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2. Intent to Leave: Jennifer Fournier

Hello and welcome to ubiquitous evolution. I'm your host Roberta Heale. In this second episode in our podcast series, we're going to be speaking with a researcher who's published in the Nurse Practitioner Open Journal. We're going to be doing this on and off throughout our podcast series and I think it's going to be an important feature because when you speak to the researchers, or the authors of articles, they really have in their research. They bring the context and they bring the research to life. Talk about how it fits in with their own views and clinical practice and all sorts of things so really looking forward to that.

Remember that the Nurse Practitioner Open Journal is fully accessible online. You do not need a membership or subscription, or anything like that to access the articles and authors can publish, free of charge. This is really important for nurse practitioners who may or may not always have access to funds to publish. I do hope you'll take a look at the articles that we're going to be discussing.

The first guest is Jennifer Fournier, Dr. Jennifer Lynn Fournier, who I've known for many, many years. Actually, we first met when we work together and emergency department as registered nurses. I remember when I had a brief moment on a break, taking out some of the material that I was reviewing for the nurse practitioner program and I was taking, and Jennifer looked at me said "Oh, what's that all about?" I guess it was intriguing to her because she soon afterwards took the nurse practitioner program. And I think we've been friends and colleagues and research partners and all sorts of things ever since then. But today we're going to be speaking to her about research that she's completed for her PhD. It will focus on an article that she published in NPOJ called "Nurse Practitioner Intent to Leave. A Grounded Theory Study." Jennifer will tell you a lot more about herself in the introduction, so I won't go into more detail, but it was a great discussion. And here we go.

Okay, so welcome Jennifer would you start by telling us a little bit about yourself?

I'm Dr. Jennifer Lynn Fournier. I live north of Sudbury, Ontario and a small community called Capreol. I've been a nurse practitioner for over 20 years, I've run an NPLC (Nurse Practitioner-Led Clinic). I've worked rural. I've worked in virtual care. I serve as an educator and researcher, have just enjoyed every minute of the career that I've had, and I've been a good friend of our interviewer here Dr. Roberta Heale, for many decades as well so thank you very much for having me.

Yeah, I think some of our escapades would take quite a few podcasts over a very long period of time. But thank you for showing up for this podcast today. So, your study focuses on nurse practitioner's intent to leave. And why did you want to do this research?

Yeah, so when I did my PhD a couple of years back. We did a first of all, of course a literature review and we noticed that there was quite a bit of material published on nurse practitioner job satisfaction. Most of it, as with most of these kinds of studies, was sort of geography specific. We sought to develop theories. We started to develop a theory of nurse practitioner job satisfaction and it ended up that there were these threads of this other concept that kept coming in and that were attached but probably should have been separate.

One of the researchers on the team, Dr. Sylvie Larocque, had suggested that the intent to leave should be addressed as a separate component, but possibly within the same study, which is what we agreed to do. We collected data on both job satisfaction and intent to leave within a qualitative study. So, I did telephone interviews, kind of like what you, Roberta, are doing with me today. Then we really looked at that information, those transcripts, to try and pull out theories about each. At the same time, we were integrating knowledge that we thought through reviewing the literature, which at one point, it became clear to us from the human resource literature that job satisfaction, or dissatisfaction, and intent to leave exist on a continuum.

So, as we started to develop our theory, around nurse practitioners in Northern Ontario and how they're satisfied or dissatisfied and whether they wish to leave, we ended up actually building a theory that moved from satisfaction, dissatisfaction, into the leaving part, but split it up into two publications just as a matter of course, so that it was in a format that would work this way. But if you if you look at the diagram that's published in some places you will notice that it's actually a continuum.

You mentioned something really interesting to me, and I wonder if you can give us a bit more information about that and that is that you want it to develop a theory. Why do you think developing a theory was important in this case?

Well, a lot of the work that we saw really just was, it was survey-based research. They used a survey which is the Misener Job Satisfaction Survey for Nurse Practitioners, it's an American

item, and it has been around for quite a long time, a validated tool. What I wondered was if it was, you know, perhaps in different geographic areas, there would be additional items, or location -specific features of work and working life for these nurse practitioners that weren't present at the time that that instrument was developed. So, the purpose of doing what we did was to see if anything unique might come forward by virtue of the work that we were doing.

So that's interesting so then you can build on that and you don't necessarily have to use a survey that isn't specific to the area. Tell us more about how you conducted the research.

We put a call out through the Nurse Practitioners' Association of Ontario. And that's how we reached most of our respondents but what we discovered was that certain areas of the upper part of Ontario, they might have only had one or two nurse practitioners, and perhaps these individuals happen to not be members of the professional association. As we learned later some of the reasons for this were due to geography and inadequate time off for travel and collaboration. So, if it took you two to three days to get from where you were stationed working to Toronto for a conference you'd be less likely to go there for you be less likely to join the organization that was putting the call of for respondents.

As we moved along in the study and we pinned on a map the locations where I actually did get to speak with practicing nurse practitioners, we noticed those areas where we had gaps and we actually pivoted into a snowball sampling setup where we called people in communities close to there, or we thought might know someone from there, and got referrals that way to find additional interviewees so that we can round out the findings nicely and that we can ensure that the more rural and remote part of the study population were included.

Hmm. Ok. So, the interesting part now what were the findings of your study?

So, what we found is that there's decrease intent to leave in in certain populations of nurse practitioners that, you know, they if they're paid enough, if they have a good government pension, if they have good relationships with management, and if they have good benefits to cover themselves and their families, then they'd be less likely to be interested in leaving their job. The reason we're interested in finding out who might be thinking about leaving their job is because we know that if someone starts thinking, or even opens one job ad, that the likelihood of them leaving is very, very great provided there's an opportunity.

So having those things in place and supporting financially those kind of programs will help places to maintain nurse practitioners as employees or contractors and incumbents and decrease the risk of them leaving, which in turn costs you a lot of money in turnover. Then a new position, if someone was going to leave, then we say well what would they be looking for? So that's the next thing.

If these kind of jobs came open and someone wasn't happy they might take them. If people were going to leave, they were looking for, usually more money and benefits, perhaps something closer to home, or a little bit of a safer drive to work from where they live. And also, if they were going to seek work outside of the nurse practitioner role they'd look at things like administration and education as other avenues for themselves to pursue it in order to keep working in the profession but maybe not an employee role.

It would be really important, Roberta, to note now that it's been a couple of years since we started doing this study and I've noticed lately that a lot more nurse practitioners are exploring entrepreneurship. That wasn't reflected here, but what I do know is that I'm getting quite a few reach outs through social media and so on, from nurse practitioners who maybe taught in academia who are now interested in entrepreneurship. So that wasn't included here but I would bet that if I repeated this study at this time in this geographic area which is Northern Ontario, we probably find that out as well.

Yeah, that seems quite possible. I think there's a lot has changed since you did this study because it was pre- COVID, if I'm not mistaken.

Yes it was.

I was just doing an interview this morning with CTV about the same thing and we know that COVID put a huge burden on health professionals and nursing and nurse practitioners, in particular. We expect that it probably would be the tipping point for some people in terms of a job change or a total career change. This study, having been done prior to COVID, it is useful because it highlights things other than COVID with the related factors that might lead to someone thinking about leaving their job. In other words, if employers address some of these features and factors, they may then be able to circumvent some of the departures that could have been triggered during COVID or just in the post COVID phase that we're in now, if they were to beef up pay benefits. Some of some of those items they might be able to halt a process that hasn't already started.

So, before we go on to the next question I did have something that came up into my mind and I'm wondering if you think that your findings that contributed to the theory are relatable to other areas, and other nurse practitioner groups?

Yeah, so, partly and probably not totally. When I look at the literature which we all do when we're interested in this sort of thing, you know, remuneration, relationships with management, those are all items on the standard survey tools that were validated 20, 30, 40 years ago in other areas. The parts of this finding, or group of findings, that could be unique, or that might only be generalizable to a similar other are the findings related to distance, to practice setting and distance between practice settings. In other words, the findings that are linked to geography. If you worked in downtown Toronto, chances are you probably secured a position that's a short commute, because of the population density. When you're looking at Northern Ontario or rural areas of other northern parts of Canada, you may have two or three sites that are part of an Indigenous community set up, or a Health Canada set up, or just a township setup where they're sharing resources where you might travel a bit of a distance between say a long term care home, and two different primary care offices, for example, and that's not something you'd expect to see so often in an urban core.

Hmm. That makes a lot of sense. So overall, then what did you think about the findings and, was there anything surprising?

Um, I really appreciated getting insight to the features and factors that are leading to people thinking about leaving because I think they really inform employersabout how to prevent departures before the seeds are planted. So once that process is started, you know, human resource theory and psychology would say that once that process is started as actually too late.

So, it's really important for employers to know, even in our neighborhood, or in our geography or in this part of Ontario, what kind of things they can do that would be helpful. And to be honest, some of those, those items that did come up, they could be mitigated a little bit like distances between places and how you how you send out to your workforce and how you organize your workforce.

And then, you know, there could be considerations for things that cost nothing, or that are actually even sometimes less expensive, like offering something like virtual care to satellite sites on occasion, especially in the dead of winter rather than having a nurse practitioner do a physical exam isn't required, or having an Ontario telemedicine cart at the other end where maybe an RN who can run the cart and do the chest auscultation for you. I think this opens up the mind, if you're creative and if you're, you're focused on problem solving, as an executive or somebody who runs a facility or plans that system. It can open your mind then in further reflection to things that can be offered and done to mitigate some of those, those things

that would lead to somebody maybe not liking their job and starting to think about leaving.

You know you have a good point. Certainly, fear of have an accident on the road, just to get to your workplace is a huge barrier to continue to stay there.

I can appreciate that, like family and friends would certainly support someone in seeking alternative employment if they're watching that person go through that kind of process to get to work. For example, I used to love servicing a community that's more than an hour from my home, but you know in the dead of winter it wasn't so appealing. I felt strongly about attending but family and friends then would start to express concern about the fact that you're going to now already an hour and a half away from home to do what you love to do and how that might be a worry or there's a blizzard coming and, you know, that's always balanced in the practitioners mind with patient well -being and needing to see people who need service but certainly it did come across as a factor especially for a urban dwellers, or people going from an urban core out somewhere to work in a rural area perhaps because they like it perhaps because there's a job shortage in the urban core other reasons, you know.

The other thing that I find interesting about your findings is, of course, in theory, you're not going to wait the different findings, more or less than the others but certainly, you know anecdotally, I would have expected remuneration and autonomy to be front and center and I don't know if you can comment a little bit on those things.

It's really interesting because, you know, earlier I was talking to you about the fact that we saw intent to leave materials, or responses coming up blended in with our job satisfaction materials. What's actually happened is that when we went to the human resource literature after collecting the data because with qualitative of this kind, you don't always review all the literature first. What we discovered was that theorists before us had ensured that job satisfaction/dissatisfaction and intent to leave are disparate concepts. And so, if you go and look at the part of the theory that's not published here, which is the job satisfaction dissatisfaction component, you will find those items over there. So, you can be satisfied or dissatisfied in your job, and still not move towards intent to leave. It depends how many factors are out of line or are not satisfying you. It also depends upon the availability of alternative employment. People will never demonstrate, think about, or begin to enact aware or unawares and intent to leave in a community where there's no other job well so you know your comment earlier than about institutions.

Being aware of some of these factors and acting on them is really a key thing for retention of people in jobs. And actually, possibly just asking them what do you need to stay here?

Yeah, yeah you know these places have a romantic idea that they found someone and they're done. The reality is that instead of finding one they should probably find two. Number one. Number two, when there's a shortage of employment in the urban core, then new graduates will tend to take jobs in the outlying areas but as soon as there's a job in the core and they have experience, they'll end up usually coming in, whether they intended to cognitively or subconsciously at the start or not. That is what happens if they start a family. Sometimes that too will lead them to come back into the urban core so outlying areas think they've got it made because they quote, unquote found someone but the real sort of and game on that whole continuum would be that they get to keep someone.

Now I know it was interviewed based and not survey so there weren't statistics, but did you find the type of workplace seemed to make a difference, the model of the workplace, or is that something you'd be able to comment on?

Yeah, so it wasn't so much, the model because we tend to associate certain models with more or less autonomy based on the general sort of intent behind the organization or the organizational structure, but actually what came across here and I'm cognizant

of all that material about NPLCs and sort of nurse practitioner-led and all of that kind of part of the politic of organizing clinics. But what I think really became the significant feature here was the nature of the leader, regardless of the model of care. Not even the background of the leader but the nature of the leader and how they run the organization. So, if it was a model that you might associate with less autonomy and that kind of stuff, depending on the leader, it could present very much, fully autonomous where the nurse practitioners advise the leader on what is needed for patient care where the nurse practitioners have a lot of input into the budget and into the function of the clinic. I think the leader is as important as the package.

Oh, I couldn't agree with you more. Certainly true. I think we could talk about this for a very long time. I think this is amazing research and I think there's so many different types of research or considerations that arise from it but just to wrap up I'm wondering if you have anything you want to add just to close things?

Yeah, so, of course, in the trajectory of my career. I'm not going to have time to delve more deeply into each of these factors, nor am I going to have time to replicate it in other geographic areas, I feel like that you know if it's going to inform health human resource planning that there are going to be times when a situation warrants doing something like this in the area of staffing concern. Okay. But the other thing that I noticed here is like, if a young nurse practitioner is pursuing masters level education or doctoral work wanted to pull out one small part of this and do something more fulsome that it would be a really good opportunity to delve deeper. Maybe in mixed methods, into one of those parts, for example, for nurse practitioners.

I don't see anything published about rurality except romantic stories in Hallmark movies. So it would be great to see somebody just focused on say the rural population in northern Canada and what their wants and needs are, you know, as a way to perhaps inform Health Canada and other potential employers about what they need to do to retain. So there are lots of opportunities in the findings here to branch out and go further.

Wow, this has been amazing. Thank you very much, Dr. Jennifer Lynn Fournier.

Thanks for having me.

So that's a wrap on our second podcast Ubiquitous Evolution. Join us next time when we discuss another research article that has been published in the Nurse Practitioner Open Journal.

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