Female Saudi nursing student perspectives on pursuing a career in home healthcare: a qualitative study

ABSTRACT Despite the fact that the number of patients seeking home healthcare in Saudi Arabia is rising, this speciality confronts significant obstacles. This qualitative, descriptive phenomenological study investigates views, feelings and attitudes of nursing students practicing in home healthcare and how they perceive it as a future career. Data were gathered during five face-to-face focus group interviews of five students each (a total of 25 students) and analysed using thematic analysis. It was found that the majority of students did not perceive home healthcare as a viable career option compared to working in a hospital. They vacillated due to the nature of the work, safety concerns, working demands, the invariability of health cases, and a lack of opportunities for professional development. Nevertheless, some nursing students were amenable to pursuing a career in home healthcare due to the less working hours, sense of autonomy, and ability to provide holistic care and educate patients and their families. Population awareness programs are needed to overcome cultural barriers, increase student motivation, and ultimately bolster the number of certified nurses working in home healthcare.


Background
Home healthcare refers to the process of caring for patients suffering from acute, terminal, and chronic health conditions at the patient's home or designated care facilities in the community (Aceto et al., 2018). Home healthcare also provides various community services, including preventive, nursing, and psychological care and support (Alabbasi et al., 2021). This practice is unlike hospital-based services with advanced facilities that provide specific care for acute and chronic conditions; home healthcare primarily involves families, caregivers, and patients (Lafortune et al., 2015). In Saudi Arabia, home healthcare programs were started at the Green Crescent Hospital in 1980, followed by King Faisal Specialist Hospital and Research Centre in 1991, and King Fahad National Guard Hospital (KFNGH) in 1995 (Walston et al., 2008). Since then, many governmental and private healthcare organizations have implemented similar programs and offered similar services across the country (Al-Surimi et al., 2019). Its expansion is a response to the decreasing reliance on hospital care by older people with chronic diseases. As the prevalence of chronic diseases among older Saudis increases, such as diabetes, by approximately 25% (Alhabib et al., 2020). The expansion also aims to enhance access to healthcare services in rural areas where healthcare providers are limited (Al-Surimi et al., 2019). This shift towards community-based healthcare is expected to improve overall health outcomes and reduce medical expenses over time.
Home healthcare nursing has seen enhancements and growth as a result of demographic changes such as patient age, chronic diseases, and healthcare access. For example, in the US, 70.5% of home healthcare users are older adults with multiple chronic health conditions who need continuous monitoring (Han et al., 2013), similar to the situation in Saudi Arabia (Al-Surimi et al., 2019;Alabbasi et al., 2021). In addition, the rapid adoption of new technologies, such as telemedicine (Ohta et al., 2018), and telephonic nursing follow-ups (Valdivieso et al., 2018), has enhanced access to home healthcare, minimized hospital stay length, and improved quality of life (Al Anazi et al., 2020). As the number of Saudi Arabia's ageing population continues to increase, home healthcare has become an increasingly important aspect of providing quality healthcare for older people (Saudi Government, 2021). Home nursing services became more widely available, with 242 centres placed around Saudi Arabia and offering a wide range of services, including home-based medical consultations, prescription administration, disease management, rehabilitation, and long-term care (Ministry of Health, 2011, 2022. Despite global developments in home healthcare, this specialized field still faces major nursing shortages (Ohta et al., 2018). One of the considerable challenges in Saudi Arabia is a shortage of nurses in this field due to poor management, lack of suitable infrastructure, cultural barriers, low salary, interprofessional coordination and cooperation, and job dissatisfaction (Al-Hazmi & Al-Kurashi, 2005;Alodhayani et al., 2021). Other contributing factors include a lack of home healthcare equipment, insufficient security measures, and quality indicators (Dhahi, 2012). These issues contribute to nurses' stress and burnout (Alodhayani et al., 2021).
In Saudi Arabia, there is also a shortage of Saudi nurses in home care, despite the fact that more jobs have been created as a result of the growing demand for these services and the need for more Saudi nurses has increased (Alluhidan et al., 2020). The home healthcare sector currently has 26,977 employees, most of whom are foreigners (Ministry of Health, 2011). Several studies have focused on the challenges nurses face in home healthcare, while others have addressed factors that make the practice desirable. A sense of autonomy contributes to work satisfaction and nurses' desire to pursue home healthcare as a career (Jacobs, 2019). The sense of autonomy refers to individual freedom and the ability to make independent choices (Ellenbecker, 2004;Maurits et al., 2017). Other factors include favourable employment conditions, having the space and time to offer quality care, work flexibility, and support from supervisors (Ruotsalainen et al., 2020;Stutte et al., 2017).
Although the literature has provided valuable information on the challenges and benefits of home care nursing work, it has only focused on the working nurse's perspective. No research has been conducted on prospective nursing students in the home healthcare profession. There is a need for qualitative studies which provide an in-depth analysis of all these factors to encourage the recruitment and retention of homecare nurses.
Saudi nursing students especially lack home healthcare skills and knowledge. More detrimental is that this specialization is not often incorporated into the nursing curriculum of most nursing colleges (Alshehry et al., 2020). Most nursing students' clinical training generally focuses on hospital-based practice for all nursing competencies. Both governmental and private nursing schools fail to include home healthcare nursing in their list of mandatory clinical practices (Mohammed et al., 2019). Consequently, nursing students have limited knowledge of home healthcare and nursing duties compared to the key focus on the hospital-based learning experience. Moreover, the Saudi healthcare system is highly reliant on nurses (Valdivieso et al., 2018). In addition, home healthcare is primarily run by nurses with fewer direct interventions from physicians. Further exacerbating these challenges are the nursing shortage, a lack of nursing student interest in community work, and a growing number of older adults needing home healthcare. The present study aimed to addresses some of these challenges by describing how nursing students practicing in home healthcare perceive it as a potential future career.
Understanding the perceptions of female students towards training in home healthcare can be used to tailor training programmes that are more effective in meeting the needs and expectations of female students. Further, it can help identify barriers that may prevent them from pursuing a career in this field. These barriers could include cultural or societal norms that limit female participation in certain fields, a lack of access to training programmes, or other factors. By identifying these barriers, educators can work to address them and increase participation in home healthcare training. Furthermore, understanding their perception towards training in home healthcare can help identify opportunities to increase participation in this field. This is particularly important given the ageing population in Saudi Arabia, which is expected to increase demand for home healthcare services.
Research questions: (1) What are nursing students' perceptions towards working in home healthcare? (2) What factors motivate nursing students to work in home-based healthcare settings?
Self-determination theory was used for the current study to help explore how the concepts of autonomy, competence, and relatedness may influence female nursing students' decision-making about pursuing a career in home healthcare. Self-determination theory proposes that individuals are more likely to engage in behaviours that satisfy their need for competence (Deci & RM, 2015). Female nursing students may be more likely to consider a career in home healthcare if they perceive it as a field where they can develop and demonstrate their nursing skills and expertise. Further, self-determination theory suggests that individuals are more likely to engage in behaviours that satisfy their need for relatedness (Deci & RM, 2015). Female nursing students may be more likely to pursue a career in home healthcare if they perceive it as a field where they can build meaningful connections with patients and their families, as they may have greater opportunities for one-on-one interactions with patients in a home healthcare setting.

Research design
This study of nursing students' experiences and views of home healthcare as a future career used a qualitative, descriptive phenomenological approach. This methodological approach allows the researcher to understand the experiences lived by individuals (Holloway & Galvin, 2017). It offers in-depth descriptions of nursing students' different feelings, thoughts, concerns, and perceptions towards home healthcare since they experience it for the first time. The role of the researcher in the phenomenological study is to provide detailed descriptions and interpretations of the lived experience. An in-depth investigation was also conducted into the factors that motivate nursing students to work in home-based healthcare settings. The Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007) was used to ensure the study was satisfactorily reported.

Research setting and sample
The study was implemented at a Saudi government university exclusively set for women in the College of Nursing, Riyadh, Saudi Arabia. The selected college was incorporating home healthcare training into its curriculum for the first time. The training period was for almost a month and a half, three hours per visit, with a total of six visits. A purposive sampling technique was used to select undergraduate female nursing students according to the following inclusion criteria: they were (a) female nursing students enrolled in a baccalaureate nursing program. They had to be (b) enrolled in a course on nursing care for older adults and trained in older adult home healthcare as part of the course curriculum that was offered in their fourth year of study. Students who have not trained in home healthcare or spend less than two hours there were excluded.
The total number of eligible participants was N = 144; the collected sample size was n = 25.

Data collection process
All students who met the inclusion criteria were invited to participate in a focus group interview by the academic student affairs unit. The research team developed a topic guide based on existing literature to investigate the nursing students' overall experience in nursing home healthcare. This guide focused on students' feelings and opinions of home healthcare nursing and the benefits, challenges, and receptiveness to working in the specialization. Props were used to encourage student participation and provide clearer explanations and examples. Experts on the home healthcare topic guide were consulted to ensure the validity of the questions.
This was based on the "code saturation", as no more new frequent codes were noticed. Ultimately, 25 students participated in five focus groups of five students each. The focus groups emphasized interaction and discussion among the participants and described the different views in a safe, respectful environment. The groups were facilitated by the first author, conducted in Arabic, and lasted for approximately one hour. As the first author was a faculty member, many precautions were taken to minimize coercion problems. Firstly, the selected participants were not taught by the first author. Secondly, participants were informed that participation was voluntary and that their grades would not be affected. All focus groups were conducted in one of the College of Nursing meeting rooms.

Ethical consideration
Ethical approval for the study was obtained from Princess Nourah bint Abdulrahman University (ref no:19-0199). Informed consent was obtained from all participants by the research team, who explained that they could withdraw from the study at any time. All study-related information was explained to the participants by the research team, who had no direct relationship with them to avoid any incidence of coercion. Students were also reassured that their marks would not be affected. Selected identification letters and numbers were assigned to each student to promote the confidentiality and anonymity of the participants.

Data management and analysis
The audio of all five focus groups was recorded and password protected to safeguard participant confidentiality. Only research investigators had access to this information. The interviews were transcribed verbatim into English, verified using the audio recordings, and reviewed for accuracy after the first and second authors assessed them. Since, the first and second authors are bilingual, they checked the accuracy of the verbatim translation to ensure the credibility and validity of the results after translation.
Inductive thematic analysis was used to analyse the data (Braun & Clarke, 2006). First, two researchers (W. A.) and (T.A.) read the transcripts several times to familiarize themselves with the data and ensure its accuracy, as this is an essential step in phenomenological study. Second, initial notes, keywords, and ideas derived from the self-determination theory were manually coded from the relevant text sections. Third, codes were checked for patterns and similarities to develop categories as shown in Figure 1. A schematic illustration of emerging themes and subthemes. Fourth, the initial themes and subthemes were discussed by the first and second authors to come up with the final themes and subthemes. Finally, themes and supporting data from transcript extracts or quotes were outlined, as shown in Table 1.
To ensure the trustworthiness of the emerging final themes, they were verified by the participants.

Results
Three central themes emerged. These themes focused on (a) the benefits of working in home healthcare nursing, (b) the challenges of working in home healthcare nursing, and (c) working in home healthcare vs. hospital. Respondents also noted that the nature of home healthcare nursing work differs from work in hospital settings. Furthermore, students discussed their opinions on working as nurses in home healthcare and whether they would choose home healthcare as a future career path.

Benefits of working in home healthcare nursing
The students mentioned several benefits related to working in home healthcare nursing during the focus groups, including independence, and closeness and trust.

Independence at work
Independence at work identified as main them emerge from students focus group interviews. As from frequent students' answers home healthcare nurses are independent in their decision-making, with a high feeling of autonomy and self-efficacy in delivering complete care to older adults in their homes, which includes evaluation, intervention, and education. Several responses from the student to describe dependency at work the following student describe sense of autonomy by decision making: The good side of home healthcare nursing is that a nurse is able to make decisions and focus on one patient. (C2) The other students achieve independence by dealing with the patient and their family one-to-one:  Also, some students commented in their abilities to do an environmental assessment along with educating the patients and his or her household members: "For the first time, I was able to do an environmental assessment." (E3) "I got the chance to educate the patient as well as the caregivers." (A4)

Closeness and trust
The students understood the importance of the homecare nurses' ability to establish trust with their patients and families. Students discussed the great esteem in which patients and their families hold home healthcare nurses. Furthermore, being an Arabic-proficient Saudi student also helped foster trust and strengthened the relationships with patients and their families: The trust between the patient and the nurse in home healthcare nursing is higher than in the hospital. (B3) Further students describe presence of an Arabicproficient Saudi student on fostering trust and strengthening relationships: The nurses also bonded with their patients because of frequent and long-term visits. One of the nurses said that:

Challenges working in home healthcare nursing
The students indicated several difficulties with training in home healthcare. Most importantly was a lack of preparation, a difficult and demanding setting, and an uncomfortable atmosphere.

Unanticipated situations
Students frequently expressed concerns about facing unanticipated issues in home healthcare and lack of training in how to deal with aggressive and violent patients and family caregiver neglect while the incident occurs in their homes. Some students have questioned the skills they learned during the course and felt that they were not sufficiently prepared to deal with older adults and violent cases:

Complex and demanding setting
Students reported that working in home healthcare requires a particular personality type and an affinity for managing and communicating with older adult patients.

I was excited to teach the patients, but at the same time, I was anxious because of responsibility on my shoulders as I'm the only Saudi female who's giving them the information. (B4)
The nurse acting as a social worker, psychologist. She was doing multiple roles at once (E5).
In addition, some students felt that while the sense of autonomy in home healthcare is high, this puts more pressure on them to do all the care work independently, with minimal help from others.

Home healthcare vs. hospital
The primary student perception was that they would prefer to work in a hospital rather than a home healthcare setting. Furthermore, they indicated how different the nursing jobs performed in the two environments were.

Working nature
Students highlighted the lower workload in home healthcare, which consists primarily of basic tasks, when compared to hospital tasks. One commentator, for example, said the following to describe nursing work as routine work and not requiring specialized care: Students also felt that the home healthcare nursing tasks were too routine and limited to patient vital sign assessments, which are not as beneficial as hospital training:

Professional growth
Most interviewed students disregarded home healthcare nursing as a career option and preferred hospitals for various reasons. First, the students focused on a stimulating specialization where they could develop their clinical skills and have more opportunities for professional advancements, such as in the emergency department or intensive care unit. Some students stated hospital nurses are skilful and describe home care nurses because as limited to communication skills with older people: I think hospital nurses are skilful as they practice on a daily basis. But in-home nursing, nurses' skills are limited as they may be only following one patient's condition. (B2) Students perceived hospital nurses' work descriptions as more structured than those of home healthcare nurses, where patient-centred care is the primary focus: "At the hospital, everyone knows his/her responsibilities." (B4)

Discussion
This qualitative study provided valuable insights into the perceived benefits and challenges of home healthcare from the nursing students' perspective. Some students found home healthcare appealing because of patients' hospitality and gratitude, as a sense of belonging is important for nurses' work motivation (Albloushi et al., 2019).
Furthermore, many participants reported positive experiences as they learned to overcome their fears, be more independent, and become more patientcentred. This personal development is facilitated by the nature of home healthcare, which has a one-toone nurse-patient ratio. These circumstances nurture closer practitioner-patient relationships and enable strong interpersonal bonds to form. A study in Canada showed that nursing students gained valuable insights into their patients but also developed confidence in their abilities and took more initiative with their self-directed learning. Consequently, they experienced greater autonomy and independence over time (Moquin et al., 2018). Calma et al., (2019) demonstrated the importance of characteristics particular to home healthcare nurses, such as personality, capability, self-confidence, sociability, communication skills, and autonomy (Calma et al., 2019). Some of these factors were common to the present study, especially autonomy.
Participants indicated feelings of independence in home healthcare. They could communicate with patients in a common language, which helped them understand their patient's condition and provide better feedback and education. Anecdotal evidence shows that 70% of nurses in the Saudi healthcare system do not speak Arabic or come from different cultures (Al Anazi et al., 2020;Alodhayani et al., 2021). This may limit their ability to communicate efficiently with patients. Therefore, policymakers, healthcare organizations, educators, and healthcare professionals might adopt practices that help attract and retain Saudi nurses working in home healthcare (Legg et al., 2016).
Some students have experienced difficulties handling the holistic approach required in home healthcare nursing. According to Nabolsi et al., (2012), nurses' responsibilities and roles, such as records maintenance and patient treatment, may be vary substantially (Nabolsi et al., 2012). Some discussions with the participants in the present study regarding their workload indicated that home nursing was a highly demanding job compared to other professions (Philibin et al., 2010).
The current study demonstrated that some students felt uncomfortable or unsafe in the home nursing environment, negatively affecting their perspective on the specialization as a potential career. Research also shows that home healthcare clinics are considered an unsafe and sometimes violent work environment (Walivaara, 2013).
Accessibility of the patient homes also appears to be a challenge globally (Craven et al., 2012). The present study found that some students could not travel to a dwelling for work or were uncomfortable with travelling long distances. While the participants were familiar with the hospital location and routes, home healthcare settings are often not easily accessible or safe to approach. Thus, it is essential to ensure the accessibility and safety of home healthcare nursing for students and healthcare professionals.
Many participants were uncertain about choosing home healthcare as a career because it was perceived as a complex and demanding setting. Most nursing students prefer to work in hospitals due to better opportunities to develop professionally and apply critical thinking skills. This finding is in line with existing research (Abbey et al., 2006;Nabolsi et al., 2012;Stevens, 2011). In the Netherlands, Van Iersel et al. (2018) found that only 5.4% of first-year nursing students would consider working in home healthcare compared to 72% who would rather work in a general hospital (van Iersel et al., 2018).
Research also finds that nursing students perceived home healthcare as physically demanding, unappealing, unchallenging (Haron et al., 2013), undistinguished, and insufficiently equipped to handle the needs of the patients (Hebditch et al., 2020). However, there were nursing students who felt fulfilled by the experience and expressed a desire to pursue a career in home healthcare. Other students were uncertain of what career specialization to pursue. This may be attributed to a lack of experience or knowledge of the potential nursing career paths (Nabolsi et al., 2012). The nursing curriculum and clinical practices design substantially impact students' preferences and career choices (Bisholt et al., 2014). Similarly, students' career preferences are influenced by the programs and modules they undertake at the university level (Carlson & Idvall, 2015). Universities and educators should consider this when designing university curricula to support nursing students in career planning.
The students sampled in the present study wanted a better-structured training program. Some were shocked by the lack of preparation or introductory lectures. Some key areas for improvement in nursing education include high-quality clinical placements for exposure and skill practice. In addition, targeted educational interventions should be included in the curriculum (Brown et al., 2008). A well-designed curriculum that includes a preparatory introductory course may help ensure professional competence and quality of home healthcare. It is important to note that clinical practice may shape student perceptions (Husebø et al., 2018). Clinical placements in community care should offer students the opportunity for interprofessional collaboration, a chance to deal with the complexities of home-based patients, and engagement in an advanced care role (Philibin et al., 2010). Moreover, students should be supported by specialized staff who may work across universities and placement settings (Betony, 2012).
A well-designed preparatory course might be included in the curriculum. Continuous medical education, including academic activities to increase home healthcare knowledge, is paramount. These student development aspects may be complemented by participation in conferences and research. Furthermore, media, workshops, seminars, and symposia may promote home healthcare knowledge and awareness. The need for extracurricular activities is apparent in a study from the Eastern Province of Saudi Arabia, which found that hospital-based experience was the primary source of information for health professionals (Al-Hazmi & Al-Kurashi, 2005).
Many studies have highlighted mentors' contributions to healthcare education (Carlson & Idvall, 2015). Bjork et al. (2014) highlighted that the preceptor and clinical instructor play crucial roles in assessing training progress (Björk et al., 2014). Similarly, Bisholt et al., (2014) revealed that home healthcare behaviours are substantially influenced by clinical instructor's attitudes, indicating that her presence plays a role in building student's confidence (Bisholt et al., 2014). Research has found that the pedagogical atmosphere fostered by the relationship with supervisors was a factor in shaping first-year nursing students' perceptions of older adult care (Husebø et al., 2018).

Strengths and limitations
This study makes a valuable contribution to the existing literature as no qualitative studies have been conducted on home healthcare nursing in the Middle East and Saudi Arabia. This study provides a novel perspective on how student nurses perceive careers in home nursing. Furthermore, this study outlines the benefits and challenges of working in homecare nursing. A crucial aspect of home healthcare was identified in the interviews: the patient experience. When a nurse from the same background, speaking the same language, was treating them, patients and their families felt more comfortable-patient comfort is vital to patient care.
This study has some limitations. First, only a small sample from a single government institution was used, which may not be representative of all nursing students in Saudi Arabia. Consequently, the results may have limited generalizability. Second, only interviews were used for data collection. As such, mixed methods studies may be beneficial in future research. Future studies should engage in multi-methods research. Broader focus elements should be included, such as the experience of nurses of both genders, all grades, and from variable institutions (public and governmental). Further insights might be gained by comparing the findings of these studies with similar healthcare studies from other regions and settings.

For nursing education and practice
The results of this study offered important insight into the need for collaboration between educational and health bodies that focus on raising awareness about the benefits of working in home healthcare. This study provided an opportunity to advance our knowledge about the current perceptions towards choosing home healthcare as a future career. Early progressive involvement of nursing students in home healthcare during their academic curriculum-starting from the first year-will familiarize them with the benefits of working in home healthcare. Educators should provide individualized student mentorship via interviews or group meetings. This may aid in understanding their motivation, educational needs, and other concerns. The results of this study suggested that educators as well as family and friends may realize their role in influencing student career choices. Also, they confirmed that clinical placement environments might be educationally enriched with equipment and support from multidisciplinary teams and practitioners. This will provide more opportunities for professional development.

For policymakers
The results of this study add to the current job outlook for home health care workers in Saudi Arabia in a number of ways. Firstly, policy makers might benefit from this study by understanding that betterequipped home healthcare, clear practitioner responsibilities, and continuous onsite personnel and educational support may improve nursing students' career satisfaction and nurture a sense of professional development. Secondly, with the traditional health care system transitioning into the community, creating a positive work environment that includes a safe working environment, the ability for professional development, and a competitive salary is encouraged.

For future research
The current study has added to a growing body of literature since it is considered the first Saudi study reporting on the perceptions of nursing students towards choosing home healthcare as a future career. This study will serve as a base for future studies that may explore factors and other aspects of career awareness that impact students' decisions about home healthcare.

Conclusion
This study gives important information about how Saudi nursing students feel and think about home healthcare as a possible career path. Notably, the majority of students did not perceive home healthcare as a viable career option compared to working in hospitals. Their hesitation was largely due to the nature of the work, safety issues, a lack of experiential diversity, and a lack of opportunities for professional development. Regardless, some nursing students expressed an interest in home healthcare due to a variety of factors. These included limited working hours, a sense of autonomy, less demanding care, and the ability to educate patients and their families. Implementing population awareness programs on the role of home healthcare is needed. This will help set realistic expectations and overcome cultural barriers and prejudices among patients and their families. To address the students' preconceptions, curriculum redesign initiatives might be developed, focused on collaboration between academic and healthcare organizations. These measures will enhance the focus on and support for the home healthcare profession, which may result in more graduates opting to work in this field. Taghreed Alotaibi, a lecturer in the department of Community Health Nursing at Princess Nourah bint Abdulrahman University. Her research interests are within care older adults and home healthcare.
Savvato Karavasileiadou, PhD, is assistant professor in the Community Health Nursing Department at Princess Nourah bint Abdulrahman University. Her research interests are physical activity and wellness, prevention and promotion of health, and health education.