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The Role of Social Support Networks for Rural Hospital Nurses: Supporting and Sustaining the Rural Nursing Work Force

MacPhee, Maura PhD, RN; Scott, Jill PhD, RN

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Author Information

Author affiliations: The Children’s Hospital of Denver, Denver, Colo (Dr MacPhee); The University of Colorado Health Sciences Center, Denver, Colo (Dr MacPhee and Dr Scott).

Corresponding author: Maura MacPhee, PhD, RN, University of Colorado Health Sciences Center, 4200 E. Ninth Avenue, Box C288-8, Denver, CO 80262 (macphee@lamar.colostate.edu).

This project received the American Nurses Foundation grant for the year 2000.

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Abstract

Objective: This survey study describes the workplace social support networks of rural hospital nurses in one geographic region of Colorado. This rural sample was compared with data from a sample of urban hospital nurses in Colorado.

Background: Social support networks influence nurses’ satisfaction and retention. Nursing recruitment and retention is especially critical in rural areas where it takes healthcare facilities 60% longer than urban facilities to fill nursing vacancies. Little is known about rural nurses’ social support networks.

Methods: The Social Network Questionnaire (SNQ) was mailed to all nurses within one rural region of Colorado. Descriptive, correlational and comparative statistics were used to evaluate the structure and function of these nurses’ networks.

Results: The nurses’ networks were predominantly peer-based, but managers provided significant functional supports. The types of support provided by managers depended on the managers’ placement in the nurses’ networks. Some managers provided only performance feedback, and other managers offered physical assistance and emotional support. Rural nurses expected more guidance from management than did their urban counterparts.

Implications: This sample of nurses clearly delineated the types of leadership styles most beneficial to them. Communication of roles and expectations between staff and management can enhance nursing satisfaction in the workplace setting.

As the nation addresses the looming nursing crisis, rural healthcare agencies are particularly taxed with nursing recruitment and retention issues. 1,2 Rural healthcare facilities take 60% longer than urban facilities do to fill nursing vacancies. 3 Even during the early and mid-1990s, as urban hospitals felt relief from shortages, rural areas experienced widespread nursing shortages. 2 This staffing challenge continues to haunt rural hospitals. Sufficient nursing staff members are critical for rural hospitals to serve a population that faces many health challenges, such as high rates of infant mortality, more chronic illnesses, and a higher elderly population. 4 Scant ongoing research explores the status of rural hospital nurses. Rural health research has not provided in-depth analysis of factors (eg, the professional social climate) that are known to affect nursing retention and job satisfaction. 5,6

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The Rural Nursing Work Force

Although the nursing work force is aging nationwide, rural and frontier counties have the largest percentage of older nurses and are the least financially equipped to recruit aggressively in a highly competitive work force market. 4,7 Devising effective methods to recruit and to retain nurses in rural settings presents many challenges that escalate with the growing nursing shortage. Research suggests that the two most positive recruitment factors are: attracting rural natives back to their community, and enticing non-natives into rural practice by emphasizing the special qualities of the community and region. 8 Some rural hospitals and home care agencies have used a “grow your own strategy,” recruiting individuals from the community and paying for their education. 8

Stratton et al examined the nursing and non-nursing recruitment barriers in rural community hospitals. 6 Their research suggested three distinct factors that create barriers to bringing new nurses into rural areas. These barriers included: nursing-related barriers (work load and job benefits); community-related barriers (social amenities in the community and spousal employment); and professional interaction barriers (professional relationships with other healthcare providers, particularly physicians). Historically, rural nursing leaders believed that community-related barriers were most detrimental to recruitment efforts. However, the research of Stratton, et al indicated nursing-related barriers and professional interaction barriers were better predictors of what influenced nurses’ choices. 6

A survey of rural nurses in various settings suggests that “poor professional relationships” would most influence their decision to leave their current jobs. 5 Pan et al examined the factors that affect rural nurse retention in three different venues: hospitals, community agencies, and skilled nursing facilities. 5 Despite setting, job satisfaction was the strongest predictor of whether a nurse would leave his or her current position. Nurses’ thoughts about their work had a stronger impact on job satisfaction than other factors, such as demographic and community characteristics. Muus et al surveyed nurses working in rural community hospitals, comparing personal, demographic, and practice characteristics with self-reported intentions to stay in their present positions. 9 The researchers considered task requirements, organizational climate, professional status, salary, autonomy, interactions, and benefits or rewards. Regardless of whether nurses intended to stay more than or less than 5 years, both groups were dissatisfied with administration, staff problems, and insufficient respect from physicians. Studies of rural nursing indicate that geographic isolation does not provide the complete picture for what brings and retains nurses in rural and frontier America. Studies do suggest that professional, supportive relationships are essential in creating a desirable working environment for nurses. 5,6,8,9

Regardless of setting, research has shown that a “supportive” work environment is the most important predictive factor of nurses’ job satisfaction. 5,10 In addition, there is a significant relationship among job satisfaction, quality patient care, and patient satisfaction. 11 Garrett and McDaniel found a negative relationship between burnout and the social climate of the workplace, suggesting that social supports are important during times of change and uncertainty in the work environment. 12 A supportive workplace may stabilize high-turnover work settings. Therefore, rural nursing leaders must understand the social and relational aspects of nurses’ work environments, because social supports can ultimately influence the care of patients, staff satisfaction, and recruitment and retention of a precious resource...the rural nurse.

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Work-based Social Support Networks

Nurses’ workplace relationships and social supports can be operationalized and studied by examining the structure and function of their social support networks. 13,14 Certain types of support networks have been shown to ameliorate work-related stress and enhance individuals’ sense of self-efficacy and control. 15,16 Self-efficacy is defined as a “judgment of one’s ability to organize and execute given types of performances.”15 Bandura’s research has shown that an individual’s performance is significantly affected by his or her sense of self-efficacy. Actual skills may be less significant to task performance than efficacy beliefs, which are socially shaped. When people receive helpful modeling, guided practice, and constructive feedback through their social support networks, they achieve a higher level of work efficacy and satisfaction. Bandura also has shown that when people interact as teams in the workplace, a “collective efficacy” can be accomplished. 15 Other research has shown that constructive social support networks can foster innovation and retention of newcomers. 7,18

Nursing leaders must understand the nature of social support networks to improve patient care, nursing staff satisfaction, and retention. Based on previous social support research, there are three critical aspects of social support shown to predict psychological and physical adjustment across various populations. 18 These components are the structural, functional, and satisfaction aspects of support networks.

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Structural Support

Structural support refers to the number of members in a person’s network and each member’s closeness to the person. Research indicates that the number of network members is less significant than their perceived closeness to the person. 13,20,21 Antonucci developed a tool comprised of a series of “closeness rings” to represent schematically a person’s structural support network. In addition to measuring the number of overall members and the number of members within each ring, the tool also captures the role of each member. 22 Role information has been useful for better describing the types of people found within certain individuals’ support networks. Role labels, such as “nurse,” “manager,” et cetera, help define who we are and what we do in relation to the environment and to others. 22 By examining the types of people and the roles they serve, we can better understand the composition of a successful social network.

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Functional Support

Functional support is defined as the provision of socio-emotional and instrumental aid to meet a person’s needs. 19 The relative importance of these types of aids was difficult to discern in previous research, because operationalization of functional support varied across studies. Recent research is beginning to delineate and operationalize functional support according to nine functional aspects most cited in the literature. Clarification of functional support is especially important because research findings suggest that, depending on the type of work environment, certain types of functional support may be responsible for managing personal and workplace stressors. 23,24 Figure 1 lists and defines the nine types of functional support.

Figure 1
Figure 1
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Satisfaction With Support

Fiore et al developed a standardized tool to assess satisfaction with functional support. 19 Their research used the spouses of patients with Alzheimer’s disease and demonstrated that the spouses’ satisfaction with the nine functional support dimensions correlated significantly with their levels of depression and coping. The researchers concluded that examining how individuals evaluate satisfaction with functional supports may illuminate methods to intervene and improve network support. This approach was recently used to develop professional intervention strategies to assist youth with Inflammatory Bowel Disease and their family members. 21

The study of social networks, therefore, may provide us with insights into the nature of meaningful, supportive interactions, and the social obstacles and challenges that influence a person’s abilities to function successfully in his or her respective environments. Rural nurses’ social networks have not been explored with regarding the models promulgated by social support researchers, such as Atonucci and Fiore. This study was intended to provide an initial description of rural nurses’ workplace social networks. These study findings will hopefully help rural nursing leaders to develop and maintain effective workplace networks.

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Methods

Research Design and Sample

A nonexperimental, descriptive and comparative, correlational design was used to describe rural hospital nurses’ workplace social support networks in one geographic region of Colorado. The geographic region selected contains 10 hospitals in the mountains and plains and represents the rural diversity of the state. The total study population consisted of 350 nurses employed at these 10 rural hospitals. A database of nurses (N = 120) from one urban hospital in Colorado was available to compare the structural and functional aspects of nurses’ social support networks. 13

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Procedure

This survey study was approved by the Colorado Multiple Institutional Review Board. Nursing directors of the 10 rural hospitals in this geographic region were contacted by telephone and asked to participate in the study. If they agreed to include their nursing staff in the study population, questionnaire packets were mailed to them for distribution to their nursing staff. All nurses (N = 350) at the participating hospitals received a questionnaire packet with a cover letter, questionnaire, and a stamped return envelope. No names or personal identifiers were used. Two weeks after initial questionnaire distribution, reminder letters were delivered via the nursing directors to all nursing staff at the participating hospitals. The data were coded and analyzed using Statistical Package for Social Sciences (SPSS; SPSS Inc., Chicago, IL).

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Instruments

Nurses’ social support networks were measured using Fiore et al’s adapted version of Antonucci’s Social Network Questionnaire (SNQ). 19,22 The SNQ has been used extensively to study social support networks across the lifespan and across cultures. 25,26 Levitt et al found excellent 12-week stability coefficients for children’s network members, r = .79. 26 Fiore et al. tested several hypotheses pertaining to the support networks of patients with Alzheimer’s disease and found justification for the tool’s construct validity. 19

The first part of the SNQ measures structural support (Figure 2). Three nested circles provide a framework for people to diagram their social networks. The circles indicate “closeness” to the person filling out the tool. The core of the framework is a “YOU” circle. The first circle around the core contains those persons “who you feel closest to at work.” The second ring contains those individuals who “you feel close to at work, but are still important to you.” The final, third ring, contains persons “who you feel least close to at work, but they are still important to you.” In the instructions, respondents are asked to number people in their three support rings. “Number each person as you place her or him in your network.” They also are told that circles can be empty, full, or anywhere in between.

Figure 2
Figure 2
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The second portion of the SNQ consists of a Network List. An example is provided with Figure 2. The Network List asks respondents to list the first 15 members from their network rings who “are most important to you at work.” Respondents are asked to designate the role/relationship of these 15 members, and respondents are allowed to generate their own role/relationship labels, such as “peer,” “supervisor,” “doctor,” etc.

The third portion of the SNQ reflects the functional supports provided by the first 15 network members. The respondent is asked to identify those network members who provide support for each of the nine functional support types. For example, “Are there people at work who give you guidance or help you better understand a situation or problem? Please circle the numbers that correspond with the first 15 members of your network who provide guidance to you at work. If no one does, please circle 0.” The respondent also is asked to indicate satisfaction (Yes/No) with support received for each type of functional support.

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Findings

The total sample population (N = 350) was reduced to 225 when some rural hospitals chose not to participate because of staff issues in their facilities. Seventy-five rural hospital nurses responded to the survey for a return rate of 33%.

Respondents were primarily European American, non-Hispanic (85%), 40 years of age and older, with an average annual full-time income of $33,500. The mean number of years as a nurse was 16, although the mean as a rural nurse was 14 years. Most respondents held associate degrees in nursing (58%), 25% were baccalaureate prepared, and 9% were diploma graduates. Twelve percent of the sample was Hispanic and 3% was Native American. Only five (7%) of the respondents were men.

This sample of rural nurses had peer-based networks. Managers represented less than 20% of the support in any ring. Small numbers of other types of support also were reported, such as physicians, secretaries, nursing aides, housekeeping staff, et cetera. Most of those considered “other supports” occupied the third ring. The average network identified 15 persons: five in the first ring, six in the second ring, and four in the third ring. Figure 2 is an example of a typical network.

Nurses were asked to consider the functional and satisfaction aspects of their network. Overall, peers were used more than managers for all types of support. Most nurses indicated that they did not want more support, except for the appreciation and feedback categories, in which 50% of the respondents replied that they would like more appreciation and more feedback. Table 1 provides a summary of functional attributes of the network.

Table 1
Table 1
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The respondents also were asked to rate each type of support in terms of importance. Table 2 demonstrates the rank order value of each functional attribute. Repeated Measures ANOVA found no significant differences between types of support in terms of their importance ratings (F = 1.84, P = .067).

Table 2
Table 2
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Structure, function, satisfaction, and demographic relationships were then considered. Older, more educated nurses tended to have a larger first ring comprised of a greater proportion of managers than of peers. These nurses also tended to have smaller numbers of peers in their third ring, perhaps suggesting more healthcare members in this ring. No significant correlations were found among the demographic variables with the functional or satisfaction variables.

The relationship between functional supports provided by peers or managers and their placement within the network were analyzed and evaluated. As shown in Table 3, first ring peers were relied upon for emotional support, socializing, and physical assistance. Second ring peers were counted on for socializing and no significant correlations appeared for third ring peers. First ring managers were used for all types of support except for feedback. Nurses perceived first ring managers as requiring their guidance, but not their emotional support. Second ring managers were sought for guidance, emotional support, socializing, and feedback. Nurses perceived second ring managers as requiring guidance and emotional support from them. For third ring managers, the only positive correlation was for feedback.

Table 3
Table 3
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Finally, the study considered differences between urban and rural nurses’ support networks. Data on the urban sample had been obtained previously, and due to questionnaire differences between the two nurse populations, portions of the SNQ could not be compared. The urban sample was asked to respond to only two types of functional support: getting emotional support and getting guidance.

Demographically, for both samples, most respondents were women and European American, non-Hispanic. Most urban nurses were baccalaureate prepared and averaged 33 years of age. Independent sample t-tests with a Bonferoni adjustment for multiple t-tests were insignificant between the rural (n = 75) and urban (n = 120) hospital nurses regarding the structural aspects of support networks. No statistically significant differences appeared between urban and rural nurses regarding emotional support from peers or managers. There were statistically significant differences noted between urban and rural settings; rural nurses expected more guidance from managers (P = .000) and peers (P = .000).

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Discussion

This sample of rural hospital nurses represented their geographic region. Most rural respondents held Associate Degrees (58%). A recent survey in Colorado conducted through The University of Colorado School of Nursing revealed that one in six rural nurses report a desire for more education. 27 Because the motivation exists, rural nursing leaders should consider partnerships with educational centers to enhance distance education opportunities for rural nurses. Learning incentives may be valuable recruitment and retention tools for rural nurses.

Examining the first ring membership is important; previous research has shown that people tend to concentrate their most important support members in the first ring. 13,14 This study indicated that older rural nurses’ first ring had greater proportions of managers. This membership shift in the first ring may signify that younger, newer nurses are more peer-dependent and less able to make strong connections with managers. Because first ring managers are reported to provide many types of functional support, it is critical for rural nursing leaders to facilitate “helper” relationships early with new nurses on their staffs.

Rural hospital nurses reported that first line managers provided many important types of functional support. First ring managers were sought uniquely for providing guidance, physical comfort, and words of appreciation. This depicts first ring managers as clinically expert and nurturant. Nurses also indicated that these managers sought the guidance from staff. This suggests a collaborative, reciprocal relationship between staff and first ring managers, in which nursing staff expect first ring managers to provide constructive advice and ask for it from the nurses as needed.

At the second ring level, managers still were predominant sources of guidance and emotional support (versus second ring peers), and socialization. These managers were no longer viewed as providing physical assistance with tasks. Instead, the second ring managers’ primary function was for feedback. This creates a scenario in which second ring managers appear to be more removed from staff than are first ring managers. They function in more traditional managerial roles of supervising staff and providing feedback on professional behavior. However, second ring managers still were expected to turn to nursing staff for guidance and emotional support.

Second ring managers in these rural hospital settings have the difficult task of being less engaged in the physical care functions of the nurses while being expected to provide emotional support, guidance, and most professional feedback. Despite the distancing necessary to provide objective, professional criticism, these managers were expected to give advice and to seek it from staff. These managers were expected to function in both informal and formal managerial roles. This difficult balancing may have resulted in more distance from staff, which was perceived as less supportive.

At the third ring level, peers were not used for functional supports, and the third ring managers functioned only as sources of feedback. These managers may be more removed from the bedside, serving as the nursing executive at the rural hospital. Third ring managers are expected to keep staff informed of relevant information regarding hospital policies, protocols and operations.

The rural nurses from this sample discerned three types of managers with different degrees of social closeness to them. First ring managers were most like the rural hospital nurses. Second ring managers were expected to provide guidance, emotional support, and traditional feedback. Finally, third ring managers were expected to provide feedback, perhaps serving as the most formal route of information and advice between staff and the organization.

The uniqueness of this picture of rural nursing management versus counterparts in the urban setting is notable. Comparative analyses showed that the proportions of peers and managers used for emotional support were not significantly different between groups. For the rural nurses, however, significantly greater proportions of peers and managers were used for guidance, suggesting the presence of the closer rural community. When nurses share a community, personally and professionally, there are likely to be closer connections. Rural managers have to have more “hands-on” expertise because the work force is much smaller.

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Limitations

This cross-sectional study was conducted when nursing morale was reportedly low due to nursing shortages and high patient acuity loads. A time series design, examining nurses’ networks at different times, would allow us to know more about how contemporary and historical features of the work environment affect nurses’ needs for different types of social supports.

This was a small sample of rural hospital nurses from one geographic region of Colorado, which limits generalizability. National survey studies of rural hospital nurses are needed, particularly because rural areas are heterogeneous and hardest hit by nursing shortages.

This study focused on one variable known to influence job satisfaction, nursing recruitment, and retention. Social support networks are critical components of social climate and nursing work environments, but other variables, psychological demands of the work environment, and degree of work autonomy, also are known to influence nursing outcomes, such as job satisfaction.33 It should be possible, with more sophisticated statistical approaches available and with larger study samples, to better understand and manage factors most influential to nursing job satisfaction and retention.

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Implications

The results from this study support previous research on urban hospital nurses’ networks and suggest that regardless of demographics or geographic locale (urban versus rural), nurses construct networks of peers and managers that are similar. 13 Nurses, therefore, have an important need to develop a network in which there are certain role expectations of peers and managers within that network. Because they have clear definitions of what functions the different levels of managers should perform, communication between staff and managers can be enhanced by periodically surveying (formally or informally) staff about functional supports. Open, regular communication between staff and management will enhance satisfaction with manager performance. Satisfaction with management affects nursing job satisfaction, a critical component to retention and patient care quality. 28

Research on magnet hospitals has shown that strong leaders are visible and capable of providing a much guidance and emotional support. Nurses in these magnet hospitals stressed the importance of professional collaboration between staff and management. 29 These findings were confirmed in this study in which first ring managers, in particular, were used for most functional supports. They also were expected to provide guidance and to seek guidance from staff (a collaborative practice perspective). Magnet managerial qualities may be especially important in rural hospitals in which unique qualities of patient care and staffing patterns require managers and staff who are cross-trained and flexible. 30

According to research on leadership styles, changes in the healthcare arena have resulted in managers who are generalists or jacks-of-all-trades who work alongside nurses. They also are responsive managers in direct contact with the nursing staff who provide professional feedback and managers with formal, authoritarian lines between the nursing staff and the organization. 31,32 This study supports these key leadership styles in the rural hospital setting. When many manager functions are required, it may be critical to identify clearly the individuals in managerial roles who can address particular nursing staff needs. Magnet hospital research indicates that problems or dissatisfactions may arise if roles and expectations between managers and nurses are not specifically demarcated. 29 Formal surveying or informal dialogue at staff meetings can help rural nursing leaders determine how to facilitate and enhance different managerial roles for their nurses.

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Conclusions

Nursing managers play significant roles as key members of rural hospital nurses’ social support networks in the workplace. In this study, rural hospital nurses had specific expectations of their peer and manager members. In general, the nurses from this sample indicated that they needed little additional functional support. These nurses were relatively satisfied with the structural and functional aspects of their workplace networks. This type of information, particularly as it highlights the functional supports provided by different types of managers, is a valuable indicator of what nurses want and need in their work environments.

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