Intention and motivation to pursue higher education among registered nurses and midwives: a cross-sectional study during COVID-19

Introduction

Higher education is the next step in the academic ladder for nurses to obtain a baccalaureate or a post-graduate degree like master’s and doctorate. It is known that nurses pursuing higher education enhances educative, research, administrative, and patient outcomes (AACN, 2021; Bindon, 2017; Mbombi & Mothiba, 2020). In addition, due to the dynamic developments in health treatments and care, the drive to elevate the nursing profession through higher education becomes much more significant and necessary for nurses and midwives (Marć et al., 2019; Qalehsari et al., 2017; Xing et al., 2018). Nursing is continuously perceived as an evolving independent professional group capable of managing patients and taking over more tasks and responsibilities (Courtenay, 2019; Karami et al., 2017). Registered nurses and midwives can now progress to be advanced practitioners where they can provide higher levels of care in acute and primary healthcare or climb the organizational ladder as administrators or managers. In some countries, obtaining higher education is considered for salary increments and other remunerations (Broussard & White, 2014). Furthermore, the seemingly endless array of online studies and flexible multifaceted nursing programs resulted in more options for nurses to consider, especially in terms of cost, length of study, number of credits required, residency requirements, financial aid, and many more (Broussard & White, 2014). These provide great motivation for nurses and midwives to pursue higher education.

However, the American Mobile Nurses (AMN) RN Survey in 2019 showed that only 18% of the 20,000 nurses who participated in their study were enrolled in a higher education program, and only one in five had a plan to pursue higher education to become an advanced nurse practitioner (Healthcare, 2019). According to the current data from the American Association of Colleges of Nursing (AACN, 2021), declines were seen for two consecutive years in the enrollment of registered nurses with diploma to BSN (2.6%) and PhD nursing Programs (9.5%) while an increase in enrollment was seen in entry-level BSN (5.6%), master’s (4.1%), and doctor of nursing practice (DNP) programs (8.9%). Despite the number of enrollments in master’s and DNP programs, there is still a lack of nurses with post-graduate degrees to promote growth and diversification to reduce health disparities (Davis & Morrow, 2020; Poghosyan & Carthon, 2017). In addition to AACN’s report, thousands of nurses were not accepted in colleges and universities due to the shortage of clinical sites, faculty, and resource constraints (AACN, 2021). The National Academy of Medicine, formerly known as the Institute of Medicine (Shalala et al., 2011), published a landmark report recommending that 80% of American RNs should be prepared at the baccalaureate level by 2020. While the number of RN to BSN graduates increased 236% between 2009 and 2019, the goal of 80% has not been met and has reached just 59% in 2019 (Wakefield et al., 2021).

Furthermore, it is undeniable that the COVID-19 pandemic had brought a lot of challenges to nurses and midwives and disrupted the educational system globally. Nurses and midwives were stretched too thin to fill the gaps in the workforce during the pandemic. This caused a tremendous amount of stress and burnout resulting higher turnover intentions among nurses and midwives. Numerous universities and colleges had to close to minimize the transmission of the virus. Classes had to move from face-to-face to online in limited time and preparation. Clinical learning environments were suspended thus affecting learning opportunities. According to the AMN Healthcare Survey 2021, 50% of participating nurses said that COVID-19 impacted their educational plans (AMN, 2021). The effects of COVID-19 on nurses and midwives and education can serve as a catalyst to either improve the future of graduate nursing or discourage them in pursuing higher education (McCarthy et al., 2020). Preparing nurses with higher academic degrees is an essential step in advancing nurses. This inspired the current study to examine the impact of COVID-19 in the intentions and motivations of nurses and midwives, including perceived available resources and barriers, to pursue higher education (Nashwan et al., 2017).

The findings of this study will help nursing leaders identify resources and academic collaborators that can assist nurses and midwives in achieving their personal and professional goals, which will positively match with the organizational goals. Furthermore, understanding the impact of COVID-19, the motivators and barriers for pursuing higher education can help nursing leaders strategically plan the growth of nursing and midwifery careers, thus, promoting sustainability and quality healthcare. To the researchers’ knowledge, this is the first study to describe and examine the impact of COVID-19 in the intention and motivation of registered nurses and midwives to pursue higher education.

Methods

A descriptive, cross-sectional study was conducted to determine the impact of COVID-19 to the nurses and midwives’ intention and motivation to pursue higher education. An online survey was sent approximately to 12,000 nurses across Hamad Medical Corporation (HMC) using the corporate’s official email. HMC recruits the highest number of registered nurses and midwives in Qatar, where 12,000 nurses and midwives are working across different hospitals, clinics, home care, and residential services. HMC has seen a 12% increase in nursing staff from 2016 to 2018 despite the international shortfall of registered nurses and midwives (Al-Harahsheh et al., 2020). The sample size was calculated based on the number of nurses working in HMC, and with a CI of 95% (50% response distribution and 5% margin of error), the estimated sample size was 371. The online survey link was sent to all participants via their official corporate email, where it was accompanied by a research information sheet explaining the expectations and principle of informed consent. The co-investigators collected the data; which was coded and double-checked by the PI (the PI was the link between data and code list); the data were stored in a protected computer at HMC in accordance with the corporate policies and guidelines.

Statistical analysis

Data were analyzed using R software version 4.0 (Vienna, Austria). Descriptive statistics were used to analyze the distributions of responses on the questionnaire items and subscales. Inferential statistics were focused on finding the correlation between variables. The participants’ scores on different variables were compared using Chi-square, Fisher Exact, and Somer’s D test at a confidence level of 95% as appropriate. In addition, the construct validity and internal consistency were evaluated and revealed satisfactory results (The overall Cronbach’s alpha for the 3 main variables (14 items) was 0.72 and for Motivating Factors (4 items), Potential Resources (6 items), and Barriers to Pursuit of Advanced Education (6 items), 0.56, 0.82, 0.79, respectively).

Results

A total of 513 eligible nurses and midwives participated in the survey that ran from May to July 2021. The first part of the results section will discuss the basic socio-demographic characteristics of the respondents. The second section will discuss the motivations of the sampled nurses and midwives in pursuing advanced nursing education. The third section will present the potential resources available to the nurses and midwives if they wish to pursue higher education and their perception of how these resources can help them in their academics. Lastly, the fourth section will discuss the perceived barriers preventing nurses and midwives from pursuing advanced higher education in nursing.

Demographic profile

About 97% of the respondents are registered nurses (charge nurses/clinical nurses), while only 2.9% of the respondents are midwives and about 3 in every 4 respondents are female (76.61%). Most of the respondents have reached a bachelor’s degree (72.32%), 16% have a diploma, 11% have a post-graduate degree, while only 0.39% of them have an associate degree. The majority of the respondents have been working for about 11–15 years (35.38%) and a third had more than 60 h of continuing education for the past year. Based on the results, the sample is mostly composed of highly experienced nurses. Lastly, only 10.14% of the respondents are native residents of Qatar, while about 90% of the respondents came from a foreign country (Table 1).

Motivations to pursue higher education

This section will present the degree of motivation of the nurses and midwives in pursuing advanced nursing education as well as the factors that motivate them. This will also present their plan if they want to pursue higher education. Table 2 presents the level of motivation of the survey respondents in pursuing advanced nursing education. Based on the table, almost 4 out of 5 respondents are highly motivated in pursuing higher nursing education. About 17% are somewhat motivated, and only 4% of the respondents are not motivated to pursue higher education at all.

Figure 1 presents the main motivating factors that drive the nurses and midwives to pursue higher education. Based on the figure, the main motivating factors are achieving professional goals and opportunities for a job promotion. Job stability was the third most important while the salary increase was the least important. Table 3 presents the respondents’ plans for when they may begin pursuit of higher education. The majority of respondents wanted to pursue a master’s degree in nursing (61.94%). About 11% of the respondents are willing to pursue a Ph.D. degree in nursing. Meanwhile, around 3% of the respondents want to pursue a non-nursing degree. Table 4 displays the top 10 most preferred specializations the nurses and midwives are interested in pursuing. Leadership/Management courses emerged at the top for more than 45% of the respondents. About 32% of the respondents want to specialize in nursing education, while 31% of them want to specialize in the medical-surgical field. The table shows that most of the nurses want to specialize in fields that will lead them to a higher position.

Figure 1:

Motivating factors for nurses and midwives to pursue higher education.

Table 5 presents the chi-square test of association between the motivation of nurses and midwives on pursuing advanced nursing education and their demographic profiles. The variables profession, highest educational attainment, years of experience, and the number of hours of continuing education for the past year did not exhibit a significant relationship with their motivation to pursue higher education. On the other hand, gender was significantly associated with their motivation to pursue higher education (p-value = 0.04). In particular, the proportion of male respondents who are not interested in pursuing higher education is 2.38 times greater than the number of female respondents who are not interested in pursuing higher education. Moreover, the proportion of female respondents who are somewhat motivated to pursue higher education is about 60% more than the number of male respondents who are somewhat motivated to pursue higher education. Meanwhile, there is no significant difference in the proportion of male and female respondents who are highly motivated to pursue higher education.

Potential resources

This section presents the potential resources that may be available to the nurses and midwives if they wish to pursue higher nursing education. This section will also present the relationship between the motivation of the nurses and midwives towards taking higher education and their perceived value of the resources available to them.

Figure 2 presents the available programs for nurses and midwives if they want to pursue higher nursing education. Two hundred and forty-five (245) out of 494 respondents or about 49.6% of the respondents view that the face-to-face education program would be the greatest help to them. Meanwhile, around 46% of the respondents or 209 out of 494 respondents, reported that an online education program would provide much assistance to them if they enroll in advanced nursing programs. Finally, about 39% of the respondents said that accelerated programs would provide great help to them.

Figure 2:

Potential resources available for higher education – available programs.

Figure 3 displays the available external support for nurses and midwives if they want to pursue higher nursing education. Based on the figure, more than 74% of the respondents said that having a flexible work schedule would provide much assistance for pursuing higher education. Moreover, more than 71% of the respondents expressed that having a scholarship/stipend or tuition assistance will help them if they want to pursue higher education. On the other hand, relatively few respondents viewed that having a colleague enrolling in the same program would be a great help to them.

Figure 3:

Potential resources available for higher education – external support.

Aside from knowing what resources are available to the nurses and midwives, the researchers also looked at the respondents’ experience using online modes of learning. Based on the analysis, most of the respondents have experienced an online learning session. However, most of them preferred a hybrid learning environment (57.09%) over pure online learning (22.27%) and pure traditional or face-to-face (20.65%) modes of learning. This suggests that most nurses and midwives are slowly embracing online learning but still want to maintain the traditional one (see Table 6).

Table 7 presents the cross-tabulation of motivation to pursue higher education of the nurses and midwives and their perceived level of assistance from the available resources presented earlier. For both levels of motivation, most of the respondents perceived that the available resources would be a great help to them if they pursue higher education, while only a few thinks that the resources would provide a little assistance to them. Somer’s Delta was used to test if a relationship exists between the motivation to pursue higher education of the nurses and midwives and their perceived level of assistance from the available resources. Somer’s D is used to test the association between two ordinal variables. Its value ranges from −1.0 to 1.0, with values close to 0 indicates no significant association. The computed test statistic is 0.032 with a 95% confidence interval of ( − 0.0327 , 0.0968 ) . Since the confidence interval estimate contains 0, the researchers conclude that there is no significant association between the motivation to pursue higher education of the nurses and midwives and their perceived level of assistance from the available resources.

Perceived barriers

This section presents the perceived barriers that prevent the nurses and midwives from pursuing higher education. The relationship between the motivation of nurses and midwives to pursue higher education and the perceived influence of the barriers in preventing them from pursuing higher education is presented. Based on the data, the main reason why respondents choose not to pursue higher education programs was because of the high cost of the programs. More than 71% of the respondents said that the program’s cost highly influences their decision not to pursue advanced nursing education. Moreover, about 52% of the respondents said that the lack of availability or accessibility of the nursing programs prevented them from pursuing higher education, while about 49% of the respondents said that they could not pursue additional education because of their work schedule. Only 31% of the respondents said that family commitments prevented them from pursuing higher education (see Figure 4).

Figure 4:

Barriers in pursuing higher education – external reasons.

Figure 5 presents the internal reasons of the nurses and midwives for not pursuing a higher education degree. The personal reasons do not hinder the respondent as much compared to the external barriers. For example, only 12% of the respondents said that they do not want to enroll in higher education programs anymore because they are close to their retirement age, while about 11% of them said that their reluctance to embrace new technology prevents them from pursuing higher education. Overall, these barriers have little effect on the decision of the respondents to pursue higher education.

Figure 5:

Barriers in pursuing higher education – personal reasons.

The researchers also wanted to explore the educational history of the respondents. Upon investigation, about 129 nurses and midwives, or about a quarter of the sample, have quit a higher education program during the past year. The main reasons why they quit were because of the pandemic where they have little time to complete their academic requirements and because of financial reasons. Also, about 28% of the respondents said that the COVID-19 pandemic has a negative effect on their desire to go for higher education (see Table 8).

Table 9 presents the cross-tabulation of motivation to pursue higher education of the nurses and midwives and the influence of the barriers presented earlier. For all motivation levels, most of the respondents perceived that the barriers have a considerable influence on their motivation to pursue higher education. Somer’s Delta was used to test if a relationship exists between the motivation to pursue higher education of the nurses and midwives and the barriers. The computed test statistic is − 0.048 with a 95% confidence interval of ( − 0.1264 , 0.0288 ) . Since the confidence interval estimate contains 0, the researchers conclude that there is no significant association between the motivation to pursue higher education of the nurses and midwives and the level of influence of the barriers.

Table 10 presents the chi-square test of association between the impact of COVID-19 pandemic and nurses and midwifes intention to pursue higher education. The variables profession, gender, highest educational attainment, and the number of hours of continuing education for the past year show that there is no significant relationship with their opinion about the impact of COVID-19 pandemic on motivation to pursue higher education, X² (2, n=513) = 0.49, p=0.778, X² (2, n=513) = 3.0, p=0.231, X² (n=513) = 11.07, p=0.058, X² (8, n=513) = 11.70, p=0.165 respectively.

On the other hand, years of experience was significantly associated with the impact of COVID-19 pandemic on nurses and midwifes intention to pursue higher education, X² (12, n=513) = 23.41, p<0.05. In particular the proportion of those with experience of 31 years and above are positively affected by COVID-19 pandemic to pursue higher education.

While the proportion of those with experience between 16 and 20 years are negatively affected by COVID- 19 pandemic to pursue higher education.

Discussion

Many factors can influence the intention and motivation of nurses and midwives to pursue higher education. The results of this study both supports and disagrees with the findings of previous research studies. This study also described the level of motivation of nurses and midwives and the motivators and potential resources that influence their intent and barriers that dissuade them from pursuing higher education. Furthermore, this study was able to discover relationships between different variables and intention to pursue higher education and the impact of COVID-19 on the decision.

Only 10.14% of the respondents are nationals while 89.86% came from other countries. Nurses in Qatar has been predominantly led by expatriate nurses (Tieleman & Cable, 2021). The image of nursing in Qatar and other middle east countries like KSA (Kingdom of Saudi Arabia) faces challenges and resistance because of the negative conception of nursing and cultural roles of women which prompts them to recruit foreign nurses (Alsadaan et al., 2021; Levers, 2019; Tieleman & Cable, 2021). Furthermore, nurses are one of the top occupational groups with the highest migration rate which could be attributed to poor employment conditions in the source countries, globalization, and worldwide shortages of nurses (Lafortune et al., 2019). This finding warrants further investigation.

Most nurses and midwives in this study are highly motivated to pursue higher education regardless of their demographic status, the available resources, and perceived barriers which is not the case in other countries (AACN, 2021; Faller & Gogek, 2018; Mbombi & Mothiba, 2020). The nurses and midwives in the study are highly experienced university graduates; of the total respondents, 72.32% hold a bachelor’s degree, and 11% have a post-graduate degree (Al-Harahsheh et al., 2020). In comparison, in the United States, 27% of nurses hold an associate degree, 54% baccalaureate degree, 12% hold a master’s degree, and 1% with a doctoral degree (“AMN Nursing Surveys”, 2021). Internationally 10% of the nurses hold a diploma or certificate in nursing, 77% with a Bachelor of Science in nursing, 12% with master of science in nursing, and 1% with a doctoral degree (AMN, 2021) (“AMN Nursing Surveys”, 2021). Furthermore, most nurses and midwives in the study are willing to pursue a master’s degree within two years, mostly interested in leadership and management. This level of motivation and openness to pursue higher education can advance the nursing profession. Nurses and midwives who are professionally ready perceived that obtaining higher education is an efficient way of adapting to the changes in the field of healthcare (Marć et al., 2019)., Most of the nurses and midwives who are in the mid-level of their career are thinking about improving the quality of care and advancing in leadership roles (Price & Reichert, 2017). In the study by Price and Reichert (2017), continuing professional development was understood by mid-career nurses as significant in terms of maintaining competency, providing quality care, and enhancing future career opportunities (Price & Reichert, 2017).

Interestingly, a salary increase is the most negligible motivating factor for nurses and midwives to pursue higher education. Numerous studies have discovered that salary can be associated with job satisfaction and motivation; however, that is not the case with pursuing higher education (Ayalew et al., 2019; Botchwey, 2021). Due to the high number of employment opportunities with entry-level education, good pay, and remuneration, obtaining a higher salary is not a priority (Faller & Gogek, 2018). The pursuit of higher education among nurses and midwives is an intrinsic desire to improve themselves or their quality of care.

Most nurses and midwives in the study said that face-to-face programs would be the greatest help in their pursuit of higher education. However, considering online learning as an alternative may also be suitable for them. More than half of the respondents have experience in online learning, and 57.09% prefer a hybrid setup (both online and face-to-face programs). In a traditional classroom setting, students get to interact with peers and professors regularly while remote learning leads to feelings of loss and loneliness (Wallace et al., 2021). Providing nurses and midwives more option to pursue higher education, like online learning, makes it more convenient, considering flexibility and accessibility. Most nurses and midwives said that having a friend or colleague helps in pursuing higher education. Peers and faculty helps in developing a sense of community and belongingness and strategies for students and professors to collaborate (even remotely) should be considered (Wallace et al., 2021).

In an overview, the barriers that the respondents said to have higher influence (cost, available nursing programs, and work schedule) are external reasons which are out of their control. In a 2017 survey on graduate nursing students, a median amount of loan debt among master’s doctoral and advanced practice degrees was between $40,000 USD and $54,999 USD (AACN, 2021). Due to that heavy financial burden, it is not surprising that most registered nurses and midwives will forego higher education (Bekemeier et al., 2021; Bindon, 2017; Faller & Gogek, 2018; Kelly et al., 2020). Mbombi and Mothiba (2020) reported that nurses verbalized that they do not perceive any financial gain from pursuing higher education whilst highlighting that their families’ financial responsibilities are far more important (Mbombi & Mothiba, 2020). In this study, 71% of nurses and midwives who participated said that scholarships or stipends are great help for them in their pursuit of higher education. Most nurses and midwives perceived a lack of availability and/or accessibility to nursing programs. This warrants further investigation. During this study there was only one nursing school in the country of study., The majority of nurses and midwives claim that they do not have the time to accomplish postgraduation requirements. Different studies show that exhaustion from work leads to failure to accomplish post-graduate studies among nurses and midwives (Kelly et al., 2020; Mbombi & Mothiba, 2020). Most nurses and midwives who participated in the study expressed that a flexible work schedule would assist them in pursuing higher education.

With regards to the impact of COVID-19, most nurses and midwives in the study denied that the pandemic had any effect on their intention and motivation to pursue higher education. While 27.88% mentioned that COVID-19 negatively impacted their intention to pursue higher education, 18.91% mentioned that COVID-19 inspired them to pursue higher education. Comparing it to the 2021 survey of AMN healthcare, approximately 50% of nurses said that the pandemic affected their educational plans (“AMN Nursing Surveys”, 2021). According to the survey, the percentage of nurses who were enrolled in a program remained the same at 18% in 2021 and 2019 but the percentage of nurses who want to pursue higher education in the next three years noticeably increased suggesting that the COVID-19 pandemic motivated a lot of nurses to pursue higher education (“AMN Nursing Surveys”, 2021). In Wallace et al. (2020), despite the challenges of the pandemic nursing students demonstrated remarkable sense of resilience and perseverance (Wallace et al., 2021). In this study, the respondents who have resigned from a higher education program said that one of the reasons was the COVID-19 pandemic. During the COVID-19 pandemic, nurses and midwives were overwhelmed and worn out by the workload, making it challenging to complete the program (Nashwan et al., 2020a, 2021a; Swift et al., 2020; Villar et al., 2021)., schools and universities were forced to cancel their face-to-face classes and moved to online settings. Although remote learning, new uses of simulation and interactive learning modalities and new models for experiential learning are not new concepts but the development and implementation were accelerated during the pandemic (Leaver et al., 2022). Attending classes online is considered as a barrier in the study of Gillett-Swan (2017). The challenge here are the existence of technical difficulties, lack of interaction, least focused students on online teaching and learning, and find online learning unsatisfying (Farsi et al., 2021; Yusuf & Ahmad, 2020). In addition, nurses and midwives with children find it difficult to pursue higher education because they had to assist their children in their online classes as well (“AMN Nursing Surveys”, 2021). On the other hand, this can serve as an opportunity to explore and invest on improving digital technologies for education. One study showed that given the support of teaching staff and universities’ public relations, online learning could be satisfying (Aristovnik et al., 2020). Therefore, graduate schools and nursing faculties should consider the impact of pandemics on their students and create flexible options for meeting course requirements.

The findings of the study revealed that profession, gender, highest educational attainment, and hours of continuing education do not have any association with COVID-19 and their intention and motivation to pursue higher education. This is true in some studies where no relationship exists in the nurses’ demographics, like gender, age, educational attainment, and the COVID-19 pandemic (Allobaney et al., 2022; Nashwan et al., 2021a). Interestingly, the findings also suggested that years of experience have a significant impact in the intention to pursue higher education where nurses and midwives with lengthier experience were inspired by the COVID-19 pandemic. This is in contrast with other studies where the more experienced nurses were negatively impacted by the COVID-19 pandemic (Falatah, 2021; Nashwan et al., 2021b). This warrants further investigation and the researchers of this study recommends exploration of other variables like age, marital status, physical health, and exposure to COVID-19 in the intention and motivation to pursue higher education.

This study only described the impact of COVID-19 in the intention and motivation of nurses and midwives to pursue higher education, their potential available resources, and perceived barriers. The researchers recommend that a yearly survey for nurses and midwives throughout the region should be conducted to identify the status and challenges in their pursuit of higher education which can guide the development of solutions. Future researchers should also investigate the association of other variables in the intention and motivation to pursue higher education since some of the data in this study were underrepresented.

Conducting a qualitative study will help explain the phenomenon on the nurses and midwives’ perceived barriers in pursuing higher education. We also recommend expanding the research to multiple regions or countries. Lastly, investigating the perception and image of nurses in the region of nurses would be very beneficial in the sustainability of the profession. Nursing leaders should consider the development of policies that would create flexible work schedules or allow study leaves for all nurses and midwives. In addition, scholarships, stipends, or any form of tuition fee assistance are necessary to help nurses and midwives pursue higher education. Nursing colleges should communicate the challenges of COVID-19 and improving the quality of distance education (Farsi et al., 2021; Nashwan et al., 2020a, 2020b).

Limitations

The study, despite its adequate methodology and findings, has certain limitations. The major limitation in this study is that the online form of administration can raise concerns in terms of participation such as sampling bias and data validity. Although the invitation was sent to about 12,000 nurses and midwives the response rate was very low at 4.28%. The non-respondents were either too stressed to complete the survey or not interested in participating. Second, self-reports like surveys require both recall and insight, where recall bias and social desirability bias may exist. It is reasonable to assume that some nurses and midwives may under/overestimate their perception of the selected aspects in their experiences during COVID-19 and their intention and motivation to pursue higher education. Finally, the study was limited in scope since the respondents came from a single site, thus may have inherent differences from other regions.

Conclusions

Despite the challenges and disruption of the COVID-19 pandemic, nurses and midwives are highly motivated to pursue higher education as demonstrated by their desire to achieve their professional goals which is regardless of their demographic status, the available resources, and the potential barriers., the eagerness of the nurses and midwives to pursue higher education, which is rooted in their desire to grow in their profession, and readiness to accept online learning can be used as leverage by the nursing leaders to develop supportive policies and frameworks to promote the autonomy and sustainability of the profession in any country.