Introduction

With countries around the world experiencing population aging, declines in fertility, and increasing life expectancy, older adults may be expected to spend more years dealing with frailty and illness (Dixon, 2021). In China, the older adult population aged 60 years and above is growing at an unprecedented speed, rising from 222 million in 2015 to 264 million in 2020 (18.7% of the population), and the population over 65 years old was 191 million in 2020 (13.5% of the population; Tu et al., 2022). Because of China's three-decade-long one-child policy, a large number of single-child parents have entered old age, nearly half of whom are “empty nesters” (i.e., no longer living together with their children). With the acceleration of urbanization, significant numbers of younger workers in rural areas are leaving home to find work in higher-population-density areas, further increasing the care pressures on empty-nest older adult families (Wu, 2021). Families often face great difficulties in providing care for their older adult relatives.

Adults experience higher rates of various chronic diseases than the general population. Moreover, the rate of multimorbidity in older adults in China is 43.6% (R. Zhang et al., 2019). This faces older adults with complex health needs and greater challenges to care. China's traditional elderly care institutions focus primarily on meeting basic living needs. Medical institutions provide short-term hospitalization only when older adults are seriously ill, and medical care and basic older adult care are largely separate services. Since 2013, China has been working to combine medical care and elderly care to meet the medical needs of older adults with chronic diseases through hospitals for general care functions and pension institutions for specialized healthcare needs. However, the shortage of nurses providing care to older adults is a key factor limiting quality of care (Feng et al., 2020).

Similar to other countries (Dai et al., 2021), most undergraduate nursing students in China choose to work as nurses in large general hospitals, especially in the field of acute and severe nursing in wards treating adult patients. Although nursing students may have a moderate level of motivation or willingness to care for older adults, few eventually choose geriatric nursing (GN) as their career (Guo et al., 2021). This may be because general hospital positions have more advantages than GN positions in terms of, for example, salary and welfare, social recognition, and personal development (H. Zhang & Sun, 2019). Another reason may be that undergraduate nursing curricula are tailored to hospital nursing and lack the content necessary to encourage and stimulate students to choose a career in GN (Garbrah et al., 2017). Career motivation affects career commitment, satisfaction, and engagement (Somers et al., 2019).

Meaning in life (MIL) is the process by which individuals recognize and search for meaning of their own lives and includes the aspects of MIL-presence (MIL-P) and MIL-searching (MIL-S; S. S. Liu & Gan, 2010; Steger et al., 2006). MIL-P is the understanding of the purpose and mission of life, reflecting the degree to which one's life is perceived as meaningful, whereas MIL-S is the goal and mission of trying to find MIL. With economic development, the influence of diverse values, and the continuous reconstruction of MIL, young people in China experience existence anxiety that has accumulated over several generations, resulting in loss of individual MIL (Chen et al., 2021). Although young adults today desire to pursue a meaningful life, realize their self-worth, and gain recognition from the society, they are highly vulnerable to adopting a herd mentality and falling into blind compliance with social standards. When considering a career in older adult care, students in China may want to choose a job with more consideration for realizing the value of life. Alternatively, because of MIL-related uncertainty, nursing students may blindly and passively conform to family and social expectations with regard to pursuing working status and prestige and choose to work in a general hospital. Nursing students with higher levels of MIL are generally more motivated to provide better elderly care and to be more engaged at work (Tsai et al., 2018).

From the existential theoretical perspective (Cohen, 2003), career choice is motivated by the desire to find a meaningful job, which provides the opportunity to find career satisfaction and MIL. Some nursing students do not want to pursue a career that involves caring for older adults because they think it will involve suffering and waiting for death, which are depressing activities. Nursing students may also worry that GN may not allow them to effectively practice their nursing skills or become experts in their role, which can affect their pursuit of MIL (Garbrah et al., 2017). Meanwhile, other nurses believe work in GN can bring them closer to the souls of the older adults they care for and expose them to the living wisdom of care recipients. In this case, nurses can achieve MIL through listening to the older adults tell their life stories (Ferstad & Rykkje, 2023). Significant attention has been paid in previous quantitative studies to the influence of external factors such as working environment, family suggestions, social status/prestige, attitudes, and lived experiences. However, the intrinsic motivation factors affecting MIL have largely been ignored (Cheng et al., 2015; Dai et al., 2021).

According to terror management theory, defensive thinking emerges in response to awareness of and acute fear resulting from death to avoid facing the prospect of one's eventual death (Greenberg et al., 1997). Discussing death is not easy in Chinese families, with discussions about the death of parents considered unfilial and taboo because of fears over inviting bad luck. Especially in Shandong province, which is the home region of Confucius and still deeply influenced by Confucian moral thought, filial piety remains the most important of all virtues. This study was designed to examine the relationships among death attitude, MIL, and career motivation in GN (Hsieh et al., 2021), which is an issue inadequately investigated in the literature.

Methods Study Design and Sample

In this cross-sectional study, an online survey was conducted to collect data. Informed consent was obtained from all of the participants, and the protection of their privacy was ensured. A convenience sampling approach was used to enroll participants from four universities with similar 4-year undergraduate nursing programs in Shandong Province, China. The undergraduate programs included 3 years of theoretical study and one final year in which a 1-year internship at a general hospital was offered. The inclusion criteria were as follows: (a) willingness to participate, (b) being a Chinese student, (c) being enrolled in a 4-year undergraduate program, (d) taking the last semester of their fourth year, and (e) being in an internship at the time of data collection. No exclusion criteria were used in this study. The students were provided a link to the online survey form (wjx.cn). The survey was conducted between April and May 2022. Of the 740 qualified participants, 595 completed the survey (response rate: 80.4%).

Measures

The researchers independently conducted a systematic literature review of studies related to death attitude, MIL, and motivation for choosing GN as a career path to determine the measurement tools with suitably high reliability and validity. After discussions with experts from nursing universities, the structured questionnaire was developed and revised.

The data were collected using an introductory information form, the Career Choice Motivation Questionnaire for Geriatric Nursing (CCMQ-GN), the Death Attitude Profile-Revised (DAP-R), and the Meaning in Life Questionnaire (MLQ).

Sociodemographic Variables

The introductory information form included the following six sociodemographic items: age, gender, place of residence, experience cohabiting with older adults (aged ≥ 60 years), experience caring for older adults (aged ≥ 60 years), and internship experience in GN institutions. In this study, “elderly” and “older adult” are defined as individuals ≥ 60 years old, in line with the standard practice in China.

The Career Choice Motivation Questionnaire for Geriatric Nursing

This questionnaire was used to gauge the motivation of participants to choose GN as a career path. The 20-item Chinese version of the CCMQ-GN was created by Cheng et al. (2015) based on the expectancy–value theory to measure the two dimensions of motivation, that is, value and expectancy. The value dimension includes the four subscales of interest (three items), utility (three items), attainment (five items), and cost (three items). Each item is scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The cost subscale is reverse scored. The expectancy dimension includes six items, with no subscales. Higher total scores for this questionnaire indicate higher motivation for GN (Cheng et al., 2015). The CCMQ-GN has reported Cronbach's αs of .87 (value motivation) and .91 (expectancy motivation; Dong et al., 2022). In this study, the Cronbach's α was .91.

The Death Attitude Profile-Revised

The DAP-R was developed and revised by Wong et al. (1994) as a 32-item scale with five subdimensions: fear of death (seven items), death avoidance (five items), neutral acceptance (five items), escape acceptance (five items), and approach acceptance (10 items). A 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) is used to score the items, with higher average subdimension scores indicating a greater tendency toward the related attitude. Validity and reliability have been established for the Chinese version of the DAP-R (L. Tang et al., 2014), and the Cronbach's α value in this research was .897.

Meaning in Life Questionnaire

The original version of the MLQ was developed by Steger et al. (2006), and the Chinese version was validated by S. S. Liu and Gan (2010). This questionnaire is composed of nine items in the two subscales of search for meaning (MLQ-S; four items) and presence of meaning (MLQ-P; five items). Each item is scored from 1 = strongly disagree to 7 = strongly agree, and one item, “I have no clear purpose in my life,” is scored in reverse. Higher total scores are associated with a greater sense of MIL. The Cronbach's α values in this study were .754 for MLQ-P, .842 for MLQ-S, and .877 for MLQ.

Data Collection

The researchers uploaded the online questionnaire to the “Question Star” platform (wjx.cn) and generated a shared link. Next, one researcher contacted the faculty in charge of managing fourth-year intern students and explained the purpose of this study. After the faculty member agreed to cooperate in this study, the researcher sent her the questionnaire link using WeChat, which she sent to the nursing intern students using WeChat. Faculty in China commonly use WeChat to release notices and news. By clicking on the link, the participants could answer the questions on either a computer or mobile phone. In the first part of the questionnaire, the purpose of the study was introduced, and a statement on anonymity and privacy protection was provided. The participants were required to click on the “Agree” button to begin the questionnaire. All of the questions required an answer, and missing data were not accepted. After completion, submission was automatic. Researchers were able to view the questionnaire results on the platform by logging in using their name and password.

Data Analysis

SPSS Statistics Version 22.0 (IBM Inc., Armonk, NY, USA) software was used to analyze the collected data. Descriptive statistics were analyzed for frequency, percentage, mean, and standard deviation. For normally distributed variables, between-group differences were tested using an independent t test for group pairs and one-way analysis of variance for multiple groups. Pearson's correlation and a multiple linear regression model were used to evaluate the effect on career choice motivation. A two-sided p value < .05 and 95% confidence interval were deemed statistically significant.

Ethical Considerations

Before data collection, this study was approved by the institutional review board of the teaching development department at Jining Medical University (IRB No. 2020-235). All of the procedures were carried out in line with informed consent and privacy protection principles. Before questionnaire distribution, the researcher selected the privacy protection options “forbid questionnaire copying” and “block search engine retrieval.” In addition, the questionnaire link was designed as a one-time link that expired after data collection. Questionnaire responses were anonymized, and the participants were allowed to withdraw from this study at any time. All of the data collected for this study were stored in a password-protected file accessible only to the researchers using a private account.

Results Sample Characteristics

The 595 participants in this study had a mean age of 21.51 (SD = 1.08) years. As shown in Table 1, 493 (82.9%) were female, 216 (36.3%) lived in urban areas, and 416 (69.9%) lived with elderly relatives. Over one third (226, 38.0%) had no prior experience caring for older adults, whereas 316 (53.1%) had limited older adult care experience. In addition, 514 (86.4%) had never interned at a GN institution.

Table 1. - Comparison of Sociodemographic Variables and CCMQ-GN Scores (N = 595) Variable n % M SD t/F p Gender −0.72 .474  Male 102 17.1 62.98 10.15  Female 493 82.9 63.72 9.35 Place of residence −2.53 .012*  Urban 216 36.3 62.30 10.61  Rural 379 63.7 64.33 8.71 Living with older adult relatives (aged ≥ 60 years) 2.12 .034*  Yes 416 69.9 64.13 9.49  No 179 30.1 62.34 9.38 Caring for an older adult (aged ≥ 60 years) 9.35 < .001***  Often 53 8.9 67.30 9.31  Occasionally 316 53.1 64.28 8.75  Never 226 38.0 61.76 10.15 Internship experience in GN institutions 2.16 .031*  Yes 81 13.6 65.70 10.46  No 514 86.4 63.26 9.29

Note. CCMQ-GN = Career Choice Motivation Questionnaire for Geriatric Nursing; GN = geriatric nursing.

*p < .05. ***p < .001.

General Characteristic-Related Differences in Career Choice Motivation Questionnaire for Geriatric Nursing Scores

The results of the independent t test are shown in Table 1. The participants from rural areas earned a higher average score for motivation than their peers from urban areas (p < .05), those who had not lived with older adult relatives at home scored lower on the CCMQ-GN than their peers who had (p < .05), and those who had interned at GN institutions had significantly higher scores for motivation than their peers who had not (p < .05). Furthermore, the analysis of variance results showed that, compared with their peers who had never cared for or had limited experience caring for an older adult, the participants with frequent experience caring for an older adult earned a higher average score for motivation (p < .001).

Career Choice Motivation Questionnaire for Geriatric Nursing, Death Attitude Profile-Revised, and Meaning in Life Questionnaire Mean Scores and Their Intercorrelations

The descriptive statistics for career choice motivation for GN (CCMQ-GN) are summarized in Table 2. The mean score for the CCMQ-GN was 3.15 (SD = 0.49), with subscale scores of 3.53 (SD = 0.62) for interest, 3.22 (SD = 0.65) for utility, 3.14 (SD = 0.73) for cost, 3.12 (SD = 0.63) for attainment, and 3.06 (SD = 0.60) for expectancy.

Table 2. - Career Choice Motivation Questionnaire for Geriatric Nursing (CCMQ-GN) Scores (N = 595) CCMQ-GN and Subdimension Total Score Item Score M SD M SD CCMQ-GN 63.59 9.49 3.15 0.49  Value 45.23 6.84 3.23 0.49   Interest 10.58 1.87 3.53 0.62   Utility 9.65 1.96 3.22 0.65   Attainment 15.60 3.14 3.12 0.63   Cost 9.41 2.19 3.14 0.73  Expectancy 18.36 3.58 3.06 0.60

The descriptive statistics for death attitude (DAP-R) and MIL (MLQ) are summarized in Table 3. The mean scores were 4.99 (SD = 0.94) for the MLQ, 4.88 (SD = 1.08) for the MLQ-P, and 5.13 (SD = 1.09) for the MLQ-S. Mean scores for death attitude subscales were also calculated, with neutral acceptance earning the highest mean score of 3.77 (SD = 0.59), followed by escape acceptance (2.95, SD = 0.72), fear of death (2.87, SD = 0.68), approach acceptance (2.84, SD = 0.58), and death avoidance (2.72, SD = 0.74).

Table 3. - DAP-R and MLQ Scores, and Correlations Among DAP-R, MLQ, and CCMQ-GN (N = 595) Variable Total Score Item Score CCMQ-GN M SD M SD r p Death attitude (DAP-R) – – – – – –  Fear of death 20.12 4.79 2.87 0.68 −.13 .002**  Death avoidance 13.57 3.72 2.72 0.74 −.05 .226  Neutral acceptance 18.86 2.97 3.77 0.59 .03 .465  Escape acceptance 14.77 3.61 2.95 0.72 .02 .714  Approach acceptance 28.35 5.81 2.84 0.58 .08 .041* Meaning in life (MLQ) 44.92 8.44 4.99 0.94 .24 < .001***  MIL-Presence 24.42 5.40 4.88 1.08 .21 < .001***  MIL-Searching 20.51 4.35 5.13 1.09 .20 < .001***

Note. DAP-R = Death Attitude Profile-Revised; MLQ = Meaning in Life Questionnaire; CCMQ-GN = Career Choice Motivation Questionnaire for Geriatric Nursing; MIL = meaning of life.

*p < .05. **p < .01. ***p < .001.

The correlations among death attitude, MIL, and career choice motivation for GN are presented in Table 3. Significant positive correlations were found between MIL, MIL-P, and MIL-S, respectively, and motivation for GN as a career choice (r = .24, p < .001; r = .21, p < .001; and r = .20, p < .001, respectively). Fear of death and motivation for GN as a career choice shared a weak, significant, and negative correlation (r = −.13, p < .01). Although a significant and positive correlation was found between the death attitude subscale “approach acceptance” and motivation for GN as a career choice, their relationship was very weak (r = .08, p < .05).

Multiple Linear Regression Analysis on the Associations Between Death Attitude Profile-Revised and Meaning in Life Questionnaire, Respectively, and Career Choice Motivation Questionnaire for Geriatric Nursing

Multiple linear regression analysis was performed using the scores of the CCMQ-GN as dependent variables and the subscale scores of the DAP-R and MLQ as independent variables. The sociodemographic variables were also used as independent variables, and within-group statistical differences in career choice motivation scores were compared. All of the independent variables accounted for 14.5% of the variance in career choice motivation for GN (R2 = .15, F = 9.01, p < .001). Presence of meaning (p < .01), searching for meaning (p < .05), and having a death attitude of escape acceptance (p < .05) or approach acceptance (p < .001) were found to be significantly and positively associated with motivation to choose a career in elderly care. Conversely, fear of death (p < .001) and death avoidance (p < .05) were found to be significantly and negatively associated with choosing GN as a career path (Table 4).

Table 4. - Multiple Linear Regression Analysis of DAP-R, MLQ, and CCMQ-GN (N = 595) Independent Variable CCMQ-GN B ß t p 95% CI Constant 63.16 14.32 < .001*** [54.49, 71.82] Place of residence 1.47 0.07 1.93 .055 [−0.03, 2.96] Living with older adult relatives −0.81 −0.04 −0.98 .328 [−2.42, 0.81] Caring for an older adult −2.22 −0.15 −3.62 < .001*** [−3.42, −1.01] Internship experiences in GN institutions −1.56 −0.06 −1.45 .150 [−3.66, 0.56] Death attitude (DAP-R)  Fear of death −3.49 −0.25 −4.48 < .001*** [−5.02, −1.96]  Death avoidance −1.70 −0.13 −2.53 .012* [−3.02, −0.38]  Neutral acceptance −0.78 −0.05 −1.15 .249 [−2.12, 0.55]  Escape acceptance 1.63 0.12 2.23 .026* [0.19, 3.06]  Approach acceptance 3.43 0.21 3.80 < .001*** [1.66, 5.20] Meaning in Life (MLQ)  MIL-Presence 0.27 0.13 2.70 .007** [0.07, 0.47]  MIL-Searching 0.19 0.11 2.31 .021* [0.03, 0.34]

Note. F = 9.01, R = .38, R2 = .15, adjusted R2 = .13, Durbin–Watson = 2.03, p < .001. DAP-R = Death Attitude Profile-Revised; MLQ = Meaning in Life Questionnaire; CCMQ-GN = Career Choice Motivation Questionnaire for Geriatric Nursing; GN = geriatric nursing; MIL = meaning in life.

*p < .05. **p < .01. ***p < .001.

Discussion

The results of this study indicate MIL, MIL-P, and MIL-S to be positively associated with students choosing GN as their career path. The average scores for MIL, MIL-P, and MIL-S in this study were 4.99, 4.88, and 5.13, respectively. These scores fall into the medium range and are slightly higher than those reported in a study on nursing students by Kim and Kim (2017). MIL reflects one's perspective on the intrinsic value of life and perception that life is worth living (Steger et al., 2006). Higher sense of MIL is associated with greater perceived subjective happiness. In addition, students with higher MIL are more likely to be more positively motivated to discover meaning from work (Jung & Yoon, 2016; Steger & Dik, 2009).

The participants in this study showed a medium level of motivation to choose a career in GN. The mean scores of the value subscales were slightly higher, and those for the expectancy subscales were lower than those reported in Cheng et al. (2015) and Guo et al. (2021). Similar to these studies, the interest motivation subscale earned the highest score of all CCMQ-GN subscales. However, compared with these studies, the cost, utility, and attainment subscale scores for GN career choice motivation were relatively low (Cheng et al., 2015; Guo et al., 2021). Although caring for older adults can increase the motivation of students to continue caring for older adults, this does not infer they view a GN career as meaningful. Conversely, these students, especially those from urban settings, may perceive a GN career as relatively disadvantageous in terms of offering fewer promotion opportunities, lower compensation, less prestige, and a relatively depressing working environment (Cooke et al., 2021; P. Liu et al., 2021). Moreover, contemporary nursing education, which focuses greater attention on emergency and critical care skills, makes it difficult for students to correctly perceive the value of elderly care as a career path (Fetherstonhaugh et al., 2022; Garbrah et al., 2017). As most GNs have a relatively low level of education, their opportunities for better jobs and career growth are more limited than better-educated peers in other nursing specialties (Li et al., 2021).

During the COVID-19 pandemic, most elderly care institutions in China were closed to internships. In this study, only 16.4% of the participants had nursing internship experience. However, those with this experience were more motivated to care for older adults than those without internship experience. Practical experience has been shown to improve motivation to choose GN as a career (Cheng et al., 2015; Hsieh et al., 2021). Conversely, negative feelings regarding the role of nursing in elderly care engendered during an internship or lack of confidence in the knowledge and skills needed to care for older adults may lead to misunderstandings in the nursing profession about the older adult population (Okuyan et al., 2020). Hu et al. (2021) found the competencies of registered nurses providing geriatric care to be limited, which may affect the confidence of interns caring for elderly patients.

Nursing education should focus greater attention on students' sense of MIL to help them experience positive meaning imparted by knowledgeable nurses caring for older adults and to cultivate intrinsic meaning from gratitude, empathy, and prosocial activities (Cooke et al., 2021; Lee & Park, 2019; Tsai et al., 2020). Helping students overcome the challenges involved in providing nursing care to older adults and improve opportunities for career development may improve the perceived meaning in nursing students' lives and promote career choice motivation.

The findings of this study suggest a significant association in students between death attitude and motivation to care for older adults. Holding negative attitudes toward death, for example, fear of death and death avoidance, was shown to relate negatively with motivation to choose GN as a career path, whereas higher scores for escape acceptance and approach acceptance were found to relate positively with motivation to choose GN as a career path. However, neutral acceptance was not associated with motivation to choose GN as a career path. W. Tang et al. (2022) reported passive death attitude to correlate negatively with willingness to care for older adults, and Barnett et al. (2021) found higher acceptance of death to correlate positively with attitudes toward end-of-life care. When death is accepted as a natural part of life, death and aging are more likely to be perceived as normal physiological changes. This may help promote the image of GN as simply “another nursing specialty” with no need of special concern or consideration (Upasen & Thanasilp, 2020). Death attitude is known to be correlated to professional identity (Xie et al., 2021) and may be correlated to professional identity among GNs. Because aging shortens time to death, death attitude may be associated with attitudes toward and pressures on end-of-life care for older adults, thus potentially impacting motivation to choose GN as a career. However, attitude toward end-of-life care also relates to whether nurses receive educa