membership.
Survey Instrument
The basic aim of survey research is to describe and explain statistically the
variability of certain features of a population. The general logic of survey
research gives a distinctive style to the research process; the type of survey
instrument is determined by the information needed. (Marshall and
Rossman, p. 130)
The survey instrument utilized in this case study has been adapted with approval
from research originally conducted by Dr. Bernadette Curry (1994) entitled, Societal and
marketing influences upon enrollment into baccalaureate nursing programs. Dr. Curry’s
survey instrument was selected because of the particular types of questions asked. The
questions focused specifically on marketing and societal factors that may have influenced
students’ to pursue careers in nursing. In addition, the questions were structured in such a
way as to capture both exposure and level of influence that various marketing and
societal factors may have had on the respondent’s career decision.
Dr. Curry’s instrument originally consisted of a paper and pencil, self
administered survey designed to elicit student responses about societal and marketing
factors that influenced students’ decisions to enroll in baccalaureate nursing programs.
The instrument consisted of 10 objective questions which contained 49 items for response
60
(Curry, p.48). Some of the items utilized in Dr. Curry’s survey were adapted with
approval from a previous survey conducted by Cassells and Redman in conjunction with
the American Association of Colleges of Nursing (Curry, p. 48). Dr. Curry designed her
survey instrument to evaluate student responses to marketing efforts that were intended to
increase enrollment in baccalaureate nursing programs. For the purposes of this research,
the reliance solely on baccalaureate nursing programs was perceived as a research
limitation since within the United States there continues to exist three points of career
entry for Registered Nurses: Associate Degree, Diploma, and Baccalaureate nursing
programs. Subsequently, Dr. Curry’s survey instrument was modified to capture
representative responses reflective of the greater nursing population. In addition, several
items contained within some of the questions were updated to reflect the latest marketing
activities and technologies that are currently being utilized; web based advertising and
use of DVD’s.
Appendix A contains the survey instrument that was used to conduct this
research. The survey instrument contains 16 questions and 71 items for response. The
instrument consists of two basic types of questions. The first type included demographic
information; such as, age, gender, race, status in college, enrollment in a nursing
program, type of program enrolled, membership in MNSA, and educational attainment of
family members who are registered nurses. The second type of question asked
respondents about their general beliefs and attitudes about specific marketing strategies
that have been utilized to attract and recruit students into nursing careers/programs.
The first set of questions (questions 1-9) asked respondents to mark the one best
response that describes them demographically. The second set of questions, utilized a
61
combination of either likert scaling or rank scaling depending on the specific question
asked. For example, question 10 asked respondents to indicate the level of influence that
members of their family had on their decision to pursue a career in nursing. This
particular question used the following five point likert scaling: very influential,
moderately influential, influential, minimally influential, and not influential. Questions
11 and 13 asked respondents to indicate the level of influence that specific marketing
activities and program features had on their decision to pursue a career in nursing.
Questions 11 and 13, utilized the following six point likert scaling: very influential,
moderately influential, influential, minimally influential, not influential, and not used or
not aware of use. Questions 12, 14, 15, and 16 asked respondents to rank their responses
to the items listed in the questions according to their greatest level of influence.
Data Collection Procedure
The researcher contacted the president, Whitney Lewis, of the Michigan Nursing
Students Association to gain approval to access the association’s membership for
purposes of conducting this research. As part of the approval process, MNSA policy
required that all researchers must present to the Michigan Nursing Students Association’s
Board of Directors their proposed research study and respond to specific board member
questions. Originally, the researcher proposed administering a pencil and paper survey.
However, based on a discussion with the Board it became evident that members of the
MNSA are technologically comfortable with the internet and prefer correspondence and
survey’s be administered on-line. The MNSA’s board unanimously agreed to support this
research study provided the pencil and paper survey was converted to a web based
instrument that could be linked to their association’s website. MNSA board members also
62
suggested that in the event of a low response rate to the web based survey, the researcher
could attend the annual convention to raise member awareness and improve survey
participation rates.
To convert the written survey to an online survey format, the researcher compared
several companies that design and offer web based surveys. The companies were
compared based on the following criteria: how user friendly the survey would be to
construct; how data and information would be compiled and reported; data storage,
transfer, and security related issues; company response to customer questions, references
and testimonials from former researchers; and associated costs.
The web based software survey company that was chosen for this research was
SNAP Surveys. The primary reason for selecting SNAP Surveys was based on the
recommendations of Kristen Salomonson, Assistant Dean of Institutional Research at
Ferris State University, after discussing how the SNAP software system, combined with
Ferris State University’s protected website allows employees who develop web based
surveys to conveniently transfer data and information securely.
Once approval was granted by the dissertation committee, School of Business and
Technology, and Institutional Review Board (IRB) at Capella University; the researcher
re-contacted the Michigan Nursing Students Association President, Whitney Lewis, to
work out the logistical details of posting the web based survey instrument on their
website. The web based survey was originally posted for a three week period. The web
based survey began with several paragraphs comparable to a letter of introduction. The
opening paragraphs, explained the purpose of the research, invited students to voluntarily
participate in the study, responded to how data and information would be compiled,
63
reported, and confidentiality handled, reviewed participate rights to withdraw from the
study at any time without consequences, and provided a mechanism for contacting the
researcher or research chairperson, Dr. John Klocinski, in the event the participant had
additional questions or concerns.
Individuals who voluntarily agreed to participate in the study accessed the MNSA
website at their convenience to take the survey. Upon completing of the survey,
participant responses were automatically downloaded and transferred via a link from the
Michigan Nursing Students Association website to the Institutional Research Department
at Ferris State University. Access to Ferris State University’s Institutional Research
Department’s website was restricted to the researcher and Kristen Salomonson, Assistant
Dean of Institutional Research at Ferris State University. Upon completion of this
research study, the only person who has possession and will retain for a period of seven
years an electronic file containing all the data and information collected; will be the
researcher.
Data Analysis
The purpose of this case study was to examine in detail the beliefs and attitudes of
a particular group of nursing students, Michigan Nursing Students’ Association members,
to determine precisely what marketing related activities, if any, have influenced their
decision to pursue a career in nursing. A survey instrument originally developed by Dr.
Curry and subsequently modified by this researcher was downloaded into a SNAP
software program to permit online data collection. The survey was posted on the
MNSA’s website for an initial three week period. Due to a low response rate, the survey
data collection period was extended and attendance at the MNSA’s annual convention
64
was necessitated to increase participation rates. The data collected from members of the
Michigan Nursing Students Association was downloaded and aggregately reported using
a combination of descriptive and inferential statistics.
Descriptive statistics was utilized to analyze responses to the demographic
questions (questions 1-9). As indicated previously, these questions asked participants to
identify their age, gender, race, status in college, enrollment in a nursing program, type of
program enrolled, membership in MNSA, and educational attainment of family members
who are registered nurses.
Inferential statistics was used on questions 10 -15. The questions utilized likert
scaling to determine the level of influence that specific marketing activities and program
features may have had on nursing students’ decisions to pursue careers in nursing.
According to O’Sullivan, Rassel, & Berner (2002), likert scaling is often used to measure
opinions or attitudes of individuals (p. 301). In this particular research study, participants
were asked to respond to a number of items using the following Likert scaling: very
influential, moderately influential, influential, minimally influential, not influential, and
not used or not aware of use. Responses were assigned a numerical score with 1
indicating the most favorable influence and 6 representing not used or not aware of use.
Data analysis proceeded with societal and marketing influences being treated as
independent variables, and decision to enroll in nursing as the dependent variable.
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Validity and Reliability
Validity is conceptually defined as the extent to which a test or instrument
measures what it is intended to measure (Lynn, 1986). Reliability refers to the extent to
which an instrument produces the same or consistent results upon repeat testing (Cooper
& Schindler, 2003). The validity and reliability of the instrument was originally
established by Cassells, Redman, & Jackson, (1986) and reaffirmed by Curry (1994).
For example, the instrument used in this research had originally undergone a two
step process to assure content validity (Cassells, Redman, & Jackson, 1986). In the first
step, the developmental stage, the literature was reviewed to identify and establish
applicable content domain. Appropriate questions and items were generated to clearly
and concisely reflect these domains. In the second step of the content validity process,
judgmental quantification, the researchers relied on “a panel of persons to judge how well
the instrument meets the standards” (Cooper & Schindler, p. 232).
Cassells, Redman & Jackson (1986) used a project advisory committee that
consisted of deans, students, and recent nursing graduates to assure content validity of the
original instrument. Dr. Curry (1994) who replicated Cassells et al., (1986) study, chose
to reaffirm the content validity of the instrument by conducting a pilot study involving 20
nursing students who were not included in the study. The 20 nursing students were asked
to evaluate the instrument based on the following criteria: clearly defined research
purpose, and clarity and comprehension of directions, question and item appropriateness
and clarity (p.51).
66
For purposes of this research study, pilot testing was conducted on the web based
survey instrument to assure content validity. 10 board members from the Michigan
Nursing Students Association were asked to complete the online survey and provide
feedback on the instrument. Six board members responded to the pilot test and provided
feedback. Appropriate modifications to the web based survey instrument were made,
based on feedback received during the pilot test.
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CHAPTER 4: ANALYSIS AND PRESENTATION OF FINDINGS
Introduction
The purpose of this case study was to examine the beliefs and attitudes of nursing
students’ towards various marketing strategies. The primary research question this study
sought to answer is,
1. What marketing related activities, if any, have influenced nursing student’s
These secondary or subsidiary research questions included:
2. What type(s) of nursing recruitment campaigns have students seen, heard, or

accessed?
3. What particular individual(s), if any, have influenced nursing students’ decisions

to pursue a career/enroll in a nursing program.
4. Do student responses to factors that influence their decision to pursue a

The survey instrument utilized in this case study was adapted with approval from
research originally conducted by Dr. Bernadette Curry (1994) entitled, Societal and
marketing influences upon enrollment into baccalaureate nursing programs. An adapted,
draft survey instrument which contained 16 questions and 72 items for response was
submitted to Board Members of the Michigan Nursing Student Association (MNSA) to
confirm content validity. Board members were asked to complete the draft survey and
critique the instrument in terms of question clarity, readability, and item appropriateness.
Several changes were made to the draft instrument, based on, suggestions
received from MNSA board members who participated in the pilot test. The final survey
68
instrument ultimately contained 15 questions and 70 items for response. With the
exception of demographic and ranking questions, respondents used either a 5 or 6-point
Likert scale that included the following categories for response: very influential,
moderately influential, influential, minimally influential, not influential, and/or not used
or not aware of use.
A total of 109 nursing students completed the final survey. The number of
students responding to the survey represents approximately 6% of the student population
who were members of the Michigan Nursing Student Association as of August, 2006.
The low response rate to this case study has been attributed to two primary factors:
1) operational delays which resulted in the survey being posted between the
Thanksgiving and Christmas holidays, and 2) restrictions in MNSA bylaws which
prohibited the researcher and board members from sending reminder correspondence
about the survey to individual nursing student members. Albeit the low response rate
clearly limits the study’s findings from being generalized; the quality of this case study’s
responses provide researchers with preliminary insight towards understanding which
particular marketing related factors have most influenced students’ decisions to pursue
careers in nursing.
Data Presentation and Analysis
Data collected from the survey was first edited for errors and omissions. The data
was then coded and entered into the statistical program software package, SPSS 14.0.
Data analysis proceeded using the following approach. The data was first analyzed to
gain an overall understanding and appreciation for the demographic composition of the
69
respondents. Specifically, descriptive statistics was utilized to analyze responses to the
demographic questions (questions 1-9).
The data was then analyzed with respect to the primary research question,
followed by the subsequent analysis of the secondary or subsidiary research questions.
Specifically, a combination of descriptive and inferential statistics was used to analyze
responses to questions 10-15 to determine the level of influence that specific marketing
related activities and program features may have had on nursing students’ decisions to
pursue a career in nursing. Age, gender, race, and societal and marketing influences were
used as the independent variables in the data analysis and decision to enroll in nursing as
the dependent variable.
Demographic Analysis
As expected, all of the individuals responding to the survey reported being enrolled
in either a nursing program (98%) or pre-nursing courses (2%). As illustrated in Table 1,
of the total 109 respondents who reported being enrolled in either a nursing program or
pre-nursing courses, 60 (55%) were enrolled in an associate program, 48 (44 %) in
baccalaureate programs, and 1 (less than 1%) enrolled in a diploma program.
Table 1. Currently in Nursing Program by Type of Nursing Program
Currently in Nrsg Prog. Diploma Associate Baccalaureate Total

Yes 1 59 47 107
No 0 1 1 2
Total 1 60 48 109
In terms of gender distribution, of the total individuals responding to the survey
(n=109), the majority were female 96 (88%) and 13 (12%) male (refer to Table 2).
70
Table 2. Currently in Nursing Program by Gender
Currently in Nrsg Prog. Female Male Total
Yes 94 13 107
No 2 0 2
Total 96 13 109
As indicated in Table 3, crosstabulation of gender by race showed that of the total 96
females responding to the survey, 89 (92.7%) reported their race/ethnicity as White, Non-
Hispanic; 4 (4.16%) as Asian or Pacific Islander; 2 (2.08%) Hispanic; 1 (1.04%)
Black/African American, non-Hispanic; and 0 (0%) American Indian or Alaskan Native.
Demographic analysis of the 13 males who responded to the survey indicated 11 (84.6%)
reported their race/ethnicity as White, Non-Hispanic; 1 (7.69%) as Asian or Pacific
Islander; 1 (7.69%) American Indian or Alaskan Native; 0 (0%) Hispanic; and 0 (0%)
Black/African American, non-Hispanic.
Table 3. Gender by Race/Ethnicity
Race/Ethnicity
White, Black/African Asian or American
Non- American, Non Hispanic Pacific Indian or Total
Hispanic Hispanic Islander Alaskan Native
Female 89 1 2 4 0 96
Male 11 0 0 1 1 13
Total 100 1 2 5 1 109
A comparative analysis of gender by degree program (refer to Table 4) revealed the
majority, 58.3% (n=56) of female respondents were enrolled in an associate’s degree
program, 40.6% (n=39) in a baccalaureate, and 1% (n=1) in a diploma nursing program.
In comparison, of the 13 males responding to the survey, the majority 69.2% (n=9)
indicated being enrolled in a baccalaureate program, followed by 30.8% (n=4) in an
associate’s, and 0% in a diploma nursing program.

71
Table 4. Gender by Type of Nursing Program
Type of Nursing Program
Diploma Associate Baccalaureate Total
Gender Female 1 56 39 96
Male 0 4 9 13
Total 1 60 48 109
In terms of the age distribution, refer to Table 5, the greatest percentage 29.4%
(n=32) of the individuals who responded to the survey indicated they were in the age
group categorized as 21-22 year olds; 23.9% (n=26) in the age group 31-40; 16.5%
(n=18) in the age group 41+ and older; 16.5% (n=18) in the age group 25-30, 11.%
(n=12) in the age group 23-24; and 2.8% (n=3) in the age group 18-20. The low number
of students in the 18-20 age group may be explained or correspond to program
prerequisites that require students to fulfill pre-nursing courses prior to gaining
acceptance into nursing programs.
Table 5. Age Distribution
Frequency Percent Valid Percentage Cumulative Percent

Age 18-20 3 2.8 2.8 2.8
21-22 32 29.4 29.4 32.1
23-24 12 11.0 11.0 43.1
25-30 18 16.5 16.5 59.6
31-40 26 23.9 23.9 83.5
41 + 18 16.5 16.5 100.0
Total 109 100.0 100.0
According to the National Sample Survey of Registered Nurses (2004), the percent of
male nurses currently in the laborforce is estimated at 5.7%. Since the male response rate
to this survey was higher than expected (12%), the age categories were also analyzed
with respect to respondent gender in an attempt to determine at what age were males
72
pursuing careers in nursing. As illustrated in Table 6, of the 13 males who responded to
the survey, 46% (n=6) reported being in the 21-22 age category; 23.1% (n=3) in the 31-
40 age category; 23.1% (n=3) in the 41+ age category, 11% (n=1) in the 23-24 age
category, and 0% in the following two age categories: 18-20 and 25-30.
Table 6. Gender by Age
Age
18-20 21-22 23-24 25-30 31-40 41+ Total
Gender Female 3 26 11 18 23 15 96
Male 0 6 1 0 3 3 13
Total 3 32 12 18 26 18 109
The data was also analyzed in terms of respondent race/ethnicity. As illustrated in Table
7, the greatest number of respondents, 91.7% (n=100) reported their race/ethnicity as
White, Non-Hispanic; 4.5% (n=5) as Asian or Pacific Islander; 1.8% (n=2) Hispanic; 1%
(n=1) Black/African American, non-Hispanic; and 1% (n=1) American Indian or Alaskan
Native.
Table 7. Race/Ethnicity
Frequency Percent Valid Cumulative

Percentage Percent
White, Non- Hispanic 100 91.7 91.7 91.7
Black/African American 1 .9 .9 92.7
Hispanic 2 1.8 1.8 94.5
Asian or Pacific Islander 5 4.6 4.6 99.1
American Indian or Alaskan Native 1 .9 .9 100.0
Total 109 100.0 100.0
The racial/ethnicity reported in this survey is fairly consistent with the composition
reported in the 2004 National Sample Survey of Registered Nurses (HRSA, 2004). Noted
differences include, a slightly higher percentage or proportion of White, Non-Hispanics
73
(3.3%) and Asians (2.7%) responding to this survey; and 3.6% lower response rate of
Black/African American, non-Hispanic.
A comparative analysis of respondents’ race/ethnicity by type of degree program,
refer to Table 8, revealed the majority of minorities 78% (n=7) were enrolled in associate
nursing programs; followed by 22% (n=2) in baccalaureate, and none in diploma
programs.
Table 8. Race/Ethnicity by Type of Nursing Program
Type of Nursing Program

Diploma Associate Baccalaureate Total
White, Non- Hispanic 1 53 46 100
Black/African American 0 1 0 1
Hispanic 0 1 1 2
Asian or Pacific Islander 0 5 0 5
American Indian or Alaskan Native 0 0 1 1
Total 1 60 48 109
Research Question 1
Research question one, sought to determine, “What marketing related activities, if
any, have influenced nursing student’s decisions to pursue a career in nursing?”
Questions 11 and 12 of the survey instrument, addresses this particular research question.
Question 11 lists specific nursing related informational and marketing items and asked
students to identify the level of influence each item may have had on their decision to
pursue a career/enroll in a nursing program. Respondents used the 6-point Likert scaling:
very influential, moderately influential, influential, minimally influential, not influential,
and not used or not aware of use to identify each particular marketing items level of
influence. Question 12 asked the respondents to rank, from the same list of marketing
74
related items identified in question 11, the three most important marketing factors that
influenced their career decision.
Responses from question 11 were compiled and aggregately reported in Table 9
according to the order the marketing related items appeared on the survey instrument.
The data from the this table was then analyzed and reformatted in order to determine and
conveniently illustrate which specific marketing related items, identified in question 11,
nursing students reported as being influential, overall, in their decision to pursue a career
in nursing.
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Table 9. Level of Influence that Nursing-Related Information/Marketing Activities had
on Student Decision to Pursue a Career/Enroll into a Nursing Program
(1) (2) (3) (4) (5) (6)

Item Description x Very Infl Mod. Infl Influential Min. Infl Not Infl Not
(sd) n n n n n Aware
(%) (%) (%) (%) (%) n
(%)
College 2.96 11 16 20 19 8 20
Bulletin/Catalogue (1.232) (10.1) (14.7) (18.3) (17.4) (7.3) (18.3)
Nrsg Program 2.98 15 16 23 16 14 16
Brochure (1.335) (13.8) (14.7) (21.1) (14.7) (12.8) (14.7)
Newspaper Adv. 3.49 4 10 12 10 17 40
(1.325) (3.7) (9.2) (11.0) (9.2) (15.6) (36.7)
Journal Adv. 3.67 3 6 11 13 16 45
(1.231) (2.8) (5.5) (10.1) (11.9) (14.7) (41.2)
Letter from 3.48 4 6 10 7 13 52
Dean/Director (1.358) (3.7) (5.5) (9.2) (6.4) (11.9) (47.7)
Call from nrsg. 3.44 5 6 9 11 12 50
faculty/prog Rep. (1.351) (4.6) (5.5) (8.3) (10.1) (11.0) (45.9)
Contact by students in 2.95 17 8 12 11 14 35
nrsg prog (1.530) (15.6) (7.3) (11.0) (10.1) (12.8) (32.1)
Personal contact by 3.06 12 6 11 11 11 44
nrsg alumni (1.475) (11.0) (5.5) (10.1) (10.1) (10.1) (40.4)
Personal contact by 3.31 7 8 5 9 13 50
Admission Office Rep (1.506) (6.4) (7.3) (4.6) (8.3) (11.9) (45.9)
Visit to High School by 2.97 7 8 5 9 6 58
college’s rep (1.424) (6.4) (7.3) (4.6) (8.3) (5.5) (53.2)
Visit to High School by 3.03 6 6 6 3 8 61
nrsg rep (1.523) (5.5) (5.5) (5.5) (2.8) (7.3) (56.0)
Nrsg School rep. in 2.95 7 9 7 7 7 52
local/reg. college fair (1.413) (6.4) (8.3) (6.4) (6.4) (6.4) (47.7)
Open house hosted by a 2.78 10 8 12 3 8 50
nursing prog. (1.423) (9.2) (7.3) (11.0) (2.8) (7.3) (45.9)
Television Adv. 3.55 3 4 12 13 10 53
(1.173) (2.8) (3.7) (11.0) (11.9) (9.2) (48.6)
Radio Advertising Nrsg 3.61 3 6 7 17 11 48
Career (1.205) (2.8) (5.5) (6.4) (15.6) (10.1) (44.0)
Website Adv. Nrsg 3.19 7 9 18 14 10 36
Career (1.249) (6.4) (8.3) (16.5) (12.8) (9.2) (33.0)
Videotape about Nrsg. 3.41 5 5 10 10 11 52
Careers (1.341) (4.6) (4.6) (9.2) (9.2) (10.1) (47.7)
CD/DVD about nrsg 3.58 4 4 9 11 12 53
careers (1.299) (3.7) (3.7) (8.3) (10.1) (11.0) (48.6)
Poster featuring Nrsg. 3.47 5 7 11 12 14 43
Careers (1.324) (4.58) (6.4) (10.1) (11.0) (12.8) (39.4)
Career Fair hosted by 2.74 10 15 9 10 6 43
a healthcare org. (1.322) (9.2) (13.8) (8.3) (9.2) (5.5) (39.4)
Other 1.89 21 5 4 2 3 26
(1.323) (19.3) (4.6) (3.7) (1.8) (2.8) (23.9)
76
Table10 list the ten top marketing related activities that were most frequently
identified by student respondents as being either influential, moderately influential, or
very influential. The list of top ten marketing related activities was based on each items’
overall cumulative response rate. The items are listed in descending order of importance.
The top ten marketing activities identified by student respondents, included: nursing
program brochures (49.5%); college bulletins or catalogues (43.1%); contact by students
in the nursing program (33.9%); career fairs hosted by healthcare organizations and
websites advertising nursing careers, both, with corresponding response rates of (31.2%);
other (27.5%); open house hosted by nursing program (27.5 %); contact by nursing
alumni (26.6 %); newspaper advertisements (23.8%), and posters featuring nursing
careers (21.1%).
Table 10. Overall, Cumulative Response Rate to Items Identified as either: Influential,
Moderately Influential, or Very Influential
Very Infl Mod. Infl Influential Cumulative
Description n n n Total
(%) (%) (%)
Nrsg Program Brochure 15 16 23 54
(13.8) (14.7) (21.1) (49.5)
College Bulletin/Catalogue 11 16 20 47
(10.1) (14.7) (18.3) (43.1)
Contact by students in Nrsg Program 17 8 12 37
(15.6) (7.3) (11.0) (33.9)
Career Fair hosted by H.C. Org. 10 15 9 34
(9.2) (13.8) (8.3) (31.2)
Website Advertising Nrsg Careers 7 9 18 34
(6.4) (8.3) (16.5) (31.2)
Other 21 5 4 30
(19.3) (4.6) (3.7) (27.5)
Open House Hosted by Nrsg Program 10 8 12 30
(9.2) (7.3) (11.0) (27.5)
Contact by Nursing Alumni 12 6 11 29
(11.0) (5.5) (10.1) (26.6)
Newspaper Advertisement 4 10 12 26
(3.7) (9.2) (11.0) (23.8)
Poster Featuring Nrsg. Careers 5 7 11 23
(4.58) (6.4) (10.1) (21.1)
77
The identification and ranking of marketing items that yielded the highest overall
cumulative response rates were slightly different when compared to marketing items that
were most frequently identified by student respondents as being “very influential” in their
career decision. Review of the data contained within Table 10 shows the top ten
marketing items identified as “very influential” included: other (19.3%), contact by
students in the nursing program (15.6%), nursing program brochures (13.8%), personal
contact by nursing alumni (11.0%), college bulletin/catalogue (10.1%), career fair hosted
by a healthcare organization (9.2%), open house hosted by a nursing program (9.2%),
website advertising nursing careers (6.4%), posters featuring nursing careers (4.58%),and
newspaper advertisements (3.7%).
The top five marketing items ranked as “very influential” in this survey differed to a
certain degree from those observed by Curry in 1994 (refer to Table 11). For example, in
Curry’s (1994) study the marketing item ranked, number one, in terms of most frequently
cited by nursing students as being “very influential” in their career decision was the
campus meeting with nursing dean/representative. This item did not make it on the top
five “very influential” list in the most recent survey. However, new to the top five “very
influential” marketing list was personal contact by nursing alumni. Three marketing items
which were consistently mentioned on both survey, included: contact by students in the
nursing program, nursing program brochure, and college bulletin/catalogue. However, the
ordinal listing of these marketing items is different. Contact by students in the nursing
program moved up to second place from third; nursing program brochure dropped to
third place from second; and college bulletin/catalogue dropped from fourth to fifth.
78
Table 11. Comparison of Top 5 Very Influential Marketing Items
Very Curry (1994) Rewers (2007)
Influential
1 Campus meeting with nursing dean/rep. Other
(18.6%) (19.3%)
2 Nursing program brochure Contact by students in the nrsg prog
(16.1%) (15.6%)
3 Contact by students in the nrsg prog Nursing program brochure
(13.7%) (13.8%)
4 College bulletin/catalogue Contact by nursing alumni
(10.9%) (11.0%)
5 Open house hosted by nursing program College bulletin/catalogue
(10.0) (10.1%)
Question 11 also provided student respondents’ an opportunity to identify “other”
marketing activities or items they felt were particularly important in their career decision;
but were absent from the list of items contained in the current survey instrument. Thirty
nursing student respondents took the opportunity to “write-in” comments under question
11’s “other” category. A complete listing of comments can be found in Appendix B.
Six basic categories of themes emerged from the analysis of the thirty “other”
comments. The six categories, listed in descending order of identified frequency of
response, included: relatives/friends (23.3%); previous healthcare experience (20.0%);
personal interest (16.6%); school/organizational exposure (16.6%); duplicate responses -
marketing items already listed on the survey (16.6%); and personal/family illness (6.6%).
The items contained in this “other” category are further expanded upon, later in this
section.
Question 12 asked the student respondents to rank, from the list of marketing related
items identified in question 11, the three most important marketing factors that influenced
their career decision. Students were asked to rank only those marketing items they
considered their 1st, 2nd, and 3rd choices.
79
Table 12. Priority Ranking of Marketing Items
Total n 1st choice 2nd choice 3rd choice

Item Description (%) x n n n
(sd) (%) (%) (%)
College Bulletin/Catalogue 32 1.84 12 13 7
(29.3) (.767) (11.0) (11.9) (6.4)
Nrsg Program Brochure 43 2.0 15 13 15
(39.4) (.845) (13.8) (11.9) (13.8)
Newspaper Adv. 8 2.38 2 1 5
(7.3) (.916) (1.8) (0.9) (4.6)
Journal Adv. 13 2.23 4 2 7
(11.9) (.927) (3.7) (1.8) (6.4)
Letter from Dean/Director 11 2.0 4 3 4
(10.0) (.894) (3.7) (2.8) (3.7)
Call from Nrsg. Faculty/Rep. 11 2.45 2 2 7
(10.0) (.820) (1.8) (1.8) (6.4)
Contact by Students in Nrsg Prog 32 2.16 7 13 12
(29.3) (.767) (6.4) (11.9) (11.0)
Contact by Nrsg Alumni 16 1.75 6 8 2
(14.6) (.683) (5.5) (7.3) (1.8)
Contact by Admission Office 5 2.2 1 2 2
(4.5) (.837) (0.9) (1.8) (1.8)
Visit to H.S. by College’s Rep 13 2.23 4 2 7
(11.9) (.927) (3.7) (1.8) (6.4)
Visit to H.S. by Nrsg Rep 17 1.76 8 5 4
(15.5) (.831) (7.3) (4.6) (3.7)
Nrsg Rep. in College Fair 11 2.27 3 2 6
(10.0) (.905) (2.8) (1.8) (5.5)
Open House by Nrsg Prog 20 1.75 9 7 4
(18.3) (.786) (8.3) (6.4) (3.7)
Television Adv. 14 2.07 4 5 5
(12.8) (.829) (3.7) (4.6) (4.6)
Radio Advertising Nrsg Career 10 1.90 3 5 2
(9.1) (.738) (2.8) (4.6) (1.8)
Website Adv. Nrsg Career 21 1.67 10 8 3
(19.2) (.730) (9.2) (7.3) (2.8)
Videotape about Nrsg. Careers 12 2.0 2 8 2
(11.0) (.603) (1.8) (7.3) (1.8)
CD/DVD about Nrsg Careers 8 1.75 4 2 2
(7.3) (.886) (3.7) (1.8) (1.8)
Poster Featuring Nrsg. Careers 6 2.67 0 2 4
(5.5) (.516) (1.8) (3.7)
Career Fair by H.C. Org. 14 2.50 2 3 9
(12.8) (.760) (1.8) (2.8) (8.3)
Other 28 1.29 23 2 3
(25.6) (.659) (21.1) (1.8) (2.8)
80
Responses to question 12 were compiled and reported in Table 12 according to the
order the marketing items appeared on the survey instrument. The data from the
preceding table was then analyzed and reformatted in order to determine and
conveniently illustrate, overall, the marketing items most frequently identified as the
students’1st, 2nd, or 3rd choice. As observed in Table 13, the top five marketing items most
frequently ranked, overall, by student respondents as either 1st, 2nd, or 3rd choice and
listed in descending order of importance, included: nursing program brochures (39.4%);
college bulletin/catalogue (29.3%); contact by students in the nursing program (29.3%);
other (25.6%); and websites advertising nursing careers (19.2%). These top five
marketing items were followed by open house hosted by a nursing program (18.3%); visit
to high school by a nursing representative (15.5%); contact by nursing alumni (14.6%);
career fair hosted by a healthcare organization (12.8%); television advertisements
(12.8%); and visit to high school by a college representative and journal advertisement,
both, with corresponding response rates of 11.9%.
Table 13. Overall, Top Five Marking Items.
Ordinal 1st Choice 2nd Choice 3rd Choice Overall

Ranking % % % %
1 Other Nrsg Prg. Brochure Nrsg Prog. Brochure Nrsg Prog. Brochure
(21.1%) (11.9%) (13.8%) (39.4%)
2 Nrsg Prg. Brochure College Bulletin Contact by Student College Bulletin

(13.8%) (11.9%) (11.0%) (29.3%)
3 College Bulletin Contact by Student Career Fair Contact by Student

(11.0%) (11.9%) (8.3%) (29.3%)
4 Website Website College Bulletin Other

(9.2%) (7.3%) (6.4%) (25.6%)
5 Open House Videotapes Journal Adv. & H.S. Website
(8.3%) (7.3%) visit by nrsg. rep. (19.2%)
(6.4%)
81
When the aforementioned, overall, most frequently cited marketing items were
compared to marketing items specifically ranked by respondents as their “1st choice”…
different priority rankings were observed. Table 13 also provides a partial ordinal listing
of the marketing items identified by students’ as their “1st choice”. An expanded version,
the top five, list of items ranked “1st choice” includes: other (21.1%); nursing program
brochure (13.8%); college bulletin/catalogue (11.0%); websites advertising nursing
careers (9.2%); open house hosted by a nursing program (8.3%); visit to high school by a
nursing representative (7.3%); personal contact by students in the nursing program
(6.4%); personal contact by nursing alumni (5.5%); and television advertisements,
CD/DVD about nursing careers, visit to high school by college’s representative, letter
from dean/director, and journal advertisements, all with corresponding response rates of
3.7%.
Marketing items most frequently ranked by respondents as their “2nd choice,”
included: nursing program brochures (11.9%), college bulletin/catalogue (11.9%),
contact by students in the nursing program (11.9%), website advertising nursing careers
(7.3%); videotape about nursing careers (7.3%), contact by nursing alumni (7.3%), open
house hosted by a nursing program ( 6.4%), television advertisements featuring nursing
careers (4.6%), radio advertisements featuring nursing careers (4.6%), and visits to high
school by nursing representatives (4.6%).
The marketing items identified by students most frequently as their 3rd most
influential item that persuaded them to pursue a career in nursing, included: nursing
program brochure (13.8%); contact by students in the nursing program (11.0%); career
82
fair hosted by a healthcare organization (8.3%); college bulletin/catalogue (6.4%); journal
advertisement (6.4%); visit to high school by nursing representative (6.4%); nursing
representative in local/regional college fair (5.5%); television advertisements (4.6%);
newspaper advertisements (4.6%); and poster featuring nursing careers, visit to high
school by nursing representative, open house hosted by a nursing program, and letter
from dean/ director all correspondingly capturing 3.7% response rate.
Based on the review of items contained in the “other category,” which students most
frequently identified as their “1st choice,” it appears relatives/friends, previous healthcare
experience, personal interest, and personal/family illness are the most influential in a
students’ decision to pursue a career in nursing. These“1st choice” findings support the
research of Kersten et al., (1991) and Larsen et al., (2003), that exposure to healthcare,
family, and work experiences tend to be motivating factors that influence students’
decisions to pursue a career in nursing. Additionally, these 1st choice, “other” items were
followed, secondarily, by nursing program related brochures, bulletins, and open houses;
and finally, by marketing related activities designed to introduce and recruit individuals
into the nursing profession.
Anotherwords, what items ultimately influence a student to pursue a career in
nursing, appear to be different, from those marketing related activities and items designed
to initially capture students’ interest in nursing as a viable career option, and marketing
materials that are designed to promote specific nursing programs.
Research Question 2
Research question number two sought to understand “What type(s) of nursing
recruitment campaigns have students seen, heard, or accessed?” The marketing items
83
(items a-t) contained within Question 11 of the survey instrument, address this particular
research question. Specifically, descriptive statistics was used to determine whether
students were aware, or not aware, of various marketing campaign strategies. To
determine whether students were “aware of” the various marketing campaign strategies,
frequency calculations were run using the following likert categories: very influential,
moderately influential, influential, minimally influential, and not influential to determine
the overall cumulative awareness response rate (sum total) for each marketing item. This
cumulative awareness response rate corresponds to whether students had seen, heard, or
access to various marketing items. Table 14 list the cumulative awareness response rate
for each item identified in question 11 according to the order the marketing related item
appeared on the survey.
According to the cumulative responses found in Table 14, 77% of all student
respondents had seen, heard, or accessed nursing program brochures; 67.8% college
bulletins, 56.8% had heard or been contacted by students from a nursing program; 53.2%
were aware of website advertisements; 48.6% newspaper advertisements; 46.7% had
heard or been contacted by nursing alumni; 45.8% aware of or attended a career fair
hosted by a healthcare organization; 44.9% aware of posters featuring nursing careers;
40.3% aware of radio advertisements featuring nursing as a careers; and 39.4% had heard
or received a call from nursing faculty and/or program representative.
84
Table 14. Student Awareness of Various Marketing Related Campaign Strategies
(1) (2) (3) (4) (5) (6) Aware.Total

Description Very Infl Mod. Infl Min. Infl Not Infl Not Aware Categ. 1-5
n Infl n n n n n
(%) n (%) (%) (%) (%) (%)
(%)
College 11 16 20 19 8 20 74
Bulletin/Catalogue (10.1) (14.7) (18.3) (17.4) (7.3) (18.3) (67.8)
Nrsg Prog 15 16 23 16 14 16 84
Brochure (13.8) (14.7) (21.1) (14.7) (12.8) (14.7) (77.0)
Newspaper Adv. 4 10 12 10 17 40 53
(3.7) (9.2) (11.0) (9.2) (15.6) (36.7) (48.6)
Journal Adv. 3 6 11 13 16 45 49
(2.8) (5.5) (10.1) (11.9) (14.7) (41.2) (44.9)
Letter from 4 6 10 7 13 52 40
Dean/Director (3.7) (5.5) (9.2) (6.4) (11.9) (47.7) (36.6)
Call from Nrsg. 5 6 9 11 12 50 43
Faculty/Rep. (4.6) (5.5) (8.3) (10.1) (11.0) (45.9) (39.4)
Contact by 17 8 12 11 14 35 62
Students in Nrsg (15.6) (7.3) (11.0) (10.1) (12.8) (32.1) (56.8)
Prog
Contact by Nrsg 12 6 11 11 11 44 51
Alumni (11.0) (5.5) (10.1) (10.1) (10.1) (40.4) (46.7)
Contact by 7 8 5 9 13 50 42
Admission Office (6.4) (7.3) (4.6) (8.3) (11.9) (45.9) (38.5)
Visit to H.S. by 7 8 5 9 6 58 35
College’s Rep (6.4) (7.3) (4.6) (8.3) (5.5) (53.2) (32.1)
Visit to H.S. by 6 6 6 3 8 61 29
Nrsg Rep (5.5) (5.5) (5.5) (2.8) (7.3) (56.0) (26.6)
Nrsg Rep. in 7 9 7 7 7 52 37
College Fair (6.4) (8.3) (6.4) (6.4) (6.4) (47.7) (33.9)
Open House by 10 8 12 3 8 50 41
Nrsg Prog (9.2) (7.3) (11.0) (2.8) (7.3) (45.9) (37.6)
Television Adv. 3 4 12 13 10 53 42
(2.8) (3.7) (11.0) (11.9) (9.2) (48.6) (38.5)
Radio Advertising 3 6 7 17 11 48 44
Nrsg Career (2.8) (5.5) (6.4) (15.6) (10.1) (44.0) (40.3)
Website Adv. Nrsg 7 9 18 14 10 36 58
Career (6.4) (8.3) (16.5) (12.8) (9.2) (33.0) (53.2)
Videotape about 5 5 10 10 11 52 41
Nrsg. Careers (4.6) (4.6) (9.2) (9.2) (10.1) (47.7) (37.6)
CD/DVD about 4 4 9 11 12 53 40
Nrsg Careers (3.7) (3.7) (8.3) (10.1) (11.0) (48.6) (36.6)
Poster Featuring 5 7 11 12 14 43 49
Nrsg. Careers (4.58) (6.4) (10.1) (11.0) (12.8) (39.4) (44.9)
Career Fair by 10 15 9 10 6 43 50
H.C. Org. (9.2) (13.8) (8.3) (9.2) (5.5) (39.4) (45.8)
Other 21 5 4 2 3 26 35
(19.3) (4.6) (3.7) (1.8) (2.8) (23.9) (32.1)
85
The survey also shed insight into marketing strategies or items students indicated
they had no knowledge of. According to the data, 56.0% of the respondents indicated they
were “not aware of” visits to their high school by a nursing representative, nor were
53.2% of the students aware of a college representative visiting their high school. 48.6%
of the respondents indicated they were not aware of, either, CDs/DVDs or television
advertisement’s featuring nursing careers; nor could 47.7% recall any videotapes
pertaining to nursing careers. Slightly less than half of all student respondents reported
any awareness or receipt of letter/s from a dean or director of a nursing program (47.7%);
nor awareness of any nursing school representative at their local/regional college fair
(47.7%). 45.9% of the students indicated lack of personal contact by an admission’s
office representative; 45.9% had never received a call from nursing faculty/program
representative; nor were 45.9% of the students aware of any open house activities hosted
by nursing programs.
The marketing items contained within question 11 were consolidated into three
categories based upon the type of marketing method or approach utilized to attract
students into nursing careers or programs. The three basic categories or groupings,
included: personal contact, visits/fairs, and general media related items. These three basic
categories provided a mechanism for readily identifying those marketing strategies, based
on cumulative awareness response rates, that students’ were most apt to recall or
interpreted as effective marketing tools.
Within the personal contact category, refer to Table 15, 56.8% of the study’s
respondents reported the most effective marketing strategy involved some form of
personal contact by students currently enrolled in the nursing program. The second most
86
effective marketing strategy in the personal contact category involved contact by nursing
alumni (46.7%), followed by contact from nursing faculty or program representative
(39.4%); contact by admission offices (38.5%); and letter from dean/director (36.6%).
Based on this grouping, it appears survey respondents were most aware of and influenced
by fellow students currently enrolled in a nursing program or former alumnus who had
recently gone through a nursing program.
Table 15. Cumulative Awareness of Marketing Item: Personal Contact Category

(1) (2) (3) (4) (5) (6) Aware.Total
Description x Very Mod. Infl Min. Not Infl Not Categ 1-5
(sd) Infl Infl n Infl n Aware n
n n (%) n (%) n (%)
(%) (%) (%) (%)
Contact by
Students in 2.95 17 8 12 11 14 35 62
Nrsg Prog (1.5) (15.6) (7.3) (11.0) (10.1) (12.8) (32.1) (56.8)
Contact by 3.06 12 6 11 11 11 44 51
Nrsg Alumni (1.4) (11.0) (5.5) (10.1) (10.1) (10.1) (40.4) (46.7)
Contact by 3.44 5 6 9 11 12 50 43
Nrsg.Fac/Rep (1.3) (4.6) (5.5) (8.3) (10.1) (11.0) (45.9) (39.4)
Contact by 3.31 7 8 5 9 13 50 42
Adm. Office (1.5) (6.4) (7.3) (4.6) (8.3) (11.9) (45.9) (38.5)
Letter from 3.48 4 6 10 7 13 52 40

Dean/Director (1.3) (3.7) (5.5) (9.2) (6.4) (11.9) (47.7) (36.6)
In terms of the second category or marketing approach which entailed visits/fairs,
surveyed students were most aware of career fairs (45.8%). Table 16 identifies the second
most effective marketing item listed in the visit/fair’s category, as open houses hosted by
a nursing program (37.6). These two marketing approaches were followed by nursing
schools represented in local/regional college fair (33.9%); visits to high schools by
college representative (32.1%); and visits to high schools by nursing representatives
(26.6%).
87
Conversely, over half the student respondents (56.0%) reported “no awareness or use
of” visits to their high school by either a nursing representative, or college representatives
(53.2%). 47.7% of student respondents indicated they were “not aware” of a nursing
school representative participation in local/regional college fairs. Nor were 45.9% of the
students “aware” of open houses hosted by a nursing program or career fairs hosted by
healthcare organizations (39.4%).
Table 16. Cumulative Awareness of Marketing Item: Visits/Fairs Category
(1) (2) (3) (4) (5) (6) Aware.Total

Description x Very Mod. Infl Min. Not Infl Not Categ. 1-5
(sd) Infl Infl n Infl n Aware n
n n (%) n (%) n (%)
(%) (%) (%) (%)
Career Fair 2.74 10 15 9 10 6 43 50
by H.C.Org. (1.3) (9.2) (13.8) (8.3) (9.2) (5.5) (39.4) (45.8)
Open House 2.78 10 8 12 3 8 50 41

by Nrsg (1.4) (9.2) (7.3) (11.0) (2.8) (7.3) (45.9) (37.6)
Prog
Nrsg School 2.95 7 9 7 7 7 52 37

in College (1.4) (6.4) (8.3) (6.4) (6.4) (6.4) (47.7) (33.9)
Fair
Visit to H.S. 2.97 7 8 5 9 6 58 35

by College (1.4) (6.4) (7.3) (4.6) (8.3) (5.5) (53.2) (32.1)
Rep
Visit to H.S. 3.03 6 6 6 3 8 61 29

by Nrsg Rep (1.5) (5.5) (5.5) (5.5) (2.8) (7.3) (56.0) (26.6)
Within the media related category, refer to Table 17, greater than half the students
reported awareness of website advertisements featuring nursing careers (53.2%). The
second most frequently identified media related item contained in this category was
newspaper advertisements (56.8%). These media marketing items were followed by
posters and journal advertisements featuring nursing careers, both, capturing
corresponding response rates of (44.9%); 40.3% of students were aware of radio

88
advertisements; 38.5% of television advertisements; 37.6% of videotapes; and 36.6% of
CD/DVDs featuring nursing careers.
Table 17. Cumulative Awareness of Marketing Item: Media Related Category

(1) (2) (3) (4) (5) (6) Aware
Description x Very Infl Mod. Infl Min. Infl Not Infl Not Aware Total
(sd) n Infl n n n n Categ. 1-5
(%) n (%) (%) (%) (%) n
(%) (%)
Website 3.19 7 9 18 14 10 36 58
(1.25) (6.4) (8.3) (16.5) (12.8) (9.2) (33.0) (53.2)
Newspaper 3.49 4 10 12 10 17 40 53
(1.33) (3.7) (9.2) (11.0) (9.2) (15.6) (36.7) (48.6)
Poster 3.47 5 7 11 12 14 23 49
(1.32) (4.58) (6.4) (10.1) (11.0) (12.8) (21.1) (44.9)
Journal 3.67 3 6 11 13 16 45 49
(1.23) (2.8) (5.5) (10.1) (11.9) (14.7) (41.2) (44.9)
Radio 3.61 3 6 7 17 11 48 44
(1.21) (2.8) (5.5) (6.4) (15.6) (10.1) (44.0) (40.3)
Television 3.55 3 4 12 13 10 53 42
(1.17) (2.8) (3.7) (11.0) (11.9) (9.2) (48.6) (38.5)
Videotape 3.41 5 5 10 10 11 52 41
(1.34) (4.6) (4.6) (9.2) (9.2) (10.1) (47.7) (37.6)
CD/DVD’s 3.58 4 4 9 11 12 53 40
(1.29) (3.7) (3.7) (8.3) (10.1) (11.0) (48.6) (36.6)
It is also important to note at this juncture, that of the six lowest ranked marketing
related campaign strategies that were identified within Table 14 as “very influential,” five
involved media items. These five media items included: television, radio, journal,
newspapers, and CD/DVDs. The media findings observed in this study are consistent
with those found in Curry’s (1994) research. However, further analysis of these media
items revealed student awareness of these campaign strategies has improved,
substantially, in the past decade.
Table 18 illustrates how the awareness of these media marketing items have
changed over time based on a comparison of “not aware of use” response rates found in
this research; as opposed to, Curry’s (1994). For example, 85.2% of the respondents in
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Curry’s (1994) study indicated they were “not aware of” CD/DVD usage. Presently,
48.6% of nursing student respondents’ indicated they were “not aware of” a marketing
strategy that involved CD/DVD’s. This difference represents a 36.6% change in
awareness by students in the usage of CD/DVD’s in marketing nursing careers. The
greatest strides in media marketing of nursing careers involved the usage of posters,
radio, CD/DVDs, video, and websites. Obviously, the use of website marketing is a
relatively new phenomenon that coincides with advances in technological that have
occurred since Curry’s (1994) research was originally conducted.
Table 18. Comparison of Media Items Identified as “Not Aware of Use”

Curry (1994) Rewers (2007) Difference In Awareness
Description Not Aware of Use Not Aware of Use (%)
(%) (%)
Website N/A 33.0 N/A
Newspaper 50.3 36.7 13.6
Poster 69.9 21.1 48.8
Journal 50.3 41.2 9.1
Radio 82.5 44.0 38.5
Television 80.7 48.6 32.1
Videotapes 80.7 47.7 33.0
CD/DVD’s 85.2 48.6 36.6
Research Question 3
Research question three considered, “What particular individual(s), if any, have
influenced students’ decisions to pursue a career or enroll in a nursing program?”
Question 10 of the survey instrument addresses this research question by attempting to
determine the level of influence, utilizing the following five point likert scale: very
influential, moderately influential, influential, minimally influential, or not influential,
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that various family members and friends may have had on nursing students’ career
decisions.
Statistical analysis of the data began by calculating the likert categorical frequencies
of responses for each item listed in question 10. Table 19 identifies the frequency of
responses reported in each likert category and corresponding percentage this number
represents in terms of total survey responses (n=109). Additionally, calculations were
run to compare the overall influence per item, based on total number of responses
reported in the categories identified as influential and greater (categories 1-3), to those
frequencies observed in the individual likert categories. This additional step in the data
analysis process was undertaken to ensure that each items’ categorical frequency was
appropriately compared to an aggregate total and purposefully excluded responses
identified as either not influential or minimally influential.
Table 19. Level of Influence of Family and Friends

(1) (2) (3) (4) (5) Total Categ.
Description Very Infl Mod. Infl Influential Min. Infl Not Infl 1-3
n n n n n n
(%) (%) (%) (%) (%) (%)
Mother 33 19 15 10 17 67
(30.2) (17.4) (13.7) (9.1) (15.5) (61.4)
Father 27 13 20 4 23 60
(24.7) (11.9) (18.3) (3.6) (21.1) (55.0)
Sister 12 4 10 8 41 26
(11.0) (3.6) (9.1) (7.3) (37.6) (23.8)
Brother 10 5 7 10 44 22
(9.1) (4.5) (6.4) (9.1) (40.3) (20.1)
Aunt 12 8 8 6 43 28
(11.0) (7.3) (7.3) (5.5) (39.4) (25.6)
Uncle 11 2 4 8 49 17
(10.0) (1.8) (3.6) (7.3) (44.9) (15.5)
Cousin 8 5 6 8 46 19
(7.3) (4.5) (5.5) (7.3) (42.2) (17.4)
Grandmothe 14 9 13 6 36 36
r (12.8) (8.2) (11.9) (5.5) (33.0) (33.0)
Grandfather 7 12 7 6 39 26
(6.4) (11.0) (6.4) (5.5) (35.7) (23.8)
Friend 26 14 14 7 25 54
(23.8) (12.8) (12.8) (6.4) (22.9) (49.5)
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As observed in Table 19, 61.4% of the student respondents indicated their mother as
the most influential person in their career decision. The second most influential person in
students’ nursing career decisions was, not surprisingly, their father (55%). The third
most influential person reported by 49.5% of the students was a friend; followed by
grandmother (33.0%); and aunt (25.6). A comparison of the overall level of influence,
total of categories 1-3, in comparison to the very influential category revealed no
differences in the ordinal listing of the top five family members and friends who
reportedly influenced students’ decisions to pursue a career in nursing.
The categorical frequencies for family members and friends, as described above,
were also cross tabulated by gender and reanalyzed to determine if differences existed
between male and female responses. Table 20 provides an ordinal listing of the most
frequently cited family member or friend; as indicated by gender. This comparative
analysis revealed male nursing students’ career decisions were most apt to be influenced
by their father; followed by their mother. Both male and female respondents identified as
their third most influential person; a friend. Male respondents identified their brother as
the fourth most influential person; as opposed to females, who reported their
grandmother. Female student respondents’ fifth most influential person was their aunt.
Males, on the other hand, equally identified the following distant relatives: grandparents,
aunts, uncles, and cousins.
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Table 20. Ordinal Listing of Important Family Members by Gender
Ordinal Ranking Female Respondents Male Respondents

1 Mother Father
2 Father Mother
3 Friend Friend
4 Grandmother Brother
5 Aunt Distant Relatives
Research Question 4
The fourth and final research question sought to determine, if …”student responses
to factors that influenced their decision to pursue a career/enroll in a nursing program
differed based on age, gender, or ethnicity?” This question focuses, specifically, on
marketing and family related factor(s) that may have influenced students’ career
decisions. To address this research question, responses to survey questions 10, 11, 13,
and 15 were utilized. For purposes of analysis, the following three hypotheses were
developed to describe the assumptions used in evaluating this research question.
Hypothesis H1: There is no relationship between gender and students’ decision to
pursue a career in nursing with regard to:
a) individuals – family member and/or friends
b) marketing items
c) societal items
d) identified singular factor
Hypothesis H2: There is no relationship between race/ethnicity and students’ decision
to pursue a career in nursing with regard to:
b) marketing items
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c) societal items
Hypothesis H3: There is no relationship between age and students’ decision to pursue
a career in nursing with regard to:
b) marketing items
c) societal items
Due to the small sample size, nonparametric bivariate analysis using Pearson’s Chi-
Square was utilized to statistically analyze the data pertaining to student’s gender and
survey responses; and Chi-Square Test of Independence to assess race/ethnicity and age.
According to Berman (2002), Chi-square (X2) is one of the most frequently utilized
statistical tests that is used to determine whether a relationship exists between two
categorical variables. Specifically, chi-square test’s for differences between the observed
distribution or frequency of data among categories and the expected distribution (Cooper
& Schindler, 2003).
To test the first part of hypothesis H1a’s assumption, that, there is no relationship
between gender and students’ decision to pursue a career in nursing with regard to
individuals – family member and/or friends; responses to question 10 was cross tabulated
and a chi-square statistical test performed. Table 21 identifies the chi-square test results
for relatives and friends. The table also identifies the number of valid cases or individuals
who responded to each item. Not all individuals responded to each survey item; some
items were left blank by survey respondents.
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Table 21. Chi-Square Family/Friends by Gender
Item Pearson Chi-Square N of Valid Cases
Mother 6.918 94
Father .815 87
Sister 6.402 75
Brother 2.325 76
Aunt 4.207 77
Uncle .889 74
Cousin 2.366 73
Grandmother 4.537 78
Grandfather 3.31 71
Friend 5.574 86
The chi-squared test results, illustrated in the preceding table, were compared to chi-
square distribution tables containing critical values found at the 5% level of significance
and 4 degrees of freedom. According to Cooper & Schindler’s (2003) distribution table,
the critical value of a chi-square distribution at 0.05 level of significance and 4 degrees of
freedom is 9.49. Visual inspection and comparison of the chi-squared test results run for
each family member and friend to the critical value of 9.49 revealed, that all chi-square
test results were less than the critical value. Subsequently, the null hypothesis for
research question H1a which alleged “there is no relationship between gender and
students’ decision to pursue a career in nursing with regard to individuals - family
member and/or friends” was accepted. There is no statistical relationship between gender
and students’ decision to pursue a career in nursing based on family members and/or
friends.
Chi-square test statistics were also run consolidating the likert categories very
influential, moderately influential, influential, and minimally influential into one
category; influential. This additional statistical approach sought to eliminate the specific
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degrees of influence for the purpose of grouping responses into the more generic category
of either; influential or not influential. This additional step also changed the degrees of
freedom. The test statistics were compared to the critical value of 3.84 based on a 0.05
level of significance and 1 degree of freedom. As evidenced in Table 22, this additional
statistical step supported the acceptance of the null hypothesis for research question H1a;
with the exception of sister. The chi-square test statistics for sister (6.40) was greater than
the critical value of 3.84 which lead to the rejection of the null hypothesis for gender and
relative -sister. Further analysis revealed, of the 75 individuals responding to the sister
item; none (0) of the males (n=7) reported their sister as being influential in their career
decision. Of the 68 females responding to this question, 50% (n=34) reported that their
sister was influential in their decision to pursue a nursing career.
Table 22. Consolidated Chi-Square Test Statistics for Family/Friends by Gender
Item Chi-Square N of Valid Cases

Mother 0.11 94
Father 0.07 87
Sister 6.40 75
Brother 1.07 76
Aunt 3.63 77
Uncle 0.31 74
Cousin 0.55 73
Grandmother 2.98 78
Grandfather 1.47 71
Friend 1.15 86
To test the assumption contained in hypothesis H1b, that, there is no relationship
marketing items; responses to question 11 were cross tabulated and a chi-square statistical
test performed. The chi-square test results for marketing items are contained in Table 23.
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Table 23. Chi-Square Test Results for Marketing Items.
Pearson
Item Description Chi-Square N of Valid Cases
College bulletin/catalogue 3.054 74
Nursing Program Brochure 3.379 84
Newspaper 3.429 53
Journal 5.524 49
Letter from Dean/Director 3.077 40
Contact by Nursing Faculty/Representative 2.458 43
Contact by Students in Nursing Program 4.858 62
Contact by Nursing Alumni 5.023 51
Contact by Admission Office 5.066 42
Visit to High School by College’s Rep 2.512 35
Visit to High School by Nursing 1.596 29
Representative
Nursing School Rep. in College Fair 5.896 37
Open house hosted by a Nursing Program 5.081 41
Television 3.206 42
Radio 2.192 44
Website 2.947 58
Videotape 2.527 41
CD/DVD 4.912 40
Poster 2.574 49
Career Fair Hosted by a Healthcare 4.198 50
Organization
Other 4.770 35
A comparison of the critical value of 9.49, based on a level of significance of 0.05 and 4
degrees of freedom, to the chi-square test result for each marketing items revealed there
is no statistical relationship between gender and students’ decision to pursue a career in
nursing based on any of the marketing items that were listed within question 11 of the
survey.
However, by consolidating the likert categories very influential, moderately
influential, influential, and minimally influential into the broad category, influential, a
statistical difference was observed. The resulting chi-square test statistics were compared
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to the critical value of 3.84 based on a 0.05 level of significance and 1 degree of freedom.
As evidenced in Table 24, all of the chi-square test statistics were less than the critical
value; except for the marketing item CD/DVD. This additional statistical step, in general,
supports research question 4 null hypothesis H1b; there is no statistical relationship
between gender and students’ decision to pursue a career in nursing based on any of the
marketing items that were listed within question 11 with the exception of CD/DVD. In
this particular case, of the 38 females responding to the CD/DVD question;
approximately 74% indicated the marketing item was influential to some degree in their
career decision. Of the 7 males who took the survey; only 2 responded to the CD/DVD
question. Of the 2 male respondents, both males indicated the marketing item CD/DVD
was not influential in their nursing career decision.
Table 24. Consolidated Chi-Square Test Statistics for Marketing Items.

College bulletin/catalogue 0.94 74
Nursing Program Brochure 1.77 84
Newspaper 0.98 53
Journal 1.55 49
Letter from Dean/Director 0.49 40
Contact by Nursing Faculty/Representative 0.81 43
Contact by Students in Nursing Program 0.13 62
Contact by Nursing Alumni 0.88 51
Contact by Admission Office 0.94 42
Visit to High School by College’s Rep 0.68 35
Visit to High School by Nrsg Representative 0.06 29
Nursing School Rep. in College Fair 0.76 37
Open house hosted by a Nursing Program 0.51 41
Television 0.16 42
Radio 1.47 44
Website 0.18 58
Videotape 0.07 41
CD/DVD 4.91 40
Poster 0.98 49
Career Fair by H.C. Organization 0.34 50
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To test the assumption contained in hypothesis H1c, that, there is no relationship
societal items; responses to question 13 were cross tabulated and a chi-square statistical
test performed. The chi-square test results for societal items are contained in Table 25.
The table also identifies the number of valid cases or total number of individuals who
responded to each item. Some individuals did not respond to every item contained on the
survey instrument.
Table 25. Chi-Square Test Results for Societal Items
Item Description Pearson N of Valid Cases

Chi-Square
Location of Nursing Program 4.758 92
Amount of Time Required to Complete Program 1.431 91
Flexible Course Scheduling/Availability of On-line Classes 1.183 80
Costs of Financing Education 3.374 89
Greater Opportunity for Career/Education Mobility 1.763 84
Parents’ Expectation that You Acquire a College Degree 2.021 67
Desire for Comprehensive Liberal Arts/Scientific Background 6.691 66
to Complement Nursing Knowledge
Recommendation of High School Counselor 4.257 49
Advice of a Professional Nurse 7.265 65
Baccalaureate Degree will Become Sole Source of 2.357 63
Entry into the Nursing Profession
Expectation of Higher Salary 3.597 87
Opportunity to Work in Non-Hospital Setting 1.977 70
Personal Desire for Baccalaureate College Degree 9.393 75
Status of Having a Baccalaureate Degree in Nursing 1.102 69
Limitations for Employment Without a Bachelor’s Degree 7.522 70
Desire to Pursue Advanced/Graduate Education 2.851 77
Greater Knowledge and Expertise of Faculty 2.680 74
Other 1.905 8
Visual inspection and comparison of the chi-square test result for each societal item to the
critical value of 9.49 revealed all societal items, with the exception of personal desire for
baccalaureate college degree, were less than the critical value. Subsequently, the null
hypothesis for research question H1c which alleged “there is no relationship between
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gender and students’ decision to pursue a career in nursing with regard to societal factors
was accepted for all items; except, personal desire for baccalaureate college degree.
As evidenced in Table 26, consolidating the likert categories very influential,
moderately influential, influential, and minimally influential into the broad category,
influential, revealed the chi-square test statistics for all societal items were less than the
critical value of 3.84 based on a 0.05 level of significance and 1 degree of freedom which
supports null hypothesis H1c, that “there is no relationship between gender and students’
decision to pursue a career in nursing with regard to societal factors”.
Table 26. Consolidated Chi-Square Test Statistics for Societal Items

Location of Nursing Program 1.61 92
Amount of Time Required to Complete Program 0.07 91
Flexible Course Scheduling/Availability of On-line Classes 0.04 80
Costs of Financing Education 0.01 89
Greater Opportunity for Career/Education Mobility 0.22 84
Parents’ Expectation that You Acquire a College Degree 0.06 67
Desire for Comprehensive Liberal Arts/Scientific Background 0.37 66
to Complement Nursing Knowledge
Recommendation of High School Counselor 0.51 49
Advice of a Professional Nurse 0.01 65
Baccalaureate Degree will Become Sole Source of 0.39 63
Entry into the Nursing Profession
Expectation of Higher Salary 0.27 87
Opportunity to Work in Non-Hospital Setting 1.09 70
Personal Desire for Baccalaureate College Degree 0.25 75
Status of Having a Baccalaureate Degree in Nursing 0.00 69
Limitations for Employment Without a Bachelor’s Degree 0.43 70
Desire to Pursue Advanced/Graduate Education 0.36 77
Greater Knowledge and Expertise of Faculty 0.02 74
To test hypothesis H1d, that, there is no relationship between gender and students’
decision to pursue a career in nursing with regard to the singular factor (refer to appendix
C) that was wrote in by students, question 15 was cross tabulated and a chi-square
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statistical test performed. Test results indicated that of the 109 students responding to the
survey, a total of 87 (79.8%) responded to question 15. Of the 87 students responding; 79
(90.8%) were female and 9 (10.3%) male. Some student’s identified more than one item,
resulting in a total of 93 items being included in the analysis. The categories mentioned
by respondents and listed in descending order of identified frequency of response
included: desire to help others/compassion (22); personal goal/desire (16); talk with
family/friend (12); career flexibility/mobility (10); job market/security (7); illness of
self/family (6); money (5); rewarding job (5); previous employment (4); high school
career program/job shadow (2); volunteer (1); RN (1); life (1); and multi factorial (1).
The factor most frequently identified as, the single factor, that most influenced
student’s decision to become a nurse was the desire to help others/compassion.
Interestingly, of the 22 individuals that identified this factor; all 22 (100%) were female.
Of the 9 males responding to this question; 3 (33.3%) identified a more practical
explanation - the job market/security - as the single most important factor that influenced
their career decision. Of the six other males responding to this question on the survey; 2
(22.2%) of the males reported personal goals; 1 (11.1%) money; 1 (11.1%) family illness;
and 1 (11.1%) a family member as being the single most important factor in their career
decision.
The aforementioned responses were cross tabulated and a chi-square statistical test
performed. The Pearson chi-square test value was 53.776. This test value was compared
to the critical value of 3.84, based on a level of significance of 0.05 and 1 degree of
freedom. The chi-square test result indicates there is a statistical relationship between
gender and students’ decision to pursue a career in nursing based on the single factor that
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was identified by students in question 15 of the survey. Based on these results, the null
hypothesis for H1d, which states, there is no relationship between gender and students’
decision to pursue a career in nursing with regard to the singular factor that was
identified by students’ as being influential in their career decision to become a nurse was
rejected. No further chi-square statistical analysis using the consolidation of likert
categories: very influential, moderately influential, influential, and minimally influential
was warranted since only those items that respondents felt were influential in their career
decision were written in by survey respondents.
The second part of research question 4, hypothesis H2, sought to determine if a
relationship existed between race/ethnicity and students’ decision to pursue a career in
nursing with regards to the following factors: individuals – family member and/or
friends, marketing items, societal items, identified singular factor. The assumption
underlying this research question states, Hypothesis H2: There is no relationship between
race/ethnicity and students’ decision to pursue a career in nursing with regard to:
b) marketing items
c) societal items
Chi-square test of independence was utilized to statistically analyze student survey
responses. A contingency table of expected frequencies was developed from the actual
frequencies recorded for each level of influence (very influential, moderately influential,
influential, minimally influential, and not influential) based on student race/ethnicity. The
data contained within the contingency table was than used to calculate the value of the
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Chi-square test statistic. Table 27 compares the chi square statistic with the critical value
of 26.30 based on a 0.05 level of significance and 16 degrees of freedom.
Table 27. Chi-Square Statistics for Race/Ethnicity for Relative.

Item White Black Hispanic Asian American Chi- Chi- Null
Indian Square Square
Stat. C.V.
Mother 0.66 4.53 2.19 7.39 4.53 19.30 26.30 A
Father 0.64 2.78 1.50 8.89 2.78 16.59 26.30 A
Sister 0.26 0.83 0.83 5.94 0.83 8.69 26.30 A
Brother 0.73 0.73 6.46 19.8 0.73 28.45 26.30 R
Aunt 0.99 0.79 2.10 16.25 0.79 20.92 26.30 A
Uncle 1.08 0.51 0.51 22.91 0.51 25.52 26.30 A
Cousin 0.54 0.59 0.59 16.26 0.59 18.56 26.30 A
Grandmother 0.47 1.17 1.17 13.71 1.17 17.68 26.30 A
Grandfather 0.21 0.82 0.82 8.27 0.82 10.94 26.30 A
Friend 0.37 2.3 2.30 11.36 2.44 18.77 26.30 A
A= Accept R = Reject
Based on the visual inspection and comparison of the chi-square test statistics to the
critical value, each test statistic for the relative/friend items identified in survey question
10 was below the critical value of 26.30; except for, brother. The chi-square test statistic
for brother (28.44) was greater than the critical value of 26.30 which lead to the rejection
of the null hypothesis for this item. All other relative/friend items were accepted.
Subsequently, the null hypothesis for research question H2a which stated “there is no
relationship between race/ethnicity and students’ decision to pursue a career in nursing
with regard to individuals - family member and/or friends” was accepted for all items;
except, brother.
The same chi-square test of independence format was followed to also calculate the
chi-square test statistic for survey responses designed to address research question’s H2b,
H2c, and H2d. Table 28 presents the chi-square test statistics for race/ethnicity marketing
related items compared to the chi-square critical value of 26.30. The critical value is
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based on a 0.05 level of significance and 16 degrees of freedom. A visual comparison
revealed that all marketing items identified in survey question 11 were less than the
critical value. As a result, the assumption stated in null hypothesis H2b that, “There is no
with regard to marketing items is accepted; there is no statistical evidence of a
relationship.
Table 28. Chi-Square Statistics for Race/Ethnicity Marketing Related Items
Chi- Chi-
Item Description White Black Hispanic Asian American Square Square Null
Indian Stat. C.V.
College 0.59 0.0 7.25 5.91 0.0 13.75 26.30 A
Bulletin/Catalogue
Nrsg Prog. Brochure 0.27 5.0 3.62 3.47 0.0 12.35 26.30 A
Newspaper 0.24 2.11 0.0 3.83 0.0 6.18 26.30 A
Journal 0.46 2.06 0.0 6.5 0.0 9.01 26.30 A
Letter from Dean 0.33 2.07 0.0 4.38 0.0 6.78 26.30 A
Call from Nrsg Faculty 0.15 2.58 0.0 2.59 3.77 9.09 26.30 A
Contact by Students in 0.57 3.42 0.0 3.65 4.16 11.8 26.30 A
Nrsg Prog.
Contact by Nrsg Alumni 0.52 3.64 0.0 3.92 3.63 11.71 26.30 A
Contact by Adm. Office 0.62 0.0 0.0 5.91 0.0 6.52 26.30 A
Visit H.S. by College Rep 0.91 3.37 0.0 5.84 0.0 10.01 26.30 A
Visit H.S. by Nrsg Rep 0.56 3.83 0.0 3.83 0.0 8.23 26.30 A
Nursing School in 0.79 3.11 0.0 4.24 0.0 8.14 26.30 A
College Fair
Open House by Nrsg Prog 0.36 0.0 4.12 1.72 0.0 6.21 26.30 A
Television 0.64 2.23 0.0 7.37 0.0 10.17 26.30 A
Radio 0.79 1.58 0.0 5.49 0.0 7.87 26.30 A
Website 0.78 3.14 7.28 6.96 0.0 18.16 26.30 A
Videotapes 0.67 3.10 0.0 7.27 0.0 11.04 26.30 A
CD/DVD’s 0.81 2.63 0.0 8.5 0.0 11.95 26.30 A
Poster’s 1.04 8.80 0.0 12.86 2.50 25.0 26.30 A
Career Fair by H.C. Org.. 0.75 0.0 0.0 6.77 0.0 7.53 26.30 A
Table 29 illustrates the chi-square test statistics for race/ethnicity’s based on
societal related items compared to the chi-square critical value of 26.30. The critical
value was established based on 0.05 level of significance and 16 degrees of freedom.
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Table 29. Chi-Square Statistics for Race/Ethnicity’s Societal Items
Chi- Chi-
Item Description White Black Hispanic Asian American Square Square Null
Indian Stat. C.V.
Location of Program 0.16 0.58 0.58 1.01 14.33 16.53 26.30 A
Time Required to 0.17 1.21 10.37 2.43 8.10 22.31 26.30 A

Complete Program
Prog. Scheduling 0.35 1.96 3.00 5.88 0.0 11.20 26.30 A
Flexibility/On-line
Costs of Financing 0.08 10.12 8.88 1.38 7.90 28.38 26.30 R
Opportunity for 0.06 0.42 0.42 0.84 6.00 7.75 26.30 A

Career/Edu. Mobility
Parents’ Expectation 0.21 3.18 3.18 4.39 0.0 10.96 26.30 A
Desire Comprehensive 0.08 5.60 2.66 3.53 0.0 11.89 26.30 A

Liberal Arts/Scientific
Background
Recommendation of 0.30 15.33 1.13 3.72 0.0 20.45 26.30 A
H.S. Counselor
Advice of a 0.23 1.95 1.95 1.64 7.12 12.91 26.30 A
Professional Nurse
BSN will be only 0.59 4.25 4.25 5.30 4.25 18.65 26.30 A
Source of Prof. Entry
into Nrsg.
Expectation of Higher 0.21 1.28 2.62 1.26 2.62 8.01 26.30 A
Salary
Opportunity to Work 0.24 2.18 4.00 3.09 2.18 11.69 26.30 A
in Non-Hospital Setting
Personal Desire for 0.16 3.41 1.08 2.16 3.41 10.23 26.30 A
BSN
Status of BSN 0.17 3.60 1.55 3.11 0.0 8.43 26.30 A
Limitations without a 0.11 2.04 7.75 2.21 5.36 17.48 26.30 A

BSN
Desire for Advance- 0.14 0.67 0.67 0.67 0.67 2.84 26.30 A
Graduate Education
Greater Knowledge and 0.18 1.38 1.38 2.89 0.0 5.83 26.30 A
Expertise of Faculty
A visual comparison of these values indicated that all societal items identified in question
13 were less than the critical value; except for cost. The chi-square test statistic for cost
was 28.38. Subsequently, the assumption stated in null hypothesis H2c that, “There is no
with regard to societal items, is accepted; except for the item, costs.
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Further review of the data suggest, 80% of all students’ who responded to this
particular survey question (n=89) had indicated nursing program costs as being either:
influential, moderately influential, or very influential. Of the 45 students who identified
nursing program cost as very influential, 95.5% were white and the remaining 4.5%
asian. In contrast, of the 17 students who indicated nursing program costs were either not
influential or minimally influential; 11.7% had classified themselves as either black or
hispanic.
The null hypothesis, H2d, states: There is no relationship between race/ethnicity and
students’ decision to pursue a career in nursing with regard to identified singular factors’.
Table 30 illustrates the chi-square test statistics for race/ethnicity’s based on respondent
reported single factors’ as compared to the chi-square critical value of 69.83.
Table 30 Chi-Square Test Statistics for Race/Ethnicity’s Single Factor

American Chi- Chi-
Item Description White Black Hispanic Asian Indian Square Square Null
Stat. C.V.
Desire to help others 0.06 0.22 0.22 0.44 0.22 1.18 69.83 A
Goal to be an RN 0.00 0.13 0.13 0.26 5.67 6.21 69.83 A
Family/friends 0.39 0.14 5.14 10.2 0.14 16.1 69.83 A
Career mobility, 0.02 0.09 0.09 0.18 0.09 0.48 69.83 A
flexibility, opportunity
Job market, security 0.04 10.3 0.08 0.16 0.08 10.7 69.83 A
Illness: self, family 0.01 0.07 0.07 0.14 0.07 0.37 69.83 A
Money 0.01 0.06 0.06 0.12 0.06 0.32 69.83 A
Rewarding job 0.02 0.09 0.09 0.18 0.09 0.48 69.83 A
Previous Employment 0.01 0.04 0.04 0.08 0.04 0.21 69.83 A
H.S. program/job 0.00 0.02 0.02 0.04 0.02 0.10 69.83 A
shadow
Volunteer 0.00 0.01 0.01 0.02 0.01 0.05 69.83 A
Advice of RN 0.00 0.01 0.01 0.02 0.01 0.05 69.83 A
Life 0.00 0.01 0.01 0.02 0.01 0.05 69.83 A
Multifactor 0.00 0.01 0.01 0.02 0.01 0.05 69.83 A
The critical value was established based on 0.05 level of significance and 52 degrees of
freedom. Since Cooper & Schindler’s (2003) table of critical values of the chi-square
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distribution only included degrees of freedom between 1-30; the National Institute of
Standards and Technology (NIST) critical value distribution table was utilized since the
degrees of freedom contained within NIST’s table had a higher range (df 1-100).
All single factorial items chi-square statistics were less than the critical value.
Subsequently, the assumption stated in null hypothesis H2d that, “There is no relationship
between race/ethnicity and students’ decision to pursue a career in nursing with regard to
respondent self-identified single factor’s is accepted.
The third part of research question 4, hypothesis H3 asserts, “There is no relationship
between age and students’ decision to pursue a career in nursing with regard to:
b) marketing items
c) societal items
Statistical analysis of student survey responses to this research question was consistent
with the approach utilized in the preceding section; chi-square test of independence. For
example, contingency tables for expected frequencies were developed from the actual
frequencies recorded for each level of influence (very influential, moderately influential,
influential, minimally influential, and not influential) based on student age. The data
contained within these contingency tables were than used to calculate the value of the
Chi-square test statistics. However, the critical value used to determine if the null
hypothesis is accepted or rejected is different - since the degree of freedom used in this
case is 20; instead of 16. For purposes of clarification, this question used 0.05 level of
significance, 20 degrees of freedom, and a critical value of 31.41. Based on a visual
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inspection and comparison of the chi-square statistics to critical value found in Table 31,
there appears to be a statistical relationship between age and students’ decision to pursue
a career in nursing with regard to the following individuals: mother, father, cousin and
grandfather. The chi-square test statistics for each of these categories of individual’s were
greater than the critical value of 31.41. Subsequently, the null hypothesis for research
question 4, H3a is rejected based on the chi-square test of independence.
Table 31. Chi-Square Statistics For Age Based on Family Member/Friend Responses
Item 18-20 21-22 23-24 25-30 31-40 41+ Chi- Chi- Null
Square Square
Stat. C.V.
Mother 10.48 2.89 4.46 1.86 10.15 2.86 32.72 31.41 R
Father 3.87 6.65 14.33 4.86 5.50 7.17 42.41 31.41 R
Sister 0.0 4.19 7.70 4.26 0.48 5.76 22.39 31.41 A
Brother 0.0 5.62 2.20 4.18 5.13 7.46 24.59 31.41 A
Aunt 1.58 1.68 4.04 2.36 8.15 8.01 25.84 31.41 A
Uncle 1.25 3.72 1.83 2.67 4.49 4.23 18.22 31.41 A
Cousin 16.25 2.80 9.53 4.93 1.31 2.41 37.25 31.41 R
Grandmother 10 3.67 3.51 2.77 2.61 1.74 24.33 31.41 A
Grandfather 18.28 2.46 12.47 1.72 4.01 3.50 42.46 31.41 R
Friend 22.57 2.08 2.49 1.53 0.18 6.80 35.68 31.41 A
Table 32 identifies the chi-square test statistics based on the age of the respondent and
marketing related item to the critical value of 31.41. A visual comparison revealed that all
marketing items identified in survey question 11 were less than the critical value.
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Table 32. Chi-Square Statistics for Age and Marketing Related Items
Chi- Chi-
Item Description 18-20 21-22 23-24 25-30 31-40 41+ Square Square Null
Stat. C.V.
College 8.68 2.31 4.46 8.09 0.92 4.47 28.96 31.41 A
Bulletin/Catalogue
Nrsg Prog. Brochure 5.21 4.69 3.64 6.17 3.09 7.32 30.16 31.41 A
Newspaper 12.90 3.24 4.10 3.68 4.53 1.51 29.98 31.41 A
Journal 2.76 5.64 1.15 2.31 6.38 1.34 19.60 31.41 A
Letter from Dean 3.00 2.55 10.61 4.36 0.92 4.87 26.34 31.41 A
Call from Nrsg 2.58 5.48 0.72 8.30 1.09 5.27 23.46 31.41 A
Faculty/Rep.
Contact by Students 4.16 1.79 7.45 4.39 1.55 1.85 21.21 31.41 A
in Nrsg Prog.
Contact by Nrsg 3.63 3.07 4.11 8.89 7.74 1.64 29.11 31.41 A
Alumni
Contact by Adm. 4.25 2.91 2.78 4.97 6.50 0.20 21.64 31.41 A
Office
Visit H.S. by 2.88 5.77 4.81 5.47 0.79 5.43 25.18 31.41 A
College Rep
Visit H.S. by 0.0 6.50 1.73 3.46 1.04 4.42 17.15 31.41 A
Nrsg Rep
Nursing School 4.28 1.99 2.75 7.80 2.18 3.92 22.95 31.41 A
in College Fair
Open House by 3.10 1.37 11.97 7.78 4.12 0.60 28.96 31.41 A
Nrsg Prog
Television 2.50 3.15 6.53 5.06 3.35 0.96 21.57 31.41 A
Radio 7.64 1.18 4.53 2.99 2.90 1.19 20.46 31.41 A
Website 2.22 4.31 3.39 6.53 1.46 3.15 21.08 31.41 A
Videotapes 3.10 3.60 12.4 3.55 1.20 1.26 25.12 31.41 A
CD/DVD’s 3.44 3.81 10.54 4.58 1.93 3.62 27.95 31.41 A
Poster’s 3.45 1.48 18.5 2.17 2.82 3.04 31.49 31.41 A
Career Fair by 3.29 3.32 5.00 6.92 1.42 1.24 21.21 31.41 A
H.C. Org.
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As a result, the assumption stated in research question 4, hypothesis H3b, that “There is
no relationship between age and students’ decision to pursue a career in nursing with
regard to marketing items is accepted; there is no statistical evidence of a relationship.
A visual comparison of the chi-square test statistics, as described in Table 33, for
age group and societal items compared to the chi-square critical value of 31.41 indicates,
that out of the 17 societal items listed in question 13 of the survey, 6 societal items had
test statistics greater than the critical value. The 6 societal items that had chi-square test
statistics above the 31.41 included: parental expectations (50.80); opportunity to work in
non-hospital setting (38.67); flexible course scheduling/availability of on-line classes
(37.22); greater knowledge/expertise of faculty (35.70); time required to complete
nursing program (34.16); and BSN will become only source of profession entry into the
nursing profession (32.64). Based on these findings, research question 4’s, null
hypothesis H3c, which states, “There is no relationship between age and students’
decision to pursue a career in nursing with regard to societal items was rejected for the
six items just described and accepted for the remaining 11 items.
The six items whose null hypothesis was rejected, was further analyzed to determine
if these statistics made logical sense. For example, regarding parental expectations, it
seemed logical that younger students represent the age group most likely to have recently
resided with their parents and most recently under the influence of parental career
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Table 33. Chi-Square Statistics For Age and Societal Item
Chi- Chi-
Stat. C.V.
Location of Program 0.50 2.45 2.26 4.70 3.10 3.63 16.67 31.41 A
Time Required to 1.21 9.25 6.54 3.11 9.60 4.43 34.16 31.41 R
Complete Program
Prog. Scheduling 1.96 5.19 7.29 9.52 9.35 3.89 37.22 31.41 R
Flexibility/On-line
Costs of Financing 4.23 7.35 0.90 5.44 0.62 1.81 20.38 31.41 A
Opportunity for Career- 0.42 0.86 2.47 10.20 3.86 1.67 19.51 31.41 A
Education Mobility
Parents’ Expectation 5.70 20.50 3.23 1.17 6.62 13.5 50.80 31.41 R
Desire Comprehensive 4.07 1.95 3.61 7.05 2.09 6.33 25.13 31.41 A
Liberal Arts/Scientific
Background
Recommendation of 3.45 7.20 2.14 1.75 4.20 3.61 22.38 31.41 A

H.S. Counselor
Advice of a 3.33 0.41 1.85 4.20 4.01 2.14 15.97 31.41 A

Professional Nurse
BSN will be only Source 8.00 5.32 4.06 8.87 1.12 5.25 32.64 31.41 R
of Prof. Entry into Nrsg.
Expectation of Higher 1.28 3.66 2.43 7.02 3.64 1.67 19.73 31.41 A
Salary
Opportunity to Work 6.00 8.00 11.11 5.09 6.86 1.59 38.67 31.41 R
in Non-Hospital Setting
Personal Desire for BSN 1.08 4.53 4.48 7.20 5.57 2.77 25.67 31.41 A
Status of BSN 1.55 2.67 6.83 6.41 2.51 6.03 26.02 31.41 A
Limitations without 4.38 8.46 0.62 0.60 4.42 3.57 22.07 31.41 A
a BSN
Desire for Advance- 0.67 1.83 2.94 7.24 1.02 4.57 18.30 31.41 A
Graduate Education
Greater Knowledge and 6.40 3.66 5.12 6.73 7.45 6.32 35.70 31.41 R
Expertise of Faculty
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opinions. In contrast older, non traditional students, most likely, have been independent
of daily parental influence. Additionally, respondents in the older age groups are also
more likely to have friends or acquaintances that are or have been registered nurses.
Indeed, data analysis regarding parental influence revealed, 68.7% of those individuals
(n=16) who indicated that parental expectation’s were very influential were in the age
group 21-22; followed by 12.5% in the 23-24 and 25-30 age groups; 6.25% in the 31-40
group; and 0% in the 18-20 and 41+ age groups. Overall, the data analysis regarding
parental influence supports the logic described above; except for respondents in the 18-20
age group. However, there is a plausible explanation for this variation. It is important to
recall, that there were only 3 respondents in the 18-20 age group. The low number of
students in this age group corresponds to program prerequisites that require students to
fulfill pre-nursing courses prior to gaining admission/acceptance into nursing programs.
Hence, program prerequisites minimize the number of students in the 18-20 age group
from membership in the Michigan Student Nurses Association.
The forth and final part of research question 4, hypothesis H3d asserts, “There is no
relationship between age and students’ decision to pursue a career in nursing with regard
to identified singular factors (refer to appendix C). Table 34 illustrates the chi-square test
statistics for age based on respondent reported single factors’ as compared to the chi-
square critical value of 69.83.
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The critical value was established based on 0.05 level of significance and 52 degrees of
freedom. For null hypothesis H3d, the National Institute of Standards and Technology
(NIST) critical value distribution table was utilized. Based on the chi-squared statistics,
all item values were less than the critical value of 69.83. Subsequently, the null
hypothesis for all the written in items’ was accepted.
Table 34. Chi-Square Statistics For Age and Single Items
Chi- Chi-
Stat. C.V.
Desire to help others 0.21 0.08 0.06 0.47 1.78 0.17 2.57 69.83 A
Goal to be an RN 0.14 0.35 0.30 0.08 0.03 3.71 4.61 69.83 A
Family/friends 5.07 0.15 0.92 0.12 1.62 0.62 8.52 69.83 A
Career mobility, 0.09 0.03 1.11 0.11 1.63 1.39 4.37 69.83 A
flex/opportunity
Job market, security 0.07 0.39 0.86 1.22 3.29 1.08 6.94 69.83 A
Illness: self, family 0.06 0.35 0.74 0.00 0.23 1.23 2.63 69.83 A
Money 0.06 0.02 0.08 1.05 1.74 0.92 3.90 69.83 A
Rewarding job 0.09 0.17 0.70 0.21 0.60 1.85 3.64 69.83 A
Previous 0.04 1.19 0.49 0.12 4.43 0.61 6.91 69.83 A

Employment
H.S. program- 0.02 0.27 0.24 1.20 0.47 0.30 2.52 69.83 A
Job Shadow
Volunteer 0.01 1.64 0.12 0.17 0.23 0.15 2.34 69.83 A
Advice of RN 0.02 0.27 0.24 1.20 0.47 0.30 2.52 69.83 A
Life 0.01 0.29 6.20 0.17 0.23 0.15 7.08 69.83 A
Multifactor 0.01 0.29 6.20 0.17 0.23 0.15 7.08 69.83 A
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CHAPTER 5. SUMMARY, CONCLUSION AND RECOMMENDATIONS
Summary
The healthcare industry has intermittently experienced shortages of licensed
registered nurses within the U.S. laborforce. Review of the literature suggests that,
historically, these past nursing shortages were attributed to economic, workplace, social,
or demographic issues (Janiszewski Goodin, 2003). So what makes the present U.S.
nursing labor shortage, which is expected to reach 1 million nurses by 2020, any
different? Research undertaken as part of this study has identified recent changes within
the healthcare industry, that when combined, with an outmoded “image” of nursing and
alternative career options available to women as underlying causative agents or factors
associated with the present, most critical and prolonged shortage of registered nurses in
U.S. history (Heinrich, 2001; Staiger et al., 200; Nelson, 2002; Ledgister, 2003a; Auker,
2004; Hereford, 2005; and Seago et al., 2006).
This research study was undertaken to understand several important dimensions
associated with the present nursing shortage, including: the scope, contributory factors,
and, most importantly, identification of marketing strategies that could be used to reverse
the present trend of students’ towards selecting careers – other than nursing. The
conceptual framework that guided this research was based on a model originally
developed by Kimball and O’Neil (2002) for the Robert Wood Johnson Foundation
entitled, Continuum of Responses – (to) an Evolving Profession (p.9).
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The model basically identifies four stages of behavior that characteristically emerge as
healthcare industry leaders respond to nursing labor shortages. The four stages include;
scramble, improve, reinvent, and start over.
According to Kimball & O’Neil (2002), once a nursing shortage is recognized,
healthcare industry leaders and key stakeholder groups usually “scramble” to identify the
extent of and reasons for the nursing shortage. During the second stage, improvement,
collaborating committees are established for the purpose of identifying and developing
strategies that could be used to address the shortage. During the third stage, reinvent,
numerous industry and organizational tactics and strategies are implemented to ensure
that an adequate supply of nurses’ is available to meet patient care demands.
In the fourth stage, start over, registered nurses finally reach the professional
partnership stage in which organizational decision making take into consideration nurses’
opinions. As indicated by the title of the fourth stage, start over, once the supply of nurses
is sufficient to meet patient care demands, competing organizational threats begin to
monopolize the time and attention of leaders. Subsequently, support of nurse recruitment
and retention efforts begin to slowly dwindle as competing priorities being to pose more
serious threats to the immediate survival of the healthcare organization. As support for
nursing recruitment and retention efforts dwindle, working conditions for nurses
correspondingly deteriorate until increase nurse turnover and career exit rates are
observed and associated with a new nursing shortage - repeating the cyclical nature of
registered nurse labor shortages.
This research challenges the status quo associated with the underlying reactionary
assumptions contained in Kimball & O’Neil’s (2002) model. The past practice of relying
115
upon societal norms which limited the number of career options available to women to
naturally replenish the supply of nurses available within the workforce has disappeared.
This reactionary mental model has been replaced with the need to embrace proactive
inquiry and acknowledge there exists’ a new laborforce assumption or paradigm.
Healthcare industry leaders must learn to operate under a new nursing laborforce
paradigm. A new laborforce paradigm that stems from societal changes that are forcing
healthcare leaders to consciously acknowledge and accept the fact that to survive in
today’s healthcare environment, leaders must proactively compete with other industries
and professions in the war for talented -knowledge workers. Another words, healthcare
industry leaders must identify, develop, and implement ongoing marketing strategies that
will appeal to and attract a broader, more diversified group of individuals into the nursing
profession in order to adequately meet patient care demands.
The purpose of this descriptive case study is to update and expand the existing body
of knowledge pertaining to marketing factors that influence students’ decisions to pursue
careers in nursing. The primary research question this study sought to answer is:
1) What marketing related activities, if any, have influenced nursing students’

These secondary or subsidiary research questions included:
2) What type(s) of nursing recruitment campaigns have students seen, heard, or

accessed?
3) What particular individual(s), if any, have influenced nursing students’ decisions

to pursue a career/enroll in a nursing program.
4) Do student responses to factors that influence their decision to pursue a

116
A total of 109 students who were members of the Michigan Nursing Student
Association (MNSA) participated in the research study. The students voluntarily
responded to 15 questions that were contained in a survey, adapted with approval from
research originally conducted by Dr. Bernadette Curry (1994) entitled, Societal and
marketing influences upon enrollment into baccalaureate nursing programs. Responses
to the survey were analyzed and are summarized below.
Discussion of Research Question 1
Research question one, sought to determine, “What marketing related activities, if
any, have influenced nursing students’ decisions to pursue a career in nursing?”
Questions 11 and 12 of the survey instrument, addressed this particular research question.
Question 11 listed specific nursing related informational and marketing items and asked
students to identify the level of influence each item may have had on their decision to
pursue a career/enroll in a nursing program. Respondents used the 6-point Likert scaling:
very influential, moderately influential, influential, minimally influential, not influential,
and not used or not aware of use to identify each particular marketing items level of
influence.
Question 12 asked the respondent to rank, from the same list of marketing related
items identified in question 11, the three most important marketing factors that influenced
their career decision. Note, these two survey questions also provided student respondents’
an opportunity to identify “other” marketing activities or items they felt were particularly
important in their career decision; but were absent from the list of items contained in the
survey instrument. Thirty nursing student respondents took the opportunity to write-in
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comments in the “other” category. A complete listing of comments can be found in
Appendix B. Note, six basic categories of themes emerged from the analysis of the thirty
“other” comments. The six categories, listed in descending order of identified frequency
of response, included: relatives/friends (23.3%); previous healthcare experience (20.0%);
personal interest (16.6%); school/organizational exposure (16.6%); marketing items
already listed on the survey-duplicate responses (16.6%); and personal/family illness
(6.6%).
Table 35 provides an ordinal listing of the top 5 marketing items identified by
student respondents, overall, (cumulative totals of influential, moderately influential, and
very influential responses) as being influential in their career decision; as compared, to
those items identified as very influential. The differences between the cumulative and
very influential categories will be addressed later in the conclusion.
Table 35. Comparison of the Top Five Marketing Items
Cumulative Total (Likert 1-3) Very Influential

(%) (%)
1 Nursing Program Brochure Other
(49.5) (19.3)
2 College Bulletin/Catalogue Contact by Students in the Nursing Program
(43.1) (15.6)
3 Contact by Students in the Nursing Program Nursing Program Brochure
(33.9) (13.8)
4 Career Fair Hosted by Healthcare Contact by Nursing alumni
Organization (11.0)
(31.2)
5 Website Advertising Nursing Careers College Bulletin/Catalogue
(31.2) (10.1)
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Students were also asked to rank the top three (1st, 2nd, and 3rd choice) marketing
items that most influenced their career decision. The most frequently cited, overall,
marketing items were compared to those items ranked by respondents as their 1stt, 2nd , or
3rd choice. Table 36 provides an ordinal summary of the research findings.
Table 36. Overall, Top Five Marketing Items – Identified as “1st, 2nd, and 3rd choices.
Ordinal 1st Choice 2nd Choice 3rd Choice Overall
Ranking % % % %
1 Other Nrsg Prg. Brochure Nrsg Prog. Brochure Nrsg Prog.
(21.1%) (11.9%) (13.8%) Brochure
(39.4%)
2 Nrsg Prg. Brochure College Bulletin Contact by Student College Bulletin
(13.8%) (11.9%) (11.0%) (29.3%)
3 College Bulletin Contact by Student Career Fair Contact by Student

(11.0%) (11.9%) (8.3%) (29.3%)
4 Website Website College Bulletin Other

(9.2%) (7.3%) (6.4%) (25.6%)
5 Open House Videotapes Journal Adv. & H.S. Website

(8.3%) (7.3%) Visit by (19.2%)
Nrsg. Rep.
(6.4%)
Research question two sought to understand “What type(s) of nursing recruitment
campaigns have students seen, heard, or accessed?” The marketing items contained
within question 11 (items a-t) of the survey instrument, address this research question.
Specifically, descriptive statistics was used to determine whether students were aware, or
not aware, of various marketing campaign strategies. To determine whether students were
“aware of” the various marketing campaign strategies, frequency calculations were run
using the following likert categories: very influential, moderately influential, influential,
minimally influential, and not influential to determine the overall cumulative awareness
response rate (sum total) for each marketing item. This cumulative awareness response
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rate corresponds to whether students had seen, heard, or access to various marketing
items. Table 37 lists the top 5 marketing related campaign strategies that student reported
“overall” awareness of, in comparison to those marketing strategies identified as being
“very influential”.
Table 37. Top 5 Marketing Strategies Students were Most Aware Of and Influenced By
Cumulative Total (Likert 1-5) Very Influential

(%) (%)
1 Nursing Program Brochure Other
(77.0) (19.3)
2 College Bulletin/Catalogue Contact by Students in the Nursing Program
(67.8) (15.6)
3 Contact by Students in the Nursing Program Brochure
Nursing Program (13.8)
(56.8)
4 Website Advertising Nursing Careers Contact by Nursing alumni
(53.2) (11.0)
5 Newspaper Advertisements College Bulletin/Catalogue
(48.6) (10.1)
Based on the ordinal listing contained in Table 37, it appears those marketing related
strategies students indicated they were most aware of differed from those marketing
related items that most influenced their career decision. The most influential (very
influential) marketing related campaign strategy item identified by students was written-
in under the “other” category of items. These items were consolidated into the following
categorical themes: relatives/friends (23.3%); previous healthcare experience (20.0%);
personal interest (16.6%); school/organizational exposure (16.6%); marketing items
already listed on the survey-duplicate responses (16.6%); and personal/family illness
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(6.6%). Interestingly, the write-in items contained in the “other” category tended to
include individuals or experiences; as opposed to, marketing related items that utilize
various types of medium.
Research question three considered, “What particular individual(s), if any, had influenced
students’ decisions to pursue a career or enroll in a nursing program?” Question 10 of the
survey instrument addresses this research question by attempting to determine the level of
influence, utilizing the following five point likert scale: very influential, moderately
influential, influential, minimally influential, or not influential, that various family
members and friends may have had on nursing students’ career decisions.
As observed in Table 38, student respondents indicated their mother as the most
influential person in their career decision. The second most influential person in students’
nursing career decisions was, not surprisingly, their father (55%). The third most
influential person reported by 49.5% of the students was a friend; followed by
grandmother (33.0%); and aunt (25.6).
Table 38. Listing of the Most Influential Person in Students’ Career Decision
Ordinal Ranking Very Influential Responses

1 Mother
2 Father
3 Friend
4 Grandmother
5 Aunt
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Research question 4 sought to determine, if …”student responses to factors that
influenced their decision to pursue a career/enroll in a nursing program differed based on
age, gender, or ethnicity?” This question focused, specifically, on marketing and family
related factor(s) that may have influenced students’ career decisions. To address this
research question, responses to survey questions 10, 11, 13, and 15 were utilized. The
following three hypotheses were developed to describe the assumptions used in
evaluating research question 4.
Hypothesis H1: There is no relationship between gender and students’ decision to
b) marketing items
c) societal items
Hypothesis H2: There is no relationship between race/ethnicity and students’
decision to pursue a career in nursing with regard to:
b) marketing items
c) societal items
Hypothesis H3: There is no relationship between age and students’ decision to
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b) marketing items
c) societal items
Nonparametric bivariate analysis using Pearson’s Chi-Square was utilized to statistically
analyze the data pertaining to student’s gender and survey responses and Chi-Square test
of independence to assess the race/ethnicity and age component.
To test hypothesis H1a’s assumption, that, there is no relationship between gender
and students’ decision to pursue a career in nursing with regard to individuals – family
member and/or friends, a chi-square test statistic was run for each individual listed on the
survey. The test statistic for each item was less than the critical value of 9.49 based on
0.05 level of significance and 4 degrees of freedom. Subsequently, the null hypothesis for
research question H1a which alleged “there is no relationship between gender and
students’ decision to pursue a career in nursing with regard to individuals - family
member and/or friends” was accepted. Based on the survey sample, there is no statistical
relationship between gender and students’ decision to pursue a career in nursing based on
family members and/or friends.
To test hypothesis H1b assumption, that, there is no relationship between gender and
students’ decision to pursue a career in nursing with regard to marketing items; responses
to question 11 were cross tabulated and a chi-square statistical test performed.
Comparison of the critical value of 9.49, based on a level of significance of 0.05 and 4
degrees of freedom, to the chi-square test result for each marketing items revealed there
123
is no statistical relationship between gender and students’ decision to pursue a career in
nursing based on any of the marketing items that were listed within question 11 of the
survey.
To test hypothesis H1c assumption, that, there is no relationship between gender and
students’ decision to pursue a career in nursing with regard to societal items; responses to
question 13 were cross tabulated and a chi-square statistical test performed. Visual
inspection and comparison of the chi-square test result for each societal item to the
critical value of 9.49 revealed all societal items, with the exception of personal desire for
baccalaureate college degree, were less than the critical value. Subsequently, the null
hypothesis for research question H1c which alleged “there is no relationship between
gender and students’ decision to pursue a career in nursing with regard to societal factors
was accepted for all items; except, personal desire for baccalaureate college degree.
To test hypothesis H1d, that, there is no relationship between gender and students’
decision to pursue a career in nursing with regard to the singular factor that was wrote in
by students, question 15 was cross tabulated and a chi-square statistical test performed.
Test results indicated that of the 109 students responding to the survey, a total of 87
(79.8%) responded to question 15. Of the 87 students responding; 79 (90.8%) were
female and 9 (10.3%) male. Some student’s identified more than one item, resulting in a
total of 93 items being included in the analysis. The categories mentioned by respondents
and listed in descending order of identified frequency of response included: desire to help
others/compassion (22); personal goal/desire (16); talk with family/friend (12); career
flexibility/mobility (10); job market/security (7); illness of self/family (6); money (5);
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rewarding job (5); previous employment (4); high school career program/job shadow (2);
volunteer (1); RN (1); life (1); and multi factorial (1).
The factor most frequently identified as, the single factor, that most influenced
students’ decision to become a nurse was the desire to help others/compassion.
Interestingly, of the 22 individuals that identified this factor; all 22 (100%) were female.
Of the 9 males responding to this question; 3 (33.3%) identified a more practical
explanation - the job market/security - as the single most important factor that influenced
their career decision. Of the six other males responding to this question on the survey; 2
(22.2%) of the males reported personal goals; 1 (11.1%) money; 1 (11.1%) family illness;
and 1 (11.1%) a family member as being the single most important factor in their career
decision.
The aforementioned responses were cross tabulated and a chi-square statistical test
performed. The Pearson chi-square test value was 53.776. This test value was compared
to the critical value of 3.84, based on a level of significance of 0.05 and 1 degrees of
freedom. The chi-square test result indicated there is a statistical relationship between
gender and students’ decision to pursue a career in nursing based on the single factor that
was identified by students in question 15 of the survey. Based on these results, the null
hypothesis for H1d, which states, there is no relationship between gender and students’
decision to pursue a career in nursing with regard to the singular factor was rejected.
Table 39 conveniently summaries whether hypothesis H1’s underlying assumptions
were either accepted or rejected. The same statistical testing format used to address
hypothesis H1’s assumptions was also used to analyze the responses to assumptions
contained in hypothesis H2 and H3.
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Table 39. Summary of Null Hypothesis H1: There is No Relationship between Gender
and Student Decision to Pursue a Career in Nursing with Regards to:
Hypothesis Null Assumption Finding:

H1a Individual family Accept Null
member and/or friend
H1b Marketing item Accept Null
H1c Societal item Accept Null for all societal items,

except personal desire for BSN
H1d Singular factor Reject Null
Research question 4, hypothesis H2 sought to determine if a relationship existed
between race/ethnicity and students’ decision to pursue a career in nursing with regards
to the following factors: individual family member and/or friend; marketing items;
societal items; and identified singular factor. The results of the null hypothesis statistical
tests are summarized in Table 40.
Table 40. Summary of Null Hypothesis H2: There is No Relationship between

Race/Ethnicity and Student Decision to Pursue a Career in Nursing with Regards to:

H2a Individuals- family member Accept null for all items,
and/or friend except brother
H2b Marketing items Accept null for all items
H2c Societal items Accept null for all items,

except cost
H2d Singular factors Accept null
Regarding H2a, chi-squared test statistics were run for each individual listed on the
survey. The critical value of the chi-square distribution at 0.05 level of significance and
16 degrees of freedom was 26.30. All chi-square test statistics for relative/friend item’s
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identified in survey question 10 was below the critical value of 26.30; except for, brother.
The chi-square test statistic for brother (28.44) was greater than the critical value of 26.30
which lead to the rejection of the null hypothesis for this item. All other relative/friend
items were accepted. Subsequently, the null hypothesis for research question H2a which
stated “there is no relationship between race/ethnicity and students’ decision to pursue a
career in nursing with regard to individuals - family member and/or friends” was
accepted for all items; except, brother
Similarly, the chi-square test statistics were run for all marketing items identified in
survey question 11 in order to test hypothesis H2b’s assumption. The chi-square test
statistic for each item was less than the critical value of 26.30 based on 0.05 level of
significance and 16 degrees of freedom. As a result, the assumption stated in null
hypothesis H2b “There is no relationship between race/ethnicity and students’ decision to
pursue a career in nursing with regard to marketing items were accepted; based on the
sample surveyed – no statistical relations existed.
Regarding H2c, chi-square test statistics were run for all societal items identified in
question 13. The test statistics for each item was less than the critical value of 28.38
based on 0.05 level of significance and 16 degrees of freedom for each societal item;
except cost. The chi-square test statistic for cost was 28.38. Subsequently, the assumption
stated in null hypothesis H2c that, “There is no relationship between race/ethnicity and
students’ decision to pursue a career in nursing with regard to societal items was
accepted; except for the item, costs.
Null hypothesis, H2d, states: There is no relationship between race/ethnicity and
students’ decision to pursue a career in nursing with regard to identified singular factors’.
127
Chi-square test statistics were run based on respondents self reported race/ethnicity and
identified single factor. The critical value of 69.83 was established based on 0.05 level of
significance and 52 degrees of freedom. Since Cooper & Schindler’s (2003) table of
critical values of the chi-square distribution only include degrees of freedom between 1-
30; the National Institute of Standards and Technology (NIST) critical value distribution
table was utilized since it provided a higher degree of freedom range (df 1-100). All
identified single item chi-square statistics were less than the critical value. Subsequently,
the assumption stated in null hypothesis H2d that, “There is no relationship between
race/ethnicity and students’ decision to pursue a career in nursing with regard to
respondent self-identified single factor’s was accepted.
Research question 4, hypothesis H3 sought to determine if a relationship existed
between age and students’ decision to pursue a career in nursing with regards to the
following factors: individual - family member and/or friend; marketing items; societal
items; and identified singular factor. The results of the null hypothesis statistical testing
are identified in Table 41.
Regarding H3a, chi-squared test statistics were run for each individual listed in
question 10 of the survey instrument. The critical value for the chi-square distribution at
0.05 level of significance and 20 degrees of freedom was 31.41. All chi-square test
statistics for relative/friend items identified in the survey were below the critical value of
31.40; except for the following individuals: mother, father, cousin, and grandfather. The
chi-square test statistics for mother was (32.72); father (42.41), cousin (37.25), and
grandfather (42.46). The chi-square test statistics for these individuals was greater than
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Table 41. Summary of Null Hypothesis H3: There is No Relationship between Age and
Student Decision to Pursue a Career in Nursing with Regards to:
H3a Individual family Accept null for all items,
member and/or except: mother, father, cousin, and grandfather
friend
H3b Marketing item Accept null for all items
H3c Societal item Accept null for all items, except cost
H3d Singular factor Accept null for all items, except: parental
expectations; opportunity to work in non-hospital
setting; flexible course scheduling/availability of
on-line classes; greater knowledge/expertise of
faculty; time required to complete nursing
program; and BSN will become only source of
profession entry into the nursing profession
the critical value of 31.41 which lead to the rejection of the null hypothesis for these
items. All other relative/friend items were accepted. Subsequently, the null hypothesis for
research question H3a which stated “there is no relationship between age and students’
decision to pursue a career in nursing with regard to individuals - family member and/or
friends” was accepted for all items; except: mother, father, cousin, and grandfather.
Similarly, chi-square test statistics were run for all marketing items identified in
survey question 11 in order to test hypothesis H3b’s assumption. The chi-square test
statistic for each item was less than the critical value of 31.41 based on 0.05 level of
significance and 20 degrees of freedom. As a result, the assumption stated in null
hypothesis H3b were accepted, “There is no relationship between respondents’ age and
decision to pursue a career in nursing with regard to marketing items.
Regarding H3c, chi-square test statistics were run for all the societal items contained
in question 13 of the survey. Out of the 17 societal items listed, 6 items had test statistics
129
greater than the critical value. The 6 societal items that had chi-square test statistics
above the 31.41 included: parental expectations (50.80); opportunity to work in non-
hospital setting (38.67); flexible course scheduling/availability of on-line classes (37.22);
greater knowledge/expertise of faculty (35.70); time required to complete nursing
program (34.16); and BSN will become only source of profession entry into the nursing
profession (32.64). Based on these findings, research question 4’s, null hypothesis H3c,
which states, “There is no relationship between age and students’ decision to pursue a
career in nursing with regard to societal items was rejected for the six items just
described and accepted for the remaining 11 items.
Null hypothesis, H3d, states: There is no relationship between age and students’
decision to pursue a career in nursing with regard to identified singular factors’. Chi-
square test statistics were run based on respondents self reported age and identified single
factor. The critical value was established at 69.83 based on a 0.05 level of significance
and 52 degrees of freedom. All singular item chi-squared statistics were less than the
critical value of 69.83. Subsequently, research question 4, null hypothesis H3d which
stated “there is no relationship between age and students’ decision to pursue a career in
nursing with regard to identified singular factor” was accepted.
Conclusion
Although the low response rate to this case study clearly limits the study’s
findings from being generalized; the quality of this case study’s responses provide
researchers with preliminary and updated insights towards understanding which
marketing strategies have most influenced students’ decisions to pursue a career in
nursing. The following paragraphs briefly highlight the eight salient observations or
130
conclusions that were drawn from this case study. Where appropriate, recommendations
for future research have been incorporated.
The first conclusion that can be drawn from this case study involves research
question one. This research question sought to understand, “What marketing related
activities, if any, have influenced nursing student’s decision to pursue a career in
nursing?” Survey questions 11 and 12 sought to answer this research question. In
question 11, nursing students used a 6-point likert scaling of very influential, moderately
influential, influential, minimally influential, not influential, or not aware of use to
indicate the level of influence that various nursing related informational and marketing
activities may have had on students’ decision to pursue a career/enroll in nursing.
Question 11 contained 21 nursing related informational and marketing items; the last item
provided students an opportunity to “write-in” a response. The marketing items most
frequently identified by student respondents as being “very influential” in their career
decision included: other (19.3%), contact by students (15.6%), nursing program brochure
(13.8%), contact by alumni (11.0%), and college bulletin (10.1%).
Question 12 of the survey instrument asked the respondents to rank from the
same list of marketing items identified in question 11; the three most important marketing
factors they felt influenced their career decision. The marketing items most frequently
identified by student respondents as being their “1st choice” included: other (21.1%),
nursing program brochure (13.8%), college bulletin (11.0%), website (9.2%), and open
house hosted by a healthcare organization (8.3%).
Findings gathered from question 11 and 12 were compared and analyzed. Based
on this comparison, the first conclusion that can be drawn from this case study is that of
131
the 21 nursing related informational and marketing items identified on the survey, student
respondents consistently identified: other, nursing program brochure, and college
bulletins as the three most important factors that influenced their career /nursing program
enrollment decision. This study’s research findings were fairly consistent with findings
reported by Curry (1994) and Cassell & Redman (1985).
The second conclusion that can be drawn from this case study involves the review
and analysis of items written-in by student respondents under the heading of “other”. The
items contained in the “other category” which students most frequently and consistently
identified as their “1st” and “most influential” choices, included: relatives/friends,
previous healthcare experience, personal interest, and personal/family illness. The “1st”
and “most influential” choice findings reported in this case study support the research
conclusions drawn by Kersten et al., (1991) and Larsen et al., (2003), that family,
personal exposure to healthcare, and work experiences tend to be the factors that most
influence students’ decision to pursue careers in nursing.
The third conclusion that can be drawn from this research involves identification of
those nurse recruitment campaign strategies that are most and least effective as measured
by student level of awareness. The nurse recruitment campaign strategies that students
most frequently recalled, included: nursing program brochures (77%), college bulletins
(67.8%), contact by students from a nursing program (56.8%); website advertisements
(53.2%); newspaper advertisements (48.6%); contact by nursing alumni (46.7%); career
fair hosted by a healthcare organization (45.8%); posters featuring nursing careers
(44.9%); radio advertisements (40.3%); and contact by nursing faculty and/or program
representative (39.4%).
132
This case study also provided insight into marketing strategies that were identified
by students as least effective or not effectively utilized by key stakeholder groups; as
measured by students’ reported lack of knowledge. According to the data, 56.0% of the
respondents indicated they were “not aware of” visits to their high school by a nursing
representative, nor were 53.2% of the students aware of a college representative visiting
their high school. 48.6% of the respondents indicated they were not aware of, either,
CDs/DVDs or television advertisement’s featuring nursing careers; nor could 47.7%
recall any videotapes pertaining to nursing careers. Slightly less than half of all student
respondents reported any awareness or receipt of letter/s from a dean or director of a
nursing program (47.7%); nor awareness of any nursing school representative at their
local/regional college fair (47.7%). 45.9% of the students indicated lack of personal
contact by an admission’s office representative; 45.9% had never received a call from
nursing faculty/program representative; nor were 45.9% of the students aware of any
open house activities hosted by nursing programs.
The fourth conclusion that can be drawn from this research addresses what
individuals are most influential in nursing students’ career decisions. Review of the
aggregate data, indicated 61.4% of the students’ felt their mother was the most influential
person in their career decision. The second most influential person was father (55%);
followed by friend (49.5%). When the data was analyzed by gender; differences were
observed. Male nursing students’ reported the person that most influenced their career
decision as their father; followed by mother and friend.
The fifth conclusion that was reached based on this case study was that a statistical
relationship existed between gender and the following two factors: (1) personal desire for
133
a baccalaureate college degree and (2) single factor that reportedly most influenced
student’s decision to become a nurse. A comparative analysis of gender by degree
program revealed the majority, 58.3% of female respondents were enrolled in an
associate’s degree program, 40.6% in a baccalaureate, and 1% in a diploma nursing
program. In comparison, of the 13 males responding to the survey, the majority 69.2%
indicated being enrolled in a baccalaureate program, followed by 30.8% in an associate’s,
and 0% in a diploma nursing program.
Likewise, a statistical relationship existed between gender and most frequently
reported single factor that influenced student’s career decision; the desire to help
others/compassion. Interestingly, of the 22 individuals that identified the desire to help
others/compassion as the primary reason for pursuing a nursing career; all 22 (100%)
were female. Of the 9 males responding to this question; 3 (33.3%) identified a more
practical explanation - the job market/security - as the single most important factor that
influenced their career decision.
The sixth conclusion that can be reached from this study is that there is no
relationship between race/ethnicity and student decision to pursue a career in nursing
with regard to marketing items and identified singular factor. However, there is a
relationship between race and two factors: (1) societal item - cost and (2) individual
family member/friend – brother. Based on the limited number of individuals in each of
the racial/ethnic groups that responded to this survey, further research addressing these
factors is recommended to confirm the findings observed in this case study.
The seventh conclusion that can be drawn from this case study is that differences
exist between the age of nursing student’s and their decision to pursue a nursing career
134
based on the level of influence involving the following factors: (1) individual family
member/friend, (2) societal item – costs, and (3) singular factors – parental expectations,
opportunity to work in non-hospital settings, flexible course scheduling, time required to
complete nursing program, etc.
Findings from this exploratory case study suggest, overall, there exist differences in
the level of influence that various marketing, societal, and familial items play in regards
to a student’s decision to pursue a career in nursing based on gender, race/ethnicity, and
age. The eighth and final conclusion that can be drawn from this research study is that,
what items ultimately influence a student to pursue a career in nursing, appear to be
different, from those marketing related activities and items designed to initially capture
students’ interest in nursing as a viable career option, and marketing materials that are
designed to promote specific nursing programs.
Recommendations
This exploratory research investigation was undertaken to bridge the gap within the
nursing literature by adding to the existing body of knowledge pertaining to the level of
influence that various marketing campaign strategies have, or may not have had, on
nursing students’ career decision. The conclusions drawn from this case study have been
described in the preceding paragraphs. As with any research, this case study has its’ draw
backs and limitations, including a low response rate that has been attributed to two
primary factors: 1) operational delays which resulted in the survey being posted between
the Thanksgiving and Christmas holidays, and 2) restriction in the association bylaws
which prohibited the researcher and board members from sending reminder
correspondence about the survey to individual nursing student members.
135
The first, and most obvious, research recommendation would be to improve the
study’s response rate by avoiding the timeframe between the holidays. The second
recommendation would be to check association bylaws, prior to starting a study, to
determine if the bylaws prohibit the researcher from sending out reminder
correspondence to association members. A third and final recommendation would be to
refine the survey instrument to concentrate on a specific factor (i.e., age, race/ethnicity, or
gender). This action will provide researchers and interested stakeholders an opportunity
to explore and understand in greater depth the differences that exist between groups of
individuals – so that marketing strategies can be developed to target the job
characteristics and attributes that are most appealing to a particular group.
In closing, Peter Drucker (1993) once proclaimed that our society has evolved from
capitalism to a society based on knowledge workers. As knowledge workers or specialist,
leaders within each area or discipline must first and foremost define who and what they
do so that the public can understand the importance of their work to society. According to
Drucker (1993),
Specialists have to take responsibility for making both themselves and

their specialty understood. The media, whether magazines, movies, or
television, have a crucial role to play. But they cannot do the job by
themselves. Nor can any other kind of popularization. Specialties must be
understood for what they are: serious, rigorous, demanding disciplines.
This requires that the leaders in each of the knowledges, beginning with
the leading scholars in each field, must take on the hard work of defining
what it is they do. (p. 217)
As a primary knowledge worker of healthcare organizations; an adequate supply of
Registered Nurses is and will continue to be an ongoing priority for organizations. As
Drucker (1993) observed, “…organizations will always be “in competition for its most
136
essential resource: qualified, knowledgeable, dedicated people” (p. 56). To assure an
adequate supply of nurses is available, healthcare organizations will need to collaborate
with key stakeholder groups; including researchers and nursing leaders, in order to fully
understand and market the nursing profession as a rewarding and challenging career.
137
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APPENDIX A: THE WEB BASED SURVEY INSTRUMENT
148
149
150
151
152
153
APPENDIX B: QUESTION 11 WRITE IN COMMENTS
Religious Org
Set up own appt with schools nursing advisor
Own hospitalization due to surgeries
Job Shadow
Just made decision to be a nurse
Med careers program in high school
LCC's program-reputation
Colleges (LCC’s) reputation
Two great friends who are nurses
Massage Therapist wanting to stay in the medical field
Spouse Want ads full of nursing opportunities
Personal investigation into job market and personal interests
LPN going back for RN
LPN going back
Brother went back to school and told me how exciting job
Am med assistant, chose to go back to get RN on own
Daughter has rare syndrome and to take care of her influenced me
Mother
Place of employment - long term care
154
Simply decided on my own to try it out
Word of mouth
U, T, N, and biggest influence are my family and relatives.
G, S, T
u, p, b
A, B, C
I knew I wanted to help and care for others and nursing allowed me to do that
Being the child of a nurse and being exposed to this career throughout my entire life.
Already an LPN for 13yrs.
155
APPENDIX C: QUESTION 15 SINGLE ITEM SURVEY RESPONSES
1. Compassionate spirit
2. Desire to help people
3. My Own Health Experiences
4. Talked to a Nurse
6. Volunteering and talking to my aunt
7. Job Shadow
8. Comment eligible
9. Job Security
11. Job Availability/flexibility
12. The job of a nurse - personal attributes
13. Want to help people
14. Personal Growth
15. Multi Factorial
16. The rewarding experience
17. Relatives who are in medical fields
18. Want to serve the under served population
19. Want to be CRNA
20. Want to help people
21. Family experience with healthcare
22. My mother, opportunity to go where ever I want, job security, $
23. The desire to be successful and have job security
24. High school medical careers program
25. Patient advocate role
26. Working in ER as a tech
27. Job Security
28. $
29. Myself
30. "Psychic Dream" Didn't want to go into nursing- college writing prof mentioned
"you are in nursing, right?" looked into program had most pre req's done -
applied"
31. Job Market
32. Family
33. Image of Nursing
34. My father who passed from cancer
35. Needed a fufilling job
36. My mother
37. Helping people
38. Life
39. What I loved to care for people
40. My mom a nurse
156
41. Family
42. Income
43. Personal Interest
44. Better Opportunities
45. All different areas you can study
46. Life long goal put aside
47. Always wanted to be a nurse
48. Job Relocation
49. My mom
50. Money and job security
51. Opportunities and advancement many areas
52. Job security
53. Have been a tech for a long time and wanted to be more
54. Its what I've always wanted to do
55. Flexibility
56. Love of special needs children and foster care
57. Wanting to help others
58. Grandmother
59. Desire to make a difference
60. Only BSN program I got into
61. Daughter's medical condition rare syndrome
62. Mother
63. To care for people while gaining great satisfaction
64. I just have always wanted to be a nurse
66. I have always wanted to be a nurse to help people
67. Being a nurse aide for 15 years
68. Flexibility with good pay
69. I want to help others
70. Having a child who had health issues
71. Want to get a rewarding career out of it
72. Healthcare employer
73. Something I always wanted to do
74. The desire to have a job with socially redeeming value
75. My own goals personally and my kids
76. Financial
77. Care for terminal brain tumored family
78. desire to help people
79. Wanting to help others
80. My Wife
81. personal aspirations
82. personal drive
83. The love for others
84. The nursing care I received when diagnosed with cancer
157
85. Desire to help and care for people
86. "The paycheck that you don't take to the bank," as my mom calls it.
87. to help others become well, live comfortably and have a compassionate care
giver.
88. job opportunities
158

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THE NURSING SHORTAGE: A CASE STUDY OF NURSING STUDENTS’ BELIEFS

AND ATTITUDES TOWARDS VARIOUS MARKETING STRATEGIES DESIGNED

TO RECRUIT ADDITIONAL INDIVIDUALS INTO THE NURSING PROFESSION

A Dissertation Presented in Partial Fulfillment

Of the Requirements for the Degree

All rights reserved.

UMI Microform 3264303

ProQuest Information and Learning Company

AND ATTITUDES TOWARDS VARIOUS MARKETING STRATEGIES DESIGNED

TO RECRUIT ADDITIONAL INDIVIDUALS INTO THE NURSING PROFESSION

has been approved

JOHN KLOCINSKI, Ph.D., Faculty Mentor and Chair

JEAN GORDON, Ph.D., Committee Member

NATHANIEL TYMES, Ph.D., Committee Member

ACCEPTED AND SIGNED:

This research study was undertaken to understand several important dimensions

nursing?” Secondary research questions, included: What type(s) of nursing recruitment

have influenced nursing students’ decisions to pursue a career/enroll in a nursing

program. Do student responses to factors that influence their decision to pursue a

career/enroll in a nursing program differ based on age, gender, or ethnicity?

a student to pursue a career in nursing, appear to be different, from those marketing

of hardwork, perseverance, and the importance of an education. To my husband, who

dream. Thank you!

following individual members of my team who have supported me in numerous ways

hours prompting and encouraging me, reviewing my drafts, offering recommendations

test and survey of association members. Kristen Salomonson, Assistant Dean of

aspects of developing and implementing my online survey. And to my brother, Steve

Rewers, for always inquiring, “How’s it going?”

List of Tables viii

Introduction to the Problem 1

Background of the Study 6

Nursing Workforce Supply and Demand Forecasts 6

Factors Contributing to the Nursing Shortage 9

Statement of the Problem 12

Purpose of the Study 14

Significance of the Study 16

Assumptions and Limitations 24

Nature of the Study 26

Organization of the Remainder of the Study 26

CHAPTER 2: LITERATURE REVIEW 27

Image of the Nursing Profession 27

Development of Nurse Recruitment Campaign Strategies 45

Key Stakeholder Recommendations 45

Recent Nurse Recruitment Strategies 47

Johnson & Johnson’s Campaign for Nursing’s Future 50

Literature Review Summary 54

Sample and Population 58

Data Collection Procedure 62

Validity and Reliability 66

CHAPTER 4: ANALYSIS AND PRESENTATION OF FINDINGS 68

Data Presentation and Analysis 69

Discussion of Research Question 1 117

Discussion of Research Question 2 119

Discussion of Research Question 3 121

Discussion of Research Question 4 122

APPENDIX A: Web Based Survey Instrument 148

APPENDIX B: Question 11 Write in Comments 154

APPENDIX C: Question 15 Single Item Survey Responses 156

Table 1: Currently in Nursing Program by Type of Nursing Program 70

Table 2: Currently in Nursing Program by Gender 71

Table 3: Gender by Race/Ethnicity 71

Table 4: Gender by Type of Nursing Program 72

Table 5: Age Distribution 72

Table 6: Gender by Age 73