Factors that influence the recruitment and retention of graduate nurses in rural health care facilities

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1 Factors that influence the recruitment and retention of graduate nurses in rural health care facilities Jackie Lea, Mary Cruickshank, University of New England Rural nursing is a distinct practice and rural nurses in Australia constitute the largest group in the rural health workforce. However, the rural workforce is ageing and the turnover of nurses in rural areas is high. In addition, rural health services are experiencing recruitment and retention difficulties; very little is known about the recruitment and retention of new graduates nurses in rural health areas and the potential long-term investment they could offer to rural health services. A qualitative study explored the journey of transition for new graduate nurses employed in graduate nurse transition programs in northern New South Wales. This paper presents two major themes from the study that describe the factors that influenced the new graduate nurse to seek and accept a graduate nurse position within a rural health setting and the factors that influenced their retention. Findings indicate that previous connection with a rural area and positive experiences in a rural health care facility during undergraduate preparation were significant factors influencing the graduate nurses' decision to pursue a rural graduate nurse position. No guarantee of a permanent appointment upon completion of the graduate program, and graduates disappointment with graduate nurse programs, were important factors influencing their retention within rural health care facilities. Key words: new graduate nurse, rural, retention, recruitment, graduate nurse programs Jackie Lea RN BN MN(Hons), Lecturer in Nursing, School of Health, University of New England. jlea2@metz.une.edu.au Mary Cruickshank PhD, Senior Lecturer, School of Health, University of New England Introduction New graduates have identified the transition process from student nurse to registered nurse as an extremely stressful and demanding experience, both physically and emotionally (Green 1988, Dufault 1990, Madjar 1997). For the new graduate in rural practice, the transition is further complicated by the unique role of the rural nurse. For example, rural nurses work in areas where there are limited health services, facilities, and medical practitioners. As a result, their role is multidimensional and requires a broad range of skills. Several authors have highlighted common elements of rural nursing practice, including nurses often being the primary care giver and jack of all trades, and nurses working in areas that may be without ancillary or medical support that sometimes necessitate them working beyond their legal boundaries (Blue 1993, Hegney 1996, Bridgewater 1998, Keyzer 1998). Rural nurses also have a high community profile, which often results in a blurring of roles and a lack of anonymity for them, as they often have to care for and work closely with people they know professionally, personally and socially. Rural nursing: recruitment and retention issues Since the late 1980s, there has been a growing body of knowledge in Australia that recognises rural nursing as a separate and unique identity from remote and metropolitan-based nursing (Blue 1993, Hegney 1996, Bridgewater 1998, Handley 1998). While much has been written in the past about remote area nursing in Australia, very little empirical literature exists regarding the recruitment and retention issues facing rural health care facilities and even less is known about the retention and recruitment of new graduate nurses. This is highly significant to the rural workforce because without current data regarding recruitment numbers of graduate nurses, retention data, and strategies to retain graduate nurses in rural settings, issues concerning the adequacy of the rural workforce will remain unresolved. To further highlight this point, the retention and recruitment of health professionals to rural areas has been acknowledged as a chronic problem in Australia (Hegney 1996, Bell et al 1997, Courtney et al 2002). Lack of access to adequate support, education and training are identified as commonalities influencing the 22 Collegian Vol 12 No

2 Factors that influence the recruitment and retention of graduate nurses in rural health care facilities retention of the rural nursing workforce (Hegney 1996, Bell et al 1997). In addition, the rural nursing workforce is an ageing one, and numerous reports have focused on the recruitment and retention of new graduate nurses as an important issue for rural health care facilities (Hegney 1996, Bridgewater 1998, Mosel Williams 2000, Cowin 2002). There is a low turnover of nursing staff in rural health care facilities compared to metropolitan and remote areas due to the stability of rural lifestyles and because many partners of rural nurses are employed within rural communities, such as the police force, teaching and farming (Hegney 1996). For the year 2002, there were less than 200 rural graduate nurse positions available within the New South Wales New Graduate Recruitment Consortium as opposed to over 1,000 available in metropolitan areas (NSW New Graduate Nurse Recruitment Consortium 2002 Report p5). Graduate nurse positions are limited in rural areas because of the small size of individual health services and rural health agencies vary in the number of graduate nurse positions they have available. Generally, large rural health care facilities can accommodate between four to six graduate nurses while smaller rural health care facilities can accommodate only one to two graduate nurses per year. Graduate nurse programs in rural health care facilities may include a rotation for periods of up to three months to smaller satellite health facilities within the region. While similar rotations occur in some metropolitan areas, the staff ratio and skill mix within smaller rural health facilities may require new graduates to practise with very little support and to work beyond the scope of their level of competence and experience. Blue (1993), Handley (1998) and Hegney (1996) have indicated that very few new graduate nurses enter the rural workforce, and those who do go to large regional health services. Very few rural health care facilities directly employ staff members, as they come under the umbrella of a regional area health service that recruits for the smaller rural facilities. For the small group of new graduate nurses who enter rural nursing practice there is often no guarantee of a permanent position once their graduate year is completed. This can be attributed in part to the low turnover of staff in rural health facilities. However, findings from Mosel Wiliams (2000) suggest that clinicians believe new graduates should seek experience in larger facilities upon completion of their twelvemonth programs; they are therefore not encouraged to stay on in rural facilities and are often discarded (not re-employed) after completion of their initial twelve months. Mosel Williams (2000) recommended that new strategies be developed to encourage beginning practitioners to continue their career in rural practice. Despite this recommendation, most new graduates continue to leave rural areas upon completion of their graduate nurse program to seek more permanent employment in metropolitan and regional centres. New graduate nurses who enter the rural workforce enter a professional practice very different from metropolitan practice and also from what they have experienced as an undergraduate student. It is likely that new graduate nurses in a rural practice setting will have to assume workload responsibilities that are vastly different from their metropolitan or regional peers. For example, Mahnken (2001) believes the role of the rural nurse encompasses community health and development activities, front line emergency care as well as acute and aged care services, and activities requiring skills in management, leadership and policy development. The implications of this for new graduate nurses entering rural practice is that they are often required to practise beyond the scope of the beginning registered nurse role and must take on management activities for which they have not been prepared. Furthermore, the diminishing infrastructure of rural towns and the subsequent restructuring of rural health services have impacted on the staffing ratios and skill mixes within rural health care facilities (Mahnken 2001). This can mean that the new graduate may be required to move continually between clinical units throughout one shift on a daily basis if other areas within the hospital are short staffed or when staff meal relief is required. As well, the new graduate who has very little, if any emergency experience, may be required to attend to the accident and emergency area, which in rural health care agencies is generally attached to an acute ward (Australian Universities Teaching Committee 2002). They may have to assume leadership and management responsibilities, particularly when required to rotate to smaller satellite health agencies where they are the registered nurse in charge of the ward with one enrolled nurse. As a result of these concerns, we wished to explore the factors influencing new graduates' choice to accept a rural graduate transition placement. Anecdotal data collected by one of us as Clinical Coordinator of an undergraduate nursing program indicated there was a body of student nurses keen to pursue rural graduate nurse placements. However, anecdotal evidence from rural health care agencies also indicated problems for rural agencies in retaining new graduates. For example, staff from some rural agencies reported that it is common and almost expected, for new graduates to exit the rural graduate nurse program before completing the full twelve months. Rural health care staff suggested that new graduates were perhaps leaving to pursue metropolitan practice because they were not happy with their rural placement choice. Alternatively, some staff commented that they felt graduates had accepted their rural graduate program offer, while still hoping to secure a placement in a metropolitan or regional health care facility. Although no evidence had been gathered to substantiate these claims, we believed the study could elicit information that which would either negate or substantiate them. Thus, the purpose of this study was to ascertain if new graduates had made well-informed decisions to go rural and if they had any regrets regarding their decision to enter a rural graduate nurse program. Method This qualitative study utilised a hermeneutic-phenomenological framework as described by Annells (1999 p8). Hermeneuticalphenomenology is a research design that is both descriptive and interpretive and uses the process of phenomenological reflection and writing to not only describe but also to provide understanding Collegian Vol 12 No

3 of phenomena experienced in life. Through analysis of the meaning of an experience, the experience having been expressed via text (van Manen 1997 p9), hermeneutical-phenomenology aims to identify and provide an understanding of the variety of constructions that exist about phenomena (Annells 1999 p8). The researcher interprets the subjective data to identify themes, commonalities and also aspects of the experience that may be unique (Annells 1999 p5). Using this framework we aimed to develop an understanding of the feelings/emotions, interactions and meanings that the new graduate had of their transition experience into rural practice. Thus, a hermeneutical phenomenological approach was the most appropriate framework to enable the aims and objectives of the study to be met. Sample The study used a purposive sample drawn from eight rural health care facilities of northern New South Wales (NSW). The inclusion criteria were that participants had to be employed as a new graduate nurse in the first year of a graduate nurse transition program, in a rural health agency. Ethics approval for this study was obtained from the University s Human Research Ethics Committee prior to the commencement of the study. To expedite the recruitment process, this Committee gave permission for interviews to be conducted in the participants homes. This avoided the time consuming exercise of having to obtain ethical approval from each health care facility. All participants were satisfied with this recruitment process. At the time of the study, one of us was the Clinical Coordinator of an undergraduate nursing program in NSW who regularly visited rural agencies and so knew the new graduates. Potential participants were initially approached away from their place of employment and asked if they would be interested in participating in the study and were then telephoned at a later date to arrange times for the interviews to be conducted in their own homes. The sample comprised ten participants who were well established in their 12-month graduate nurse programs. Participants were interviewed in quiet, private areas away from their employing agency to ensure confidentiality. The allocation of a pseudonym for each participant further ensured confidentiality. We acknowledge this small sample is not representative of the new graduate nurse population in rural practice; it was not the intention of the study to reach statistical conclusions or construct theories that could be generalised to the new graduate population. Rather, we wanted to obtain rich data via interviews to gain a better understanding of the experience of new graduate nurses making the transition into rural practice. The findings of this study have paved the way for a subsequent larger study. Data collection and analysis Data were collected using individual, semi structured, face-toface interviews. Each interview lasted approximately one hour, was audio taped and then transcribed verbatim. Participants were asked initially to explain why they had chosen to be in a rural graduate position and then asked to describe their experience of the transition process from student to registered nurse within the rural health care agency. Using a selective approach as described by van Manen (1997 p93), significant statements and commonalities were identified and formed into major themes, representing important aspects of the new graduates' experience. To ensure transcripts were accurate and complete, copies were forwarded to the relevant participant for validation of the content. Additionally, an experienced academic researcher verified the validity of the emergent themes. This paper focuses on two major findings that specifically explored why the new graduates decided to go rural and if they had any regrets regarding their decision. Findings Theme one: Having rural connections The main consideration for the majority of participants when making a decision regarding graduate nurse programs was having previous connections with a rural area. The new graduates all indicated a strong desire to complete their graduate nurse year in a rural agency. Most had chosen the facility in which they were now employed as their first choice for a graduate position with the NSW New Graduate Nurse Recruitment Consortium. It is evident from the data that being from a rural area originally was the main factor influencing the new graduates decision to participate in a rural graduate nurse program. Overall, many of the participants in this study had previously resided in rural areas and they either wished to return home for their graduate year or to remain in a rural area so they could be within commuting distance from their town of origin. This finding is similar to findings from Hegney and McCarthy (2002) who acknowledge it is not unusual for health professionals who were raised in rural areas and are familiar with the advantages of the rural lifestyle to be more likely to continue to work there following graduation. Two of the seven graduates who returned to their place of origin also had partners who were already residing and working in the rural town. This influenced their consortium choice. One of the seven participants had never lived in a rural area but accepted the position because her partner was employed within the rural community. Of the remaining three participants, two were not from rural areas nor had they previously resided in a rural area. Their reasons for going rural were that they wanted to experience a rural lifestyle. The remaining participant, who had previously resided in a rural community, commented that the geographical environment was an influencing factor. It is important to note all participants had experienced rural nursing practice at some time during their undergraduate clinical preparation. This had usually occurred using the preceptor model of clinical education within small rural agencies. It was evident that experience in a rural agency during undergraduate nursing preparation played a considerable part in the new graduates' decision. This was despite the lack of financial support for rural placements. Participants stated their placements at these agencies gave them the opportunity to become familiar with the agency, the services offered, the rotations offered and the prevailing ward 24 Collegian Vol 12 No

4 Factors that influence the recruitment and retention of graduate nurses in rural health care facilities and organisational culture. They also believed the placement provided them with a broad range of experience. This heavily influenced them when making their decision, as reflected by Joey s comment: what attracted me to come back after being a student here was not so much the individual staff but the way the staff on each level work together (Joey) The new graduates in this study had the potential to become committed members of the rural nursing workforce. However, at the time of the interviews, several participants were actively seeking and applying for other nursing positions. This was because they did not expect there would be positions available for them upon completion of their graduate nurse program. This predicament is not specific to this cohort of new graduates. A study of Queensland graduates by Mosel Williams (2000) found there is no expectation by the rural agencies for them to stay on after the 12-month period. In fact, rural clinicians believed that new graduates should seek more experience in larger facilities on completing their twelve months. It is interesting to note that three of the ten participants left their placements shortly after the interviews. Of these three, two left to take up permanent employment in regional and metropolitan areas, and one left to travel and work as a registered nurse overseas. The remaining seven participants were all aware there was no guarantee of a permanent position upon completion of their graduate year. However, because they had a strong desire to remain in the rural towns, they intended to accept an offer to join the casual staff pool in their employing agencies, and other agencies within commuting distance from their home, until a permanent position became available. Theme 2: Having regrets The participants in this study felt that their experience in rural health care facilities, as beginning registered nurses, had provided them with a broad range of experiences as well as a broad skill base. They stated that they enjoyed the diversity of rural nursing practice, and generally, in hindsight, did not have any regrets with their choice of entering rural nursing practice. Quite a few were keen to stay on in rural nursing practice upon completion of their graduate nurse programs. However, the participants expressed dissatisfaction and disappointment with several aspects of the new graduate programs. For example, they felt that the health care facilities had not delivered what was stated in graduate nurse program advertisements and at formal orientation sessions in larger regional agencies. Identified inconsistencies included: (1) offered ward rotations did not eventuate; (2) lack of formal support in the form of mentorship or preceptorship, or specific support person to refer to and spend time with; and (3) no formal or informal feedback regarding clinical performance, to indicate if performance expectations were met. Most of the new graduates had to travel to larger regional agencies for orientation at the commencement of their graduate nurse program. The orientation usually involved an introduction to the Area Health Service, its specific policies and procedures as well as an overview of what the new graduate nurse program entailed for that particular Service. It was at this point that the new graduates began to identify discrepancies in the information they had been given. The graduates who returned to the smaller rural agencies found that upon commencing employment their program did not progress as it was stated it would at the area level, and in fact that was the only orientation they received as exemplified by the following comments: Orientation at the Base was totally removed from what you re expected to adhere to once you arrive in your rural setting. what applied in the larger hospital did not really apply here. In actual fact there is not a specific program here with specific guidelines for a grad nurse. I had been told I would be doing a theatre rotation. It seems to be really dated information, perhaps there were theatre days but obviously they have been culled down (Sally) They said, you will go back and have another orientation day and you will be given a mentor or a preceptor. It didn t happen. I just turned up on shift and was one of two RNs (Hannah) What it is and what we were told almost amounts to two different things (Anne) Three participants felt that they were misled regarding the types of clinical services available at the health agency. These participants had no previous undergraduate clinical experience at these agencies and acknowledged that they had made assumptions about the services and the size of the agencies. They were disappointed to find that there were in fact only two rotations offered, the acute area or the long-term area, and also disappointed to discover their hospitals actually only performed minor day surgery cases. I am disappointed with the surgery. They only do minor cases. I don t know why but I thought they would cover all kinds of theatre even though it is a small hospital (Becky) While these three graduates had chosen to participate in the graduate nurse programs within these agencies they acknowledged that if they had undertaken undergraduate clinical experience in these agencies they probably would not have accepted these rural positions. They felt that having surgical experience was important for them during their graduate year and had they known, they perhaps would have pursued an agency that provided more surgical experience. Several other participants were also disappointed with the rotations they were allowed to complete within rural agencies. Five participants from the larger rural agencies believed that upon completion of the medical and surgical rotations they would be given an elective where they could choose a term in an area of high dependency. They stated they had accepted their graduate nurse positions based upon their undergraduate clinical experience in these agencies and a belief from the agency that they would be given exposure in high dependency areas towards the end of their graduate nurse program. However, staffing issues and financial constraints within these rural agencies resulted in the high dependency rotations being cancelled. For some this was their only regret about their choice for rural graduate nurse positions. Only three participants from this study actually received a rotation in an elective area. The remaining seven stayed in either medical or surgical areas for the duration of their graduate year. Disappointment with the lack of choice of clinical rotations and Collegian Vol 12 No

5 with the agency s inflexibility with specialty rotations resulted in one participant deciding to exit their graduate program before completion. The participant had initially been informed of available elective rotations but upon commencement was not given any choice regarding the rotation. Consequently, at the time of interview, the participant had already submitted their resignation and had accepted a position at a larger regional health care facility that had been able to guarantee the desired specialty rotation. The disappointment felt by participants with their clinical rotations during their graduate programs is not surprising. Their choice for clinical rotations support the findings of Heslop et al (2001) who identified the most common choices for clinical rotations for the graduate year are surgical, paediatrics, emergency, medical, critical and coronary care. There was little interest by participants in the Heslop et al (2001) study for aged care, nor community, oncology or palliative care and this is consistent with findings from this cohort of graduate nurses in rural practice. Recommendations and implications for practice Findings from this study indicate it is important to offer nursing students experience in the rural facility of their choice so they are made aware of that agency's graduate nurse program and can become familiar with the facility s prevailing organisational culture. However, there are several barriers to providing undergraduate nursing students with rural clinical experience. Increasingly, staffing pressures within rural health facilities are impacting on the ability of these facilities to support undergraduate students for clinical experience. Because it is not viable for small rural health facilities to accommodate large numbers of students, some universities need to rely on the preceptor model of clinical education. While the model has been an effective approach for many years, we are well aware that this extra preceptorship role, with its added responsibility, is impacting more and more on registered nurses due to the chronic shortage of registered nurses in the rural workforce. The personal cost for undergraduate nursing students attending clinical placements at rural health care facilities can also be the deciding factor as to whether they choose to undertake a rural clinical placement. This major concern has also been identified recently by Durey et al (2003 p150) who stated that health policies should include the provision of financial support for rural and remote students and promote a broad range of health careers as challenging and rewarding life choices. This financial burden has recently been addressed by offering scholarships to assist students travel and accommodation. This strategy is appropriate given that the graduates in this study who were from rural backgrounds had made the decision to return to the rural area following registration. While this has the potential to enhance the recruitment of graduates to rural areas, there is a need to increase the number and monetary value of undergraduate scholarships, and also to establish a consultative selection process between nursing academics and the funding bodies to determine appropriate applicants. Although disappointed with the lack of clinical rotations and structured support, five participants intended to remain in the rural facility as part of the casual staff until a permanent position became available. This demonstrates the interest as stated by some nurses in pursuing rural nursing practice. Despite this, it would appear from the findings of this study and from previous research (Mosel Williams 2000) that some rural health agencies do not place an emphasis on recruiting new graduates and do not see them as an important and long-term investment. The investment made in the development of graduates can be lost at the completion of their 12-month graduate nurse program. The implications for policy makers are that if new graduate nurses are not being encouraged to enter the rural workforce, or to practise for longer than 12 months in the rural workforce, the chronicity of the rural workforce shortage will continue. It appears from this study that the issue is not whether graduate nurses choose to enter rural nursing practice, but rather the constraining factors faced by rural Area Health Services such as the increasing commodification and rationalisation of health services within rural areas in retaining new graduates in the workforce. We recommend that rural nurses make a stronger case to Area Health Services who may not realise the potential longterm investment of new graduates. Addressing this long-standing problem of recruitment and retention is of vital importance to the salvation of rural nursing practice in Australia and it needs further discussion by rural nurses, health care policy makers, and the nursing profession. Need for further research This study has exposed areas warranting further investigation. A small qualitative study to identify the reasons why new graduates do not complete their graduate nurse programs could provide valuable information concerning the retention of graduates within rural graduate nurse programs. Additionally, further research to evaluate the effectiveness of the structure and content of graduate programs is warranted. The findings from such a study could identify the functional elements of these programs that would assist with future planning and development of rural graduate nurse programs. References Annells M 1999 Evaluating phenomenology: usefulness, quality and philosophical foundations. Nurse Researcher 36 (3):5 9 Australian Universities Teaching Committee 2002 Final report learning outcomes and curriculum development in major disciplines: nursing. School of Nursing & Midwifery, Flinders University, Adelaide Bell P, Daly J, Chang, E 1997 A study of the educational and research priorities of registered nurses in rural Australia. 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6 Factors that influence the recruitment and retention of graduate nurses in rural health care facilities Dufault M 1990 Personal and work milieu resources as variables associated with role mastery in the novice nurse. The Journal of Continuing Education in Nursing 21(2):73 78 Durey A, McNamara B, Larson A 2003 Towards a health career for rural and remote students: cultural and structural barriers. Australian Journal of Rural Health 11(3): Green P 1988 Relationships between role models and role perceptions of new graduate nurses. Nursing Research 37(4): Handley A 1998 Setting the scene: Rural nursing in Australia, Vol.1, Monograph Series in: Education, Training and Support for Australian Rural Nurses, Association for Australian Rural Nurses, University of South Australia, Whyalla Hegney D 1996 The status of rural nursing in Australia: a review. Australian Journal of Rural Health 4:1 10 Hegney D, McCarthy C, Rogers Clark C, Gorman D 2002 Why nurses are attracted to rural and remote practice. Australian Journal of Rural Health 10(3): Heslop L, McIntyre M, Ives G 2001 Undergraduate student nurses expectations and their self reported preparedness for the graduate year role. Journal of Advanced Nursing 36(5): Keyzer D 1998 Reflections on practice: defining rural nursing care. Australian Journal of Rural Health 6: Madjar I 1997 Project to review and examine expectations of beginning registered nurses in the workforce 1997, Nurses Registration Board of New South Wales. Retrieved October 2001 from the World Wide Web: gov.au/corporateservices/ hprb/nrb_web/exp_brns/title.htm Mahnken J 2001 Rural nursing and health care reforms: building a social model of health. The International Electronic Journal of Rural and Remote Health Research, Education, Practice and Policy 1(104). Retrieved February 2002 from the World Wide Web: Mosel Williams L 2000 New graduates in rural practice: a place for the novice nurse? Infront Outback, 5th Biennial Australian Rural Remote Health Scientific Conference, Toowoomba, 2000 New South Wales New Graduate Nurse Recruitment Consortium 2002 Annual Report. Retrieved December 2003 from the World Wide Web: http//nursecon.org. au/nsw/index.htm van Manen M 1997 Researching lived experience: human science for an action sensitive pedagogy, 2 nd edn. Althouse Press, Ontario Collegian Vol 12 No