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THESIS PROPOSAL

Reasons for taking nursing education

Why Choose Nursing


Nursing has broadened my horizons, it's caused me to focus outside myself and my own little world. I like being in a profession that helps people. And I find the body of knowledge I've gained is helpful in everyday situations. Plus, nursing gives you lots of varied opportunities for a career, you can change from one realm of nursing to another and the flexibility of the schedules offered is a definite plus for those of us trying to balance family life with work. As the nurse quoted above states, there are many reasons to consider becoming a professional nurse. In addition to the career advantages and personal satisfactions, the demand for registered nurses in the U.S. health care market has never been higher. Today people ranging in age from their 20s to their 50s are changing careers and moving to nursing. They're finding that when they've already trained and worked in another field, they can leverage their knowledge and training in a new career that offers them challenge, stability, and fulfillment.

One profession, lots of possibilities


As a professional nurse, you can use your knowledge and experience in so many different ways. You could organize a disaster relief effort manage a hospital educate the community deliver babies shape public policy or make new discoveries doing critical research. Each day is anything but routine nurses must always be ready to think on their feet. Check out some of the specialties and career paths available for nurses today. You'll find the question should be less about Why be a nurse? and more about What kind of nurse do you want to be?

Consider all the benefits of professional nursing


Personal satisfaction and growth. As a nurse, you're making a real difference in people's lives every day. No two days are the same, and nursing provides you with knowledge and experience you can use for yourself, your family, and your community, in addition to your patients. Career mobility. Once you become a registered nurse (RN), you can take your career in other directions, too. You could work on the front lines in trauma care or in the justice system as a legal nurse consultant. You can work as a teacher, a writer, or as a researcherinteract with children or the elderlywork directly with patients or direct a health care agency. The

opportunities are virtually unlimitedespecially for nurses who continue to learn and educate themselves in their fields of interest. Job security. Because there's a shortage of nurses nationwide, you can find career options no matter where you want to live in the U.S. If you're married and your spouse is transferred for work, you won't have to worry about finding nursing work in your new community. Scheduling flexibility. More than half of the nation's professional nurses work full time. You could work the day, evening, or night shift. Nurses can work three 12-hour shifts and have four days a week off! Some professionals are part-time or per-diem nurses. Many nurses like the fact that they can combine a real career with the demands of raising a family. The best of both worldsa profession that offers both collaboration and independence. Yes, nurses often work in teams. But they also have a great deal of autonomy. With advanced education, many nurses enjoy a great deal of independence as managers, educators, researchers, nurse practitioners, clinical nurse specialists, and more. Nursing is a great second-career choice. In fact, nursing has become one of the most popular choices as a second career, in part due to salary levels. Nursing allows single parents to support their families on one income, and for two-income families, nursing provides an additional and flexible financial resource. And as people are laid off in other industries or decide to find more personal satisfaction in their work, nursing offers the chance to fill that need and help them make a real difference every day. The University of Rochester School of Nursing has a program specifically designed for students who already have at least a bachelor's degree in another field and want to become registered nurses. It's called the Accelerated Bachelor's and Master's Programs for Non-Nurses (APNN), and it provides the education you need to enter a wide range of generalist nursing roles in just one year. There is even a three-year option for those who wish to become nurse practitioners. Find out more. Competitive salaries. More job opportunities for nurses translate into higher salary and competitive benefits for you as a future nurse. According to the U.S. government's Occupational Outlook Handbook, earnings for registered nurses are above the national average. The median annual salary for registered nurses was $48,090 in 2002. The median annual salary for nurse practitioners is well into $60,000 nationally. Advanced practice nurses (APNs) can expect annual salaries of $60,000-$90,000, depending on their geographic location and previous experience, according to the Nursing Programs 2005 10th Edition. What other profession offers you as much mobility, challenge, personal satisfaction, and job security? Once you become a registered nurse, the opportunities are virtually unlimited. We're always available to speak to prospective students about nursing as a career. Simply call (585) 275-2375 or email (Elaine Andolina) our Admissions Director for a personal chat about your options in the field of nursing.

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2011 University of Rochester School of Nursing Last updated: Monday, April 9, 2012

Journal of Applied Business and Management Studies, Volume 1 No.1 <http://www.jabms.net>

Influences on Students Choice of Nursing Education in Singapore An Exploratory Study


Ching Li Gwendoline Tan-Kuick Southern Cross University ctanku10@scu.edu.au Yong Ngee Keith Ng Southern Cross University keith.ng@scu.edu.au Tel: +65 90214323
Copyright 2010, Journal of Applied Business and Management Studies. In accessing the web pages on the Journal of Applied Business and Management Studies (JABMS) web site, you agree that you will access the contents for your own personal use but not for any commercial use. You can download and you can print out hard copies of any part of the content on JABMS online web site for your personal use. Uses beyond that allowed by the "Fair Use" limitations require permission of the publisher. Any uses and or copies of this Journal in whole or in part must include the customary bibliographic citation, including author attribution, date and article title. Journal of Applied Business and Management Studies, Vol. 1 2

Abstract
Title Influences on Students Choice of Nursing Education in Singapore - An Exploratory Study Purpose The purpose of this paper is to propose a theoretical model amalgamating the factors that influence students choice in choosing nursing education as their tertiary study in Singapore. Design/methodology/approach The approach taken to construct the theoretical model is to review extant literature that influence different facets of the students decision making process in selecting a nursing study. Findings The findings indicated that the factors influencing students choices in selecting a nursing study are i) education and career aspirations (includes students belief that nursing is the choice of career or education, students belief that there is advancement in nursing career or education), ii) personal ability (includes stress management, motivation, perseverance and self confidence), iii) socioeconomic status (includes job security, images, sexual stereotypes and monetary reward) and iv) parental and peer encouragement (parental and peer perceptions and support). Research limitations/implications (if applicable) This study is conducted in the Singapore context and generalisability is not claimed. Originality/value This is the first study conducted in Singapore to understand student choice process in selecting a nursing study. This study will provide information in the creation of targeted marketing strategies and profession-friendly work practices by the Health Ministry and the healthcare provision industry, which may help arrest or reverse the current trend by enticing to school-leavers to join the nursing profession. Category of Paper Research Paper Journal of Applied Business and Management Studies, Vol. 1 3

Influences on Students Choice of Nursing Education in Singapore An Exploratory Study


Introduction Singapore nursing education has experienced a number of significant changes in recent years. Singapore healthcare education industry is finding the competition for the limited pool of students with better grades increasingly difficult. This had been felt acutely, as the high quality of students Singapore Nursing has had over the years was a prominent contributing factor to the well-received professional image of the Singapore nursing workforce. The shortage of competently trained nurses is a global phenomenon. Previous studies (Knox, Irving & Gharrity, 2001; Fonza & Tulker-Allen, 2007; Zysberg & Zisberg, 2008) reported that fewer qualified school leavers chose to be trained as nurses. The resultant shortage of nurses has raised many healthcare delivery concerns globally. In Singapore, there is a gradual chronic manpower shortage of healthcare workers over recent years. While registered nurses form the largest segment in the frontline work-force in the Singapore healthcare system, training sufficient competent registered nurses is now a priority in the local healthcare system. The continued inability of the nursing profession to attract sufficient new recruits demonstrates that a mismatch still exists between incentives and disincentives of the profession. Therefore, it is critical for the healthcare education industry to understand factors which influence students choice of nursing education and the relationship among those factors. But the factors have not been documented by research locally. The purpose of this paper is to propose a theoretical model amalgamating the factors that influence students choice in choosing nursing education as their tertiary study in Singapore. Particularly, this study aims to explore the factors that attract students to undertake nursing study against the background of multi-racial and multi-cultural Singapore. Thus, this paper analyses different facets of the students decision making process and tries to explain those factors that determined their choices and the relationships underlying the process of selecting their appropriate education programs. With this aim in mind, this paper reviews extensive literature to determine the influences that eventually made students decide upon nursing study, and proposes an amalgamated model. Background of the Study The nursing education in Singapore is provided by both tertiary and private healthcare education institutes. These institutions generate approximately one thousand nurses for the industry each year. School-leavers can enroll for the Polytechnic or University Nursing education directly after their GCE O or A levels school-leaving examination. This is a three years full time study, and Journal of
Applied Business and Management Studies, Vol. 1 4

these students would be awarded with the Diploma or Degree of Nursing upon graduation, and become registered nurses. Up till 2004, the nursing education was offered by a single Polytechnic. In 2005, it was joined by two other tertiary institutions and they now account for an average of fifty percent of graduating nurses each year. A third private healthcare education institution has entered the market recently in 2008 and had just started its first class. Despite the efforts made in increasing the number of education institutions offering nursing courses, significant nursing manpower shortages are still projected by the Ministry projection in the coming years. While working conditions had been reworked and wages of nurses had been subjected to regular revisions to ensure that competitiveness in the tight job market, these attempts fall short in stemming the decline of nurses in Singapore. While many studies (Law & Arthur, 2003; Meadus & Twomey, 2007; Sweet, 2004) examined students preferences of nursing as a career choice, there is currently no study done in the context of Singapore that specifically explores the factors that influence the youths in their choice of the nursing profession. This study will attempt to bridge this knowledge gap which can potentially find useful application beyond the healthcare education institutions. Access to this information may assist in the creation of targeted marketing strategies and profession-friendly work practices by the Health Ministry and the healthcare provision industry, which may help arrest or reverse the current trend by enticing to school-leavers to join the nursing profession. Conceptual Framework The shortage of competently trained nurses is a global phenomenon for over a decade (CarpenitoMayet, 2002; Jinks & Bradley, 2004; Wilson, 2006). In the ideal scenario, the number of new nurses entering the workforce; either trained locally or recruited from overseas, will match the attrition in the industry and cover expansion requirements. In reality, there are fewer entering the profession with more and more exiting (Buerhau, Staiger & Auerback, 2000; Crow & Hartman, 2005; Mavundla & Mabemella, 1997). This phenomenon and its negative impact on healthcare service have attracted much discussions and studies in recent times. Bolan and Grainger (2003) provided possible reasons as to why few adolescents view nursing as a career option. Their study suggests that perceived characteristics of these adolescents ideal career were markedly different from their perceptions of the characteristic of a nursing career. This would help explain why fewer youths are opting for the nursing course as their choice of education, and also why a greater number of junior nurses are choosing to leave the profession. American Nurses' Association (1991) described a decline of 19% in youth enrolling for nursing education from 1995 to 2000, and this was compounded by a similar increase in young nurses leaving the industry shortly after they have graduated. The result is an imbalance between the number that enter the professions and those who have left it (Dragon 2009). Journal of Applied Business
and Management Studies, Vol. 1 5

The general feeling in recent years is that emphasis on increasing enrolment will likely to have a bigger impact than emphasis on reducing attrition. The healthcare and education industry recognize that our youths are becoming increasingly more sophisticated and complex in their needs and wants. The push and pull factors would need to be managed properly in order to entice more youths to enter the healthcare industry (Canadian Nurses Association, 2002). Previous studies (Davidhizar & Bartlett, 2006; Gaynor, Allasch, Yorkston, Stewart & Turner, 2006; Jrasat, Samawi & Wilson, 2005; Liegler, 2000; Joel, 2002; Wilson, 2006; Zysberg & Zisberg, 2008) examined explicit and implicit factors that provide insights into why high-school leavers pick nursing as their study of choice. Knowing these factors could help explain the phenomenon of decline in enrollment of better grade school leavers over the past years. The theoretical model The factors that influence the choice of students choosing nursing as a career have analogous findings with many other studies. In order to predict the choices of these students, it is important to consider both explicit and tacit influences that they make. The model presented in this paper aims to explain the factors influencing the enrolment choice of entering the nursing program. The intention is to examine how these influencing factors interplay in the choice process of the students and as a predictor for the preferential choice of these students in order to improve the industry marketing efforts as an education service provider. The theoretical model comprises the students career choice as a dependent and four factors with a total of four categories of independent variables identified in existing literature. The factors identified are education and career aspirations (includes students belief that nursing is the choice of career or education, students belief that there is advancement in nursing career or education), personal ability (includes stress management, motivation, perseverance and self confidence), socio-economic status (includes job security, images, sexual stereotypes and monetary reward), parental and peer encouragement (parental and peer perceptions and support). The model is illustrated in Figure 1. Education and Career Aspirations Brennan, Best and Small (1996) suggest that when considering nursing as a career, students tend to view nursing as a rewarding and challenging profession. Potential nursing students indicated that they enjoy caring and helping others as the most frequently stated reason why students chose to enroll in the nursing program (Liegler, 2000). Young college leavers were found to own career aspirations that may dissuade them from taking nursing study (Scanlon 2008). In Singapore, the nursing career choices available for registered nurses include teaching, research, healthcare management and business enterprises. Local academic advancement for registered nurses ranges from diplomas, advanced diplomas, bachelor and master. Various overseas doctoral and PhD degrees are possible educational advancement for registered nurses. In Scanlons (2008) study young college leavers were found to own negative career and education aspiration about nursing that have dissuaded them from taking nursing as their tertiary study. Journal of Applied Business and Management
Studies, Vol. 1 6

Figure 1 - A model of students choice of nursing education in Singapore (developed for this research) Personal Ability Another study by Beggs, Bantham and Talyors (2008) found that the main factor that entices young college school leavers into choosing nursing as their choice of career was the positive self-perception of nursing as a caring and helpful profession. For personal qualities rating, most of the participants see themselves as caring, helpful, patient and understanding. However, the startling truth is that out of 106 participants who took part in this research study, only 21% expressed interest in choosing nursing as their career. The study also examined the reasons as to why 79% of the participants were not interested in nursing as their choice of career and there appeared to have a range of deterring factors. The most commonly cited reason was that the career does not appeal to me. Low expected pay was ranked second. Notably, most of the participants who cited these two reasons are also males. On the contrary, females cited dislike the sight of blood and hard work as their top two reasons. To identify the possible personal ability effect on the students choice, items such as I chose nursing because nursing is a reliable job, I can work in demanding and stressful environment, I feel good about myself whenever I care and look after people, I enjoy meeting people and I am good in interpersonal skills such as listening, caring and understanding were used as measurements. Socio-Economic Status Low expected pay was ranked second among fifteen variables that affected the school leavers choice to choose nursing as higher education (Beggs et al., 2008). Consistently in a descriptive study done by Law and Arthur (2003) suggested that many students harbored a view that nursing is a low-status profession that does not generally command respect leading to the notion that nursing is not a good choice for higher study. However, another study indicated that job security as the prime reason why school leavers choose nursing as their higher education and career Journal of Applied Business and
Management Studies, Vol. 1 7

(Brodie, Andrews, Andrews, Thomas, Wong & Rixon 2009). A similar result was reported in a correlation study by Rognstad, Aasland and Granum (2004), and Williams, Wertenberger and Gushuliak (1997). Thus this study will look into the effect of job security, nursing image, sexual stereotypes and wages on local students choice for nursing education. This study will explore student choice by asking whether nursing is positively viewed in Singapore as a profession and whether students feel that they will be respected as nurses. Parental Encouragement Parental influence plays a substantial part on students choice of nursing study (Beggs et al, 2008). The results found that parental influence featured strongly in affecting the choice of choosing nursing as a career. These results were consistent with a recent study by Law and Arthurs (2003) that reported a 28% of sampled high school students were interested in studying nursing, and that their choice was significantly influenced by parental influence or demographic factors such as gender. A similar study by Harrigan et al (2003) identified parental pressure as the major factor in preventing the Native Hawaiian, Samoam and Filipino students from choosing nursing as their career. Paa and McWhirter (2000) studied the extent to which peer pressures have on high school students career choices. They reported that peers and parental influence do significantly influence the students eventual choice, especially in circumstances when the specifics of the course program are not familiar to them. Interestingly, advice from these students school counselors influences the least. In Singapore, nursing career is perceived as a hospital-based profession. There is a lack of information on career choices available to registered nurses, which can include teaching, research, healthcare management and business enterprises. This has led to an increased demand for welleducated nurses. This lack of public awareness may be one of the causes that youths tend to undervalue the nursing profession and reject it prematurely. Many of the above-mentioned studies suggest that factors such as latterly educational and career progression, socio-economic status, personal ability and parental encouragement are all influential in whether a person chooses nursing as a study choice. This is supported by a similar study surveying 167 college entrants, which found that main factors influencing students college choice included intellectual and social emphases, practicality and advice of others (Kinzie, Palmer.-Hossler, Jascob & Cummings, 2004). Research Propositions The above theoretical framework allows us to set forth the following research propositions: Hypothesis 1: Educational and career aspiration has direct positive correlation on students choice of post-secondary study. Hypothesis 2: The level of students perception on socio-economic status in nursing positively correlates their choice in choosing nursing program. Hypothesis 3: The students interpretation of their personal ability in coping with the perceived demands imposed in nursing study is positively correlated to their eventual choice. Journal of Applied
Business and Management Studies, Vol. 1 8

Hypothesis 4: Peer and parental encouragement has a direct positive correlation and will likely influence students choice in choosing nursing program. Conclusion Until now, there is no recorded research study conducted in Singapore that specifically explores the factors that influence youths in their choice of the nursing profession. Existing literature has concentrated on identifying the elements which play a part in students selection choice of nursing program. However these studies did not go on to form an amalgamated point of view; which is the central focus of this paper. This study aims to contribute to bridging the knowledge gap which can potentially find useful applications beyond the healthcare education institutions. A theoretical model is suggested that integrates different factors that influence the enrolment choice of entering the nursing program. The model presented in this paper demonstrates how enrolment choice is dependent on four factors: educational and career aspirations; socio-economic status; personal ability and parental encouragement. These factors provide an explanation on the interplay in the choice process and as a predictor of enrolment choice made by the student. Access to this information may assist in the creation of specific marketing strategies and professionfriendly work practices by the healthcare education industry and the healthcare industry of Singapore; which may help arrest or reverse the current trend by enticing school-leavers to join the nursing profession. The healthcare education industry in Singapore must recognize that there is a need for more focused marketing to attract young school-leavers into choosing nursing study as their tertiary academia. Many universities across the globe are increasingly tailoring their marketing approach to suit student choice. This comes about as the students of today have become better informed, more mobile and more able to make important judgments about a range of potential preferred institutes either locally or overseas. Reference American Nurses' Association (1991). Nursings' agenda for healthcare reform. Washington DC: American Nurses Publishing. Beggs, J., Bantham, J., & Taylor, S. (2008). Distinguishing the factors influencing college students' choice of Major. College student Journal, 42(2), 381 394. Bolan, C., & Grainger, P. (2003). High school to nursing: given todays nursing shortage, it is crucial that universities select the nursing school applicants who most likely to succeed academically. The Canadian Nurse, 99(3), 18 - 24. Brennan, A., Best, D., & Small, S. (1996). Tracking student progress in a baccalaureate nursing program: Academic Predictors. Canadian Journal of Nursing Research, 28(2), 85 - 97. Brodie D., Andrews, E., Andrews, J., Thomas, G., Wong, J., & Rixon, L. (2009). Perceptions of nursing: confirmation, change and the student experience. International Journal of Nursing Studies, 41(7), 721 - 733. Journal of Applied Business and Management Studies, Vol. 1 9

Buerhaus, P, Staiger, D., & Auerback, D. (2000). Implication of an aging registered nurse workforce. Journal of America Medical Association, 283(22), 2948 - 2954. Canadian Nurses Association (CNA). 2002. Planned for the future: nursing human resources projections. Ottawa, ON: Author. Crow, S., & Hartman, S. (2005). Attrition in nursing-perspectives from national survey of college graduates. The Health Care Manager, 24(4), 336 - 346. Carpenito-Moyet, L. (2002). Nurses its time to dust off your caps. Nursing Forum, 37(3), 3 - 6. Davidhizar, R., & Bartlett, D. (2006). Re-entry into registered nursing work forced. The Journal of Continuing Education in Nursing, 37(4), 210 - 218. Dragon, N. (2009). Nursing education:Our students our future. Australia Nursing Journal, 16(7), 22 25. Fonza, M., & Tuker-Allen, S. (2007). Nursing education and health care in china: A study tour. The ABNF Journal, 58 - 61. Gaynor, L., Gallasch, T., Yorkston, E., Stewart, S., & Turner, C. (2006). Where do all the undergraduate and new graduates nurses go and why? Journal of Advanced Nursing, 24(2), 26 - 32. Harrigan R., Gollin L., & Casken J. (2003). Barriers to increasing native Hawaiian, Samoan, and Filipino nursing students: perceptions of students and their families. Nursing Outlook, 51(1), 25 -30. Jinks, A., & Bradley, E. (2004). Angel, handmaid, battleaxe or whore? A study which examines changes in newly recruited student nurses' attitudes to gender and nursing stereotypes. Nursing Education, 24(2), 121 - 127. Joel, L. (2002). Education for entry into Nursing Practice. Online Journal of Issues in Nursing, March. Jrasat, M., Samawi, O., & Wilson, C. (2005). Belief, attitudes and perceived practice among newly enrolled students at the Jordanian Ministry of health nursing colleges and institutes in 2003. Education for Health, 18(2), 145 - 156. Kinzie, J., Palmer, M., Hossler, D., Jacob, S., & Cummings, H. (2004). Fifty Years of College Choice: Social, Political and Institutional Influences on the Decision-Making Process. New Agenda Series, 5(3), 1 - 76. Knox, S., Irving, J.A., & Gharrity, J. (2001). The nursing shortage. Journal of Nursing Administration, 20(9), 35 - 44. Journal of Applied Business and Management Studies, Vol. 1 10

Law, W., & Arthur, D. (2003).What factors influence Hong Kong school students in their choice of a career in nursing? International Journal of Nursing Studies, 40(1), 23 - 34. Liegler, R. (2000). Predicting student satisfaction in baccalaureate nursing programs: Testing a causal model. Journal of Nursing Education, 36(8), 357 - 364. Mavundla, T., & Mabandla, Z. (1997). The perception of the image of Nursing. Curationis, 15(11), 73 - 77. Meadus, R., & Twomey, J. C. (2007). Men in nursing: making the right choice. Canadian Nurse, 103(2), 13 - 16. Paa, H., & McWhirter, E. (2000). Perceived influences on high school students current high school expectations. Career Development Quarterly, 49(1), 29 - 44. Rognstad, M., Aasland, O., Granum, V. (2004). How do nursing students regard their future career? Career preferences in the post-modern society. Nurse Education Today, 24(7), 493 - 500. Scanlon, A. (2008). How do university clinical school of nursing graduates choose their graduate nurse year program? Australian Journal of Advanced Nursing, 26(2), 34 - 38. Sweet, H. (2004). Wanted: 16 nurses of the better education type: provision of nurses to South Africa in the late 19th & 20th centuries. Nursing Inquiry, 11(3), 176 - 184. Williams, B., Wertenberger, D., & Gushuliak, T. (1997). Why students choose nursing. Journal of Nursing Education, 36(7), 346 - 348. Wilson, C. (2006). Why stay in nursing. Nursing Management, 12(9), 24 - 32. Zysberg, L., & Zisberg, A. (2008). Nursing students' expectations of college experience. Journal of Nursing Education, 47(9), 389-394.

Reasons Registered Nurses Leave or Change Employment Status


By Kimberley Zagoren, eHow Contributor

Burnout and job dissatisfaction are among the top reasons nurses leave their jobs.

With complaints of heavy workloads on the rise, it is no surprise that many registered nurses choose to leave the field or change from full-time to part-time or per-diem (as needed) positions. Every year the demands placed on nurses increase while respect for nurses as valuable members of the health care profession continues to decline.
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Reasons Registered Nurses Leave Nursing

The Importance of Staff Retention to Nurses

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1. Stress and Burnout


o

Whether looking for a career that would make a difference in the lives of others or one known for stability even in rough times, many new nurses are surprised to realize how different working as a nurse is compared to what they experienced during their training. In September of 2007, Dr. Christine Kovner published a study in the "American Journal of Nursing" that found 13 percent of newly licensed RNs changed jobs after one year and 37 percent reported they felt ready to change jobs.

Burnout
. exhaustion: psychological exhaustion and diminished efficiency resulting from overwork or prolonged exposure to stress reported a high rate of burnout among nurses

2. extremely exhausted person: somebody affected by psychological exhaustion (informal) 3. MECHANICAL ENGINEERING machine failure through heat: failure of a machine or part of a machine to work because of overuse or excessive heat or friction 4. AEROSPACE rocket failure: failure of a rocket or jet engine to work because the fuel supply has been exhausted or cut offMicrosoft Encarta 2009. 1993-2008 Microsoft Corporation. All rights reserved.

Today's registered nurses are expected to handle higher caseloads and more paperwork than before. Nurses often leave work late, skip lunch and miss breaks during their shifts just to keep up with the demands being placed on them. In addition, many hospitals require that nurses "float" to different units they might not be familiar with and work mandatory overtime as needed. Scheduling is often an additional concern. "Nurses are much more reluctant to work nights and weekends than they used to be. They want a reasonable lifestyle like other people. Heavy workloads and the practice of 'floating' nurses exacerbate nurses' dissatisfaction," says Judy Huntington, president of the Washington State Nurses Association, in an interview with the "Western Journal of Medicine". In addition to the stress placed on nurses by the demands of the job, nurses also face many emotional stressors. Critically ill patients, death and mourning are regular parts of many nurses' lives. It is this combination of both physical and psychological stress that causes many nurses to suffer burnout and leave the profession.

2. Lack of Respect
o

Many nurses feel disrespected and under-appreciated, not only by patients and families but by other staff members. It is often said in nursing that nurses eat their young. Kathleen Bartholomew, RN, MN, author of "Ending Nurse to Nurse Hostility" explains in an interview with Reality RN, "Studies show that nurses are

typically seen as unequal in power to doctors--they are 'oppressed,' so to speak. It's called Oppression Theory. Nursing has never been considered an empowering profession. Since its inception, nurses have been considered handmaidens to the physicians in a male-dominated society. As a result, nurses assume the label and become unprofessional--cliquey, catty, mean-spirited, and intimidating, especially toward new nurses." Sponsored Links

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3. Lifestyle Changes
o

While many nurses leave due to stress and dissatisfaction, some find it necessary to leave full-time positions due to changes in lifestyle. The schedule of a full-time nurse can vary greatly. Some employers require nurses to rotate from day to night shifts and almost all nurses have some form of weekend and holiday requirement as part of their contracts. Because of this, a family emergency or new baby can force nurses to make the switch to part-time or per-diem status.

Opportunities
o

Aside from the negative aspects that can cause a nurse to leave the profession, there are also opportunities for advancement that can entice nurses to make a change. Today's registered nurses have many career choices available to them in addition to staff nursing. Often nurses with advanced degrees leave the headaches of hospital nursing behind to find their niche in careers such as advanced practice nursing, midwifery, nursing education and legal nurse consulting.

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Western Journal of Medicine: "Why Nurses Choose to Leave Nursing Field" American Association of Colleges of Nursing: "Nursing Shortage" Photo Credit lovely doctor 36 image by Paul Moore from Fotolia.com

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By Debra Wood, RN, contributor More than 120,000 nurses are working outside of the profession in a diverse range of jobs, according to a new study, which also discovered that dissatisfaction with the nursing workplace is a key reason for RNs leaving their chosen field. We really need to address workplace issues so we can retain [nurses] after we recruit them to the profession, said lead author Lisa Black, Ph.D., RN, an assistant professor in the Orvis School of Nursing at the University of Nevada, Reno.

Lisa Black, Ph.D., RN, found that more than 27 percent of nurses working outside the profession cited burnout or stressful work environments as a reason for leaving the profession.

Black and colleagues sought to learn more about U.S. nurses who are active in the labor market but working outside of the nursing profession. While talking with legislators, hospital leaders and others to shape health policy, Black found the policy makers appreciated the anecdotal stories she relayed, but asked for data. Black hopes her recent research and data will provide answers and encourage changes to the environment. Frustration with the workplace shows there is room for policy work, added Joanne Spetz, Ph.D., associate professor in the Department of Community Health Systems at the University of California, San Francisco School of Nursing, a co-author of the paper. She hopes the paper provides evidence that chief nursing officers can use to convince financial and administrative officials to improve the work environment, which would boost retention and save on recruitment costs. The team used data from the 2004 National Sample Surveys of Registered Nurses, a sample of 35,635 registered nurses from all 50 states and the District of Columbia.

The researchers found 4.2 percent of the 2.9 million registered nurses licensed to practice in the United States were working in non-nursing employment and 12.1 percent were not working at all.

Joanne Spetz, Ph.D., hopes the research she conducted helps provide CNOs with data to convince administrators of the need to improve work environments for nurses.

Nurses not working cited retirement (44.6 percent) and home and family obligations (38.4 percent) as the reason for their not participating in the labor market. More than 27 percent cited burnout or stressful work environments, 23.4 percent the physical demands, 20 percent inadequate staffing, and 20 percent said inconvenient scheduling were reasons for not working. The authors found that nurses state retirement as a reason for not working at younger ages than other female-dominated professions, such as teaching or secretarial work. Nearly half of the respondents, between the age of 45 and 64 years, who are not working in nursing (44.7 percent) indicated they were retired. Of the nurses employed in positions other than nursing, 15.8 percent were working for a healthrelated service provider and 4.2 percent were working in pharmaceutical sales. Another 15.4 percent said they held administrative or management positions, and 3.4 were working in a faculty or instructor role. Not all of those nurses working outside the nursing profession are doing something that isnt valuable to the health care system, Spetz said. Their nursing experience has been very important. Nurses also might be working as legal nurse consultants, teaching health education courses or collaborating with software developers on information technology solutions for health care. Many of the nurses who stated they work in government may be in regulatory roles. Spetz expects half of the nurses who reported that they are working outside of nursing are still doing something related to health care. The paper states that nurses who worked outside of nursing predominantly cited career change (65.8 percent), burnout/stressful work environment (41.3 percent), scheduling challenges or working too many hours (38.7 percent), better pay in non-nursing employment (31.4 percent), inadequate staffing (30.8 percent) and the physical demands of working in nursing (25.8 percent) as reasons for seeking employment outside of the nursing workforce. According to the survey, younger nurses were more likely to cite workplace concerns than older nurses, 91 percent for nurses younger than age 30 vs. 63.8 percent for nurses age 45 years to 64

years. Nurses who had been out of school the least amount of time were the most likely to be working outside of nursing due to concerns with the nursing workplace. The authors urge nursing leaders and decision makers to develop strategies that will retain nurses and offer incentives for those who have left to return to the nursing workforce. Black said nurses have the power to make those changes, if they come together. Only through decided efforts to address these continued gaps in existing health policy will nursing, the health care industry, and policy makers be able to meet the nursing needs of future generations, the authors concluded.
2009. AMN Healthcare, Inc. All Rights Reserved.

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Practice nurses' workload, career intentions and the impact of professional isolation: A cross-sectional survey
Catherine A O'Donnell*, Hussein Jabareen and Graham CM Watt

* Corresponding author: Catherine A O'Donnell Kate.O'Donnell@clinmed.gla.ac.uk

Author Affiliations General Practice & Primary Care, Division of Community-based Sciences, Faculty of Medicine, University of Glasgow, 1 Horselethill Road, Glasgow G12 9LX, UK For all author emails, please log on. BMC Nursing 2010, 9:2 doi:10.1186/1472-6955-9-2

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1472-6955/9/2

Received: 14 August 2009 Accepted: 25 January 2010 Published:25 January 2010

2010 O'Donnell et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract Background

Practice nurses have a key role within UK general practice, especially since the 2004 GMS contract. This study aimed to describe that role, identify how professionally supported they felt and their career intentions. An additional aim was to explore whether they felt isolated and identify contributory factors.
Methods

A cross-sectional questionnaire survey in one large urban Scottish Health Board, targeted all practice nurses (n = 329). Domains included demographics, workload, training and professional support. Following univariate descriptive statistics, associations between categorical variables were tested using the chi-square test or chi-square test for trend; associations between dichotomous variables were tested using Fisher's Exact test. Variables significantly associated with isolation were entered into a binary logistic regression model using backwards elimination.

Results

There were 200 responses (61.0% response rate). Most respondents were aged 40 or over and were practice nurses for a median of 10 years. Commonest clinical activities were coronary heart disease management, cervical cytology, diabetes and the management of chronic obstructive pulmonary disease. Although most had a Personal Development Plan and a recent appraisal, 103 (52.3%) felt isolated at least sometimes; 30 (15.5%) intended leaving practice nursing within 5 years. Isolated nurses worked in practices with smaller list sizes (p = 0.024) and nursing teams (p = 0.003); were less likely to have someone they could discuss a clinical/professional (p = 0.002) or personal (p < 0.001) problem with; used their training and qualifications less (p < 0.001); had less productive appraisals (p < 0.001); and were less likely to intend staying in practice nursing (p = 0.009). Logistic regression analysis showed that nurses working alone or in teams of two were 6-fold and 3.5-fold more likely to feel isolated. Using qualifications and training to the full, having productive appraisals and planning to remain in practice nursing all mitigated against feeling isolated.
Conclusions

A significant proportion of practice nurses reported feeling isolated, at least some of the time. They were more likely to be in small practices and more likely to be considering leaving practice nursing. Factors contributing to their isolation were generally located within the practice environment. Providing support to these nurses within their practice setting may help alleviate the feelings of isolation, and could reduce the number considering leaving practice nursing.
Background

Practice nurses are an integral part of general practice/family medicine teams in the UK, with a role which encompasses general treatment room duties, nursing duties and chronic disease management [1].

In 2004, a new General Medical Services contract was introduced in the UK. Unlike previous contracts, this is held at practice-level, not with individual general practitioners (family practitioners) [2]. Another key development was the introduction of the Quality and Outcomes Framework (QOF), a pay-for-performance measure covering both clinical and organisational areas of work [3]. Within the clinical domains, there is a focus on chronic diseases with points awarded for care in areas such as coronary heart disease, diabetes and asthma and it is estimated that practices can now earn up to one-third of their income from QOF payments, by meeting these targets [4]. Practice nurses have played a key role in the achievement of QOF points [5-7], as predicted when the contract was implemented [3,8]. However, while the evidence suggests that practice nurses are embracing these new roles, there have been negative consequences too. Nurses complain that their workload has increased dramatically, that adherence to "box-ticking" for the QOF impacts on the holistic nature of the nurse-patient consultation and that their remuneration has been less than expected, given the financial gains for practices [5-7]. Practice nurses are employees of the doctors in the practice where they work. While there are advantages to this in terms of the cohesiveness of practice teams, disadvantages include the exclusion of practice nurses from many strategic documents, including Agenda for Change which outlined new terms and conditions of employment for non-medical NHS staff [9], and the lack of nationally recognised terms and conditions for employment [10]. Practice nurses, particularly those working in small practices, may also be more likely to work alone with fewer opportunities for inter-professional contact, reflecting the situation faced by doctors working in small practices. However, while the impact of isolation has been the focus of attention when it affects doctors [11], there has been little or no attention paid to professional isolation as it impacts on practice nurses. These developments need to be considered in the wider context of nursing recruitment and retention. Recruitment and retention of staff presents challenges for both nursing and medicine, in the UK and abroad [12-16]. While many studies have focussed on secondary care nursing, primary care is faced with similar problems [17,18]. Buchan identified that, by 2010, one in four nurses would be aged 50 or more, with general practice nursing particularly affected [17]. Other

factors associated with problems in the recruitment and retention of nurses include job dissatisfaction [12] and perceived work ability, a concept which includes commitment to education and training, employment history, relationships with colleagues and managerial support [16]. In an attempt to explore some of these issues, and to inform the development of later qualitative work exploring nurses' views of their role post-GMS contract, we conducted a questionnaire survey in one large urban Health Board area in Scotland. Conducted late in 2005, we wished to describe the role that practice nurses were undertaking post-GMS contract, to find out how professionally supported they felt in their work and to identify their career intentions. In particular, we used this as an opportunity to explore whether or not nurses felt isolated in their daily role and what factors may contribute to that. This work was conducted in collaboration with the Health Board, who wished to use the findings of the questionnaire to develop support structures for practice nurses and to inform workforce planning.
Methods Study design and setting

The study was a descriptive cross-sectional survey of practice nurses working in general practice within a large, urban Health Board, using a self-completion postal questionnaire. It was conducted in collaboration with the Health Board's Primary Care Division practice nurse advisor and the workforce planning project manager.
Study population and questionnaire distribution

The target population was all 329 practice nurses working within the Health Board in 2005. The practice nurse advisor distributed the questionnaire on our behalf; completed questionnaires were returned to the research team. The Local Research Ethics Committee requested that no nurse or practice identifier be included on the questionnaire, thus a blanket reminder was sent out 21 days after the initial questionnaire, again through the practice nurse advisor. Completion of the questionnaire was taken to mean the nurses consented to participate in the survey, i.e. implied consent.

Questionnaire design

Questionnaire items were derived from three sources: a literature review on the role of practice nurses; discussions with nurses in management positions within the Health Board; and a previous questionnaire conducted by the practice nurse advisor in early 2004. The literature review covered a range of areas, including the development of the practice nurse role in primary care; practice nurse workload; policy drivers contributing to the development of the practice nurse role (for example, Liberating the Talents [19] and Agenda for Change [9]; and literature on skill mix and role development, including work by Sibbald et al on skill mix [20] and Daly and Carnwell's work on developing a framework for nursing roles [21]. Items from the previous questionnaire on nursing activities and training were also included. The final questionnaire covered six domains, with 90 items (see Additional File 1). The domains were personal demographics; practice structure; professional and educational qualifications and career intentions; workload and clinical roles; training and continuing professional development; access to professional support. Additional file 1. Practice nurse survey. Format: DOC Size: 128KB Download file This file can be viewed with: Microsoft Word Viewer Most items were categorical variables, some dichotomous. At the end of the questionnaire respondents were given the opportunity to add any further comments regarding their role and support issues. Before distribution, the questionnaire was shown to colleagues and nurses undertaking the Master in Primary Care within General Practice and Primary Care to assess the ease of completion and validity of the questionnaire.
Data entry and analysis

Responses were entered into SPSS 11.5 by HJ. A 10% sample was double entered by a departmental secretary to check for data quality and consistency. No major issues in the accuracy of data entry were detected.

Descriptive univariate analyses were conducted using frequency tables; not all practice nurses provided an answer for every question, so the results are presented as the number and frequency (%) of responses. Continuous variables were not normally distributed, therefore median and inter-quartile ranges were reported and comparisons analysed by the Mann-Whitney U test. Bivariate analysis was used to further explore the association between isolation and a range of variables. Associations between categorical variables were tested using the chi-square test or, where one variable was ordered, the chi-square test for trend. Fisher's Exact test was used to examine associations between dichotomous variables [22]. Variables that, on bivariate analyses, were significantly associated with isolation (p < 0.05) were entered into a binary logistic regression model using backwards elimination [23].
Ethical approval

The study was approved by the NHS Greater Glasgow Primary Care Research Ethics Committee (REC Reference Number: 05/S0706/30).
Results Demographics and practice characteristics

A response rate of 61% was obtained (200/329 nurses). All respondents were female. About half (49.0%) were aged 40-49 years; 29.0% were 50 or more (Table 1). The majority were Grade G nurses and were Registered General Nurses or State Registered Nurses. However, most had multiple qualifications: 80 (40.0%) had 2 qualifications; 54 (27.0%) had 3 or more. These included district nursing, specialist nurses in general practice and the practice nurse certificate (Table 1). Table 1. Description of respondents. Respondents had worked as practice nurses for 0.5 to 24.0 years, median = 10.0 years (interquartile range (IQR): 5.0 - 15.0 years). The length of service in their present practice ranged from 0.5 to 24.0 years, median = 7.0 years (IQR: 3.0 - 12.0 years).

The majority (102, 53.4%) worked in practices with between 2000 and 6000 patients, although about one-fifth worked in very small (<2000 patients) or very large (>10,000 patients) practices (Table 1). Reflecting this, 43.0% worked with one other nurse, 26.0% worked with two other nursing colleagues, but 31.0% worked alone (Table 1). Almost all respondents (192, 98.0%) worked in clinics with an appointment system with a median of 26 appointment slots per day (IQR: 20.0 - 33.8). The median length per appointment was 15.0 minutes (IQR: 10.0 - 15.0 minutes).
Workload and training

Nurses were asked about their current clinical activities within the practice (Table 2). Amongst those who responded to these questions (approximately half of the total sample), the most common activities were coronary heart disease (CHD) management (92.0%), cervical cytology (91.7%), travel immunizations (89.8%) and health promotion (87.7%). The next most common activities involved chronic disease management (stroke (85.1%), asthma (84.0%), diabetes (84.0%) and chronic obstructive pulmonary disease (COPD) (80.2%)). The least common activities were childhood immunizations (29.9%) and assisting with minor surgery (23.6%). Nurses had received specialist training in all clinical areas, particularly cervical cytology (92.6%), diabetes (88.4%), CHD (86.2%) and asthma (83.0%). The areas where least training had been received were men's health (24.4%) and assisting with minor surgery (23.0%). Reflecting this, 64.2% of respondents wanted more training in men's health; however the biggest request was for more training in treating minor illness (66.9% of respondents). Table 2. Workload and training needs amongst practice nurses (Number answering yes/Total number of respondents (%)). Continuing professional development over the previous three years reflected the increasing focus on chronic disease management, with 134 (67.0%) of respondents attending courses on diabetes, 92 (46.0%) CHD courses and 81 (40.5%) courses on stroke. 40 nurses (20.0%) had attended a nurse prescribing course, although 48 (24.0%) reported regularly prescribing medication; only 10 (5.0%) had attended a nurse practitioner course.

In-house training was common, with 149 (76.4%) participating in training activities in their practice in the previous 6 months and 126 (63.6%) participating in shared training sessions with the GPs in their practice in the previous 6 months.
Professional support and career intentions

164 (86.3%) respondents had a Personal Development Plan and 173 (87.4%) had had a formal appraisal within the previous three years. However, only half the respondents felt their appraisal had been productive (85, 49.4%), with 70 (40.7%) finding it only a little productive and 17 (9.9%) reporting their appraisal to be unproductive. With regard to other professional support, 181 (91.4%) reported having someone they could discuss a clinical or professional problem with; 145 (74.0%) reported having someone they could discuss a personal problem with. When asked about isolation, however, 86 (43.7%) reported sometimes feeling isolated and 17 (8.6%) reported always feeling isolated. Finally, 30 nurses (15.5%) did not intend to continue working as a practice nurse in the coming 5 years. There was a significant association between age and the intention to leave practice nursing (Chi-square test for trend = 10.631, df = 1, p = 0.001), with 18 (60.0%) of those intending to leave aged 50 or more, however the other 12 (40.0%) were under 50 years.
Association of isolation with demographic and workload variables

The factors associated with feeling isolated were examined more fully. Those replying "yes" or "sometimes" to the question of whether they ever felt isolated were grouped together and categorised as "isolated" with the others categorised as "non-isolated". Those reporting feelings of isolation were more likely to be aged 40-49 and to be G Grade nurses, although these associations were not statistically significant (Table 3). Both groups had been practice nurses for a similar length of time (isolated group: median = 10.0 years (IQR: 4.0 15.0 years); non-isolated group: median = 11.0 years (IQR: 7.0 - 15.0 years); Mann-Whitney U test = 3875.5, p = 0.096). Isolated nurses worked in smaller practices (Table 3). The median practice list size for the isolated group was 5000 patients (IQR: 3000 - 7500); for the nonisolated group the median was 5500 patients (IQR: 4000 - 8500; Mann-Whitney U test = 3510.5,

p = 0.016). Isolated nurses were more likely to work on their own or in smaller teams (Table 3). There was, however, no significant difference in either number of appointments or appointment times between the two groups (data not shown). Table 3. Risk of feeling isolated by demographic and practice characteristics (Number (%)). There were no significant differences in the qualifications/certificates obtained by both groups (data not shown), but only 64 (67.4%) of isolated nurses felt their training and qualifications were used to the full in their current job compared with 85 (92.4%) of non-isolated nurses (Fisher's Exact test, p < 0.001). There was little difference between the clinical activities undertaken by isolated and non-isolated nurses (Figure 1). However, a greater proportion of isolated nurses were involved in almost all of the listed clinical tasks. This difference was statistically significant for treatment room sessions (75.0% of isolated vs 54.3% of non-isolated: Fisher's Exact test, p = 0.038) and men's health (72.1% of isolated vs 52.2% of non-isolated: Fisher's Exact test, p = 0.043).

Figure 1. Isolated and non-isolated practice nurse clinical activities (% of nurses reporting participating in each clinical activity). Isolated nurses were more likely to report needing more training (Table 4). This reached statistical significance for family planning, screening for new registrations, COPD, stroke, CHD and health promotion. Slightly fewer isolated nurses had attended recognised CPD courses across a range a clinical areas, but this was not statistically significant (data not shown). Isolated nurses were less likely to participate in within practice training sessions with other colleagues: 71.3% of isolated nurses vs 82.8% of non-isolated nurses (Fisher's Exact test, p = 0.063). Isolated nurses had had slightly fewer study days in the previous year, but this difference was not significant (isolated nurses: median of 4.0 days (IQR: 2.13 - 5.75); non-isolated nurses: median of 5.0 days (IQR: 3.00 - 9.25); Mann-Whitney U test = 3103.0, p = 0.087).

Table 4. Need for future training amongst isolated and non-isolated nurses carrying out the listed clinical activities (Number answering yes/Total number of responders (%)). Personal development plans were reported by 82.7% of isolated nurses and 90.1% of nonisolated nurses (Fisher's Exact test, p = 0.146). Both groups also reported similar levels of appraisal (84.5% isolated nurses vs 90.4% non-isolated nurses; Fisher's Exact test, p = 0.284). However, isolated nurses were more likely to report that their appraisal was unproductive (66.7% vs 33.3% non-isolated nurses, Fisher's Exact test, p < 0.001). Fewer isolated nurses had access to someone with whom they could discuss a clinical or professional problem (85.4% isolated nurses vs 97.9% non-isolated nurses, Fisher's Exact test, p = 0.002) or a personal problem (62.7% isolated nurses vs 86.0% non-isolated nurses, Fisher's Exact test, p < 0.001). Only 77.3% of those who felt isolated planned to continue working as a practice nurse for the coming 5 years compared with 91.4% of non-isolated nurses (Fisher's Exact test, p = 0.009). Within the Health Board area, there were opportunities for practice nurses to meet together. Approximately half of all practice nurses were able to attend these meetings. There was, however, no difference in attendance between nurses who felt isolated and those who did not (data not shown).
Predictors of isolation

The results of the final binary logistic regression model are shown in Table 5. After accounting for the other variables, working alone was a highly significant predictor of isolation with singlehanded nurses over 6-times more likely to report feeling isolated. Nurses working in teams of two were 3.5-times more likely to feel isolated. Training and qualifications being used to the full and having a productive appraisal both significantly reduced feelings of isolation, as did the intention to continue working as a practice nurse in the future, but this was not statistically significant. Table 5. Association of nurse and practice characteristics with feeling isolated: Binary logistic regression model.

Discussion

Nurses working in UK general practice are an important part of the primary care workforce, particularly since the implementation of the new GMS contract [5,6,8]. In general, our findings agree with other national surveys conducted over the past 15 years, which showed that most practice nurses were aged 40 and over; most were Grade G nurses and that their workload covered a range of clinical activities, with immunization, cervical cytology, health promotion and chronic disease management clinics featuring prominently [24-27]. However, none of these surveys identified the feeling of isolation that was found here, nor its strong association with intentions to leave practice nursing. These nurses were older, more likely to be employed as Grade G nurses, worked in smaller practices and were either working alone or with one other nursing colleague. Although there was little difference between isolated and non-isolated nurses with respect to their qualifications, isolated nurses were more likely to feel that their qualifications were not being used to the full in their current job and were less likely to be planning to remain in practice nursing. Isolated nurses were no busier than non-isolated nurses. Clinically, both groups had similar roles, although a greater proportion of isolated nurses participated in each clinical area - particularly in the provision of treatment room sessions, treating minor illness and men's health. More nonisolated nurses took part in activities related to clinical leadership and staff management and in assisting with minor surgery, suggesting that non-isolated nurses may take on more advanced roles within the practice. Although there may appear to be a contradiction in the findings that isolated nurses felt their skills were not used sufficiently, when they appeared to carrying out similar clinical tasks, there are potential explanations. Isolated nurses may be engaged in a wider range of activities, and so have less chance to develop in-depth knowledge in particular areas which could enhance their job satisfaction and sense of being needed in a team; alternatively, they may be feeling more uncertain in their role, particularly if they are covering many areas that they feel unprepared for. These issues could be explored in future studies. A productive appraisal also appeared to mediate against feeling isolated. Participation in training activities within the practice and attendance at external practice nurse forum meetings was the

same in both groups, suggesting (perhaps surprisingly) that such activities did not affect nurses' feelings of isolation. One potential explanation for this, however, might be that only around half of the respondents reported being able to attend such meetings in the first place. Other studies have examined characteristics associated with intending to leave the profession, both in nursing[12,15,16] and general practice [28-30]. While factors such as age and workload were important, a key factor was job satisfaction. In some, this related to satisfaction with the job itself [28], while in others it related to wider factors, including dissatisfaction with promotion and training opportunities [12], changing requirements of the job and perceptions of being valued [15,16]. Feeling undervalued has been consistently reported by practice nurses since the advent of the 2004 GMS contract [5,6]. While we did not ask practice nurses directly about their level of satisfaction with their job, the finding that isolated nurses worked in smaller teams, felt that they did not use their training and qualifications to the fullest and had unproductive appraisals all point to potentially higher levels of dissatisfaction with their role today.
Strengths and limitations

The survey targeted the entire population of practice nurses working in the Health Board area at that time. It achieved a response rate of 61%, lower than that obtained by Atkin et al in 1992 [24], and Caldow in 2000 [25], similar to that obtained by The Centre for Innovation in Primary Care in 2000 [26] and much higher than that obtained by the WiPP Snapshot Survey in 2006 [27]. It was also conducted at a time when practice nurses were coming to terms with the new GMS contract. The lack of a practice nurse or practice identifier (as stipulated by the local ethics committee) meant that we could not gauge the representativeness of the responders in relation to the entire population, particularly in relation to the practice population served. In addition, as practice nurses are employees of UK general practitioners (themselves independent contractors), there is no centrally-held data on the demographics of this population. Responders were broadly similar to the characteristics reported for respondents in other, recent surveys of practice nurses [25-27]. Again, however, these surveys could not report on the characteristics of non-responders due to

the lack of population-level data about this workforce. Based on respondents estimates of their practice list size, we can infer that there were more responses from nurses working in large practices (list size > 6000 patients: 37% of respondents' practices versus 26% of NHS Greater Glasgow's practices) and less from small practices (list size < 6000: 60% of respondents versus 75% of actual practices). Given the association between small practices and areas of socioeconomic deprivation [31], this implies that there were fewer responses from nurses working in areas of deprivation. We also had no way of independently verifying the data, particularly in relation to workload and clinical activities. This survey was conducted in late 2005, a time of great change within UK general practice as teams became used to the requirements of the new contract. Given the findings from more recent qualitative work, it is likely that nurses remain feeling isolated while dealing with an increasing workload associated with QOF. Nonetheless, it would be timely to repeat this work, and extend it to a national level, to clarify the current picture in relation to this important professional group. The questionnaire used was one developed from that previously used within the health board and developed be reviewing the literature and in consultation with nursing colleagues within the board area. Although questionnaires have been used in other studies, these were not completely suitable either because of their content or their focus on hospital-based nursing [16,25,32,33]. However European studies of nurses' plans to leave hospital-based practice do confirm that issues such as perceived work ability, working conditions and support are important in nurses' views as to whether they wish to stay in nursing [16,32,33]. Finally, within the constraints of a self-completion questionnaire, it was not possibly to fully explore what nurses meant by isolation, nor whether this was a frequent or occasional feeling. Free text comments indicated a number of reasons for isolation, including that of working alone within a practice and lack of opportunities for clinical teaching and supervision. In order to fully explore this issue, further qualitative work is recommended.

Conclusions

Finding solutions to nurses' reports of isolation is of paramount importance, not only for practice nurses as a profession but also for the future development of general practice. Recognition of the role of practice nurses, nationally agreed terms and conditions and more multi-professional training initiatives have been suggested [34,35]. One explanation may be that nurses who report feeling isolated are also, in themselves, less likely to seek opportunities for training and support. However, our findings show that isolated nurses had similar amounts of study leave as nonisolated nurses and attended similar numbers of external practice support meetings. This suggests that while area-based initiatives are important, many of the solutions lie within general practices themselves. Research shows that job satisfaction, and presumably lack of isolation, is highest in practices with a good team climate, irrespective of the number of practice staff [36,37]. Therefore, we suggest that primary care organisations target their effort on supporting and building the team environment within general practices, regardless of size or staff composition, and that improving conditions for one group of staff should have a positive effect on all staff.
Competing interests

The authors declare that they have no competing interests.


Authors' contributions

CO, HJ and GW designed the study; HJ conducted the study as part of his PhD degree and conducted the main analyses, with COD and GW supervising. COD conducted additional analyses and drafted the manuscript; all authors commented on the drafts, saw and approved the final version.
Acknowledgements

We would like to thank all the nurses who completed the questionnaire; Gillian Hallyburton, NHS Greater Glasgow Practice Nurse Manager and Chris Carron, NHS Greater Glasgow Workforce Planning Project Manager for invaluable help in designing the questionnaire and for facilitating access to the practice nurses; Glasgow Local Medical Committee for allowing access

to practice nurses; and Michere Beaumont, General Practice and Primary Care for assisting with data entry. HJ was supported by a scholarship from The Palestinian Ministry of Higher Education. The views expressed are those of the authors and not necessarily those of the funders or their employers.
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