THE INFLUENCE OF JOB AND COMMUNITY SATISFACTION ON RETENTION OF PUBLIC HEALTH NURSES IN RURAL BRITISH COLUMBIA by Mary H enderson Betkus, RN, B.Sc.N., Lakehead University, 1978 B.A., University of W estern Ontario, 1980 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER O F SCIENCE in COMMUNITY HEALTH SCIENCE © Mary H enderson Betkus, 2002 THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA January, 2002 All rights reserved. This work may not be reproduced in whole or in part, by photocopy or other m eans, without the perm ission of the author. 1 * 1 National Library of Canada Bibliothèque nationale du Canada Acquialtlona and B&aographie Servie## Aoquiaitionael aervice# bWiographiquea 3 #SW#angionS#e#« 3#S.m«W#amglon Oamm ON K1A0N4 OamwmON K1A0N4 Cmnmd# Cmmmdm % Nonrni^fmm ItemnAorhasgnmledanooN»üommlLîb™ycf Canada to rqxoduce, loan, disthbute or KÜ ctfiea of this dieais m microAxm, paper or electromc Rxmats. L'anteor a accordé une Ikence non exchsivBpermettant Ala B ib h o & è^ nationale du Canada (k rqaoduire,pr&er, distnlxoerou vendre des copies de cette dkses .2 small, > .5 medium. 65 and > .8 large. The descriptors for correlations w ere > .1 small, > .3 medium, and > .5 large. The relation of job and community satisfaction to intent to stay (retention) w as thoroughly scrutinized. ANOVAs w ere used to exam ine all of the c a se s, then u sed to reexam ine th e d ata with the casual em ployed public health nurses and the public health n u rses over 55 years of ag e rem oved. Finally, com m ents from the respondents w ere utilized to understand the effect job and community satisfaction have on retention. The self reported com m ents ranged from point form com m ents, full paragraphs, to an extra page stapled to two of the questionnaires. 66 CHAPTER FOUR: RESULTS The purpose of this research w as to exam ine the satisfaction perceived by public health nurses in their job and in their community and the effect of this satisfaction on remaining in their practice in rural British Columbia. Section I describes th e sam ple of public health nurses. Section II provides an sw ers to the specific research questions: W hat job com ponents do public health n u rses in rural British Columbia identify a s satisfying and im portant? W hat a s p e c ts of the community are identified a s satisfying for public health n u rses in rural British Columbia? W hat are the differences betw een rural and non-rural public health nurses in their satisfaction with their job and comm unity? Finally, interpretation of the overall d ata is need ed to answ er the com plex question; how d o es job satisfaction and community satisfaction influence retention of public health n u rses in rural British Colum bia? Section I This section is divided into the characteristics of public health nurses, practice related characteristics, and retention related characteristics. The dem ographics, family configuration, partners’ em ploym ent and the size of the com m unities the public health n u rses live in and work in, help to describe characteristics of rural public health nurses. The practice related characteristics give a profile of their educational preparation, em ploym ent statu s, size of office, and the distance travelled to deliver service. The retention related characteristics for th e n u rse s a re their perceived isolation, choice to practice in a rurai setting, 67 intent to remain in their p resen t position, benefits, and perceived em ploym ent opportunities. The results are show n a s valid resp o n ses for each question. However, the non-response rate per question is reported for the total sam ple. The average non-response rate per question is 5%, any non-response rate g reater than this has been noted in th e text. An examination of public health n u rses who are 35 y ears or younger has been included b e c a u se th e se are the n u rses who potentially have m ore work years left. This su b se t {n = 29) of the total sam ple is referred to a s the younger cohort. No statistical difference w as found betw een the rural and non-rural public health n u rses in this younger cohort w hen exam ined for job and community satisfaction, a sp e c ts of isolation and intent to stay. Hence, any descriptive differences are reported collectively for the group. The younger group com prised only the respondents that reported their a g e (9% of the total sam ple did not identify their age); within this younger group occasionally one or two of the respondents omitted a question. Therefore no com m ents are m ad e in the text regarding a non-response rate for the younger cohort group. Characteristics of Public Health Nurses in Rural British Columbia Gender and marital status. As expected, the majority of public health n u rses in rural British Columbia w ere fem ale and married. The resp o n d en ts w ere predominantly fem ale (99%). This sam ple followed the provincial profile that reported that a g reater proportion of fem ales than m ales w ere em ployed in community health. Although 7% c h o se not to indicate their g en d er this would not 68 have altered the predom inate fem ale ratio. The majority (90%) of th e public health nurses in this sam ple w ere married or had partners. Age of public health nurses. The ag e of the public health n u rse s in this sam ple is similar to the provincial profile a s displayed in Table 4. However, the study population had a higher p ercentage (23%) of public health n u rse s under 35 years and a lower p ercen tag e (8%) of public health n u rses 55 y ears or over than the provincial profile which had 15% and 17% respectively in th e se a g e categories (RNABC, 2001b). Although the majority of th e sam ple is over 40 years, there are younger n u rses entering public health nursing to maintain the m ean a g e 43 (42.5 y ears) which is not notably different from the m ean a g e 41.2 of public health n u rses identified by Tomich (1993). In com parison, the m ean ag e of n u rses in C an ad a is 43.3 years (C anadian Institute for Health Information [CIHI], 2001) and in British Columbia the m ean a g e is 44 y ears (RNABC, 2001b). Table 4 R ange o f A ges /or Pub//c Hea/tf? /Vurses p e r Hea/fA R eg/ons a n d Pmv/nc/a//y The 8 Health Regions Total Province " Y ears n P n P 2 2 3 <1 <25 2 5 -2 9 6 5 91 5 3 0 -3 4 18 167 16 9 3 5 -3 9 11 9 223 12 4 0 -4 4 22 25 340 19 21 4 5 -4 9 29 26 379 5 0 -5 4 14 12 296 16 7 5 5 -5 9 6 221 12 1 5 1 >60 96 A/ofe. "Data from R egistered N urses Employed in Nursing by A rea of Responsibility in Direct C are and Age Group 1999 (RNABC 2001b) 69 There w as no statistical difference betw een the m ean ag e for rural public health n u rses 43 (43.1 y ears) and non-rural public health n urses 42 (41.7) at an alpha level of .05. Additional evidence of an older work force w as dem onstrated by examining the y ears th e respondents w ere first licensed to practice, with 60% first licensed 20 or m ore years ago (S ee Table 5). Using five y ears a s an indicator of retention and with 89% of th e se public health n u rses licensed before 1995, this sam ple could be considered to have dem onstrated retention in nursing. No definitive com m ent can be m ade b e c a u se the respondents w ere not ask ed how many y ears in total they had been em ployed in nursing to enable this com parison. Table 5 Number of PuMc Hea/fb Nurses by Range of Years wben F/rsf L/censed fo Practice as a Registered Nurse in Canada R ange of Y ears 1961-1965 1966-1970 1971-1975 1976-1980 1981-1985 1986-1990 1991-1995 1996-2000 n 6 9 17 39 7 16 11 13 P 5 8 14 33 6 14 9 11 Ages of dependents. The respondents identified their children and ag ed p aren ts living at hom e with them . Two of the respondents identified that their p aren ts w ere living with them . Thirteen percent of d ep en d en ts w ere over 20 y ears old and 36% w ere teen ag ers, that is 13 to 19 years. Having older children w as ex p ected b e c a u se the majority of resp o n d en ts w ere over 40 y ears old. 70 Twenty-eight percent of d ep en d en ts w ere children betw een 5 to 12 y ears and 17% w ere under 4 y ears old. Spouse’s employment. The three m ost comm on occupations for partners of public health n u rse s w ere professional (23%), forestry an d related (17%) and trade (15%) displayed in Table 6. Considering that 10% do not have a partner the non-response rate for this question adjusts to 6%. The younger cohort had partners who w ere professional (33%), trade (15%) and labourer (15%). The num ber of partners em ployed in forestry and related fields (7%) w as not a s prominent with this younger cohort. Table 6 Partner’s Occupation for Public Health Nurses In the Health Regions Occupation Trade Professional Self-employed Forestry and related M anagem ent Law enforcem ent Labourer Unemployed Other n P 16 24 11 18 6 6 11 4 8 15 23 11 17 6 6 11 4 8 Sixty percent (n = 61) of the public health n urses felt it would be e a s y for their sp o u se/p artn er to find new em ploym ent if they relocated. Adjusting the nonresp o n se rate b e c a u se of "no partners" gives a n on-response of 8%. Assuming this 8% would split evenly with this y es or no question it a p p e a rs that approximately two thirds of the public health n u rses feel their partn ers are easily em ployable. The public health n u rses w ere asked to indicate how much of their family income w as rep resen ted by their salaries. Eleven percent did not respond 71 to this question. Sixty-eight percent of the pubiic health n u rses stated they earn e d 50% or less of their total family income, in contrast, 15% earned betw een 51% and 90% of their family income. Sixteen percent of the respondents earn ed 100% of their family income. This see m e d reaso n ab le when considering that 10% reported no partner and 4% reported their partner w as unem ployed. Community size and years spent in the community. Half of this sam ple of pubiic health n u rses lived (50%) and worked (53%) in com m unities of 10,000 25,000 (S ee Table 7). C overage of so m e small rural com m unities w as from the larger offices in the a re a for exam ple, P e a c e Liard. However, 11% lived and 8% worked in places with a population of less than 2,500. it can be surm ised that so m e com m uted to larger places to work. Table 7 Percentage of Public Health Nurses p er Size o f Community for Birthplace, Currently Living and Working, and Partner’s Childhood Size of Community PHN" bom in partner grew up in PHN <2,500 2,5004,999 5,0009,999 10,00025,000 > 25,000 P P P P P 22 10 13 13 42 18 11 12 21 38 11 16 22 50 1 8 17 21 53 1 currently living in PHN currently work Note. ®PHN in place of public health nurse 72 Approximately one quarter (22%) of the public health nursing sam ple w as born in communities of populations under 2,500 while 18% of their partners grew up in communities of this size. This is a sm aller p ercentage than w hat has been identified by other research ers. H egney et al. (1997) found 55% w ere raised in rural a re a s while Dunkin et al. (1992) found 61% w ere raised in com m unities with population less than 2,500. The num ber of y ea rs public health n u rses have sp en t in their com m unities is displayed in Table 8. S eventy-seven percent of the public health n u rses had lived in their present community for 5 years or more. Therefore m ost respondents w ere long term residents of their communities. This question had a 7% non-response rate. Forty-three percent of the younger cohort had been in their community iess than 5 y ears and 25% had oniy been iiving in their p resen t community for 5 years. Tabie 8 R an g e o f Y ears for Pub//c HeaAh /Vurses p e r R es/dency /n Tlhe/r CommunAy Y ears < 5 years 5 to 9 years 10 to 14 years 15 to 19 years 20 to 24 years 25 to 29 y ears 30 to 34 years n P 28 31 21 8 18 8 2 24 27 18 7 16 7 2 Sixty-three percent (n = 71) of the pubiic heaith n u rses reported they w ere satisfied to very satisfied with their community while 88% (n = 95) felt this issue w as important to very important to them . S p o u se s’ or p artn ers’ satisfaction with the community w as also considered. Ninety- seven percent of the public health 73 nurses with s p o u se s ’/partners’ responded to this question on p artn ers’ satisfaction with the community. Eleven percent of the public health n u rses reported that their sp o u se s or partners w ere dissatisfied to very dissatisfied with the community com pared to 66% who felt their partners w ere satisfied to very satisfied with the community. However, 88% of the respondents felt their partners’ satisfaction with the community w as important to very important. Practice Related Characteristics of Public Health Nurses Som e characteristics helped to describe the rural practice setting. The practice related characteristics w ere factors that affected the public health n u rses’ positions, such a s educational preparation, em ploym ent statu s, length of em ploym ent in public health nursing, size of office, and the d istan ce travelled to deliver service. Educational preparation. As expected, 96% had their D egree in Nursing b e cau se a baccalau reate is a prerequisite for public health nursing in British Columbia. Fifty-three percent of the public health n u rses received their degree secondary to their diploma in nursing. Place of educational preparation. Fifty percent received their educational preparation outside of British Columbia, in particular Ontario (14%), Alberta (12%), and S askatchew an (8%). Three percent w ere ed u cated outside of C anada. T he n o n -resp o n se rate for this question w as 9%. Currently, "[British Columbia] supplies only 50% of its annual dem and for registered n u rse s” (Solving N urse S hortage, 2000, p. 4). This sam ple d em o n strates a similar trend for filling public health nursing positions. 74 The resp o n d en ts w ere asked to indicate the province they w ere first licensed to practice a s a registered nurse (S ee Table 9). The num bers per province absorbed the num ber educated outside of C anada. Again, the predom inate provinces w ere British Columbia (54%), Ontario (14%), Alberta (11%), and S askatchew an (10%). Table 9 Place First Licensed to Practice as a Registered Nurse in Canada Place British Columbia Alberta Saskatchew an Manitoba Ontario Q uebec New Brunswick Nova Scotia n P 63 13 12 5 16 4 2 2 54 11 10 4 14 3 2 2 Emp/oym enf sfafi/s. The majority of resp o n d en ts w ere em ployed in perm anent part-time positions (S ee Table 10). This followed the provincial profile, in general, half of the fem ale registered n u rses work part-time (RNABC, 2001b). Four percent of the respondents w ere in casual positions. The high n o n-response rate (12%) for this question w as due to re sp o n se s being omitted b ec au se the num ber provided could not be converted into an FTE. The younger cohort varied from this profile with 61% working full-time, 32% part-time and 7% casual. 75 Table 10 The Full Time Equivalency Worked per Public Health Nurses in the Health Reg/ons FTE Part-time perm anent Full-time perm anent Part-time casual Full-time casual n 53 52 3 1 P 49 48 3 1 Length of present employment. Half of the respondents (47% ) reported having worked in their p resen t em ploym ent less than 5 y ears w h e re a s the other half (54%) reported working from 5 to 31 years in public health nursing (S ee Table 11). Therefore, half of th e se em ployees have already dem onstrated retention in their job. It is interesting to note that 51% of the public health n u rses have lived in their community less than 10 years (Table 8). This a p p e a rs to coincide with the 47% of public health n u rses who have worked le ss than 5 years in their present position. Of th e younger cohort 71% had worked in their present position less than 5 y ears while 25% had worked for 5 to 9 y ears in the sam e position, 4% had worked for 10 y ears in their current position. T he younger cohort would ap p ear to be th e group to target for retention. Table 11 Length o f Emp/oymenf p e r Y ears /n P re se n t Pos/t/on Y ears <5 5 -9 1 0 -1 4 1 5 -1 9 >20 n 53 33 13 3 10 P 47 30 12 3 9 76 Size of office. The office sizes ranged from sole practices (7%) to an office with 13 public health n u rses (1%). The m ost com m on size of offices w as 2-nurse offices, 6-nurse offices and 5-nurse offices at 22% , 21% and 16% respectively. As previously reported half of th e se positions would be part-time. T here w as 8% non-response. However, the exam ination of th e younger cohort revealed 11% worked in single nurse offices, 21% worked in a 2 nurse office. Both the 5-nurse (18%) and the-6 nurse (18%) offices had the s a m e proportion of younger public health nurses. Distance to travel for service delivery. Public health n u rses w ere ask ed to indicate the farthest they had to drive to provide public health nursing service (S ee Table 12). Eleven percent did not respond to this question. Since the majority (73%) travelled less than 70 kilometres to provide service it is not expected that this n o n-response rate would influence the trend s e e n in the results. Twelve percent travelled betw een 100 and 200 kilometres, how ever a few w ere travelling g reat distances, up to 600 kilometres to deliver service. On av erag e the difference in travel betw een the rural and non-rural public health n u rses w as 20 kilometres. This difference w as not important. T he com m ents described the extrem e travel experiences: • I leave my family and travel approximately 300 kilom etres aw ay once per month for a w eek. • I live in o n e place and my work is 4 -5 0 0 kilom etres aw ay. I fly/drive th ere once a month for a w eek each month ' I don't like th e long drive to get to this job especially on winter roads. 77 Table 12 D/sfance PuM c Hea/f/r /Vurses Tirade/ A)r Se/v/ce Oe/A/ery D istance (km) <20 21 - 6 9 7 0 -7 9 8 0 -8 9 9 0 -9 9 100 - 200 300 400 500 600 n 29 52 4 3 5 13 2 1 1 1 P 26 47 4 3 5 12 2 1 1 1 Summary The results of this study Indicated that the eight health regions surveyed have an older population of fem ale public health n u rses who have s p o u se s or partners. Half of this sam ple have worked for five or m ore y ears in their p resent position and work in com m unities with populations of less than 10,000. Most of the public health n u rses would be considered long term residents of their com m unities. Many of th e se n u rses have had their educational preparation outside of British Columbia. The majority of public health n u rses have partners who are em ployed a s professionals or have em ploym ent in the forest industry. Few er partners of the younger cohort work in the forestry industry. Two thirds of this younger group works full-time and a third are em ployed in a 1 or 2 nurse office. Retention Related Characteristics of Public Health Nurses O ther characteristics w ere exam ined to determ ine w hat effect they might have on retention. T h e se were: the n u rse s’ perceived isolation, their choice to 78 practice in a rural setting, their intent to remain in their present position and w hether there w as attractive alternative em ploym ent. The public health n urses identified the benefits they received and rated the im portance of th e se benefits. Perceived geographic, professional and social isolation. O ver half (64%) of th e respondents felt geographically isolated. Fifty percent {n = 58) of the public health n u rses indicated professional isolation, w hereas, 46% (n = 53) reported social isolation. The non-response rate ranged from 6% to 7% giving th e se three items a similar resp o n se rate. The younger cohort dem onstrated a difference from the total sam ple. The younger public health n u rses reported feeling isolated geographically (83%), professionally (66%), and socially (62%). Rural public health nurses (42%) felt they w ere socially isolated while 50% of th e non-rural group felt socially isolated. The rural public health nurses reported professional isolation (51%) and geographical isolation (65%) while the non-rural group indicated 48% and 62% respectively. There w as no significant group difference betw een rural and non-rural public health n u rses on th e se three asp e c ts of isolation with an alpha level of .05. T he n on-response rate for the rural group w as 8% while the non-rural group w as 5%. The assum ption w as m ade that geographical and professional isolation m ay have so m e effect on the public health n u rse s’ ability to stay current. Ninetysix p ercent (n = 106) of the respondents ag reed that it w as im portant to very important to remain current in their practice yet only 48% of public health n u rses w ere satisfied to very satisfied with their ability to stay current in their practice. Even though the n o n-response rate varied betw een the a sp e c t of “im portance” 79 (11%) and the “satisfaction” (8%) the results depict a difference betw een the perceived im portance of staying current to the perceived satisfaction with their ability to stay current. Runs/ pracf/ce seff/ng a n d accep tan ce of die p re se n t pos/t/on. Two questions w ere asked to gain som e perspective of why n u rses c h o se a rural practice setting. T h e se w ere “w hat factors led you to practice nursing in a rural a re a ? ” and “which factor played a greater role in influencing your decision to accept your present position?”. Most respondents indicated m ore than one factor that influenced them to practice nursing in a rural setting. S om e of th e se were the community (30%), partner (24%), job availability (21%) and family and friends (9%). O ther re aso n s given w ere the autonom y and independence, the variety and scope of practice, and so m e indicated choosing a rural setting b e c a u se of challenge an d adventure. The top three factors why public health n u rses accep ted their p resen t position reflect the re a so n s they c h o se to practice in a rural a rea. T h e se w ere job availability (32%), partner (23%) and community (15%). Ten percent indicated accepting the position b e c a u se of the health care ag en cy and 20% indicated the category “other”. S om e of the self reported com m ents for other were: ' opportunities for ch an g e and growth " paid more ' no night shifts or w eek ends ' health promotion 80 The younger cohort w as very similar to the total sam ple in their reaso n s for accepting their job. T h ese w ere job availability (38%) and partner (30%), however the community w as reported less frequently at 10%. It can be surm ised that for the younger nurses, the ch an ce to find em ploym ent w as the motivating factor to accept their p resen t position. Planned tenure for public health nurses. Tenure exam ined how long public health n u rses would be committed to their p resent position (S ee Table 13). The survey also ask ed the public health n u rses if there w ere other em ploym ent opportunities for them nearby and had they looked for other em ploym ent opportunities. Table 13 Public Health Nurses’ Intent to Stay in their Present Position Intent to Stay < 1 year 1 - 2 y ears 2 - 4 y ears > 5 years n P 13 20 23 60 11 17 20 52 Even though 7% did not respond, m ore than half (52%) of the public health n u rses said they would stay in their job for 5 or m ore years. A similar p ercen tag e (51%) indicated they had not looked for other em ploym ent. However, of the 49% who said “y e s ” to looking for other em ploym ent 68% had only looked for nursing em ploym ent, while 11% had only looked for non-nursing em ploym ent, and 21% had looked for both nursing and non-nursing employment. The majority of th e resp o n d en ts did not feel there w ere attractive em ploym ent 81 opportunities outside of nursing (73%) or in nursing (75%) in or nearby their communities. The younger cohort dem onstrated a different profile for tenure. Forty-six percent of the younger cohort indicated they planned to stay for 5 years or more while 11% indicated they would work another 2 to 4 years. However, 43% of the younger cohort reported they planned to leave in 2 years or less. Benefits currently received. Benefits and rew ards (Table 14) are often thought of a s retention strategies (Stratton et al., 1995), therefore th e se public health n u rses w ere asked, “w hat benefits do you receive” and “how important are the benefits”. The top three benefits rated for im portance w ere their “vacation time” (96%) followed by “inservice” (95%) and then the “retirem ent” benefits the job would provide (95%). Stratton et al. also found vacation rated a s m ost important in benefits. S om e of the public health nurses com m ented that inservices had been cancelled. Benefits that w ere least important w ere “day c are” (38%), “cell/mobile phone” (60%) and “isolation allow ance” (61%). Although the non-response rate for the im portance a sp e c t of e ach benefit varied from 11% to 15%, m ost being at the lower value there w ere still 105 to 111 re sp o n se s for eac h item. The younger cohort valued m ore benefits. The m ost important w ere "health Insurance" (96%), "vacation" (96%), "sick/matemity leave" (93%), "health unit c ar” (93%), “retirem ent benefits” (92%), and “inservices” (92%). The least important w as “cell phone” (69%) and “d ay care” (73%). 82 Table 14 Benefits Received and Perceived Importance of Benefits for Public Health Nurses Benefits Vacation Inservice Retirement Health Insurance Sick/matemity Tuition Health unit vehicle Telephone conference with peers Isolation Allowance Cell/mobile phone Day care child/elder Y es No Neutral Im portant P P P P 94 95 85 88 92 46 47 84 6 5 15 12 8 54 53 16 1 3 3 3 6 10 13 15 96 95 95 92 91 85 81 77 16 46 1 84 54 99 19 30 20 61 60 38 Two benefits w ere exam ined more closely, one b e c a u se of contract bargaining and o n e b e ca u se of its assu m ed effect on professional isolation. The availability of a health unit vehicle w as rated in seventh place with 81% of the respondent indicating it w as important to them . At the time of sam pling this w as considered an important issu e in the upcoming contract bargaining. Yet, 53% (n = 62) of the public health n u rses reported not having a health unit vehicle for service delivery while 47% {n = 55) reported having or sharing a vehicle. Six percent did not respond to this part of the question. The rural group rated the im portance of a vehicle M = 4.41 while the non-rural group indicated the im portance M = 4.26 but this w as not a significant difference at an alpha level of .01. Eleven percent did not indicate the im portance of a health unit vehicle to them . 83 Professional isolation h as been identified a s an issue in rural nursing (Davis & Droes, 1993, Hegney, 1996b). Collectively, “telephone conference with p e ers” w as indicated by 84% (n = 101), a s a benefit they received. Seventyseven percent {n = 84) perceived this benefit a s important to very important to them. Fifteen nurses (12%) did not rate the importance of this benefit. The rural public health n u rses {M = 4.31) rated telephone conferencing a s m ore important than the non-rural group of n u rses {M = 3.89). The im portance of telephone conferences with p eers com pared betw een rural and non-rural groups revealed a significant difference {t = 2.26, d f ~ 107, p < .03). The research er decided to report this result even though it is outside of the alpha level of .01 initially s e t in the M ethods chapter b e c a u se of the calculated C ohen’s d = .43. More research is n eed ed to determ ine w hether this result can be repeated. A nother notable difference regarding benefits is shown by 16% of the resp o n d en ts indicating they received isolation allow ance yet 61 % indicated it is important, no speculation can be made regarding this. C om m ents collected throughout the questionnaire point to a lack of satisfaction with educational opportunities. Som e of th e se statem en ts included: • Really m iss e a sy a c c e s s to educational opportunities with travel, distance and cost being the biggest deterrents ' Rural nurses have even more challenges than urban nurses to stay current • Frustrated at lack of agency encouragem ent for ad v an ce training other than inservices or ‘on th e job’. Our allow ance is cap p ed a t $400 per year. This d o e sn ’t even pay for a return flight to m ost cen tres in British Columbia! Not to mention other related costs. 84 Likewise, public health n urses gave suggestions on w hat worked or might work. • I think having occasional major educational events sh ared in sm aller communities not only financially is a bonus for th e se n u rses but also will reach nurses that otherwise would not attend the education opportunities ' G reat to s e e St. Paul's and UBC doing "rounds' over the internet with teleconferencing very e asy to a c c e s s Summary The retention-related characteristics exam ined how the sam ple of public health nurses felt about their jobs. Overall, m ore than half of the public health n u rses admitted to feeling geographically isolated, this w as especially true for younger public health nurses. About a quarter of the resp o n d en ts had accepted their present position b ec au se their sp o u se s or partners w ere em ployed in the community. Only half of the public health n u rses w ere planning to stay for another five years in their p resent job. Approximately one quarter of the younger cohort w as planning to leave their jobs in the next two years. Overall, the resp o n d en ts identified the m ost valued benefits of their p resen t em ploym ent w ere vacation time, inservice and retirem ent benefits. The younger n u rses also valued health insurance, sick and maternity benefits and having a health unit vehicle. Section I! The results p resented in Section II identify the job com ponents and community variables that public health n u rses perceive a s satisfying and important. It also a d d re ss e s the general and specific differences betw een rural and non-rural public health n u rses in their satisfaction with job and community. 85 This section contributes to understanding the effect of this information on retention. Job Component Satisfaction and Importance The statem en ts are grouped into the su b scales for each work com ponent to determ ine job satisfaction and importance. As m entioned in the M ethods chapter, work satisfaction w as ad d ressed by four approaches. First, descriptive analysis w as u sed to exam ine each statem ent. Second, the alpha coefficient w as calculated for e ach subscale. Third, the m ean score of each work com ponent w as done to enable ranking of the work com ponents. Fourth, su b scales of each work com ponent w ere com pared for difference betw een rural and non-rural public health nurses. The 38 questions used to indicate the job com ponents and h en ce job satisfaction w ere the m ost frequently answ ered questions by the resp o n d en ts with non-response rates less than 5%, the m ost com m on being 2%. The work com ponents are professional status, salary, autonom y, task requirem ents, organizational climate, interaction, and benefits and rewards. Each work com ponent (Table 15 to 21) is introduced with its operational definition. As described in the M ethods chapter, the specific statem en ts for the su b sca les w ere determ ined by reviewing the research of Dunkin e t al. (1992) and S tam ps and Piedm onte (1986), along with having them reviewed by Stratton (personal communication, April 20, 1999). Public health n u rses indicated their resp o n ses to specific state m e n ts from 1 (strongly disagree) to 5 (strongly agree). S om e statem en ts are negatively stated, therefore bold print h a s b een used to 86 indicate a common direction of the resp o n ses. The neutral re sp o n se s are not reported. The work com ponent, professional status, described the n u rses' perception of the im portance of nursing to them selves and the community (Dunkin, et al 1992). The three statem en ts used to explore this com ponent are displayed in Table 15. Table 15 Level of Agreement with Professional Status Items S tatem ent 1 have no doubt in my mind that what 1do on my job is really important. 1am proud to talk to other people about w hat 1do on my job. If 1 had the decision to m ake all over again 1would still go into nursing and PHN. A gree P 90 D isagree 89 4 62 25 P 4 Although public health nurses ag reed their job w as im portant and w ere proud to explain to people w hat they did in their job only 62% would go into nursing and public health again. This w as a similar value to w hat w as found in an American sam ple of n u rses (59.1%) and physicians (59.2% ) who responded to the sa m e question (S tam ps & Cruz, 1994). Com m ents describing the perceived lack of valuing were: • I am discouraged by the devaluing of public health nursing - by physicians, acu te care nurses (we still seem to be in the medical model w here our worth is m easured by d e g re e s of separation from the physician): the public d o es not understand our role until they have c a u se to interact with us; we are devalued by our adm inistration in that vacation is not back filled; w e are devalued by our union that sacrificed us in the last contract for the “greater good” [and] the classification tool w as biased in favour of acu te care settings. 87 ' I feel strongly th at community n u rses have no voice in health care acute care is the focus, yet "prevention" is w hat sa v e s our governm ent money. The com ponent, salary, w as the perceived ad equacy of am ount paid for work done (Dunkin, et al. 1992). The four statem en ts used to exam ine this com ponent are displayed in Table 16. Table 16 Level of Agreement with Salary Items S tatem ent B ased on feedback from PHN in other health units, the pay at this health unit is fair. Pay sca le s for PHN personnel need to be upgraded. Considering w hat is expected of PHN personnel at this health unit, the pay we receive is reasonable. My earning potential in this health unit is reasonable. A gree D isagree P P 38 33 94 1 14 79 17 55 The mixed ag reem en t by the respondents on “B ased on feedback from PHN in other health units, the pay a t this health unit is fair" could be due to the inappropriateness of the wording in this statem ent for public health n urses b e c a u se they have a provincial collective agreem ent so that all public health n u rses within the province have the sa m e pay scale. S om e public health n u rses wrote beside this question “contract”. The provincial collective ag reem en t could also be th e explanation for 79% of th e public health n u rses indicating their pay is reasonable. The majority (94%) of public health nurses ag reed th at pay scales n eed ed to be improved. C om m ents regarding salary were: « It's interesting th at my husband and I m ake the sa m e am o u n t of money. I sp en t 5 years a t University and [have] worked full time for alm ost 20 years. He h as 2 y ears of University and h as worked full tim e for 10 years. • Would be nice to g et paid on line with other people with 4 y ear d egrees. The com ponent, autonom y, exam ined perceptions of the am ount of decision making, independence, and control n u rses have over their job (Dunkin et al. 1992). Seven statem en ts in Table 17 w ere used to exam ine this. Table 17 Level of Agreement with Autonomy Items Statem ent 1have little control over my work. A great deal of independence is permitted if not required of me. 1am som etim es required to do things on my job that are against my better professional nursing judgem ent. 1 have too much responsibility and not enough authority. 1am som etim es given m ore responsibility in decision making that 1 am prepared to handle. 1 have the support of my supervisor to m ake important decisions in my work. 1 have sufficient input into implementing program s for the clients/family/community. Agree D isagree P P 15 88 67 7 12 78 22 47 24 62 77 12 59 25 Most of th e resp o n d en ts (88%) felt they had a g reat deal of independence and 77% felt supported in their decision making by their supervisor. The n u rse s’ com m ents reflected opposing views on this job com ponent, som e identified: • Jo b flexibility, I am able to prioritize my own caselo ad an d function independently, while others described: 89 ' Not having th e control over dispensing the public health program s. Task requirem ents described the task s that w ere regularly done by the nurse a s part of th e job (Dunkin, et al. 1992). The five statem en ts in Table 18 w ere used to investigate this com ponent. Table 18 Level of Agreement with Task Requirements items S tatem ent 1 have plenty of time to d iscuss PHN concerns with my colleagues. In this health unit PHN are expected to perform non-nursing tasks. Too much p ap er work is required of PHN personnel in this health unit. The types of activities required of m e are reasonable. 1 have sufficient time to accom plish my job responsibilities. A gree P 50 D isagree P 40 68 20 64 14 84 8 34 58 Although 68% felt they w ere expected to perform non-nursing task s a majority (84%) felt the types of activities they w ere required to do w ere reasonable. Even though there a p p ears to be a contradiction h ere from the resp o n d en ts m ore exam ination will need to be done to identify the non-nursing tasks. It a p p e ars that there is not a consistent ag reem en t in w hat are non­ nursing ta sk s when such a high percen tag e feel the activities they perform are reasonable. It could be surm ised that public health n u rses ac c e p t som e non­ nursing ta sk s a s part of their job. C om m ents reflecting the public health n u rses' thoughts about their job task s were: 90 • Job has becom e very stressful - too much to do and not enough time to do it. Increase in com puter u se and not enough training on com puter. More work to do and no m oney to hire m ore nurses. 'T o o much paperw ork to fill out for administration • We seem to sp en d more time immunizing and less time given to community nursing. The com ponent, organization climate, explored the ch aracter of the work environment affected by m anagem ent, leadership styles and program policies (Dunkin et al. 1992). The six statem ents used to exam ine this com ponent are displayed in Table 19. Table 19 Level of Agreement with Organizational Climate items S tatem ent PHN-client ratios in this health unit are conducive to implement client/family/ community services. T he PHN adm inistrators or Seniors generally consult with PHN staff on daily problem s and procedures. PHN staff have sufficient control of the total num ber of hours worked. A great gap exists betw een administration in this health unit and the daily problem s of PHN service. PHN staff have sufficient control in scheduling their own work hours in this health unit. 1 have all th e voice in planning and procedures that 1want. Agree D isagree P P 37 49 42 43 58 29 41 41 76 16 39 45 The resp o n se s w ere mixed to m ost of th e se statem ents. T he statem ent “A great g ap exists betw een adm inistration...and the daily problem s of PHN service” w as evenly split on ag reem en t and disagreem ent. Interestingly, R em us e t al. (2000) reported a larger difference for S askatchew an comm unity nurses, 27% ag reed and 73% disagreed with this statem ent. This could b e due to the 91 mix included in her sam ple of community nurses. This sam ple of public health nurses agreed with scheduling of their own work hours (76%) and having sufficient control over num ber of hours worked (58%). However, th e com m ents revealed a stronger view on health care ch an g es that affect public health nursing: • With regionalization community health /prevention is not s e e n as important a s acu te care/hospital beds. It would be better to have the strength of a provincial system that we had before. Also, with regionalization w e PHNs are left hanging without a supervisor who is familiar with PHN issues. • Really feel a lack of support from upper m an ag em en t for work done by front line n u rse s - really need to involve front line w orkers in initiating, evaluating and changing program s. • Devolving from the governm ent has changed the environm ent at the Health Unit. Not enough support staff to sustain a health infrastructure. M anagem ent and staff all seem to be overworked. • Health care restructuring h a s im pacted on job satisfaction [due to] health authorities, new em ployees, frequent turnover of CEO, public health nursing m an ag ers not facilitating our role in the community, staff m em bers off sick with no replacem ent h a s worn full time staff m em bers to the b o n e. The work com ponent of interaction exam ined cooperation, support and respect from peers, coworkers, and individuals in supervisory roles (Dunkin, et al. 1992). The six statem en ts in Table 20 w ere used to exam ine interaction. 92 Table 20 Leye/ o M g m em en fs mf/) /nferacf/on /ferns S tatem ent My immediate co-workers are com petent. The PHN personnel in this health unit are not a s friendly or supportive as 1would like A good deal of networking is p resent betw een various levels of PHN personnel in this health unit. New PHN are not quickly m ade to feel at hom e in this health unit. The PHN personnel in this health unit do not hesitate to take the time to consult with m e or support m e w hen things get in a rush. 1wish the physicians here would show m ore resp ect for the knowledge/skill of the PHN staff. Agree D isagree P P 90 2 16 77 66 19 12 73 79 12 64 14 The majority (90%) agreed that their co-workers w ere com petent. The respondents (79%) also felt that public health nursing personnel would take the time to consult or support them . T he public health n u rses (77%) felt that their health unit w as friendly and new staff w ere w elcom ed. R em us et al. (2000) found community n u rses in general w ere m ore likely to ag re e with this statem ent than institutional n u rses. Com m ents presented both positive and negative perceptions of peers, coworkers and supervisors: • I feel like I’m part of a team , respected, I feel I have time to do a good Job, I have time to study, I have a lot of responsibility but I feel supported, I can ask questions at any level of public health nursing personnel. • My co-workers are great • Lack of support and respect from co-workers plus internal strife making th e office an unhappy place to work. 93 Benefits and rew ards Included job related benefits that are tangible or Intangible, and that recognize the n u rses’ achievem ents (Dunkin, et al. 1992). Table 21 contains th e six statem en ts used to exam ine this com ponent. Table 21 Lave/ o f ^ g reem en f w/fh B a n a l s a n d R ew ards /tarns Statem ent Agree 20 D isagree P 50 71 18 11 13 81 67 18 41 68 42 P This health unit offers opportunities for advancem ent/prom otion. PHNs in this health unit are encouraged to participate in continuing education. 1am frequently ask ed to work overtime. This health unit financially rew ards advanced training/education. 1work w eekends. 1do not receive so m e benefits that are important to me. The small p ercen tag e that agreed to opportunities for advancem ent/prom otion is not surprising since advancem ent would only be available at the larger offices that have senior nurse positions. T he respondents (71%) felt encouraged to participate in continuing education. Most of th ese statem en ts could be answ ered y es or no. This is reflected by the high or low p ercen tag es who ag reed or disagreed. Most public health n u rse s do not work overtime, the contract allows for “flex tim e”. Therefore any extra hours they work they take back in “time ofT. Most public health n u rses work M onday to Friday, so m e may schedule them selves to work a w eekend to teach prenatal classes, have a clinic or hold a health fair. O thers m ay work w eekends if their health unit h as an “early maternity discharge” program. The notable difference is the similar 94 split on “do not receive som e benefits”. No speculation can be m ade on what benefits they would like to receive. Scale development job satisfaction. Each work com ponent su b scale w as exam ined for internal consistency using the alpha coefficient (S ee T able 22). The higher alpha value indicates the scale w as m easuring the job com ponent in question (Polit & Hungler, 1999). A C ronbach’s alpha of >.70 to indicate satisfactory internal consistency w as su g g ested by a Co-Principal Investigator with the National Survey: Nursing Practice in Rural and R em ote C an ad a (N. Stewart, personal communication June 3, 2001). This w as not achieved for every subscale. The overall job satisfaction scale w as th e sum of each work com ponent su b scale plus the score from the individual question “Overall, I am very satisfied with my job". The alpha coefficient for th e overall sca le indicated a strong operational definition for job satisfaction (.830). Likewise, not all the su b scales used by Dunkin et al. (1992) tested over .70, but the overall job satisfaction scale had an alpha of .876. T he score from the individual question on overall job satisfaction in Table 23 and 24 is not u sed but is presented for interest. The assum ption is m ade that the sco re from th e scale will give a more stable m easu re of overall job satisfaction b e c a u se not all com ponents that m ake up a job are equally liked. 95 Table 22 Alpha Coefficients for Satisfaction per Work Component Com ponent T ask requirem ent Salary Benefits and R ew ards Autonomy Professional status Interaction Organizational climate Overall job satisfaction Dunkin et al. 1992 .595 .859 .514 .666 .350 .652 .730 .876 P resen t research .619 .759 .429 .641 .670 .652 .584 .830 Ranking of job components. The m ean score of each s e t of statem en ts w as used to give a satisfaction score for each work com ponent, displayed in Table 23. The highest satisfaction rating w as 5 and the lowest satisfaction rate w as 1. Overall, the m ost satisfying work com ponent for th e se public health n u rses w as professional status, rated 4.10. This w as followed by the work com ponents, Interaction (3.66) and autonom y (3.65). T h e se public health n u rses w ere least satisfied with the work com ponent, salary, rated 2.17 this w as also w as true for the younger cohort. T h ese results reflected the top three satisfiers, how ever in a different order a s identified by Dunkin et al. (1992) which w ere professional status, autonom y, and interactions. The least satisfying com ponent identified by Dunkin’s et al. w as salary. S om e research found a s the n u rse s ’ a g e increased so did their job satisfaction (Hegney, et al. 1997; Irvine & Evans, 1995). T he results of this research did not support a correlation betw een a g e and job satisfaction (r= .041 p > .05). Age w a s not correlated to any of the se p a ra te job com ponents. However so m e correlations w ere noted betw een the specific job com ponents. 96 The public health n u rse s’ satisfaction with autonom y had m edium to large effect sizes (Cohen, 1992) w hen correlated to t)enefits and rew ards (r = .337 p = .01), interaction (r= .537 p = .01), organization climate (r= .663 p = .01), professional statu s (r= .455, p = .01), and task requirem ents { r - .401 p = .01). A medium effect size (Cohen) w as observed for a relation betw een organizational climate and interaction (r= .400 p = .01), professional statu s (r= .423 p = .01) and task requirem ents (r = .448 p = .01 ). Table 23 Satisfaction Scores of Public Health Nurses per Work Component Com ponent Professional S tatus Interactions Autonomy Benefits and Rew ards Organizational Climate Task R equirem ents Salary Question Overall Job Satisfaction Overall Job Satisfaction scale 4.10 All SO .76 122 Rural M SO .71 4.19 3.66 3.65 3.21 .61 .54 .56 120 120 117 3.68 3.74 3.26 3.09 .66 119 2.84 .66 2.17 3.80 3.33 M 67 Non-rural M SO 3.99 .82 55 .50 .43 .58 65 67 66 3.64 3.54 3.15 .71 .64 .54 55 53 51 3.17 .56 64 2.99 .75 55 122 2.81 .63 67 2.87 .70 55 .74 .95 120 122 2.21 3.93 .74 .88 66 67 2.12 3.64 .74 1.02 54 55 .47 109 3.39 .40 60 3.25 .53 49 n n n The younger cohort {M = 3.32) and the total group {M = 3.33) had a similar sco re for the overall job satisfaction scale. The sco re for th e individual question on “overall job satisfaction” w as higher than the score from the scale. The public health n u rses indicated m ore satisfaction with so m e work co m p o n en ts (S ee Table 23). However w hen a sk ed how satisfied they w ere with their job the public 97 health n u rses reported the general question more favorably. T he reason for this is not known. In Table 24 the sa m e technique w as used to give an im portance score for each work com ponent. Therefore the im portance of each work com ponent w as rated 1 (least important) to 5 (m ost important). In general, w hen the public health nurses rated the im portance of their work com ponents, they valued professional statu s the highest at 4.38. The next m ost im portant w as interaction (4.34) followed by salary (4.33). The least important work com ponent w as benefits and rew ards. This differed from the results found by Dunkin e t al. (1992). The American n u rses rated professional sta tu s and interaction equally in first place, then salary and autonom y. The American n u rses also had two com ponents tied for least im portance they w ere task requirem ents and benefits and rew ards. Table 24 /mporfance Scores of Pub//c Hea/f/) Nurses per l/Vb/fr Component Com ponent Professional statu s Interactions Salary Autonomy Organizational climate Task R equirem ents Benefits and R ew ards Question Overall Jo b Satisfaction Overall Jo b Satisfaction S cale 4.38 All SO .59 n 115 Rural SO 4.37 .58 n 66 Non-rural SO 4.38 .61 49 4.34 4.33 4.21 4.13 .56 .64 .50 .61 115 115 113 110 4.39 4.34 4.24 4.14 .41 .62 .39 .47 62 65 64 60 4.29 4.32 4.18 4.11 .70 .68 .61 .75 53 50 49 50 4.09 .56 115 4.11 .47 62 4.07 .65 53 3.87 .68 107 3.93 .62 61 3.79 .75 46 4.42 .78 118 4.44 .68 66 4.38 .89 52 4.24 .49 90 4.28 .43 51 4.19 .58 39 n 98 Differences between rural and non-rural public health nurses. The rural public health nurses rated the top three work com ponents a s professional status (4.19), autonom y (3.74), and Interactions (3.68). The non-rural public health nurses had the sa m e top three in a different order, professional statu s (3.99), interactions (3.64) and autonom y (3.54). Rural public health n u rse s rated their overall job satisfaction sco re 3.39 while the non-rural public health n u rses rated their overall job satisfaction 3.25. Although, previous research dem onstrated that public health nurses w ere m ore satisfied with their jobs than other n u rses (Dunkin, Stratton et al. 1994; Juhl et al. 1993), the difference in job satisfaction betw een rural and non-rural public health n u rses had not b een explored. With an alpha level of .05, the sum m ated sco res for each work com ponent su b scale and the overall job satisfaction scale w ere used to com pare differences betw een rural and non-rural public health nurses. There w as no statistical significance betw een th ese two groups with their satisfaction per work com ponents or overall job satisfaction. Summary Overall, the public health n u rses w ere m ost satisfied with their professional status, professional interaction, and autonom y. In contrast, for im portance, public health n u rses rated the job com ponents: professional status, professional interaction and salary a s m ost im portant to them . T here w as no significant difference in satisfaction levels of job com ponents betw een rural and non-rural public health nurses. Two-thirds (61 %) of th e se public health n u rses would still choose public health nursing a s a profession. This is a similar 99 response a s an American sam ple of n urses and physicians who said they would choose th e sam e profession again (Stam ps & Cruz, 1994). Commun/fy S af/s^cf/on Community satisfaction w as evaluated similarly to the m ethod used to exam ine job satisfaction. First, frequency end o rsem en t w as d one to exam ine each community item. This w as done to look a t w hat public health nurses perceived a s satisfying and important. The m ean sco res for each community item w ere also done. S econd, the alpha coefficients w ere d o n e to exam ine the internal consistency of several com binations of scales. This w as used along with the descriptive analysis to determ ine which scale would be used for community satisfaction. Third, eac h community asp ect w as com pared for group differences betw een rural and non-rural public health nurses. S elect correlations w ere done to determ ine relations. T here w as a medium correlation (C ohen, 1992) when examining the relation betw een a g e and community satisfaction (r= .318 p = .01). The correlation for num ber of years in the community and community satisfaction (r= .269 p = .01) w as small (Cohen). The frequencies of resp o n ses helped to determ ine w hat community a sp e cts to u se for th e community satisfaction scale (S ee Table 25). Approximately two thirds of the respondents w ere satisfied with the community ac cep tan ce of their sp o u se/p artn er (79%), the friendliness of their community (71%), safety (68%), their friends (65%), and size of their community (66%). 100 Table 25 Percentage of Public Health Nurses Indicating Level o f Satisfaction with CommunAy /ferns Statem ent a Level of Anonymity b Friendly c Trusting d Social/recreational opportunities e Friends f Place of worship g Quality of schools (K-12) h Safety i Overall environm ent for children j Community ac cep tan ce of spouse/partner k Consulted on work issu es outside of work 1 Size of community m Distance away from major centre n Ability to stay current in your practice 0 Local governm ent p Overall community satisfaction Satisfied Neutral Dissatisfied P P P 48 71 59 55 65 54 48 68 61 79 27 25 33 29 24 41 34 22 30 17 26 4 8 16 11 5 19 10 10 4 42 41 17 66 25 48 19 24 17 15 51 35 26 63 45 31 29 5 Even though, the respondents com m ented on the difficulty of scoring for im portance and so m e resp o n d ents omitted this part of the questionnaire, the im portance frequencies displayed in Table 26 w ere useful in deciding w hat items should be tested in the scale. The highest frequencies for im portance were: safety (96%), their ability to stay current in their practice (96%), the overall environm ent for children (94%), their friends (93%), a friendly com munity (91%), social/recreational opportunities (91%), a trusting community (89%), the quality of the schools (86%), and community accep tan ce of sp o u se/p artn er (83%). 101 Table 26 P ercen tag e o fP u M c Hea/t/? N urses /nd/catmg Leye/ o f /m porfance vWt/i Commun/ty /fem s Statem ent Important Unimportant 50 91 89 91 93 49 86 96 94 83 Neutral P 36 8 11 8 8 22 8 4 4 12 49 42 9 72 72 96 63 88 24 26 4 36 12 4 3 0 2 0 P a Levei of Anonymity b Friendly c Trusting d Social/recreational opportunities e friends f P lace of worship g Quality of schools (K-12) h safety i Overall environm ent for children ] Community acce p tan c e of spouse/partner k Consulted on work issu e s outside of work 1 Size of community m D istance aw ay form major centre n Ability to stay current in your practice 0 Local governm ent p Overall community satisfaction P 14 1 0 1 0 29 6 0 3 6 The m ean of e ach sco re displayed in Table 28 w as used to determ ine a satisfaction sco re for each a sp e c t of the community. T he resp o n d en ts w ere ask ed to rate 15 item s specific to their community satisfaction. T he rating w as 1 (least satisfying) to 5 (m ost satisfying). Overall, the top four item s of community satisfaction w ere “community accep tan ce of the partner" (4.10), “friendly community" (3.88), and "friends" (3.83), and "piace of worship" (3.72). The three least satisfying community factors w ere their “ability to stay current in their practice" (3.15), “local governm ent" (2.92), and “distance com m unity is away from major centre" (2.62). For th e younger cohort the top four community a sp e c ts w ere "community's acce p tan ce of their partner" (4.00), "place to worship" 102 (3.74), "friendly community" (3.62), with "friends" and "safety" at 3.55. The three asp ects of the community the younger cohort w ere least satisfied with w ere "ability to stay current in their practice" (2.72), "local governm ent" (2.66), and "distance community is aw ay from major centre" (1.90). In general public health nu rses rated community satisfaction Af = 3.50 while the younger cohort rated community satisfaction M = 3.16. The im portance of ea ch community item w as rated 1 (least important) to 5 (most important) and the m ean score calculated. W hen th e se public health n u rses rated w hat they perceived a s m ost important to them in their comm unities they indicated “safety” (4.66), the “ability to stay current” (4.60) and their “friends” (4.50). Many of th e items identified by the public health n u rses a s satisfying and important w ere th e sam e a s identified for rural physicians by Kazanjian, et al. (1991,1998). T he younger cohort considered so m e different community a sp e c ts a s Important. T h e se w ere "ability to stay current" (4.83), "safety" (4.67), and “overall environm ent for children” (4.59) and “social and recreational opportunities” (4.59). The least important to the younger cohort w ere “being ask ed work related questions outside of work” (3.86), “local governm ent” (3.83) and “place to w orship” (3.14). S ca/e deve/opm enf Aor commun/fy saf/s/acf/on. Several a sp e c ts of the community w ere com bined to test different sca le s (S ee Table 27). The 15-item su b sc ale for community satisfaction gave a satisfactory C hronbach’s alpha (.859) for th e scale. However, using th e respondents' preferen ces for community a sp e c ts by exam ining their perceived satisfaction and im p o r ta n t, other 103 combinations of item s w ere tested to determ ine if a scale with few er item s w as also adequate. O ne combination for a su b scale exam ined Items from Filkins' e t al. (2000) research which w ere “friendly”, “friends”, “trusting”, “social/recreational opportunities", "place of worship", "quality of schools", "safety", "local governm ent”, and from Allen & Filkins (2000) “size of community”. Of th e se nine community a sp ec ts the p resen t sam ple of public health n u rses indicated that 49% felt “place to worship" w as important and only 63% thought “local governm ent” w as important so th e se item s w ere rem oved. A community satisfaction su b scale of 7 item s (see Table 27) gave a C ronbach’s alpha = .793 and when “overall community satisfaction” w as added the C ronbach’s alpha for th e 8-item scale w as .840. The research er decided to consider th e 7-item scale th e basic community satisfaction scale. Table 27 C o e^ c /en fs p e r Commun/fy Saf/sfacf/on S ca/es Com ponent alpha # of items Community .837 15" Overall Community 16" .859 Community T .793 Overall Community 8 .840 lid Community .811 Overall community 12 .844 /Vote. The letters refer to th e community Items listed in T able 25 an d 26 that have b een used in the scale, ^items a,b,c,d,e,f,g,h,l,j,k,l,m ,n,o. T he overall community satisfaction item is added to com posite scales, ‘’overall community h as the previous items plus “p”. '’item s b,c,d,e,g,h,l. ''item s a,b,c,d,e,g,h,k,l,m ,n. 104 Four other item s w ere added specific to public health nursing in rural communities b e c a u se of th e research er's personal experience. T h e se w ere satisfaction with "level of anonymity", "consulted outside of work hours", "ability to stay current" and "distance to major centre". This last item can affect the public health n u rses’ “ability to stay current". This 11 -item su b scale had a C ronbach’s alpha of .811. The overall community satisfaction scale (12-item) gav e a C ronbach’s alpha of .844. All of th e se com binations gave a strong operational definition of community satisfaction. C onsistent with the m ethod u sed for an overall job satisfaction score, the overall community satisfaction (12-item) u ses the 11-item su b scale plus the single question of “overall com munity satisfaction”. Again the assum ption w as m ade that the score of multiple a s p e c ts of the community would give a m ore stable m easure of community satisfaction. The sco re for th e individual question on overall community satisfaction h a s been presented in Table 28 for interest. 105 Table 28 Saf/s/acf/on M easu/iem enfs CommunAy /ferns /or PuW c Hea/f/i /Vurses All Item Community’s accep tan ce of spouse/partner > Friendly" > Friends P lace of worship > Trusting > Size of community > Social/recreation opportunities > Safety Overall environm ent for children > Quality of schools (K-12) > Being asked work related questions outside of work > Level of Anonymity > Your ability to stay current In your practice Local governm ent > Distance your community is away from a major centre > Question Overall community satisfaction > Overaii community satisfaction scale (12) score Non-rural Rural n M n 4.11 SO .86 3.88 3.82 3.72 3.68 3.64 .78 1.02 1.02 .89 1.05 121 121 121 112 3.95 3.85 3.73 3.80 3.52 3.62 1.16 121 3.45 1.21 65 3.82 1.06 56 3.61 3.60 .82 .83 115 3.73 3.66 59 59 3.48 3.54 .89 .89 56 115 .74 .76 56 3.35 1.05 117 3.27 1.13 64 3.45 .95 53 3.25 .98 112 3.00 1.01 58 3.52 .89 54 3.22 1.15 120 3.17 1.28 66 3.28 .98 54 3.14 1.14 114 3.07 1.18 60 3.22 1.09 54 2.91 2.61 .94 1.21 113 2.93 113 2.58 .93 1.21 59 59 2.89 2.65 .97 1.23 54 3.73 .78 112 3.81 .71 59 3.64 .86 53 3.50 .60 103 3.46 .56 56 3.56 .64 47 104 4.24 114 Note. ®boid print indicates 12-item scale and sco re SO .86 3.96 SO .84 55 49 .74 .99 1.03 .81 1.06 65 65 62 65 58 3.79 3.79 3.71 3.54 3.78 .83 1.07 1.02 .95 1.02 56 56 52 56 54 n 54 106 Differences between rural and non-rural public health nurses. O ne characteristic that h as b een identified a s unique to rural nursing is lack of anonymity (Bigbee, 1993; Hegney, 1996b, Leipert, 1999). Therefore, before examining asp ec ts of the community, public health n urses w ere ask ed to indicate their level of anonymity from low (1 ) to high (5). Sixty-seven percen t of the public health nurses indicated their level of anonymity a s low, 18% w ere neutral and 15% felt they had high anonymity. It w as expected that rural n u rses would have lower anonymity in their community (S ee Table 29). The majority (74%) of the rural group indicated low anonymity while the non-rural group 57% reported low anonymity. The independent f-test supported this view (f = -2.47, off = 118, p < .02). The C ohen’s of effect size h a s been calculated to be 0.44. It is a small effect, lending support th at this result h as som e practical significance. Table 29 P uM c HeaAh A/urses' Perce/vecf Leve/ o f )4nonym/fy Low n Rural Non-rural 49 31 P 74 57 Neutral n P 14 9 24 13 High n 8 10 P 12 19 All 15 items for community satisfaction w ere included for com parison betw een non-rural and rural using independent f-tests. All testing for the community a sp e cts w ere tested with an alpha level of .01 and all effects sizes calculated, there w as o n e exception which is stated here. Rural and non-rural public health nurses differed in their satisfaction with being ask ed work related questions outside of work (S ee Table 30). For all public health n u rses, 17% w ere dissatisfied with this item. W hen the rural and non-rural groups w ere exam ined 107 separately, 27% of the rural public health n u rses w ere dissatisfied with this item com pared to 5% of the non-rural public health n u rses who w ere dissatisfied with the sam e item. Table 30 Satisfaction with being Consulted Outside of Work Unsatisfied Rural Non-rural Neutral n P n P 16 3 27 5 24 22 41 42 Satisfied n P 19 32 28 53 Consequently, the item that significantly differed on satisfaction betw een rural and non-rural public health n u rses w as “being ask ed work related questions outside of work” (f = -3.14, d f= 110, p < .002) with a calculated C ohen’s d effect size of .57. H egney (1996b), Hegney et al. (1997) and Leipert (1999) reported rural n u rses w ere consulted outside of work. T he p resen t research identified that rural public health n u rses w ere less satisfied with this a s p e c t of rural living. The sam ple did not support a difference betw een rural and non-rural on their satisfaction with level of anonymity (S ee Table 31 ). For the respondents in this study, being easily recognized in the community is not the issue, but being asked work-related questions, which is a by-product of lack of anonymity, is an issue. O ne respondent sum m ed it up with: “lots of people know me, I like it, or rather [I] am not bothered by it”. T he results su g g e st the term anonymity may not be a d eq u a te to explore how anonymity is perceived by public health n urses living in rural places. T here m ay b e a sp e c ts of lack of anonym ity th at a re satisfying or not satisfying to public health nurses. There w as no significant difference with overall community satisfaction betw een groups. 108 Table 31 Satisfaction with Perceived Level of Anonymity Unsatisfied Rural Non-rural n 21 10 P 31 2 Neutral P 22 17 32 n 15 Satisfied n P 31 46 26 49 Two percent of non-rural w ere unsatisfied with their level of anonymity a s opposed to 31% of th e rural public health n u rses who w ere unsatisfied with their level of anonymity. This had a negligible (Cohen, 1992) effect (.12) and it w as not significant with a less conservative alpha. However the difference here supports that this should be explored in detail. Further discussion is found in C hapter 5. W hen ranking rural and non-rural, the rural group rated "community's accep tan ce of sp o u se/p artn er” (4.24), “friendly” community (3.95) and their “friends” (3.85) a s the top three satisfiers. T he non-rural group rated “community a cc ep tan ce of partner” (3.96), th e “social and recreation opportunities” (3.82) followed by “friendly” community (3.79) and “friends” (3.79) a s their top three satisfiers. Although “social and recreation opportunities” is rated seco n d for the non-rural group this item is rated eighth for the rural public health nurses. Descriptively, th e younger cohort indicated lower satisfaction with “social and recreational opportunities” with a m ean sco re of 3.37 placing it sixth in satisfaction scores. Rural and non-rural ap p eared initially to differ on social and recreational opportunities (S ee Table 32). The rural public health n u rses reported 23% 109 unsatisfied and 48% satisfied with their social and recreational opportunities while the non-rural group reported 7% unsatisfied and 64% satisfied. The research er decided to draw attention to the results b ecau se (f = -2.01, off = 119, p < .047) and C ohen’s d effect of .36 (small). This community a s p e c t will need m ore exploration to verify w hether this a sp e c t of the community should be considered of practical significance. Table 32 Satisfaction with Sociai and Recreational Opportunities Unsatisfied Rural Non-rural n P 15 4 23 7 Neutral n P 19 29 16 29 Satisfied n P 32 48 35 64 The “community a cc ep tan ce of partner” and “partner’s satisfaction with the community” w as scrutinized (S e e Table 33) b ec a u se physicians reported dissatisfaction with s p o u se s limited or lack of career possibilities (Hamilton, et al. 1997; Kazanjian, e t al. 1991). It w as surm ised that spousal dissatisfaction for w hatever reason would be reflected in th e se two questions. Both rural and nonrural public health n u rses reported equal dissatisfaction (4%) with the “community’s ac cep tan ce of partner”. Likewise both groups had high levels of satisfaction with this a sp e c t of the community. T here w as no significant difference betw een th e se two groups at an alpha level of .01. 110 Table 33 Saf/s/acf/on Lei/e/ wif/7 C o m m u n ie s ,4ccepfance of P a/fn er Unsatisfied Rural Non-rural n 2 2 P 4 4 Neutral n P 6 11 12 24 Satisfied n P 48 86 35 71 The sep a rate question s p o u se s’ or partners’ satisfaction with the community indicated that the non-rural public health n u rses rated their s p o u s e s ’ community satisfaction M = 3.80 while the rural group rated their s p o u s e s ’ community satisfaction M = 3.77. This difference w as not significant at a .05 alpha level. Summary Descriptively the th ree community items that m ost satisfied all the public health nurses w ere the “community’s accep tan ce of their partner”, a “friendly” community, and their “friends”. Social and recreational opportunities w ere also rated in the top th ree satisfiers for non-rural public health n u rses but not for rural n u rses or the younger cohort. The younger cohort w as least satisfied with the distance their community w as away from a major centre. T he community a sp e c ts all public health n u rses perceived a s m ost important in their community w ere “safety”, their “ability to stay current in their practice” and their “friends”. T here w ere two a re a s of significant difference betw een rural and non-rural public health n u rses in the community: anonymity, and consultation outside of work. Rural public health n u rses had lower levels of anonymity how ever they Ill w ere not dissatisfied with the low level of anonymity. Rural public health nurses w ere less satisfied with being consulted outside of work hours. 77)6 /n^uence of Job and Commun/fy Saf/sfacf/on on Refenf/on Job and community satisfaction did not support retention for this sam ple of public health nurses. This differed from Dunkin's e t al. (1992) research finding of job satisfaction supporting retention. Likewise, the retention model (Dunkin, Stratton et al. 1995) supported the influence of community satisfaction on retention. Community satisfaction w as rated higher than Job satisfaction when com pared within their respective groups. The public health n u rses rated their overall job satisfaction a s 3.33 for the collective group, 3.39 for the rural group and 3.25 for the non-rural group. The community satisfaction w as 3.52 for the collective group, 3.48 for the rural group, and 3.57 for the non-rural group. This group of public health n u rses seem ed to be m ore satisfied with their com m unities than their jobs. However, when the younger cohort w as exam ined on its own descriptively, the younger public health n u rses rated overall job satisfaction (3.32) higher than community satisfaction (3.16). A P earso n product-m om ent correlation w as used to exam ine job satisfaction, community satisfaction and retention for a relationship. Job and community satisfaction had a medium effect size (Cohen, 1992) for correlation (r = .477 p < .01). There w as not a correlation betw een job and community satisfaction with retention in this sam ple of public health n urses. Likewise, this sam ple did not support that job satisfaction influenced retention or that community satisfaction influenced retention. 112 Reasons for staying or leaving present employment. It is recognized that nurses leave their jobs m ore often b e c a u se of personal re a so n s rather than professional reasons, such a s relocating with a sp o u se (Dunkin, e t al. 1992; Dunkin, Stratton, et al. 1994). Q uestions 63. 64 and 65 w ere open-ended questions allowing the public health n urses to elaborate on their answ ers. Most of the com m ents have a d d ressed the variables from this survey for exam ple, the job satisfaction com ponents, overall job satisfaction, and community satisfaction. Som e issu es b ecam e apparent that had not been a d d re sse d in the survey. T h ese issu es w ere; 1 ) financial considerations that w ere not asso ciated with the variable, salary, and 2) loss of portability of seniority and benefits when moving to another public health nursing position outside of th e n u rses' own region (lost with the am algam ation of acu te and community n u rs e s ’ provincial contracts). Som e issu e s w ere given a s a reason for staying and also a s a reason for leaving em ploym ent. Retirem ent w as m entioned by 16% of the resp o n d en ts a s a reason for staying or leaving, for exam ple they w ere staying b e c a u s e it w as “too close to retirem ent” to leave, or they would leave due to early retirem ent. This w as not surprising w hen 17% of the respondents indicated they w ere 55 years and older. S p o u se s or partners w ere m entioned by 33% of the resp o n d en ts a s affecting retention either positively or negatively. Public health n u rse s reported they would stay in their job b e c a u se their sp o u se w as em ployed in the community or leave their job if their sp o u se relocated d u e to em ploym ent. 113 Question 63 asked “W hat are the main factors that are influencing you in remaining in your current position in this com m unity?” Ninety four percent of the respondents com m ented on their reaso n for staying in their job. Com m ents that reflected so m e a sp e c ts of the work com ponent, benefits and rew ards, w ere given for reaso n s for staying in their p resen t position; • Do not w ant to go back to shift work • Too close to retirem ent to move • Last 5 years before retirem ent are m ost important to get anything for pension • Unable to transfer within province a s previously with provincial governm ent contract • P resen t benefits Common re sp o n se s for staying in their p resen t em ploym ent related to their opportunities were: • real e sta te not selling, not prepared to m ove and have ho u se sell for loss • sp o u se ’s job is stable em ploym ent • no other job available closer or in my hom e community Yet, other re sp o n se s w ere related to personal circum stances: • financial debt • family com m itm ents, children finishing school • love the community, great for raising children S om e com m ented on their job satisfaction: • a very diverse and challenging position, I work alone and have num erous freedom s in defining my scope of practice ...a m part of a very effective health care team 114 • after 14 years of acute care nursing, I have discovered that public health nursing is the perfect nursing role for me - I am interested in families, communities and working with people to identify and build on their strengths. Question 64 ask ed 1/Vhat factors might c a u se you to /eav e your current position within the next 5 y e a rs? ”. Ninety six percent of the resp o n d en ts w ere quite clear about w hat would m ake them leave their job. S om e respondents indicated both personal and professional reaso n s while others only m entioned personal reasons. Seventy two percent cited personal re a so n s while 66% cited professional reasons. S om e of the professional issu es w ere related to Job satisfaction such a s “interpersonal conflict and loss of job autonom y”, “deteriorating nursing working conditions and w ag es”, and “lack of advancem ent and lack of support /re sp ec t from cow orkers”. S om e personal re a so n s for leaving a position w ere “children’s educational n e e d s”, “partner is RCMP [member] moving is part of their job”, and “the need for a larger community”. Professionalism , to se e k learning opportunities, w as indicated by public health n u rses to influence their decision to leave their jobs within th e next 5 years. Som e com m ents to support this were: • N eed growth in my nursing career • To further my education Com m ents related to salary for reaso n s to leave their position were: • Low w ages • If w e don’t get a raise I may seriously consider retirem ent a t 55. 115 Typical re sp o n se s from public health nurses for leaving their job reflected personal circum stances and opportunities. S om e cited they wouid ieave their job a s a result of a serendipitous event. C om m ents were: ' Reiocate closer to family, post secondary education ' N eed a change, new opportunities for a job • Partner unable to find work • Win the lottery or gain an inheritance. O ther re sp o n ses indicating job dissatisfaction were: • Co-worker negativism, unsupporting attitudes, and lack of direction in term s of overall public health nursing program in goals, objectives and how to accom plish them • Isolation an d p ressu re of working solo much of the time • Organization structure change under New Directions led to lack of support for public health nursing program • Fed up with nursing getting closer to quitting every day • Q uestion m an ag em en t’s com petencies - enough so that i could easily leave tomorrow! Only 49% responded to question 65, “Any com m ents you wish to m ake concerning your job, community, rural nursing in general or this study”. S om e of th ese resp o n ses have been used throughout the results to support the n u rse s’ perceptions of job or community com ponents. O ther com m ents reflected the n u rses’ perceptions of w hat it m ean s to work in a rural community, issu es around staying current, and issu es around job com ponents. For exam ple: • I have worked in a larger centre for awhile and if you are looking to be specialized in a specific area this is great. Rural nursing is for those who like to keep current in everything but requires much m ore educational 116 support to do this a s working rural d o es m ean you are further rem oved from the ability to readily a c c e s s education opportunities ' we are a health unit with th e main office elsew here. I probably would have answ ered questions quite differently on the rating sca le s if I w as working in th e iarger office • we have a very responsive community to health related issu e s which m akes the work m ore enjoyable • networking and connection with w hat others do is so valuable. A num ber of n u rses appreciated the opportunity to reflect on their public health nursing practice. Many com m ents described the difference betw een acu te care nursing and public health nursing. Most of th e se com m ents w ere supportive to public health nursing for exam ple “[a] completely different nursing culture than hospital [public health nursing is] supportive, respectful, feeling of being valued, no oppression". S om e of the resp o n d en ts took the time to com m ent on the form at of the questionnaire, especially the length of time to fill out questionnaire and the sp a c e provided to them for responding. O thers ex p ressed that “our office is not exactly rural” how ever the office m et the Statistics C anada definition of rural. Summary This sam ple of public health n u rses reported m ore satisfaction with their community than with their Jobs. Although job and community satisfaction are significantly correlated with each other, they w ere not correlated to retention. In this research neither job satisfaction or community satisfaction supported retention. The written com m ents revealed that the s a m e re a so n s that would keep public health n u rses in their jobs for another five y ears w ere also given by 117 Others for reasons to leave their jobs within the next five years. S p o u se s ’ Jobs, relocation or retirement, family commitments, such a s children’s education, aging and sick parents, and benefits are som e of the factors that can positively or negatively affect retention. 118 CHAPTER FIVE: DISCUSSION This research provides a C anadian perspective of job and community satisfaction in the retention of public health nurses, with a direct exam ination of public health n u rses who work and live in eight predominantly rural health regions of British Columbia. Som e comm unities within th e se regions have populations over 10,000, and thus are considered non-rural (Statistics C anada, 2000). Hence, the research er com pared rural and non-rural public health nurses within th e se eight a re a s with respect to perceived job and community satisfaction. This study explored two a sp ects of retention, in particular, job satisfaction and community satisfaction. The results show ed even though public health n u rses have job and community satisfaction th e se factors are not reflected in their intent to stay in their present position (retention). O ther issu e s have surfaced that affect retention of public health n u rses in various ways. The results show job satisfaction plays a role in retention. Jo b satisfaction tak es place in the community where the public health n u rses work and live. H ence, community satisfaction “surrounds” job satisfaction (S ee Figure 2). Public health n u rse s have identified other rea so n s for “staying” or “leaving” their current position. T h e se other reaso n s a p p eared to act a s a filter to retention, regardless of their personal perceptions of job and community satisfaction. I have used the analogy of filter factors to m ean promoting or limiting retention. Three groups of factors have been identified which filter the effect of job and community satisfaction on retention. T h ese filter factors are grouped into 119 COMMUNITY PERSONAL PERCEPTION JOB SATISFACTION SATISFACTION FILTER DEMOGRAPHICS -age -place of nursing education -spouses’ occupation FACTORS PERSONAL CIRCUMSTANCES -financial need -family needs and commitments -professional growth -retirement -no shift work STAY OPPORTUNITIES -economy real estate spouses’ employment -job availability -loss of portability of benefits -serendipitous event LEAVE RETENTION or RECRUITMENT OUTCOME Figure 2. The effect of filter factors on job and community satisfaction in retention. 120 dem ographics, personal circum stances and opportunities. C onsistent with this conceptualization, the research findings are discussed to a d d re ss retention. Public health n u rse s’ job satisfaction is discussed followed by their community satisfaction b e cau se it is th e setting for their jobs and personal lives. The filter factors in the three groups a re exam ined in the context of how they influence retention regardless of the public health n u rses' perception of job and community satisfaction. Job Satisfaction There is no statistical difference in job satisfaction betw een rural and nonrural public health n u rses. Public health n u rses are m oderately satisfied with their job although they a p p e a r m ore satisfied with so m e job com ponents than others. This w as su g g ested by their m ean sco res for the job com ponents and the self reported com m ents. The consistent identification of three job com ponents that public health n u rses find m ost satisfying, professional status, interaction and autonom y are similar to the results found by Dunkin, e t al. (1992). The com ponents of professional interaction (Hegney, e t al. 1997; Leipert, 1996; Tomich, 1993; W oodcox, et al. 1994) and autonom y (Hegney, e t al; Stew art & Arklie, 1994; Woodcox, et al.) have been commonly identified in the research as satisfying to public health nurses. The public health n u rses value three job com ponents over th e rest. T h e se are professional interaction, professional statu s and salary. Professional statu s and interaction are im portant and public health n u rses indicate satisfaction with th e se com ponents, therefore th ese com ponents m eet their n e e d s (Vroom, 1964). 121 Salary is Identified a s the least satisfying job com ponent, but at the sam e time salary is highly valued a s a job com ponent. According to Vroom (1964) this difference leads to dissatisfaction. Salary h as b een a well-identified detractor (Dunkin, et al. 1992; Hegney, et al. 1997; Juhl, et al. 1993; Lucas, et al. 1988; Rem us, et al. 2000; W oodcox, et al. 1994). T he resp o n d en ts identify dissatisfaction with salary a s a reason to leave their jobs. Salary h as m any implications. If salary is competitive it can be u sed to recruit or retain public health nurses (RNABC, 2001a). The public health n u rses rated the organizational climate {M = 3.09) within which they work. The com m ents revealed concerns with this job com ponent. The nurses claim they are undervalued for their role in health care supporting their claims by citing that their positions are not filled w hen on vacation or off sick. They perceived lack of support due to reorganization of health care by decentralizing services, and by non-public health n u rses a s im m ediate m anagers. C om m ents such a s “who are the m an ag ers”, “question com petency of m anagem ent”, “m anagem ent and public health n u rses over w orked” and “not enough time to do work” indicate dissatisfaction and concern with this a sp e c t of their job. The dissatisfaction with “not enough tim e” h as been previously docum ented by other research ers (Leipert, 1999; R eutter & Ford, 1996; Stew art & Arklie, 1994). O ne respondent identified that th e strength of th e old provincial system w as the support it gav e public health. H egney e t al. (1997) found restructuring of health services stressful for nurses. This continued feeling of lack of value and support can underm ine the workforce, causing public health 122 nurses to leave their positions. This can be supported by statem en ts from the respondents revealing they w ere considering eariy retirem ent b e c a u s e of dissatisfaction with organizational change or leaving their position b e c a u se they w ere “fed-up” with poor m anagem ent at the organizational level. The public health n u rses agreed autonom y is satisfying but it is not rated in the top three job com ponents for im portance, perhaps b e c a u s e autonom y is taken for granted a s an a sp e c t of public health nursing practice. T he idea that autonom y is part of rural practice is held by m ost rural re se a rc h e rs (Bigbee, 1993; Davis & Droes, 1993; Hegney, 1996b). Yet, public health n u rse s inherently have autonom y in their practice w hether they are rural or not (Leipert, 1996; Rem us, et al. 2000; R eutter & Ford, 1996; Woodcox, et al, 1994). T here may be a sp ects of autonom y that a re m issed by present research m ethods. Further support for this com es from physician studies; physicians have autonom y of practice yet Kazanjian e t al. (1991) did not find a significant difference in autonom y betw een rural and urban physicians. Therefore the conceptualization of autonom y may not be sufficient for rural professionals. Logically th ere are few or no p eers to consult with, public health n u rses are responsible for implementing all public health nursing program s similar to rural hospital n u rses saying “W e’re it” (MacLeod, 1999). C onsequently, a m ore inclusive scale m ay need to be developed in order to distinguish w hat rural public health n u rses m ean by autonom y a s opposed to w hat non-rural public health n u rses m ean by this term. Not all individuals s e e autonom y a s positive. H egney et al. (1997) reported that 7% of the n u rses in her study described autonom y a s negative b e c a u s e of 123 perceived lack of support. There m ay be a sp e c ts of autonom y th at rural public heaith nurses will identify differently if m ore a sp e c ts of autonom y a re expiored. Professional isolation h as been cited throughout the literature a s a com ponent of rural nursing practice (MacLeod, e t al. 1998). However both rural and non-rural n u rses rate professional interactions and professional statu s In the top three com ponents for satisfaction and im portance. Therefore w hat the n u rses are satisfied with, and w hat is important to them are closely aligned. The literature d iscu sses the broad range of knowledge and skills that a re needed for rural nursing (Bigbee, 1993) and rural public health n u rses (Bushy, 1996, 2000; Leipert, 1999). This broad range of knowledge tends to be term ed “generalist” but w hether specialization prom otes professional statu s is arguable. Leipert (1999) found that public health n u rses in one and two nu rse offices had less ch an ces of specializing. The com m ents from the resp o n d en ts in this study verified that specialization w as difficult for rural public health n u rses but other com m ents supported that rural public health nursing w as specializing in its own right. Retention can be positively affected by the benefits and rew ards the n u rses perceive a s important to them (Stratton, e t al. 1995). T he three m ost important benefits to this sam ple of public health n u rses are vacation, retirem ent and inservice education. Vacation time is the m ost valued benefit. The im portance of retirem ent benefits to this sam ple of public health n u rses reflects their a g e group, with 73% of the public health n u rse s over 40 y ears of age. The last 5 y ears of work a re important for maximizing retirem ent benefits and 33% of 124 this sam ple is over 50 y ears of ag e. Therefore the im portance of retirem ent benefits is not surprising. The benefit "inservice" a d d re ss e s two issu e s in rural nursing “staying current” and having professional interaction. The ability to stay current will be discu ssed in relationship to the community but will be discussed here in relationship to work. Both n u rses and the em ployers have a responsibility in the n u rse s’ ability to stay current (Griffiths, 1999). Inservices for public health n u rses are one way em ployers provide educational updates. Inservices are usually held in a central location, for exam ple at the main public health office, which allows the public health n u rses who are geographically isolated to travel in for the inservices. This provides p eer interaction and a c c e s s to am enities in a larger centre, which d e c re a se s the s e n s e of professional and geographical isolation. Professional isolation can be d e crease d by telephone conferences with p eers. The rural public health n u rses perceived this a s m ore im portant than their non-rural counterparts. This should not replace inservices, how ever it is a less expensive way to network and could be used to supplem ent inservices. Community Satisfaction The community is considered the setting for the job and inevitably h a s an im pact on th e public health n u rses’ personal lives and their public health nursing practice. This research piloted a scale to determ ine community satisfaction for public health nurses. The community satisfaction scale d o es not reveal what a sp e c ts of the community would c a u se public health n u rses to leave a community. It d o es add to our understanding of w hat public health n urses find 125 satisfying or dissatisfying in their community and en ab les th e re se a rc h e r to score community satisfaction. Although this research used a previously tested questionnaire the item s for community satisfaction in the original questionnaire w ere limited a s listed in the M ethods chapter. There w ere 16 item s (S e e Table 25) in the p resen t questionnaire to exam ine community satisfaction. Even though the content validity of the scale w as b ased on the literature review and the research er’s personal experience, the resp o n ses from this sam ple of public health n u rses helped to refine the content validity and shorten th e scale. The research er determ ined the minimum num ber of item s for the community satisfaction scale w as seven. T h ese item s reflected general a sp e c ts of the community. T h e se w ere “friendly”, “trusting”, “social and recreational opportunities”, “friends”, “quality of schools (K-12)”, “safety” and “size of the community”. T h ese w ere the sa m e items identified by Filkins e t al. (2000). However, Filkins et al. also identified “place of worship” and “local governm ent”. T h ese item s w ere omitted here b e c a u se the public health n u rse s in this sam ple did not indicate th e se item s w ere a s important to them . T he 7-item scale a s tested gave a reliable operational definition (a = .793) for community satisfaction which could give a general community satisfaction score. The community’s a cc ep tan ce of sp o u se w as not kept in th e scale. Although public health n u rses (79%) w ere satisfied with this a s p e c t of the community they did not indicate it w as a s important to them a s so m e other asp e c ts of the community. S om e had no partners. Even though it could be 126 argued that so m e had no children therefore any a sp e c t related to children could be omitted, this sam ple of public health n u rses have indicated the “overall environment for children” (94%) and “quality of schools” (86%) a s m ore important than “community’s ac cep tan ce of partner” (83%). Therefore “quality of schools” h as been retained in the scale b e cau se it w as used by Filkins et al. (2000). The realities of rural nursing practice, including public health nursing practice are physical and professional isolation from other n u rse s (Davis & Droes, 1993; Hegney, 1996b; MacLeod, et al. 1998), familiarity within the community (Bigbee, 1993; Bushy, 1996, 2000; Hegney, 1996b; Leipert, 1999) and lack of anonymity (Bigbee; Bushy, 2000; Hegney, 1996b; Leipert). The re search er surm ised that over time th e se community a sp e c ts could affect the rural public health n u rse s’ satisfaction with their community. Therefore “level of anonymity”, “consulted on work issues outside of work”, “distance aw ay from major centre ”, and “ability to stay current in your practice” w ere included. This 12-item scale which is th e 11-item scale plus “overall community satisfaction” gav e a scale that is minimized and h as internal consistency (a = .844). This 12item scale is u sed to describe the public health n u rse s’ overall community satisfaction in this research. In general, public health nurses felt m ore satisfaction with their community (M = 3.50) than with their Job {M = 3.33). It w as noted that the younger cohort rated satisfaction with the Job {M = 3.32) and the com munity {M = 3.16). The public health n u rses’ a g e and their num ber of y ears living in the community did not reveal a relation to overall community satisfaction. A larger num ber (77%) of 127 the public health n u rses in general have lived in their community for five or more years. With only 46% of public heaith n urses feeling socially isolated in this sam ple it could be dem onstrating the Gemeinschaft nature of rural com munities. The public health n u rses are known and know the community well, along with the "adoption" of neighbours and friends in place of extended family (Leipert, 1999). Conversely, a larger num ber (68%) of the younger cohort have lived five years or less in their community with 62% of the younger cohort reporting social isolation. A reason for the younger cohort to feel less satisfied in the comm unity could be lack of feeling “co nnected” to the community (Cutchin, 1997; Leipert, 1999). This could be due to few er y ears in the community. The four community a sp e c ts that are m ost important (Table 26) to public health n u rses are ability to stay current, safety, overall environm ent for children and friends. R esearch by Leipert (1999) supported that rural public health n u rses valued their friends and safety. Her research indicated that sports and recreational opportunities w ere also valued. However the four m ost satisfying (from the scale items) w ere a friendly community, friends, a trusting community, and the size of community. The younger cohort identified that the m ost important a s p e c t of the community w as their ability to stay current which w as rated over safety, w hereas the total sam ple rated th e se a sp e c ts equally important. All w ere least satisfied with the distance their community w as from a major centre. The ability to stay current affects both public health n u rse s’ job satisfaction and community satisfaction. This item is included in community satisfaction 128 b ecau se size of community and distance to a iarger centre can affect avaiiabiiity and e a s e in obtaining educationai up-dates. Staying current is a responsibility of public health n u rses a s a professional standard (Griffiths, 1999) reg ard less of w hether their em ployer helps or not. Public heaith n u rse s ag reed staying current in their practice is important, yet less than half are satisfied with their ability to stay current, in fact, 64% of the total sam ple and 83% of the younger cohort report geographical isolation; this can contribute to the difficulty public health n urses have to stay current. Many of the respondents report barriers to their ability to stay current. S om e of th e se are the annual financial limit of $400.00 tow ards tuition and con feren ces a s well as other incurred co sts (financial and otherwise) of being aw ay from hom e and work. T h ese include time sp en t travelling, hotel and related co sts, plus no work coverage for them w hen they are away. This w as consistent with th e research by H egney et al. (1997). O ther costs not m entioned, but which would be expected with a younger cohort of public health nurses, would be extra childcare ex p e n ses w hen the public health n u rses are aw ay from hom e. Rural public health n u rses perceived they had lower anonym ity than nonrural nurses. Yet, public health n u rses w ere not dissatisfied with their level of anonymity in their community, w hether it w as low or high. Low levels of anonymity or lack of anonym ity did not a p p e a r to be the issu e for rural public health n u rses in this study. This reflects the results found by R em us e t al. (2000). Rather, for th e resp o n d ents in this study, the issu e of concem w as the side effect of low anonym ity and familiarity, that is, being consulted about work 129 related concerns outside of work hours. The p resent research identified this a s the issue that dissatisfies rural public health nurses. The effect of being consulted outside of work h a s b een well docum ented (Bushy, 2000; Hegney, et al. 1997; Leipert, 1999), in that n u rses have a s e n se of “never being off duty” (Hegney, et al). Tw enty-seven percent of the rural public health n u rses w ere dissatisfied with this a sp e c t of the community a s com pared to only 5% of nonrural public health nurses. However, 41% of rural public health n u rse s w ere neutral about being consulted outside of work. Obviously, there w ere public health n u rses who w ere not bothered by being consulted, and others who could fend off the questions with comfort. Caution should be used, therefore when conceptualizing and defining or rejecting the im portance of anonymity, b e c a u se other a sp e c ts of satisfaction or dissatisfaction related to anonymity in a rural community could be m issed. Rural public health n u rses ranked social and recreational opportunities in eighth place w h ereas non-rural public health n u rses ranked the sa m e item as second place for satisfaction. The younger cohort w as also less satisfied with this a sp e c t of their community. The difference betw een the rural and non-rural public health n u rses w as significant at p = .05. However, when social and recreation opportunities w ere exam ined with m ore rigorous testing (p = .01) this item w as no longer significant. Yet, it would seem logically that social and recreational opportunities are different betw een rural and non-rural communities in w hat is available or th e num ber of choices. Lack of choice of social and recreational opportunities h as been identified a s a detractor for so m e n u rses and 130 their families causing them to leave a community (Canitz, 1992). T he public health nurses in this study reported the need for a larger community, advanced education for their children and for them selves, and to be closer to family a s reaso n s they would leave their community. Effect of Filter Factors on Retention Retention of a nursing workforce is one strategy to minimize the effects of a nursing shortage (CNA, 1997). In this sam ple retention h as already occurred for half of the public health nurses. This em phasizes th e need to know w hat d o es affect retention. The filter factors are grouped into the n u rse s’ dem ographic characteristics, personal circum stances, and opportunities of th e public health n u rses and their families. Personal circum stances refer to factors that the public health nurses im pose upon them selves or have so m e control over for exam ple, early retirement. W hereas, opportunities are im posed on them by actions of others, giving the public health n u rses only the opportunity to a c c e p t or decline for exam ple, job availability. Som e filter factors can cro ss into an o th er filter category. For exam ple, a g e is a dem ographic factor but affects retirem ent under personal circum stances. Likewise, “m arried” is a dem ographic factor but has implication under opportunities, that is, moving b e c a u se of s p o u s e ’s job. The filter factors can influence w hether the n u rses will stay or leave their public health nursing positions. Demographics of the Public Health Nurses The dem ographic filter factors of this sam ple of public health n u rses are; age, place of nursing education, and married (which relates to th e s p o u se ’s 131 occupation). Although th e m ean ag e of this sam ple is 42.5 years, a g e h as not increased dramatically from Tomich’s (1993) province wide study which found public health n u rses ag e, M = 41.2 y ears. This p resen t sam ple of public health n u rses h as a higher p ercentage of n u rses under 35 years when com pared to the provincial profile prepared by the RNABC. It a p p e a rs that a sufficient num ber of younger n u rses have entered public health nursing to maintain a lower m ean age. The RNABC (2001a) h as noted a d e c re a se In the registration of all n urses over the ag e of 58. Public health nursing is a less physically dem anding job than acu te care nursing therefore public health n u rses could conceivable work longer. However, so m e of th e se public health n u rses cite their reaso n for leaving public health nursing Is b e c a u se their husband will be retiring while others m entioned early retirem ent for them selves. H egney et al. (1997) identifies that a s the a g e of the n u rse in creases so do es job satisfaction. Irvine & E vans’ (1995) research found a low correlation betw een a g e and job satisfaction. However, this study did not find any correlation betw een a g e and job satisfaction. Public health n u rses need to have job satisfaction to maximize the num ber of years they will w ant to work and possibly prevent early retirement. Ultimately ag e will underm ine retention regardless of job satisfaction. Half of the public health nurses in this study have been em ployed for 5 years or longer in their p resen t public health position and half indicate that they will stay for another 5 years or more. However, 27% report they will leave in the 132 next two years. S om e of th e n u rses will be leaving due to retirem ent since 17% have reported they a re 55 y ears and older. It becom es ap p aren t that within the next 2 to 5 y ears th e need for recruitm ent will increase and becom e the dom inant issue. Retention strateg ies n eed to target the younger a g e group. T h e se n u rses are 35 years or younger (26%) have lived in their community 5 y e a rs or less (68%), have been in public health nursing 5 years or less (75%), and have reported that 43% plan to leave their job in 2 years or less. Although so m e older n u rses have entered public health nursing in the last 5 years, retention of n u rses 35 y ears or younger will help to lessen the nursing shortage. T h e se are the n u rses who need job satisfaction to stay. Age will prom ote retention in the younger cohort group and limit retention in the older cohort group. The older cohort of public health n u rses need job satisfaction so they will not retire early. Y oder (1995) contends th at job satisfaction in creases for n u rses with mentoring. Therefore it will be important to continue to have a mix of experienced and new public health n u rses not only for knowledge sharing but to m entor the younger cohort, possibly enhancing job satisfaction. The supply of n u rses for positions in British Columbia not only com es from British Columbia but from other provinces and countries (RNABC, 2001a; Solving N urse Shortage, 2000). This sam ple is no different, 50% of public health n urses have had their nursing education outside of British Columbia, in particular Ontario, Alberta and S askatchew an. RNABC (2001a) predicts that competition for n u rses will com e from all provinces and other countries, not ju st from British 133 Columbia. Since th e n u rses in this sam ple have cited unhap p in ess with their salary a s a reaso n to leave their job. British Columbia m ust offer competitive salaries to effectively recruit and retain n urses for n eed ed positions. Married public health n u rses m ay have partners w hose occupations reflect the resource b ased econom y British Columbia is known for, in particular the forest industry (17%). T he younger cohort w as less likely to have partners in the forest industry (7%). As well, many public health n u rses (23%) are married to other “needed professionals”, for exam ple, teachers, doctors, and dentists. Since public health n u rses are predominantly fem ale and the majority are not the sole family providers, it w as not surprising that a typical com m ent for leaving their public health nursing position w as a change in em ploym ent for their spouse. Two-thirds (60%) of the respondents indicated it would be e a s y for their partners to find other em ploym ent, this supports the concept that m arriage to a partner (in a needed occupation) can limit retention of public health n urses. This would be due to the partner’s c a re e r flexibility and desire to relocate for exam ple a sp o u se who is a RCMP m em ber. Public health n urses who are m arried could stay or leave depending on their s p o u se s ’ em ployment. Personal Circumstances O ther filter factors a re related to the public health n u rse s ’ personal circum stances. T h e se are factors the n u rses have so m e control over. T hese involve financial need, family com m itm ents and the n u rse s’ perceived need for professional growth. S om e public health n u rses admit to financial debt that k eep s them working at their jobs. O thers recognize that a s their children pursue 134 advanced education the need for income rem ains important and k eep s the n u rses in their jobs. Thus, financial need prom otes retention. The public health n u rses’ family com m itm ents either m ake them stay or leave their position. Many of the n u rses say they are staying in their present Job b e ca u se of commitment to their family and friends in the community. The nurses are also staying to create stability for their children who are in high school. O thers would leave their jobs to take care of sick and aging parents. As well, they would leave if a family m em ber n eed ed m ore medical care than could be offered in their community. Professional growth, an asp ect of professional statu s which public health n u rses value and find satisfying. Is also a reason for leaving their public health nursing position. T he n u rses said they would leave to experience other practice settings and to ad v an ce their education. Two a sp ec ts of benefits and rew ards prom ote retention. Public health n u rses are remaining in their jobs for the pension benefits a s previously d iscu ssed in job satisfaction. H ence, pension benefits prom ote retention by retaining public health n u rses who do not w ant to forfeit pension benefits by moving and changing jobs. An intangible benefit of public health nursing is the lack of shift work. Public health n u rses like their hours of work and the fact they do not do shift work. They report that this a s p e c t of their job would keep them in their p resen t position. 135 Oppo/funWes Issues, outside of dem ographics and personal circum stances, related to retention are opportunities. O pportunities are beyond public heaith n u rses' control other than choosing to accept or decline w hat is offered. T he down turn in British Colum bia's econom y can effect th e sp o u se s' occupation, em ploym ent in general and the econom ic climate of the community. The sp o u se h a s to have an occupation that is need ed and can be supported in the com munity to prom ote retention for public health nurses. The overall econom ic climate in th e resource communities of British Columbia, for exam ple forestry, m ay c a u s e an increase in attrition of public health n u rses if the sp o u se is transferred, lo ses job, or is promoted to a larger centre. Conversely, the econom ic clim ate can c a u se retention when public health n u rses are unable to sell their h o u se s or refuse to sell their h o u ses a t a loss. Likewise, retention is prom oted if public health n u rses are tied to the community until their h u sb an d s’ change jobs. H egney et al. (1997) found nurses stayed b e c a u se of their h u sb an d s’ em ploym ent. T h e se factors point to the broader role of th e econom ic health of a community in retention. O ne benefit, portability, lost to contract bargaining h a s b een identified by this sam ple of public health n u rses. This lost benefit h a s created a lost opportunity for public health n u rses but is positive for retention. Prior to March 1998, community n u rses had portability of seniority, w age level, and benefits betw een public health nursing jo bs throughout the province. This benefit has been lost with th e am algam ation of contracts betw een the acu te and community nurses. This am algam ation w as initiated b e c a u se of regionalization and 136 devolving to local health authorities. Animosity am ong public health n u rses has rem ained about the lo sses. At the sam e time, this loss of portability a s it relates to pension benefits prom otes retention. Job availability can prom ote retention w hen there are no alternative attractive em ploym ent positions and limit retention w hen other em ploym ent opportunities are available. Public health n urses cite the econom ic downturn and the loss of portability a s rea so n s for remaining in their p resen t position. In this sam ple of public health nurses, 75% felt there w ere no attractive em ploym ent opportunities in nursing in or n ear their community. Dunkin, Stratton, et al. (1994) reported that the m ore nursing opportunities public health n u rse s have to choose from the m ore job satisfaction they have. The n u rses who are staying b e cau se of “econom ic down turn” or “lack of portability” or “too close to retirem ent” may not necessarily have job satisfaction. A num ber of public health n u rses reported a serendipitous event such a s an inheritance or a lottery winning would cau se them to leave their jobs. This finding w as unexpected. Good fortune for the public health n u rses would be negative for retention. How likely th e se events would occur is unknown but it d o es indicate so m e underlying dissatisfaction with their job. Conclusions By using the questionnaire from Dunkin et al. (1992), the p resen t research found that this sam ple of public health n u rses in British Columbia reported similar satisfaction with work com ponents a s their American counterparts. Professional status, professional interaction and autonom y w ere the top three work 137 com ponents that w ere satisfying for public health n u rses in both studies, albeit in a different order. Public health n u rses in both studies ranked the s a m e top three work com ponents a s important but in a different order. The public health n urses in British Columbia rated professional interaction (first), professional status (second) and salary (third). Both sam ples of n u rses w ere least satisfied with the salary com ponent. However, this study did not support Dunkin’s e t al. (1992) finding that job satisfaction increased retention. Even w hen casu al em ployees and public health n u rses who would retire within five y ears w ere rem oved from the sam ple, this study did not find job satisfaction and retention to be related. Job and community satisfaction are related, how ever neither have a relation to retention. Even so, com m ents from the respondents su g g e st that job and community satisfaction are still important factors to consider in retention. The public health n u rses also report other factors are p resen t that filter job and community satisfaction. The duality of the filter factors prom ote so m e to stay (retention) and limit retention for others. The econom ic climate and lack of portability of benefits betw een health authorities have a positive affect on retention. Public health n u rses are remaining in place w hen they otherw ise would leave, b e c a u se if they leave they would be losing a num ber of years of seniority and benefits. A lack of portability can work against recruiting and retaining new public health n u rses b ecau se n u rses m ay take a rural position for a few years but not invest a num ber of years when they know they will lose the seniority and benefits accum ulated during 138 th o se years. Public health n u rses need to remain in their jobs d u e to contentm ent rather than b e c a u se opportunities m ake it difficult for them to move. The em p h asis should t)e on retaining the younger cohort using the information they have provided in this study. Due to their age, they have more work years left. Therefore retirem ent will not be a filter factor. A s m entioned, “loss of portability of benefits” may not be a filter factor that retains the younger cohort b ecau se they have less to lose than an older public health nurse with several years of service. However this younger cohort h a s indicated they value the ability to stay current and they have reported g reater feelings of geographical, professional and social isolation. Therefore organizations that can prom ote and enable th e se younger n u rses to stay current and d e c re a se their s e n s e of professional and social isolation will en h an ce satisfaction with th e Job and community for th e se younger nurses. Retention of public health n u rses in rural British Columbia is a complex issue. Certainly public health nurses have positive re sp o n se s about their overall job, their professional statu s, their interactions with p eers and cow orkers, and their autonomy. Although they ex p ress dissatisfaction with their salary and asp ec ts of the organizational climate, which som e gav e a s re a so n s they would leave their jobs, it is not known if they would act on their intent to leave. Likewise public health n u rses have positive feelings tow ards the community they live in. They are satisfied with the safety, friendliness, their friends in th e community and the environm ent for their children. T h ese are all compelling re a so n s for som e 139 public health n u rses to remain in their position. The younger n u rses are less satisfied with the distance their comm unities are aw ay from a larger centre. The filter factors can have an impact on w hether retention occurs or not. Retention can be limited for any of the following reasons: a g e n ear retirement, partner who can be easily em ployed elsew here, partner w hose em ploym ent can be affected by a down-turn in the econom y, com m itm ent to family living som ew here else, a need for professional growth either by returning to school or choosing another practice setting, and a serendipitous event. However, retention can occur for th e following reasons: young with m ore years to work, partner who h a s stable em ploym ent in the community, occupation skills that are not affected by th e econom y, debt, the desire for regular M onday to Friday hours and no shift work, poor real e sta te market, job availability and loss of portability of benefits. Retention is influenced by filter factors regardless of the public health n u rse s’ satisfaction or dissatisfaction with their Job or community. It is still important to know w hat is satisfying and dissatisfying about the job and the community b e c a u se the perceived satisfaction with th e se two a sp e c ts m ay be the deciding factor, consequently, “swaying” the public health n u rses to act on their intent to stay or leave. Issues in Implementing the Study Issu es that b ecam e apparent during the research have been grouped into the categories of rural and questionnaire for discussion purposes. Rural. By th e Rural and Small Town definition the entire health region of W est Kootenay Boundary is rural. C astlegar and Nelson are the large offices 140 with five public health nursing positions each, a t the time of the survey. Public health nursing m an ag ers are resident in both offices. The C astlegar office, the main office, will be the support for the region, similar to other main offices that are non-rural. T h ese rural offices that function similar to non-rural offices may modify the differences betw een rural and non-rural public health nurses. This type of office may m ask the actual difference betw een rural and non-rural public health nurses on specific job com ponents, for exam ple organizational climate. It would also follow that the community s e n s e may be different in th e se larger, yet rural centres b ec au se they double a s the main econom ic centre for the region. The n u rses’ perceptions of the rurality of their community could have an effect on retention that is not explored. For exam ple, n u rses in rem ote rural villages within a single day drive to Vancouver m ay not feel a s isolated a s n u rses in larger centres with am enities but their a c c e s s to V ancouver tak es two days. The questionnaire. S om e limitations w ere due to the form at of the questionnaire and did not becom e ap p aren t until data entry. T he resp o n d en ts noted that the questionnaire took them longer than 30 m inutes to com plete. R espondents also cited frustration with the size of the print and not enough sp a c e betw een questions and lines. This w as dem onstrated w hen so m e resp o n d en ts circled a resp o n se twice on one line and m issed the following line. A num ber of respondents ex p ressed difficulty with understanding how “im portance” w as to be rated. This could explain why so m e resp o n d en ts omitted rating th e Importance of th e job and community satisfaction item s. More experienced research ers have ex p ressed concerns that the im portance item is 141 confounding (personal communication, N. Stewart, Ju n e 20, 2001). Therefore the Importance m easu rem en t n eed s to be se p a ra te from the satisfaction m easurem ent for each com ponent. Dunkln’s study had som e low alpha coefficients that put In question the internal consistency of so m e of the job com ponent scales. T he s c a le s did not have an equal num ber of Items therefore averaging each sco re of the job com ponent w as n eed ed for ranking. Therefore, th e se m ethodological w e ak n e sses w ere carried over to this present study. The alpha coefficients for this present study Improved on so m e scales ranging from .429 to .759, with “benefits and rew ards” (a = .429) and “organizational climate” (a = .584) being th e lowest. Therefore, th e se Issues limited so m e Interpretations of the data to description only. Even so, this research h as Initiated som e Insight Into rural public health nursing practice In British Columbia. It should be noted th at while this thesis research w as being com pleted other similar C anadian nursing research w as taking place. A study by R em us et al. (2000) used a questionnaire with similar questions and work com ponents to Dunkin et al. (1992). A nother study (with the questionnaire b a se d on som e of Dunkin et al. research) Is still In progress “Nursing Practice In Rural and Rem ote C an ad a” (MacLeod, Kullg, PItblado, & Stewart, 2001) using both quantitative and qualitative data. This research will give a m ore In depth view of various rural nursing practice settings and job satisfaction along with community and life satisfaction. Either of th e se studies should be exam ined for future u se b ecau se of their refinem ent and expansion of scale developm ent for job satisfaction. 142 Implications of the Findings The findings of this research have implications for health authorities, m an ag ers of public health n u rses and overall health policy. For Health Authorities and Public Health Nursing Managers Even though retention is a com plex issue, public health nursing m anagem ent and health authorities need to a d d re ss the com ponents they can control. Obviously, so m e of th e se are out of the imm ediate control of health authorities such a s sp o u se ’s occupation and w hat the community h a s to offer. Health authorities and the m an agers they employ can en h an ce a s p e c ts of job satisfaction. The public health n u rses in this sam ple have clearly stated the “ability to stay current” is important. The n u rses w ant to have contact and support from public health nursing m an agers who are familiar with public health nursing issu es. Public health n u rses do not w ant to be consulted on work issu es outside of work and they value their vacation time. All of th e se issu es can be ad d ressed by health authorities and m anagers. Health Authorities need to develop creative w ays to help public health n u rses stay current in their practice. T h ese solutions should be identified by the n u rses so that the solutions m eet their need s. O ne creative solution could be short-term ex ch an g es betw een rural and non-rural offices so public health nurses can sh a re their expertise and learn from others. Health authorities need to set asid e educational m oney that e n co m p a sse s th e se creative solutions including relocation, travelling, m eals, daycare e x p e n se s and “back filling” while public health n u rses are aw ay for education. 143 Public health n u rses su g g est that one w ay to recognize the im portance of public health n u rses is to cover their positions w hen they are aw ay from work. Health authorities could fund for coverage for holiday and sick relief, a s well a s recruiting and training relief staff for th e se positions. Health authorities could recognize the expertise of public health n u rses and incorporate them into advisory com m ittees to aiiow them a "voice" in planning, not oniy a t th e regional level but a ssu re them a position in planning at a local level w hen they are m anaged by a non-public health nurse m anager. Another part of this “recognizing im portance” is for m anagers and public health n u rses to define a vision and goals, then work together to attain the goals. Health authorities could initiate program s to help health providers to deal with infringement of their private time such a s education in assertiv e n e ss training and conflict resolution. Vacation h as b een identified a s the m ost important benefit. Therefore health authorities can u se this knowledge for a retention and recruitm ent strategy by offering a deferred salary leave program similar to w hat the school boards offer their teach ers. Deferred leave program s authorize a y ear of leave for any reason that public health n u rses feel they need a t the time, from education to fun or trying another job, without loss of seniority, other benefits and vacation time accruem ent. For Public Policy Job satisfaction theory offers an explanation a s to why and how public health n u rses have contentm ent in their jobs. Job satisfaction is only one part of 144 the retention model for public health n u rses a s developed by Dunkin, Stratton, et al. (1994). This model gives a very micro or personal view. However job satisfaction and retention may n eed m ore of a m acro view within th e province of British Columbia. T here have b een many c h an g es to the health care system , such a s a d e cre a se in transfer paym ents from the federal governm ent, regionalization, inequities w here rural doctors are given m oney but n u rses are not, and m anagem ent of public health nurses by non n u rses or non public health nurses. Therefore, on a personal level pubtic health n u rses may like their job but they feel dissatisfied with th e organizational context in which they work. Several of the public health n u rses who w ere surveyed said that they w ere frustrated by the way in which their work role w as adm inistered. Job satisfaction is dynamic; various influences could change how public health n u rses feel about their job at any given time. Consequently, health care policy should support public health nu rses to be more actively involved in how their work life is m anaged. Public health n u rses could help sh a p e health care policy to support their role and th e com m unities they serve by participating on advisory com m ittees to policy m akers. Public health nurses could contribute their knowledge of rural com m unities and their knowledge of the role they play in prevention, for exam ple injury prevention, immunization and healthy outcom es for m others and children, which can reduce th e dem an d s on the acute health care system . Public health n u rses, with their experience in community developm ent and health promotion, can provide valuable information on w hat is n eed ed and how policy could be 145 implemented to support them and their rural communities. T he Ministry of Health n eed s to ensure that policies and ad eq u ate funding for public health nursing positions extend to health authorities so that public health n u rses feel valued and supported in their work a t all levels. This would help to retain public health n u rses working a t th e community level providing continuity of service to communities in rural British Columbia. Future Research Findings in this study are suggestive that future research is n eed ed . Future studies can validate and expand on the results found in this research . 1. Extend this study with a province-wide sam ple to exam ine urban and nonurban, rural and non-rural public health n u rses to determ ine w hether differences exist for work com ponents and community satisfaction when health regions th at are not predom inantly rural are incorporated. 2. To have a m ore com prehensive understanding of rural retention, research involving public health n u rses who have left their positions should be included. 3. R esearch is n eed ed to further explore the concepts of anonym ity and autonom y with resp ect to public health n u rses in rural and non-rural settings. R esearch can b e u sed to identify the item s that would accurately describe the concepts of anonym ity and autonom y of public health n u rse s in rural and nonrural settings. By using this information m ore com prehensive scales can be developed to te st anonymity and autonom y of public health n u rse s in rural and non-rural settings. 146 Summary The purpose of this research w as to identify and exam ine w hat public health n u rses find satisfying in their rural practice and in their rural com munities and w hat effect this satisfaction h as on retention in rural British Columbia. For m any of the public health nurses, retention had already taken place and the em phasis n ee d s to shift to recruitment. However, retention rem ains a practical but limited solution for the p resent nursing shortage. This research found filter factors influence retention regardless of job and community satisfaction. 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Canadian Journal of Public Health, 85 (3), 185-187. Yoder, L. (1995). Staff n u rse s’ career developm ent relationships and self-reports of professionalism, job satisfaction, and intent to stay. /Vursmg R esearc/i, 44 (5), 290-297. 155 Appendix A Statistics C an ad a definition for Rural and Small Town C an a d a Health Unit Regions used In this research and the rural designation of each office. 156 Rural Definition Statistics C an ad a (M endelson & Bollman, 1998) describes: Rural and Small Town (RST) C an ad a a s referring to the population living outside th e commuting zo n es of larger urban cen tres - specifically, outside C en su s Metropolitan A reas (CMAs) and C en su s Agglomeration (CAs). A CMA h as an urban core of 100,000 or over and includes all neighbouring municipalities w here 50 percent or m ore of the work force com m utes into the urban core. A CA h as an urban core of 10,000 to 99,000 and includes all neighbouring municipalities w here 50 percent or m ore of the work force com m utes into the urban core. Thus, RST C anada rep resen ts th e non-CMA and non-CA population. It includes all the residents outside the commuting z o n es of larger urban cen tres. Only a small sh are of th e se resident live on farms, (p. 2) Health Regions and their offices: * d en o tes offices that fit the Rural and Small Town definition (M endelson & Bollman, 1998). Isolation pay a s designated by Provincial Collective A greem ent (1998). Population a s denoted by Statistics C an ad a (2000) in statistical profile of C anadian com m unities c e n s u s 1996. Cariboo Health Unit: Region #15 Office location Population Williams Lake CA 38,552 City 10,472 District Municipality DM 1,771 DM 1,850 ‘Bella Coola *100 Mile House Quesnel Isolation pay BCNU contract yes Address 3™ flr,540 Borland V2G 1R8 Box 220, V0T1C0 Box 458, 385 Dogwood Cres. VOK 2E0 511 Reid St. V2J 2M8 CA 25,279 City 8,468 C oast Garibaldi Health Unit Region # 11 Office Population ‘Gibsons Town 3,732 Regional District RD Isolation pay BCNU contract Address Box 78, 494 S. Fletcher Rd. VON 1V0 157 ’ Pemberton Powell River ’ Sechelt ‘Squamish ’Whistler 13,075 Village 855 RD 2,191 CA 19,936 Sub Regional D 6,207 DM 7,343 RD 13,075 (as Pemberton) DM 13,994 RD 13,075 (as Gibsons) Sub Div 1,684 DM 7172 Box 8, Portage Rd. VON 2L0 43138 Alberta Ave. V8A 5G7 5571 Inlet Ave. Box 1040 VON 3A0 Box 130, 38075 2™ Ave. VON 3G0 202-4380 Lorimer Rd. VON 1B4 RD2191 (as Pemberton) Northern Interior Health Unit Region # 1 8 Office Population Prince George CA 75,150 City 75,150 F raser Fort George 13,622 Village 1,793 Regional District 6,891 Village 2,046 Bulkley-Nechako Subd.A 6,891 District Municipality 4,401 Bulkley-Nechako Subd.A 6,891 (as Ft. St Jam es) 1,344 District Municipality 5,997 Village 740 Village 1303 ’Burns lake ’Fort St. Jam es ’Vanderhoof ’ Fraser Lake ’ Mackenzie ’ McBride ’Valemount Isolation Pay BCNU contract no Address yes Box 301, 744 Centre St. V 0J1E 0 Box 1257, VOJ IPO yes 1444 EdmontonSt. V2M 6W5 No for PHN (but hospital nurses do) RR#2 VOj 3A0 yes yes Box 369 VOJ ISO Bag 5000 VOJ 2C0 yes Box 97 VOJ 2E0 Box 1 VOE 2Z0 yes P e a c e River Health Unit Region #17 Office Population Dawson Creek CA 11,125 City 11,125 District municipality 2,980 P eace River Subd.C. 9,305 Town 4,4001 Liard Subd.A. 1,005 CA 15,021 City 15,021 Fort Nelson-Liard Subd.A 1,005 DM 1,122 District municipality 3,775 ’Chetv/ynd ’Fort Nelson Fort St. John ’ Hudson's Hope ’Tumbler Ridge Isolation pay BCNU contract no Address yes 1001-11-th Ave. V IG 4X3 Bag 105 VOC 1J0 yes Bag 1000 VOC 1R0 no 10115-110"’ Ave. V IJ 6M9 yes yes C/o Chetwynd Box 1090 V0C2W0 158 S k een a Health Unit Region #16 Office Population Terrace CA 20,941 *Dease Lake *Hazelton RD 1,001 Village 347 Isolation pay BCNU contract Address yes 3412K alum St. V8G 4T2 Box 296 VOC 1L0 Box 321 VOJ 1Y0 yes Box 321 VOJ 1Y0 RD 2,098 ‘ Houston KItlmat ‘ M asset Prince Rupert ‘Q ueen Charlotte City ‘Smithers ‘Stewart District municipality 3,934 CA 11,136 Village 1,293 CA 17,414 City 16,714 Not listed Town 5,624 Bulkley-Nechako Subd.B. 6,505 DM 858 Regional SubD 341 Box 321 VOJ 1Y0 BOX215V0T1M0 333 Fifth St. V8J 3L6 yes yes yes B ox419V 0T ISO Bag 5000 3782 Alfred Ave. VOJ 2N0 Box 692 VOT 1W0 Upper Island Health Unit Region #14 Office Population Courtenay Comox CA 54,912 City 17,335 Village 612 CA 35,183 District muncipality 28,851 Comox-Stratcona Subd.B 5,469 Town 11,069 ‘Gold River Village 2,041 ‘Port Alice ‘Port Hardy Village 1,331 District Municipality 5,283 yes yes ‘Port McNeill ‘Tahsis Town 2,925 Village 940 yes yes ‘Alert Bay Campbell River Isolation pay BCNU contract yes Address 480 Cumberland Rd. V9N 2C4 Box 4 VON 1A0 New address 1729 Comox Ave. V9N 3Z8 Box 158, Trumpeter Dr. VOP 1G0 C/o Port Hardy Bag 11000 7070 Market St. VON 2P0 C/o Port Hardy Box 426 VOP 1X0 E ast Kootenay Health Unit Region #1, Office Population Cranbrook ‘Elkford(Sparwood) City 18,131 CA 18,131 Town 4,816 RD 8,017 DM 2,729 ‘Femie City 4,877 ‘Creston Isolation pay BCNU contract Address 1212-2™ St., N. V1C4T6 Box 1370, 531-17**'Ave. S.,V0B1G0 Box 137, 212 Alpine Way, VOB 2G0 Bag 1000, 302-2™ Ave., 159 ‘Invermere RD 3,574 Town 3,968 RD 3,305 DM 2,687 ‘Kimberley City 6,738 ‘Sparwood DM 3,982 ‘Golden VOB 1M0 Box 369,907-9* Ave., V0A1H0 Box 157, 1100-10" St. VOA 1K0 1565 Victoria Ave., V1A3A2 Box 137, 603 Pine Ave., VOB 2G0 W est Kootenay-Boundary Health Unit Region #2. Office Population ‘Castlegar ‘Fruitvale City 7,027 RD 8,031 Village 2,117 ‘Grand Forks City 3,994 ‘Greenwood City 784 RD 15,354 Village 1,063 ‘Kaslo ‘Nakusp ‘Nelson ‘Trail Village 1,736 RD 8,031 City 9,585 City 7,696 RD 3,968 Isolation pay BCNU contract Address 813-10" St., V1N2H7 yes yes Box 10, 1947 Beaver St., VOG 1L0 Box 25, 7343-4* St., VOH 1H0 Box 167, 255 Gomment St. VOH 1J0 Box 309, 4* St. VOG 1M0 Box 315, Broadway St. VOG IRQ 333 Victoria St. V1L4K3 1051 Farwell St. V 1R 4S9 160 Appendix B Original Q uestionnaire of the UNO Rural Health R esearch C enter Modified Q uestionnaire Com parison Chart of the seven Job Satisfaction C om ponents Review of S tam ps and Piedm onte 1986 and S tam p s 1997 UNO RURAL HEALTH RESEARCH CENTER University of North Dakota • S ch ool of M ed icin e « 501 C olum bia R oad • Grand Forks. North Dakota 5 8 2 0 3 • ( 7 0 1 )7 7 7 - 3 8 4 8 Dear Colleague: As a registered nurse practicing in a rural area, you are undoubtedly aware of the difficulties facing rural health care. Nursing supplies, wage differentials, and staffing patterns are only several o f the areas which set our rural environments apart from the urban. Because you are a rural practitioner, your viewpoints and perceptions are an invaluable and imperative resource in examining these issues. It is for this reason we are inviting your participation in this a study of this very crucial and timely topic. The Center for Rural Health, in collaboration with the University o f North Dakota School o f Nursing, is conducting the study to identify and examine factors which influence your choice to practice nursing in a rural environment. Although some items require a bit more thought than others, completing the attached questionnaire should take no more than 20 minutes. To ensure that all responses are strictly confidential, we have provided a self-addressed stamped envelope for you to return the completed questionnaire at your earliest convenience. Since your participation is totally anonymous, we encourage you to be honest in your responses. This study is about rural nurses and is NOT an evaluation o f specific individuals or agencies. And, although you are under no obligation to participate in the study, the issues at hand are ones which only you can provide valid insights into. Your returned questionnaire will be taken as evidence of your willingness to participate and your consent to have the information used for the purpose o f the study. Although results o f the study may not benefit you directly, findings may be used to formulate subsequent policy recommendations to enhance health care delivery to the citizens o f rural America. Upon completion of this study, an abstract of the overall findings from the six-state sample will be sent to nursing directors of all participating agencies. If requested, a personal copy will be forwarded to you directly. Please accept our appreciation in advance for your participation in the study. Should you wish any further explanation, please f&l free to contact us at (701)777-4529 or (701)777-4522. We welcome your involvement in any capacity. Thank you. Sincerely, 4eri Dunkin, Phi), RN Director Rural Health Nurse Specialist Program Nyla Juhl, PhD, RN Chair Family & Community Nursing RURAL NURSING MANPOWER SURVEY The following statements have been expressed by nurses. Do you agree? Please respond by indicating strongly- disagree (SD), disagree (D), neutral (N), agree (A), or strongly agree (SA). In addition, concepts presented in these statements contribute to job satisfaction. Please indicate how important each of these factors are to you very unimportant (1), unimportant (2), neutral (3), important (4), or very important (5). Please circle your response to the statement. Please circle the level of importance to you. SA 1 2 3 4 5 1. I have plenty of time to discuss nursing concerns with my colleagues. SD D N 2. I have little control over my work. SD D N A SA 1 2 3 4 5 3. My co-workers are competent. SD D N A SA 1 2 3 4 5 4. This agency offers opportunities for advancement/promotion. SD N SA 1 2 3 4 5 In this agency nurses are expected to perform non-nursing tasks. SD N SA 1 2 3 4 5 A great deal of independence is permitted if not required of me. SD D N SA 1 2 3 4 5 The nursing personnel in this agency are not as friendly and outgoing as I would like. SD D N SA 1 2 3 4 5 Nurse-patient ratios in this agency are conducive to safe patient care. SD D N SA 1 2 3 4 5 No No No No No No 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 4 4 4 4 4 4 5 5 5 5 5 5 5. 6. 7. 8. 9. Which benefits do you currently receive from this agency; a) health insurance b) retirement c) day care (child/elder) d) vacation/holidays e) sick/matemity leave f) tuition reimbursement Yes Yes Yes Yes Yes Yes 10. Too much paper work is required of nursing personnel in this agency. SD D N SA 1 2 3 4 5 11. I am sometimes required to do things on my job that are against by better professional nursing judgement. SD D N SA 1 2 3 4 5 12. A good deal of teamwork is present between various levels of nursing personnel in this agency. SD D N SA 1 2 3 4 5 13. The nursing administrators generally consult with staff on daily problems and procedures. SD N SA 1 2 3 4 5 14. Based on feedback from nurses in other agencies, the pay at this agency is fair. SD N SA 1 2 3 4 5 A Please circle your response Please circle the level to the statemenL of Importance to you. 15. I have too much responsibility and not enough authority. SD D N A SA 1 2 3 4 5 16. New employees are not quickly made to feel at home in this agency. SD D N A SA 1 2 3 4 5 17. Nurses in this agency are encouraged to participate in continuing education. SD D N A SA 1 2 3 4 5 18. Pay scales for nursing personnel need to be upgraded. SD D N A SA 1 2 3 4 5 I am sometimes given more responsibility in decision making than I am prepared to handle. SD D N A SA 1 2 3 4 5 Nursing staff have sufficient control of the total number of hours worked. SD D N A SA 1 2 3 4 5 Considering what is expected of nursing personnel at this agency, the pay we receive is reasonable. SD D N A SA 1 2 3 4 5 I have the support of my supervisor to make important decisions in my work. SD D N A SA 1 SD D N A SA 1 2 3 4 5 I have no doubt in my mind that what I do on ray job is really important. SD D N A SA 1 2 3 4 5 Nursing staff have sufficient control in scheduling their own work shifts in this agency. SD D N A SA 1 2 3 4 5 The types of activities required of me are reasonable. SD D N A SA 1 2 3 4 5 I have all the voice in planning policy and procedures that I want. SD D N A SA 1 2 3 4 5 28. I am frequently asked to work overtime. SD D N A SA 1 2 3 4 5 29. The nursing personnel in this agency do not hesitate to pitch in and help one another when things get in a rush. SD D N A SA 1 2 3 4 5 I am proud to talk to other people about what I do on my job. SD D N A SA 1 2 3 4 5 I wish the physicians here would show more respect for the knowledge/skill of the nursing staff. SD D N A SA 1 2 3 4 5 19. 20. 21. 22. 23. A great gap exists between administration in this agency and the daily problems of nursing service. 24. 25. 26. 27. 30. 31. 2 3 4 5 Please circle your response to the statement Please circle the level 32. I have sufficient input into the program of care for each of my patients. SD D N A SA 1 2 3 4 5 33. This agency financially rewards advanced training/education. SD D N A SA 1 2 3 4 5 34. My earning potential in this agency is reasonable. SD D N A SA 1 2 3 4 5 35. I have sufficient time to accomplish my job responsibilities. SD D N A SA 1 2 3 4 5 36. I work weekends. SD D N A SA 1 2 3 4 5 37. I do not receive some benefits that are important to me. SD D N A SA 1 2 3 4 5 38. If I had the decision to make all over again, I would still go into nursing. SD D N A SA 1 2 3 4 5 39. Overall, I am very satisfied with my job. SD D N A SA 1 2 3 4 5 of importance to you. 40. What is your educational background? Check all that apply: Year Degree Received State or Country Degree Received lex. Texas! LPN/LVN Diploma Associate Degree in Nursing Bachelors Degree in Nursing Bachelors Degree in Another Field Masters Degree in Nursing Masters Degree in Another Field Doctoral Degree in Nursing Doctoral Degree in Another Field 41. What year were you first licensed to practice as a RN in the United States? 42. a. In what state were you first licensed as a R N ? ________________________ b. In what states are you currently licensed?___________________________ c. How many years (or months if less than 1 year) have you been practicing as a RN? continue on back 43. List your professional job history over the past 5 years beginning with your present place of employment. Type of Agency (hospital, nursing home, clinic, home health, community, school, other) Length of Employment (in years/ months) State Position (staff nurse. Admin., Educ.) Primary Reason for Change Full/ Pan Time miles (one way) 44. How far do you trayel to work? 45. What is the distance in miles to the next nearest health care facility where you could haye possible employment? (one way) 46. What is the distance in miles to the nearest community of 50,000 or greater? _ (one way) 47. Haye you been employed outside of nursing in your recent past? No Yes 48. In your community or nearby are there attractiye employment opportunities outside of nursing?___ 49. In your community or nearby are there attractiye employment opportunities in nursing? No Yes Yes _____ No 50. How long do you expect to stay in your present job? less than 1 year _____ 1-2 years 2-4years 5or more 51. Haye you looked for other employment opportunities within the past year? If yes, i n nursing non nursing o r both? Yes No 52. Beginning with yourself, list the ages (in years, if less than 1 enter 0) and circle the sex of the members of your household. M = Male F = Female yourself AGE SEX _____ M F MF MF 53. Marital status: married AGE SEX SEX M F M F M F AGE ME M F M F AGE _ single_____ widowed _ separated diyorced SEX MF MF M F 54. If currently married, spouses occupation? 55. Would it be easy for your spouse to find employment if you decided to relocate? Yes No 56. What is your personal annual income from nursing before taxes? S 9,999 or less $10,000.$12,999 $13,000-515,999 $16,000-318,999 $19,000-521,999 $22,000-524,999 $25,000-527,999 $28,000-530,999 $31,000 or aboye 57. What percentage of your family income does this represent? more 58. Please indicate the size of the community in which you were raised: rural (less than 2500)_____________________ _____city (25,000-50,000) small town (2500-10,000)__________________ _____urban (50,000-100,000) town (10,000-25,000)______________________ _____metropolitan (over 100,000) 59. How long have you resided in the community where you currently live (estimate to the nearest year)? 60. On a scale of 1 to 5 with 5 being highest, please rate your satisfaction with your community as a place to: live raise children build a new home invest your savings start a new business worship provide ample social opportunities 1 1 1 1 1 1 1 2 2 2 2 2 2 2 3 3 3 3 3 3 3 4 4 4 4 4 4 4 5 5 5 5 5 5 5 Please indicate the size of the communitv in which vou currently work: _____town (10,000-25,000) _____city (25,000-50,000) rural (less than 2500) small town (2500-10,000) 62. What factors led you to practice nursing in a rural area? 1. 2. ____________________ 3. 63. Which factor played a greater role in influencing your decision to accept your present position? health care agency job availability _____community _____other (please specify) 64. What factors might cause you to leave your current position within the next 5 years? 1. 2. 3. 65. Any comments you wish to make concerning your job, rural nursing in general, or this study: Rural Nursing Job and Community Satisfaction Survey A. Please indicate the region you work in: Northern Interior Peace - Liard Cariboo Kootenay East Kootenay West/Boundary Upper Island - Central Coast B. How many PHNs work in your office (counting yourself)? C. How many FTE’s do you work? Skeena - Northwest Coast Garibaldi __________ _________ The following statements have been expressed by nurses. Do you agree? Please respond by indicating strongly disagree (SD), disagree (D), neutral (N), agree (A), or strongly agree (SA). In addition, concepts presented in these statements contribute to job satisfaction. Please indicate how important each of these factors are to you very unimportant (1), imimportant (2), neutral (3), important (4), or very important (5). Please circle your response to the statement. Please circle the level of importance to you. 1. I have plenty of time to discuss PHN concerns with my colleagues. SD D N A SA 1 2 3 4 5 2. I have little control over my work. SD D N A SA 1 2 3 4 5 3. My immediate co-workers are competent. SD D N A SA 1 2 3 4 5 4. This health unit offers opportunities for advancement/promotion. SD D N A SA I 2 3 4 5 5. In this health unit PHNs are expected to perform non-nursing tasks. SD D N A SA 1 2 3 4 5 6. A great deal of independence is permitted if not required of me. SD D N A SA 1 2 3 4 5 7. The PHN personnel in this health unit are not as friendly or supportive as I would like. SD D N A SA 1 2 3 4 5 8. PHN-client ratios in this health imit are conducive to implement client/family/community services. SD D N A SA 9. Too much paper work is required of PHN personnel in this health unit. SD D N A SA 10. I am sometimes required to do things on my job that are against my better professional nursing judgment. SD D N A SA 11. A good deal of networking is present between various levels of PHN personnel in this health unit. SD D N A SA 12. The PHN administrators or seniors generally consult with PHN staff on daily problems and procedures. SD D N A SA Please circle your response to the statement. Please circle the level of importance to you. 13. Based on feedback from PHNs in other health units, the pay at this health unit is fair. SD D N A SA 1 2 3 4 5 14. I have too much responsibility and not enough authority. SD D N A SA 1 2 3 4 5 15. New PHNs are not quickly made to feel at home in this health unit. SD D N A SA 1 2 3 4 5 16. PHNs in this agency are encouraged to participate in continuing education. SD D N A SA 1 2 3 4 5 17. Pay scales for PHN personnel need to be upgraded. SD D N A SA 1 2 3 4 5 18. I am sometimes given more responsibility in decision making than I am prepared to handle. SD D N A SA 1 2 3 4 5 19. PHN staff have sufficient control of the total number of hours worked. SD D N A SA 1 2 3 4 5 20. Considering what is expected of PHN personnel at this health unit, the pay we receive is reasonable. SD D N A SA 1 2 3 4 5 21. I have the support of my supervisor to make important decisions in my work. SD D N A SA 1 2 3 4 5 22. A great gap exists between administration in this health unit and the daily problems of PHN service. SD D N A SA 1 2 3 4 5 23. I have no doubt in my mind that what I do on my job is really important. SD D N A SA 1 2 3 4 5 24. PHN staff have sufficient control in scheduling their own work hours in this health unit. SD D N A SA 1 2 3 4 5 25. The types of activities required of me are reasonable. SD D N A SA 1 2 3 4 5 26. I have all the voice in planning policy and procedures that I want. SD D N A SA 1 2 3 4 5 27. I am frequently asked to work overtime. SD D N A SA 1 2 3 4 5 28. The PHN personnel in this health unit do not hesitate to take the time to consult with me or support me when things get in a rush. SD D N A SA 1 2 3 4 5 29. I am proud to talk to other people about what I do on my job. SD D N A SA 1 2 3 4 5 2M« Please circle your response to the statement. Please circle the level of importance to you. 30. I wish the physicians here would show more respect for the knowledge/skill of the PHN staff. SD D N 31. I have sufficient input into implementing programs for the clients/families/communities. SD D N A SA 2 3 4 5 32. This health unit financially rewards advanced training/education. SD D N A SA 2 3 4 5 33. My earning potential in the health unit is reasonable. SD D N A SA 2 3 4 5 34. I have sufficient time to accomplish my job responsibilities. SD D N A SA 2 3 4 5 35. I work weekends. SD D N A SA 2 3 4 5 36. I do not receive some benefits that are important to me. SD D N A SA 2 3 4 5 37. If I had the decision to make all over again, I would still go into nursing and become a PHN. SD D N A SA 2 3 4 5 38. Overall, I am very satisfied with my job. SD D N 39. Which benefits do you currently receive from this agency. Please mark Yes or No a) health insurance b) retirement c) day care (child/elder) d) vacation/holidays e) sick/matemity leave f) tuition reimbursement g) isolation allowance h) health unit vehicle i) cell/mobile phone j) telephone conference with peers k) inservices Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes What is your level of anonymity in your present community. How satisfied are you with the following factors in your present community and how important are these factors to you? a) level of anonymity b) friendly c) trusting d) social/recreation opportunities e) friends f) place of worship g) quality of schools (K-12) Low 1 2 2 2 2 2 2 2 2 SA Please circle the level of Importance to you. No No No No No No No No No No No 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 High 3 Not satisfied 1 1 1 1 1 1 1 SA 4 5 Very satisfied 3 3 3 3 3 3 3 4 4 4 4 4 4 4 5 5 5 5 5 5 5 Not important 1 1 1 1 I 1 1 2 2 2 2 2 2 2 Very mportant 3 3 3 3 3 3 3 4 4 4 4 4 4 4 5 5 5 5 5 5 5 How satisfied are you with the following factors in your present community and how important are these factors to you? Not satisfied Very satisfied Not important Very important h) safety i) overall environment for children j) community’s acceptance of spouse/partner k) being asked work related questions outside o f work 1) size of commimity m) distance your community is away from a major centre. n) your ability to stay current in your practice o) local government p) overall community satisfaction 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 If married/partnered, how satisfied is your spouse/partner, overall, with the community? 1 2 3 4 5 1 2 3 4 5 43. Do you ever feel isolated: a) socially c) geographically N Y Y _N b) professionally N Province or country degree received (e.g. Ontario) 44. What is your educational background? Check ail that apply: Year degree received a) Diploma b) Bachelors Degree in Nursing c) Bachelors Degree in Another Field d) Masters Degree in Nursing e) Masters Degree in Another Field f) Doctoral Degree in Nursing, or Another Field 45. In what year and province were you first licensed to practice as a RN in Canada? year: provmce: 46. List your professional job history over the last 5 years begiiming with your present place of employment. Length of employment (in years/months) Type of agency Province Position (staff nurse. Admin., Educ.) (hospital, nursing home, clinic, home health, community, school, other) Fuli/Part Time 47. WTiat is the longest distance you must travel to deliver service? _______________ Primary reason for change Km (one way). 48. Have you been employed outside of nursing in your recent past? Yes No 49. In your community or nearby are there attractive employment opportunities outside of nursing? Yes No 50. In your community or nearby are there attractive employment opportunities in nursing? Yes No 4M# 51, How long do you expect to stay in your present job? less than 1 year _____ 1-2 years 5 or more years 2-4 years 52. Have you looked for other employment opportunities within the past year? If yes, in nursing non-nursing or Yes _ both 53. Beginning with yourself, list the ages (in years, if less than 1 enter 0) and circle the sex of the members or your household. M = Male F = Female AGE Yourself SEX AGE AGE SEX SEX AGE SEX M F M F MF M F M F M F M F M F M F M F M F M F M F M F M F 54. Marital status: married/partnered MF separated widowed . single divorced 55. If you are currently married or have a partner, what is his/her occupation? 56. Would it be easy for your spouse/partner to find employment if you decided to relocate? _ 57. Please estimate your annual income from nursing to the nearest $1,000. No Yes ____________________ 58. What percentage of your family income does this represent? _________________ 59. How long have you resided in the community where you currently live (estimate to the nearest year)? 60. Please circle the population ranges that best answer the following: a) size of the community you were bom in Rural Sm all Town Tow n City Urban 2.500 2 , 500 - 4,999 5 - 9,999 10 - 25,000 50 - 100,000 1 2 3 4 5 4 5 < b) if married, the size of the community your spouse/partner grew up in. c) size of community you are currently living in 2 4 d) size of community in which you currently work 2 4 61. What factors led you to practice nursing in a rural area? 62. Which factor played a greater role in influencing your decision to accept your present position? health care agency community other(pleasespecify) job availability partner employed in/near community No 63. What are the main factors that are influencing you in remaining in your current position in this community? 64. What factors might cause you to leave your current position within the next 5 years? 65. Any comments you wish to make concerning your job, community, rural nursing in general, or this study: (Feel free to add more paper if needed) Thank yon for your help! 173 Job satisfaction divided into com ponents. F irst co lu m n is original wording. S e c o n d co lu m n is the revision to reflect PHN terminology. All ch an g es in wording are indicated in boid print. Task Requirem ents 1. 1 have plenty of time to discuss nursing concerns with my colleagues. 5. In this agency nurses are expected to perform non-nursing tasks. 9. Too much paper work is required of nursing personnel in this agency. 25. The types of activities required of me are reasonable. 35. 1have sufficient time to accomplish my job responsibilities. 1. 1have plenty of time to discuss PHN concerns with my colleagues. 5. In this health unit PHN are expected to perform non-nursing tasks. 9. Too much paper work is required of PHN personnel in this health unit. 25. The types of activities required of me are reasonable. 35. 1have sufficient time to accomplish my job responsibilities. Organization Climate 8. Nurse-patient ratios in this agency are conducive to safe patient care. 12. The nursing administrators generally consult with staff on daily problems and procedures. 19.Nursing staff have sufficient control of the total number of hours worked. 22. A great gap exists between administration in this agency and the daily problems of nursing service. 24. Nursing staff have sufficient control in scheduling their own work shifts in this agency. 26.1 have all the voice in planning policy and procedures that 1want. 8. PHN-client ratios in this health unit are conducive to implement client/family/community services. 12. The PHN administrators or Seniors generally consult with PHN staff on daily problems and procedures. 19. PHN staff have sufficient control of the total number of hours worked. 22. A great gap exists between administration in this health unit and the daily problems of PHN service. 24. PHN staff have sufficient control in scheduling their own work hours in this health unit. 26. 1have all the voice in planning and procedures that 1want. 174 Professional S tatus 23. 1have no doubt in my mind that what I do on my job is really important. 30. 1am proud to talk to other people about what 1do on my job. 38. If 1had the decision to make all over again, 1would still go into nursing. 23. 1have no doubt in my mind that what 1do on my job is really important. 30. 1am proud to talk to other people about what 1do on my job. 38. If 1had the decision to make all over again 1would still go into nursing and PHN. Salaa 13. Based on feedback from nurses in other agencies, the pay at this agency is fair. 17. Pay scales for nursing personnel need to be upgraded. 20. Considering what is expected o f nursing personnel at this agency, the pay we receive is reasonable. 34. My earning potential in this agency is reasonable 13. Based on feedback from PHN In other health units, the pay at th is health u nit Is fair. 17. Pay scales for PHN personnel need to be upgraded. 20. Considering what is expected of PHN personnel at th is health unit, the pay we receive is reasonable. 34. My earning potential in this health u nit is reasonable. Autonomy 2. 6. 1have little control over my work. A great deal of independence is permitted if not required of me. 10. 1am sometimes required to do things on my job that are against by better professional nursing judgement. 14. 1have too much responsibility and not enough authority. 18. 1am sometimes given more responsibility in decision making than 1am prepared to handle. 21. 1have the support of my supervisor to make important decisions in my work. 32. 1have sufficient input into the program of care for the each of my patients. 2. 1have little control over my work. 6. A great deal of independence is permitted if not required of me. 10. 1am sometimes required to do things on my job that are against by better professional nursing judgement. 14. 1have too much responsibility and not enough authority. 18. 1am sometimes given more responsibility in decision making than 1am prepared to handle. 21.1 have the support of my supervisor to make important decisions in my work. 32. 1have sufficient input into Im plem enting program s fo r the cllents/fam lly/com m unlty. 175 Interactions 3. 7. My co-workers are competent. The nursing personnel in this agency are not as friendly and out going as 1would like. 11. A good deal of teamwork is present between various levels of nursing personnel in this agency. 15. New employees are not quickly made to feel at home in this agency. 28. The nursing personnel in this agency do not hesitate to pitch in and help one another when things get in a rush. 31. 1wish the physicians here would show more respect for the knowledge/skill of the nursing staff. 3. My immediate co-workers are competent. 7. The PHN personnel in this health unit are not as friendly or supportive as 1would like. 11. A good deal of networking is present between various levels of PHN personnel in this health unit. 15. New PHN are not quickly made to feel at home in this health unit. 28. The PHN personnel in this health unit do not hesitate to take the time to consult with me or support me when things get in a rush. 31.1 wish the physicians here would show more respect for the knowledge/skill of the PHN staff. Benefits and R ew ards 4. This agency offers opportunities for advancement/promotion. 16.Nurses in this agency are encouraged to participate in continuing education. 27. 1am frequently asked to work overtime. 33. This agency financially rewards advanced training/education. 36. 1work weekends. 37. 1do not receive some benefits that are important to me. 4. This health unit offers opportunities for advancement/promotion. 16. PHN in this health unit are encouraged to participate in continuing education. 27. 1am frequently asked to work overtime. 33. This health unit financially rewards advanced training/education. 36. 1work weekends. 37. 1do not receive some benefits that are important to me. 176 Stamps and Piedmonte 1986 1. My present salary is satisfactory. 2. Most people do not sufficiently appreciate the importance of nursing care to hospital patients. 3. The nursing personnel on my service don’t hesitate to pitch in and help one another out when things get in a rush. 4. There is too much clerical and “paperwork’ required of nursing personnel in this hospital. 5.The nursing staff has sufficient control over scheduling their own work shifts in my hospital. 6. Physicians in general cooperate with the nursing staff on my unit. 7. I feel that I am supervised more closely than is necessary. 8. Excluding myself, it is my impression that a lot of nursing personnel at this hospital are dissatisfied with their pay. 9. Nursing is along way from being recognized as a profession. 10. New employees are not quickly made to “feel at home” on my unit. 1 1 .1think I could do a better job if I didn’t have so much to do all the time. 12. There is a great gap between the administration of this hospital and the daily problems of the nursing service. 1 3 .1feel I have sufficient input into the program of care for each of my patients. 14. Considering what is expected of nursing service personnel at this hospital, the pay we get is reasonable. 15. There is no doubt whatever in my mind that what I do on my job is really _________ __ important. U niversity North Dakota Stamps 1992 1994 1997 34. My earning potential in this 1 .My present salary is satisfactory. agency is reasonable. 9. Most people appreciate the importance of nursing care to hospital patients. 29. The nursing personnel in this agency do not hesitate to pitch in and help one another when things get in a rush. 3. The nursing personnel on my service pitch in and help one another out when things get in a rush. 10. Too much paper work is required of nursing personnel in this agency. 4. There is too much clerical and “paperwork" required of nursing personnel in this hospital. 5. The nursing staff has sufficient control over scheduling their own shifts in my hospital. 6 . Physicians in general cooperate with nursing staff on my unit. 7. I feel that I am supervised more closely than is necessary. 8. It is my impression that a lot of nursing personnel at this hospital are dissatisfied with their pay. 2. Nursing is not widely recognized as being an important profession. 10. It is hard for new nurses to feel “at home” in my unit. 25. Nursing staff have sufficient control in scheduling their own work shifts in this agency. 16. New employees are not quickly made to feel at home in this agency. 23. A great gap exists between administration in this agency and the daily problems of nursing service. 3 2 .1have sufficient input into the program of care for each of my patients. 21. Considering what is expected of nursing personnel at this agency, the pay we receive is reasonable. 2 4 .1have no doubt in my mind that what I do on my job is really important. 1 5 .1think I could do a better job if I did not have so much to do all the time. 12. There is a great gap between the administration of this hospital and the daily problems of the nursing service. 1 3 .1feel I have sufficient input into the program of care for each of my patients. 14. Considering what is expected of nursing service personnel at this hospital, the pay we get is reasonable. 11. There is no doubt whatever in my mind that what I do on my job is really important.____________ ____ 177 16. There is a good deal of teamwork and cooperation between various levels of nursing personnel on my service. 1 7 .1have too much responsibility and not enough authority. 18. There are not enough opportunities for advancement of nursing personnel at this hospital. 19. There is a lot of teamwork between nurses and doctors on my own unit. 20. On my service, my supervisors make all the decisions. I have little direct control over my own work. 21. The present rate of increase in pay for nursing service personnel at this hospital is not satisfactory. 2 2 .1am satisfied with the types of activities that I do on my job. 23. The nursing personnel on my service are not as friendly and outgoing as I would like. 2 4 .1have plenty of time and opportunity to discuss patient care problems with other nursing service personnel. 25. There is ample opportunity for nursing staff to participate in the administrative decision­ making process. 26. A great deal of independence is permitted if not required of me. 27. What i do on my job doesn’t add up to anything really significant. 28. There is a lot of “rank consciousness” on my unit, with nursing personnel seldom mingling with others of lower ranks. 2 9 .1have sufficient time for direct patient care. 3 0 .1am sometimes frustrated because all of my activities seem programmed for me. 31. i am sometimes required 12. A good deal of teamwork is present between various levels of nursing personnel in this agency. 16. There is a good deal of teamwork and cooperation between various levels of nursing personnel on my service. 1 7 .1have too much 1 5 .1 have too much responsibility and not enough responsibility and not enough authority. authority. 18. There are not enough 4. This agency offers opportunities for advancement opportunities for advancement/promotion. of nursing personnel at this hospital. 19. There is a lot of teamwork between nurses and doctors on my own unit. 2 . 1 have little control over my 20. On my service my work. supervisors make all the decisions. I have little direct control over my own work. 21. The present rate of increase in pay for nursing service personnel at this hospital is not satisfactory. 26. The types of activities 22. i am satisfied with the required of me are reasonable. types of activities that I do on my job. 7. The nursing personnel in 23. The nursing personnel on this agency are not as friendly my service are not as friendly and outgoing as I would like. and outgoing as I would like. 1 . 1 have plenty of time to 2 4 .1have plenty of time and discuss nursing concerns with opportunity to discuss patient my colleagues. care problems with other nursing service personnel. 25. There is ample opportunity for nursing staff to participate in the administrative decision­ making process. 6 . A great deal of 26. A great deal of independence is permitted if independence is permitted, if not required of me. not required, of me. 2 2 .1 have no doubt in my mind 27. What I do on my job does that what I do on my job is not add up to anything really really important. significant. 28. There is a lot of “rank consciousness” on my unit: nurses seldom mingle with those with less experience or different types of educational preparation. 3 5 .1 have sufficient time to 2 9 .1have sufficient time for accomplish my job direct patient care. responsibilities. 30 I am sometimes frustrated because all of my activities seem programmed for me. 1 1 .1 am sometimes required 31. i am sometimes required 178 to do things on my job that are against my better professional nursing judgement. 32. From what I hear from and about nursing service personnel at other hospitals, we at this hospital are being fairly paid. 33. Administrative decisions at this hospital interfere too much with the patient care. 34. It makes me proud to talk to other people about what I do on my job. 3 5 .1wish the physicians here would show more respect for the skill and knowledge of the nursing staff. 3 6 .1could deliver much better care if I had more time with each patient. 37. Physicians at this hospital generally understand and appreciate what the nursing staff does. 38. If I had the decision to make all over again, I would still go into nursing. 39. The physicians at this hospital look down too much on the nursing staff. 4 0 .1 have all the voice In planning and procedures for this hospital and my unit that I want. 41. My particular job really doesn’t require much skill or “know-how”. 42. The nursing administrators generally consult with the staff on daily problems and procedures. 4 3 .1have the freedom in my work to make important decisions as I see fit, and can count on my supervisor to back me up. 44. An upgrading of pay schedules for nursing personnel is needed at this hospital. to do things on my job that are against my better professional nursing judgement. 14. Based on feedback from nurses in other agencies, the pay at this agency is fair. to do things on my job that are against my better professional nursing judgment. 32. From what I hear about nursing service personnel at other hospitals, we at this hospital are being fairly paid. 33. Administrative decisions at this hospital interfere too much with patient care. 34. It makes me proud to talk 3 0 .1am proud to talk to other to other people about what 1 people about what I do on my do on my job. job. 3 5 .1wish the physicians here 3 1 .1wish the physicians here would show more respect for would show more respect for the skill and knowledge of the the knowledge/skill of the nursing staff. nursing staff. 3 6 .1could deliver much better 8. Nurse-patient ratios in this agency -are conducive to safe care if I had more time with each patient. patient care. 37. Physicians at this hospital generally understand and appreciate what the nursing staff does. 38. If I had the decision to 38. If I had the decision to make all over again, I would make all over again, I would still go into nursing. still go into nursing. 39. The physicians at this hospital look down too much on the nursing staff. 2 7 .1 have all the voice in 4 0 .1have all the voice in planning policies and planning policy and procedures for this hospital procedures that I want. and my unit that I want. 41. My particular job really doesn’t require much skill or “know-how”. 13. The nursing administrators 42. The nursing administrators generally consult with the staff generally consult with staff on on daily problems and daily problems and procedures. procedures. 4 3 .1have the freedom in my work to make important decisions as I see fit, and can count on my supervisors to back me up. 44. An upgrading of pay 18. Pay scales for nursing schedules for nursing personnel need to be personnel is needed at this upgraded. hospital. 20 Nursing staff have sufficient control of the total number of hours worked. 3. My co-workers are ___________ competent. 179 5. In this agency nurses are expected to perform non­ nursing tasks. 9. Which benefits do you currently receive from this agency: a) health insurance b) retirement c) day care (child/elder) d) vacation/holidays e) sick/maternity leave f) tuition 17. Nurses in this agency are encouraged to participate in continuing education. 2 8 .1am frequently asked to work overtime. 33. This agency financially rewards advanced training/education. 3 6 .1work weekends. 3 7 .1do not receive some benefits that are important to me. 39. Overall, I am very satisfied with my job. ____________ __ Question: If Stamps 1997 was available when UNO was devising their questionnaire would it have influenced the final product, i.e. the UNO questionnaire? It is my opinion Stamps 1997 would not have changed the formulation of the LIND questionnaire because: There is little changed from Stamps and Piedmonte 1986 to Stamps 1997 basically question order e.g. question 9 became question 2. Some negatively expressed questions were changed to the positive or vice versa, e.g. Most people do not sufficiently appreciate the importance of nursing care to hospital patients (old), to Most people appreciate the importance of nursing care to hospital patients (new). However LIND did not use this question. UND used or modified 28 of Stamps and Piedmonte 1986 questions of these 28 only 4 were changed in the Stamps 1997. These 4 questions have been highlighted entirely in bold print for ease of referencing. Ten questions are unique to UND questionnaire when assessing job satisfaction. These are listed at the bottom of column comparing UND. Most of these questions refer to benefits and rewards which is not explored by Stamps in either version. Since my research is based on research by UND it is important for me to keep the UND questionnaire so that I can do a comparison of my findings to the similar study done by Dunkin, et al. 1992. Also, UND is a more comprehensive study because it is attempting to assess job satisfaction and community satisfaction. Any version of Stamps is only assessing job satisfaction. From personal knowledge the shorter the questionnaire and ease of completing it, circle or tic marks, the better the chance of having the questionnaire returned. UND is user friendly plus it 180 allows me to explore community satisfaction. Time of filling out the questionnaire remains around 30 minutes. UND has modified wording to be used by nurses in community health. Stamps and Piedmonte 1986 or Stamps 1997 has the wording geared towards hospital nurses. This can be “off-putting” for a community nurse who has to fill out a questionnaire obviously devised for hospital nurses. This was a loudly voiced frustration of my colleagues when we went through our classification process with the amalgamation of the various branches of BCNU. Finally, Stamps (1997) in reviewing Dunkin, Stratton, (1994) which uses the same questionnaire as Dunkin et al, (1992) considers the UND questionnaire as a shortened version of Stamps IWS. Stamps (1997) comments on UNO’s use of the 5 point Likert scale stating “The correlation with responses to that item and overall score on the IWS was greater than .80, reinforcing the structural integrity of the IWS” (p.279). 181 Appendix C Letters of Verification and Perm ission to Survey Chart of Health Units 182 date Health Unit A ddress Dear I am a public health nurse and a graduate student at the University of Northern British Columbia in the Community Health Program . T he purpose of my research is to investigate the influence of job and community satisfaction on the retention of public health n u rses in rural British Columbia. Public health n u rses m ake a significant contribution to health care delivery in rural com m unities. The findings of this study may have future use by you and the health authorities in retaining public health n u rses in rural areas. This letter h as two purposes. The first purpose is to ask your perm ission to survey the public health n u rses in your health region. This mailed survey questionnaire would take place by the first of Decem ber. The second purpose is to ask you to verify the location of each office, the num bers of public health n u rses and the vacant positions in your health region. To facilitate this I have enclosed a chart with the offices for your a re a listed. Would you please en ter the information and m ake any n e cessary corrections to the list of offices? P lea se return by email m bbetkus@ m cbridebc.net or by faxing (250) 569-2355. I would like to thank you for your support and cooperation in my study. If you have any questions p lease contact me at (250) 569-3202 evenings (collect). For m ore information, you may also contact Martha M acLeod, Ph.D., RN, Chair of th e thesis com m ittee at (250) 960-6507, Nursing Program , University of Northern British Columbia. If you have any com plaints about this study please contact the Office of R esearch and G raduate Studies, UNBC at (250) 960- 5820. Sincerely, Mary H enderson Betkus, RN, BScN MSc Student Community Health 183 As senior manager responsible for public health nurses for (West) Kootenay/Boundary Health Unit Region, do you give permission to Mary Henderson Betkus to survey the public health nurses by mailed survey questionnaire? Y E S ______ NO _____ YOUR NAME This questionnaire will take place by the first of December. Please fill in the total number of public health nurses working in the sp ecific office regardless of whether they are full time or part time. Also note if there are any vacant public health nursing positions for each office. Indicate if the office is covered by a public health nurse from another office and which office. Please review the populations and addresses and correct if necessary. PLEASE RETURN TO FAX 250-569-2355 OR EMAIL TO mbbetkus@mcbridebc.net EXAMPLE: Office ‘Fort St. Jam es # of PHNs working and # of vacant PHN positions 2 PHN 0 vacancies Population Address Village 2,046 Bulkley-Nechako Subd.A 6,891 Box 1257, VOJ IPO W est Kootenay-Boundary Health Unit Region #2. Population Address ‘Castlegar City 7,027 RD 8,031 CKHU 813-10'" St., VIN 2H7 *Fruitvale Village 2,117 CKHU Box 10. 1947 Beaver St., VOG 1L0 ‘Grand Forks City 3,994 CKHU Box 25, 7343-4'" St., VOH 1H0 ‘Greenwood City 784 RD 15,354 ‘Kaslo Village 1,063 CKHU Box 167, 255 S. Government St. VOH 1J0 CKHU Box 309, 4'" St. VOG 1M0 ‘Nakusp Village 1,736 RD 8,031 CKHU Box 315, 611 Broadway St. VOG 1RO ‘Nelson City 9,585 CKHU 333 Victoria St. 2"" Floor, V1L4K3 ‘Trail City 7,696 RD 3,968 CKHU 1051 Farwell St. V 1R 4S9 Office T h an k You # of PHNs working and # of vacant PHN positions 184 Appendix D Letters For clarification of wording of the modified questionnaire. For C onsent to Participant First Follow-up letter S econd Follow-up letter For Individual Opening Mail 185 (Date) Nam e Director of Public Health A ddress Dear I am a graduate student at the University of Northern British Columbia in the Community Health Program . My thesis is to identify and exam ine the factors that public health n u rses find satisfying about their nursing practice and their rural community and the effect of this on retention in rural British Columbia. I am seeking your help in previewing my questionnaire for clarity of wording before it is sen t to rural public health nurses. You have been chosen b e cau se you m an ag e a health unit that provides service for a rural health region that serv es small tow ns with rural populations and rem ote com m unities. Your knowledge of rural public health nursing m akes your input valuable and will help to en su re that all questions will be understood. Previewing the questionnaire will take about 30 m inutes. Any ch an g es may be written on the questionnaire. Will you fax the questionnaire with your com m ents back to m e at 250-569-2232? If you have any questions please contact m e at (250) 569-3202 evenings (collect). For m ore information, you may also contact M artha M acLeod, Ph.D., RN, Chair of the th esis com m ittee at (250) 960-6507, School of Nursing, University of Northern British Columbia. If you have any com plaints about this study please contact the Office of R esearch and G raduate Studies, UNBC at (250) 960-5555. Sincerely, Mary H enderson Betkus, RN, BScN MSc Student Community Health UNIVERSITY OF NORTHERN BRITISH COLUMBIA November 30, 2000. Dear Colleague, I am a public health nurse and a graduate student at the University of Northern British Columbia in the Community Health Program. The purpose of my research is to investigate the influence of job and community satisfaction on the retention of public health n u rses in rural com m unities of British Columbia. You have been chosen to receive this questionnaire b ecau se you provide service for a rural health region that serv es small tow ns with rural populations and remote communities. As public health nurses w e m ake a significant contribution to health care delivery in our communities. The findings of this study may have future use by health authorities in retaining public health nurses in rural areas. The questionnaire will tak e approximately 20 minutes to complete. Your resp o n ses will be anonym ous. Confidentiality will be maintained by not identifying any individual resp o n ses. All data will be grouped. Only the researcher and the supervisors will have a c c e s s to the individual responses. The questionnaire will be kept in a secure place during the progress of the research and will be destroyed at th e completion of the study. The questionnaires are removed from the envelopes and the envelopes are destroyed before the questionnaire is given to th e researcher. For the results to be useful I need a s many questionnaires returned as possible. P le a se retu rn th e questionnaire in the enclosed stam ped addressed envelope by D ecem b er 15, 2000. Thank you in adv an ce for taking time in your busy schedule to com plete this questionnaire and supporting this important research. By returning the com pleted questionnaire it will be assu m ed that you are consenting to participate in the study. You are under no obligation to participate and you have the right to withdraw at any time. Executive sum m aries will be mailed to each public health nursing m anager of all participating health regions. A personal copy of the summary will be sen t directly to you by requesting it by emailing m bbetkus@ m cbridebc.net. If you have any questions please contact me at (250) 569-3202 evenings (collect). For more information, you may also contact Martha MacLeod, Ph.D., RN, Chair of the thesis com m ittee at (250) 960-6507, Nursing Program, University of Northern British Columbia. If you have any com plaints about this study please contact the Office of R esearch and G raduate Studies, UNBC at (250) 960- 5820. Sincerely, Mary Henderson Betkus, RN, BScN, MSc Student Community Health (//V/yERS/TY OF A/OF7WEF/V BF/T/SH COLOMB//^ December 18, 2000 Dear Colleague, Two w eeks ago you received a questionnaire from me. If you have already returned it thank you for your support in my research. If you have not returned the questionnaire would you return it at your earliest convenience? I am a public health n urse and a g rad u ate student at the University of Northern British Columbia in th e Community Health Program. T he purpose of my research is to investigate th e influence of job and community satisfaction on the retention of public health n u rses in rural com m unities of British Columbia. You have been chosen to receive this questionnaire b e c a u se you provide service for a rural health region that se rv e s Small tow ns with rural populations and rem ote communities. As public health n urses w e m ake a significant contribution to health care delivery in our com m unities. T he findings of this study may have future use by health authorities in retaining public health n urses in rural areas. The questionnaire will take approxim ately 20 m inutes to com plete. Your resp o n ses will be anonym ous. Confidentiality will b e maintained by not identifying any individual re sp o n ses. All data will be grouped. Only the research er and th e supervisors will h av e a c c e s s to the individual resp o n ses. The questionnaire will be kept in a secu re place during the progress of the research and will be destroyed at th e completion of th e study. The questionnaires are removed from the envelopes and the envelopes are destroyed before the questionnaire is given to th e researcher. For the results to be useful I need a s m any questionnaires returned as possible. P lease return th e questionnaire in the enclosed stam ped ad d ressed envelope at your earliest convenience. Thank you in advance for taking time in your busy schedule to com plete this questionnaire and supporting this important research. By returning the com pleted questionnaire it will be assu m ed that you are consenting to participate in the study. You are under no obligation to participate and you have the right to withdraw at any time. Executive sum m aries will be mailed to each public health nursing m anager of all participating health regions. A personal copy of th e sum m ary will be sen t directly to you by requesting it by emailing m bbetkus@ m cbridebc.net. If you have any questions please contact me at (250) 569-3202 evenings (collect). For more information, you may also contact Martha MacLeod, Ph.D., RN, Chair of the thesis com m ittee at (250) 960-6507, Nursing Program, University of Northern British Columbia. If you have any complaints about this study please contact the Office of R esearch and G raduate Studies, UNBC at (250) 960- 5820. Sincerely, Mary Henderson Betkus, RN, BScN, MSc Student Community Health 190 January 3, 2001 Dear Colleague, Four w eeks ago you received a questionnaire from me. If you have already returned it th a n k y o u for your support in my research. If you have n o t returned th e questionnaire would you return It at your earliest convenience? I am a public health nurse and a graduate student at th e University of Northern British Columbia in the Community Health Program . The purpose of my research is to investigate th e influence of job and community satisfaction on the retention of public health n u rses in rural communities of British Columbia. You have been chosen to receive this questionnaire b ecau se you provide service for a rural health region that serv es small tow ns with rural populations and rem ote communities. As public health n u rses w e m ake a significant contribution to health care delivery in our communities. The findings of this study m ay have future u se by health authorities in retaining public health n u rses in rural areas. The questionnaire will take approximately 20 m inutes to com plete. Your resp o n ses will be anonym ous. Confidentiality will be m aintained by not identifying any individual resp o n ses. All data will be grouped. Only the research er and the supervisors will have a c c e s s to the individual resp o n ses. The questionnaire will be kept in a secu re place during the progress of th e research and will be destroyed at th e completion of the study. The questionnaires are rem oved from th e envelopes and the envelopes are destroyed before the questionnaire is given to th e researcher. For the results to b e useful I need a s many questionnaires returned a s possible. P lea se return th e questionnaire in the enclosed stam ped ad d ressed envelope at your earliest convenience. Thank you in ad v an ce for taking time in your busy schedule to com plete this questionnaire and supporting this important research. By returning the com pleted questionnaire it will be a ssu m ed that you are consenting to participate in the study. You are under no obligation to participate and you have the right to withdraw at any time. Executive sum m aries will be mailed to each public health nursing m an ag er of all participating health regions. A personal copy of th e sum m ary will be se n t directly to you by requesting it by emailing m bbetkus@ m cbridebc.net. If you have any questions please contact me at (250) 569-3202 evenings (collect). For more information, you may also contact Martha MacLeod, Ph.D., 191 RN, Chair of the thesis com m ittee at (250) 960-6507, Nursing Program , University of Northern British Coiumbia. if you have any com plaints about this study please contact th e Office of R esearch and G raduate Studies, UNBC at (250) 960- 5820. Sincerely, Mary Henderson Betkus, RN, BScN, MSc Student Community Health 192 2000-11-30 To who ev er op en s th e mail: I have received perm ission to survey public health n u rses from the senior public health nursing m anager for your health region. T he m anager h as confirmed the num ber of public health n u rses in your office. Would you p lease give each public health nurse in your office a questionnaire to be com pleted and the attached stam ped self ad d re sse d envelope? Thank you for your cooperation. Sincerely, Mary H enderson Betkus, RN, BScN Public Health Nurse