title: The changing nature of nursing work in rural and small community hospitals.
abstract: BACKGROUND
  The nursing literature includes descriptions of rural nursing workforces in Canada, the United States of America and Australia. However, inconsistent definitions of rural demography, diverse employment conditions and health care system reorganization make comparisons of these data difficult. In 2007, the Ministry of Health and Long-term Care in Ontario, Canada, transferred responsibility for decision-making and funding to 14 regional governing bodies known as Local Health Integration Networks (LHINs). Little is known about rural-urban variations in the nursing workforces in the LHINs because existing data repositories do not describe them. This study investigated the influence of demographic characteristics, provincial policies, organizational changes and emerging practice challenges on nursing work in a geographically unique rural region. The purpose was to describe the nature of nursing work from the perspective of rural nurse executives and frontline nurses. The study was conducted in 7 small rural and community hospitals in the Hamilton Niagara Haldimand Brant LHIN.
  
  
  METHODS
  Data collection occurred between August and November 2007. A qualitative descriptive study design was chosen to facilitate exploration of nursing in the rural setting. Study participants were identified through purposive snowball sampling. All nurses, nurse managers and nurse executives currently employed in the 7 study hospitals were eligible to participate. Data collection included the use of questionnaires and semi-structured interviews. Memos were also created to describe the relevance and applicability of concepts, categories and properties emerging from the data. Themes were compared across interviews to determine relevance and value.
  
  
  RESULTS
  Twenty-one nurses from 7 different hospitals participated. The nurses reflect the aging trend in the provincial and regional workforces of Ontario. All study participants anticipate a substantial increase in retirements during the next decade, which will alter the structure and capacity of the rural workforce. Rural nursing practice is generalist in nature, requiring personal flexibility and a broad knowledge base. The nurses in the study preferred this type of practice. However, they felt that new nurses have different values and goals and are more likely to choose the specialized practice opportunities available in urban tertiary centres. Structural changes to the health system influenced relationships between hospitals and altered the internal organization of individual hospitals. Nurse executives were positive about new opportunities for cost savings, sharing best practices and continuing education. Yet they also felt that organizational changes significantly increased their administrative responsibilities and limited their opportunities for communication with frontline nurses. The nurses thought that the changing organizational structures increased opportunities to seek multiple employers to augment the lack of full-time positions in the region. Many reported that part-time and casual nurses often seek employment in other hospitals and long-term care homes to supplement their income. However, multi-site employment within and across healthcare organizations contributes to scheduling issues because casual nurses are unavailable to fill vacant shifts. Patient transports, the implementation of e-technology and emerging disease patterns in the patient population were identified as additional practice challenges.
  
  
  CONCLUSIONS
  This study has implications for health human resource planning in rural and small community hospitals. The findings indicate that demographic trends pose an immediate threat to the sustainability of the nursing workforce in the rural setting. Many nurses are nearing retirement, but the lack of opportunities for full-time positions as well as specialized and expanded nursing practice are attracting younger nurses to urban centres. Government policies focussing on the retention of clinical expertise, the recruitment of new graduates and expanding the role of registered practical nurses have been more difficult to implement in the rural setting. Implications for future research include the need to address data gaps to facilitate workforce planning and to evaluate the effectiveness of provincial recruitment and retention strategies in the rural context.
authors.affiliation: Nursing Health Services Research Unit, McMaster University Site, Hamilton, Ontario, Canada. clauseaa@mcmaster.ca
authors.forename: Amy
authors.initials: A
authors.lastname: Montour
authors.forename: Andrea
authors.initials: A
authors.lastname: Baumann
authors.forename: Jennifer
authors.initials: J
authors.lastname: Blythe
authors.forename: Mabel
authors.initials: M
authors.lastname: Hunsberger
mesh_terms: D000328:Adult; D002391:Catchment Area, Health; D004522:Educational Status; D006280:Health Workforce; D006764:Hospitals, Community / Q000639:trends; D006780:Hospitals, Rural / Q000639:trends; D006801:Humans; D008875:Middle Aged; D009726:Nurses / Q000600:supply & distribution; D009739:Nursing Services / Q000458:organization & administration* / Q000639:trends; D009740:Nursing Staff / Q000458:organization & administration / Q000600:supply & distribution*; D009864:Ontario; D010559:Personnel Management; D010560:Personnel Selection; D010561:Personnel Staffing and Scheduling; D010563:Personnel Turnover; D012040:Regional Health Planning; D012179:Retirement; D019035:Rural Health Services / Q000639:trends; D011795:Surveys and Questionnaires