THE RECRUITMENT AND retention of advanced

Transcription

1 THE INTENTION OF ADVANCED PRACTICE REGISTERED NURSES TO REMAIN IN POSITIONS AT FAMILY PLANNING CLINICS SERVING LOW-INCOME WOMEN AN-LIN CHENG, PHD, PATRICIA J. KELLY, PHD, MPH, APRN, KIMBERLY CARLSON, MPH, AND JACKI WITT, JD, MSN, APRN Federally funded Title X Family Planning Clinics are critical safety nets for reproductive health services in which advanced practice nurses (APRNs) provide the majority of care. The goal of this study was to identify factors affecting APRN's intention to remain in positions at these clinics. An Internet-administered survey was completed by 406 APRNs working in Title X clinics. The survey, based on a causal model of retention adapted for APRN practice, included 10 factors. Factor significance and model selection criteria were used to determine model fit. Intention to remain in current positions was associated with greater family responsibilities and lower levels of involvement in professional associations. Less routinization, more integration, and a greater sense of distributive justice were significant causal paths to job satisfaction (a significant mediator for intention to remain). Results provide Title X administrators information that can guide them in policy development to maximize APRN retention. (Index words: Workforce; Federally funded clinics; APRNs; Family planning clinics) J Prof Nurs 30:72 79, Elsevier Inc. All rights reserved. THE RECRUITMENT AND retention of advanced practice registered nurses (APRNs) is an ongoing concern for clinics, especially for those serving the vulnerable populations seen in subsidized health centers and rural communities. An increase in the number of APRN programs and graduates has resulted in new opportunities for practice sites and patient populations (Cooper, 2007). However, these enhanced opportunities Associate Professor, University of Missouri-Kansas City, School of Nursing, Kansas City, MO. Professor, University of Missouri-Kansas City, School of Nursing, Kansas City, MO. Research Associate, University of Missouri-Kansas City, School of Nursing, Kansas City, MO. Associate Clinical Professor, University of Missouri-Kansas City, School of Nursing, Kansas City, MO. Address correspondence to Dr. Kelly: University of Missouri-Kansas City, School of Nursing, 2464 Charlotte Street, Kansas City, MO kellypj@umkc.edu /12/$ - see front matter may make APRN recruitment and retention more difficult for federally funded Title X family planning clinics, which typically offer lower salaries than private practice or hospital settings, less heterogeneity of clinical tasks, and/ or limited opportunities for advancement. While these differences may be responsible for difficulty with retention and lower satisfaction, little research-based information is available to guide Title X administrators and policy makers in these staffing issues. The perspectives of students in APRN programs may be limited in their conceptualization of future job opportunities. Although some may be able to move into new roles in familiar institutions, others, especially those living in small town or rural communities, may feel constrained by the seemingly limited number of positions available for them in community settings. The understandable emphasis on the economic necessity of employment often overshadows issues of an appropriate fit with the agency. Likewise, faculty members in these APRN programs may be less aware of the specifics of employment in many community agencies Journal of Professional Nursing, Vol 30, No. 1 (January/February), 2014: pp Elsevier Inc. All rights reserved.

2 INTENTION TO REMAIN 73 From a policy perspective, information on the supply, recruitment, and retention of APRNs that are working with vulnerable populations is limited and must be extrapolated from a variety of sources. The American Academy of Nurse Practitioners estimates that approximately 97,000 APRNs are licensed to practice in the United States (Sipe, Fullerton, & Schuiling, 2009). The Graham Center puts the number at 115,000 APRNs, with 92,000 working in primary care (Robert Graham Center, nd). Bowman, in his discussion of the standard primary care year, that is, the contribution of different professions to the primary care workforce, asserts that APRNs contribute less than 3 years of primary care practice per graduate, in comparison with physician assistants who contribute 6 years and graduates of family medicine residency programs who contribute 29.3 years (Bowman, 2008). An older study focusing on physician retention in community health centers found the median tenure to be approximately 3 years, with only 36% still working at their site after 5 years (Singer, Davidson, Graham, & Davidson, 1998). The Title X Family Planning Program has provided contraceptive and related preventive health services, giving priority to low-income women, since 1970 (Family Planning Services & Population Research Act of 1970, 1970). Contraceptive supplies, health education, breast and cervical cancer screening, diagnosis and treatment of sexually transmitted infections, HIV testing, and pregnancy testing and counseling are all available on a sliding fee scale based on income. In 2008, the Title X network of more than 4,500 community-based clinics provided services to 5 million women and men with incomes between 100% and 250% of the poverty level, their target population. One quarter of U.S. women who obtain contraceptive services, including half of low-income women, obtain them from a clinic that receives Title X funding (Frost, 2008). The clinics include local health departments, hospitals, university health centers, and independent, not-for-profit clinics run by community agencies. All services are voluntary and confidential. APRNs provide the overwhelming majority of care at these clinics. In 2009, over 2,000 APRNs provided 7,081,264 encounters or 60% of the total (U.S. Department of Health and Human Services [USDHHS], 2010). This study was undertaken as part of the work of the Clinical Training Center for Family Planning. The center has worked for the past 5 years with over 234 APRNs from Title X agencies across the country through a national family planning preceptor training program. During these trainings, numerous anecdotes about problems with APRN recruitment and retention were heard from clinicians in the field. In addition, a recent unpublished study of administrators found that one third of 114 clinics had vacancies for APRNs, with 22.8% of these open for more than 6 months (Witt & Kelly, 2011). The need for additional information about this issue was reinforced by the 2009 review of the Title X Family Planning program conducted by the Institute of Medicine (IOM) to determine the extent to which the Title X program's mandated objectives are being met. One of the 10 recommendations of the report was to assess workforce needs for both present and future programming, given the current and predicted personnel needs throughout the program (Butler, Clayton, & Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program, 2009). Although APRN retention and turnover are important issues for clinics to ensure adequate patient care, theoretical models to explain provider motivations are limited. The causal model was developed to address the lack of inclusiveness in previous retention studies. The goal of the model is to understand the relative contribution of significant theoretical factors in the retention literature by bringing together a synthesis of factors that can explain personnel turnover. These factors are opportunity, general training, professionalism, distributive justice, family responsibility, work effort, advancement opportunity, participation, integration, and routinization (Price & Mueller, 1981). This study used a modification of this model to identify factors that influence APRNs to continue to work at Title X family planning clinics. Methods A Web-based cross-sectional survey was conducted with a national convenience sample of APRNs working in federally funded Title X family planning clinics. Permission to conduct the study was obtained from the institutional review board of our university. Population and Sampling An initial solicitation with a Web link to the survey was sent to APRNs who had participated in Clinical Training Center for Family Planning trainings between 2006 and Participants were asked to forward the solicitation to other APRNs working in Title X clinics. An electronic function of the data program restricted more than one submission per person and did not permit linkages between responses and participants. All participants were directed to a separate link to register to enroll in a drawing for a US$100-gift card in appreciation for their time spent. Instrument For this study, the instrument used in Price and Mueller's Causal Model (Price & Mueller, 1981) was adapted for APRN practice settings. The dependent variable, intention to remain in one's position, was assessed with two items, Have you ever thought about leaving your current family planning position? with four response choices (never, occasionally, regularly, and all the time) and Are you thinking of leaving your current family planning position? with yes/no response choices. Job satisfaction was hypothesized to be a precursor to the dependent variable and assessed with the sum of six items, I find real enjoyment in my family planning job, I like my job better than the average worker does, I am seldom bored at my job, I would not consider taking another job,

3 74 CHENG ET AL Most days I am enthusiastic about my job, and I feel fairly well satisfied with my job. These items each had five possible response choices ranging from strongly agree to strongly disagree. Higher scores indicated more satisfaction. The 10 predictor variables of intention to remain in one's position were the following: External opportunity or the availability of alternative jobs in the organization's environment was assessed with three items: Within this geographic area, How many APRN jobs are available? How easy would it be to find another APRN job as good as the one you have? and How easy would it be to find another APRN job better than the one you have? These items had a Cronbach's alpha of.842. Higher scores indicated more and more difficulty in finding jobs. General training, which was assessed with three items: nursing degrees earned, non-nursing degrees earned, and board certification. Higher scores indicated more training. Professionalism, or the degree of involvement in professional organizations, was assessed with two checklists, one listing possible membership in any of eight national or local professional organizations and the second asking for level of involvement (attend meetings, serve as officer, attend conferences, and/ or serve on conference committee). Higher scores suggested greater levels of professionalism. Distributive justice, or the degree to which rewards and punishments are related to the amount of input into the organization, was assessed with two items: How do you feel about the pay that you receive compared to the effort you put into your job? and compared to nurse practitioners who work in other settings in your community? These items had a Cronbach's alpha of.861. Higher scores indicated more positive feelings about their salary. Family responsibility was assessed with three items: marital status, number of children less than 21 years old living in their household, and relatives living within 50 miles. Higher scores indicated more family responsibility. Work effort was assessed with four items: You can measure a person's commitment by how good a job s/ he does, I'm really a perfectionist about my job, I feel particularly annoyed when other people do poor quality work, Sloppy work by anyone makes me very angry. All items were answered on a 5-point Likert scale, with choices ranging from strongly agree to strongly disagree. Higher scores indicated more effort. Advancement opportunity, or amount of potential movement from lower to higher strata within an organization, was assessed with one item: Which statement most accurately describes your current job? There were three response choices: no opportunity for advancement, some opportunity for advancement, or good opportunity for advancement. Higher scores indicated greater opportunity. Participation, or the degree of power that an individual exercises concerning the job, was assessed with four items: How much do you have Freedom as to how you do your job? Get to make decisions on your own? Participation in decisions that affect you? and A say in what happens on your job? These items had a Cronbach's alpha of.852. Higher scores indicated more freedom. Integration, or the degree to which an individual has close friends among organizational members, was assessed with two items: What is the atmosphere in your immediate work group? and How frequently do people help you find ways to do a better job? These items had a Cronbach's alpha of.688. Higher scores indicated more integration or friendliness. Routinization, or the degree to which a job is repetitive, was assessed with four items: To what extend does your job require that you Keep learning new things? Do different things on your job? Acquire a high level of skill? and Be creative? We also asked questions about the average number of patients seen by the APRN on a daily basis and at the clinic on a yearly basis, as well as the number of hours worked per week. These items had a Cronbach's alpha of.709. Higher scores indicated less routinization. Figure 1 shows the relationships for the hypothesized causal model. Analysis Descriptive statistics were generated to characterize the sample of APRNs that participated in this study. Data screening analyses were performed to evaluate the (a) univariate non-normality of items; this was defined for skewness N 2 or for kurtosis N 3, (b) correlations between the 10 items (correlation matrix available upon request), and (c) multicollinearity using variance inflation factor (Kline, 2005). All data screening were performed using SPSS Causal Model Parameter Estimation and Model Fit Criteria. To estimate the causal model parameters (beta weights), we used maximum likelihood estimations on covariance matrices (available upon request). Both modification indices and P value were used jointly as tools for variable selection. The model fit was evaluated using the model chi-square fit statistics, root mean square error of approximation (RMSEA; 90% confidence interval), standardized root mean square residual (SRMR), and comparative fit index (CFI; Hu & Bentler, 1998; Kline, 2005). However, given the large size of the sample, it was expected that the chi-square fit statistics would indicate statistical significance, suggesting inadequate model fit (Kline, 2005). Therefore, model fit was based on the following criteria: RMSEA b 0.05, close approximate fit; , reasonable approximate fit; N 0.1, poor fit.

4 INTENTION TO REMAIN 75 Family Responsibilities External Opportunity General Training * Professionalism * Routinization 0.371* Work Effort Job Satisfaction 0.060* Intent to Remain Integration 0.476* Participation * Distributive Justice Advancement Opportunity * P <.05 Figure 1. Original hypothesized model. SRMR b 0.05, good model fit. CFI b 0.90, inadequate fit; , adequate fit; and N 0.95, good fit. The beta weight for each path was estimated and tested for statistical significance. For all analysis, P value b.05 was considered statistically significant. The causal model was fitted using R package with Lavaan library (R Development Core Team, 2011). Results There were 406 APRN respondents to the survey. Participants were older, with less than 20% being less than 40 years of age. Twice as many worked in urban and suburban areas than in rural areas. Participants were well educated, that is, almost two thirds had master's degrees, and more than 80% were board certified. Over half worked full time and had benefits. Details of these demographics are presented in Table 1. Participants in this study resided in all of the USDHHS regions; Regions IV and IX were relatively underrepresented, and Regions VI and X were slightly overrepresented (Table 2). There was a range of average scores on all of the variables of the model. For external opportunity, participants had an average score of 9.39 out of a possible 14; for advancement opportunity, an average score of 1.39 out of a possible 4; for training, an average score of 3.40 out of a possible 5; for routinization, an average score of out of a possible 20; for work effort, an average score of out of a possible 20; for professionalism, an average score of 9.57 out of a possible 56; for integration, an average score of 7.72 out of a possible 10; for participation, an average score of out of a possible 20; for distributive justice, an average score of 5.25 out of a possible 10; for job satisfaction, an average score of out of a possible 30; for family responsibilities, an average score of 5.15 out of a possible 8; and for intent to remain, an average score of 3.45 out of

5 76 CHENG ET AL Table 1. Characteristics of Sample Characteristic Sample n = 406 Age (n = 371) % b N Location of practice (n = 373) % Urban Suburban Rural Education level (n = 395) % Associate degree Bachelor Master's Doctorate Board certified (n = 406) % Yes Employment status (n = 381) % Hourly Part time, no benefits Part time, with benefits Full time, with benefits Length of time in current % position (n = 373) Less than 1 year years years years N 10 years Note. All cells do not sum up to sample total of 406 because of missing data. a possible 6. Table 3 provides a summary of the descriptive statistics for each item. Original Model The sample satisfied the normality assumption, and no multicollinearity was identified. Our original hypothesized model (Figure 1) demonstrated inadequate fit (RMSEA = 0.106, SRMR = 0.044, and CFI = 0.763). Work effort, participation, and advancement opportunity were not statistically significant paths in explaining job satisfaction. External opportunity and general training were not statistically significant paths in explaining intent to remain (Table 4). Final Model The results from the original model suggested removing those insignificant terms to achieve a more adequate causal model. The final model (Figure 2 and Table 5) had RMSEA = 0.124, SRMR = 0.056, and CFI = 0.820, which retained all paths that had statistical significance. Table 4 shows the interpretation of the magnitude of the beta weights (the equivalent of a regression coefficient). More family responsibility (β =.086) and lower levels of professional activities (β =.027) each had a significant impact on intention to remain in the current position. Less routinization (β =.431), more integration (β =.578), and a greater sense of distributive justice (β =.463) were all significant causal paths to job satisfaction. Job satisfaction (β =.061) was a significant mediator for intention to remain. Discussion In applying the causal model to APRNs' intention to remain in their current clinical positions in Title X clinics, our results suggest that two factors have a direct impact on this intention: higher levels of local family responsibilities and less involvement in professional organizations. Although the first is intuitive, the second is less so. One possibility is that the association is driven in the reverse direction, that is, APRNs who have less time/energy/interest in working in professional organizations find a good fit in Title X clinics because such membership is not necessarily an expectation in these positions. Their network may be the system in which they work, for example, a local Planned Parenthood affiliate or the local health department. As hypothesized by both the model and by logic, job satisfaction was a significant mediator for intention to remain in a current position. Most relevant for practical application, the three significant predictors for intention to remain were (a) less routinization, that is, more variety in daily job tasks, (b) more integration or a positive work atmosphere, and (c) a greater sense of distributive justice, that is, that one's salary reflected individual effort and had parity with those in the immediate community. Table 2. Comparison of Location of Sample and National Population of Title X Providers USDHHS region Sample n/% Population of Title X providers, by region n/% Difference between sample and population % I (ME, NH, VT, MA, RI, CT) 21/ / II (NY, NJ, PR) 15/ / III (PA, MD, DE, VI, WV) 30/ / IV (KY, TN, NC, SC, GA, FL, AL, MS) 21/ / V (MN, WI, IL, IN, MI, OH) 51/ / VI (NM, TX, LA, OK, AR) 69/ / VII (KS, MO, NE, IA) 45/ / VIII (MT, ND, SD, WY, CO, UT) 41/ / IX (NV, CA, AZ, HI) 44/ / X (WA, OR, ID, AK) 45/ /

6 INTENTION TO REMAIN 77 Table 3. Descriptive Statistics for Variables of Model M SD Range Skewness Kurtosis External opportunity Advancement opportunity General training Routinization Work effort Professionalism Integration Participation Distributive justice Job satisfaction Family responsibilities Intent to remain These results suggest that program administrators consider variations in their patient care routines as strategies for increasing job satisfaction. Although the homogeneity of patient mix and scope of practice might not be amenable to negotiation, ideas about flexible work schedules, especially to accommodate family responsibilities, might be more feasible. Such flexibility can also serve as a counter to a small community agency's limitations in matching the salaries that might be offered in large hospital systems or private practices. Clinicians' participation in community outreach activities that are mutually beneficial to both the agency and the APRN could also serve as a counter to routinization. Receptivity to new ideas for serving patients such as group visits or waiting room education can also function to minimize routinization and increase job satisfaction. The positive association between distributive justice and job satisfaction suggests that students considering their first APRN jobs, especially those interested in working in low-resource settings and/or serving vulnerable populations, be encouraged to consider alternatives to financial awards and higher salaries. As part of professional development, APRN faculty can work with students to consider ideas for creativity in practice settings. Students can be aware of both their leverage as potential clinicians in such facilities but, also, their possible needs for flexibility to meet their family responsibilities. Also interesting about these results was that external opportunity (availability of alternative jobs in the community) and advancement opportunity were not significant predictors of intention to remain. The fact that 53.6% of the sample had worked in their current role for more than 6 years may be relevant to understanding the lack of significance of external opportunity. Clinical positions in which one has competence and a mastery of the role, routines, and expectations may be desirable for many clinicians; once such a position is attained, it becomes highly desirable to remain. In terms of the lack of significance of Family Responsibility 0.086* Professionalism * Routinization 0.431* Job Satisfaction 0.061* Intent to Remain Integration 0.578* Distributive Justice 0.463* * = <0.05 Figure 2. Final model.

7 78 CHENG ET AL Table 4. Parameter Estimation Results on Hypothesized Causal Model of APRN Retention Direct effect Unstandardized path value (beta weight) SE Z value Family responsibility intent to remain External opportunity intent to remain General training intent to remain Professionalism intent to remain Job satisfaction intent to remain Work effort job satisfaction Integration job satisfaction Participation job satisfaction Distributive justice job satisfaction Advancement opportunity job satisfaction P b.05. advancement opportunity, it is certainly possible that APRNs have a clear understanding when taking a clinical position in a Title X agency of the limitations for advancement within the clinic or agency. APRNs may not be interested in an advancement or promotion that would almost certainly take them out of their direct patient care role for many, especially the older population of this sample (61.5% were more than the age of 50 years), their current role might be considered one of high achievement. Although this study included APRNs from clinics across all USDHHS regions, the sample was not random. Therefore, the results have the limitations of nongeneralizability inherent in all convenience samples. A second limitation is that the index of the final model is not at the optimal level with CFI less than 0.9. The results do, however, provide an important initial explanation that can be useful to administrators to identify parameters of APRN retention. Future work in this area is needed to fully follow up Recommendation 4 9 from the IOM report, assess workforce needs in Title X clinics. To make accurate workforce projections and assess current and future workforce training needs, next steps might include the following: An exploration of the contribution of the scope of practice in Title X clinics to workforce recruitment and retention. A systematic assessment of the efficiency of clinic practices and their ability to allow APRNs to work at their maximal skill and education level. Such practices must both ensure patient safety and care while assigning educational and nonclinical responsibilities to other staff. An assessment of current local and national health care provider recruitment strategies, including the role of federal loan forgiveness programs. An appraisal of the exposure of APRN students to the practices and patients seen in Title X clinics. Conclusion Policy makers and administrators in Title X clinics have had minimal evidence-based information to guide them in the development of policies and practices to maximize the retention of their APRN clinical staff. Our results provide initial data about personal explanatory factors over which employers have no control (family responsibilities, involvement in professional organizations) and environmental factors, which can be changed. In addition to advocating for APRN salaries that are equitable to those in the immediate community, the results of this study indicate that recruitment should ensure that the APRNs have a clear understanding of the scope of practice in Title X clinics. Attention might also be paid to maximizing the variety of patients seen, which would result in less routinization of daily clinical responsibilities. Strategies that contribute to job satisfaction and a positive work environment should also be considered. Acknowledgments This research was conducted as part of the work of the Clinical Training Center in Family Planning, which was Table 5. Parameter Estimation Results on Final Causal Model of APRN Retention Direct effect Unstandardized path value (beta weight) SE Z value Family responsibility intent to remain Professionalism intent to remain Job satisfaction intent to remain Routinization job satisfaction Integration job satisfaction Distributive justice job satisfaction P b.05.

8 INTENTION TO REMAIN 79 funded by the Department of Health and Human Services, Office of Population Affairs, Office of Family Planning Contract # 2 FPTPA References Bowman, R. (2008). Measuring primary care: The standard primary care year. Rural and Remote Health, 8, Butler, A., & Clayton, E. (Editors), Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program (2009). A review of the HHS Family Planning Program: Mission, management, and measurement of results. (p. 143). New York: Institute of Medicine. Cooper, R. (2007). New directions for nurse practitioners and physician assistants in the era of physician shortages. Academic Medicine, 82, Family Planning Services and Population Research Act of 1970, Pub. L. No , 1, 84 Stat. 1504, Frost, J. (2008). Trends in US women's use of sexual and reproductive health care services, American Journal of Public Health, 98, Hu, L., & Bentler, P. (1998). Fit indices in covariance structure modeling: Sensitivity to overparameterized model misspecification. Psychological Methods, 3, Kline, R. B. (2005). Principles and practice of structural equation modeling. New York: Guilford Press. Price, J., & Mueller, C. (1981). A causal model of turnover for nurses. Academy of Management Journal, 24, R Development Core Team. (2011). R: A language and environment for statistical computing. R Foundation for statistical computing, Vienna, Austria. Retreive September 3, 2011, from Robert Graham Center. (nd). Physician assistant and nurse practitioner workforce trends. Retrieve August 28, 2011, from: onepagers/2005/op37-workforce-trends.html. Singer, J., Davidson, S., Graham, S., & Davidson, H. (1998). Physician retention in community and migrant health centers: Who stays and for how long? Medical Care, 36, Sipe, T., Fullerton, J., & Schuiling, K. (2009). Demographic profiles of certified nurse midwives, certified registered nurse anesthetists, and nurse practitioners: Reflections on implications for uniform education and regulation. Journal of Professional Nursing, 25, USDHHS/Department of Health & Human Services. (2010). Family planning annual report: 2009 national summary. Retrieve September 3, 2011, from familyplanning/toolsdocs/index.html. Witt, J., & Kelly, P. (2011). Title X clinic administrators survey. Unpublished raw data.