Introduction

With the dearth of nursing professionals predicted to reach one million by 2010 and the increasing evidence supporting the impact of nursing ratios on patient outcomes, the role of retention efforts has become a significant and serious task for nursing leaders.

The United States is at present experiencing a critical insufficiency of registered nurses (RNs) (Buerhaus, Staiger, & Auerbach, 2000; Letvak, 2002). Causes for the shortage are abundant. Currently, it is estimated that one-third of working nurses are in the age of 50 or more. The average age of nurses in 2000 was 43.3 years. Nurses are expected to be retiring in large numbers over the next ten years. As a consequence, the RN vacancy rate is expected to be 15% by 2003 and 20% by the year 2020 (Buerhaus et al., 2000). Nursing schools are not giving out enough nurses to meet present-day demands. While enrollments in schools of nursing are beginning to increase slightly, there remains a projected shortfall of one million new nurses by the year 2010 (Rosseter, 2001). The number of students who graduated with master's degrees in nursing education, though rising slightly (1.1%) from 2000 to 2001 (Berlin, Stennett, & Bednash, 2002), are not enough to offset earlier declines. From 1997 to 1998 alone, the number of master's students in nursing education fell at 27.5%. The average age of nursing educators is 49 years, giving rise to serious concerns about anticipated mass retirements in the next several years. With inadequate new faculty to replace retirees, the country is facing a nursing educator void (Frase-Blunt, 1999). This will directly affect the ability of schools of nursing to admit additional nursing students.

Further, nurses across the nation are said to report increased stress and dissatisfaction with the nursing profession (Boyle, Bott, Hansen, Woods, & Taunton, 1999; Bratt, Broome, Kelber, & Lostocco, 2000; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2001; Shader, Broome, Broome, West, & Nash, 2001). Nurse-physician conflicts aggravate the already taxing and nerve-racking work environment (Rosenstein, 2002). One in five nurses plan to leave the profession within the next 5 years (Letvak, 2002). Taking all these issues into consideration, it becomes urgent and a real necessity to search for ways to retain experienced nurses.

Identification of the Problem

State, County and Municipal Employees, that speaks and stands for 60,000 nurses. “The nursing shortage is really a self-inflicted wound” (Duff, 2002).

Undergoing a profound and deteriorating workforce shortage in both urban and rural areas, the healthcare industry must radically develop and vary its efforts to attract young people to the field, most especially to the nursing profession. The challenge is gargantuan that the industry can't solve it on its own; government, educators and the media must help. The worker shortage is cutting across nearly all job descriptions. A recent American Hospital Association study found that 89% of hospital chief executive officers nationwide are reporting ``significant'' workforce shortages, with a 13% vacancy rate for registered nurses, a 15.3% vacancy rate for imaging technicians and a 12.7% vacancy rate for pharmacists (Raske, 2002).

Furthermore, experts say modifications and adjustments in the delivery of health care in a managed care environment have led some nurses to become disillusioned and disenchanted. Their grievances and protests have discouraged newcomers from entering the field. In a survey released by the American Nurses Association, 54% said they would not recommend their profession to their children or their friends. It also found that 75% felt the quality of nursing care where they worked had declined. A majority, or 56% of the 7,299 nurses surveyed, commented that they had less time to care for patients. On top of that, 40% would worry about sending a family member or someone close to them to be cared for at the facility where they work. However, the shortage iFinding nurses is one thing. Keeping them is another. The latter is something unions say the Nurse Reinvestment Act doesn't adequately address.

“Nurses don't want to be in hospitals because the conditions are so unpleasant,” opined Barbara Coufal, Legislative Affairs specialist with the American Federation of s far from universal at this stage. It tends to be felt hardest in isolated rural areas, depressed urban environments, and key specialty areas (American Nurses Association).

All of this comes at a time when the demand for healthcare services is increasing because of an aging population and an explosion in the number of new treatments and technologies. The federal Bureau of Health Professions projects that the number of healthcare jobs will need to grow to more than 14 million in 2010 from 11 million in 2000 to meet increased demand.

The healthcare industry must form meaningful and lasting collaborations with education leaders to make sure that students are drawn to the health professions and that they are adequately prepared for technical school, college and graduate programs. High school guidance counselors need to understand the healthcare community's needs as well as its diverse career opportunities-including clerical jobs such as medical records coders, technical jobs such as radiation technicians and professional jobs such as nurses, pharmacists and physicians (Raske, 2002).

Purpose and Significance of the Study

This paper’s major purpose is to establish the dynamics of nurse retention in the rural healthcare setting. It also proposes to investigate on concerns such as: (1) why many nurses in the rural healthcare scenario leave their profession; (2) what are the ways and means of retaining and sustaining these nurses; (3) what causes nurse shortage and (4) what can be done to alleviate this problem in the rural healthcare system. Likewise, this study aspires to provide a combined rundown of nursing personnel distribution and distinguishes vital recruitment and retention issues. Results can direct nursing leaders in developing their future recruitment and retention initiatives and resource allotment, particularly, nursing position allocations in economically tough times. Through the research survey that will be employed, the results can be used to back up and steer workforce policy and comparative research studies in other settings.

Review of Relevant Literature

The social conditions of the workplace are the prime movers of a nurse's intention to stay or leave. Social climate is a determining factor of work frustration (a negative influence), and work excitement (a positive influence). These factors directly influence job stress, leading to job satisfaction or dissatisfaction (Moos, 1994). As it is, job satisfaction and/or dissatisfaction is the strongest gauge of whether to stay on or leave the job (Bratt et al., 2000; Bruffey, 1997; Davidson et al., 1997; Garrett & McDaniel, 2001; Taunton, Boyle, Woods, Hansen, & Bott, 1997).

Burnout is positively associated with job dissatisfaction. Garret and McDaniel (2001) depicted environmental insecurities as being vital in all facets of burnout. Aiken et al. (2002) revealed nurses with the highest nurse-to-patient ratio experience burnout and dissatisfaction more than twice as much as those with lower ratios. The researchers noted that 43% of nurses who reported high levels of burnout and dissatisfaction proposed to leave their jobs within a year. This was compared to nurses who did not complain of burnout or dissatisfaction. Only 11% of these nurses planned to leave their current job positions.

Bratt et al. (2000) found that no difference in job stress was evident when factoring in education, the age of the nurse, or the shift worked. They did find a significant decrease in job satisfaction when nurses worked rotating shifts. In comparison to experienced nurses, newer and inexperienced nurses had increased job stress. Contrary to other researches, their findings indicated no relationship between nurse-physician interaction and job stress.

In like manner, Nevidjon and Erickson (2001) reported that nurses’ desire increased autonomy in their work environments. Aiken et al. (2002) determined that increased autonomy is one of the factors decreasing emotional exhaustion of nurses in magnet hospitals (hospitals recognized by the American Nurses Credentialing Center for attracting nurses and providing excellent nursing care). In another study of magnet hospitals, Laschinger, Shamian, and Thomson (2001) affirmed that autonomy, or control over the practice environment, had a positive influence on nurses' job satisfaction, managerial trust, and their assessment of the quality of care delivered to their patients. Davidson et al. (1997) affirmed the relevance of autonomy by demonstrating the reverse; decreased job satisfaction is associated with decreased autonomy. Among critical care nurses, autonomy was indirectly affected by the leadership of their managers (Bruffey, 1997). Bratt et al. (2000) described a positive correlation between job satisfaction and nursing leadership. Management style, perceived as empowering nurses to perform their jobs effectively, was strongly related to job satisfaction.

Tumulty, Jernigan, and Kohut (1994) found that though autonomy was a considerable indicator of job stress, it was not as significant a determinant of stress as task orientation. As with autonomy, Ingersoll et al. (2002) found a positive perception of task orientation associated with increased job satisfaction and intent to stay. Davidson et al. (1997) confirmed this with the finding of increased routinization and decreased work pressure leading to decreased job stress. The researchers discussed the merits of increased communication improving the perceptions of nurses regarding task orientation, autonomy, and work pressure. Taunton et al. (1997) stressed the importance of management/leadership behaviors. Managers/leaders perceived as equitable increased staff perceptions regarding autonomy and decreased perceptions regarding work pressures. Together, these factors led to lower job stress and its inevitable association with intent to leave (Bruffey, 1997).

Work pressure was the most common and a crucial indicator of organizational work satisfaction and dissatisfaction (Bratt et al. 2000; Davidson et al., 1997; Ingersoll et al., 2002; McNeese-Smith, 1999). McNeese-Smith emphasized some of the factors of work pressure contributing to increased job stress and they were (a) overload due to heavy patient assignment, too many patient needs, and/or too few staff members to meet these needs; (b) exhaustion; (c) fear of making a mistake due to exhaustion; and (d) high patient acuity. Bratt et al. (2000) reported additional work pressure factors including (a) rapid turnover of patients, (b) shift work, (c) excessive noise, (d) lack of space, (e) lack of available equipment, and (f) managerial pressures. Nurses with increased patient loads were more likely to describe feelings of burnout, emotional exhaustion, and job dissatisfaction than their counterparts with lighter patient loads (Aiken et al., 2002). As with autonomy and task orientation, work pressure is a precursor to intent to leave.

Designs and Methods

This particular study will use a qualitative and quantitative approach to gather information from two hundred fifty nurse informants. (How did you arrive at this number? What sort of power analysis did you use in order to determine significance?) The objective is to elicit information that will describe their perceptions of how they have been viewed professionally by those above them, their views and assessments on how they fared in the performance of their jobs in relation to their environment, and their opinion on their progress as healthcare professionals located in rural communities. The interviews will take place in their respective localities where these professionals are assigned.

Informants and Focus Group Participants The informants will be carefully selected for individual interviews. These nurses will be identified as potential informants because of their in-depth knowledge of the community and their ability to articulate the health care needs of its residents. Whatever information these key informants will churn out will be verified and substantiated through conversations with other community residents.

Participants for the focus groups will develop from convenience sampling, recruited by word of mouth. One of the research team members will announce the opportunity to participate in the study to the congregation in a local church. All participants will be selected from volunteers with in the local rural communities. Ages for participants in the focus groups will range from the 20’s to the 50’s and there needs to be a mixed representation of health care employment statuses to reflect the communities’ demographics. Key informants may encourage and recruit using nominated sampling with other volunteers who may have experiences useful with in the research.

Consents and Forms

Institutional approval will be obtained before the interviews will be carried out. All the informants in the focus groups will sign a human subjects’ disclaimer form (appendix A) and the study will be explained to everyone before the interviews and discussions will begin. The investigators will see to it that everyone understands that they are under no obligation to participate in the study, that they could withdraw/leave the interview/focus group at any time and that all of the information gathered would be used in such a way that no one person could be identified. It will likewise be explained that at any time during the discussion or interview that they could request for the tape recorder to be turned off. Also all key informants and research assistants will sign the research confidential agreement being provided.

Data Collection All individual interviews and focus group sessions will be tape recorded. The recorded tapes will be destroyed after transcription. The investigators will develop and give a series of quantitative semi-structured questionnaires that parallel the interviews and focus group’s open-ended, lead-in and discussion-generating questions to initiate a general conversation about health care, health care services and their own well-being as rural healthcare professionals. As a data collection instrument, the Likert Scale, a ten-item feedback-form, will be used in conjunction with the questionnaires. In this instrument, 5 represent the highest score and 1 the lowest. For example, a statement saying – I am satisfactorily compensated in my current nursing job – will be answered this way: 5 4 3 2 1 -- where 5 means strongly agree, 4 agree, 3 neutral, 2 disagree, and 1 strongly disagree.

Data Analysis

The data will be analyzed using strategies consistent with both a qualitative and quantitative approach. Each interview and focus group discussion will be transcribed, organized, coded and interpreted in terms of recurrent verbal patterns and expressions. Each interview will be transcribed, read and compared to the quantifying questionnaire. Each of the investigators will read and make comments on the transcribed interviews and questionnaires and then will meet to discuss interpretations. The dialogue that will emerge between and among the investigators will reveal congruent interpretations and comparisons for most of the questionnaires and interviews.

Recurrent patterns and frequency of data from the questionnaires will be grouped or synthesized into categories that will fit and will be linked together. The links will be compared and contrasted and will in turn be grouped back together into common themes. There will be anticipation of constant looping backwards and forwards as new ideas and thoughts will emerge and will be identified from the data by the investigators. In addition, for each theme that will be identified, there will become a general descriptor related in terms of “my story” that will emerge. Each focus group participant’s questionnaires and discussions will express the need to describe “their story” and the essence of these stories will then serve as narrative examples and descriptors of the themes.

Once descriptors and themes are identified, specific common responses will be focused on and measured; send another more structured questionnaire and eventually come to a consensus on the descriptive factors of nurse retention. Following data analysis, data will be complied and presented to the local rural health care agencies to be utilized in their facilities thereby enabling them to make appropriate changes in their polices and practices related to retention and recruitment of nurses.

Limitations and Recommendations

Due to rapid changes in the health care system, it may be difficult to keep up with the transformation of nursing profession’s role in each area of patient care, resources, education, and the growing nursing shortage. Hopefully, this will be a step in the right direction of the continual struggle for nursing staff.

Limitation of this study may be within the sampling. Factors due to availability of volunteers and conflict of work and personal schedules may make it difficult to participate. Also, limitations in the varieties of the sample may be constrained due to the locality of the sample. Educational levels of community participants can be a limitation since it will affect the participant’s understanding and abilities to completely contribute to the survey.

Another limitation forecasted is time. Time availabilities for the researchers and participants will be hard to establish and the collecting time required for collecting data will be undetermined until data saturation is reached.

A strong recommendation would be to duplicate the research in other rural communities and future researches that would emphasize the positive affiliations of nursing schools and their impact on nurse retention and recruitment.

Conclusion

There are many varied opportunities for nurses especially in the rural setting. Nurses and health care providers must learn what rural communities prefer relative to their health care needs. Together as partners, effective solutions can be developed to meet rural nursing care need and to achieve the goals specified in healthy people 2010 in a culturally appropriate manner. Regardless of location, environment, and politics, one must adhere to the established standards of practice. Providing safe, quality care is essential. However, in rural areas, achieving this will necessitate an innovative and creative approach due to the lack of resources and/or great distances involved. The key to the success in this endeavor is effective communication among nurses, clients, administrators, the community, and local health care providers.

References

Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288, pp.1987-1993.

Berlin, L.E., Stennett, J., & Bednash, G.D. (2002). Enrollment and graduations: In baccalaureate and graduate programs in nursing. Washington, DC: American Association of Colleges of Nursing.

Boyle, D.K., Bott, M.J., Hanson, H.E., Woods, C.Q., & Taunton, R.L. (1999). Managers' leadership and critical care nurses' intent to stay. American Journal of Critical Care, 8, pp.361-371.

Bratt, M.M., Broome, M., Kelber, S., & Lostocco. L. (2000). Influence of stress and nursing leadership on job satisfaction of pediatric intensive care unit nurses. American Journal of Critical Care, 9, pp.307-317.

Bruffey, N.G. (1999). Job satisfaction and work excitement: Organizational considerations. Seminars for Nurse Managers, 5, pp.202-208.

Buerhans, P.I., Staiger, D.O., & Auerbach, D.I. (2000). Implications of an aging registered nurse workforce. Journal of the American Medical Association, 283, pp.2948-2954.

Davidson, H., Folcarelli, P.H., Crawford, S., Duprat, L.J., & Clifford, J.C. (1997). The effects of health care reforms on job satisfaction and voluntary turnover among hospital-based nurses. Medical Care, 35, pp.634-645.

Duff, S. (2002). Retention still a problem. Modern Healthcare. Crain Communications Inc.

Frase-Blunt, M. (1999). Faculty shortages intensify nation's nursing deficit. American Association of Colleges of Nursing. http://www. aacn.nche.edu/Publications/issues/IB 499WB.htm

Garrett, D.K., & McDaniel, A.M. (2001). A new look at nurse burnout: The effects of environmental uncertainty and social climate. Journal of Nursing Administration, 31, pp.91-96.

Ingersoll, G.L.. Olsan, T., Drew-Cates, J., DeVinney, B.C., & Davies, J. (2002). Nurses' job satisfaction, organizational commitment, and career intent. Journal of Nursing Administration, 32, pp.250-263.

Laschinger, H.K., Shamian, J., & Thomson, D. (2001). Impact of magnet hospital characteristics on nurses' perceptions of trust burnout quality of care, and work satisfaction. Nursing Economics, 19, 5, pp.209-219.

Letvak, S. (2002). Retaining the older nurse. Journal of Nursing Administration, 32, pp.387-392.

McNeese-Smith, D.K. (1999). A content analysis of staff nurse descriptions of job satisfaction and dissatisfaction. Journal of Advanced Nursing, 29, pp.1332-1341.

Moos, R.H. (1994). Work environment scale manual: A social climate scale: Development, applications, research (3rd ed.). Pale Alto, CA: Consulting Psychologists Press.

Needleman, J., Buerhaus, P.I,, Mattke, S., Stewart, M., & Zelevinsky, K. (2001), Nurse staffing and patient outcomes in hospitals. US Department of Health and Human Services. Health Resources and Services Administration Boston: Harvard School of Public Health.

Nevidjon, B., & Erickson, J. I. (2001). The nursing shortage: Solutions for the short and long term. Journal of Issues in Nursing, 6, 1. http://www.nursingworld.org/ojin/topic14/ tpc14_4.htm

Raske, K. (2002). One problem we can’t staff out: Healthcare worker shortage won’t go away until the industry takes action. Modern Healthcare.

Rosenstein, A.H. (2002). Nurse-physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 102, 6, pp.26-34.

Rosseter, R. (2001). Enrolments rise at U.S. nursing colleges and universities ending a six-year period of decline: Enrollment increase insufficient to meet the projected need for new nurses [News Release]. American Association of Colleges of Nursing, http://www.aacn.nche.edu/Media/NewsReleases/enrl01.htm

Shader, K., Broome, M.E., Broome, C.D. West, M., & Nash, M. (2001). Factors influencing satisfaction and anticipated turnover for nurses in an academic medical center. Journal of Nursing Administration, 31, pp.210-216.

Taunton, R.L., Boyle, D.K., Woods, C.Q., Hansen, H.E., & Butt, M.J. (1997). Manager leadership and retention of hospital staff nurses. Western Journal of Nursing Research, 19, pp.205-222.

Tumulty, G., Jernigan, I.E., & Kohut, G.F. (1994). The impact of perceived work environment on job satisfaction of hospital staff nurses. Applied Nursing Research, 7, 2, pp.84-90.