The lure of the bush: Do rural placements influence student nurses to seek employment in rural settings?
Article Outline
- Summary
- Introduction
- Background to the study
- Methods
- Population and sampling method
- Procedure
- Results
- Discussion
- Conclusion
- References
- Copyright
Summary
The aim of this study was to investigate whether rural clinical placements for student nurses at a rural university in New South Wales influence their decision to join the rural and remote Registered Nurse workforce. The study utilised a convenience sample of final year Bachelor of Nursing students at a rural university campus, and consisted of two stages of data collection. Stage One employed a pre- and post-clinical placement survey design that elicited both demographic and qualitative data. Stage Two consisted of individual interviews with a sample of final year nursing students while they were on a rural clinical placement. The findings highlight the factors that influence final year students’ decisions to seek employment in rural healthcare facilities. These findings will be of interest to nurse academics concerned with ensuring that undergraduate nursing curricula relate to rural nursing practice in Australia and to those involved in recruitment of new graduate RN's to rural nursing practice.
Keywords: Rural nursing practice, Rural clinical placements, Nursing students
Introduction
Rural nursing is a distinct practice and rural nurses constitute the largest group in the rural health workforce. However, the rural nursing workforce is ageing, the turnover of nurses in rural areas is increasing, and attracting nurses to these areas is becoming more difficult. The possibility of attracting a substantial number of nurses from metropolitan and urban areas remains remote while there is an overall shortage of nurses in Australia. As a result, rural health services are experiencing recruitment and retention difficulties and a lack of attention to these workforce issues from universities and the Federal Government has further compounded the problem. Because of this little is known about the barriers surrounding the recruitment and retention of new graduate nurses in rural areas and if this situation is left to continue, the potential long-term investment that graduate nurses could make to the rural workforce will be lost.
In recent years, there has been increasing attention on nurse workforce planning both at state, territory and national levels in response to the nursing shortage in Australia. In 2004, the Federal Government announced additional nursing places in the higher education sector for 2005. However, according to the Australian Health Workforce Advisory Committee Annual Report (2004, p. 33), while these additional places will benefit the nursing workforce, ‘they will not be sufficient to meet projected demand based on replacement (turnover and retirements), population growth and ageing and increasing demand for health services’. An inadequate supply of nurses entering, and remaining in, the Australian nursing workforce will further compound the problem of recruitment in rural areas.
Background to the study
While much has been written in the past about remote area nursing in Australia, little empirical literature exists regarding the recruitment and retention issues facing rural health care facilities and even less is known about the recruitment of new graduate nurses in rural areas. According to Orpin and Gabriel (2005, p. 412), ‘there are still large gaps in the evidence base for the effectiveness of Australian undergraduate rural coursework and placements programs designed to increase the numbers of health graduates choosing rural practice’. This is highly significant to the rural nursing workforce because without current data regarding recruitment and retention issues and effective strategies to recruit new graduates into rural settings, problems concerning the adequacy of the rural workforce will remain unsolved.
New graduate nurses who enter the rural workforce enter a professional practice very different from metropolitan practice. Hegney (1996) believes that the difference between rural and metropolitan nursing practice may be attributed partly to the scope and diversity of rural nursing practice whereby the level of responsibility and skills differs from that of their metropolitan peers. The literature also identifies the positive and negative characteristics of rural practice. The positive characteristics include the broad, diverse clinical role associated with rural practice, greater autonomy enjoyed by rural health professionals, and the benefits of living in a small community such as community recognition, a country lifestyle that includes family and friends, and familiarity with patients (Barney, Russell, & Clark, 1998; Mitchell, 1996; Peach & Bath, 2000; Smith, Edwards, Courtney, & Finlayson, 2001; Talbot and Ward, 2000; Wolfenden, Blanchard, & Probst, 1996). Previous studies (Hegney, McCarthy, Rogers-Clark, & Gorman, 2002; Lea & Cruickshank, 2005; Neill & Taylor, 2002) have identified the negative aspects of rural nursing which include staff shortages, physical and emotional demands of the job, issues related to isolation, and inadequate support for new graduates.
While authors have identified the specific characteristics of rural nursing practice little is known about the effectiveness of recruitment strategies for undergraduate nursing students into rural settings. Some authors have suggested that graduates’ decisions regarding their choice of workplace employment can be influenced by the workplace exposure they gain as undergraduate students (Courtney, Edwards, Smith, & Finlayson, 2002; Glover, Clare, Longston, & De Bellis, 1998; Gum, 2007; Talbot & Ward, 2000). Furthermore, Nugent, Ogle, Bethune, Walker, and Wellman (2004) suggest that evidence, from the work of Courtney et al. (2002), indicates that pre-registration nursing students who have completed courses at rural and remote campuses may be more likely to enter the rural and remote nursing workforce. Murray and Wronski (2006, p. 37) also believe that ‘there is compelling evidence for the success of the “rural pipeline” (rural student recruitment and rural based education and professional training) in increasing the workforce’.
There is also a strong belief that a rural background influences the choice of employment in a rural area (Courtney et al., 2002; Lea & Cruickshank, 2005; Orpin & Gabriel, 2005; Playford, Larson, & Wheatland, 2006). In contrast, offering a rural clinical placement to students who are not from a rural background can provide them with the opportunity to become familiar with a rural work environment. Neill and Taylor (2002, p. 239) believe that encouraging and assisting students ‘especially those from an urban background to experience living and working in rural areas has been overlooked as a potential recruitment strategy’.
The emphasis in the literature is predominately focused on rural placements for non-rural students and there is not a lot of evidence to suggest that exposure to rural practice through rural clinical placements is having any substantial effect in a commitment to the rural nursing workforce (Orpin & Gabriel, 2005, p. 12). Therefore, the aim of this study was to investigate whether rural clinical placements for final year nursing students’ at a university located in rural New South Wales did influence their decision to join the rural Registered Nurse workforce.
The university is located in a large rural town whose population base and geographical location, or distance from metropolitan centres is such that it is considered to be rural using the Rural, Remote and Metropolitan Areas Classification Method (Department of Primary Industries and Energy, 1994, cited in Handley, 1998, p. 2). Furthermore, the university used for the current study, has previously been described by Nugent et al. (2004) as a rural and remote campus.
Although the University provides students with a choice of non-compulsory rural clinical placements throughout their 3-year undergraduate program, at the time of this study, there was limited rural curriculum content. It was anticipated that the findings from this study would assist nurse academics with the planning and design of greater rural curriculum content and rural clinical placements, which would better prepare student nurses for the rural workforce.
Methods
This study, consisting of two stages, was conducted in the final semester of the nursing students’ undergraduate 3-year program. The study utilised a convenience sample of all 75 final year Bachelor of Nursing students at a rural university in New South Wales in 2005.
Stage One employed a descriptive survey design. Data collection included two surveys which consisted of closed (yes/no) and open-ended questions. The pre-clinical placement survey asked students to identify why they had chosen a particular clinical placement and what factors encouraged them to choose this placement. The post-clinical placement survey sought to explore students’ perceptions of their clinical placement. In addition, this survey sought to identify positive and negative factors that could impact on their decision to enter the rural nursing workforce as a new graduate. The surveys were coded to assist in the identification of non-respondents and to match the pre-and post-survey respondents. Both surveys were piloted on a small sample of second year nursing students prior to distribution.
Stage Two consisted of individual in-depth interviews with a sample of final year nursing students while they were on a rural clinical placement. This stage utilised an interpretive approach to gain understanding of the student's perspectives of their experience working in a rural health service, the skills they felt were required to work in rural health services, the undergraduate preparation for rural nursing practice and the factors that would influence their choice to enter the rural nursing workforce. An Interview Schedule was developed from the data obtained in Stage One. Ethical approval to conduct this study was obtained from the University Human Ethics Committee prior to data collection.
Population and sampling method
The population under study consisted of all final year Bachelor of Nursing students at a rural university of New South Wales who were enrolled in clinical units of study in 2005 (n
=75). To ensure the avoidance of sampling bias and sampling error all final year student nurses enrolled in final semester clinical units were surveyed.
Procedure
Stage One
Prior to clinical placement, the pre-clinical placement survey plus duplicate Consent Forms were distributed to each final year nursing student and a copy of the Consent Form was retained by each participant. The post-clinical placement survey was placed in the students Clinical Practice Record Book which they took with them on clinical placement to have signed by the healthcare agency staff. The students were asked to fill in this survey at the completion of their clinical placement and prior to returning their Clinical Record Book by mail to the university. This method of returning the post-clinical placement survey with their Clinical Record Book helped ensure a high response rate, as return of the Clinical Record Book to the university is compulsory.
Stage Two
This stage was conducted while the students were on a rural clinical placement in Semester Two, 2005. Prior to clinical placement, potential participants were invited to participate in an individual interview. All final year students who indicated, in the pre-clinical placement survey form, a willingness to be interviewed during their rural clinical placement were included in the individual interviews (n=30). The aims of this stage of the study were explained and participants were asked to sign a Consent Forms. The participants were informed that the data collected during the study would be cleaned of any identifying names prior to data analysis to maintain confidentiality. Individual interviews were conducted with thirty final year students across rural northern New South Wales. A semi-structured interview technique was used and the 40–50min interviews were audio-taped with the participants’ permission. A recursive interviewing approach was used to collect data and four data generating questions guided the interviews:
Interviews were conducted away from the clinical placement healthcare facility and in the participant's own time to ensure privacy and confidentiality for the participants. The researchers believed that conducting the interviews with the students away from their clinical placement agency would reassure the participants that the study would in no way affect their future employment prospects within that healthcare facility, and it would also allow participants to speak freely about their experiences in the rural context.
In Stage One, analysis of the demographic items consisted of frequency distributions and the data from the open-ended questions were analysed using content analysis processes to draw common themes from the written text regarding students views and opinions regarding: experiences of rural clinical placements, career intentions, influences on seeking rural employment, preparation and skills required for rural nursing practice. Two of the researchers conducted separate content analysis of the data and then compared and contrasted their findings to establish interrater reliability. For Stage Two, the individual in-depth interviews were recorded and transcribed and thematic analysis was used to identify the key concepts and themes in the data.
Results
Stage 1: pre-clinical placement survey
There was an 81% response rate (n=57) for the pre-clinical placement survey. The majority of the respondents were aged between 18 and 25 years and were currently living or had previously resided and worked in a rural area. More than 50% of respondents indicated that their choice of a rural clinical placement was influenced by personal and financial factors. For example, the learning experiences available in rural health services, the culture of rural environments, financial considerations, and the students’ rural origins emerged as recurrent themes that influenced clinical placement choices.
The majority of respondents stated they had chosen a rural clinical placement because they felt they could obtain valuable experience in a rural practice setting that would assist them in their overall development as a registered nurse. Students believed that the broad experience they were exposed to would allow them to develop more independence and responsibility at this crucial time in their undergraduate preparation, particularly in an environment that would expose them to a wide variety of clinical experiences. In addition, respondents believed that smaller rural hospitals would allow them to practise and refine their generalist skills in a non-threatening environment where they felt they were included and made to feel part of the team.
Stage 1: post-clinical placement survey
The post-clinical placement survey yielded a response rate of 57% (n=40). Respondents identified the relaxed and friendly working environment of rural health services and the proximity of the rural health service to friends and family as positive aspects of their rural clinical placement that would influence their future employment intentions. Negative aspects of the clinical placement that students believe would discourage them from seeking rural employment were a lack of resources and technology, the patient acuity in rural health services, and the lack of support available for staff. Eighty percent of respondents believed that their undergraduate education had prepared them for rural nursing practice while 85% indicated that they would consider working in a rural health service at some stage in their career. This is consistent with the findings of Orpin and Gabriel's (2005) study. Of these respondents, 35% indicated that they wished to work in a rural health service upon completion of their undergraduate program. Recurrent themes in identifying the attributes that students felt were important for working in a rural health service were a broad knowledge and skill base, good interpersonal skills and effective time management and organisational skills.
Stage 2: results of in-depth interviews
Four main themes emerged from the data in Stage Two in relation to the students’ experience of the rural clinical placement.
Characteristics and positive influences of rural clinical placementsThe respondents focused predominately on the support offered to students by rural nursing staff. Students perceived the rural clinical environment as positive and friendly, nursing staff were ‘approachable and more supportive’, and ‘staff had more time to teach, encourage and give more attention’. Additionally, the students commented that rural nurses were very knowledgeable about the rural communities in which they worked, and the staff, ‘know exactly where the patients were coming from’. Students’ perceived the clinical experiences gained in the rural health services as having ‘provided a global view of what nursing was about’.
Skills required for rural nursing practiceThe respondents believed that the skills required in order to function as a rural nurse includes an ability to carry out the workload in isolation and switch their clinical focus quickly as well as being able to multitask. In addition, the students observed that rural nurses need confidence and initiative with decision-making and they also require an ability to communicate on many different levels. For example, one participant commented that staff members were ‘able to talk about the weather and know that rainfall is talked about in inches’. Refined observation and assessment skills were also observed to be imperative to the rural nurses scope of practice and many respondents commented that the rural nurses were confident in their scope of practice which is a necessity for effective rural nursing practice.
Adequacy of undergraduate preparation for rural nursing practiceMany of the respondents believed that block clinical placements that utilised a preceptorship model had greatly assisted them in their preparation for rural nursing practice. However, some participants felt that this model of clinical education was inadequate, as it had an isolating effect because there was not always sufficient registered nursing staff available to provide debriefing or support for the student. The students also revealed that more emphasis on the application of assessment skills specifically for rural clinical practice would have enhanced their undergraduate preparation because they realised how important it was for rural nurses to possess competent assessment skills.
Influences that impact on seeking rural employmentMany respondents felt that their final clinical placement in a rural health service had provided them with good insight into what their graduate year would be like in a rural health service. They also believed they would spend part of their professional life practising in a rural area which is consistent with the findings of the post-clinical placement survey and Orpin and Gabriel's (2005) study.
However, participants expressed concern and disappointment with the skill mix, the demanding workloads, and the graduate programs, particularly as they had observed that there did not appear to be a specific support person allocated to new graduates in rural health services. Even when a support person was available they were required to fulfil many roles and so were not available to provide ‘hands on’ assistance to new graduates. One participant remarked ‘they might have the best educator in the state but that person is not easy to get hold of and talk to’, while another also expressed her concern by saying ‘with 10 patients (to care for) I need to be able to access somebody all the time, day and night’! The respondents believed the graduate programs in rural health services did not provide adequate support for them with respect to skill mix and workload allocation and this was a factor that would discourage them from seeking rural employment. For example, one participant stated, ‘in the 3 days I have been here I have been given nothing positive of why I should come here’. These findings are consistent with the findings of Hegney et al. (2002) and Neill and Taylor (2002) that showed that emotional and physical demands of the job, staff shortages and inadequate support significantly impacted on the retention of nurses in the rural workforce.
The clinical rotations offered during a graduate program were of particular importance for the participants. Many of them wanted to rotate through specialty areas such as Intensive Care and Emergency Departments. The limited availability to these areas for new graduates was cited as a key factor in their choice for a graduate employment program.
Discussion
In this study many of the participants had rural origins and so their rural background increased the chances of them choosing a rural placement. This is not surprising as a correlation between a rural background and rural practice is well established in the literature (Courtney et al., 2002; Lea & Cruickshank, 2005; Orpin & Gabriel, 2005; Playford et al., 2006).
Half of the participants in this study opted to undertake rural clinical placements because of the nature of the rural working environment that students had previously experienced as being supportive, friendly and offering a diverse clinical experience. As a result, many participants felt that the rural environment would allow them to advance their nursing knowledge and skills. These findings are consistent with Dalton's (2004) study in which it was found that clinical practice undertaken in the rural environment provides optimal learning opportunities for students to advance their clinical knowledge and skills, and assists them with developing a professional identity. Students in this study confirmed the unique skills that rural nurses possess which allow them to communicate and function on many different levels. For example, the ability of the rural nurse to multitask and change their clinical focus quickly made a lasting impression on many of the participants. Students’ identified refined and well developed assessment and communication skills with individuals and the community, as specific skills required for rural nursing. This is consistent with the findings of previous studies that found that the rural nurse–patient relationships are at a deeper level, based on intimate understandings, because of the nature of the small rural community (Dalton, 2004; Orpin & Gabriel, 2005).
While the participants in this study felt well prepared for rural practice they could not recall specific coursework preparation for rural practice throughout their 3-year program. This finding is similar to Orpin and Gabriel's (2005, p. 12) finding which showed that students had ‘a patchy recall of coursework’. However, Orpin and Gabriel (2005, p. 12) also found that ‘the rural course content actually discouraged them from pursuing rural practice’, a finding which is not consistent with the findings of this study nor the previous findings by Lea and Cruickshank (2005).
Of particular concern in this study was that the participants had changed their minds in the final semester about seeking rural employment upon graduation. Initially, they believed that rural clinical placements throughout their 3-year program had encouraged them to pursue rural practice even though at times the preceptorship model was isolating and often not supportive of individual students needs. However, with the prospect of graduation looming, some participants now felt that the final rural clinical placement experience had actually discouraged them from pursuing rural practice. So, although they were initially keen to pursue rural practice, it appears that perhaps their interest may have been lost because of their expectations as new graduates and the realities of rural practice that were not consistent with their expectations of the graduate year. For example, the lack of allocated support persons for new graduates, the skill mix, and the demanding workload expectations that are experienced in rural health services were cited as factors that would discourage them from choosing rural practice. These factors need to be addressed by encouraging the “rural pipeline” which ‘involves recruiting students from rural backgrounds, delivering training in the regions, rural curriculum providing repeated rural exposures, and building regionally based postgraduate training pathways’ (Murray & Wronski, 2006). While the literature emphasises the need to recruit students from rural backgrounds, Neill and Taylor (2002, p. 239) also believe that students from both urban and non-urban backgrounds should be encouraged to undertake rural and remote clinical placements and identifying strategies to support students should be ‘an important strategic and funding priority’.
Conclusion
This study builds on previous work and it has provided further insight into rural healthcare facilities and rural nursing practice that positively and negatively influence students’ employment intentions. It has also identified factors that influence final year students’ choice for rural graduate positions. A limitation of this study is that these results only represent the responses of final year nursing students in one university so they cannot be generalized. Nevertheless, the results are consistent with the findings of previous studies and while many participants in this study indicated that they would take up a rural position, a longitudinal study is required to explore how many students actually followed through with their rural intentions once they graduated. Further evaluative research is also needed into undergraduate rural clinical placement experience, which will assist when planning and implementing the rural component in undergraduate curricula.
While government bodies, professional nursing groups, and rural employers are attempting to address the problem of recruitment and retention within the rural workforce, nurse academics can play a significant role at the grass roots level by providing more comprehensive exposure to rural nursing practice and rural course content in undergraduate curricula. They can also offer more support to rural clinicians who are often expected to preceptor student nurses and facilitate new graduates.
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PII: S1322-7696(08)00010-3
doi:10.1016/j.colegn.2008.02.004
Crown Copyright © 2008. Published by Elsevier Inc. All rights reserved.
