Between February 2015 and May 2018, 85 public health nurses enrolled in the BCHCP process evaluation delivered the NFP program. During that time, 38 nurses across 5 health authorities left their NFP positions and exit interviews were conducted with 28 of these nurses (73.6%). Of the 10 nurses not participating in an exit interview reasons included: unable to set up interview before NFP exit date (n=9); and, nurse did not respond to invitation (n=1). Participant characteristics are summarized in Table 1.
Through the accounts of 28 public health nurses, we observed that these nurses were enthusiastic about the opportunity to deliver NFP. However, despite their satisfaction with NFP, multiple voluntary and involuntary factors challenged their capacity to remain in the program. An in-depth examination and analysis revealed three key stages that emphasize the workforce cycle for NFP public health nurses: joining the NFP team, making a difference, and deciding to leave. Stages represent the processes of recruitment, retention, and turnover and key findings are summarized and presented in Table 2.
Recruitment: Joining the NFP Team
Participants emphasized that the opportunity to deliver an “evidence-based program” and potentially have a long-term impact on families’ lives motivated them to join the NFP team. Throughout the interviews, nurses referred to NFP as an “evidence-based program,” even though the effectiveness of the program in British Columbia has not yet been established. An experienced, end-of-career nurse described what motivated her in this role,
I really felt like I wanted to do something in my career that I felt would really be able to make a difference and I felt a real connection with just core values and then the NFP client-centered principles, and just the social impact that NFP had not only for the client's family but even then through generations.
This perception of NFP being a program that “makes a difference” for families is underpinned in the NFP core education where NFP nurses in British Columbia are introduced to the positive outcomes measured in the US trials. Nurses expressed fulfillment in working in the area of maternal-child health and with high-priority populations, such as teenage girls and young women experiencing complex, chronic health and social issues: I love young moms and the connection I was making with some of the vulnerable ones … Knowing that that was basically my clientele was a huge draw for me. Providing evidence-based nursing care to young mothers was a motivating factor for nurses who applied to work in NFP.
Previous experience working in public health parenting programs without adequate time, clear guidelines, and resources to address complex client needs piqued nurses’ interest to apply to work in the NFP program. One participant shared her discontentment with prior practices,
One [reason for applying to NFP] was maybe the dissatisfaction of my ability to work with vulnerable populations in general public health. I just found that it was getting more challenging to find the time to be available to the families that needed us most because we were spread so thin with other duties. And also, there was no template for which to work with these families, so everybody did their own thing and I just felt that there was a better way but just didn't know what that better way was.
In contrast to having limited guidelines to structure their home visiting practices in general provincial home visiting programs, some nurses expressed frustration about previous experiences that did not allow for them to consistently apply their nursing skills, judgement, or work at their full scope of practice. The lack of autonomy within their previous nursing practice and its increase in scripted responses and “checklist nursing” was described in this quotation:
I had done the other jobs in public health for a long time and it was getting more narrow and narrow all the time. We were told what to do and when to do it. A lot of it was like phones and scripts. So, it wasn't a very interesting job.
Participants hoped NFP would provide them with the opportunity to complete a robust program of nurse education, improve their knowledge and skills, and have access to visit-to-visit guidelines, tools, and resources to integrate into home visits.
Nurses found the potential to become home visiting experts and experience a sense of personal and professional fulfillment in providing a program informed by theory, based in evidence, and guided by focused client-centred principles appealing. Furthermore, they valued the education and support offered by the NFP program model. Participants, even those with significant maternal-child expertise, viewed NFP as an opportunity to increase their skill set working with high priority populations, “I was very interested in the program because it was an opportunity to learn new skills and to become a bit of an expert in this area.” Nurses appreciated the advanced education they received. Even more significant, nurses highly valued that the program model allowed for, even encouraged and provided support, time, and flexibility, for nurses to do whatever was required to establish, build and maintain a strong, consistent therapeutic relationship with the client. Nurses new to public health practice were also drawn to NFP for similar reasons:
There's a lot of support and backing from supervisors and management to get education to broaden ourselves, and also to do self-care. You don't see any of those things in the hospital really. So that was what I was lacking and what I needed and so it totally fit the need for me in NFP.
Nurses exiting the program provided insights into recruiting strategies and stressed the importance of job fit. They perceived that the personal qualities necessary to be successful in the NFP role included being flexible with how they implemented program elements and exhibiting openness and self-awareness. The necessity of job fit was explained:
If [a nurse] doesn’t fundamentally have the right attitude - if they're not open, if they're not able to roll with the punches, if they're not able to really critically look at themselves, their boundaries, their reaction to things, if they don't have that insight or aren't willing to develop it, they won't get, or last in, the program.
Additionally, there was a set of past professional nursing experiences that participants identified as critical considerations when NFP teams or nurse supervisors were advertising and recruiting for new nurses to join the team, including: 1) practice with populations experiencing adversity or marginalization; 2) confidence and competence in home visiting; 3) demonstrated abilities to establish professional boundaries with clients; 4) understanding of system level facilitators and barriers to meeting multiple client health and social needs; and 5) the ability to frame and deliver care and services from a strengths-based, rather than a deficit-focused, approach.
Retention: Developing Relationships
The nurses were all asked to reflect on their time delivering NFP to pregnant/parenting girls and young women and their experiences working with other NFP team members, and then to identify the key factors that they perceived, influence nurses in general, to want to remain working in the program. There was broad consensus, that the two primary reasons public health nurses are motivated to continue to work in this program are the opportunities to develop genuine therapeutic relationships with families as well as to work at their full scope of nursing practice. As one nurse concluded: “I loved the fact that it was a long-term relationship that you’d be building and that there were so many educational opportunities that came with NFP.” Within these two conditions, nurses expressed a deep commitment to making a difference in the lives of their clients and were encouraged by the opportunity to have a greater impact through their work in the NFP program.
Nurses identified that the nature and depth of the nurse-client relationship established within the context of this program contributed to their overall job satisfaction. NFP nurses valued building trusting relationships with clients and recognized the importance of establishing foundations for a therapeutic relationship: “I'd say the relationships and getting close to people that are usually very guarded and don't trust a lot of people. That they trust you and then they work with you.” In addition to relationship building, nurses were highly satisfied when they were able to witness positive client outcomes: “When you have success with your clients, it’s brilliant ... When you have those moments where your clients do something amazing and maybe I had a part in that. Look at this - I’ve made a difference!” Observing mothers becoming more confident in their parenting skills, infants meeting their developmental milestones, and families breaking inter-generational cycles of poverty or trauma were valued by nurses. These factors were identified by nurses as retention factors (for the time they remained in the program).
Participants also pointed out the importance of contextualizing the concept of success in the NFP program. One nurse shared how NFP changed her nursing practice: “It’s liberating as a nurse to be able to do that [strength-based work] because [in comparison to other programs] … I always felt the emphasis as a nurse [was] you're always looking for problems.” At the individual client level, participants reported successes including positive parent/child attachments, leaving abusive partners/negative influences/toxic relationships, quitting or reducing their use of substances (i.e. alcohol, tobacco), attending/completing school, acquiring employment, and receiving mental health support. For one public health nurse, the connection that she had to her client and the ability to focus on, and celebrate, her strengths were evident:
Just watching my girls succeed and it looked different for each one of them. I mean one of my girls, the baby was apprehended multiple times and I think permanently after the [NFP] program, but her baby was born with an intact brain and that's something she [the client] wasn't given. She avoided drugs and alcohol throughout her entire pregnancy. And her baby got a normal brain, and this is a mom that was born with FAS [fetal alcohol syndrome]. So even though she didn't successfully parent maybe in the way we look at, I saw her breaking the cycle and it was so neat to see those little changes and how that will impact not only her daughter but her daughter's children too.
The repetition of the term “my girls” in this participant narrative reflects the commitment and connection that the nurse felt towards her clients. Despite a child apprehension, the nurse was able to identify client strengths that she attributed to NFP exposure. Client success in NFP was not an all or nothing binary outcome. Because NFP is client-focused and strength-based, public health nurses could celebrate all successes.
Positive working relationships with the NFP team and supervisor were generally experienced as supportive and encouraged participants to remain in their position. Required weekly reflective supervision was consistently mentioned as a benefit to being in NFP: “Some of the things that are very helpful to retaining nurses, I think, are supportive supervision and regular reflective [supervision].” Engagement in reflective supervision provided dedicated time to critically reflect on situations and receive essential support from supervisors to advance nursing practice. One nurse shared why reflective supervision and a supportive environment was so important: “NFP is a program where, as the practitioner, you need a ton of support because it's heavy work.” The notion of team cohesion and positive working relationships as a means to deal with the challenging work of NFP was echoed: “I think the team meetings and the reflective practice are huge for retention and, well, decreasing burnout. But also, for growth as well, the case conferences that we do are really engaging, and I actually miss them.” Regularly reflecting, discussing, and debriefing with supportive colleagues and an assigned NFP supervisor who understand the nature and stresses of the program allowed nurses to feel connected and supported in their work.
Retention: Developing New Skills
Participants recognized that professional development, such as the completion of NFP core education and the availability of ongoing learning opportunities, supported them to advance their professional nursing knowledge and skills. Nurses attributed their clinical successes to the intensive educational opportunities provided and suggested that it may be a factor for ongoing retention of NFP nurses: “I really enjoyed the ongoing learning and education that was part of the NFP that was a real retention piece for me.” Opportunities to gain and apply knowledge were found to enhance professional growth for public health nurses: “Using that research base and developing knowledge and skills more intensely in a way of applying theory and research … to develop as a professional.” Being in a role that supported professional growth and development was important to nurses.
With advanced knowledge and in a supportive environment, nurses were able to work at their full scope of nursing practice. This milieu allowed for regular, in-depth nursing assessment, planning, intervention, and evaluation: “I felt like I was using all my nursing muscles instead of just a few of them.” The ability to learn new assessment techniques used in NFP and apply them in their public health nursing practice was professionally stimulating. Another nurse reflected on her time in NFP: “It's been a really interesting role that I will definitely take a lot from.” Many nurses noted that NFP was the most challenging nursing position they had experienced: “[During training] I was like, ‘oh it can't be that hard’. It can't be any harder than what I've already had to deal with as a nurse. And, no … I've lived that.” Providing complex nursing care to NFP clients using an array of new resources, skills, and knowledge was meaningful to nurses.
Turnover: Deciding to Leave
Participants identified a variety of voluntary and involuntary factors that contributed to their decision to leave the NFP program, as presented in Table 3. Contributing factors are presented and described in this section.
Involuntary reasons for job turnover, as described by the nurses, included: 1) health authority restructuring or reallocation; 2) union grievance; and 3) position terminated for no known reason. For one health authority, the NFP program was discontinued as the health authority restructured programs: “My health authority has decided that, with their switch to a new model of delivering public health services, that [NFP] does not fit with their new model, and so they've deleted my position in the program.” Under these circumstances, some nurses did not want to exit NFP: “I'm not leaving my position, I'm being displaced.” How leadership communicated decisions about who would exit the NFP role mattered to how the nurse experienced it (i.e. collaborative decision making versus no control). Regardless of the reason for the involuntary turnover, supportive communication about program changes and opportunities to process them influenced how changes were received and experienced by participants.
Institutionally, union regulations, system reorganization, and reallocation of nursing resources were structural barriers that imposed constraints and resulted in involuntary turnover. Participants perceived that interference from the nurses’ union may have caused hiring practices that could be responsible for increased turnover. Specifically, some nurses explained their perception that the union mandated that seniority ranked over personal and professional attributes when hiring into NFP positions and existing positions were grieved. A concerned nurse stated: “[It’s] almost like [the union] is treating [hiring] like a nurse is a nurse is a nurse. And I don't believe that's true.” The importance of hiring for job fit during recruitment was reinforced when participants discussed turnover. In one instance, the reason for being asked to leave NFP was unknown to the participant.
In BC, NFP was implemented by four regional health authorities as part of the BCHCP RCT evaluation of the program’s effectiveness; meanwhile, four health authorities are continuing to implement NFP as part of enhanced public health services while awaiting RCT final outcomes. At the front-line practice level, however, limited communication about the long-term delivery of NFP within local offices increased frustrations for some NFP teams. While participants recognized that the Ministry of Health and the BCHCP research team may have conveyed information about long-term NFP planning possibilities to health authority leadership, nurses disclosed that they did not consistently receive clear messaging at the frontline. Participants perceived the demands on busy supervisors could have led to a lack of information-sharing and shared how team members responded: “We had this joke … that we were mushrooms; we were kept in the dark.” Participants feared the unknown and were challenged when they were in environments that lacked transparency, particularly when higher-level decisions might have the potential to impact the roles and positions that they work within.
The transition from delivering NFP as part of a research study to direct delivery of NFP as an integrated public health program was also handled differently amongst health authorities, which led to a range of positive and negative participant experiences, as it related to involuntary turnover. For sites where there was a reduction in NFP nurses, when nurses were included in the decisions about who would leave NFP, through respectful dialogue, the experience was considered positive:
We were all approached. It was very respectfully done … [the supervisor] explained what was happening. And so, I thought well for me, getting close to the end of my nursing career, that it would make sense that I would be the one who would step aside.
Communicating program changes and resource allocation, with clarity and transparency, allowed for a more positive experience for exiting NFP nurses.
For participants working in smaller communities, isolation was a factor influencing participants’ decision to leave. While the majority of NFP nurses reported not being co-located at the same office as their supervisor, a few were also the only NFP nurse located within an office and expressed feelings of isolation. Nurses at these lone sites were concerned that they were at a greater risk of burnout if they stayed in their positions. In addition to lacking an NFP supportive team physically co-located with them, these nurses often lacked adequate coverage during illnesses or vacations. One participant shared the following suggestion:
[Make] sure there's no lone nurses. I mean, I think, that it's really scary. And I actually have said that to my colleague that's taking over. ‘You're going to be really tired you know. There are going to be days where you're going to be like, I don't feel great and normally would've been like stay home but I got to see so and so and I know she's not in a great place and so I got to be on my game’.
The pressure to be present for clients without readily available and in-office NFP team support was identified by nurses as one factor that contributed to turnover for participants working as the sole NFP nurse in their area.
Personal reasons were cited at times for choosing to leave the NFP program. These included family needs, retirement, taking another position for career development, and relocating outside of the office catchment area. Other nurses shared that the working environment was stressful or unsupportive and within the context of their own health or a family member’s health, the decision to leave was necessary. Some retiring participants stayed connected to the program through ongoing employment in casual relief positions: “I'm not leaving because I don't like my job, I'm leaving because of my age … But I've agreed to go back as a casual a little bit.” Many of the participants noted that NFP was a good nursing position: “I would say that the program is everything you've ever dreamed of for your nursing practice.” Despite their reasons for leaving, many nurses enjoyed the experience and urged implementing organizations to address issues associated with turnover.
At the clinical level, the ongoing challenges of engaging “hard-to-reach clients” and managing a complex caseload while dealing with time constraints associated with traveling to clients’ homes and completing the subsequent documentation also influenced nurses’ decisions to leave:
I was done with the role, feeling burned out … expected to do a lot of driving and not being supported with having different worksites. And just feeling unable to properly get my charting done and properly have time to prep for visits.
Many nurses who voluntarily left the program shared concerns about being overburdened by the work of NFP. Where reflective supervision was not being provided adequately for nurses this became a contributing factor for attrition. Supervisor turnover for some nurses also contributed to lack of adequate support. Where supervisors had no prior understanding of NFP, reflective supervision less than optimal.
In some contexts, during periods of carrying smaller caseloads nurses were returned in a part-time capacity to non-NFP public health nursing. These participants expressed feeling less confident in the multiple roles assigned due to limited exposure, “I felt so scattered. I didn't have my foot in regular public health any more … And maintain the connection with public health and be able to also try and learn the NFP when your brain wasn't functioning anymore.” This was also the experience of some nurses who were regularly working in a dual role of both NFP nurse and generalist public health nurse. During busy public health times, such as school or flu immunizations, NFP nurses were expected to designate specific workdays to each role. NFP nurses who also had other non-NFP assignments experienced frustration and job dissatisfaction:
It was very clearly told to me at the beginning that - when I'm NFP, I'm NFP and when I'm [communicable diseases] I do [communicable diseases] and it does not cross. And, that's a challenge because the realistic part of it is if a family, an NFP family, calls me in crisis - I answer my phone. I can't really say, ‘well I'm sorry but I can't help you with this until Friday. I know it's only Tuesday but you're going to have to just figure it out.’ And, similarly I can't just not answer my phone or respond to [communicable diseases] things … It's kind of you know unethical or a pull between the two jobs.
NFP nurses who had multiple assignments often experienced concomitant negative consequences, i.e. stress, and physical and mental strain which contributed to their leaving NFP.
The stress associated with supporting young mothers navigating a range of complex crises also created the potential for nurses to experience vicarious trauma. Because of the frequency and intensity of home visits, and the strong relationships formed with clients, nurses found it difficult when clients experienced challenges: “You feel like you're making so much headway with the client and … then they go off the rails. And it's like everything they've been working towards falls apart … and that's pretty hard to witness.” Participants described experiencing a great deal of stress and worry over client and child safety, and feelings of moral distress when clients disclosed information around perceived risks that they had no ability to change. As one nurse characterized her work in the NFP program: “The hardest job you’ll ever love … really tough work emotionally.”