P54 AYLWARD ARTICLE 6_6_11 54 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 NURSE RECRUITMENT AND RETENTION IN RURAL NEWFOUNDLAND AND LABRADOR COMMUNITIES: THE EXPERIENCES OF HEALTHCARE MANAGERS Mark Aylward, MN, RN1 Alice Gaudine, PhD, RN2 Lorna Bennett, MN, RN3 1Mental Health Nurse Case Manager, Eastern Health, NLmark_aylward@hotmail.com 2 Memorial University of Newfoundland, agaudine@mun.ca 3 Memorial University of Newfoundland, lorna@mun.ca Key Words: Rural Nurse, Recruitment, Retention, Rural Newfoundland and Labrador ABSTRACT Nurse recruitment and retention in rural Newfoundland and Labrador (NL) can prove to be a challenge for rural healthcare managers due to a variety of issues and factors. The characteristics of rural communities along with vast nursing shortages throughout Canada and the world can certainly contribute to those challenges. Research on the topic of nurse recruitment and retention in rural NL is limited, particularly from the perspective of rural healthcare managers. The purpose of this study is to explore and describe the experiences of rural NL healthcare managers contending with nurse recruitment and retention by using a qualitative descriptive design and using content analysis to analyze the data. The findings were categorized to outline barriers and facilitators to nurse recruitment and retention. Implications for further research on this topic are discussed, as well as implications for nursing practice and education. INTRODUCTION Healthcare systems in rural Newfoundland and Labrador (NL) and in rural areas around the globe are encountering major challenges. The challenge of nurse shortages is particularly significant as it may have a negative impact on adequate healthcare provision (Murray, 2002; Newhouse, 2005). The population of NL is aging, particularly within the rural and remote communities that spread hundreds of kilometers around the rugged coastline of the province. The impact of an aging population with increasing health demands and an out-migration of young professionals has created a strain on the rural healthcare systems throughout NL. This increased pressure on rural systems ultimately leads to an increased pressure on the urban tertiary health facilities because of the need for more advanced procedures and treatment. After the 1992 cod fishery moratorium in NL, rural communities that relied heavily on the fishery for economic stability have experienced some hardship. Individuals employed in some sectors of the fishery have sought employment elsewhere, or have obtained education for some other trade or profession. This means communities have experienced a vast out-migration of younger inhabitants. Because of the lack of opportunity in these communities, a majority of high school graduates and post-secondary graduates have opted for career opportunities outside of their home community, and even outside of their native province. With increased demands for registered nurses (RNs) outside of NL, new nurse graduates also opt to leave NL for better incentives elsewhere. As many RNs are currently, or soon will be eligible for retirement, nurse recruitment and retention has been a challenging obstacle for rural healthcare managers. The purpose of this study is to explore and describe experiences of rural NL healthcare managers with nurse recruitment and retention. A qualitative descriptive study design using 55 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 content analysis to analyze the data was used in this study. Healthcare managers not only contend with the urgency of recruiting nurses to their healthcare institutions and community settings, but they must also find creative ways to retain these nurses. By discussing the challenges and successes that these managers experience, valuable information and knowledge can be generated regarding the issue of nurse recruitment and retention in rural and areas of NL. RELEVANCE OF STUDY AND LITERATURE REVIEW A literature search was conducted to review current information about rural nursing and the associated factors for rural areas around Canada and the world. Based on this search, there was a dearth of literature specifically related to nursing recruitment and retention in rural NL. There is clearly a need to explore the issue of nurse recruitment and retention in rural NL. In our literature search, some of the issues pertaining to rural nursing in Canada that we have found, include the migration of nurses in and out of Canada (Pitblado, Medves, & Stewart, 2005; Little, 2007), predictors of career satisfaction for rural Canadian nurses (Penz, Stewart, D’Arcy & Morgan, 2008), and other general issues concerning nurses in rural Canada (MacLeod, Browne, & Leipert, 1998). The findings of these studies are relevant to recruitment and retention efforts to help us gain insight into the reasons why nurses move away from rural areas. Pitblado et al. (2005) used data from a national survey to assess migration patterns of rural Canadian RNs. This survey reported that NL was the province least likely to attract RNs who were educated in another province in Canada. In the year 2000 in particular, there were no RNs coming into NL from other provinces. At the same time, the RN workforce in the territories relied on attracting RNs from other provinces, including 12.8% of its overall RN workforce recruited directly from NL, or nurses who were originally from NL. In a discussion paper, Little (2007) noted that Canada is facing and will continue to face a major nursing shortage. Although Canada produces many nursing graduates per year, many of these nurses emigrate to other countries, the United States in particular. With the nursing workforce continuing to age, a net loss of nurses will continue in this country. Little (2007) further suggested that immigration of nurses into Canada from other countries will unlikely compensate for this loss of nurses. Therefore, Canada must develop strategies to attract, recruit, and retain more nurses. Predictors of job satisfaction for rural Canadian nurses were examined in a national survey of 944 registered nurses (Penz et al., 2008). Penz et al. (2008) examined individual, workplace, and community characteristics that may contribute to job satisfaction in rural health settings. Having adequate and up-to-date equipment, good scheduling, and less demanding workloads were workplace related factors associated with greater job satisfaction identified in this study. Satisfaction with living in the individual’s home community was also associated with job satisfaction. This suggests that displaying the benefits of rural lifestyle in recruitment and retention approaches could be beneficial. Our search for literature specifically addressing nurse recruitment and retention and nurse staffing issues in rural NL yielded limited findings. Interestingly, the Association of Registered Nurses of Newfoundland and Labrador (ARNNL) released a position statement pertaining to staffing issues in institutional settings (ARNNL, 2006). The statement noted that an important consideration indirectly related to nurse recruitment and retention is the necessity of adequate staffing levels to ensure the provision of safe patient care. Thus, the ability to recruit adequate numbers of RNs is essential for meeting appropriate standards of care. Dyson et al. (2002) also 56 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 released a discussion paper that focused on the recruitment and retention of health and education professionals in northern parts of Labrador. This document focuses on the many unique challenges to recruiting and retaining professionals in rural areas, emphasizing the need for further research in the development of recruitment and retention strategies specifically designed for rural parts of this province. Some of the challenges mentioned in Dyson’s et al. (2002) paper include the lack of basic services in some rural areas of Labrador, an aging workforce, lack of transportation options, and geographic isolation. Other factors noted in the literature that have an influence on rural nurse recruitment and retention include allocation of resources, geographical isolation, full-time employment, available technology, adequate staffing (MacLeod et al., 1998; Murray, 2002; Flynn, 2005; Lea & Cruickshank, 2005; Newhouse, 2005), good leadership, interdisciplinary teams (MacPhee & Scott, 2002; Kleinman, 2004; Flynn, 2005; Teasley et al., 2007;), educational opportunities, adequate orientation (Kleinman, 2004; Flynn, 2005; Lea & Cruickshank, 2005; Salt, Cummings & Profetto-McGrath, 2008), having rural connections (Lea & Cruickshank, 2005), and of course, salaries (Murray, 2002; Flynn, 2005; Newhouse, 2005; Teasley et al., 2007;). MacLeod et al. (1998) discusses the issues and challenges that many rural nurses face such as accessibility to adequate medical resources and geographic isolation. In some northern and coastal communities, the nurse is often the only medical professional available, and thus must take on multiple roles. When communities are widely dispersed, health centres can be hundreds of kilometers away from a patient in need of service. This results in transportation obstacles for the patient getting to a health facility, or for the community-based nurse who must travel to the patient. Newhouse (2005) also identified challenges to rural recruitment including geographic isolation, aging populations, and high turnover rates in staffing that lead to inconsistency in care. In Newhouse’s (2005) study, focus groups of nurse administrators were utilized to identify issues in rural healthcare settings, and to establish recommendations to address those issues. Some recommendations included improving access to care, and using alternative approaches to healthcare provision in rural areas in response to its unique characteristics. However, the study did not provide details as to what these approaches to healthcare provision should entail. Although many rural areas experience difficulties with nurse recruitment and retention, there are some positive aspects to rural nursing as well. Teasley et al. (2007) identified the managerial support and autonomy in rural nursing as positive factors that often entice nurses to rural settings. Providing adequate support to nursing staff can increase job satisfaction and improve workplace morale in any workplace, both rural and urban. MacPhee and Scott (2002) also examined the positive impact that managerial support can have on rural nurse recruitment and retention. These researchers also mention the positive impact that workplace social networks have on nurse retention in many rural settings. Flynn (2005) discusses general nurse retention strategies that may be beneficial for rural or urban centres such as having good orientation programs, ensuring adequate staffing levels, maintaining professional competencies, and providing strong managerial support. Most of the literature accessed in this search yielded much information pertaining to rural nursing recruitment and retention in general. However, literature specifically pertaining to nurse recruitment and retention in rural NL is very limited. Also, there are few studies that look at rural nurse recruitment and retention from the perspectives of healthcare managers. As a result, examining the experiences of healthcare managers in rural NL may contribute to an enhanced understanding of issues that surround rural nurse recruitment and retention in this province. 57 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 METHODOLOGY This study used a qualitative descriptive design to describe the experiences of rural NL healthcare managers contending with nurse recruitment and retention. Qualitative descriptive design does not utilize any one particular theoretical context, but commits to providing a descriptive summary of the phenomenon under study (Sandelowski, 2000; Polit & Beck, 2004). To analyze the collected data, content analysis as outlined by Graneheim and Lundman (2003) and Elo and Kyngas (2007) was used. Content analysis is useful when the intent of the research is to describe a phenomenon, and to gain an understanding of that phenomenon (Hsieh & Shannon, 2005). Qualitative content analysis includes developing categories for the data. This generation of categories involves a process of grouping data into sub-categories, and eventually reducing the number of overall headings by clustering similar sub-categories into broader categories. Participants A purposive sample of eight participants was used for this study. Nine participants were initially recruited, but one participant excluded herself from the study prior to data collection. We did note a trend of consistent findings from the eight participants, and no new categories were formulated. As such, we felt the number of participants was sufficient to meet the purpose of this study. The criteria for participation in this study included willingness to participate in the study, and current employment as a healthcare manager in a rural NL town or community. Rural NL community was not specifically defined in terms of population or geographic size, but could include any town or community other than any of the three cities in NL. The participants for this study were recruited from three different rural towns. All eight participants were female. Participant experience as a healthcare manager in rural NL ranged from six months to twenty- two years. Procedure A semi-structured interview guide was developed as the means of data collection for this study. Each participant was interviewed once and given the opportunity to contact the primary researcher if they later wanted a second interview to share additional experiences relevant to the study. Four of the participants were interviewed in person, and four were interviewed via telephone due to travel constraints. Participants were asked to select a location for interviewing that was convenient and private. All interviews were audiotaped for transcription purposes. Open-ended questions were used during the interview process, and we endeavoured to use minimal directive questioning in order to allow the participants to give their own detailed descriptions about their experiences with nurse recruitment and retention. Each interview began with the statement “Describe in as much detail as possible, your experiences as a healthcare manager contending with nurse recruitment and retention in your area.” We asked the participants to share specific examples and stories of their encounters with nurse recruitment and retention, and how their experiences with recruitment and retention had evolved throughout their management career. We sought clarification at times to ensure that the message intended by the participant was being received accurately. The participants in this study spoke of their experiences with nurse recruitment and retention in their work areas, including barriers and facilitators to recruitment and retention. At the end of each interview, participants were given the option to contact the primary researcher to schedule another interview if they later thought of experiences that they might have 58 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 neglected to share. However, none of the participants opted for a second interview. As indicated to participants prior to the study process, all interviews were then transcribed verbatim into text. Ethical Considerations This study was approved by the Human Investigation Committee (HIC) of Memorial University of Newfoundland (MUN), and by the Research Proposals Approval Committee (RPAC) of Eastern Regional Health Authority. When recruiting participants for this study, a written letter was mailed followed by telephone and/or email correspondence explaining the purpose of the study, and ensuring confidentiality throughout and after the study process. Furthermore, potential participants were informed that they could withdraw from the study at any time without prejudice. Data collected for this study is stored on password-protected electronic files, and hard data (typed transcripts, audiotapes) is stored in a locked cabinet. Any possible identifying information within the typed transcripts has been coded. Analysis Sandelowski (2000) points out that qualitative content analysis is usually the preferred approach to analyzing the collected data in a qualitative descriptive study. Qualitative content analysis is used to summarize the contextual meaning of the data to give a description of the phenomenon under study (Sandelowski, 2000; Hsieh & Shannon, 2005; Elo & Kyngas, 2008). The audiotaped interviews were listened to repeatedly to accurately transcribe the text verbatim. The researchers reviewed the typed texts for analysis. The transcripts were read repeatedly to identify commonalities and variances. Each transcript was read word for word in order to gain an understanding of the participants’ experiences in a context specific way. While immersed in the data, we coded data by making notes throughout each transcription (Graneheim & Lundman, 2004; Elo & Kyngas, 2008). During this process, we then categorized data that had some commonality. We coded and categorized barriers or deterrents to nurse recruitment and retention in rural NL, and facilitators or motivators to nurse recruitment and retention in rural NL. Initially, there were numerous categories created. We then condensed the categories by placing data into broader categories with the purpose of creating a general description of the phenomenon. This process was carried out until the researchers came to an agreement on the development of the categories. FINDINGS Through vigorous analysis of the collected data in this study, we were able to obtain rich data specific to nurse recruitment and retention in rural NL. Figures 1 and 2 outline the categories of barriers and facilitators to nurse recruitment and retention in rural NL respectively. Barriers As shown in Figure 1, a number of experiences and observations of barriers to nurse recruitment and retention noted by the managers have been clustered into categories. These barriers have been categorized as undesirable aspects of rural life. This category and its subcategories are described below. 59 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 Figure 1. Barriers to Nurse Recruitment and Retention in Rural NL Student debt No family ties in area → No employment for spouse Individual attitudes → Lack of services and resources Small institution size Diminishing population Isolation factors → Lack of full-time jobs Mainly float positions Decreased professional development Excessive overtime/workloads Lack of nurses in system Undesirable Aspects of Rural Life Commonalities arose in many of the participants’ experiences in relation to rural NL in general. Findings from this study show that decisions not to practice nursing in rural NL may be attributed to more personal reasons. It is also apparent from the findings that some people, including professionals such as nurses, deem rural and remote areas as having unattractive characteristics or an undesirable lifestyle associated with it. Sub-categories of this broad category include a) personal factors, b) rural NL characteristics, and c) limiting nature of rural nursing structure. Personal Factors Throughout many of the interviews with participants in this study, it was apparent that personal matters of the individual nurse often play a role in the decision not to practice in rural parts of NL. These characteristics of individual nurses that affect their decision not to practice in a rural setting can include factors such as student loan debt, or their connections to a particular community. One participant made the following observation pertaining to having no family ties in the rural area, “Sometimes they move because…. they have family in other areas, it is not always just the big bucks.” According to this participant, money is not always the major factor that may attract or deter nurses, but rather, having no family in the rural area is often a barrier to recruitment and retention. It was also noted that nurses often choose to stay or leave an area based on family commitments or career opportunities rather than monetary incentives. “So a lot of our staff are moving on for personal reasons, financial might not be the big thing. A lot of it is other family commitments, or wanting to move on in their career in areas that we can’t offer.” A constant factor noted by a number of participants in this study, was the lack of employment in rural NL areas for the nurse’s significant other or spouse. These healthcare managers noted that nurses are not enticed to relocate to a rural community when there is no employment opportunity for their spouse. “To attract the nurses to [name of community] they either have to have some family roots here, [be] dating someone, or have work for their spouse.” Personal Factors Rural NL Characteristics Undesirable aspects of rural life Limiting nature of rural nursing structure 60 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 This also applies to retention. When the significant other of a nurse has to relocate for employment purposes, the nurse also leaves. With a nation-wide nursing shortage, these nurses are able to be mobile. Nurses are commodities in many healthcare organizations throughout the country, thus they have a wide array of choices as to where they work. “They’re coming out pretty mobile and there’s a nursing shortage across the nation.” Another participant states, “….right now there’s nurses who are, you know, their spouses are working in Alberta and Alberta is crying for nurses like we are, you know, they can make more money out there.” Another interesting perception identified in this study with respect to personal characteristics was the participants’ reference to the sense of entitlement amongst younger nurses. One participant felt that many young nurses do not have the same work ethic that many seasoned nurses have, and that this attitude may contribute to some of the barriers that rural healthcare is facing. “….young people today grow up with a sense of entitlement…. you know, what does the world offer me? As opposed to, what can I offer the world?” Another participant in the study also had a similar opinion of young nurses. ….we’re finding that the attitudes of nurses have changed. It doesn’t seem to be what it was years ago. And nurses now come out with an attitude of, not what I can do for you but what you can do for me. And I’ve even heard [them say] ‘you should be thanking us for coming to rural settings.’ Rural NL Characteristics Many of the barriers to nurse recruitment and retention in rural NL identified in this study were perceived as being related to the structure and characteristics of rural and remote NL communities. Some of the participants had talked to nurses, and discovered that it was the limiting characteristics of these rural areas and the nursing position structure within rural health institutions that often deter the nurse from either coming, or staying for any length of time. For example, some of the managers spoke of the geographic isolation of many rural communities, and harsh weather conditions during the winter. These characteristics often dissuade individuals from moving to a rural area unless they have some vested interest in that particular location. “Some people just don’t want to live in a rural area. They have no desire to be in that area.” Common aspects of rural NL that the participants often referred to are the lack of social activities and services within many rural and remote communities. “The social aspects, there is no movie theatre here and shopping is [limited] here.” Other characteristics of rural NL identified by participants include declining populations, and limited availability of certain resources and services. As a result, many younger nurses are not enticed to reside and work in these rural areas. Another participant noted, “….we’re in a very rural setting and services are not in the community to keep these young people here.” Limiting Nature of Rural Nursing Structure The third sub-category developed from the identified barriers to rural nurse recruitment and retention is the limiting nature of rural nursing, or systemic structures. This sub-category encompasses limitations within the healthcare system itself that often deter nurses from practicing in rural and remote areas of NL. A component of the nursing structure referred to by some of the managers in this study relates to the requirements of nursing positions in rural NL. For example, many rural health facilities post nurse float positions, which require the nurse to work on two or more units, or even in different facilities. Some rural managers in this study feel that nurses are not attracted to these positions, but would rather work on a specific unit, that they 61 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 are familiar and comfortable with. “Unless they’re guaranteed a job there, they are not going to take a float position where they could be, you know, they are an O.R. nurse and they don’t want to be down on long-term care.” Another example of the limiting nature of rural nursing position structure in rural facilities is the posting of many temporary positions rather than permanent full-time positions. “I’ve found it extremely frustrating hiring people on temporary assignments for so long. I’ve just thought it’s criminal for people to be hired on temporary assignments all the time and have their lives disrupted.” Participants noted that some of the more difficult to recruit areas are usually institution-based units such as long-term care facilities or acute medicine units. As a result, when nurses on these units leave their positions to go into more desirable specialty positions such as community health, managers have great difficulty replacing these positions. ….people kind of like community health roles because number one, well not only the job and the skills and those things, but I guess the lifestyle. You know, they’re away from shift work and those types of things, so that in itself is enticing. So it’s not so much a problem getting them but it’s backfilling where they’re coming from… it’s a domino effect. As noted by this manager, when a nurse successfully obtains a more desirable position within the same organization, the manager may have difficulty replacing that nurse. Thus, the manager may be unable to allow the nurse to begin in the new position, resulting in the nurse being temporarily detained in his/her original position. Many of the managers interviewed also noted that there was a sense of low work satisfaction and low morale in their workplaces resulting from lack of adequate staffing. When replacement staffing is not available, nurses end up working excessive overtime resulting in stress, low job satisfaction, and potential burnout. As one manager pointed out, the cycle of lack of staffing and excessive workload leads to an inability to recruit. “If you don’t have staff, then workloads are bad and you can’t get time off, and that’s the messages that are out there, so nobody wants to come in.” The unavailability of replacement staff not only prevents nurses from obtaining vacation leave, but other forms of leave as well, such as education leave. Nurses are sometimes unable to avail of professional development opportunities because managers cannot replace them, or they are just simply tired of working excessively. One participant made note of the difficulty in utilizing professional development opportunities. “But the ability to use some of that [professional development] is often hampered by the fact that now you’re spending a lot of time doing overtime shifts or covering shifts, you know, it’s hard to implement programs when people are that stretched.” Facilitators Figure 2 gives an outline of facilitating factors to rural nurse recruitment and retention found in this study. The main category developed is the desirable aspects of rural life, which includes three sub-categories a) connection to the community, b) supportive work environment, and c) rural benefits. 62 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 Figure 2. Facilitators to Nurse Recruitment and Retention in Rural NL Family ties Spousal employment → Social networking Sense of belonging in community Full-time employment → Variety of experiences Professional development opportunity Independent practice → Opportunity for creativity Desirable Aspects of Rural Life This study yielded positive experiences from the participants in relation to nurse recruitment and retention in rural NL. Although recruitment and retention can prove to be challenging at times, the managers in this study shared their successes, and their perspectives of how they could improve on recruitment and retention strategies. They described the overall good qualities of rural nursing and rural life. Connection to the Community Some of the facilitating factors to nurse recruitment and retention in rural NL areas are actually two-edged. For example, having family ties and a sense of connection to the area, and having employment for the nurse’s significant other in the area were noted as facilitators to recruitment and retention. On the other hand, having no family connections, or no spousal employment, were identified as barriers to recruitment and retention. One participant made the following observation. “I guess that, to attract the nurses …. they either have to have some family roots here, [be] dating someone, or have work for their spouse.” The sense of connectedness within smaller institutions in rural NL was also identified as a positive factor in recruiting and retaining nurses in these small communities. “Everybody in your community and in the place you work, what I find is that everybody works together because that’s all you’ve got, that’s your support.” This sense of connectedness in rural areas creates supportive work environments, which is described in the next section. Supportive Work Environment Some of the participants in this study noted that they usually sense a supportive working atmosphere in small rural communities that promotes closeness and teamwork in the nursing workplace. “Nurses have been able to find a balance between work life and you know, probably because it’s such a small group they are able to socialize and mingle and become a social network inside and outside of work.” Another participant noted the benefit of interdisciplinary teams in rural health centres. Having the nurse as part of the interdisciplinary team so they have the support of the team members. I think that’s important and that’s been a very significant piece of retaining community mental health nurses because they do feel they have the support of their counterparts. There’s Connection to the community Supportive work environment Desirable aspects of rural life 63 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 only a small group of community-based mental health nurses in rural [NL] but I do feel there is good connectivity and there [are] good networks set up so that they have the support of each other. And again, it’s that working support and also the support of their team. To me that’s a success story. One participant felt that rural nursing often promotes independent practice, but at the same time, the nurse does have a team of professionals that they can connect and consult with. It’s an excellent way to start, you know, you have a certain level of independence that you wouldn’t have in a bigger center. So, that to me is a great benefit. And again, I guess it’s your network both socially and professionally, you know, they will work as part of a team. In this study, managers also identified professional development as being an important component in creating supportive environments for nurses. Furthermore, managers in this study realized that it is sometimes just showing respect for nurses that really helps in supporting nurses. “I think we have to be supportive to our staff. We have to be available to them as a manager.” Another manager noted, “….for the most part it’s just the little things, the day-to-day little things, you know, appreciating the extra mile that somebody’s gone, you know, just a smile in the morning and a ‘how are you doing.’” As explained by this participant, the little things may include showing signs of gratitude and appreciation for the nurse’s work and dedication. According to this participant, nurses appreciate being respected and thanked, and this may play a role in retention. It was also recognized that another supportive strategy in rural areas is to be competitive in the market for nurses by providing adequate salaries and bonuses, and incentives that recognize and value the work of nurses. “What I do think is positive is the monetary things that they’ve put in place for rural, you know, sign-on bonus, the bursaries while they’re still students which are tax free, and I think we offer relocation, living allowance for the first six months.” Another manager noted other support incentives such as housing. A mental health nurse that we had recruited, we arranged housing for her for a short time until she could get settled in and find a place of her own and those kinds of things. Sometimes, that’s major because if you are coming into a small rural community and you have no family here or contacts, if you don’t really know where you are going, you know, so if you can give someone a couple of months of housing, I think that works wonders. Rural Benefits. Some managers recommended promoting rural NL as an ideal place to live as a strategy to recruit nurses in their area. One manager gives a description of rural NL. “It’s a beautiful countryside. You’ve got the ocean there, you can leave your house and go on snowmobile in the winter, you know, the recreational aspects of living in [rural] Newfoundland are a huge plus that you can’t get in the city.” Another participant elaborated on rural NL as being a great place to live despite the lack of some services and resources. 64 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 It’s the lifestyle, it’s the pace, you know you’re not stuck in traffic jams and those kinds of things, so it’s that and sometimes rural Newfoundland gets a bad rap because there is nothing to do, but I mean there is lots of things to do. It depends on what your interests are, you know. If you are an outdoors person then what better place is there to be, right? But even in terms of a social network, um, like it’s so different in rural Newfoundland…. I think sometimes it’s easy to say, ‘well who’s going to come here?’ Because there is nothing here and we are our own worst enemies because we all say that, but there is a lot of people here, young couples starting their families and if you talk to some of them they’ll tell you that there’s no better place to be. So, sometimes I think we need to get out there selling the place and celebrating what we have right? There’s history, there’s site-seeing, there’s roots and a sense of belonging that you can’t really compare to anywhere else. So, there’s lots of good things to sell about rural Newfoundland. Although rural characteristics were found to be barriers to recruitment and retention, the findings of this study suggest some nurses appreciate rural life. Therefore, rural characteristics may also be facilitators to recruitment and retention, so promoting these rural characteristics may indeed enable recruitment success. DISCUSSION The findings from this study show that there are a variety of experiences amongst healthcare managers in rural NL with nurse recruitment and retention. The data analysis led to the portrayal of nurse recruitment and retention in these rural NL communities from two viewpoints, the barriers or inhibiting factors to rural nurse recruitment and retention, and the facilitators or aiding factors in rural nurse recruitment and retention. Some of the facilitators and barriers identified in this study are actually the reverse of each other. For example, spousal employment can be perceived as a facilitator or a barrier to nurse recruitment and retention in rural NL. With a lack of employment in many rural NL communities, many people have sought employment in other places, including places outside of NL. Over the past decade, the development of the Alberta oil sands has been attractive to many trades-people, including many Newfoundlanders and Labradorians. Unfortunately for the province of NL, many residents of the province have opted to relocate to Alberta as a result of better employment opportunities. In some cases, these residents included the spouses of nurses. When spouses of nurses are required to move to other areas for employment, nurses also leave, making it difficult for rural health managers to retain and recruit nurses. On the other hand, when there is employment for a nurse’s spouse in the rural area, retaining the nurse is much easier. Another example of a two-edged facilitator/barrier to recruitment and retention identified in this study is having a rural connection. Participants in this study pointed out that nurses are easier to recruit and retain when they have family relations in a rural community, whereas it is usually difficult to recruit and retain nurses who do not have any personal connection to the community. From all accounts of the managers’ experiences in this study, it is evident that nurse recruitment and retention in these rural NL communities has proven to be challenging in recent years, which is consistent with many rural and remote areas throughout Canada and other 65 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 countries. Many of the factors identified in this study are consistent with rural factors noted in the literature review. An increasing elderly population and decreasing younger population (Roberge, 2009), the isolating nature of rural communities, and a lack of resources and services have been described as challenges for rural nurse recruitment and retention. Anonymity and confidentiality in small rural communities also affect rural nurses as these nurses often know residents personally, and are usually active members within the community (McCoy, 2009; Roberge, 2009; Jackman, Myrick, & Yonge, 2010). As McCoy (2009) alludes to, this can lead to ethical dilemmas and role strain for the nurse. Other factors that have been found to affect rural nurse recruitment and retention in this study include having rural connections, patient workloads, professional development opportunities, adequate orientation, and salaries. It is apparent that many factors affecting nurse recruitment and retention in rural NL are not necessarily unique to rural NL, but also applicable to rural areas throughout Canada and the world. Salary is a major factor in recruitment and retention of nurses in NL and across Canada. At the time of data collection, nurses of NL were negotiating a collective agreement with the provincial Government that increased salaries to become the second highest paid nurses in Atlantic Canada for the next four years. Preceding this agreement however, NL nurses were the lowest paid in the country, which was identified in this study as a major disadvantage to recruitment and retention. Nurse recruitment and retention in NL was a major topic in the negotiations for that collective agreement, and it is hoped that the new contract will now aid in recruitment and retention efforts. There have been other interesting factors noted in this study that affect nurse recruitment and retention in rural NL that were not identified in the literature review. Such factors include spousal employment, sense of belonging in rural communities, social networking, attitudes of younger nurses, and the beauty of rural NL. The attitude of younger nurses was a notable concept mentioned by some participants in this study. It was mentioned that they have a different work ethic than older nurses. This perceived difference in work attitudes among generations of nurses is an interesting finding. Young nurses expect to advance in their careers quickly, and feel that their managers and colleagues should be thanking them for working with them. The older nurses, on the other hand, are resentful towards younger nurse graduates who acquire large signing bonuses for short contracts while they do not receive any such bonuses for their loyalty to the workplace. This often causes much tension and conflict between generations of nurses in some workplaces. The attitudes of younger nurses reflected in this study are not specific to rural settings, but may be applicable to other areas as well. The benefits of rural NL were acknowledged in this study. Managers talked about the serene lifestyle in rural NL communities. This lifestyle is attractive to many people, and may entice nurses to work in these rural communities. Many of the participants in this study felt that the beauty of rural NL should be portrayed in recruitment and retention initiatives. Marketing rural NL can be successful in attracting nurses that may not even realize the beauty of these rural communities. Thus, it is important that rural administrators consider marketing rural living as a recruitment and retention strategy. The role of managerial support in healthcare settings was also identified as an important component to providing supportive work environments, which is consistent with other research (MacPhee & Scott, 2002; Flynn, 2005; Salt et al., 2008). Nurses want to be appreciated for their work and expertise. Managers can show this appreciation through simple gestures of gratitude, or 66 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 by other means such as providing professional development opportunities and/or allowing flexible scheduling options. This is important for both rural and urban centres. The managers in this study did not elaborate on the human resources (HR) specialist role in nurse recruitment and retention. Two of the participants noted that they must work in constant collaboration with HR personnel while recruiting new nurses, but they perceived recruitment and retention as a dual role of both the HR person and the manager. Throughout this study, the participants talked about the importance of providing support to their staff as a retention strategy, and about providing adequate orientation and professional development as recruitment and retention strategies. Seven of the eight participants in this study were frontline managers, who were involved directly with nurse recruitment and retention, and throughout this study they have provided ideas for enhancing recruitment and retention strategies. However, these frontline managers are required to abide by organizational policies around recruitment and retention, and they are confined to specific budgets for recruitment and retention. Offering monetary incentives such as signing bonuses and bursaries, and the actual act of seeking new nurses, is the responsibility of HR. Further consultation between these frontline managers, senior administrators and HR may be necessary to boost recruitment and retention initiatives in rural NL. This study did not obtain the perspectives of nurses themselves as to why they choose not to work in rural areas. However, a probable reason for deciding not to work in rural healthcare may be the lack of opportunity for advancement in their career. Many rural settings have only one manager on site. There is usually minimal turnover in rural management, so frontline nurses may have little to no chance of obtaining a management position in a rural area. Furthermore, rural nursing mainly consists of clinical nursing. Rural settings usually do not have positions for clinical nurse specialists, nurse educators, or nurse researchers. As a result, many nurses may feel stagnant in rural settings because of the lack of opportunity for movement and advancement. To ensure credibility of this study, we remained true to the descriptions given by the participants. According to Sandelowski (1986), auditability of qualitative research refers to the consistency of findings when the research method is adhered to. To do this, we attempted to remain true to the method of qualitative descriptive design and qualitative content analysis by reading about this method. LIMITATIONS & IMPLICATIONS FOR NURSING A limitation to this study is the small participant size. Although there were no new categories created after analyzing six participant interviews, we would have preferred a larger participant size to ensure that no new themes would arise from the data. A second limitation is the selection of participants from one geographic region. As a result, the findings of the study may not be transferable to other areas. Four of the interviews were via telephone, which was more difficult to conduct than the in person interviews. A limitation of telephone interviewing is the inability to see nonverbal cues. We would recommend using in person interviewing and focus groups for future study on this topic. Focus groups may have been a useful data collection method for this study in order to allow brainstorming, and sharing thoughts and ideas about rural nurse recruitment and retention. This study has implications for nursing research. We recommend that research on the experiences of healthcare managers contending with nurse recruitment and retention be conducted in other rural areas of the island of Newfoundland, rural and remote areas of 67 Online Journal of Rural Nursing and Health Care, vol.11, no.1, Spring 2011 Labrador, and rural areas throughout Canada in order to obtain a broader scope of experiences of Canadian healthcare managers contending with nurse recruitment and retention. These studies could then be confirmed with studies of the experiences of healthcare managers living in other countries related to nurse recruitment and retention. We recommend further research on nurse recruitment and retention in rural NL from the perspectives of nurses themselves, as they may contribute more knowledge of the reasons why nurses stay or leave rural areas. Future study on the topic of rural nurse recruitment and retention may focus on the perceived and actual roles and responsibilities of HR. Studying multi-generational nursing in relation to recruitment and retention is another implication for nursing research. Do younger nurses really feel that rural managers should be thankful that they have decided to work in a rural setting? How do the attitudes of younger nurses affect rural nurse recruitment and retention? How do the attitudes of more seasoned nurses affect rural nurse recruitment and retention? This study also has implications for nursing education. MacLeod et al. (1998) points out that remote nurses often have a multispecialist role in that they tailor their practice to the culture and the needs of the community. Thus, nursing education may need to encompass the distinct aspects of rural nursing. In relation to recruitment and retention of nurses in rural areas, nurse educators may play a role in educating nursing students in the field of rural nursing. Nursing programs may be modified to allow compulsory rural placements. Implications of this research for healthcare administrators are also pertinent. Administrators must consider the barriers and facilitators identified in this study when planning and implementing recruitment and retention tactics. CONCLUSION We have described the experiences of eight rural NL healthcare managers contending with nurse recruitment and retention in their settings. We categorized these experiences under the headings of barriers and facilitators to rural nurse recruitment and retention. The participants within this study are experienced in human resource planning and the provision of health services, thus they offered rich information for planning recruitment and retention initiatives. Their experiences and perspectives contribute to a better understanding of the unique complexities rural managers often face when attempting to recruit and retain nurses. While discussing some of the barriers to recruitment and retention, it was our impression that the managers in this study at times expressed a sense of discouragement due to the inability to recruit and retain adequate nurse staffing levels to maintain optimal patient/resident care in their facilities. They also observed that these factors usually have a negative impact on the workplace environment. However, they have shared their successful experiences in recruitment and retention as well, giving way to some of the facilitators to recruitment and retention of nurses in rural areas. REFERENCES Association of Registered Nurses of Newfoundland and Labrador. (2006). Staffing for Quality Care in Institutional Settings: Position Statement. Canadian Institutions of Health Research, Natural Sciences and Engineering Research Council of Canada, Social Sciences and Humanities Research Council of Canada. (1998, with 2000, 2002, 2005 amendments). 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