Specializations in nursing : the students ' perspective

Introduction: In Slovenia, nursing students and professionals do not yet have the possibility for specialized career development. The aim of the study is to determine the students' plans for their career development and their views on nursing specialization. Methods: Data were collected via an online questionnaire (alpha = 0.82). The sample included students from three faculties in Slovenia that offer nursing programmes. 385 questionnaires were returned. Data analysis was performed with the SPSS software (version 20.0): t-test, ANOVA, Pearson's correlation and factor analysis. Results: 258 (67 %) of respondents would continue their studies. The specializations most often identified are: urgent medical assistance (20 %), anaesthesiology and intensive therapy (14 %) and surgical care (11 %) and so forth. Older students choose reasons that are linked more to nursing, while younger students choose reasons that are linked more to medicine. It is more characteristic of men to put an emphasis on economic reasons for developing specializations (t = 0.552, p = 0.011). Students in a more senior year (F = 2.407, p = 0.041) or with a higher average grade put an emphasis on reasons for specializations that are linked to nursing. Discussion and conclusion: Students view specializations as necessary to ensure a sustainable health care system in Slovenia and as an option for continuing their studies.


Introduction
The economic and social crisis, altered demographical structure of the populace, increased occurrence of chronic illnesses and so on strongly affect both the organisation of the health care system and nursing around the world (Požun & Skela Savič, 2011).Due to the altered structure of the populace and its health care needs and other factors, new opportunities for nursing are also arising (Rod, 2009).In certain countries, specializations in nursing can be considered the response of nursing to the changed needs of the beneficiaries of the health care system.
The development of postgraduate specialist knowledge in the field of nursing started relatively early, in the 1960s and 1970s in the United States, Canada and Great Britain, as a response to the shortage of doctors, the changing demographic structures of the populace (an aging population and thereby an increase in patients with chronic illnesses), the growing needs of the populace for affordable health care services, the constantly growing health care costs etc.Throughout history, specializations in nursing developed also due to fast technological advancements and the expansion of professional knowledge, based on scientific foundations (Pask, 2011).In certain countries, specializations in nursing thus became an important and indispensable part of the health care system (Delamaire & Lafortune, 2010).
In countries where specializations in nursing have already been established, experts have been proving for some time now that specialist knowledge significantly and positively impacts the development of nursing and health care as a whole, as well as contributes to better and safer treatment of patients (Brown & Grimes, 1995;Bryant-Lukosius, et al., 2004;Delamaire & Lafortune, 2010;Pulcini, et al., 2010).Numerous studies are therefore focusing on measuring the efficiency of graduate nurses with specialist knowledge, with the aim of proving their usefulness and significance in everyday clinical practice (Horrocks, et al., 2002;Delamaire & Lafortune, 2010;Pulcini, et al., 2010).Patients that come into direct contact with graduate nurses have a smaller chance of being admitted to hospital and are more likely to receive treatment based on clinical guidelines and evidence (Grothier, 2012).A study by Horrocks and colleagues (2012), carried out in Great Britain, even shows that a patient's results in primary health care, reviewed by a graduate nurse with specialist knowledge, are equal to doctors' results, with patients even displaying increased satisfaction in most areas.Furthermore, when it comes to transferring tasks and duties from doctors to graduate nurses at the primary level, the study shows that graduate nurses with specialist knowledge in primary health care achieve health results for patients that are comparable to those of doctors when it comes to diagnostic precision and health condition evaluation.
In countries where specializations were developed in the second half of the previous century, studies proved very early on that graduate nurses with specialist knowledge also spend more time on the medical treatment of patients, which affects the patients' satisfaction (Brown & Grimes 1995;Horrocks, et al., 2002).Lower treatment expenses, shorter periods of hospitalization, lower readmission rates and increased satisfaction with the patient's medical treatment were recorded with patients that were treated by a graduate nurse with specialist knowledge in areas such as neonatology, geriatrics or obstetrics and certain others (Bryant-Lukosius, et al., 2004).And especially worth emphasising, it was determined that graduate nurses with specialist knowledge play a key role from the standpoint of long-term financial sustainability of the health care system by providing quality, evidencebased nursing (Grothier, 2012).
In Slovenia, Starc and colleagues (2009) have determined that the offer of nursing specializations by European Union Member States and the Anglo-Saxon world is extensive and difficult to review.There is no uniformity in the definitions, regulations and manner of education in the field of specializations.Specialized programmes and certain modules (i.e.prescribing medication) are carried out by higher education institutions and various associations.Specialist knowledge in the field of nursing can thus be obtained in psychiatric nursing, district nursing, oncological nursing, palliative nursing, nursing for patients with dementia, pediatric nursing etc.The International Council of Nurses, which issues guidelines and recommendations for the development of nursing, prepared a broad array of nursing specializations already in 1992.It proposed that specializations be prepared in major nursing fields, such as geriatric nursing, public health, pediatric nursing, psychiatric nursing, health care for women and children, district nursing, internal medicine nursing, surgical nursing, etc. (International Council of Nurses, 2009).In Great Britain, graduate nurses with specialist knowledge have thus been carrying out preventive checks and screenings for various illnesses, taking on various duties in the field of health promotion, health counselling, guidance for patients with chronic illnesses, patient follow-up and re-examinations after conclusion of treatment, and carrying out various interventions in accordance with treatment guidelines.They are active on both the primary and the secondary level of health care (Dubois & Singh, 2009).
Despite good practices around the world and the proven advantages of graduate nurses with specialist knowledge, postgraduate specialist training for graduate nurses in Slovenia has not yet been developed.In Slovenia, professionals in nursing and students do not yet have the possibility for specialized career development after concluding their studies, though discussions to this end have been going on for some time now (Bregar, et al., 2013;Lokar, 2013;Skela-Savič, 2013).Despite nursing being exposed to great burdens as a consequence of demographic changes, an aging population, increased public awareness, organisational changes in the health care system and imbalances in the strategic development of health care so far (Poplas Susič & Marušič, 2011), the development of specializations and the significance of an increased role of graduate nurses has not been enabled in Slovenia.One of the major problems in Slovenia is the demographic situation, meaning that were the current increase in the share of older inhabitants and the increasing share of patients with chronic illnesses to continue, or the existing demographic trends to continue, the pressure on nursing will continue to grow, placing an increasing burden on health care finances (Starc, 2004).We can therefore state that this also creates room for developing specializations in nursing, among other things (Pajnkihar & Jakl, 2013).
Due to all these reasons, it is logical and necessary for developed societies and health care service providers to prepare for the increased demand for health care services.It is sensible and wise to organise health care so that it is financially sustainable in the long term without a decline in quality.That is why we have already launched certain activities in the field of nursing.Based on the opinions and wishes expressed by the domestic professional public, we have formulated a broad selection of specializations, some of which are already being prepared (Vilar & Ažman, 2011;Kadivec, et al., 2011;Horvat, et al., 2013).These opinion surveys included employed professionals in nursing.Students were not involved in these discussions.That is why our study focused on undergraduate and postgraduate nursing students.We posed a research questions regarding the students' attitude towards nursing specializations, as it is the students that will be inquiring after education in the future.Seeing as we are aware of the future demand for health care services, it is important that we are also aware of the students' preferences regarding postgraduate knowledge, as we can then direct their preferences with an appropriate approach during their studies.

Aim and objective
The aim of the study was to determine and get to know the career development plans of students of select health care faculties in Slovenia, or whether they identify specializations as a logical continuation of their education.The study aimed to answer the following research questions: Which are the areas in health care where undergraduate and postgraduate students of nursing most identify the need for specializations?To what degree do the students agree that with additional specialist knowledge, they could take on certain competencies of the doctors?
Why are specializations in nursing required, according to the students' opinion?Which factors are linked to the students' attitude towards specializations?

Methods
The study was based on the descriptive method of empirical research.We used a non-experimental quantitative research method.We used an anonymous structured survey questionnaire to gather data.

Description of the research instrument
We composed the questionnaire based on a review of domestic and foreign literature on specializations in nursing (Bryant-Lukosius, et al., 2004;Pulcini, et al., 2009;Starc, et al., 2009;Delamaire & Lafortune, 2010;Vilar, 2011;Skela-Savič, 2013).We decided on online surveying, which is why we entered the questionnaire into the 1KA online survey website.The questionnaire contained 20 closed-ended questions in two sets.The first set of nine questions contained demographic data about the respondent: gender, age, year and type of studies and previous education, and certain other questions.The second set contained various statements regarding the students' opinions on nursing specializations, which students answered according to the Likert scale from 1 to 5, meaning: 1 -I completely disagree, 2 -I disagree, 3 -I partially agree, 4 -I agree, 5 -I completely agree.To analyse the reliability of each set of questions, we used the Cronbach alpha test.In each individual set, Cronbach's alpha was over 0.8, proving the high reliability of the questionnaire (Cencič, et al., 2009).

Description of a sample
The study included full-time and part-time students of the first, second and third years and senior undergraduates of nursing at the Faculty of Health Care Jesenice (FZJ), the Faculty of Health Sciences in Ljubljana (UL ZF) and the University of Primorska Faculty of Health Sciences (UP FVZ), and full-time and part-time postgraduate students of the first and second years of nursing at the above-mentioned faculties.We used a non-probability convenience sampling technique.A total of 1333 questionnaires were sent out via the faculties' databases.A total of 385 questionnaires were completed in full, which amounts to a sample response rate of 29 %.The description of the sample can be found in Table 1.
The first year of undergraduate nursing studies was attended by 56 (15 %) students, the second by 113 (32 %), the third by 98 (28 %), and 90 (25 %) respondents were senior undergraduates.The first year of postgraduate nursing studies (master's degree) was attended by 8 (29 %) students, and the second by 20 (71 %).The students' grade-point average was 7.8.The average age of the respondents was 27 years (s = 7).The highest level of education attained by the students so far was as follows: 258 (68 %) with a finished secondary school of nursing, 37 (9 %) with a finished other secondary technical school, 52 (13 %) with a finished grammar school and 38 (10 %) with the obtained education at an institution of higher education or above.

Description of the research procedure and data analysis
We obtained study approval from FZJ, ZF and FVZ beforehand.We informed respondents in advance of the aim of the study and that participation in the study is voluntary and anonymous.The study took place in the period from July 22. 2013 to Septembre 16. 2013.The student office at each faculty was tasked with sending out the questionnaire, thus sending the questionnaire to all students whose e-mail addresses were in the student office's database.The expected and planned response rate of the sample was lower than is characteristic of electronic surveying, due to the fact that the survey was implemented during the summer holidays.However, we repeatedly sent a reminder to the contact persons or study year representatives to send the questionnaire to the students again.In October 2013, we organised all of the obtained data with the aid of the Microsoft Office Word 2007 and Microsoft Office Excel 2007 software and analysed them statistically with the SPSS 20 software (IBM; SPSS Inc., Chicago, IL, USA).We presented the results of the statistical software with the aid of figures and tables.When interpreting the results, we used the t-test, ANOVA, Pearson's correlation and factor analysis.Differences were considered for statistically significant data where the level of statistical significance was p < 0.05.

Results
In addition to the demographic data (Table 1), the first set of questions in the questionnaire asked the students about their wishes regarding continued career development in nursing.A total of 258 (67 %) respondents would continue studies in the field of nursing.107 (28 %) respondents expressed doubts about continuing their studies.156 (41 %) respondents would continue their studies in a narrower specialized field, while 60 (15 %) would continue it in a nursing master's degree programme (only undergraduate students were responding).113 (30 %) respondents would take a job in nursing without continuing their studies, 27 (7 %) would continue their studies in a different master's degree programme, 26 respondents were not yet considering career development, and 3 (1 %) students would leave the profession and look for employment in another field.
Below we present the results of the study according to individual study questions.
In which health care areas do undergraduate and postgraduate students of nursing see the most need for specializations?
First and foremost, 67 students (20 %) recognised the need for specializations in emergency medical assistance.49 students (14 %) recognized the need for specializations in nursing in anaesthesiology and intensive therapy.39 students (11 %) would choose a specialization in surgical nursing.33 students (10 %) would choose a specialization in paediatric nursing.In fifth place, 32 students (9 %) would choose a specialization in district nursing.In sixth place, 30 students (8 %) would choose a specialization in psychiatric nursing.The remaining specializations are as follows: 22 students (6.5 %) opted for public health and health promotion, 16 students (4.7 %) for oncology nursing, 15 students (4.4 %) for internal medicine nursing, 10 students (2.8 %) for palliative care, 8 students (2.4 %) for nursing of the elderly.The least sought-after specializations were the following specializations: 7 students (2 %) for nursing in occupational, traffic and sports medicine, 5 students (1.4 %) for nursing of patients suffering from chronic diseases, 5 students (1.4 %) for hospital hygiene and infections, and 2 students (0.6 %) for enterostomal therapy.To what degree do students believe that they would be able to take over certain competences of doctors with additional specialist knowledge?
Students were asked to rate the statements on a Likert scale with a range of 1 to 5 (1 -not important, 2 -somewhat important, 3 -important, 4 -very important, 5 -the most important).
The majority of competences have an average of above 3, i.e. were graded as 'important' in the questionnaire.The competences graded above 4, i.e. very important, are: a higher degree of expertise for the implementation of health care, health education and health promotion, and the management of patients with chronic diseases.In the middle, i.e. between 3.7 and 3, we find the following competences: referrals for examinations (X-ray) and laboratory tests (blood, urine), carrying out minor surgical procedures, e.g.administering stitches, prescribing therapeutic appliances, independent medical history review, patient referrals to other experts, implementation of preventive tests (ultrasound, endoscopy), authority to receive and discharge a patient to/from hospital.At the bottom of the list (with a grade of under 3) we find competences such as: deciding on diagnostic procedures, prescribing medication, the authority to give medical diagnoses.

According to students, why are specializations in nursing necessary?
The respondents were asked to rate the statements on a Likert scale with a range of 1 to 5 (1 -I completely disagree, 2 -I disagree, 3 -I partially agree, 4 -I agree, 5 -I completely agree).The respondents were provided with 10 statements.The development of new technologies and the need for advanced skills was above the rest, with an average of above 4, followed by reasons such as: due to an increasingly burdened health care system, due to the increase in the number of chronic patients, and due to the increased demand for health services.In the middle, i.e. with an average of between 3.6 and 4, we find answers such as: due to the life-span of chronic patients.Lastly, with an average of 3.6 or less, we find economic factors: so that doctors are more accessible and to lessen the burden placed on them, to decrease the cost of nurses, due to the greater cost of medical treatment for the elderly because of changes in the demographic structure (an increase in the number of older people), and due to rising life expectancy.
Using factor analysis (the rotation method), we wanted to determine whether the link between the observed variables (the responses of students to the statements about why specializations are required) can be explained by a smaller number of indirectly observed variables or factors, through which we may then investigate the attitude of students to specializations.We verified the suitability of the correlation matrix for factor analysis by using the Kaiser-Mayer-Olkin test (KMO-test), which has a value of 0.836 (the recommended limit is above 0.5), and Bartlett's test, which is statistically significant.The results of both tests indicate that the use of factor analysis is suitable.By using factor analysis, we identified three factors among the statements about the students' view of the necessity of specializations.The three factors accounted for 66.57 % of the total variance, with the communalities of individual variables all above 0.50 (which is a prerequisite) and the majority of them (out of a total of ten variables) greater than 0.6, on the condition that their own value is greater than 1.
With the first factor -demographic reasons, we account for 32.54 % of the variance.With the second factor -reasons due to health system burden, we account for 19.81 % of the variance.With the third factor -economic reasons, we account for 14.21 % of the variance (Table 2).

Which factors are significant in relation to the students' attitudes towards specializations?
Below we will examine the significance of various factors, such as gender, age, year of study and the significance of the students' grade-point average for each individual factor.

Gender
The significance of gender was examined using a t-test for independent samples.The only factor that exhibited statistical relevance was Economic reasons.We can conclude that on average, male students list economic reasons for the development of specializations in nursing more often than female students (t = 0.552, p = 0.011).

Age
In examining the significance of age on individual factors, we utilised Pearson's correlation, where we found a weak and positive correlation with the first factor demographic reasons (r = 0.354, p = 0.018) and a weak and negative correlation with the second factor reasons due to health system burden (r = -0.322,p = 0.034).This means that older students attribute greater significance to demographic reasons for specializations and see less sense in the development of specializations due to the increasingly burdened health care system.

Year of study
To assess the importance of the year of study, we used the ANOVA test, which was used to determine whether there are statistically significant differences in the responses of students to the factors according to the respondent's year of study (first-, secondand third-year students and senior undergraduate students; the latter category also includes all postgraduate students).There were statistically significant differences in the responses of students for each year of study only in relation to the first factor -demographic reasons (F = 2.407, p = 0.041).Figure 1 shows that senior students attribute greater importance to the necessity of specializations to provide high quality care for the elderly and care for patients with chronic disease.

The significance of the grade-point average
The significance of the students' grade-point average on individual factors was established with an ANOVA test.The students were divided into four groups, according to their grade-point average (from 6.0 to 6.9; from 7.0 to 7.9; from 8.0 to 8.9; from 9.0 to 10.0).The ANOVA test established that there are statistically significant differences among answers in relation to the importance of students' grade-point average on the factor -economic reasons (F = 3.222, p = 0.023).From Figure 2 we can conclude that the higher the average score, the lower the score of the need for specializations to make doctors more accessible and to lessen the burden placed on them and to decrease the cost of nurses.The importance of the decision on the continuation of education We divided the students into three groups, based on their answers (no desire to continue, desire to continue, strong desire to continue).Statistically significant differences between groups occurred with the second factor -an increasingly burdened health system (F = 3.664, p = 0.027).We conclude that the more students want to continue their studies, the more significance they see in the development of specializations to address the issue of an increasingly burdened health system (increased demand for health services, the burden on the health system and the development of new technologies).

Discussion
This study established that students are open to further career development in the direction of specializations.However, we can say that in Slovenia, we have not yet reached a point where specializations would be recognized within the health care system.In Slovenia, nursing professionals and students are not yet able to advance their careers in the area of specializations, though discussions to this end have been going on for some time now (Bregar, et al., 2013;Lokar, 2013).Additionally, professional associations and institutions of higher education in the field of health care are increasingly emphasising and promoting the development of specializations, modelled on other countries (Požun & Skela-Savič, 2011;Skela-Savič & Klemenc, 2011).We have established that students see numerous reasons that speak in favour of specializations within nursing, such as demographic reasons, reasons due to the increasing burden on the health care system and economic reasons.Most of the students included in the research see further career development in continuing their education in the field of nursing, a large part of whom wish to undertake specialization studies of nursing, in contrast to a survey in which employed nurses were asked about the possibility of furthering their education, which they were less inclined to do (Altman, 2011).It is important to emphasise that the majority of our respondents would like to continue their specialization studies full-time.This information is important because we assume that medical faculties and higher schools are to a large extent also financially dependent on the tuition paid by part-time students.Likewise, Skela-Savič (2013) draws attention to the increasingly truncated fiscal policy of the state, which affects the development of health care and higher education and the training of employees, and makes it difficult to finance new programs.It is encouraging that the majority of students wish to further their careers, also in the form of a master's degree in the field of nursing.Studying at the graduate level of the Bologna process -a master's degree in nursing -is also important because most other countries and the International Council of Nurses require this level of education to be able to engage in specialized forms of nursing (International Council of Nurses, 2005;Delamaire & Lafortune, 2010).Additionally, a master's degree in nursing is significant because it substitutes a university degree in nursing, which is not yet available in Slovenia (Skela-Savič & Klemenc, 2011).
Among the range of specializations available to the students in the survey, the most frequently selected option was urgent medical assistance.Among the top choices we also find anaesthesiology, intensive therapy and surgical nursing, from which we assume that students want specializations where medicine and nursing care are increasingly intertwined and which require numerous medical and technical interventions.This can perhaps be explained by the fact that the surveyed students are young individuals looking to work and specialize in areas that are more intertwined with medicine, so as to obtain more references, which also gives them a better chance for further employment in other areas or even abroad.Similarly, Vilar (2011) states that the development of specializations is particularly important where nursing and medicine are intertwined.On the other hand, we can assume that if we had chosen to survey employed graduates of nursing, i.e. older members of the profession, specialized areas of nursing that we believe to be less stressful and more strongly related to the changing demographic structure of the population, would most likely be more prominent.This is confirmed by our results that older students place greater importance on demographic reasons, i.e. nursing of the elderly.A survey conducted for the Chamber of Nursing and Midwifery of Slovenia by Vilar and Ažman (2011) established the opposite of our findings.In their survey, respondents mostly opted for nursing in occupational, traffic and sports medicine, community nursing, psychiatric nursing, gerontological nursing, and specialization in hospital hygiene.In our opinion, the different results of the two surveys can also be explained by the selection of the sample of respondents by the Chamber, which did not include direct providers of nursing, and whose sample size was small.
The students included in the research are aware of the fact that specializations in nursing are needed due to the development of new technologies and the need for advanced skills, the increase in the number of patients with chronic illnesses, longer life-spans, an increasingly burdened health care system and the increased demand for health care services.Nevertheless, the respondents do not find specializations which are distinctly associated with changes in the demographic structure (e.g.gerontological nursing) to be interesting, as they did not select specializations related to this factor.Pask (2011) notes that specializations developed as a result of rapidly-developing sophisticated technology and the expansion of scientific knowledge.In our case we assume that this answer correlates with the respondents' young age or that they are more accustomed to technology than older nursing professionals, as they grew up during a time of especially rapid technological development.Once again it is worth stressing that nursing for the elderly rises alongside the respondents' age and their year of study.However, in our opinion, it is worrying that we do not know how to get more young people interested during their studies in areas which will be very salient in the future, as it is expected that care for the elderly and consequently age-related problems will only increase.Additionally, certain international authors have argued that gerontology is one of the less desirable fields for health care professionals and that further activities are necessary to recruit them into this field (Brown, et al., 2008;Shen & Xiao, 2012;Grymonpre, et al., 2013).
The literature suggests that the development of specialist skills in nursing began in the 1960s and 1970s in the United States, Canada and Great Britain as a response to the shortage of doctors, the changing demographic structures of the populace (an aging population and thereby an increase in patients with chronic illnesses), the growing needs of the populace for affordable health care services, the constantly growing health care costs etc. (Delamaire & Lafortune, 2010).Our survey established that older students and senior students are more susceptible to demographic reasons (care for the elderly), which can be explained by the influence of certain academic courses (nursing for the elderly with gerontology and rehabilitation).Male respondents placed greater importance on economic considerations (to decrease the cost of nurses, increase the accessibility of doctors), but we are unable to account for these differences at this point.The economic reasons for the development of specializations are more prevalent with students who have a lower grade-point average, which can most likely be explained by the fact that those who are more successful in their studies have a greater appreciation for nursing.Delamaire and Lafortune (2010) list economic reasons as the main motivator that could foster the development of specialized nursing.Students that wish to continue their education are leaning more towards the second factor, which details the reasons for the increasing burden placed on the health care system.All of the above speaks in favour of the supposition that students view their studies as a gateway to the nursing profession, and not so much in the sense of substituting a doctor.We also believe that they do not underestimate their work in terms of costs.
The respondents mostly hold the opinion that a nurse with a degree and specialized knowledge contributes to the higher quality and safety of nursing.Specializations will allow them further career development, which is very important to the respondents, i.e. students.In several European Union countries (Poland, Cyprus, Ireland, Czech Republic) they believe that the development of specialist skills in nursing also serves to encourage nurses to pursue postgraduate education and thus by improving their career opportunities, it makes it easier to keep them from moving to another country, since more and more nurses are moving to other countries, where they have better conditions for employment and career development (Aiken & Cheung, 2008;Delamaire & Lafortune, 2010).
The importance of the development of specializations exhibits great importance in the fields where nursing and medicine are intertwined.The respondents are aware of the fact that specializations must be developed alongside the changing needs in Slovenia, which has been stressed repeatedly at the annual conference Moja kariera -Quovadis -My career, organized by the Faculty of Health Care Jesenice, and which has been proven for some time by the Organisation for Economic Co-operation and Development (Delamaire & Lafortune, 2010).
Contrary to expectations, results show that students do not put an emphasis on competencies that are in the domain of doctors, e.g.prescribing medication, giving diagnoses, discharging patients, but rather place an emphasis on competencies that are more related to nursing, some of which they are already implementing.However, we can say that this appears to be in conflict with the range of specializations most often selected by the respondents -they demand more medical and technical interventions.

Limitations of the study
We encountered certain obstacles when conducting the survey.The expected and planned response rate of the sample was lower than is characteristic of electronic surveying, due to the fact that the survey was implemented during the summer holidays.We used opportunity sampling, which prevents generalization of the results to the population of nursing students.We also included first-year students in the survey, who in our opinion have not yet fully formed their career paths.

Conclusion
For the students included in the survey, career development in the form of specializations in nursing is important and is something that they want to do.In terms of the preferred areas of specialization, the respondents expressed a preference for fields associated with medicine and those that include more medical and technical interventions.However, it should be noted that different factors such as gender, age, year of study, grade-point average and decisions about further education in the field of nursing played a part in the attitude of students towards specializations.More successful students, those that are older and senior students, and those who wish to continue their education place a greater importance on specializations that are more closely connected with nursing and prioritize nursing.The desire for certain additional competences also shows that rather than placing an emphasis on medical knowledge, they value greater expertise in the field of nursing, health education, promotion of health, and the management of patients with chronic illnesses.Nonetheless, the development of specializations in nursing will benefit users as well, as they will receive treatment of higher quality and safety.
According to the aim and objectives of the research, we can conclude that we have succeeded in defining the attitude of students to the development of specialized nursing.Specializations in nursing and the development of postgraduate skills are also important for the sustainability of the health system, but health policy makers do not allow for equal development of all professions in the health care system.We also believe that students allow for the possibility that due to positioning and well-paid jobs, the medical lobby would not allow for the diffusion of certain competences of doctors to certified nurses.However, we must be careful and deliberate in the development of specialized nursing, in order to avoid unemployment for nurses that specialize in a narrow specialist field.Moreover, we must not forget that the key mission of nursing care is nursing, by which we offer the patient human warmth in the process of medical treatment, as well as establish a genuine relationship and understanding -something that is not provided by other, more technically-oriented professions in the health care system.

Table 1 :
Description of the sample Tabela 1:

Table 1 :
Description of the sample

Table 2 :
Factor analysis of variables