Factors Influencing Male Nursing Students' Adaptation to College Life in Korea

ABSTRACT Background Male nursing students face challenges in the nursing profession because of its female-centered nature. In particular, most male students in South Korea must complete military service while in college. Although these kinds of situations may make it difficult for them to adapt to college life, the number of male nursing students is gradually increasing. Therefore, it is important to identify the influencing factors to promote male nursing students' successful adaptation to college life. Purpose This study was developed to investigate the relationship between self-efficacy, social support, stress coping, and adaptation to college life among male nursing students in Korea. Factors that influence their adaptation to college life were also analyzed. Methods A cross-sectional study was conducted on 217 male nursing students from seven colleges in Korea. Participants completed a questionnaire that was designed to measure self-efficacy, social support, stress coping, and adaptation to college life. Data were analyzed using descriptive statistics, independent t test, one-way analysis of variance, Scheffé test, Pearson's correlation coefficient, and multiple regression. Results Male nursing students' self-efficacy, social support, stress coping, and adaptation to college life were shown to all positively correlate with each other. The main factors influencing adaptation to college life were social support, self-efficacy, satisfaction with major, and problem-solving-centered stress coping. Conclusions Strategies to enhance social support, self-efficacy, satisfaction with major, and problem-solving-centered stress coping should be developed to improve male nursing students' adaptation to college life.


Introduction
The number of male nurses is gradually increasing worldwide as the awareness of nursing as a profession grows and selecting a job according to one's interest and aptitude becomes more common (Donmez & Ozsoy, 2016;M. Yu et al., 2017). However, male nurses are still a minority in the female-centered nursing profession, with 14% in America, 35% in Africa, 16% in Europe, and 21% in Southeast Asia (Boniol et al., 2019). In South Korea, men started entering the nursing field in 1962, and the 121 male nurses in 2004 accounted for only 1.1% of the total nursing population. The number of male nurses has since risen to 10,542 in 2016and to 21,042 in 2020(Korean Nurses Association News, 2020. This increase is related to the advantages of the nursing occupation, which include job stability, financial security, and career mobility and opportunities (Gavine et al., 2020;Meadus & Twomey, 2011;Whitford et al., 2020). The number of male nursing students is expected to continue to increase.
A successful college life is influential in promoting nursing students' capabilities as future nurses. However, male nursing students feel alienated and face challenges in developing relationships in this predominantly female field (Powers et al., 2018). In addition, gender differences in consciousness, behavioral patterns, and expressions may cause misunderstandings and conflicts, making male students' adaptation to college life difficult (Younas et al., 2019). Moreover, male nursing students must interrupt their schooling because male citizens in South Korea between the ages of 18 and 28 years are required by law to participate in compulsory military service, which makes adapting back to a school setting and creating new relationships there more difficult (Kim et al., 2014). As male nursing students repeatedly encounter such barriers, some of them withdraw from school or transfer to a different major and give up their nursing career aspirations. Thus, it is necessary to understand and address the related factors to promote male nursing students' successful adaptation to college life.
Several studies have reported on the factors that affect students' college life. For example, Jeong and Park (2009) suggested that the influencing factors may be divided into learners' variables, including internal and environmental elements. Their study reported that college students' adaptation was determined by subjective elements of self-efficacy and stress coping as well as the environmental element of social support. Selfefficacy is the belief in one's ability to control and affect the course of actions necessary to achieve a particular project. This attribute affects the process of selecting and maintaining certain behaviors significantly (Stajkovic et al., 2018). Self-efficacy is one of the most influential psychological factors affecting the ability of college students to maximize learning efficacy (Valencia-Vallejo et al., 2018). Moreover, it is an important factor in nursing students' adaptation to college life, as they must be actively involved in their learning and career. Because students with a high level of self-efficacy tend to display positive attitudes and constantly make an effort to improve their behaviors, they are better able to efficiently cope with various problems in the adaptation process (G. Ko & Sim, 2015).
Social support encompasses various types of environmental support from important people, which include family, friends, peers, and professors who may significantly influence one's quality of life (E. K. Yu & Seol, 2015). When recognized effectively, social support can help college students cope with and overcome stress. In addition, social support may enhance college students' adaptation to college life. A study found that when students have strong social support, they are better able to actively cope with problematic situations, adapt, and maintain psychological well-being (Poots & Cassidy, 2020). In particular, for a relatively small number of male nursing students, physical and emotional support from external resources are more important to ensure their better adaptation (Younas et al., 2019).
Male nursing students experience complex stress both internally and externally. If this stress is not managed, their self-confidence and academic motivation are likely to decline, resulting in poor academic performance and poor adaptation to college life (Varghese et al., 2015). Therefore, coping with stress efficiently is crucial to helping male nursing students manage stress and better adapt to college life (Salinas-Harrison, 2018). Stress coping involves both cognitive and behavioral efforts to effectively moderate the challenges of a stressor or change (Lazarus & Folkman, 1984). Although two main stress-coping mechanisms exist (adaptive and maladaptive), the best strategy to use in a situation depends on the situation and status of the individual. Thus, nursing educators should be more aware of students' stress coping mechanisms and help male students develop positive or adaptive coping strategies (Salinas-Harrison, 2018).
To help male nursing students adapt well to college life, there is a need to clarify the various influencing factors. Previous studies of male nursing students have investigated their college experiences (DeVito, 2016;Gao et al., 2019;Powers et al., 2018;Yang et al., 2017), the relation between selfesteem and psychological distress (Feng et al., 2019), and the mediating effects of social support and resilience on the relationships between campus life adaptation and clinical competence (S. Park et al., 2019). As the number of male nursing students has increased, nursing researchers have paid great attention to this issue. However, few empirical studies of the variables that may affect male nursing students' adaptation to college life have been conducted. Therefore, this study was developed to examine the relationship between Korean male nursing students' self-efficacy, social support, stress coping, and adaptation to college life. The factors that influence male nursing students' adaptation to college life were also explored to suggest strategies that may better facilitate their transition into the nursing profession.

Research Design and Participants
This descriptive cross-sectional study examined the factors that affect male nursing students' adaptation to college life. Participants were a convenience sample of 217 male nursing students in their first to fourth year recruited from seven 4year colleges located in G city and C province in South Korea. The number of the participants was determined using the G*Power 3.1.7 program. With 15 predictors selected in a multiple regression analysis as the basis, a minimum sample size of 199 was calculated using the following conditions: effect size of .15, significance level (α) of .05, and test power (1 − β) of 95.0%. With the addition of an expected dropout buffer, 245 questionnaires were distributed. To reduce bias in the convenience sample, students from nursing departments with a similar curriculum were recruited. Thirty-five copies of the questionnaire were distributed at each school, with eight to nine copies allocated to each grade in each school. Two hundred twenty-one completed questionnaires were collected (90.2%), and after excluding four incomplete questionnaires, the data from 217 (88.6%) were used in the final analysis.

Instruments
Self-efficacy Self-efficacy was measured using a scale, developed originally by Sherer et al. (1982) and validated in Korean by H. Y. Hong (1995). The factor analysis in H. Y. Hong indicated that the two factors in the instrument accounted for 34.3% of the variance. This scale consists of 23 items in two subscales: general self-efficacy with 17 items to measure selfefficacy in general circumstances and social self-efficacy with six items on relationships. A 5-point Likert scale is used for scoring, ranging from 1 (not at all) to 5 (very much). Thirteen negatively worded items were reverse coded, with a higher score indicating a higher level of self-efficacy. The Cronbach's alpha for this scale was .86 in H. Y. Hong and .84 in this study.

Social support
To measure students' social support, a scale developed by J. W. Park (1985) and validated for Korean college students by E. K. Yu and Seol (2015) was used. Confirmatory factor analysis in E. K. Yu and Seol revealed good model fit, with comparative fit index = .914, Tucker-Lewis index = .905, and root mean square error of approximation = .064. This scale was designed to assess four different areas using 25 items: emotional support with seven items measuring love and understanding, encouragement and trust, and interest; evaluative support with six items measuring commendation and recognition; informative support with six items assessing the provision of information related to problem solving; and material support with six items evaluating direct help with time, money, work or belongings. This scale is scored using a 5-point Likert scale ranging from 1 (not at all) to 5 (very much), with higher scores indicating a higher level of social support. The Cronbach's alpha for this scale was .94 in E. K. Yu and Seol and .96 in this study.

Stress coping
Stress coping was measured using the Coping Strategy Indicator developed by Amirkhan (1990) and validated in Korean by Shin and Kim (2002). Factor analysis in Shin and Kim indicated that the three factors in this instrument accounted for 41.6% of the variance. This 33-item scale examines the three dimensions of social support pursuit, problemsolving-centeredness, and avoidance-centeredness with 11 items in each dimension. Respondents are asked to recall a stressful event from the past 6 months and to evaluate the extent to which they had used coping strategies in the situation. The 11 negatively worded items of avoidance-centeredness are reverse coded. This measure is scored using a 3-point Likert scale, with 1 = not at all, 2 = a little, and 3 = a lot and with higher total scores indicating higher stress coping ability. The Cronbach's alpha for this measure was .84 in Shin and Kim and .82 in this study.
Adaptation to college life Adaptation to college life was measured using the scale of adaptation to college developed by Jeong and Park (2009). Factor analysis in Jeong and Park indicated that the five factors in the instrument accounted for 64.0% of the variance. This scale is composed of five subscales with 19 items. Four items are included in each of the subscales for interpersonal relationships, academic activities, career preparation, and individual psychological status, and three items are included in the subscale for social experiences. A 5-point Likert scale is used for scoring, ranging from 1 (not at all) to 5 (very much) and with a higher score indicating a higher level of adaptation to college life. The Cronbach's alpha for this scale was .86 in Jeong and Park and .89 in this study.

Data Collection
Before collecting study data, ethical approval from the institutional review board at Honam University (1040198-191018-HR-110-02) was obtained. Data were collected between September 5 and November 7, 2016. Before distributing the questionnaire, researchers explained the purpose of the study to the deans of the participating colleges and received their approval. The researchers also described the study purpose and procedures to potential participants, who were reassured that their participation would be anonymous and confidential and that they could withdraw at any point if they did not wish to continue. They were also told that the collected data would be used only for this study. Written consent was obtained from all of the participants. The researchers distributed and collected the self-reported questionnaires and gave the participants small gifts. Completing the questionnaire required approximately 10-15 minutes.

Data Analysis
Data were analyzed using IBM SPSS Statistics 21.0 (IBM Inc., Armonk, NY, USA). Participants' general characteristics and levels of self-efficacy, social support, stress coping, and adaptation to college life were analyzed using descriptive statistics. The differences in adaptation to college life based on general characteristics were analyzed using the t test, analysis of variance, and the Scheffé test. The relationships among selfefficacy, social support, stress coping, and adaptation to college life were analyzed using Pearson's correlation. Finally, multiple regression was conducted to identify the factors affecting the participants' adaptation to college life.

Differences in Adaptation to College Life Attributable to General Characteristics
The differences in participants' adaptation to college life attributable to their general characteristics are shown in Table 1. The score of adaptation to college life showed significant differences associated with military service experience (t = 2.36, p = .019), major selection (t = 2.52, p = .013), motivation of major selection (F = 4.57, p = .011), and satisfaction with major (F = 19.24, p < .001). Moreover, the Scheffé test revealed that the score of adaptation to college life was higher in those who considered their aptitude when choosing a nursing major than in those who were motivated primarily by the high employment rate in nursing. The adaptation score was also higher in those who were satisfied/extremely satisfied with their major than in those who were unsatisfied/extremely unsatisfied.

Scores of Self-Efficacy, Social Support, Stress Coping, and Adaptation to College Life
The means and standard deviations of the variables are summarized in Table 2. The mean score for self-efficacy was 3.48 (SD = 0.47) out of 5, whereas the mean score for social support was 3.73 (SD = 0.54) out of 5, with the highest score for emotional support being 3.77 (SD = 0.59). The mean score for stress coping was 2.15 (SD = 0.24) out of 3, whereas the mean score for adaptation to college life was 3.43 (SD = 0.57) out of 5, with the highest score for academic activities being 3.79 (SD = 0.69).
Factors Influencing Male Nursing Students' Adaptation VOL. 30, NO. 4, AUGUST 2022 Relationships Among Self-Efficacy, Social Support, Stress Coping, and Adaptation to College Life The correlations among self-efficacy, social support, stress coping, and adaptation to college life are presented in Table 3.
All of the variables were found to be positively correlated with each other. Specifically, adaptation to college life was positively correlated with self-efficacy (r = .55, p < .001) and social support (r = .52, p < .001). Stress coping was also positively related to adaptation to college life in the areas of support pursuit (r = .26, p < .001), problem-solving-

Factors Influencing Adaptation to College Life
A stepwise multiple regression analysis was performed to investigate the factors influencing the participants' adaptation to college life. The independent variables used in this analysis included military service experience, major selection, motivation of major selection, and satisfaction with major. Selfefficacy, social support, and stress coping such as social support pursuit, problem-solving-centeredness, and avoidancecenteredness were also included. Multicollinearity, normality, and homoscedasticity were examined to test the assumptions of the regression analysis for the independent variables. The Durbin-Watson statistics was 2.04, indicating no autocorrelation. One outlier was detected with an absolute value greater than 3 in the case diagnostics. After removing this outlier, the stepwise regression was conducted with 216 participants. The correlation coefficients between the variables ranged from −.01 to .55, and there was no explanatory variable over .80, indicating that the predictors were independent of each other. The tolerance was 0.63-0.93, which was greater than 0.10. The variance inflation factor was between 1.08 and 1.60, which did not exceed the reference value of 5. Therefore, the basic assumptions of multiple regression were all satisfied, and the results of the regression analysis were considered reliable.
The results of the multiple regression analysis are shown in Table 4. On the basis of the results of the regression model, the significant predictors of the participants' adaptation to college life were social support (β = .32, p < .001), selfefficacy (β = .26, p < .001), being satisfied/extremely satisfied with their major (β = .24, p < .001), and problem-solvingcentered stress coping (β = .14, p = .015). The explanatory power of these factors was 45.6% (F = 46.11, p < .001).

Discussion
Male nursing students experience various challenges in adapting to female-centered nursing department environments. Moreover, particularly in South Korea, most male nursing students must complete military service while in college. Previous studies have found the score for adaptation to college life to be significantly lower in male students than female students (M. S. Ko, 2015; J. L. . As the number of male nursing students continues to increase, there is a need to explore ways to help these students adapt to college life successfully. Thus, this study aimed to identify the factors that influence adaptation to college life in male students in Korea. The main findings of this study are presented in the following paragraphs. The level of adaptation to college life among male nursing students who had completed their military service was higher than among those who had not yet completed or had been   VOL. 30, NO. 4, AUGUST 2022 exempted from military service. One reason for this finding may be that male nursing students' flexibility and adaptability improved through their various military service experiences. Furthermore, while living with colleagues majoring in nonprofessional courses in college, they may have become more convinced in their choice of career (J. E. Hong, 2018). This indicates that military service may enhance male nursing students' adaptation to college life after returning to school. In contrast, Kim et al. (2014) reported that male nursing students in Korea faced difficulties adapting to college life when returning to school after 18 months of military service because they mostly entered the army in their first or second year and experienced both gaps in their academic courses and separation from classmates. However, this study's cross-sectional findings did not confirm these difficulties with college life adaptation among students discharged from the army. Therefore, longitudinal studies may be needed to explore male nursing students' detailed adaptation trajectory from entrance to graduation, including before and after military service.
In particular, the level of adaptation to college life was higher when students entered the nursing department because of their perceived aptitude for the field than when they entered the department based on the perceived attractiveness of nursing's high employment rate. The adaptation level was also higher in students who were satisfied or extremely satisfied with their nursing major than in those who were unsatisfied or extremely unsatisfied. These results are consistent with previous findings that male students' satisfaction with their major had a significant and positive effect on their willingness to become nurses (Feng et al., 2016). Because selecting a major based on perceived aptitude facilitates adaptation to college life, it is essential to provide professional and practical career education opportunities in high school so that male students may obtain useful information about nursing.
Interestingly, the highest mean value for adaptation to college life was in academic activities, whereas the lowest was in social experience. Social experience in this study refers to participation in various clubs and organizations on and off campus to experience social life (Jeong & Park, 2009). Extracurricular activities are known to promote self-confidence, teamwork, problem solving, and communications skills and to build social support networks (Buckley & Lee, 2021), which in turn contribute to better student experiences and rates of retention. Considering that 71.0% of the participants had military experience, it may be presumed that their general level of social experience was minimal because they likely did not have opportunities to join extracurricular activities after returning from the military service. Therefore, male nursing students should be encouraged to get more actively involved in social experiences to enhance their college experience.
In addition, the findings identified positive relationships among self-efficacy, social support, stress coping, and adaptation to college life, with the strongest correlation identified between self-efficacy and adaptation. Self-efficacy is defined as an individual's belief in his or her ability to effectively manage future activities and to enhance independence and self-confidence (Masoudi Alavi, 2014). Because self-efficacy motivates individuals to participate in activities that are expected to lead to successful results in the future, it helps students adapt to college life.
Furthermore, the positive relationship found between social support and adaptation to college life aligns with the findings of Turkpour and Mehdinezhad (2016), who reported social support as a significant environmental factor helping college students resolve psychological and social problems. When the level of social support is high, students are more likely to obtain better academic results, develop stronger relationships, and adapt better to college life.
In this study, three types of stress coping were also found to relate positively to adaptation to college life. According to Won (2015), finding ways to cope with stress and taking efforts to solve problems may significantly affect adaptation to college life. Among male nursing students, several coping strategies are used to overcome the various challenges in their college life, with specific coping strategies chosen differing among individuals. Therefore, understanding how students cope with stress and guiding them to use the best possible strategy in their context are essential.
Finally, the most important factor influencing male nursing students' adaptation to college life was social support followed by self-efficacy, satisfaction with their major, and problem-solving-centered stress coping. Social support is an Note. Stepwise method including variables: self-efficacy, social support, stress coping (social support pursuit, problem-solving-centeredness, avoidancecenteredness), experience of military service (dummy variables: yes = 1), major selection (dummy variables: self-determined = 1), motivation of major selection (dummy variables: aptitude = 1), and satisfaction with major (dummy variables: satisfied/extremely satisfied = 1). Only significant results are reported. Adjusted R 2 = .456, F = 46.11, p < .001.
The Journal of Nursing Research Hwajin LEE et al. essential predictive factor in successful adaptation to college life (Ferrell & DeCrane, 2016). Male nursing students are likely to encounter discrimination and alienation in a predominantly female learning environment, thus finding it difficult to adapt to school life (Sedgwick & Kellett, 2015). Meadus and Twomey (2011) also found that male nursing students received considerable help from their families, friends, graduates, and professors with regard to continuing their schooling. This finding suggests that male nursing students should obtain social support in various ways to manage their negative feelings and adapt better to college life. Another study also found self-efficacy to be a significant variable influencing life satisfaction in college students (J. Lee et al., 2016). Given that self-efficacy is an internal resource of individuals (He et al., 2018) and is viewed as a subfactor of psychological well-being, it is necessary to help nursing students enhance their psychological well-being through self-growth or selfcontrol programs in college. Students may benefit from programs that encourage positive self-acceptance.
The findings of this study also verified satisfaction with major to be an important element affecting adaptation to college life. This result aligns with the idea that male nursing students expected a successful future and were satisfied with their major based on the high wages and social status of nurses, which motivated their college life (Chan et al., 2014). This finding indicates that offering male nursing students a clear career path and direction for employment after graduation should strengthen their attachment to the department and their determination to become professional nurses.
In this study, the problem-solving-centered stress coping mechanism was found to be a significant factor affecting adaptation to college life. This result is consistent with Younas et al. (2019), who claimed that using an active, problemcentered strategy helped male nursing students adapt better to their educational and clinical learning environments. Therefore, it is suggested that male nursing students be provided with information on recognizing and applying problem-focused coping strategies to help them eschew passive, avoidance-centered stress coping strategies in favor of more positive coping strategies.
This study is critical as it investigated male nursing students' adaptation to college life in the Korean cultural setting, where military service is required for most males. However, this study was affected by several limitations. First, this study utilized regional preponderance in the sampling process, which may not represent the entire male nursing student population in Korea. Thus, it is suggested that future studies employ a more diverse sample of male nursing students. Second, only male nursing students were included in this study. Future studies should be conducted on both male and female nursing students to allow comparisons between genders. Finally, because of the cross-sectional nature of this study, we were not able to adequately verify changes in male nursing students' adaptation to college life. Therefore, a longitudinal study is recommended to identify college life adaptation trajectories and provide effective strategies for each period.

Conclusions
Male nursing students struggle with various challenges in college departments dominated by female students. This study found that social support, self-efficacy, satisfaction with major, and problem-solving-centered stress coping may influence male nursing students' adaptation to college life. On the basis of these results, it is suggested that nursing colleges and educators develop policies and strategies to help male nursing students adapt better to college life by considering the following: Providing a variety of social resources, including support groups with male mentors, may help explore more-constructive strategies; developing self-growth or selfcontrol programs may promote psychological well-being and improve self-efficacy; students may have higher levels of satisfaction with their major when clear career paths and goals are presented and a successful future is expected; and pursing an active problem-solving-centered rather than a passive, avoidance-centered approach is more helpful to coping with stress. Thus, this study contributes to understanding male nursing students' adaptation to college life and suggests effective strategies.

Authors Contributions
Study conception and design: HL, HP Data collection: HL Data analysis and interpretation: All authors Drafting of the article: All authors Critical revision of the article: HP, NYK, ML