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Who Wants To Be a Nurse? Understanding Emirati Female Students’ Knowledge and Attitudes About Nursing as a Career

Maymoun, Nazneen; Sohail, M. Sadiq

Author Information
Nursing Education Perspectives: May/June 2020 - Volume 41 - Issue 3 - p E14-E19
doi: 10.1097/01.NEP.0000000000000659


Nurses are essential to health care and comprise the largest component of the health care workforce (Fort, Deussom, Burlew, Gilroy, & Nelson, 2017). An increasing gap between supply and demand has triggered a shortage of nurses across the globe (Haczyński, Ryć, Skrzypczak, & Suchecka, 2017). The shortage of nursing professionals is a multifaceted phenomenon requiring intervention from various stakeholders. Although numerous studies have attempted to understand and develop strategies for overcoming the nursing shortage, there is a need to consider a wider perspective globally as well as local causes leading to the nursing shortage (Marć, Bartosiewicz, Burzyńska, Chmiel, & Januszewicz, 2019). A systematic review of literature concluded that there are complex reasons triggering the shortage (Chan, Tam, Lung, Wong, & Chau, 2013).

Several studies have also been undertaken on strategies to attract and retain nursing professionals (Kroezen et al., 2015). Most of these have been undertaken in developed countries. A recent study in the United States found that the educational system has failed to address factors dampening the graduation of sufficient numbers of students (De Chesnay & Anderson, 2019).

The nursing shortage is no different in Middle Eastern nations. The shortage of qualified nurses in these countries has been alleviated by hiring expatriate nurses, primarily from the Philippines, India, Egypt, and other Arab and Asian countries. However, for the last several years, with rising unemployment, governments have made efforts to provide jobs to the local population. Nations have put employment programs in place and coined terms such as Saudization in Saudi Arabia, Omanization in Oman, and Emiratization in the United Arab Emirates (UAE).

There is a paucity of research in the UAE on the reasons for the shortage of local nurses and how to attract students to the profession. This study is an attempt to fill that gap. As nursing is predominantly a female profession and public schools in the UAE segregate high school students by gender, the target population for this study was students from female schools. The purpose was to understand high school students’ attitudes and knowledge about the nursing profession and their intent to pursue this profession. The findings will be useful to policy makers and nursing management for devising appropriate recruitment strategies.


The UAE has a high-quality health system characterized by well-equipped, well-staffed, and qualified health care providers. The competency of nurses is taken seriously and with high stakes, including legal consequences for malpractice (Aqtash et al., 2017). Qualified Emirati nurses are required to have a baccalaureate and master’s degree to work as RNs in public hospitals; expatriate nurses require a bachelor’s in nursing with at least two years' experience. In addition, nurses are required to pass a written exam in English before obtaining a license to work; registration and licensure are under the jurisdiction of the Health Authority of Abu Dhabi, Dubai Health Authority, and the UAE Ministry of Health (Brownie, Hunte, Aqtash, & Day, 2015).

Professional competence is determined by the Ministry of Health with input from employers and the nursing profession (UAE Ministry of Health, Health Authority Abu Dhabi, & Dubai Health Authority, 2014). For RNs in public hospitals, there is a well-established competency validation program; a competency matrix defines the nature and scope of mandatory, general, and unit-specific competencies. Mandatory competencies are validated by a senior nurse during orientation and are repeated yearly; general competencies are validated during probation and may be validated again during the course of employment; unit-specific competencies are assessed in real nursing situations during probation and revalidated every second year (Aqtash et al., 2017). The competency evaluation is undertaken on an individual basis and is designed to meet the region’s need for general nurses with specialist capabilities.

With a shortage of local nurses, the UAE health care system has relied on expatriate nurses since the early 1960s (El-Haddad, 2006). The UAE has only 31 nursing and midwifery staff for every 100,000 people, far below the average in many developed countries. In the United Kingdom, for example, the average is 88; the average is 93 in France and 115 in Germany (World Health Organization [WHO], 2015). The average is also lower than in most other Middle East nations, for example, the average in Kuwait is 45; in Saudi Arabia, it is 48; and in Qatar, it is 118. The percentage of local nurses is 9, far lower than in Bahrain (49 percent) and Oman (77 percent; WHO-EMRO Report, 2006). A further concern is that the demand for nursing professionals is increasing. It has been projected that UAE will need 13,000 new nurses by 2022 (US-UAE Business Council, 2016). Considering the vision to “Emiratize” the workforce, the need for recruiting nurses will be a priority.

Much of the research on nursing career choice has focused on high school students (Wilkes, Cowin, & Johnson, 2015). Cohen, Palumbo, Rambur, and Mongeon (2004) found that, in general, nursing is considered an unattractive profession for several reasons, including the type of work nurses must do, their limited decision-making opportunities, and salary. However, studies have also shown that altruistic reasons — what students can do as nurses (care, help, make well, contribute to society and community) — will positively influence the decision to pursue a nursing career (Wu, Low, Tan, Lopez, & Liaw, 2015).

Studies have shown that career choice varies across cultures. In Asian cultures, for example, career choice is influenced by the family (Law & Arthur, 2003); negative family views can be a deterrent in the selection of nursing as a career (Neilson & Jones, 2012). Students in the United States and other Western nations are more likely to make a career choice independently, whereas students in Asian countries are more likely to value parents’ expectations (Liaw et al., 2016; Oettingen & Zosuls, 2006). In the Middle East, a sample of Kuwaiti students perceived nursing to be a physically exhausting profession (Al-Kandari & Lew, 2005).


This study is rooted in early theories of human behavior using psychological determinants. The theory of reasoned action (TRA), put forward by Fishbein and Ajzen (1975), proposes that attitudes, along with behavioral norms, predict intention. TRA has been used extensively in social and psychological disciplines (Sohail & Al-Jabri, 2017). The model proposes that attitude is an important determining factor with regard to the decision to perform or not to perform a particular action (Hostler, Yoon, Guo, Guimaraes, & Forgionne, 2011). The theory has been used to test attitudes and their relation to intention in health care, business, and social psychology (Hackman & Knowlden, 2014; Holden & Karsh, 2010; Zarzuela & Antón, 2015). It has also been applied to learning motivation, occupational tendency, and consumer behavior (Bagozzi, Lee, & Loo, 2007; Weber, Martin, & Corrigan, 2007; Yarbrough & Smith, 2007). High school students have many possible career choices. How female students view a nursing career will influence their choice to pursue a nursing career. We hypothesized that attitude will be an independent predictor of intention to pursue nursing education (Hypothesis 1).

The extent of knowledge an individual has about a product or object will also influence behavioral intention (Park, Mothersbaugh, & Feick, 1994). This has also been emphasized in the nursing profession (Danielson & Berntsson, 2007). The construct of knowledge is a combination of objective and subjective knowledge (Alba & Hutchinson, 1987). Objective knowledge refers to precise information, which one has in memory. Subjective knowledge refers to one’s perception of what and how much one knows about something. It is argued that the extent of knowledge will influence one’s intention to induce a behavior; hence, we hypothesized that knowledge will be an independent predictor of pursuing nursing education (Hypothesis 2).

This study examines the simultaneous interaction effect of attitude and knowledge on intention to pursue nursing education. Interaction effects in analytical models provide a better representation and understanding of the relationship between dependent and independent variables and help explain variability in the dependent variable (Kasim, 2011). Studies in social psychology conclude that knowledge moderates the attitude-behavior relationship (Davidson, Yantis, Norwood, & Montano, 1985). Analysis of the interaction between independent variables makes a significant contribution to generalization of results. Therefore, we further hypothesized that attitude and knowledge will interact to influence nursing education (Hypothesis 3).



Multi-item measurement scales were used to operationalize the dependent and independent variables. The scales and constructs adopted for this study were validated by previous studies. Following Ajzen (1987), a five-item behavioral intention measurement scale was used to measure high school students’ intention toward pursuing a nursing career. To measure attitudinal factors, eight items were identified from the study of Kim, Jeong, and Hwang (2013).

The knowledge construct consists of 12 items adopted from the studies of Ajzen and Fishbein (1977) and Hagger, Chatzisarantis, Biddle, and Orbell (2001). All items were slightly modified to suit the nursing context and sent to four nursing education experts who were asked to rate their relevance. The resulting content validity index of items was within the acceptable range of 0.75 to 1.00 (Polit, Beck, & Owen, 2007). All items were measured on a 5-point Likert scale, with 1 representing strongly disagree and 5 representing strongly agree. The survey instrument also captured demographic information.

Data Collection

The study employed a clustered sampling method; 10 high schools across the Sharjah Emirate were identified for the survey. Sharjah is geographically widespread and representative of UAE. Female students studying in Class 12, the final year of high school, were targeted for study as they were on the verge of making decisions for their future.

Institutional approval was obtained from the Ethics Committee; permission to conduct the study was also obtained from the principals/headmasters of the 10 schools. Nurses in each school distributed the survey, explaining its purpose and that participation was voluntary; students who agreed to participate were asked to complete a consent form and were given instructions to maintain randomness and anonymity. To further oversee data collection and ensure data quality, the first author made frequent follow-up visits to each school. These efforts yielded 162 responses. The sample came from the 10 schools with an even distribution of about 10 percent from each.

Responses were checked to eliminate surveys that were more than 20 percent incomplete (Hair, Hult, Ringle, & Sarstedt, 2014); two surveys were eliminated. All surveys were then assessed for normality and outlier cases, means, standard deviations, skewness, kurtosis, and univariate and multivariate assessments. These procedures resulted in the exclusion of three extreme cases from further analysis. Overall, 157 responses were included in the final data set for a response rate of 78.5 percent.

The measurement models and conceptual model were tested using structural equation modeling using AMOS Version 18 software. Following procedures suggested by Anderson and Gerbing (1988), a two-stage analytical procedure was employed, first to test the validity and reliability of the measurement model and then to test the hypothesized relationship of the structural model.


The ages of participants ranged from 15 to 18 years (M = 16.1, SD = 1.14). About half had excellent academic achievement during the previous year; 46 percent (n = 73) had relatives or friends who worked in the nursing profession (see Table 1 for additional data).

Table 1
Table 1:
Demographic Profile

Validity and Reliability of Measures

A confirmatory factor analysis was undertaken to confirm the reliability of measures. Convergent validity was tested by inspecting the loadings, average variance extracted (AVE), and composite reliability (CR). One item from the construct of knowledge, two items from the construct of attitude, and one item from intention were deleted because they did not meet the critical threshold limit of 0.50 (Anderson & Gerbing 1988; Bagozzi & Yi, 1988). The AVE met the minimum criteria of 0.5, confirming convergent validity (Fornell & Larcker, 1981). Internal consistency reliability was also achieved as the CR values were greater than the cutoff requirement of .70 (Hair, Anderson, Tatham, & Black, 1998). Scale items, loadings, CR, and AVE are provided in the Supplemental Digital Content at

To assess discriminant validity, the square root of the AVE for each construct was compared to all correlations (Fornell & Larcker, 1981). The AVE of each construct was greater than the highest squared correlations with other constructs (Chin, 2010), pointing to no issues of validity. Anderson and Gerbing (1988) proposed a threshold of approximately 150 respondents for structural equation models with three or four constructs; the sample size for this study was deemed adequate.

Structural Model Results/Hypotheses Tests

The coefficient of determination (R2) of the model was .473, implying that attitude and knowledge together explained 47.9 percent changes or variations in intention among respondents. R2 values of .19, .33, and .67 are considered weak, moderate, and substantial, respectively (Chin, 1998). The R2 value of this study can be considered moderately substantial.

The regression results supported two of the three hypotheses, with a positive relationship between attitude and intention (ß = 0.694, p < .001) supporting Hypothesis 1. The findings of this study are consistent with a study undertaken in Saudi Arabia, which revealed that attitude is a predictor of intention of high school students to pursue nursing as a profession (Al-Omar, 2004). Hypothesis 2 postulated that knowledge is a predictor of intention to pursue a nursing career; the results were not significant (ß = 0.027, ns), in contrast with that of the Al-Omar (2004) study.

This study found no empirical support for the interaction effect of attitude and knowledge as a significant predictor of intention (ß = 0.162, p < .01). This result specifically suggests that attitude predicted intention but did not predict knowledge. However, the combined effect of both constructs predicted a significant effect on intention. An interaction plot was utilized to better understand the interaction effect. Figure 1 establishes that knowledge strengthens the positive relationship between attitude and intention, revealing that intention is most significant when attitude is high and knowledge is low. A high amount of knowledge and a higher attitude score will lead to lower intention.

Figure 1
Figure 1:
Interaction plot.


This study tested the usefulness of a revised TRA model and investigated the role of knowledge and attitude and their interaction effect on intention to pursue nursing as a profession. Attitude was a significant predictor of intention; knowledge had no effect on intention. These findings contrast with results of the Al-Omar (2004) study in Saudi Arabia, which found that having more knowledge about nursing would attract students to the profession. A possible reason for the difference in findings is the multidimensional nature of the knowledge construct as acknowledged in research by Pillai, Brusco, Goldsmith, and Hofacker (2015).

This study also uncovered that knowledge moderates the relationship between attitude and intention in a positive direction. From the lens of TRA, this finding is supported by previous studies (e.g., Bang, Ellinger, Hadjimarcou, & Traichal, 2000; Shepherd & Towler, 2007).Furthermore, the finding that intention is most significant when attitude is high and knowledge is low implies that attitude plays an important role in high school students’ intention to pursue a nursing career. Attitudinal shifts may help combat a lack of knowledge about nursing. Research in sociology and psychology suggest investigation of the hedonic and utilitarian components for a better understanding of attitude (Voss, Spangenberg, & Grohmann, 2003). It would be worthwhile to investigate the effect of these two dimensions on students’ intention to pursue a nursing career and bring about attitude change.

The results of this study have implications for the nursing professionals in the UAE. The shortage of nurses and challenges in attracting students and new recruits are nation and context specific. Great Britain faces the largest nursing shortage, a problem that is expected to worsen due to Brexit (Donnelly, 2017). The shortage of nurses in Canada is due to limited education facilities for future nursing staff (Bartfay & Howse, 2007). The shortage in Europe is due to the migration to countries that offer better pay and working conditions (Lupieri, 2013). However, in the Gulf countries, the nursing shortage is due to social and cultural reasons. For example, a study in Jordan revealed that nurses struggle to attain respect from the public and hold a subordinate position through the years, which makes the profession unattractive (Oweis, 2005). Studies conducted in the region have shown that students believe that nursing is below their ambitions and dreams (Mrayyan & Acorn, 2004). Another study in Jordan found that the attitude of families toward their daughters’ pursuing a nursing career often met with disapproval (Abualrub, 2007). Within the last decade, with rapid economic development and modernization, the region and the UAE in particular have seen many social changes while retaining strong Arab and Islamic influences. A study measuring social progress of 132 countries placed the UAE first in treating women with respect, with an overall ranking of 37 for social progress (Maio & Ayson, 2014).

Nursing professionals must share responsibility in educating high school students about professional nursing practice. It is important to create a favorable attitude about the profession to attract female high school students to nursing. Emirati high school authorities and hospital administrators need to inform female high school students about the promising features of modern nursing and the nobility of the profession. There is also a need to educate parents about the nature and promising features of modern nursing and its growing admiration as a skilful job. They need to know that that nursing provides chances for secure employment with a variety of opportunities.

As in most empirical studies, this study is not without limitations. First, it was undertaken with sample drawn from Sharjah. Although this region is representative of UAE, future studies should focus on high school students across all Emirates to increase the generalizability of the study. Second, this study was limited to female students. Although this choice was justified as nursing is largely seen as a woman’s job, future studies must take samples from males who would like to enter the field. Third, this study employed multi-item measures, with all items assessing each construct included in the survey instrument. The results need to be cross-validated through an experimental research design by obtaining overt measures of behavior and minimizing the influence of response bias. Longitudinal study is suggested to scrutinize the effect of constructs in the model over time.

Cross-sectional data make inference tenuous. Students’ changing perceptions of nursing are an important issue. Past studies have shown that students’ perceptions of nursing as a career change over time (Ten Hoeve, Castelein, Jansen, Jansen, & Roodbol, 2017). Future studies would make worthwhile contributions to our body of knowledge.


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Attitude and Knowledge; Nursing Career; Student Intention

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