Factors that affect career success of nurses who practice in assisted reproductive technology

Objective: to examine the relationship between career success and work environment of nurses who practice in assisted reproductive technology and to identify factors that affect career success. Method: a cross-sectional study conducted in 53 fertility centres in 26 provinces in mainland China. Data were collected using a demographic data questionnaire, a specialised nursing competence questionnaire, the Career-Success Scale, and the Nursing Work Environment Scale. Descriptive and inferential statistics were applied. Results: 597 assisted reproductive technology nurses participated in our survey, and 555 valid questionnaires were collected. Theoverall mean scores for career success and work environment were 3.75 [standard deviation (SD) = 1.01] and 3.42 (SD = 0.77) respectively. There was a strong positive correlation between career success and work environment (r = 0.742, p < 0.01). Multiple regression showed that attending academic conferences, psychological care, professional development, support and care, salary, and welfare were significant factors that influence career success. Conclusion: attending academic conferences, psychological care, and work environment are positively related to career success. Administrators should consider ways to address these factors.


Introduction
Infertility is newly defined as "a disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person's capacity to reproduce either as an individual or with his/her partner" (1) . As the infertility incidence is increasing due to greater age and lifestyle and environmental factors (2) , so is the number of individuals seeking infertility treatment from healthcare professionals. Assisted reproductive technology (ART) began in the United Kingdom in 1978 with the birth of Louise Brown, the first in vitro fertilization (IVF) baby.
Since then, nurses have been involved in the treatment, and they play an important role in the management of treatment cycles (3) . Research evidence has shown that infertility nursing care can enhance patients' well-being, treatment compliance (4) and quality of life (5) .
However, the increasing number of infertility patients and special occupational characteristics, such as strict protection of patient privacy and being highly involved in the diagnosis and treatment details, can make ART nursing a busy and stressful occupation (6) . Meanwhile, compared with rapidly developing reproductive medicine, ART nursing is still a young subject. A recent study discovered a scarcity of assistance models and nursing specialists in the area of ART nursing (7) . Currently, infertility nursing undergraduate-level curricula have neither been defined nor established in the university setting, and there has been a limited number of publications related to ART nurses' career development in mainland China.
Career success includes positive emotions and achievements pertaining to work that are accumulated and gradually obtained during the work experience (8) .
At present, the majority of research on career success is concentrated in the field of enterprise management, but research is gradually shifting to the field of nursing (9) . Previous studies have shown that career success is helpful to promote innovative behaviour among nurses, and it can improve the quality of nursing service, reduce the turnover rate of nurses, and stabilize nursing teams (10)(11) . Recent studies have shown that demographic characteristics, self-efficacy, social support, information literacy, working in shifts, and having a good individual income and work environment are the influencing factors in nurses' career success (9,12) . Work environment refers to the organizational characteristics of work settings that facilitate or constrain professional nursing practice. Improving the nursing work environment has been suggested as an effective strategy for addressing the nursing shortage by increasing nurse job satisfaction (10)(11)(12)(13)(14) . Previous research has revealed that the work environment has a significant relationship with career success among nurses (10) . All items were mandatory to prevent missing data, and each WeChat account could submit only one of each questionnaire in order to avoid the possibility of double registration. All data were examined for authenticity and credibility, and cases were deleted manually if they met the following criteria: an abnormal questionnaire with obvious regularity or logical confusion.
As for consent, the first page of the questionnaire provided a purpose statement of for this study.
The respondents could access the survey questions after they had read the informed consent and agreed to it. The participants were considered to have given informed consent once they had completed and submitted the survey.
The participants were included if they met the following criteria: being a registered nurse; having at least one year of work experience in a fertility centre; and having voluntarily expressed the intention to participate. Nurses on sickness or maternity leave for more than six months were excluded.

Measures
The demographic data questionnaire Previous literature (10)(11) was used to identify potential variables that may affect nurses' career success.
The questionnaire included seven sociodemographic characteristics (gender, age, marital status, the presence/ absence of children, education level, hospital level, and average monthly income), six occupational characteristics (professional title, employment type, work departments before the reproductive department, night shift, years of working experience, and satisfaction with income) and eight research work characteristics (presided over or joined in scientific research projects, academic posts, published papers, been a peer reviewer, undertaken teaching work, participated in academic conferences, undergone further education abroad, and participated in compiling a textbook). Before the formal survey, we invited eight nurse managers in different infertility settings to assess the self-designed questionnaire. As a result, a few alterations were made to the questionnaire design. First, we changed "years of working experience" to "years of working experience in the fertility nursing profession". Second, we deleted the "employment type" item of occupational characteristics.
The content validity index was 0.815.

Questionnaire
We developed the ART Specialised Nursing Competence Questionnaire based on literature reviews (15) and expert consultation. Considering that our study translated and adapted the English-language questionnaire into the Chinese language, the cultural differences between western countries and China

Chinese version of the Career-Success Scale
The Chinese version of the Career-Success Scale (CSS) is widely used (8) . It contains 11 items that are categorized into three subscales: career satisfaction (five items), perceived within-organisation competitiveness (PWOC, three items), and perceived external organisation competitiveness (PEOC, three items). A 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree) is used.
The total score ranges from 11 to 55, with higher scores representing higher career success. The Cronbach's www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2023;31:e3927. alpha for each subscale was .86 to .87 and .87 for the total scale. Test-retest reliability was 0.93.

The Nursing Work Environment Scale
We measured the nursing work environment using the following subscales of the Chinese version of the Nursing Work Environment Scale (16)

Data analysis
The data analysis was conducted using SPSS version Finally, multiple regression analysis was performed to determine the variables that best predict career success.
The variance analyses were bilateral, and the significance level was set at p < 0.05.

Ethical considerations
The study was approved by the Ethics Committee of the Chongqing Reproductive and Genetics Institute (No.2019/608).    Compared with previous studies, the ART nurses'

Results
career success was at moderate to high levels (M=3.42, SD=0.77), and it was significantly higher than that of nurses in emergency departments (17) (M=2.86,SD=0.51), and nurses with a master's or doctoral degree (10) (mean=3.18, standard deviation=0.72) in China.
The results indicate that ART nurses have better career success. The subscale findings were similar to those for nurses with a master's or doctoral degree (10) , and career satisfaction was the highest ranked, which further confirms previous researcher's suggestion that staff members in infertility settings have a fairly high degree of job satisfaction (18) .
The high career satisfaction score may be due to the following reasons. First, the ART nurses in our study were relatively young, and most had a bachelor's degree.
Second, they generally had multiple responsibilities, including providing nursing care, auxiliary diagnosis, treatment plan management, consultation, and patient education, which were linked at all levels with the patients, clinicians, and related disciplines. This nursing practice may significantly contribute to patient care and promote self-development. Third, the job satisfaction of employees working fixed nights is reduced (19) . A review of job satisfaction among nurses working in hospitals found that nurses working in shifts had a lower level of job satisfaction than those working  only daytime shifts, and that nurses without weekly night shifts had a higher level of job satisfaction than those with two or more night shifts (20) . However, in our study, more than three-quarters of the nurses did not have night shifts, which may enhance their work and career satisfaction. Fourth, the PEOC subscale had the lowest score, followed by the PWOC subscale. These results may relate to the lack of unified management standards for Chinese fertility centres, which makes nurses less competitive among different infertility settings. Of the ART nurses in our study, 42.5% had worked in infertility settings for less than five years; therefore, they are more eager to develop a career within their own hospital platform, which limits the flow of quality care resources. To promote continuing professional development, organizations need to recognize nurses' personal goals and unique strategies and provide available and accessible resources (12) .
In the present study, the ART nurses reported a moderate level of satisfaction with the work environment, which is lower than that for registered nurses in China (21) . Our findings showed that recognition of value was scored highest by the respondents, which may be because fertility nursing is a specialised practice area where nurses are at the forefront of emerging care that involves a wide range of highly specialised skills (14) . However, staffing adequacy was scored the lowest, which is consistent with the findings of other studies (22) . As infertility rates increase, so does the number of individuals seeking infertility treatment from healthcare professionals (23) . A systematic review showed that an increased nurse-to-patient ratio increased the burnout levels of nurses (24) , thus, inadequate nurse staffing becomes a more serious problem. Additionally, ART nurses have multiple roles and are burdened with heavy workloads, and patientcentred care is an important criterion when patients are selecting fertility clinics (25) , which can make the nurses' workloads heavier. We found that the work environment was positively and strongly related to career success. In addition, our results showed that the seven subscales of the nursing work environment affected the nurses' career success. We thus conclude that a better work environment contributes to ART nurses' greater career success.
We found that attending academic conferences was positively related to career success. Attending conferences is an excellent way to obtain an up-to-date perspective on what is happening in the field, and is an important part of an academic career (26) . One reason is that attendees are required to present key findings and ideas about how these can be used to improve practice in their workplace after the conference (27) (29) .
Consistent with recent literature (10) , our study identified the work environment as a positive aspect of career success. The subscales of professional development, support and care, and salary and welfare were associated with career success. Professional development, and salary and welfare, appear to reflect organisational traits at the hospital level (15) .
Promoting optimal assisted reproduction outcomes and emphasising innovation and evidence-based practice are important challenges for ART nurses. Strong career development support, like the defined registered nurse career ladder, and organisational investment in nurses' knowledge and skill development, may minimise turnover by displaying their organisational commitment to employees (30) .
Salary level is considered to be an objective measure of career success, and research with Italian (31) , Iranian (32) and Turkish (33) nurses found that the higher the income, the higher the job satisfaction and career success. Welfare refers to the Chinese social insurance system, which includes endowment insurance, medical insurance, unemployment insurance, maternity insurance, occupational injury insurance, and housing funds. Salary and welfare play an important role in the nursing work environment (34) . Support and care that is focused on social relationships typically occurs at the unit level, and leadership and management highlights the supervisors' support and assistance (15) . www.eerp.usp.br/rlae Rev. Latino-Am. Enfermagem 2023;31:e3927.
A systematic review showed that leadership affects the nursing workforce and work environment (35) .