title: Degree of value alignment - a grounded theory of rural nurse resignations.
abstract: BACKGROUND
  The shortage of nurses willing to work in rural Australian healthcare settings continues to worsen. Australian rural areas have a lower retention rate of nurses than metropolitan counterparts, with more remote communities experiencing an even higher turnover of nursing staff. When retention rates are lower, patient outcomes are known to be poorer. This article reports a study that sought to explore the reasons why registered nurses resign from rural hospitals in the state of New South Wales, Australia.
  
  
  METHODS
  Using grounded theory methods, this study explored the reasons why registered nurses resigned from New South Wales rural hospitals. Data were collected from 12 participants using semi-structured interviews; each participant was a registered nurse who had resigned from a rural hospital. Nurses who had resigned due to retirement, relocation or maternity leave were excluded. Interviews were transcribed verbatim and imported into NVivo software. The constant comparative method of data collection and analysis was followed until a core category emerged.
  
  
  RESULTS
  Nurses resigned from rural hospitals when their personal value of how nursing should occur conflicted with the hospital's organisational values driving the practice of nursing. These conflicting values led to a change in the degree of value alignment between the nurse and hospital. The degree of value alignment occurred in three dynamic stages that nurses moved through prior to resigning. The first stage, sharing values, was a time when a nurse and a hospital shared similar values. The second stage was conceding values where, due to perceived changes in a hospital's values, a nurse felt that patient care became compromised and this led to a divergence of values. The final stage was resigning, a stage where a nurse 'gave up' as they felt that their professional integrity was severely compromised. The findings revealed that when a nurse and organisational values were not aligned, conflict was created for a nurse about how they could perform nursing that aligned with their internalised professional values and integrity. Resignation occurred when nurses were unable to realign their personal values to changed organisational values - the organisational values changed due to rural area health service restructures, centralisation of budgets and resources, cumbersome hierarchies and management structures that inhibited communication and decision making, out-dated and ineffective operating systems, insufficient and inexperienced staff, bullying, and a lack of connectedness and shared vision.
  
  
  CONCLUSIONS
  To fully comprehend rural nurse resignations, this study identified three stages that nurses move through prior to resignation. Effective retention strategies for the nursing workforce should address contributors to a decrease in value alignment and work towards encouraging the coalescence of nurses' and hospitals' values. It is imperative that strategies enable nurses to provide high quality patient care and promote a sense of connectedness and a shared vision between nurse and hospital. Senior managers need to have clear ways to articulate and imbue organisational values and be explicit in how these values accommodate nurses' values. Ward-level nurse managers have a significant responsibility to ensure that a hospital's values (both explicit and implicit) are incorporated into ward culture.
authors.affiliation: Australian Nursing and Midwifery Accreditation Council, Canberra, Australian Capital Territory, Australia. sbragg@anmac.org.au.
authors.forename: S M
authors.initials: SM
authors.lastname: Bragg
authors.affiliation: Queensland University of Technology, Brisbane, Queensland. Australia. ann.bonner@qut.edu.au.
authors.forename: A
authors.initials: A
authors.lastname: Bonner
mesh_terms: D000328:Adult; D005260:Female; D066296:Grounded Theory; D006801:Humans; D007588:Job Satisfaction; D008297:Male; D008875:Middle Aged; D009517:New South Wales; D009726:Nurses / Q000523:psychology* / Q000600:supply & distribution*; D010563:Personnel Turnover / Q000706:statistics & numerical data*; D011787:Quality of Health Care / Q000458:organization & administration; D019035:Rural Health Services / Q000458:organization & administration; D000078329:Workforce