Globally, the demand for nurses continues to outstrip the available supply (WHO 2016). Nursing shortages prove to be a global challenge, as an under-resourced healthcare workforce attempts to deal with health needs, ultimately negatively influencing goals of improving patient care and health systems (Patidar et al. 2011:176; WHO 2016). Addressing both negative and positive attitudes held by nurses towards the profession (Fillman 2015:252; Miligi & Selim 2014:198; Patidar et al. 2011:176) represents an important aspect of understanding the issue of the nursing shortage (Al Jarrah 2013:147; Miligi & Selim 2014:197).

Global nursing shortages (WHO 2016) are set to increase further as nurses leave the profession (Liu et al. 2017:12; Uğur & Kocaman 2011:65; WHO 2016). The result is an imbalance in nurse supply and demand, which creates a serious workforce crisis, affecting the ability to fight disease and improve health (Liu et al. 2017:3; WHO 2016). Estimations predict that the global deficit of skilled healthcare professionals will be 15 million by 2030 (Liu et al. 2017:6). Looking at the United States alone, shortages are suggested to grow to more than 1 million nurses by the year 2020 (Littlejohn et al. 2012:3).

Numerous contributory factors to the undersupply of nurses in developed and developing countries have been given by different authors (Anarfi et al. 2010; Dywili, Bonner & O’Brien 2013:512; Littlejohn et al. 2012:23). These factors include the ageing nurse workforce, declining nurse enrolment because of other more attractive alternate career opportunities for school leavers, emigration (Anarfi et al. 2010; Dywili et al. 2013:512; Littlejohn et al. 2012:23), as well as the poor nursing image and working conditions that result in job dissatisfaction (Al Jarrah 2013:147; Anarfi et al. 2010:14; Patidar et al. 2011:176; Zarea et al. 2009:32).

Ghana is aligned with global nursing trends of attrition, resulting in critical shortages of nurses (Mwini-Nyaledzigbor et al. 2014), with the existence of just over 22 000 nurses representing a ratio of under 10 nurses to 10 000 population, despite an increase in nurse recruitment since 2003 (Pillinger 2011:11). In a study on the psychosocial factors influencing the perception and choice of nursing as a profession, a positive correlation was found between student nurses’ intention to travel abroad after graduation and their choice of nursing as a career (Mwini-Nyaledzigbor et al. 2014). This finding can be linked to the attitudes student nurses have towards the nursing profession, which is a significant aspect in the issue of the nursing shortage (Al Jarrah 2013:147; Miligi & Selim 2014:197). Positive attitudes towards the nursing profession contribute to nurses remaining in the profession (Miligi & Selim 2014:197).

A response rate of 87.5% (n = 70) was obtained.

The respondents were not representative of the Ghanaian student population as there were no respondents over 30 years of age. A Ghana requirement for student selection into training is that the applicant falls within the age range of 18–35 years and in the study respondents were mainly (89.71%) within the age group of 20–25 years. Students over 30 years are not usually many in the colleges, which reflects the Ghanaian educational system where a student who had uninterrupted training from primary school at the acceptable age of 6 years enters and graduates from college by the age of 20 years (MOH-Ghana 2014).

Despite the 31-35-year age group not being represented, there was no significant difference between represented age groups and attitude towards nursing (U = 1.60; p = 0.361), and, therefore, the practice of a cut-off at 35 years for new recruits is suggestive of review, thereby increasing the eligible applicants for nursing training. Anarfi et al. (2010:24) suggested an increase in the number of nurses undergoing training to counter the exit of nurses from Ghana. The finding of no significance between age groups and attitude is contrary to the significance (p = 0.05) found by Miligi and Selim (2014:205), when examining Saudi Arabian nursing students’ attitudes towards the nursing profession, as students in the age group 20–24 years showed more positive attitudes than the younger (less than 20 years) and older (25 years or more) age groups.

There is an increase in the number of male students joining nursing in Ghana with a ratio of 60% female to 40% male students (Lievens et al. 2011:16), where nursing is perceived as a suitable profession for both men and women (Ofori 2007:24). Ghanaian perceptions are unlike the more general perception that nursing is a career choice for women (Ashkenazi et al. 2017:166; Buthelezi et al. 2015:4; Zamanzadeh et al. 2013:51). The respondents’ agreement that nursing is not predominantly for women reflects Ghana’s non-stigmatising approach in terms of societal views on gender and nursing and the close ratio of male to female nurses (Lievens et al. 2011:16). In other countries such as Canada and the United States, there is gender bias that favours women as society views nursing as a female profession with only 5% of nurses being men; a similar situation exists for male representation in England (10%) and Ireland (4%) (Zamanzadeh et al. 2013:49). However, in recent times a revived interest for nursing amongst Ghanaian women shows that about 80% of female students who complete senior high school will opt for nursing over any other profession (Addy 2015). Furthermore, the Ghana nursing recruitment policy requires an equal ratio of male to female students (MOH-Ghana 2014).

Variance exists in the literature regarding gender and attitudes to nursing. Some authors report differences in gender and attitude towards nursing (Fillman 2015:252; Zamanzadeh et al. 2013:223), while others disagree in there being a difference (Mullan & Harrison 2008:533). In this study, there was a near-significant difference (U = −1.93, p = 0.054) in gender and the attitude score and a clearly significant difference (U = −2.25, p = 0.024) when comparing attitude categories. In contradiction to other findings (Ashkenazi et al. 2017; Buthelezi et al. 2015:6; Mahran & Al-Nagshabandi 2012:19), male respondents had a greater inclination to be more comfortable with the idea of being a nurse, seeing nursing as an interesting profession, with greater expressed enjoyment of caring and a sense of fulfilment in seeing patients getting better.

It is perhaps these positive attitudes that contribute to male nurses’ job satisfaction. Ofori (2007:24), examining the ‘glass elevator’ phenomenon in male nurses in Ghana, identified a high level of job satisfaction. This holds significance in the recruitment of male students who evidently hold the values of the nursing profession. Evidence of greater levels of caring in the male nurses in the study is counter to descriptions of female nurses as more maternal and caring than male nurses (Mahran & Al-Nagshabandi 2012:19), while some authors offer a possibility that male nurses could be as caring as female nurses (McMurry 2011:24).

Despite the portrayal of the positive attitudes, the majority (n = 40, 57.14%), especially the male nurses (n = 28, 73.6%) perceived that the pay in nursing is unreasonable. This is reflective of the current underfunding of the healthcare system in Ghana, forcing nurses to leave the country soon after training, into care provision in NGOs, which offer higher salaries (Anarfi et al. 2010:17; Mwini-Nyaledzigbor et al. 2014:26; Pillinger 2011:7). Ghanaian men have greater financial responsibilities (Zamanzadeh et al. 2013:51), which possibly explains the level of discontent with the salaries, yet it is noted that Anarfi et al. (2010:11) identified that the motivation to join nursing by Ghanaian male students was driven by financial gains and prestige. In favour of retention and despite the salary issue, Ghanaian male nurses are perceived as loyal to the profession and not discriminated against for promotion (Ofori 2007:25). Recognition must be given in this setting to the fact that men found nursing to be a less secure profession and the loyal trends of the past could change.

In addition to the male respondents, the urban respondents (n = 23, 60.5%) drove the discontent with wages, which matches the findings by Antwi and Phillips (2012:2) in that the impact of wages on attrition was strongest in urban areas. Despite these findings, the urban students, in comparison to the rural students, saw greater job security and opportunities for universal employment, which is suggestive of their exposure to other nursing environments in the urban setting (Miligi & Selim 2014:206) and an opportunity to moonlight (Lievens et al. 2011:11). Healthcare facilities in rural areas of Ghana are poorly resourced and sparsely located (Anarfi et al. 2010:9; Lievens et al. 2011:10). Furthermore, the financial dissatisfaction is suggestive of a catalyst in urban settings for nurses to move to other employment. The majority (n = 38, 58.46%) of respondents were from the urban areas, which could influence their choice of work setting post qualification, favouring an urban environment, drawn by a lifestyle of greater opportunity as compared to rural areas (Anarfi et al. 2010:9; Lievens et al. 2011:10). This has the potential to pose difficulties in retaining nurses for the rural areas (Anarfi et al. 2010:9; Lievens et al. 2011:9).

Ghana has instituted incentive schemes such as a Deprived Area Incentive Allowance for persons working in districts designated as deprived; however, recruitment to rural areas remains a challenge (Anarfi et al.2010:9; Lievens et al. 2011:21). Perhaps there is further learning Ghana can glean from South Africa’s rollout of the rural allowance (Ditlopo et al. 2011:589). It is important that Ghana revisits the Deprived Area Incentive Allowance, with ‘tangible handsome allowances’ as opposed to verbal promises, as well as exploring the constraints of working in rural areas (Donkor & Andrews 2011:222; Lievens et al. 2011:21). In addition, a possibility exists to examine the opportunity in rural areas for job progression, as the majority of the respondents (n = 44, 63.8%), in particular the male nurses (n = 24, 63.1%), intended to stay in nursing post qualification despite the long-existing problem of low salary levels (Anarfi et al. 2010; Pillinger 2011:8). In the retention of male nurses it is concerning that Ghana could lose loyal caring male nurses to the drawcard of money. It is of interest to note that just over half of the respondents (n = 35, 51.43%) did not see nursing to have opportunities for world travel, with limited perceptions (n = 35, 51.43%) on universal job availability. However, Ghana has lost large numbers of its nurses to emigration, often the United Kingdom (Anarfi et al. 2010:17: Donkor & Andrews 2011:222), which aligns with society’s view of nursing offering job security (Fillman 2015:252) and a stable future (Zamanzadeh et al. 2013:223).

The positive attitudes displayed by the respondents towards the nursing profession are relevant (Al-Omar 2004:153) and could have a strong sway over the deterrent of the salary. Miligi and Selim (2014:197) stated that positive attitudes towards the nursing profession contribute to an increase in the number of nurses who are devoted and stay in their profession. The predictive significance of positive attitudes towards retention and the respondents’ view that nursing is without universal employment prospects fails to answer the question of ‘why the attrition to places off Ghana’s shores’ (Anarfi et al. 2010; Mwini-Nyaledzigbor et al. 2014:26). Maybe the answer lies in current nurses’ changing view to stay within the shores of Ghana or answers will sought in a focus group of a future study. A focus group will also allow for further unpacking of the perception by the majority (n = 56, 81.16%) that nursing is a challenging career and not a secure profession (n = 42, 60.0%).

In examining habitation and attitude categories of favourable and less favourable, a significant difference (U = −2.08, p = 0.037) was found, which aligns with the study by Patidar et al. (2011:182) (p = 0.039) and gives meaning to the findings by Miligi and Selim (2014:206). The study by Miligi and Selim (2014:206) revealed that respondents from more modern and urbanised regions had positive attitudes towards nursing, which is explained by the presence of several colleges of nursing in public and private universities and students more oriented about nursing (Miligi & Selim 2014:206). In the context of Ghana’s geographical terrain, in the rural areas, resource restriction for equipment as well as a smaller proportion of skilled professionals (Anarfi et al. 2010:9), the study’s findings of significantly less favourable attitudes of the nurses from rural locations together presents a challenge to Ghanaian policymakers. In an attempt to meet the demand for nurses, the rural context suggests recruitment of nurses with stronger clinical reasoning skills capable of flexibility and thinking creatively. It is unfortunate that the nurse in the rural setting is at risk of disparagingly receiving the label of ‘the village nurse’ (Lievens et al. 2011:27). This further strengthens the previously mentioned need for a drawcard to attract into the rural areas the urban nurses (particularly the male nurses) who displayed more positive attitudes and were greater in number.

The lack of association between age (p = 0.613), gender (p = 0.335) and habitation (p = 0.989) with intention to stay in nursing is contrary to a previous study by El-Jardali et al. (2009:7), where age (p = 0.001) and gender (p = 0.037) had a significant bearing on intent to stay in nursing. Wang et al. (2012:551) also found age to be significant (p < 0.001). The medium positive correlation between intent to stay in nursing and the attitude dimension of the study is consistent with Al-Omar’s (2004:155) findings that the more positive attitude towards nursing, the more likely that the student would stay in nursing.

The study was not representative of all age groups. Hawthorne effect (Brink, Van der Walt & Van Rensburg 2012:164) seen in negative skewness might have influenced data relating to the intention to stay in nursing given that the students were in their final year and desiring employment post completion.

Recruitment and retention strategies with related policies should focus on recruiting more men, improving the attitudes of female and rural nurses and, specific to Ghana, possibly increasing the limit of the recruitment age.

Furthermore, Ghana-specific recommendations are the implementation of a rural allowance to draw urban male nurses into rural areas, development of an attitude scale specific for the context of lower income countries and repeating the study for Ghana. Run focus groups to identify perceived challenges posed by nurses in order to intercept and address these earlier in nurses’ training.

Generally, respondents (n = 70), in particular students from urban areas and male students of the select college had favourable attitudes towards nursing. Ghanaian male student nurses’ attitudes are non-typical of general stereotypes held of nurses and gender. However, amongst northern Ghana final-year student nurses, aspects that require focus in developing favourable attitudes, which could contribute towards retention and prevent early exit of nurses, are salary and addressing the perception that nursing is a challenging career.

The demographic variables hold a small amount of value in the development of attitudes in Ghanaian nurses and perhaps the greater link in attitude development lies in nurses’ training. Knowledge acquired through training develops favourable attitudes towards nursing (Miligi & Selim 2014:206).