Entrepreneurial tendency of Nursing students: a comparison between graduating beginners and undergraduate students*

Objective: to compare the entrepreneurial tendency between beginner and graduating students from undergraduate Nursing courses. Method: this is a cross-sectional and quantitative research study. Data was collected from 377 Nursing students from four undergraduate Nursing courses in different Brazilian regions, 162 of them in first year and 215 in last year. Data was collected by means of a social and academic characterization form and the General Entrepreneurial Tendency Test. Data analysis was conducted by means of descriptive and inferential statistics. Results: the scores of the beginner students were below the mean in all dimensions of the instrument. The senior year students were above the test mean in the Impulse and determination dimension. A statistically significant difference was identified in relation to the course period and to the entrepreneurial tendency in the following dimensions: Need for achievement (p=0.001) and Impulse and determination (p=0.000). Conclusion: the results indicate the importance of investment by universities in the development of an entrepreneurial culture in higher education in Nursing.


Introduction
In general, entrepreneurship is defined as the realization or introduction of something new and different from what is traditionally done, based on the identification of unmet opportunities or needs (1) . It can be developed in different forms, the three main ones being: business entrepreneurship, intra-entrepreneurship, and social entrepreneurship. The first typology is better known and consists of the creation of a company or business that allows for autonomous professional practice. In intraentrepreneurship, the entrepreneurs are motivated by the growth of the company or organization with which they have an employment relationship, while social entrepreneurs want to promote social changes in the context in which they are inserted (1)(2) .
These three forms of entrepreneurship apply to Nursing. The nurse can have a company to work directly with patient care or providing consultancy services.
It also highlights its potential in the development of technologies and the search for innovations in care processes within the health services. In addition, it acts as a transformation agent and seeks better conditions for the care of individuals, families and communities in the health systems (2)(3) .
In this sense, the importance of the nurses' entrepreneurial potential in the operationalization of good health care practices, as well as for social and economic development, is discussed worldwide. This is due to the numerical representativeness of Nursing professionals as the largest workforce in the health area and their presence in the most diverse care scenarios, which can contribute and enhance the universal offer and coverage of health care in an integrated, continuous, and interdisciplinary way (4)(5) .
For an entrepreneurial performance, specific skills are needed, such as, for example: communication, leadership, decision-making, and problem-solving skills (2)(3)6) . Thus, it is important to develop and improve these skills throughout the Nursing training, by means of innovative teaching methodologies and strategies, and the existence of university management capable of influencing the formation of an entrepreneurial profile.
It is essential to instigate in the student the knowledge of the different areas of the professional practice and how nurses can exercise their autonomy, in addition to stimulating their characteristics to act as future entrepreneurs in the profession. For the development of these skills and entrepreneurship in Nursing, courses and practices that guide creative and innovative activities should be included in the Nursing curriculum, as well as contributing to skills for coping with risks, and with undefined and complicated situations (7) .
In view of the increasingly dynamic and competitive contemporary work context, entrepreneurial characteristics are an important differential for the insertion and professional development of nurses in the health work market. In addition, an entrepreneurial behavior represents an opportunity to establish new relationships with the social context, act to guarantee comprehensive care, make decisions, and intervene in the work process with a focus on improving health care practices and the visibility of the profession (2)(3)(4) .
Worldwide, some universities have already adopted the premise that entrepreneurial education can contribute to a country's social and economic development, such as the Massachusetts Institute of Technology and Stanford University that offer courses related to entrepreneurship.
In this perspective, the university is considered as the place for the dissemination and deepening of this theme, because it is in the process of academic training that critical thinking, the formation of opinions and the dissemination of knowledge are built (3,8) .
However, even though it is an area of transversal knowledge for many professions, entrepreneurship is explained in a variable and uneven manner between higher education courses in Brazil. While in the Administration course, 65% of the students have already taken an entrepreneurship discipline, only 27% had an opportunity in the health sciences area (8) , which corroborates the need to raise awareness on the subject in the context of Nursing, mainly in the sense of knowing how this approach occurs throughout the training of nurses.
It is important to note that there is a gap in scientific knowledge related to entrepreneurship among Nursing students in Brazil. A search the Virtual Health Library (Biblioteca Virtual da Saúde, BVS), using the terms "nursing" and "entrepreneurship", with no time frame, resulted in 36 articles. Considering the publications since 2010, 26 articles were found, but two studies were duplicated and three were editorials, thus totaling 21 articles. Of these studies, two (9-10) were related to undergraduate Nursing education, but none of them addressed the entrepreneurial tendency of undergraduate Nursing students.
Similarly, two recent literature reviews on entrepreneurship in Nursing (2,3) , which included international databases such as Publisher Medline highlighted the shortage of studies on entrepreneurship in Nursing education. It is noteworthy that there were no studies comparing specifically the entrepreneurship of students beginning and finishing the Nursing course in the scientific production on the theme (3,7,11) . Thus, the relevance and contribution of this study to the national and international scientific community is justified. including in the area of Nursing (3,11,14) .
The test consists of 54 statements, for which the respondent must mark "I agree" or "I disagree". In odd questions, one point is added for each disagreement noted; in the even questions, a point for the indicated agreement is added. Thus, the score for each question is added and the final sum of each dimension is added.
For the Need for Achievement dimension, the maximum GET score is 12 and the mean score is 9. In the Need for Autonomy/Independence dimension, the maximum score is 6 and the mean is 4. For the other dimensions, the maximum score is 12 and the mean is 8. Therefore, the entrepreneurial trend increases the higher the mean score in each dimension (12) .
For data analysis, the Kolmogorov-Smirnov normality test was applied, which showed that the data followed a normal distribution. Descriptive statistical tests and relative and absolute frequency tests were used. In the inferential analysis, the Student t test for independent samples was applied. The level of significance used as a parameter was 5%. The Statistical Package for the Social Sciences (SPSS) for Windows program, version 19.0, was used.

The study was approved by the Ethics and Research
Committee, under CAEE number 66306117.9.2008.5238.
All the national and international recommendations for research with human beings were followed.

Results
A total of 377 Nursing students participated in the study, 162 (43%) from first year and 215 (57%) from last year. The mean age of the students was 22.5 (±5.2) years old. The sociodemographic characterization of the study participants is shown in    (Table 3).

Discussion
The sociodemographic characterization of the participants in this study is similar to the profile of students in the health field from other federal universities in Brazil, in which young women predominate, aged between 18 and 24 years old and single (14)(15) . In addition, the predominantly female profile of the participants portrays a historical characteristic of the Nursing profession in Brazil and in the world, which has been perpetuating over time (16) .
In relation to the academic and professional activities, the involvement of the Nursing students in research and extension activities was highlighted, especially by those in the final stretch of the course. In the United States, most undergraduate Nursing courses do not teach concepts of innovative behavior and entrepreneurship, despite the recommendations of multidisciplinary and Nursing organizations that support the need for nurses to act as innovative agents and promoters of change (17) .
From the results of the GET, it was identified that the beginning students obtained scores below the mean in the five dimensions of the test. The graduating students were above the mean in only one of the dimensions of the instrument: Impulse and Determination.
This result can be explained by the lack of formal education on entrepreneurship throughout the undergraduate course, in order to develop specific skills and competences for an entrepreneurial profile (17)(18) .
Furthermore, knowledge on the subject is still embryonic in the country, which makes it difficult to disseminate the entrepreneurial culture in the university environment (19)(20) .
The dissemination of an entrepreneurial culture in the academic environment requires discussions about the teachers' competences in the health area. The results of a systematic review indicate that leadership and entrepreneurship are competencies assessed as being of average knowledge by the teachers of the area (21) . The existence of a faculty with an entrepreneurial spirit and that recognizes the need to educate the Nursing students about innovation is necessary to support education, research and professional development initiatives (17,19) .
The training institutions need to incorporate the perspective that entrepreneurship in Nursing enables different perspectives of performance, which differs from the traditional work patterns, providing opportunities for individual and economic development through the creation of new ways of acting in the labor market (22)(23) .
Along the same lines of thought, an Australian study also highlights the importance of supporting class bodies in defining specific policies for the development of entrepreneurship in the Nursing practice (24) .
In Brazil, studies using the GET in Nursing have been carried out previously and also showed that students and nurses had a low entrepreneurial tendency (14,18,25) . Nursing professionals have been widely absorbed by the hospital services, mainly by the Unified Health System (model adopted in Brazil) and by private services, which can lead nurses to seek work as employees, especially in countries like Brazil, with a still unstable economy (26) .
Another aspect to be signaled is the taboo that this theme represents to the profession. Historically, Nursing has been seen as a women's work associated with charity and donation, with limited potential to be remunerated and offered freely through entrepreneurship. In addition, the vast majority of nurses work as salaried professionals, and the monetary exchange between professionals and patients (2) is unusual and often considered unethical.
Despite the general results of the students' entrepreneurial tendency being low, it is important to highlight that the graduating students presented mean values with a statistically significant difference in the following dimensions: Need for Achievement and Impulse and Determination. A high score on these items can indicate that future nurses, as they approach insertion in the job market, are more attentive in the search for opportunities or in creating them, with self-confidence and determination in their attitudes and knowledge to fulfill their professional dreams and objectives (27) .
In contrast, students in the initial period of the recognition and professional advancement (2,27) . Such feeling can intensify throughout the training process.
The nurse has a humanistic training that is guided by ethics, which allows looking at all the dimensions that make up the human being, always thinking about the integrality and quality of care. In this sense, social entrepreneurship stands out in Nursing and collaborates in the training of professionals who are agents of significant positive changes for patients and families (22) .
Nurses know what needs to be developed in their communities, what services are needed or how they can be delivered more effectively, so as to achieve different health goals and objectives (5) .
In addition to social entrepreneurship, there is also business and intra-entrepreneurial in Nursing (2,3,28) . Thus, it can be considered that entrepreneurship is not only an important competence for nurses who seek autonomous practice, but also a differentiating characteristic of the professional to work in health services. in the market, and the implementation strategy (17) .