Retainment incentives in three rural practice settings: variations in job satisfaction among staff registered nurses

Retainment Incentives in Three Rural Practice Settings: Variations in Job Satisfaction Among Staff Registered Nurses Terry D. Stratton, Jeri W. Dunkin, Nyla Juhl, and Jack M. Geller

Researchers have demonstrated repeatedly the importance of the relationship linking job satisfaction to employee retention. In rural areas of the country, where a persistent maldistribution of nurses continues to hamper health care delivery, the potential benefits of bolstering retention via enhancements in job satisfaction are of utmost utility to administrators and providers alike. Data were gathered from a multistate survey of registered nurses (RNs) practicing in rural hospitals, skilled nursing facilities, and community/public health settings (N = 1,647; response rate = 40.3%). The investigators found that the use of tuition reimbursement corresponded significantly with increased levels of job satisfaction among nurses in all three practice environments, as did day care services for nurses in acute care settings. Also, among hospital-based RNs, level of nursing education was found to be a significant factor in the relationship between tuition reimbursement and job satisfaction, with the highest level occurring among diploma-prepared nurses. Copyright © 1995 by W.B. Saunders Company

LTHOUGH THE SEVERITY of the nationwide shortage of nurses is thought to have eased markedly, select regions of the country continue to face uphill battles to recruit and retain adequate numbers of nursing personnel. Most notably in rural counties of the United States, where the overwhelming majority of the 622 federally designated nurse shortage areas are situated (Stratton, Ludtke, Juhl, Dunkin, & Geller, 1993), an increased supply of available nurses seemingly has been much slower to impact nursing delivery. Subsequently, the maldistribution away from rural practice settings, which has resulted in a mean registered nurse (RN)-to-population ratio roughly half that of metropolitan areas (Movassaghi, Kindig, Juhl, & Geller, 1992), does not appear likely to equalize anytime soon. BACKGROUND Staff Retention In light of the heightened demand and competition for nurses, recruitment and retention continue to be among the most widely discussed aspects of nursing delivery (Sills, 1993; Stratton et al., 1993). Typically, managerial and/or administrative leadership, including such related emphases as empowerment, staff recognition, and professional Applied Nursing Research, Vol. 8, No. 2 (May), 1995: pp. 73-80

advancement, have been the most studied approaches to retention (Ames et al., 1992; Klingesmith, Ivey, & Wall, 1993). Other researchers have stressed the importance of the educational experience, often touting the beneficial effects of apprenticeship programs and preceptorships (Cole-

From the Department of Behavioral Science, School of Medicine, University of Kentucky, Lexington, KY, and the College of Nursing and School of Medicine, University of North Dakota, Grand Forks, ND. Terry D. Stratton, MA: Doctoral Student in Sociology and Graduate Research Assistant, Department of Behavioral Science, School of Medicine, University of Kentucky, Lexington, KY; Jeff W. Dunkin, PhD, RN: Associate Professor and Coordinator of Research, School of Nursing, Medical College of Georgia, Augusta, GA; Nyla Juhl, PhD, RN: Associate Professor and Director, Graduate Parent~Child Nursing Specialty, College of Nursing, University of North Dakota, Grand Forks, ND; and Jack M. Geller, Phl): Associate Professor and Director, Rural Health Research Center, School of Medicine, University of North Dakota, Grand Forks, ND. Supported by the Office of Rural Health Policy in the Health Resources and Services Administration, United States Department of Health and Human Services Grant No. CSRO00005-OI-O. Address reprint requests to Jeri W. Dunkin, PhD, RN, Center for Nursing Research, School of Nursing EB-202, Medical College of Georgia, Augusta, GA 30912-4205. Copyright © 1995 by W.B. Saunders Company 0897-1897/95/0802-000555.00/0

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man, 1990; Dunkin, Semmen, Muus, Stratton, & Szigeti, 1995; Hitchings, 1989). Still others have focused on (a) organizational barriers within the individual institution and, on a more macrostructural level, on the impact of barriers inherent in the geographic environment (Cordes, 1989; Fuszard, Slocum, & Wiggers, 1990; Stratton et al., 1993); (b) the health care delivery system (Hall & Stevens, 1991); and (c) the profession itself (Curran & Miller, 1990). Especially in rural areas, where the subsequent influence of the costs (monetary and otherwise) associated with extended recruitment activities are substantial, nursing administrators have been urged to focus (when possible) their efforts on retaining existing staff rather than face the arduous challenge of attracting replacement personnel (Dunkin, Juhl, Stratton, Geller, & Ludtke, 1992; U.S. Department of Health and Human Services, Secretary's Commission on Nursing, 1988). As these staffing dilemmas continue to plague many rural settings, an even greater emphasis on retainment can be anticipated in the future. Job Satisfaction Although many significant forces thought to influence the retention of nurses have been identified, among the most consistent predictors has been satisfaction with one's job and the factors that shape it. For instance, Prescott and Bowen (1987) identified staffing, scheduling, lack of stimulation, supervision, and staff shortages as factors influencing nurse retention. Similarly, Prestholdt, Lane, and Mathews (1988) reported that work environment, beliefs concerning other employment options, advancement opportunities, and salary were related to job turnover. Pooyan, Eberhardt, and Szigeti (1990) found that satisfaction with promotion, performance constraints, supervision, organizational tenure, opportunities for participation, and salary constituted significant predictors of nurses' intentions to quit. However, because of environmental factors that are unique to rural settings, some researchers have suggested that job satisfaction may be perceived differently by nurses practicing in such environments (Coward, Home, Duncan, & Dwyer 1992; Dunkin et al., 1992; Fuszard et al., 1990). For example, Fuszard et al. contended that because of much smaller nursing staffs, lack of autonomy in

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clinical decision making was not perceived as a dissatisfier by rural nurses. In many cases, the void between personal expectations and professional reality is greatest with regard to salary. Dunkin and Stratton (1991), exploring variations in job satisfaction between RNs practicing in rural hospitals and those practicing in skilled nursing facilities (SNFs), found that nurses in both settings were least satisfied with salary, despite the fact that salary constituted the most important satisfier in their job. Sills (1993), examining the influence of a salaried compensation program, also found monetary compensation to be essential to staff retention. To alleviate exceedingly high rates of employee turnover, researchers have concluded that increasing retention by enhancing nurses' job satisfaction is best accomplished by implementing changes in the work environment (Lucas, McCreight, Watkins, & Long, 1988). However, as Prescott (1986) noted, a great deal of turnover-related research that centrally incorporates the notion of job satisfaction tends to focus on individual nurses as the unit of analysis, too often ignoring the influence of organizational factors. In a preliminary attempt to examine such factors, this study compared variations in nurses' job satisfaction across three rural practice settings, with specific emphasis on the use of various retainment incentives within each. Vroom (1964) identified five factors related to job satisfaction: working conditions, tasks associated with the job itself, relationship with coworkers, salary, and amount of control exercised by individuals in day-to-day activity. Researchers have further refined these broad categories, identifying specific aspects related to job satisfaction. For instance, Blegen and Mueller (1987), in their longitudinal study of nurses' job satisfaction, used a total of 13 separate theoretical determinants to comprise the construct of job satisfaction. Debate continues regarding both the theoretical composition of the job satisfaction construct itself and the validity of the measurements used to empirically tap all internal dimensions. Suffice it to say, then, that job satisfaction is thought to be a rather complex construct comprised of numerous dimensions. Although some studies have attempted to further elucidate the theoretical composition of job satisfaction, seven essential components (or dimensions) have appeared consistently throughout much of the literature.

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According to Stamps and Piedmonte (1986), task requirements are those things that must be done as a regular part of one's job. Autonomy is the amount of work-related independence, decision making, initiative, and freedom either permitted or required in day-to-day work activities. Professional status is the overall importance felt about nursing at a personal level as well as its importance to the organization and the community. Professional interaction is the component that encompasses the opportunities and requirements associated with formal and informal social and professional contact during working hours, including cooperation and respect from peers and supervisors. Organizational climate is the personality of the work environment, including the limits imposed on work activities by the organization's management, the leadership style of supervisory and administrative personnel, and institutional policies. Benefits and rewards are those compensatory perks (both tangible and intangible forms other than monetary compensation) that often are provided or awarded to provide recognition and advancement to nurses (e.g., performance awards, staff commendation, job-related benefits). Last, salary is the perceived adequacy of dollar renumeration received for work performed.

METHODS Sample The findings presented are based on a two-stage research design targeting RNs practicing in rural acute care, long-term care, and community health settings located in Arkansas, Colorado, Georgia, Montana, Nebraska, and Vermont. To avoid redocumenting regional trends, state selection was based on supply and demand projections for the years 1990 and 2000 (U.S. Department of Health & Human Services, Division of Nursing, 1988), with states approximated to be oversupplied, selfsustaining, or undersupplied. By varying these study populations, it was expected that a greater diversity of rural areas could be represented, this ensuring a more accurate reflection of the actual distribution of nurses. Because counties that are adjacent to metropolitan areas have been purported to be atypical both in terms of health care costs (Polangin, 1987) and demographics (Pickard, 1988), eligible facilities were required to be located in a county not within

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or adjacent to a metropolitan area. These facilities included hospitals offering, but not limited to, primary care services, long-term facilities licensed to provide skilled nursing care, and all public health settings as indicated by the most recent health facilities directory supplied by each state's department of health. Based on the criteria specified, a total of 222 hospitals, 271 SNFs, and 127 community health agencies comprised the target population. After obtaining the consent of each facility's director of nursing (DON) via a brief telephone interview that documented facility-based characteristics, more detailed questionnaires were sent directly to the DON for distribution to staff RNs. Respondents were guaranteed anonymity, and questionnaires were accompanied by a self-addressed stamped envelope. Because the number of eligible facilities in several of the states were quite small, all were included in the study. The final enumeration yielded 556 completed institutional interviews, representing a response rate of 89.67%. Within these 556 rural practice settings, a total of 8,719 questionnaires were sent to practicing RNs. Of these, 3,514 were returned, for an overall individual response rate of 40.3%. Response rates varied by practice setting, with hospitals garnering the lowest rate (37.59%), whereas those for SNFs and public health agencies were markedly higher (50.28% and 53.19%, respectively). Response rates among individual states did not vary substantially.

Representativeness To explore the possibility of a response bias, personal characteristics (i.e., age, sex, and educational preparation) of staff RNs were compared with similar state- and setting-specific data contained in the Division of Nursing's 1988 Sample Survey of Registered Nurses (U.S. Department of Health and Human Services). The greatest variation was found to be among the educational preparation of rural nurses, with the Sample Survey reporting 11% more diploma-prepared RNs and 8% fewer associate-prepared RNs. Age and gender of rural nurses did not vary substantially.

Survey Instrument The instrument was a two-part design, section one consisted of 37 job satisfaction-related items

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based on the Stamps and Piedmonte (1986) Index of Job Satisfaction. Nurses were asked to rate their satisfaction with, and the perceived importance of, each item on a five-point Likert scale, with 1 being strongly disagree and 5 being strongly agree for satisfaction and 1 being very unimportant and 5 being very important for perceived importance. Corresponding to the seven theoretical dimensions previously outlined, subscales included task requirements, organizational climate, professional status, salary, autonomy, professional interactions, and benefits and rewards. Section two included cultural, sociodemographic, and practicerelated questions. Reliability and validity testing included a pilot study of six health care agencies located in a state not included in this study. Content validity was established after a thorough review of the instrument by DONs in participating pilot agencies. Reliability for the satisfaction and importance scales were established using Cronbach's alpha, a test for internal consistency. The alpha coefficients for total satisfaction and total importance were .89 and .94, respectively. The use of retainment incentives was recorded by combining data gathered from the directors of nursing via telephone interviews (career ladders, continuing education, flex time, and educationand certification-based wage differentials) with those compiled from the self-report mail questionnaires of the individual staff RNs (health insurance benefits, day care services, vacation and holiday leave, and sick and maternity leave). One incentive, the use of tuition reimbursement, was asked of both DONs and staff RNs.

Research Design In addition to formalized administrative retention programs, many retainment incentives examined exist in the form of work-related benefits (e.g., health insurance). Although such incentives may not be perceived to be formalized retainment strategies per se, they can be assumed reasonably to have the potential to exert some retaining effect. Because many of these benefits are limited to fulltime employees, the following analyses are based on only those RNs who indicated full-time employment at the time of the survey. Furthermore, because previous analyses indicated that those RNs holding administrative positions were significantly more satisfied with their jobs than their staff coun-

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terparts, the analyses are based exclusively on staff RNs. Based on earlier findings that indicated that the most efficient model for predicting rural nurses' job satisfaction was not uniform across all practice settings (Dunkin & Stratton, 1991; Dunkin, Stratton, & Juhl, 1992), the analyses are presented independently for RNs practicing in each of the three practice settings. Last, to ascertain whether or not differential influences exist among individual nurses, analyses were performed that examine variations in job satisfaction among staff RNs in each practice setting based on educational preparation, annual income from nursing, and age.

RESULTS To better understand the relationship between retainment incentives and job satisfaction, it was necessary to examine the various aspects of job satisfaction within the context of the nurses' own value system (the importance of a particular factor to that nurse). Clearly, the importance a nurse assigns to any given factor will ultimately weigh heavily in his or her future plans. The job satisfaction of rural RNs in relation to the perceived importance each dimension holds for them is shown in Table 1. Salary and rewards and benefits exhibit the greatest disparity between perceived importance and current satisfaction. Nurses reported their present satisfaction with professional status to be most in line with its perceived importance. The use of incentives and job-related benefits thought to enhance the retention of nurses is shown in Table 2. Not surprisingly, the overwhelming majority of full-time staff RNs reported receiving vacation and holiday leave, with almost as many receiving some type of continuing education benefits. The least frequently used incentive was day care services, with only 6.4% (n = 103) of all nurses indicating they currently receive such benefits. Used as a data-reduction technique, the stepwise backward application of ordinary least squares (OLS) regression allows variables that make no significant contribution to explaining the variance of the independent variable (in this case, job satisfaction) to be removed systematically from the model. As nonsignificant variables are selectively dropped, the gap between the multiple correlation squared and the adjusted multiple correlation

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Table 1. Means of Dimension-Specific Job Satisfaction and Perceived Importance of Full-Time Staff RNs by Type of Rural Practice Setting Hospitals Dimension Professional status Professional interaction Autonomy Organizational climate Task requirements Benefits and rewards Salary Overall satisfaction

Satisfaction 4.04 3.51 3.45 2.81 2.76 2.58 2.46 3.05

Skilled Nursing Facilities

Importance

Satisfaction

4.34 4,37 4.22 4.25 4.00 4.06 4.43 4.22

3.97 3.52 3.57 3,20 2.75 2.70 2.52 3.15

Community/Public Health Settings

Importance 4.31 4.35 4.22 4.18 3.95 3.98 4.35 4.19

Satisfaction

Importance

4.25 3.79 3.72 3.16 2.79 3.30 2.01 3.29

4.43 4.38 4.23 4.18 4.05 4.01 4.46 4.23

All scale items are measured on a five-point scale; RNs, registered nurses.

squared narrows, resulting in a more parsimonious model. Ultimately, this allows independent variables to be segregated into two groups, that is, those that make significant contributions to explaining the variance in nurses' job satisfaction and those that do not. In all regression analyses used in this study, the pairwise deletion option was specified to minimize the cases lost because of missing data on any single independent variable. Before formulating the available variables into three separate, although singular, regression equations, a number of exploratory analyses were conducted to ensure that the sample population was adequately suited to such an analytic technique. First, a correlation matrix was constructed to diccern whether or not significant intercorrelations existed among any independent variables. No such relationships were found, hence multicollinearity was deemed not to be a problem. Second, for each

regression analysis, a scatterplot of the standardized residuals was produced to confirm that the slope of the regression line was not being biased by the presence of extreme outliers. In all instances, the distribution of the residuals closely approximated normality, which allows the use of linear OLS regression. Results from the stepwise backward regression analyses for staff nurses practicing in acute, longterm, and public/community health settings, combining the use of the 11 retainment incentives with the nonadministrative factors previously established to be significant predictors of job satisfaction (Dunkin & Stratton, 1991; Dunkin, Stratton, & Juhl, 1992), are shown in Table 3. For acute care nurses, tuition reimbursement and day care services both corresponded with higher levels of job satisfaction, although the influence of the latter was statistically significant only at the p ~<. 10 level.

Table 2. Retainment Incentives Received by Full-Time Staff RNs by Type of Rural Practice Setting Percent and Number of RNs Currently Receiving (n) Incentive Career ladders Continuing education Tuition reimbursement Flex time Education-based wage differentials Certification-based wage differentials Health insurance Retirement benefits Day care services Vacation/holiday leave Sick/maternity leave N = 1,647; RNs, registered nurses.

Hospital 27.7 92.8 82.7 57.9 25.6 73.9 85.2 70.2 7.0 97.1 91.3

(374) (1254) (1118) (783) (346) (958) (1141 ) (928) ( 87) (1302) (1200)

Skilled Nursing Facilities 26.3 78.8 58.5 54.8 27.2 45.0 71.0 43.1 5.1 94.9 73.4

(57) (171) (127) (119) (59) (90) (152) (88) (10) (206) (152)

Community/Public Health Settings 26.3 ( 5 9 ) 90.6 (203) 56.3 (126) 82.6 (185) 82.6 (185) 48.6 (101) 85.8 (187) 92.8 (206) 2.9(6) 99.6 (222) 96.9 (216)

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Table 3. Results of Stepwise Backward Regression Predicting Job Satisfaction of Full-Time Staff RNs in Three Rural Practice Settings Variables in the Equation Hospitals Alternative nursing employment options Satisfaction with community Intent to stay in present position Size of community employed Tuition reimbursement Recent nonnursing employment Annual income from nursing Years worked as RN Distance to town of 50,000 + Years in present community Importance of job satisfaction Level of nursing education Day care services (adult/child) Skilled nursing facilities Intent to stay in present position Alternative nursing employment options Tuition reimbursement Size of community employed Career ladders Community/public health settings Intent to remain in present position Satisfaction with community Tuition reimbursement Size of community employed Size of community raised Alternative nursing employment options Distance to town of 50,000+ Nonnursing employment options Age

!3

T

Sig T

Rz

-.255 .132 .122 -.112 .094 .081 .080 .082 .068 -.063 -.054 .056 .049

-8.85 4.46 4.15 -3.80 3.31 2.85 2.69 2.62 2.36 -2.14 -1.94 1.91 1.74

~.0001 ~.0001 ~.0001 .0001 .0010 .0044 .0072 .0087 .0182 .0323 .0518 .0564 .0822

.076 .097 .112 .121 .130 .139 .147 .150 .155 .159 .162 .165 .168 a

.319 -.191 .157 -.135 -.135

4.46 -2.66 2.09 -1.91 -1.79

~.0001 .0085 .0375 .0570 .0754

.129 .156 .170 .192 .208 b

.281 .218 .212 -.181 .153 -.150 .134 .128 .132

3.86 3.09 3.04 -2.46 2.19 -2.17 1.90 1.90 1.89

.0002 .0023 .0027 .0145 .0295 .0312 .0581 .0582 .0594

.074 .118 .139 .156 .175 .190 .210 .226 .242 c

Retainment incentives are coded "1" when used and "0" when not used; also, the incremental multiple correlation squared was obtained using the forced entry specification of regression analysis rather than the stepwise backward procedure. a (F(13, 1,058) = 16.39, p ~< .0001); b(F(5, 162) = 8.49, p ~< .0001); C(F(9, 171) = 6.05, p ~< .0001).

For full-time staff RNs working in rural longterm care settings, the use of tuition reimbursement is the only retainment incentive that contributed significantly to increased levels of job satisfaction. Curiously, the use of career ladders was associated with decreased job satisfaction, albeit at a level of statistical significance that was only moderate. For their full-time colleagues practicing in rural community health settings, only one incentive, tuition reimbursement, showed a significant impact on enhancing the job satisfaction of staff RNs. To test for the presence of a significant interaction effect, analyses of covariance (ANCOVA) were performed among staff nurses practicing within each type of setting: Does the relationship between strategy use and job satisfaction vary

among rural nurses because of some individuallevel attribute? Only one such interaction, that of tuition reimbursement and level of nursing education among acute-care RNs, was found to be statistically significant [F(2, 1,054) = 3.68; p < .05]; further analyses showed that the most dramatic increase in job satisfaction based on the use of tuition reimbursement existed among diplomaprepared RNs. Differences in job satisfaction among associate and baccalaureate-prepared RNs, although positively associated with the use of tuition reimbursement, were less pronounced. DISCUSSION Generally, the influence of most retainmentrelated incentives on rural nurses' job satisfaction

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has been shown to be negligible. However, the use of tuition reimbursement consistently corresponds with significantly higher levels of job satisfaction among staff RNs in all three rural practice settings. Indeed, tuition reimbursement (i.e., being payed to further one's nursing education) may influence nurses' job satisfaction in different ways. For example, with an increasingly greater emphasis being placed on educational credentials, attaining a higher educational certification (particularly a four-year degree, presumably the credential of choice) would logically enhance one's professional status. Enhanced autonomy also may result from the widened breadth of knowledge acquired via the baccalaureate education experience. Last, and perhaps most obvious, increasing staff RNs' levels of job satisfaction with regard to rewards and benefits as well as salary also may result from rural facilities' practices of financially subsidizing the educational process. In rural acute care settings, the differential impact of day care services on job satisfaction is less clear. Although it might be expected that acute care nurses, because of their comparatively younger age, would find this incentive more beneficial, the presence of preschool age children was tested using the ANCOVA procedure and was found not to be a significant factor. Because of the much larger numbers of hospital-based respondents, the moderately significant finding related to job satisfaction and the use of day care services also may be a function of the comparatively larger numbers of hospital-based nurses. IMPLICATIONS

Although the severity of the nursing shortage is thought to have eased, it continues to problematic in rural areas (Dunkin et al., 1995). This is of concern when placed in context of the shifting health care delivery system. As very ill patients move into the home community (both local hospital and community health agencies) for care, highly skilled nurses are needed to provide support for these patients. In rural areas, where access to both formal and informal educational experiences is limited, the potential for attaining the needed skills is lessened, adding unneeded strain, which may entice rural nurses to work in more urban settings. Therefore, the types of retainment incentives that rural nursing administrators can use to keep nurses in their facilities is of critical interest.

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In addition, knowing what incentive will do the most to maintain or increase the level of job satisfaction of staff nurses may help in making tough decisions about the expenditure of scarce resources. These analyses have attempted to discern variations in the levels of job satisfaction among rural RNs based on the presence of certain retainment incentives. However, it should be noted that although a causal order between retainment incentives and job satisfaction can be inferred theoretically, the necessary prerequisites to empirically demonstrate causality cannot be adequately satisfied given the cross-sectional research design. Because it is not known for certain whether implementation of the retainment incentives actually preceded nurses' reported levels of job satisfaction, directly attributing higher (or increased) levels of job satisfaction to the use of a given retainment incentive is not possible. Furthermore, it is likely that a generic retainment incentive, such as tuition reimbursement, includes various levels of reimbursement, a factor that could conceivably influence satisfaction levels. Clearly, future research should be undertaken with these issues in mind, obtaining more detailed information on the retainment incentives themselves as well as following up changes in nurses' levels of job satisfaction over time. In addition, although using tuition reimbursement as a retainment strategy may directly exert some positive influence on rural RNs' job satisfaction, the real issue facing rural administrators is that of efficacy. Is investing one's retainment efforts in tuition reimbursement the most costeffective method to ensure a reasonably low level of staff turnover and vacancy rates? Clearly, because such costs are not constant but rather can be expected to vary based on state of practice, distance to campuses, presence of distance learning, and percentage of tuition reimbursed by the facility, this is a question that must be answered solely within the context of each individual practice setting. The cost-effectiveness of paying for staff RNs to upgrade their educational credentials is dependent on a number of factors, perhaps not the least of which is the financial viability of the individual institution. However, whether or not money earmarked for staff retainment might be better spent on leadership training for nursing administrators, for example, is a valid question that was not tested

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in this study. C o n s e q u e n t l y , the next level o f research that e x a m i n e s the impact o f retainment incentives (via e n h a n c e m e n t s in satisfaction w i t h o n e ' s job) m u s t include s o m e measures o f cost associated with c o n t i n u e d implementation. O n l y w h e n the tangible worth o f such efforts parallels the merit associated with e n c o u r a g i n g m o r e highly

skilled nurses will nursing administrators feel c o m pelled to i m p l e m e n t such programs. ACKNOWLEDGMENT The authors gratefully acknowledge the statistical assistance provided by T. Robert Harris, PhD, Assistant Professor, Department of Mathematics, University of North Dakota.

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