Research Article Nursing Workforce Retention in Rural Ghana: The Predictive Role of Satisfaction, Rural Fit, and Resilience Collins Atta Poku ,1,2 Eva Mensah ,1 Josephine Kyei ,1 and Adelaide Maria Ansah Ofei 1 1School of Nursing and Midwifery, University of Ghana, Legon, Accra, Ghana 2Department of Nursing, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Correspondence should be addressed to Collins Atta Poku; attapokucollins@yahoo.com Received 20 October 2022; Revised 2 February 2023; Accepted 11 February 2023; Published 21 February 2023 Academic Editor: Tarja Kvist Copyright © 2023 Collins Atta Poku et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. High turnover of nurses in rural healthcare settings contributes to challenges in healthcare delivery. Various incentive packages have been introduced in rural healthcare settings to curb this phenomenon, but the canker still exists.Te study aimed at assessing the predictive role of job satisfaction, rural ft, and resilience on nurses’ retention in rural Ghana.Materials and Methods. A multicentre cross-sectional design was adopted to collect data from 462 nurses. Analysis through descriptive statistics, one-way ANOVA, Pearson moment product correlation, and multiple regression was done. Results. Tere was low resilience and rural ft among nurses with higher turnover intention, which was predicted by average daily attendance (β� 0.108), rural ft (β� −0.144), resilience (β� −0.350), satisfaction with prospects (β� −0.187), and satisfaction with prospect and pay (β� −0.171) at the signifcance of 0.05. Conclusion. Policymakers can be assured that not just improving fnancial incentives to nurses, but the integration of nurses to rural settings, commensurate workload and improving pay and prospects for professional growth and resilience are needed for rural retention. Implications for nursing management, nurse managers, and policymakers have a role to develop sustainable strategies to integrate rural ft, resilience, and job satisfaction to help reduce turnover among nurses. 1. Introduction Human resources for health care are among the six pillars of the health system. Health systems can signifcantly be ef- fective when there is a satisfactory health workforce, thus, the key to improving health service coverage and outcomes, although multifaceted, depends on the adequacy and skill mix of the workforce [1]. Globally, there is an increasing worry about human re- source shortages in rural healthcare settings, especially, in low- and middle-income countries (LMICs) with Sub-Saharan Africa (SSA) experiencing the severest form. Te capacity of the health workforce in these regions is insufcient to meet the population’s health objectives [2]. Te health system is con- frontedwith health workforce shortages, and this disparity is an important limitation in realizing the health-related sustainable development goals (SDGs) [3]. Meanwhile, the need for more workforce is projected to signifcantly go up due to multiple factors: adolescent-related challenges, ageing of the current generation, changing distribution of diseases, high incidence of noncommunicable diseases (NCDs) resulting from a sedentary lifestyle, overpopulation, and high pace of the technology- induced world [4]. Te strain on the workforce is imminent if the challenges on the workforce are not addressed, and therefore, plans are needed for the management of human resources in the health sector [5]. In the interim, there has been an estimated shortage of nine million nurses, and this fgure is projected to increase further by two million by 2030 with a disproportionate efect on the SSA [6].Moreover, the problemof the lownumber of nurses in rural areas is further aggravated by absenteeism, with its glitches of shortages, skill mix disparities, and unfair distribution [7], increased turnover [8], inadequate specialised knowledge-base of some providers [9], and poor work environment [10]. Hindawi Journal of Nursing Management Volume 2023, Article ID 9396817, 7 pages https://doi.org/10.1155/2023/9396817 https://orcid.org/0000-0002-5065-3048 https://orcid.org/0000-0002-4513-9685 https://orcid.org/0000-0003-3633-366X https://orcid.org/0000-0002-0481-009X mailto:attapokucollins@yahoo.com https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://doi.org/10.1155/2023/9396817 Te uneven human resource distribution in rural areas is the foremost problem that is most noticeable in the nursing workforce which is considered the linchpin of the health system responsible for providing the bulk of healthcare services to its clients [11]. Te major contributor to this shortage is workforce turn- over; which is expressed as the percentage of the workforce that has stopped their job. Park and Yu [12] highlight the multi- dimensional factors that impact the turnover of nurses in rural health facilities. Turnover is noted to have a signifcant impact on the health system, as an average of $37,000 to $67,000 is paid for replacements [13] while retention minimizes fnancial costs and boosts good patient outcomes [14]. Nurses’ turnover intentions are infuenced by so many factors [15]. Te COVID-19 pandemic has worsened the situation as a result of increased migration due to the global shortfall. Tere is a range of reported cases of job dissat- isfaction, challenges to patient and workforce safety, burnout, and unfavourable scheduling in rural settings [16] with regions with low densities of workforce producing the worst health outcomes [17]. Te challenge of retaining nurses in rural areas of Ghana still poses a challenge [18]. To improve the status of over- worked nurses and patient outcomes, efective execution of human resource management methods is required [19]. Tough many strategies [20] have been instituted in the past to address the problem of workforce disfavouring in rural areas in Ghana, there are still challenges to the rural re- tention of nurses. Te study, therefore, assessed the pre- dictive role of job satisfaction, rural ft, and resilience on nursing workforce retention in rural areas. 2. Materials and Methods 2.1. Design. A cross-sectional descriptive survey was employed to determine factors that predict nursing work- force retention in rural healthcare settings in Ghana. 2.2. Study Setting. Te study was conducted in selected facilities in the Ashanti region, a region which lies in the middle belt of Ghana. According to the 2014 Demographic Health Survey conducted by the Ghana Health Service (GHS), almost half of the inhabitants reside in rural areas [21]. Te region has 530 facilities, comprising government (170), mission (71), private (281), and quasi-government (8) facilities, with 48.7% of the facilities found in rural districts. It has a nursing workforce of 11,412, with about half in rural districts [22]. A district is considered rural and deprived if it lacks basic amenities for its populace, has low-performing health indicators and human resource retention, and is also difcult to reach through transportation and Internet connectivity. Out of the 43 districts in the region, fourteen (14) have a rural population exceeding the urban population and, therefore, classifed as rural [21]. 2.3. Study Population. Te population included registered nurses (RNs)—general nurses and specialist nurses in rural healthcare facilities. All RNs with permanent postings to their facility were included in the study while RNs who had not worked for at least 6months at the present post were excluded. Te data collection was carried out between May and August 2022. 2.4. Sampling and Sample Size. Based on Slovin’s formula, a total of 571 RNs was estimated, using a margin of error of 4% and a confdence level of 95% and recruited for the study [23]. Te participants were sampled through a multistage sampling approach. Five districts out of the 14 rural districts were selected randomly once they satisfed the criteria for the classifcation in the region. A simple random sampling was done to select fve health facilities from each of the fve selected districts (25 facilities overall). A proportionate stratifed sampling approach based on the numerical strength of the nursing workforce of the 25 facilities was done. Convenience sampling was used in recruiting the participants throughout the 25 facilities by the researchers. 2.5. Measures. Sense of Community Index II, the Brief Resilience Scale, three subscales of the Measure of Job Satisfaction Scale, and the Turnover Intention scales were used to measure the variables under study. 2.5.1. Rural Fit. A 24-item Sense of Community Index II (SCI II) was used to measure the rural ft of RNs and; thus, how RNs felt about their location of work [24]. Responses for items ranged from 1� strongly disagree to 5� strongly agree on a 5-pointLikert-type scale. A composite mean score of 2.5 and above indicated higher levels of rural ft. Studies have used the tool and have reported Cronbach’s alpha between 0.75 and 0.85 [25]; in this study, it was 0.79. 2.5.2. Resilience. Te Brief Resilience Scale (BRS), which is a 6-itemself-report measure, was used to assess RNs’ resil- ience [26]. Te scale measures the ability to bounce back or recover from stress. Participants rated each item on a Likert scale of 1-Strongly disagree to 5-Strongly agree. Te score is computed through the average of the six (6) items. Com- posite mean scores above 2.5 indicate RNs’ high resilience among RNs. BRS has been used in many studies and has reported Cronbach alpha scores of 0.80 to 0.95 [27], the BRS presented a high internal consistency (Cronbach’s α� 0.88) in this study. 2.5.3. Satisfaction. Te study used three subscales (satis- faction with workload (8 items), satisfaction with pro- fessional support (8 items), and satisfaction with pay and prospects (10 items)) from the Measure of Job Satisfaction scale [28]. Items were scored on a 5-point Likert scale (1� very dissatisfed and 5� very satisfed). A score for the scale was done by summation of individual items. Com- posite scores above 2.5 were considered as higher job sat- isfaction. Te scale has been used in many studies and has reported higher reliability coefcients between 0.80 and 0.93 [29]. Te internal consistency in the present study was 0.89 2 Journal of Nursing Management (overall scale), 0.91 (satisfaction with the workload), 0.78 (satisfaction with professional support), and 0.84 (satisfac- tion with pay and prospects). 2.5.4. Turnover Intention. A six-item Turnover Intention scale designed from scales by Mobley et al. [30] and Ganesan and Weitz [31] was used to measure RNs’ turnover intention. Te items were measured on a fve-point scale; from 1� “Strongly disagree” to 5� “Strongly agree.” A score above 15 indicated higher turnover intentions. Te internal consistency coefcients for the scale in other studies ranged between 0.80 and 0.90 [32]. Te Cronbach’s alpha for the scale after the pre-test was 0.84. 2.6. Data Analysis. Te data was analysed using SPSS version 26 through descriptive and inferential statistics at a signifcance of 0.05. Descriptive statistics were conducted on participants’ demographics. Associations between turnover intention, average patient attendance, rural ft, resilience, and RN satisfaction were analysed using Pearson’s moment product correlation, while diferences in turnover intention scores between certifcate, diploma, and bachelor degree nurses were tested using one-way ANOVA. A multiple linear regression analysis using the stan- dard approach was conducted to predict nurses’ turnover in- tention in the rural setting. 2.7. Ethical Consideration. Ethical approval was sought from the Institutional Review Board of NoguchiMemorial Institute of Medical Research (IRB-NMIMR CPN 012/21-22). Permission was obtained from the management of the selected facilities. Additionally, participants’ anonymity and confdentiality were assured. 3. Results 3.1. Sociodemographic Characteristics of Participants. A total of 462 participants responded to the scale (response rate of 80.9%). Te results on socio-demographic characteristics of participants in the study showed that the majority of the participants (66.5%) were below 30 years, unmarried par- ticipants (60.2%), had a diploma (58.4%), worked at the wards (44.8%), and were paid below US$500 as a monthly salary (69.3%). Details on sociodemographic data are pro- vided in Table 1. 3.2. Job Satisfaction, Rural Fit, Resilience, and Turnover In- tentions among Nursing Workforce. Te fndings on the nursing workforce’s satisfaction, rural ft, resilience, and turnover intention in rural healthcare settings are presented in Table 2. Te composite mean score of RN’s satisfaction was 2.81, satisfaction with professional support (n� 3.13), satisfaction with pay and prospects (n� 2.01), and satis- faction with workload (n� 3.28). Moreover, the composite mean scores of resilience (n� 2.33) and rural ft (n� 2.10) meant “low resilience” and “low rural ft,” respectively. On the extent of nursing workforce turnover intentions in rural healthcare settings, a composite mean of 2.83 indicated a high turnover intention. 3.3.ComparisonofTurnover IntentionamongCategories of the Nursing Workforce. A between-subjectone-way ANOVA was performed to compare the turnover intentions among nursing workforces’ highest qualifcations (certifcate, diploma, and bachelor degrees).Te results as shown in Table 3 which showed a statistically signifcant diference in turnover intentions (F(2,459)� 12.635, p< 0.001) among the various categories of the nursing workforce in rural healthcare settings. A follow-up post hoc analysis using Tukey’s HSD (α� 0.05) showed that the nursing workforce with bachelor’s degrees had higher turnover intention compared to those workforces with a certifcate [MD� 3.783, p< 0.000] and diploma (MD� 3.704, p< 0.000). Although nurses with diplomas had high turnover intentions than certifcate holders (MD� 0.075, p> 0.05), the diference was not statistically signifcant. Table 1: Registered nurses’ sociodemographic and professional information. Variables Categories Frequencies (N� 462) Percent Age group 30 and below 307 66.5 31–40 139 30.1 41 and above 16 3.4 Gender Male 108 23.4 Female 354 76.6 Marital status Single 267 57.8 Married 184 39.8 Others 11 2.4 Highest qualifcation Certifcate 132 28.6 Diploma 270 58.4 Bachelor degree 60 13.0 Unit of work RCH unit 38 8.2 Maternity unit 53 11.4 Emergency unit/OPD 164 35.5 Ward 207 44.8 Level of salary Below $500 320 69.3 $500–$750 139 30.1 $750 3 0.6 Journal of Nursing Management 3 3.4. Relationship between Work Characteristics, Rural Fit, Resilience, Satisfaction, andWorkforce Retention in the Rural Health Setting. Te Pearson product-moment correlation determining the relationship between turnover intention, average daily attendance, rural ft, resilience, and satisfaction of the RNs in the rural healthcare setting is shown in Table 4. Tere was a signifcant positive correlation between turnover intention and average daily attendance (r� 0.131). Tere was, however, a statistically signifcant but negative corre- lation between turnover intentions and resilience (r� −0.357), rural ft (r� −0.168), and satisfaction with pay and prospects (r� −0.187). Tis implies that nurses turn to quitting their job or profession when resilience is low. Similarly, inadequate rural ft and dissatisfaction with pay and prospect are linked with increased turnover intentions. 3.5. Predictive Efects of Satisfaction, Resilience, and Rural Fit on RNs’ Turnover Intention in the Rural Healthcare Settings. Multiple linear regression was used to evaluate the efect of average daily attendance, satisfaction, resilience, and rural ft on nurses’ turnover intention in rural settings. Te result predicting turnover intention is shown in Table 5.Temodel was signifcant, predicting 21.9% of the turnover intention among RNs (R2 � 0.219, F(5,456) � 25.59, p< 0.001). When all variables were considered in a single model; average daily attendance by RNs (β� 0.108), rural ft (β� −0.144), resil- ience (β� −0.350), and satisfaction with pay and prospects (β� −0.187) remained signifcant predictors. 4. Discussion Te purpose of the study was to investigate the re- lationship between rural ft, resilience, and satisfaction of the nursing workforce on nurses’ turnover intentions in rural healthcare facilities. Te fndings indicate that several strategies have signifcant correlations with subsequent rural retention. Nurses’ satisfaction, rural ft, resilience, and average daily attendance of patients contribute to future rural retention, and policymakers can be confdent of overcoming the challenge if these determinants are addressed. Te study fndings indicated that nurses with bachelor’s degrees are more likely to leave their jobs than their counterparts with diplomas and certifcates, and this posi- tion is supported by Fontes et al. [33]. Tis may be due to inefcient communication about conditions that enhance personal fulflment, professional success, and the delivery of high-quality nursing care. Moreover, the high workload in rural settings combined with low pay and lack of prospects for professional growth could be blamed for the phenom- enon [34, 35]. Additionally, the fact that most rural hospitals have local conditions where nurses are exposed to poor working conditions and few career chances infuences turnover intention [36]. Consistent with Holland et al. [37], the fndings of this study posit that a perceived workload had a detrimental efect on nurses’ satisfaction, with a resultant increase in turnover intention. Te results show that workplace policies that prioritize the workload of nurses can reduce turnover. In other domains, nurses believe that the combination of fnancially viable incentives, such as hardship allowances and free transportation are adequate to cover the oppor- tunity costs related to working in remote locations [38]. Te fnding of this study indicated that satisfaction with pay and prospect by most nurses serves as a motivation to remain at the post. While the staf are encouraged to stay in rural places, it is important to prioritize higher compensation and benefts [12]. Te major challenge, however, is the disregard for the WHO recommendations on rural incentives for health worker motivation in rural areas [20], which are not being implemented. Although in individual countries, there are policies for rural incentives in the form of allowances; they are either not paid or insufciently paid [39]. Salary and allowances are two of the major elements that afect health professionals’ decisions to remain in rural employment. However, overreliance on fnancial incentives to curtail high turnover among rural nurses may be a smokescreen as other important strategies should equally be considered [40]. Yong et al. [41] found that nurses in rural settings are not infuenced to remain by fnancial incentives, and suggested that any monetary incentives should be targeted only to those whose decisions to practice in rural settings are persuaded by money. Increasing wages and good working conditions are signifcant inducements for nurses to stay in the health industry in many LMICs, raising wages in en- vironments with limited resources has, however, been a challenge; it is therefore, critical to employ a variety of solutions to solve the shortage of nurses in LMICs [42]. Moreover, the fndings of the study highlighted that nurses who fnd themselves rurally ft are willing to remain in the post. Graduates’ likelihood of returning to practice in rural areas is increased by their rural upbringing as per- sonnel from rural backgrounds continue to work in rural areas for a decade or more years on average after passing out [43, 44]. In a similar vein, recruiting staf for their home region has yielded a positive response, as support from family and friends has benefted them and increased re- tention [45]. When considering models of rural nursing retention, this fnding ofers additional help for un- derstanding how the nurse is integrated into the community environment. Te results highlight the signifcance of rurality’s cultural aspects as nurses are not content with their work unless content with the rural setting. Unfortunately, people who like the leisure activities and lifestyles of urban locations are likely to have increased turnover intentions [46]. Table 2: Nursing workforces’ satisfaction, rural ft, resilience, and turnover intentions. Variables Mean SD Satisfaction 2.81 0.88 Satisfaction with professional support (8 items) 3.13 0.88 Satisfaction with pay and prospects (10 items) 2.01 0.87 Satisfaction with workload (8 items) 3.28 0.88 Rural ft (24 items) 2.10 0.58 Resilience (6 items) 2.33 0.63 Turnover intentions (6 items) 2.83 0.92 4 Journal of Nursing Management As a means of improving rural retention, policymakers should consider the development and implementation of the professional programme as recommended by theWHOon rural retention. Tus, nurse managers can assist nurses to advance their careers through study leave policies and fexible training schedules. Such arrangements have been successful as reported in other settings, which discovered that employment in the rural public sector was more alluring given the possibility of receiving health sponsorship or scholarships [47]. However, to encourage nurses’ trust in the system of career advancement, strong ad- herence to the policy’s implementation is required, such as establishing open procedures to end corruption in adminis- trative promotion would inspire providers to follow this course for their professional advancement. Constraints of rural practice, such as poor infrastructure, lack of recreational activities, limited lodging facilities, work overload, and feelings of isolation, may serve as unfavourable indicators of retention [48]. Te capacity to put up with these constraints is the panacea for the retention of nurses. Peoplewith high levels of resilience can endure these constraints and make meaning out of the situation [49]. Te results of this study accordingly support the idea that traits of resilience are likely to help nurses’ ability to survive and remain in rural settings for long periods. Tese fndings are signifcant for workforce ini- tiatives in rural areas because they give us a foundation for understanding resilience.Te idea has been suggested in the past that building resilience assists nurses to overcome burnout and lower turnover expenses [50]. On contrary, it is also likely that nurses who fnd it difcult to recover from work stresses may consider quitting to solve their issues. If this is the case, en- couraging nurse resilience might be one tactic to reduce turnover. Additionally, a poor nurse-job ft could weaken the resilience of nurses [47]. Posting of nurses to rural areas should be done cautiously taking into account all the factors enu- merated in this study to enable the retention of RNs. 5. Limitation Te cross-sectional nature of the study makes it difcult to infer causal relationships. Again, the data was all gathered by self-report, and this could have exaggerated the con- nections between the variables. Only part of the Measure of Job Satisfaction scale was used; this made a comparison with previous studies that used the whole scale prob- lematic. Te researchers, however, discussed the job satisfaction of RNs based on the individual subscales. Future research should consider a qualitative study to explore the nature of resilience and job satisfaction among nurses, and this can help the course of rural retention. Table 3: Comparison of nursing workforce turnover intention in terms of the highest qualifcation. Sum of squares df Mean square F Sig Turnover intention Between groups 727.784 2 363.892 12.635 0.000 Within groups 13219.169 459 28.800 Post hoc analysis Variable (I) highest qualifcation (J) highest qualifcation Mean diference (I-J) Std. error Sig Turnover intention Certifcate Diploma −0.07593 0.56995 1.000 Bachelor degree −3.78333∗ 0.83557 0.000 Diploma Certifcate 0.07593 0.56995 1.000 Bachelor degree −3.70741∗ 0.76594 0.000 Bachelor degree Certifcate 3.78333∗ 0.83557 0.000 Diploma 3.70741∗ 0.76594 0.000 p value <0.05. Table 4: Correlation between turnover intention, average daily attendance, rural ft, resilience, and satisfaction of the nursing workforce. Variables 1 2 3 4 5 6 (1) Turnover intention 1 (2) Average daily attendance 0.131∗∗ 1 (3) Rural ft 0.168∗∗ 0.014 1 (4) Resilience −0.357∗∗ −0.035 −0.289∗∗ 1 (5) Satisfaction with pay and prospects −0.187∗∗ −0.014 0.101∗ −0.042 1 (6) Satisfaction with workload −0.127 −0.036∗ 0.328 0.163∗∗ 0.238 1 (7) Satisfaction with professional support −0.230 0.038 0.201 0.288∗∗ 0.312∗ 0.025 ∗∗Correlation is signifcant at the 0.01 level (2-tailed). ∗Correlation is signifcant at the 0.05 level (2-tailed). Table 5: Multiple linear regression model testing the relationship between rural ft, resilience, satisfaction with pay and prospect, and turnover intentions of the nursing workforce. B SE Β T Sig (Constant) 27.688 1.570 17.635 0.000 Average daily attendance 0.034 0.013 0.108 2.602 0.010 Rural ft 0.057 0.018 −0.144 3.190 0.002 Resilience −0.510 0.063 −0.350 −8.059 0.000 Satisfaction with pay and prospects −0.196 0.047 −0.187 −4.146 0.000 Model summary: R2 � 0.219, F(4,457) � 25.59, p< 0.001. a. Dependent vari- able: turnover intentions. Journal of Nursing Management 5 6. Conclusion Tough there is a growing corpus of research available on strategies to increase nurses’ retention in rural settings, policymakers can be assured that not just improving f- nancial incentives to nurses who work in rural settings, but taking into account the background of nurses, improving the prospects for professional growth, nurses’ resilience, and removing obstacles connected with a longer stay in rural areas can improve nurses’ retention. 6.1. Implication for Nursing Management. Te retention of the rural workforce depends on activities to integrate rurality into health staf living conditions, increase nurse-job sat- isfaction, and build resilience. Tese fndings give decision- makers more assurance and broaden their arsenal of po- tential actions to increase retention, ofset signifcant f- nancial and human costs and promote nurses’ interests to better ft their communities. We contend that efective management of the nursing workforce, specifcally through a satisfactory practice environment and the provision of organizational assistance via professional support, should be a key component in the development of a skilled nursing workforce in the healthcare industry. Nurse managers should also come up with practical solutions to aid their nurses in blending in well with the rural environment as turnover intentions will ultimately depend on nurses’ capacity to meet the demands of their work environment. Nurses succeed greatly when managers pro- vide practical assistance, including fexible work hours, professional support, work-life balance, and support for overcoming obstacles in life. Additionally, initiatives to increase nurses’ resilience, such as training programmes and cultivating a pleasant workplace culture are other successful ways to further reduce turnover intentions in rural settings. 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