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© 2007 National Rural Health Association 179 Spring 2007

ABSTRACT : Context: Effective recruitment and

retention of professional nurses is a survival strategy for

health care facilities, especially in rural areas. Purpose: This study examines the use of the Individual Workload

Perception Scale to measure nurse satisfaction by a small

rural hospital in order to make positive changes in the

work environment for nurses. Methods: Baseline work

environment perceptions of nurses employed in a rural

Kentucky hospital were assessed using the Individual

Workload Perception Scale, a validated 38-item

instrument. Nurses reviewed the results and

brainstormed on potential interventions to address areas

of concern. The 4 interventions selected for

implementation by the nursing staff included (1)

implementation of a shared decision making or

governance model; (2) enhanced role of licensed practical

nurses within the organization; (3) augmentation of

administrative support on night and weekend shifts; and

(4) utilization of wireless communication devices. After

implementation of the interventions, staff nurse

perceptions were reassessed using the same tool.

Findings: The follow-up survey revealed improvements

in all areas measured by the Individual Workload

Perception Scale, with the greatest improvement in the

perception of the work environment noted among night

nurses. The increase in positive work environment

perception among these nurses, with greater than or equal

to 11 years of professional experience, was statistically

signifi cant. Conclusions: Tools exist to support the

development and evaluation of interventions to improve

the work environment for nurses practicing in rural

health care settings. By addressing issues of specifi c

concern, both job satisfaction and retention of this

talented pool of professionals can be enhanced.

Prior research suggests that rural hospitals may be unique in their nursing workforce issues. 1 MacPhee and Scott reported in 2002 that recruitment in rural facilities can be problematic as it frequently takes rural

hospitals approximately 60% longer than urban facilities to fi ll nursing vacancies. 2 In addition, the current demographics of the rural nursing workforce are such that a large percentage of the staff may choose retirement within the next decade. The large number of vacancies caused by voluntary retirement may challenge rural hospitals as they seek to recruit and retain younger nursing professionals to nonurban areas. The recruitment of new nurses to fi ll vacancies may be particularly challenging given the lower salaries that have been reported to exist in rural institutions. 3 Furthermore, rural facilities frequently have fewer resources to support the needs of nurses working on the evening shift. 4,5

On the positive side, evidence suggests that nursing practice in rural areas has its advantages. According to a report, nurse staffi ng per occupied beds in rural hospitals was greater than staffi ng levels in urban institutions. 6 In addition, other research suggests that job satisfaction for rural nurses can be greater than that reported by urban nurses, particularly with respect to professional status, task requirements, organizational policies, and autonomy. 3 With the exception of pay, the results indicated that nurses employed in very small rural hospitals are more satisfi ed with their jobs. 3

The effectiveness of any organization is contingent upon its ability to recruit and retain high-quality staff. This is certainly true for rural health care organizations. 7 Ensuring a stable nursing workforce continues to be a priority area for nursing leadership in all facilities regardless of their size. This article

1 Patient Care Services, Children ’ s Mercy Hospitals and Clinics,

Kansas City, MO.

2 School of Nursing, University of Missouri—Kansas City, Kansas City MO.

3 Department of Nursing, Spring View Hospital, Lebanon, KY.

For further information, contact: Kathleen A. Sexton, RN, BSN, MA,

Patient Care Services, Children ’ s Mercy Hospitals and Clinics, 2401

Gillham Road, Kansas City, MO 64108; e-mail ksexton@cmh.edu .

Improving Work Environment Perceptions for Nurses Employed in a Rural Setting Susan L. Teasley , RN ; 1 Kathleen A. Sexton , RN, BSN, MA ; 1 Cathryn A. Carroll , PhD ; 1 Karen S. Cox , PhD, RN, FAAN ; 1,2 Michele Riley RN, MSN ; 3 and Kathleen Ferriell RN, MSN 3

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The Journal of Rural Health 180 Vol. 23, No. 2

describes how one rural hospital developed a system by which nurse perceptions of the work environment could be evaluated and enhanced, thereby serving as a tool to support retention of nurses within that institution. Specifi cally, the goals of the project were to (1) use nursing staff input to identify interventions that may improve the nursing work environment and (2) assess nurse perceptions before and after the adoption of these interventions to see if the desired results were obtained.

Methods Spring View Hospital is a 75-bed facility in a rural

Kentucky community of approximately 5,000, located about 60 miles from any major metropolitan area. The study population included a convenience sample of nurses in the hospital. After approval by a human subjects review committee, nurses across all practice settings and shifts were allowed to participate if they wished. Enrollment in the study was encouraged by the organization ’ s nursing leadership. Baseline data collection occurred in 2003 with a sample of 31 nurses and was repeated following implementation of study interventions in December 2004, using a second sample of 36 nurses. The respondents in the baseline and follow-up surveys were not all the same individuals. Data specifi c to nurse perceptions of the work environment before and after the interventions were collected using the Individual Workload Perception Scale (IWPS) and analyzed using SPSS version 12.0 (SPSS Inc., Chicago, Ill).

Equipped with the results of the baseline assessment, nursing leadership asked the nursing staff to participate in meetings that generated and prioritized a list of interventions for implementation (these are described in the Results section).

After the implementation of the intervention program, a second assessment of nurses ’ perceptions of the work environment was conducted using the IWPS. Thirty-six nurses agreed to participate in the postevaluation survey. Data analysis was carried out, and changes in nurse perceptions from baseline were reported to nursing leadership at Spring View for their consideration.

Individual Workload Perception Scale. Nurses provided data specifi c to their perceptions of key characteristics of the work environment through the completion of the IWPS. 8 The IWPS is a validated tool, with responses provided on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The instrument measures nurse self-reported perceptions of key characteristics of the work environment, including manager support, unit support,

peer support, and perceived workload. In addition, nurses ’ responses signal their intent to stay within the organization for at least the 12 months. An aggregate measure of overall nursing satisfaction can be computed using an average of the other domain scores. The psychometric properties (validity and reliability) of the IWPS, as tested in a sample of over 800 pediatric nurses, are described elsewhere. 9 Internal consistency has been demonstrated with the instrument, with Cronbach ’ s alphas ranging from 0.66 to 0.92. 9 The proven consistency of the tool motivated the primary selection of this instrument over other tools to assess nurse perceptions of the work environment. Also, the tool is short and can be completed without substantial time commitments on the part of nursing staff. In general, higher responses on the IWPS are indicative of more positive perceptions of the work environment across all domains.

Results The 4 strategies chosen for implementation, based

on nursing staff feedback gained through the baseline IWPS and nursing staff meetings, included (1) a shared decision making or governance model; (2) enhanced role of licensed practical nurses (LPNs) within the organization; (3) augmentation of administrative support on night and weekend shifts; and (4) utilization of wireless communication devices. These interventions cost about $225,000 to implement.

The fi rst intervention was the development of a nursing specifi c decision-making body, known as the Patient Care Council, to discuss and address important patient care issues through policy and protocol revisions. In addition, this group developed standardized policies for employee tenure, seniority for job selection, and absenteeism. These initiatives fueled staff participation in the shared governance model as a means of making differences in the nursing practice and work environment at Spring View Hospital. The adoption of the shared governance model occurred without additional economic burden on the facility beyond those costs of educating staff on the role members are expected to play in this type of governance model.

The second intervention adopted by the organization focused on staffi ng issues. Although the LPN has a more limited scope of practice than the registered nurse, LPNs are more readily available in rural communities so frequently faced with nursing shortages. 10,11 In addition, LPNs can alleviate staffi ng issues that occur because of census fl uctuations. 12 Another benefi t of the increased utilization of the LPN is that it permits nurses with other skill sets to coordinate care and evaluate outcomes.

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Teasley, et al. 181 Spring 2007

The third intervention focused on ensuring adequate managerial support for staff 24 hours per day. Nursing house supervisor positions were added to both the night and weekend shifts to provide staffi ng support, clinical guidance, and administrative oversight. Prior to this time, the emergency room charge nurses maintained a dual function of “ Staff Advisors ” in addition to their staff nurse and administrative liaison responsibilities.

The fi nal intervention focused on the use of wireless technology to foster effi cient communication between key stakeholders within the organization. Wireless phone systems were piloted to see if communication between nurses at the bedside and physicians, ancillary staff, family members, and others could be enhanced. The results of the pilot program were positive, as assessed by a separate questionnaire (not the follow-up IWPS), so the wireless phone system was implemented strategically within the facility.

Responses to the follow-up IWPS suggested that adoption of this multifactor strategic interventional program designed through the input of nursing staff was successful in improving nurse work environment perceptions, self-reported intent to stay, and overall nursing satisfaction. The greatest improvement in nurse perceptions occurred in the workload and intent to stay domain. Statistically signifi cant improved perceptions of workload were reported for registered nurses and individuals with more than 11 years in nursing. Interestingly, nurses working on the night shift appeared to report greater improvements in perceptions of their work environment than their colleagues working on the day shift ( Table ). The lowest level of improvement occurred in the unit support domain, which might be intuitive as the intervention was designed and primarily focused on nursing roles and not assistance by ancillary personnel. Improvements in manager and peer support were also observed but not to the same degree as the improvements seen in the nurse perceptions of their workload.

Discussion Opportunities exist, irrespective of geographic

location or facility size, to improve the working environment for nursing professionals. This article outlines an example of a simple method to assess nurse perceptions, design interventions based on the results obtained, and then reevaluate whether the desired programmatic goals were achieved.

The motivation for this evaluation was the recognition that unique issues exist for the recruitment and retention of nurses working in rural hospitals. It is

the responsibility of nursing leadership to provide a positive work environment for rural nurses. Signifi cant improvements in work environment perceptions for nursing were observed on the night shift, which may refl ect the increase in managerial support provided to night and weekend staff as well as the improved communication that was facilitated through technology. As such, the needs of all nurses working in the facility were covered 24 hours a day. 13

As with any investigation, limitations of this study exist. First, the recruitment for study participation was primarily driven by nursing leadership, which could bias results. Also, the study sample was small and within 1 institution, limiting the ability to generalize the fi ndings. The convenience sampling methodology as well as the differences in the individual nurses participating in the pre- and postassessment may have infl uenced the fi ndings. The limitations of this work and the dearth of literature specifi c to rural hospital nursing and work environment speak to the importance and need of future work in this area.

Comparison of Mean IWPS Scores * by Work Shift (Day/Night) of Respondent

IWPS Domains

Pretest, Days (n = 16),

Nights (n = 15)

Posttest, Days (n = 25),

Nights (n = 11)

Manager support Day shift 3.83 3.29 NS † Night shift 2.74 3.86 P < .003 Peer support Day shift 4.10 3.88 NS Night shift 3.52 4.23 P < .010 Unit support Day shift 3.72 3.30 NS Night shift 3.18 4.00 P < .001 Workload Day shift 3.47 3.47 NS Night shift 2.90 3.90 P < .004 Intent to stay Day shift 3.77 3.40 NS Night shift 2.77 4.28 P < .002 Nurse satisfaction Day shift 3.88 3.47 NS Night shift 3.05 4.04 P < .000

* The IWPS includes multiple items within the work environment domains of manager support, unit support, peer support, and perceived workload. Aggregate measures for the domains are presented here. Averages are based on a 1-5 Likert scale, with 5 being the most positive response.

† Not signifi cant.

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The Journal of Rural Health 182 Vol. 23, No. 2

Nevertheless, this small evaluation suggests that improving the work environment can improve overall satisfaction for nurses working in rural hospitals. Moreover, given the potential loss of experienced rural nurses in the near-term because of aging of the workforce, nursing leadership working in rural hospitals should seize the opportunity to improve workload for these individuals. A proactive strategy encouraging a healthy work environment for experienced rural nurses seems like a far more logical choice than enduring the lengthy delays in recruiting new nurses to fi ll vacancies. In this regard, our efforts support the fi ndings from prior efforts that suggest that rural nursing administrators and policy makers should give priority to retention strategies that focus on improving the job environment within rural hospitals. 14

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