Concerns, Satisfaction, and Retention of Canadian Community Health Nurses

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Concerns, Satisfaction, and Retention ofCanadian Community Health NursesMarjorie Armstrong-Stassen & Sheila J. CameronPublished online: 07 Jun 2010.

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Concerns, Satisfaction, and Retentionof Canadian Community Health Nurses

Marjorie Armstrong-Stassen, MLHR, PHD,and Sheila J. Cameron, RN, EDD

University of Windsor

This study of Canadian community health nurses (N = 1,044) compared the work-relatedconcerns, job satisfaction, and factors influencing the retention of public health, home care,and community care access center (CCAC) nurses. Community health nurses identifiedsimilar work-related issues as being of greatest concern to them, but there were significantdifferences among the 3 groups of nurses in the magnitude of these concerns. There werealso significant differences among the 3 groups for satisfaction with their jobs and their im-mediate supervisors, with CCAC nurses being the least satisfied except for the greater dis-satisfaction of home care nurses with their pay and benefits. For the retention factors, thedifferences were primarily in the areas of job features and supportive work relationships.There are both similarities and differences among public health, home care, and CCACnurses. Initiatives to address community health nurses’concerns, improve their job satisfac-tion, and increase their retention will require interventions tailored to the specific commu-nity health care setting.

The objective of this study was to identify the work-related concerns of nurses employedin different community health care areas, their satisfaction with various aspects of theirjob, and the factors that are important in influencing their decision to remain in commu-nity health nursing. There has been little research on community health nurses in generaland especially on the work characteristics and organizational attributes that influence thedecision of nurses to remain in community health nursing (Cumbey & Alexander, 1998;Flynn & Deatrick, 2003; Jansen, Kerkstra, Abu-Saad, & van der Zee, 1996; Reutter &Ford, 1996; Simmons, Nelson, & Neal, 2001). There has been even less research compar-ing community health nurses employed in different types of community health care set-tings (Juhl, Dunkin, Stratton, Geller, & Ludtke, 1993).

In the province of Ontario, the majority of community health nurses are employed inthree health care areas: public health, home care, and community care access centers

JOURNAL OF COMMUNITY HEALTH NURSING, 2005, 22(4), 181–194Copyright © 2005, Lawrence Erlbaum Associates, Inc.

Correspondence should be addressed to Marjorie Armstrong-Stassen, Management and Labour Studies,Odette School of Business, University of Windsor, Windsor, Ontario N9B 3P4, Canada. E-mail: [email protected]

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(CCACs). About 30% of the registered nurses (RNs) employed in community health careare public health nurses, 33% are home care nurses, and 22% are CCAC nurses (Collegeof Nurses of Ontario, 2004). Public health nurses focus on health promotion and diseaseprevention in a wide range of settings, including workplaces, schools, community cen-ters, and other community agencies. Home care nurses focus on the care of individualsand their families in settings that include people’s homes, group residences, school class-rooms, shelters, and the street. In the mid-1990s, the Ontario Ministry of Health restruc-tured the home care system from a noncompetitive system to a system of managed com-petition in which agencies compete for contracts to deliver services. As part of thisrestructuring, CCACs were established throughout the province. There are currently 42CCACs that provide home care, placement services, and referrals. Both for-profit andnot-for-profit home care agencies bid for contracts with the CCACs to provide services(Denton, Zeytinoglu, & Davies, 2003). The agencies that can provide quality care at thelowest cost will win the contracts. RNs working in CCACs assess clients, develop careplans, and ensure appropriate services are provided.

Onthebasisof theempirical literature,we identified threecategoriesofconcerns relatedto community health nursing—client-related concerns, concerns about working condi-tions, and safety concerns. The client-related concerns include the increasing number ofclients and large caseloads (Baldwin & Price, 1994; Chalmers, 1995; Jansen et al., 1996),increasingly complex needs of clients (Chalmers, 1995; Evans, 2002), working with vul-nerable families with many problems (Fletcher, Jones, & McGregor-Cheers, 1991; Reutter& Ford, 1996), dealing with difficult clients and uncooperative family members (Baldwin& Price, 1994; Denton, Zeytinoglu, Webb, & Lian, 1999; Jansen et al., 1996; Stewart &Arklie, 1994), and not having sufficient time for client care (Baldwin & Price, 1994;Boswell, 1992; Reutter & Ford, 1996; Shuster, 1992; Stewart & Arklie, 1994). Concernsabout working conditions include continual change and uncertainty in programs being of-fered (Evans, 2002; Kipping & Hickey, 1998), lack of adequate resources (staff, equip-ment, facilities) to do one’s job (Baldwin & Price, 1994; Evans, 2002), time spent travelingto clients and the cost of maintaining a car for work (Baldwin & Price, 1994; Denton et al.,2003), and isolation from one’s agency base (Chapin, 1999). The safety-related concernsdeal with physical safety issues such as threats of physical danger or assault; unsafe, un-clean clients’ homes; and the danger of work-related injuries (Denton et al., 1999, 2003;Fagin, Brown, Bartlett, Leary, & Carson, 1995) as well as psychological distress—theemotional effects of the job (Fagin et al., 1995; Fletcher et al., 1991).

Researchers have investigated the job satisfaction of community health nurses in gen-eral (Boswell, 1992; Jansen et al., 1996; Riordan, 1991; Stewart & Arklie, 1994) as wellas the job satisfaction of public health nurses (Beall, Baumhover, Gillum, & Wells, 1994;Campbell, Fowles, & Weber, 2004; Cumbey & Alexander, 1998; Lucas, McCreight,Watkins, & Long, 1988) and home care nurses (Curreri, Gilley, Faulk, & Swansburg,1985; Lynch, 1994; Shuster, 1992). Only one study, conducted in the United States, wasfound that compared the job satisfaction of public and home health care nurses. Juhl et al.

182 Armstrong-Stassen and Cameron

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(1993) found that public health nurses were significantly more satisfied with benefits andrewards, task requirements, and professional status than home care nurses, but home carenurses were significantly more satisfied with their salary than public health nurses. Weexamined how satisfied public health, home care, and CCAC nurses were with their jobin general and various aspects of their job (pay, benefits, rewards, resources, equipment)as well as how satisfied they were with their immediate supervisor.

Given that community health nursing is predicted to play an increasingly importantrole in the Canadian health care system in the future, the retention of community healthnurses needs to be addressed (The Community Health Nurses’ Initiatives Group, 2000).We currently know very little about the job and work environment factors that are impor-tant in influencing the decision of nurses to remain in community health nursing. Weidentified those factors in the community health nursing literature found to contribute tothe satisfaction or dissatisfaction of community health nurses because there is a strongassociation between job (dis)satisfaction and turnover (Griffeth & Hom, 1995). The re-tention factors were grouped into three categories: job features, organizational factors,and supportive relationships. The job features include use of skills and abilities (Curreriet al., 1985), autonomy (Cameron, Armstrong-Stassen, Bergeron, & Out, 2004; Dentonet al., 1999; Flynn & Deatrick, 2003), participation in decision making (Cameron et al.,2004; Evans, 2002; Lynch, 1994), performance feedback (Braddy, Washburn, & Carroll,1991; Cameron et al., 2004; Fletcher et al., 1991), meaningfulness of job (Baldwin &Price, 1994; Denton et al., 1999), adequate time to do one’s job (Baldwin & Price, 1994;Boswell, 1992; Reutter & Ford, 1996), scheduling flexibility (Baldwin & Price, 1994;Braddy et al., 1991), and work–family balance (Doran et al., 2004; Evans, 2002; Lynch,1994). The organizational factors include compensation (Doran et al., 2004; Juhl et al.,1993), advancement opportunities (Beall et al., 1994; Chapin, 1999), training and devel-opment opportunities (Chapin, 1999), recognition (Cameron et al., 2004; Lucas et al.,1988; Lynch, 1994), and adequate resources (staff, facilities, equipment) to do one’s job(Evans, 2002; Fletcher et al., 1991; Flynn & Deatrick, 2003). Supportive relationships in-clude relationships with one’s supervisor and colleagues (Beall et al., 1994; Fletcher etal., 1991; Jansen et al., 1996; Stewart & Arklie, 1994).

This study was designed to address the following research questions:

1. Do public health, home care, and CCAC nurses express similar work-related con-cerns, or are there significant differences across these three areas of communityhealth nursing?

2. Do public health, home care, and CCAC nurses express similar levels of satisfac-tion with their job and immediate supervisor, or are there significant differencesacross these three areas of community health nursing?

3. Are the factors that are most important in influencing nurses’ decisions to remainin community health nursing similar or are there significant differences amongpublic health, home care, and CCAC nurses?

Concerns, Satisfaction, and Retention 183

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METHOD

Participants

The participants were 1,044 community health RNs employed in public health (n = 386),home care (n = 410), and CCAC (n = 248) agencies in Ontario. Their average age was 44years (SD = 9.62). They had been employed in their present positions an average of 8years (SD = 6.99), had been with their current agency an average of 8 years (SD = 6.85),and had worked as a nurse an average of 20 years (SD = 10.13). Half were employed fulltime and half were employed part time. The majority (85%) were married and over 98%were women. Close to 50% had a baccalaureate degree in nursing, 31% had an RN col-lege diploma, and 16% had a hospital-based school of nursing RN diploma.

Measures

Work-related concerns. We created a list of 17 concerns relevant to communityhealth nurses. Six of the concerns were client related (large caseloads, complex needs ofclients, working with vulnerable families, dealing with difficult clients and uncooperativefamily members, and time for client care). Seven of the concerns focused on working con-ditions such as changes in programs being offered, inadequate staffing, poor facilities, lackof equipment, travel time and cost, and isolation from agency base. Four of the concernswere related to physical safety and psychological distress issues (physical danger, unsafeclient homes, danger of work-related injuries, and the emotional effects of the job). The listwas prefaced with the statement: “Listed below are issues that are relevant to communityhealth nurses. To what extent is each of these a concern to you personally?” The responsecategories ranged from 1 (no concern at all) to 5 (a very great concern).

Job satisfaction. The nine job satisfaction items were adapted from the job satis-faction scales developed by Spector (1997) and Cammann, Fichman, Jenkins, and Klesh(1983). Five of the items referred to overall satisfaction (e.g., job is enjoyable, like doingthe things I do, like working here, and feel a sense of pride in doing my job). Four of theitems related to satisfaction with specific aspects of the job such as pay, benefits, rewards,and having the necessary equipment and resources to do the job. For the seven items as-sessing satisfaction with immediate supervisor, one was adapted from Ellickson (2002),three were from Gimbel et al. (2002), and three were developed for this study. The satis-faction with supervisor items referred to the respondent’s immediate supervisor allowingthem the authority to do their jobs, asking for their opinions on how to solve problems,being approachable, providing coaching and useful feedback, and noticing and showingappreciation for doing a good job. The response categories ranged from 1 (strongly dis-agree) to 5 (strongly agree).


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Retention factors. We generated a list of 20 retention factors. Eight of the retentionfactors were associated with job features—able to use skills and abilities on the job, au-tonomy, participation in decisions related to one’s job, feedback, meaningfulness of job,adequate time to perform one’s job, scheduling flexibility, and job duties that do not in-terfere with family responsibilities. Nine of the items were organizational attrib-utes—compensation (pay and benefits), advancement opportunities, training and devel-opment opportunities, recognition, and adequate resources (staff, equipment, facilities).Three of the factors involved supportive relationships with colleagues and one’s immedi-ate supervisor. Respondents were asked to indicate how important each of these factors isin influencing their decision to remain in community health nursing. The response cate-gories ranged from 1 (not very important) to 5 (absolutely crucial). The questionnairewas pretested with a group of nurses and based on their feedback, some modificationswere made to the questionnaire. One such modification was changing the original re-sponse category of extremely important to absolutely crucial.

Demographic variables. The demographic variables included setting currentlyemployed in (public health, home care, CCAC, other), current position, number of yearsemployed in current position, number of years employed in current workplace, numberof years employed as a nurse, work status (full time, part time), age, and marital status.

Design and Procedure

The protocol for this research project was approved by the research ethics board of the re-searchers’ academic institution. This cross-sectional descriptive field study was con-ducted in 2003. Questionnaire packets were mailed to 3,000 community health nurseswhose names were randomly selected from the College of Nurses of Ontario. The ques-tionnaire packets contained a cover letter from the researchers, an information consentform (used when questionnaires are anonymous), a questionnaire booklet, and a busi-ness-reply envelope for the return of the completed questionnaire. Nine questionnairepackets were returned because the person had moved, 21 questionnaires were returnedbut not completed, and 14 nurses declined to participate because they had retired re-cently, had an illness in the family, were no longer a community nurse, or were too busy.There were 1,524 completed questionnaires, giving a response rate of 52%. In this article,we have excluded those nurses (n = 223) who indicated they worked in a setting otherthan public health, home care, or a CCAC (such as family practice or physicians’offices),and those (n = 32) who did not indicate their employment setting. We also limited the dataanalyses to those who were practicing in the community and omitted those respondents(n = 225) who were in management-level positions.


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Data Analysis

To determine if there were significant differences among the three groups of communityhealth nurses for the work-related concerns, satisfaction, and retention factors, we usedmultivariate analysis of covariance (MANCOVA) with tenure (job, agency, nurse) andwork status as covariates. Tukey post hoc comparisons were conducted to identify signif-icant differences among the three groups of nurses. Researchers have found significantrelations between tenure and work status (full-time, part-time) and nurses’ assessment ofworking conditions, relationship with supervisor, and the importance ratings of variousretention factors (Cumbey & Alexander, 1998; MacRobert, Schmele, & Henson, 1993;Proenca & Shewchuk, 1997).

RESULTS

The means, standard deviations, and MANCOVA F values for the work-related concernsare presented in Table 1. Four of the five top-ranked concerns were the same across thethree groups of community health nurses, although the magnitude of these concerns andthe order varied among the three groups. The four concerns were inadequate staffing, in-creasingly complex needs of clients, working with vulnerable families with many prob-lems, and dealing with difficult clients. In their top five concerns, public health nurses in-cluded continual change and uncertainty in programs being offered. The top-rankedconcern for home care nurses was the cost of maintaining a car for work. CCAC nursesincluded the increasing number of clients and large caseloads.

There was a significant overall effect for setting, F(34, 1822) = 19.63, p < .001.There were significant differences among the three groups of community health nursesfor 15 of the 17 concerns. CCAC nurses reported significantly greater concern aboutclient-related issues, continual change and uncertainty in programs being offered, andinadequate staffing than did home care and public health nurses. CCAC nurses also ex-pressed greater concern about the emotional effects of the job than did the other twogroups of nurses. Home care nurses reported significantly greater concern over work-ing conditions (travel time to visits, cost of maintaining a car for work, isolation fromagency base) and safety issues (unsafe clients’ homes and danger of work-related in-jury) than did public health and CCAC nurses. Public health nurses reported signifi-cantly greater concern about poor facilities such as cramped office accommodationsthan did home care and CCAC nurses. For about half of the 15 concerns, public healthnurses reported significantly less concern than home care nurses, who, in turn, reportedsignificantly less concern than CCAC nurses.

Following the list of 17 concerns, respondents were asked to identify other issues thatwere of concern to them. Only 9% of the respondents responded to this request. Other is-sues identified as concerns were as follows:


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1. Lack of government funding: inadequate resources to do the job, staffing short-ages and staffing mix, bearing the brunt of clients’ reactions to program changesand cutbacks, employment instability, and a reduction in time spent for each clientand a decrease in number of visits

2. Lack of information and communication: lack information about work schedules,high-risk clients, program changes, and poor communication among team mem-bers and between CCACs and agencies

3. Lack of support: from management, physicians, and peers (not having someonewith whom to discuss cases)

4. Unclear roles: who is responsible for what5. Lack of access to technology: computers, cell phones, Internet, and up-to-date

technology, especially computers6. Lack of cooperation: between agencies, between agencies and CCACs, between

agencies and hospitals, between different types of community health care provid-ers, and between different types of community health nurses (diploma vs. degree)

7. Care-related decisions being made by nonnursing managers8. Workload demands: extra unpaid duties such as evening telephone calls and extra

paperwork being done at home, effect on family life, and unpredictable or fluctu-ating caseloads


TABLE 1Means, Standard Deviations, and MANCOVA F Values for the Concern Items

Public Health Nurses Home Care Nurses CCAC Nurses

Concern M SD M SD M SD F

Client-relatedIncreasing number of clients 3.14a 1.08 3.14b 1.07 3.97a,b 0.93 49.48Increasingly complex needs 3.22c,d 1.08 3.40c,e 1.01 4.06d,e 0.81 50.85Families with many problems 3.32f 1.17 3.34g 0.94 3.93f,g 0.84 29.11Dealing with difficult clients 3.19h 0.99 3.27i 0.96 3.80h,i 0.89 32.49Uncooperative family members 2.88j,k 1.05 3.20j,l 0.98 3.59k,l 0.92 39.42Insufficient time for client care 2.59m,n 1.06 3.01m 1.14 3.23n 1.13 27.51

Working conditionsChange in programs offered 3.29o 0.93 3.18p 1.02 3.74o,p 0.91 23.76Inadequate staffing 3.42q 1.07 3.54r 1.12 4.00q,r 0.96 25.95Poor facilities 3.06s,t 1.35 2.24s,u 1.09 2.64t,u 1.18 29.40Lack of equipment for care 2.37 1.11 2.52 1.04 2.52 1.03 3.75Travel time to visits 2.28v,w 1.04 3.26v,x 1.07 2.56w,x 1.21 68.83Cost of maintaining car 2.93y 1.23 3.81y,z 1.11 3.00z 1.30 56.23Isolation from agency base 2.11A,B 1.09 3.14A,C 1.17 2.41B,C 1.16 68.33

Safety issuesThreat of physical danger 2.38 1.06 2.45 1.05 2.37 1.09 1.47Clients’ homes unsafe, unclean 2.43D,E 1.21 2.95D,F 0.98 2.77E,F 1.07 24.57Danger of work-related injury 2.36G,H 1.03 2.93G,I 1.05 2.59H,I 1.11 29.72Emotional effects of the job 2.92J 1.06 3.22K 1.05 3.33J,K 1.08 14.19

Note. CCAC = community care access center. Means with the same subscripts differ significantly at p < .001.

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The means, standard deviations, and MANCOVA F values for the job and supervisorsatisfaction items are presented in Table 2. Community health nurses were relatively sat-isfied with their jobs in general. They liked doing the things they do at work and they felta sense of pride in doing their job. They were much less satisfied with their pay and thebenefits they receive. There was a significant overall effect for setting, F(14, 1908) =8.54, p < .001. There were significant differences among the three groups of communityhealth nurses for six of the seven job satisfaction items. CCAC nurses were significantlyless satisfied with their jobs in general, found their jobs less enjoyable, and were less aptto like doing the things they do at work especially in comparison to home care nurses.Home care nurses were significantly more likely to feel a sense of pride in doing theirjobs than the other two groups of nurses but at the same time expressed the greatest dis-satisfaction with their pay and benefits.

There was a significant overall effect for setting for the satisfaction with supervisoritems, F(14, 1982) = 8.22, p < .001. Public health nurses were significantly more likely tofeel that their supervisor asks for their opinions about how to solve problems and appreci-ates the work that they do than were home care and CCAC nurses. Home care nurseswere significantly more likely to feel that their supervisor allows them the authority andresponsibility to do their jobs well and that they can talk freely with their supervisorswhenever they have difficulties at work than were public health and CCAC nurses.CCAC nurses were significantly less satisfied with their supervisors than were publichealth and home care nurses. CCAC nurses were significantly less likely to feel that theyget coaching from their supervisors to help them do a better job, that their supervisors


TABLE 2Means, Standard Deviations, and MANCOVA F Values for the Satisfaction Items


Concern M SD M SD M SD F

Job satisfactionSatisfied with job 3.83a 0.79 3.81 0.80 3.66a 0.84 3.39*Job is enjoyable 3.97b 0.70 4.01c 0.66 3.72b,c 0.76 11.30***Like doing the things I do 4.04 0.60 4.11d 0.55 3.94d 0.60 6.57**Satisfied with benefits 3.16e 1.14 2.62e,f 1.12 3.10f 0.99 16.22***Satisfied with pay 2.94g 1.15 2.40g,h 1.15 2.99h 1.10 27.07***Like working here 4.01 0.64 4.01 0.65 3.90 0.74 2.03Feel sense of pride in job 4.06i 0.64 4.31i,j 0.58 4.16j 0.62 14.12***

SupervisorAllows employees authority 3.73k 0.98 3.97k,l 0.65 3.64l 0.84 12.82***Asks for employees’ opinions 3.64m,n 0.96 3.44m 0.97 3.44n 0.96 5.25**Can talk freely to supervisor 3.65o 1.06 3.87o,p 0.88 3.59p 0.99 6.21**Provides coaching 3.16q 1.05 3.29r 1.01 2.87q,r 1.01 11.67***Provides useful feedback 3.28s 1.11 3.20t 1.09 2.88s,t 1.14 12.21***Shows appreciation 3.64u 0.98 3.59v 0.86 3.37u,v 0.92 8.99***Appreciates job I do 3.34w,x 1.03 3.17w,y 0.99 2.87x,y 0.99 19.27***

Note. CCAC = community care access center. Means with the same subscripts differ significantly.*p < .05. **p < .01. ***p < .001.

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provide them with useful feedback about how they are performing their jobs, that thework they do is appreciated by their supervisors, and that their supervisors notice whenthey do extra things.

The means, standard deviations, and MANCOVA F values for the retention factors areshown in Table 3. Three of the 5 top-ranked retention factors were identical across thethree groups, although the order of ranking varied among the groups. Community healthnurses reported that feeling what they are doing on the job is really important, having ad-equate time to perform their jobs, and receiving adequate training for what they do on thejob are highly important factors in influencing their decision to remain in communityhealth nursing. There was a significant overall effect for setting, F(40, 1950) = 3.44, p <.001. There were significant differences across settings for 7 of the 20 retention factors.Public health nurses reported that being allowed to participate in decisions that affecttheir jobs, receiving adequate feedback on their job performance, and having good rela-tionships with their supervisors and colleagues were significantly more important to theirdecisions to remain in community health nursing than did home care nurses. Home care


TABLE 3Means, Standard Deviations, and MANCOVA F Values for the Retention Items


Retention Factor M SD M SD M SD F

Job featuresAble to use skills and abilities 3.77 0.83 3.75 0.92 3.82 0.79 <1.00Decide how to do my job 3.99 0.69 3.88 0.76 3.93 0.77 2.06Participate in decision making 3.82a 0.82 3.60a 0.93 3.74 0.90 3.61*Receive adequate feedback 3.68b 0.89 3.48b 0.96 3.62 0.92 3.41*Feel what I do is really important 4.10 0.78 4.16 0.71 4.12 0.72 <1.00Adequate time to perform job 4.10 0.68 4.13 0.75 4.22 0.75 1.70Ability to arrange hours, schedule 4.20c 0.75 4.20d 0.76 3.90c,d 0.90 10.84***Job duties do not conflict with

family responsibilities 4.04e 0.91 3.85e 0.92 3.94 0.89 3.49*Organizational factors

Adequately paid 4.07 0.82 4.15f 0.88 4.00f 0.87 4.30*Receive adequate benefits 4.03 0.77 4.05 0.91 3.97 0.87 1.94Opportunities to advance career 3.50 1.09 3.31 1.14 3.35 1.18 <1.00Receive adequate training 4.18 0.70 4.25 0.74 4.20 0.75 <1.00Professional development

opportunities 4.00 0.74 3.90 0.83 3.95 0.81 <1.00Receive recognition for job I do 3.71 0.87 3.68 0.95 3.78 0.92 <1.00Feel work is appreciated 3.97 0.84 3.98 0.84 3.97 0.82 <1.00Adequate staffing 4.05 0.82 4.00 0.95 4.18 0.87 2.65Good facilities and equipment 3.87 0.79 3.85 0.86 3.82 0.84 <1.00

Supportive relationshipsGood relationship with supervisor 4.07g,h 0.77 3.88g 0.84 3.81h 0.93 7.57***Good relationship with colleagues 4.17i 0.75 3.96i 0.84 4.09 0.79 5.17**Opportunities to share feelings

with colleagues3.81 0.86 3.67 0.89 3.81 0.91 2.87

Note. CCAC = community care access center. Means with the same subscripts differ significantly.*p < .05. **p < .01. ***p < .001.

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nurses rated feeling they are adequately paid as health care professionals as significantlymore important than did CCAC nurses, and both public health and home care nursesrated having the ability to arrange their work hours and work schedules as significantlymore important than did CCAC nurses.

DISCUSSION

Community health nurses identified inadequate staffing and client-related factors as theissues of greatest concern to them. These, along with the emotional effects of the job,were of greater concern to CCAC nurses than to public health and home care nurses.CCAC nurses, in particular, talked of the challenges they face providing assessment andcare to increasing numbers of clients. As one CCAC nurse commented, “Our assessmenttool now takes 2 hours or more to complete. Frail and unwell clients are exhausted and soam I at the end of the assessment.” CCAC nurses also talked of the constant change re-sulting in high levels of staff frustration. For home care nurses, aspects of their workingconditions (travel time, car costs, and isolation from agency base) and safety issues wereof greater concern to them than to public health and CCAC nurses.

The findings show that although there is similarity in what is of most concern to thethree groups of community health nurses, there were significant differences in the levelof concern across the three settings, with CCAC and home care nurses expressing greaterconcern about aspects of their jobs and working conditions than did public health nurses.The results indicate that researchers should not treat community health nurses as a homo-geneous group and that they need to take into consideration the setting in which commu-nity health nurses are employed. It also suggests that changes in policies and practices de-signed to address the major concerns of community health nurses should be specificallytailored to the particular community health care setting.

In general, community health nurses liked working for their agencies, liked the thingsthey were doing, and felt a sense of pride in doing their jobs. They expressed less satisfac-tion with their immediate supervisors and were least satisfied with their pay and benefits.These results are consistent with those of other researchers, who have found communityhealth nurses to have high levels of intrinsic job satisfaction but low levels of extrinsic jobsatisfaction (Cameron et al., 2004; Denton et al., 2003; Lucas et al., 1988). Home carenurses were significantly less satisfied with their pay and benefits than were public healthand CCAC nurses. In the move to a managed competition system for home care ser-vices—in which providers of home care services compete for service contracts—manyhome health nursing employers in Ontario have reduced wages and decreased or elimi-nated mileage allowances and other benefits. In turn, this is contributing to high turnoverrates and a rapidly increasing shortage of home care nurses (The Community HealthNurses’ Initiatives Group, 2000; Denton et al., 2003). Home care nurses’greater satisfac-tion with other aspects of their jobs and supervision may not make up for the low pay and


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benefits and the increases in job insecurity and workload created by the managed compe-tition system. One nurse wrote “I would like to work more, but we don’t have the refer-rals. … We are paid by the visit so it is very unpredictable. I am presently looking for asecond job to supplement my present job. I have 4 children to support and can’t do it on 4or 5 visits!” This quote illustrates many of the challenges of home care nursing in Ontariotoday. As another nurse told us “I find myself in a very difficult place. My heart is in com-munity nursing. I believe people recover more quickly at home, I believe that communitycare is more cost effective, and for many preferable to hospital care. At the same time Iam seriously considering a move from the not for profit community health care.” Thisnurse cited time pressures, too few resources, and being drained, used up, and burned outin her current setting.

According to The Community Health Nurses’ Initiatives Group (2000), by 2010 morethan half of employed nurses in Ontario will practice in the community. Recruitment andretention of nurses will be a major challenge for community health care agencies. The find-ings of this study show that the retention of community health nurses rests on providingthese nurses with adequate training to perform their job effectively, assigning meaningfulwork tasks that give these nurses the feeling that they are making a difference, ensuring thatthese nurses have adequate time to do their jobs, and making sure that they feel they are be-ing adequately paid as health care professionals. What is noteworthy is the number of jobfeatures, organizational factors, and supportive relationships that were identified as veryimportant in influencing the decisions of these nurses to remain in community health nurs-ing. Of the 20 retention factors, only 1—having opportunities to advance one’s ca-reer—had an overall mean under 3.5, and many of the means were above 4. The findingsalso indicate that the typeof retention initiativewilldependtosomeextenton thesetting,al-though there was greater similarity among the three groups of nurses for the retention fac-tors than there was for work-related concerns and job satisfaction. The differences amongthe public health, home care, and CCAC nurses were primarily in the areas of job featuresand supportive relationships. Nurses across the three settings rated the importance of theorganizational factors, with the exception of adequate pay, very similarly.

Although the move to managed competition has resulted in employment instabilityand increased turnover for home care nurses (Denton et al., 2003), it is the CCAC nurseswho reported greater client-related concerns and less satisfaction with their jobs and im-mediate supervisors than either home care or public health nurses. CCAC nurses conductan initial assessment of the types of services that are needed by a client, but the actualcare of the client is provided by the home care nurses. Thus, CCAC nurses are in the roleof coordinating home care services without being actively engaged in providing theseservices. The relationships that home care nurses develop with their clients are a majorsource of job satisfaction for them (Denton, Zeytinoglu, & Davies, 2002). Denton et al.found that home care nurses viewed their close relationships with clients, being able towork one on one with clients, and feeling needed and appreciated as very positive aspectsof their job. This is missing from the job of the CCAC nurse.


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There are limitations to this study. The items for two of the three major variables ex-amined in this study were developed for the study and therefore do not have previouslyestablished psychometric properties. Although only 9% of the respondents answered theopen-ended question asking them to identify other concerns, the eight additional con-cerns that emerged from the open-ended question indicate that not all of the concerns ofcommunity health nurses were captured by the 17-item measure developed for this study.These additional concerns should be included in future research. In addition, some of therespondents, primarily nurse managers, indicated that many of the concerns were not rel-evant to them because they were not directly involved in client care. This suggests thatthese nurses should be provided with the option of checking a not applicable responsecategory. The findings are based on questionnaire data and are therefore limited in fur-nishing the type of detail that in-depth interviews provide. Qualitative data would be es-pecially useful in explaining the significant differences found between the CCAC nursesand public health and home care nurses.

To date, most of the existing studies compare community health nurses with nurses inhospital settings (Juhl et al., 1993). This study is one of very few studies to investigate thesimilarities and differences among community health nurses employed in different com-munity health care settings. The findings demonstrate the importance of recognizing thatcommunity health nurses are not a homogeneous group, especially in regard to theirwork-related concerns and job satisfaction. Initiatives to address the concerns of commu-nity health nurses and to improve their job satisfaction, as well as to increase their reten-tion, will require interventions tailored to the specific community health care setting.

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Documents

Concerns, Satisfaction, and Retention of Canadian Community Health Nurses