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Sun M, Huo B, Dow T, et al. Career Factors Valued by Medical Students Interested in a Surgical Career. Intl J Surgical Education (IJSED). Published online September 9, 2022.
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  • Table 1. Demographics and residency choice N=107
  • Figure 1. Career factor rating of importance based on student career interest
  • Table 2. Univariate and Multivariate Logistic regression with surgery
  • Appendix 1. Distribution of Medical Student Factors N=107
  • Appendix 2. Univariate and Multivariate Logistic regression with Students Interested in Medical Specialities
  • Appendix 3. Univariate and Multivariate Logistic regression with Undecided in Career Interest

Abstract

Background

Studies suggest that early specialty exposure positively influences medical student career interest in that given field. Residency programs should consider implementing programs that focus on optimizing factors that have been identified to increase student interest to attract the best applicants. The purpose of this study is to identify factors associated with student interest in surgical and non-surgical specialties at the pre-clerkship level.

Methods

Online surveys were distributed to all first and second-year medical students at Dalhousie Medical School. The survey assessed demographics, current career interest, and career-influencing factors. Multivariate logistic regression was conducted incorporating variables with p≤0.20 on univariate analysis to identify factors associated with student interest of surgical disciplines, non-surgical disciplines, or undecided.

Results

Of the 107/219 (49%) students that completed the survey, 20 (18.7%) and 30 (28.0%) listed surgical and non-surgical disciplines as their current career interest, respectively. Multivariate analysis revealed lower prioritization of lifestyle-related career factors to be associated with interest in surgical disciplines (p=0.032), while older age (p=0.001) and decreased interest in research (p=0.001) were associated with interest in medical disciplines.

Conclusion

Our study identified low prioritization of lifestyle-related career factors among students with surgical career interests, while those with undecided career interests were correlated with prioritizing lifestyle-related factors. Our findings suggest that medical students still consider surgery as a specialty with a culture of poor work-life balance. Students who value work-life balance may rule out surgery early on or delay their career decisions.

Introduction

There is a decline in medical student interest in surgical careers in Canada.1–3 Recent data from the Canadian Resident Matching Service (CaRMS) shows a decline in applicants ranking surgical programs as first choice from 28% in 2008 (589/2110) to 21% in 2019 (621/2934).4 This reduction in new trainees may result in an inability to meet the surgical demands of an aging population.5,6

Numerous factors are known to influence students’ career decision-making including gender, perception of lifestyle, prestige, mentorship, and role models, among others. Specifically, gender discrimination and limited early surgical exposure are core factors that negatively influence a student’s interest in a surgical career.7 Student “fit” into the culture of surgery is an additional deterrent to surgical career interest. The culture of surgery has traditionally been described as prolonged work hours, negative impacts on work-life balance and unique patient-interactions in surgery.7 In contrast, early surgical interest, having family or friends practicing in surgery, previous experiences volunteering in sports, and interest in medical over social problems, have been identified as predictors of choosing a career in surgery.8,9

The primary objective of this study was to identify factors associated with pre-clerkship student interest in surgery versus non-surgical specialties. In addition to demographic variables and career-influencing factors as identified by Scott et al., research interest, and residency factors were included to provide a more holistic assessment of medical students interested in surgical disciplines, medical disciplines, or undecided.

Methods

Questionnaire Development & Variables

Career factors for the survey were derived from a thorough literature review, with reference to the factor analysis performed by Scott et al. (2011). The survey was revised to ensure clarity and feasibility by three medical students (T.D, S.H, and M.S) prior to survey dissemination. The survey was composed of four sections. The first section of the survey assessed demographics such as gender, age, education level prior to medical school, current marital status, highest level of parental education, parental status, whether the participant had immediate family in medicine, and varsity sport participation. The second section of the survey assessed current career interests (medicine, surgery or undecided) and top-three career choices. The third section allowed participants to rate the importance of career factors using a Likert scale (1-Not Very important, 5-Extremely Important). Thirty-two previously identified career factors were grouped under the following themes: lifestyle, community orientation, prestige, hospital orientation, scope of practice, role model and other (Table 2). A mean score was obtained for each group. New factors to be explored and factors with low internal consistency were kept separate in further analyses.

Dissemination

Using a cross-sectional approach, electronic surveys were distributed to medical students in their first and second year of training at Dalhousie University. At our institute the first two years of teaching are mainly classroom based and are prior to students receiving significant clinical first-hand experience. Opinio (Object Plant, Oslo, Norway) was used to collect anonymous responses over a four-week period. Students were only able to complete the survey once. Informed consent was submitted with survey completion.

Data Analysis

All results of the questionnaire were blinded during data analysis using participant specific identifiers. Comparisons between study groups were made using the chi-square test and Fishers exact test when cells were ≤5. Factors associated with current career interests (surgery, medicine or undecided) were evaluated using logistic regression. Multivariate logistic regression was conducted using the enter method, incorporating variables and factors which were significant or near-significant (p≤0.20) on univariate analysis. Based on previous research demonstrating their association with career interests, age and gender were also included in the models.9 Results were considered statistically significant at p-value <0.05. Analyses were conducted using SAS version 9.4.

Ethics

This study conformed to the guidelines outlined by Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Study approval was obtained through the Nova Scotia Health Authority Research Ethics Board (No. 1023325 & 1023087 for the first-year and second-year class, respectively).

Results

Demographics

Participant demographics are listed in Table 1. Overall, 107/219 (48.9%) students responded and 66/107 (61,7%) were female, 62/107 (57.9%) were between 20 and 24 years of age and 59/107 (55.1%) were first year medical students. There were 57/107 (52.3%) students that were undecided in their career path. Eighteen students (16.8%) had participated in varsity sports.

Table 1.Demographics and residency choice N=107
Total no. (%) Surgery no. (%) Medicine no. (%) Undecided no. (%) p
Gender 0.362
Male 41 (38) 10 (24) 9 (22) 22 (54)
Female 66 (62) 10 (15) 21 (32) 35 (53)
Age 0.002
20-24 62 (58) 13 (21) 9 (15) 40 (65)
25-26 24 (22) 6 (25) 10 (42) 8 (33)
27+ 21 (20) 1 (5) 11 (52) 9 (43)
Pre-medical education 0.639
Bachelors 72 (67) 12 (17) 19 (26) 41 (57)
Masters 33 (31) 8 (24) 10 (30) 15 (45)
PhD 2 (2) 0 (0) 1 (50) 1 (50)
Year of medicine <0.001
1 59 (55) 16 (27) 2 (3) 41 (69)
2 48 (45) 4 (8) 28 (58) 16 (33)
Relationship status 0.477
Single 85 (79) 17 (20) 24 (28) 44 (52)
Common law 13 (12) 3 (23) 2 (15) 8 (62)
Married 9 (8) 0 (0) 4 (44) 5 (56)
Children 1.000
Yes 2 (2) 20 (19) 29 (28) 56 (53)
No 105 (98) 0 (0) 1 (50) 1 (50)
Parental education 0.702
Highschool 15 (14) 3 (20) 6 (40) 6 (40)
Professional 24 (22) 3 (13) 8 (33) 13 (54)
University 40 (37) 10 (25) 10 (25) 20 (50)
Graduate 20 (19) 2 (10) 4 (20) 14 (70)
Other 8 (7) 2 (25) 2 (25) 4 (50)
Family member in medicine 0.262
Yes 26 (24) 2 (8) 9 (35) 15 (58)
No 81 (76) 18 (22) 21 (26) 42 (52)
Varsity sports 1.000
Yes 18 (17) 3 (17) 5 (28) 10 (56)
No 89 (83) 17 (19) 25 (28) 47 (53)
GRIT Scores 0.129
2.5-2.9 16 (15) 2 (13) 9 (56) 5 (31)
3.0-3.4 66 (62) 12 (18) 16 (24) 38 (58)
3.5-3.9 25 (23) 6 (24) 5 (20) 14 (56)

>>p from a chi-square. If cells ≤5 a fisher’s exact test was used

When assessing the seven career-influencing factor themes, several trends were identified. Factors allocated to the “Lifestyle” theme were important (mean=3.7 ± SD=0.7) influences on student decisions, which included flexibility, acceptable hours of practice and on-call schedules (Appendix 1). Students also rated “Community Orientation” (3.3 ± 0.7) as an important theme, which included health promotion, long-term relationship with patients, focus on patients in the community, social commitment, and interesting patient population (Appendix 1). “Hospital Orientation” (3.0 ± 0.7) was further rated as an important theme, including a focus on urgent care, a focus on in-hospital care, results of interventions being immediately available, and a preference of medical to social problems. “Prestige” (3.4 ± 0.7) included students’ preferences for careers in which they would have adequate income to eliminate debt and have a stable future. “Role model” (2.7 ± 0.9) appeared to be a factor of a lower significance for most students. Of the other survey items, students were interested in finding a good match career choice for themselves (4.1 ± 0.8) and being well supported in their residency program (3.9 ± 0.9; Figure 1).

Figure 1.Career factor rating of importance based on student career interest

On multivariate analysis (Table 2), lower prioritization of an acceptable lifestyle was independently associated with an interest in pursuing a surgical career (OR 0.32 95%CI (0.11-0.91)). Male gender (0.086) was noted to be approaching significance. Older age (OR 10.14 95%CI (2.27-45.28)) and a decreased interest in research (OR 0.27 95%CI (0.27 (0.13-0.60)) were associated with an interest in medical specialties, while controlling for other factors. A community orientation (interest in health promotion, outpatient medicine and longer-term relationships with patients) demonstrated a trend towards significance (p=0.071) of association with the career choice of medical disciplines. Older students (OR 0.20 95%CI (0.06-0.65)) and students in their second year (OR 0.18 95%CI ((0.06-0.54)) were less likely to be undecided in their career choices. Higher scores for lifestyle (valuing acceptable hours of practice, job flexibility and acceptable on-call schedules) closely correlated with reporting an undecided career choice (p=0.055). The factors and demographic variables included in the multivariate models account for the variance in the undecided (34%), surgery (45%) and medicine (50%) models.

Table 2.Univariate and Multivariate Logistic regression with surgery
No. (%) Univariate
Surgery
OR (95%CI)
p Multivariate
Surgery
OR (95%CI)
p
Demographic characteristics
Gender 0.237 0.086
Male 10 (24) 1.81 (0.68-4.81) 3.49 (0.84-14.55)
Female 10 (15) Ref Ref
Age 0.239 0.261
20-24 13 (21) Ref Ref
25-26 6 (25) 1.26 (0.42-3.81) 1.40 (0.29-6.69)
27+ 1 (5) 0.19 (0.02-1.54) 0.15 (0.01-1.74)
Pre-medical education 0.443
Bachelor 12 (17) Ref
Masters/PhD 8 (23) 1.48 (0.54-4.04)
Relationship status 0.498
Single 17 (20) Ref
Married/Common law 3 (14) 0.63 (0.17-2.39)
Parental education 0.889
High School 3 (20) Ref
Others 17 (20) 0.91 (0.23-3.57)
Family member in medicine 0.116 0.128
Yes 2 (8) Ref Ref
No 18 (22) 3.43 (0.74-15.90) 4.33 (0.66-28.58)
Varsity sports 0.809
Yes 3 (17) Ref
No 17 (19) 1.18 (0.31-4.54)
GRIT Scores 0.179 0.096
Unit = 1 score point (mean) 3.3 4.16 (0.52-33.35) 13.39 (0.63-284.74)
Medical Student Factors
Factor 1 – Lifestyle <0.001 0.032
Unit = 1 score point (mean) 3.1 0.22 (0.10-0.49) 0.32 (0.11-0.91)
Factor 2 – Community orientation 0.019 0.151
Unit = 1 score point (mean) 2.9 0.39 (0.18-0.86) 0.37 (0.10-1.43)
Factor 3 – Prestige 0.002 0.173
Unit = 1 score point (mean) 3.0 0.30 (0.14-0.65) 0.44 (0.14-1.43)
Factor 4 – Hospital orientation 0.246
Unit = 1 score point (mean) 3.2 1.56 (0.74-3.28)
Factor 5 – Scope of Practice 0.064 0.988
Unit = 1 score point (mean) 3.5 0.48 (0.23-1.04) 1.01 (0.26-3.87)
Factor 6 – Role model 0.218
Unit = 1 score point (mean) 2.5 0.72 (0.42-1.22)
Other Survey Items
Good match to career 0.034 0.506
Unit = 1 score point (mean) 3.8 0.52 (0.28-0.95) 0.73 (0.29-1.86)
Focus on non-urgent care 0.054 0.699
Unit = 1 score point (mean) 2.4 0.56 (0.31-1.01) 0.82 (0.29-2.29)
Research Interest 0.714
Unit = 1 score point (mean) 2.7 1.08 (0.72-1.61)
Speciality Competitiveness 0.681
Unit = 1 score point (mean) 2.5 1.11 (0.67-1.85)
Input from Classmates or Preceptors 0.381
Unit = 1 score point (mean) 2.8 0.81 (0.50-1.30)
Input from Family and Friends 0.381
Unit = 1 score point (mean) 2.6 0.81 (0.50-1.31)
Short post-graduate training 0.044 0.521
Unit = 1 score point (mean) 1.7 0.52 (0.28-0.98) 1.35 (0.54-3.41)
Personal dislike for uncertainty 0.059 0.428
Unit = 1 score point (mean) 2.0 0.61 (0.37-1.02) 0.74 (0.34-1.57)
Narrow variety of patient problems 0.320
Unit = 1 score point (mean) 2.4 1.31 (0.77-2.23)
Residency population demographics 0.467
Unit = 1 score point (mean) 2.4 0.85 (0.54-1.32)
Support from residency program 0.148 0.373
Unit = 1 score point (mean) 3.7 0.68 (0.41-1.15) 1.62 (0.56-4.69)

>> multivariate method age and gender plus all vars p<0.20 w/ enter method (highlighted pvalues in univariate analysis)

Discussion

In our cohort of medical students who have not yet received clinical hands-on teaching, students valued career factors such as lifestyle, prestige, and being well supported in residency. Recruitment strategies for residency programs to attract medical students may be improved using this data. Specifically, residency programs can utilize this data in career discussions with medical students and elaborate on the career factors deemed most valuable by students interested in the specialty.

Medical Specialty Interest

Both age and decreased interest in research were associated with medical specialty interest, which is reflected in other studies.10,11 Interestingly, student interest in academic medicine has historically been associated with older age.12 It is possible that the students are still attracted to other aspects of an academic career such as teaching, which was not captured here. Additionally, previous research has demonstrated that interest in a career in a medical specialty has been linked with high prioritization of specialty lifestyle,10,13 but this was not evident among our students. The traditional belief that medical specialties carry a good lifestyle may be changing. For instance, one study found that the prevalence of burnout among second-year internal medicine residents is 42.6%.14 This may be due to an increasing prevalence of major chronic disease in Canada,15 but this was not assessed in this study.

Surgical Specialty Interest

Lifestyle is a significant factor in medical student career navigation,16,17 which is reported by our students. However, surgical interest was associated with low prioritization of a lifestyle-related career factors. Other studies have found similar results.7,8,18 Peel and colleagues found that students interested in surgery tend to consider lifestyle as less important when making career decisions, while students not interested in surgery highly valued lifestyle.7 Our study may demonstrate that these beliefs are still prevalent, even in medical students in their pre-clinical years. Furthermore, it may indicate that students who value life-style related career factors are ruling out a career in surgery early on in their teachings, prior to clinical exposure to surgical specialties. This may contribute to a perpetual culture where surgical disciplines are perceived as having a poor lifestyle. While lifestyle can vary across disciplines, pre-clinical medical student perceptions may not accurately represent the demands of a certain specialty or the variety of ways to practice within it. The narrow focus on lifestyle within surgery does not account for other factors of surgical practice and may lead medical students to rule out surgical careers prematurely. To overturn this culture, surgical residency programs should take this into consideration and ensure that accurate, honest work-life balance discussions are held with medical students. Such information sessions are often held in later years of schooling, aimed at attracting medical students with surgical interest to a specific field of surgery. Our findings suggest that information sessions should be held at an earlier stage to better assist pre-clinical medical students plan their careers. Additionally, medical students must ensure that they carefully self-examine each of their career options and determine how their own unique values fit into the work culture prior to ruling them out prematurely.

Undecided Specialty Interest

Half of our students were undecided in their career plans and were closely correlated with a preference for a good lifestyle. To our knowledge, this has yet to be reported and may indicate that students who specifically value a strong work-life balance are delaying choosing a career path in order to closely examine each specialty for the one which best meets their value in this area. This also suggests that a significant portion of medical students value a good “work-life balance”, which is “'the ability to balance work commitments with personal time in which you are able to relax, socialise and pursue extra-curricular interest.”19 This demographic is understudied compared to their counterparts with defined career interests, and more research must be conducted on this population. Residency programs should use this information and not “shy away” from honest work-life balance discussions with medical students.

There are several limitations inherent to this study. Firstly, the data stems from a single institution and conclusions drawn may be affected by inter-institutional variabilities in medical education curricula, research milieu, and level of exposure to various specialties. However, Canadian medical schools are routinely assessed by the Association of Faculties of Medicine of Canada (AFMC) and must meet accreditation expectations set out by the Committee on Accreditation of Canadian Medical Schools (CACMS), therefore a degree of standardisation exists, and these findings can likely be extrapolated to other institutions to some degree. Additionally, career interest was grouped into “medicine,” “surgery,” and “undecided.” The nuances of choosing specialties and sub-specialties that do not fall directly into these categories may not be well reflected. Nonetheless, our findings do provide meaningful data that can be considered when optimizing career exposure and interest in medical students.

Conclusions

This study provides an in-depth analysis of career-related factors of medical students in their pre-clinical years. Our analysis demonstrates that lifestyle-related career factors were less valued in students interested in surgery. Furthermore, students with undecided career interests were highly correlated with a high value of lifestyle-related career factors. This indicates that students may delay career decisions to identify a specialty that matches their ideal work-life balance. Furthermore, it may indicate that students who highly value lifestyle-related career factors are ruling out a career in surgery in their pre-clinical years.


Conflicts of Interest

None to report.

Funding

No funding to report.

Accepted: September 04, 2022 EDT

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Appendices

Appendix 1.Distribution of Medical Student Factors N=107
Mean (SD) 1 =
Not very Important
no. (%)
2 = Somewhat Important
no. (%)
3 = Moderately Important
no. (%)
4 = Important
no. (%)
5 = Extremely Important
no. (%)
Factor 1 – Lifestyle 3.7 (0.7)
Acceptable hours of practice 3.7 (0.8) 2 (2) 4 (4) 29 (27) 57 (53) 15 (14)
Flexibility inside of medicine 3.7 (0.9) 0 (0) 11 (10) 23 (22) 55 (51) 18 (17)
Acceptable on-call schedule 3.7 (0.8) 1 (1) 8 (7) 29 (27) 56 (52) 13 (12)
Factor 2 – Community orientation 3.3 (0.7)
Health Promotion 3.4 (1.0) 3 (3) 14 (13) 38 (36) 38 (36) 14 (13)
Long term relationship with patients 3.1 (1.1) 7 (7) 27 (25) 30 (28) 34 (32) 9 (8)
Focus on patients in the community 3.1 (0.9) 4 (4) 22 (21) 42 (39) 34 (32) 5 (5)
Social commitment 3.2 (0.9) 3 (3) 18 (17) 49 (46) 30 (28) 7 (7)
Interesting patient population 3.4 (0.9) 4 (4) 9 (8) 40 (37) 44 (41) 10 (9)
Factor 3 – Prestige 3.4 (0.7)
High income potential 3.0 (0.9) 8 (7) 20 (19) 44 (41) 34 (32) 1 (1)
Adequate income to eliminate debt 4.0 (1.0) 1 (1) 9 (8) 17 (16) 43 (40) 37 (35)
Status Among Colleagues 2.5 (1.0) 19 (18) 28 (26) 44 (41) 15 (14) 1 (1)
Stable/ Secure Future 4.1 (0.9) 1 (1) 4 (4) 15 (14) 49 (46) 38 (36)
Factor 4 – Hospital orientation 3.0 (0.7)
Focus on Urgent Care 3.0 (1.0) 9 (8) 22 (21) 44 (41) 24 (22) 8 (7)
Focus on in-hospital care 3.1 (1.0) 6 (6) 25 (23) 38 (36) 32 (30) 6 (6)
Results of interventions immediately available 3.1 (1.0) 8 (7) 21 (20) 40 (37) 32 (30) 6 (6)
Preference of Medical to Social Problems 2.9 (1.0) 11 (10) 22 (21) 49 (46) 18 (17) 7 (7)
Factor 5 – Scope of Practice 3.7 (0.7)
Wide variety of patient problems 3.6 (0.9) 1 (1) 12 (11) 35 (33) 41 (38) 18 (17)
Mentor Availability during training 3.8 (0.9) 1 (1) 10 (9) 25 (23) 47 (44) 24 (22)
Intellectual interest of involved disease groups 3.8 (1.0) 2 (2) 7 (7) 29 (27) 42 (39) 27 (25)
Factor 6 – Role model 2.7 (0.9)
Meaningful past experience with physician 2.9 (1.2) 17 (16) 20 (19) 38 (36) 23 (22) 9 (8)
Emulating a physician 2.6 (1.0) 19 (18) 30 (28) 35 (33) 23 (22) 0 (0)
Other Survey Items
Good match to career 4.1 (0.8) 0 (0) 4 (4) 16 (15) 53 (50) 34 (32)
Focus on non-urgent care 2.7 (0.8) 11 (10) 25 (23) 60 (56) 10 (9) 1 (1)
Research Interest 2.6 (1.2) 25 (23) 30 (28) 26 (24) 19 (18) 7 (7)
Speciality Competitiveness 2.4 (1.0) 20 (19) 37 (35) 36 (34) 13 (12) 1 (1)
Input from Classmates or Preceptors 3.0 (1.0) 9 (8) 25 (23) 37 (35) 31 (29) 5 (5)
Input from Family and Friends 2.7 (1.0) 14 (13) 29 (27) 38 (36) 24 (22) 2 (2)
Short post-graduate training 2.1 (0.9) 32 (30) 42 (39) 27 (25) 6 (6) 0 (0)
Personal dislike for uncertainty 2.4 (1.1) 24 (22) 36 (34) 28 (26) 17 (16) 2 (2)
Narrow variety of patient problems 2.2 (0.9) 27 (25) 43 (40) 30 (28) 6 (6) 1 (1)
Residency population demographics 2.5 (1.1) 24 (22) 29 (27) 33 (31) 17 (16) 4 (4)
Support from residency program 3.9 (0.9) 2 (2) 4 (4) 24 (22) 48 (45) 29 (27)
Appendix 2.Univariate and Multivariate Logistic regression with Students Interested in Medical Specialities
<
No. (%) Univariate
Medicine
OR (95%CI)
p Multivariate
Medicine
OR (95%CI)
p
Demographic characteristics
Gender 0.272 0.421
Male 9 (22) 0.60 (0.24-1.49) 0.62 (0.19-1.99)
Female 21 (32) Ref Ref
Age 0.002 0.001
20-24 9 (30) Ref Ref
25-26 10 (42) 4.21 (1.43-12.34) 10.14 (2.27-45.28)
27+ 11 (52) 6.48 (2.13-19.66) 34.00 (4.78-241.81)
Pre-medical education 0.587
Bachelor 19 (26) Ref
Masters/PhD 11 (31) 1.28 (0.53-3.10)
Relationship status 0.929
Single 24 (28) Ref
Married/Common law 6 (27) 0.95 (0.33-2.73)
Children 0.501
Yes 1 (50) 2.62 (0.16-43.27)
No 29 (28) Ref
Parental education 0.271
High School 6 (40) Ref
Others 24 (26) 0.53 (0.17-1.64)
Family member in medicine 0.392
Yes 9 (35) Ref
No 21 (26) 0.66 (0.26-1.71)
Varsity sports 0.979
Yes 5 (28) Ref
No 25 (28) 1.02 (0.33-3.15)
GRIT Scores 0.019 0.162
Unit = 1 score point (mean) 3.1 0.12 (0.02-0.70) 0.17 (0.01-2.04)
Medical Student Factors
Factor 1 – Lifestyle 0.055 0.743
Unit = 1 score point (mean) 3.9 1.97 (0.99-3.92) 0.82 (0.24-2.76)
Factor 2 – Community orientation 0.125 0.071
Unit = 1 score point (mean) 3.4 1.66 (0.87-3.16) 2.79 (0.92-8.50)
Factor 3 – Prestige 0.165 0.341
Unit = 1 score point (mean) 3.6 1.60 (0.83-3.10) 1.66 (0.59-4.71)
Factor 4 – Hospital orientation 0.444
Unit = 1 score point (mean) 2.9 0.78 (0.42-1.47)
Factor 5 – Scope of Practice 0.501
Unit = 1 score point (mean) 3.8 1.25 (0.66-2.36)