Norma J Stewart

University of Saskatchewan, Saskatoon, Saskatchewan, Canada

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Publications (46)45.56 Total impact

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    ABSTRACT: Abstract Introduction: Patient satisfaction is a key aspect of quality of care and can inform continuous quality improvement. Of the few studies that have reported on patient satisfaction with telehealth in programs aimed at individuals with memory problems, none has reported on the psychometric properties of the user satisfaction scales used. Materials and Methods: We evaluated the construct validity and internal consistency reliability of the Telehealth Satisfaction Scale (TeSS), a 10-item scale adapted for use in a rural and remote memory clinic (RRMC). The RRMC is a one-stop interprofessional clinic for rural and remote seniors with suspected dementia, located in a tertiary-care hospital. Telehealth videoconferencing is used for preclinic assessment and for follow-up. Patients and caregivers completed the TeSS after each telehealth appointment. With data from 223 patients, exploratory factor analysis was conducted using the principal components analysis extraction method. Results: The eigenvalue for the first factor (5.2) was greater than 1 and much larger than the second eigenvalue (0.92), supporting a one-factor solution that was confirmed by the scree plot. The total variance explained by factor 1 was 52.1%. Factor loadings (range, 0.54-0.84) were above recommended cutoffs. The TeSS items demonstrated high internal consistency reliability (Cronbach's alpha=0.90). Satisfaction scores on the TeSS items ranged from 3.43 to 3.72 on a 4-point Likert scale, indicating high satisfaction with telehealth. Conclusions: The study findings demonstrate high user satisfaction with telehealth in a rural memory clinic and the sound psychometric properties of the TeSS in this population.
    Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 10/2014;
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    ABSTRACT: Introduction: Rural and remote settings pose particular healthcare and service delivery challenges. Providing appropriate care and support for individuals with dementia and their families living in these communities is especially difficult, and can only be accomplished when the needs of care providers and the context and complexity of care provision are understood. This paper describes formal and informal caregivers’ perceptions of the challenges and needs in providing care and support for individuals with dementia living in rural and remote areas of Saskatchewan, Canada. Methods: A mixed-methods exploratory approach was used to examine caregivers’ needs. This research was a component of a broader process evaluation designed to inform the initial and ongoing development of a community-based participatory research program in rural dementia care, which included the development of the Rural and Remote Memory Clinic (RRMC). Four approaches were used for data collection and analyses: (1) thematic analysis of consultation meetings with rural healthcare providers: documented discussions from consultation meetings that occurred in 2003–2004 with rural physicians and healthcare providers regarding plans for a new RRMC were analysed thematically; (2) telephone and mail questionnaires: consultation meeting participants completed a subsequent telephone or mail questionnaire (2003–2004) that was analysed descriptively; (3) thematic analysis of referral letters to the Rural and Remote Memory Clinic: physician referral letters over a five-year period (2003–2008) were analysed descriptively and thematically; and (4) examination of family caregiver satisfaction: four specific baseline questionnaire questions completed by family caregivers (2007–2010) were analysed descriptively and thematically. Results: Both physician and non-physician healthcare providers identified increased facilities and care programs as needs. Physicians were much more likely than other providers to report available support services for patients and families as adequate. Non-physician providers identified improved services, better coordination of services, travel and travel burden related needs, and staff training and education needs as priorities. Physician needs, as determined via referral letters, included confirmation of diagnosis or treatment, request for further management suggestions, patient or family request, and consultation regarding difficult cases. One-third of informal caregivers expressed not being satisfied with the care received prior to the Rural and Remote Memory Clinic assessment visit, and identified lack of diagnosis and long wait times for services as key issues. Conclusions: Delivering services and providing care and support for individuals with dementia living in rural and remote communities are especially challenging. The need for increased extent of services was a commonality among formal and informal caregivers. Primary care physicians may seek confirmation of their diagnosis or may need assistance when dealing with difficult aspects of care, as identified by referral letters. Differences between the needs identified via referral letters and questionnaire responses of physicians may be a reflection of the rural or remote context of care provision. Informal caregiver needs were more aligned with non-physician healthcare providers with respect to the need for improved access to additional healthcare professionals and services. The findings have implications for regional policy development that addresses human and other resource shortages.
    Rural and remote health 08/2014; 14:2747. · 0.98 Impact Factor
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    ABSTRACT: Background/Aims: To estimate the prevalence, severity, and covariates of depressive symp- toms in rural memory clinic patients diagnosed with either mild cognitive impairment (MCI) or dementia. Methods: In a cross-sectional study of 216 rural individuals who attended an interdisciplinary memory clinic between March 2004 and July 2012, 51 patients were diag- nosed with MCI and 165 with either dementia due to Alzheimer’s disease (AD) or non-AD de- mentia. The Center for Epidemiologic Studies of Depression Scale (CES-D) was used to estimate the severity and prevalence of clinically elevated depressive symptomatology. Results: The prevalence of elevated depressive symptoms was 51.0% in the MCI patients and 30.9% in the dementia patients. Depressive symptoms were more severe in the MCI patients than in the dementia patients. Elevated depressive symptoms were statistically associated with younger age for the MCI group, with lower self-rated memory for the dementia group, and with increased alcohol use and lower quality of life ratings for all patients. In the logistic re- gression models, elevated depressive symptoms remained negatively associated with self- rated memory and quality of life for the patients with dementia, but significant bivariate as- sociations did not persist in the MCI group. Conclusions: The high prevalence and severity of depressive symptoms among rural memory clinic patients diagnosed with either MCI or dementia warrant continued investigation.
    Dementia and Geriatric Cognitive Disorders Extra. 07/2014; 4(2):209-220.
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    ABSTRACT: Caregiving in a rural context is unique, but the experience of rural caregivers is understudied. This paper describes how rural caregivers cope with caring for a loved one diagnosed with mild cognitive impairment or dementia using qualitative description to generate a low-inference summary of a response to an open-ended question. This approach allowed these rural caregivers to describe their positive experiences in addition to the more commonly explored caregiver experiences related to stress. Analyses of coping revealed use of social support, engaging in relaxing and physical activity, and cognitive reframing. In addition, caregivers reported strong faith and religiosity, and to a lesser frequency behavioral changes, checking in with the person with dementia via telephone, and joint activity. Predominantly, these methods reflect approach-based strategies. The current data suggest that these caregivers manage well and adopt adaptive coping strategies to meet the demands of the caregiving role.
    Dementia (London, England). 06/2014;
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    ABSTRACT: Forecasts of increasing prevalence of dementia in rural settings, coupled with reliance on family caregiver support, indicate that a greater understanding of caregiver distress in these contexts is necessary. The purpose of this study was to examine family caregiver burden and severity of distress on the day that a family member was diagnosed with dementia at a memory clinic that serves a rural population. Participants in this retrospective study were 231 primary family caregivers of a rural community-dwelling person with dementia. On the diagnostic day, women reported more burden and severity of distress than men and spouses reported more severity of distress than adult children. A structural equation model was not supported for the entire sample, but was supported for women caregivers only (n = 161). Caregiver distress related to dementia-specific behaviors explained both global distress and burden. Patients' functional decline was related to caregiver burden.
    Journal of applied gerontology : the official journal of the Southern Gerontological Society. 01/2014;
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    ABSTRACT: Although only 20–50% of individuals with dementia are diagnosed, early diagnosis enables patients and families to access interventions and services, and plan for the future. The current study explored the experiences of rural family caregivers in the period leading up to a diagnostic assessment at a Canadian memory clinic, their hopes and expectations of the assessment, and their experiences in the six months following diagnosis. Using a longitudinal, retrospective and prospective qualitative research design, caregivers of 30 patients referred to the clinic were interviewed during the diagnostic assessment process and again six months after the diagnosis. Most caregivers reported first noticing symptoms two years prior to diagnosis. The pre-diagnostic interviews revealed a prevalent ‘need to know’ among caregivers that drove the help-seeking process. Caregivers hoped that the diagnosis would have the benefits of ‘naming it,’ ‘accessing treatment,’ ‘knowing what to expect,’ and ‘receiving guidance.’ When asked six months later about the impact of the diagnosis, the main theme was ‘acceptance and moving forward.’ Caregivers reported that the diagnosis provided ‘relief,’ ‘validation,’ and ‘improved access to services.’ These findings can inform care practices of primary health care providers who represent the first point of contact regarding expectations and experiences of dementia-related diagnoses.
    Social Science [?] Medicine 01/2014; 102:111–118. · 2.73 Impact Factor
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    ABSTRACT: ABSTRACT Nursing homes have become complex care environments where residents have significant needs and most have age-related dementia. Building on research by Hirdes et al. (2011), we describe a resident profile in a representative sample of 30 urban nursing homes in the prairie provinces using Resident Assessment Instrument - Minimum Data Set 2.0 data from 5,196 resident assessments completed between 1 October 2007 and 31 December 2011. Residents were chiefly over age 85, female, and with an age-related dementia. We compared facility support and related services and resident characteristics by province, owner-operator model, and number of facility units. We observed differences in support and related services by both unit count and province. We also found that public facilities tend to care for residents with more demanding characteristics: notably cognitive impairment, aggressive behaviours, and incontinence. No clear trends associating the number of units in a facility with resident characteristics were observed.
    Canadian Journal on Aging / La Revue canadienne du vieillissement 08/2013;
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    ABSTRACT: Context is increasingly recognized as a key factor to be considered when addressing healthcare practice. This study describes features of context as they pertain to knowledge use in long-term care (LTC). As one component of the research program Translating Research in Elder Care, an in-depth qualitative case study was conducted to examine the research question "How does organizational context mediate the use of knowledge in practice in long-term care facilities?" A representative facility was chosen from the province of Saskatchewan, Canada. Data included document review, direct observation of daily care practices, and interviews with direct care, allied provider, and administrative staff. The Hidden Complexity of Long-Term Care model consists of 8 categories that enmesh to create a context within which knowledge exchange and best practice are executed. These categories range from the most easily identifiable to the least observable: physical environment, resources, ambiguity, flux, relationships, and philosophies. Two categories (experience and confidence, leadership and mentoring) mediate the impact of other contextual factors. Inappropriate physical environments, inadequate resources, ambiguous situations, continual change, multiple relationships, and contradictory philosophies make for a complicated context that impacts care provision. A hidden complexity underlays healthcare practices in LTC and each care provider must negotiate this complexity when providing care. Attending to this complexity in which care decisions are made will lead to improvements in knowledge exchange mechanisms and best practice uptake in LTC settings.
    The Gerontologist 07/2013; · 2.48 Impact Factor
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    ABSTRACT: Little is known about the views of rural family physicians (FPs) regarding collaborative care models for patients with dementia. The study aims were to explore FPs’ views regarding this issue, their role in providing dementia care, and the implications of providing dementia care in a rural setting. This study employed an exploratory qualitative design with a sample of 15 FPs. All rural FPs indicated acceptance of collaborative models. The main disadvantages of practicing rural were accessing urban-based health care and related services and a shortage of local health care resources. The primary benefit of practicing rural was FPs’ social proximity to patients, families, and some health care workers. Rural FPs provided care for patients with dementia that took into account the emotional and practical needs of caregivers and families. FPs described positive and negative implications of rural dementia care, and all were receptive to models of care that included other health care professionals.
    Primary Health Care Research & Development 04/2013;
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    ABSTRACT: To explore gender differences and similarities on personal, employment and work-life factors and predictors of job satisfaction among registered nurses in rural and remote Canada. Research suggests that men and women are attracted to nursing for different reasons, with job security, range of employment opportunities and wages being important for male nurses. Using data from a large national survey of registered nurses in rural and remote Canada, descriptive and multiple linear regression analyses were used to identify gender differences and similarities. A larger proportion of male nurses reported experiencing aggression in the workplace. Age, annual gross income and colleague support in medicine were not found to be predictors of work satisfaction for the male nurses, although they were for women. There are more similarities than differences between male and female registered nurses in factors that affect job satisfaction. Nursing management needs to increase their awareness of the potential for workplace aggression towards male registered nurses and to explore the perceptions of interpersonal interactions that affect satisfaction in the workplace.
    Journal of Nursing Management 05/2012; 20(4):561-70. · 1.45 Impact Factor
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    Kelly L Penz Mn, Norma J Stewart
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    ABSTRACT: In a secondary analysis of a national survey of Registered Nurses (RNs) working in rural and remote Canada, two groups of acute care nurses were compared on the work satisfaction variables of autonomy and nurse-physician interaction based on whether their workplace community population was rural (10,000 or less) or small urban (>10,000 but <100,000). For this analysis, the variable "size of community" served as a proxy indicator for hospital size. Kanter's (1993) theory on the structure of power in organizations was the basis of the hypotheses. As predicted, the rural RNs (n=811) working in the smaller hospital organizations had significantly higher levels of autonomy [F(1, 1229)= 5.602, p<0.05] and higher levels of nurse-physician interaction [F(1, 1229)=27.78, p<0.001] than the small urban RNs (n=427). The findings suggest that the size of an organization or hospital setting does have an influence on the level of autonomous practice and interaction between nurses and physicians.
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    ABSTRACT: This study examined nursing aides' (NAs) perspectives of specific incidents of combative behavior from nursing home residents with dementia, particularly their attributions for the behaviors. This research is part of a larger mixed-method study exploring combative behavior as experienced by NAs. The data for this component were collected using a cross-sectional survey design. NAs used a prospective event-reporting log or "diary" to record consecutive incidents of combative resident behaviors. Eleven rural nursing homes located in a mid-Western Canadian province. Eighty-three full-time, part-time, and casual NAs. NAs used the diary instrument to document details of each incident of combative behavior over a 144-hour period. Findings from the diaries were explored in subsequent focus groups (reported elsewhere). The 83 NAs reported 409 incidents linked to residents with dementia, with a range of 1 to 28 incidents per aide. The frequency of incidents in the preceding month was reported as follows: none (11.1%), 1-5 times (58.7%), 6-10 times (11.1%), more than 10 times (19.0%). Most incidents occurred in residents' rooms (65%) during personal care, with the most frequent behaviors reported as slapping, squeezing, punching or hitting, and shoving. The main perceived causes of the behavior were cognitive impairment and residents not wanting care. NAs reported they could control or modify the cause in only 3% of incidents, and they were not optimistic about preventing future combative behaviors. They continued to provide care in 89% of incidents. In the diaries, NAs identified resident-related factors (cognitive impairment and not wanting care) as the main causes of combative behavior, and they reported having no control over these factors. In the focus groups conducted to explore diary findings, NAs reported system-level factors, also beyond their control, which affected their practices and increased their risk of exposure to combative behavior. Taken together, the results of this research program suggest a need for a broad multifaceted strategy aimed at addressing the modifiable risk factors, which includes recognizing NAs as equal partners in a team process backed by strong organizational support and commitment.
    Journal of the American Medical Directors Association 08/2011; 13(3):220-7. · 5.30 Impact Factor
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    ABSTRACT: Examination of factors related to the retention or voluntary turnover of Registered Nurses (RNs) has mainly focused on urban, acute care settings. This paper explored predictors of intent to leave (ITL) a nursing position in all rural and remote practice settings in Canada. Based on the conceptual framework developed for this project, potential predictors of ITL were related to the individual RN worker, the workplace, the community context, and satisfaction related to both the workplace and the community(s) within which the RN lived and worked. A national cross-sectional mail survey of RNs in rural and remote Canada provided the data (n = 3,051) for the logistic regression analysis of predictors of ITL. We found that RNs were more likely to plan to leave their nursing position within the next 12 months if they: were male, reported higher perceived stress, did not have dependent children or relatives, had higher education, were employed by their primary agency for a shorter time, had lower community satisfaction, had greater dissatisfaction with job scheduling, had lower satisfaction with their autonomy in the workplace, were required to be on call, performed advanced decisions or practice, and worked in a remote setting. The statistical evidence for predictors of ITL supported our framework with determinants related to the individual, the workplace, the community, and satisfaction levels. The importance of community makes this framework uniquely relevant to the rural health context. Our findings should guide policy makers and employers in developing retention strategies.
    The Journal of Rural Health 01/2011; 27(1):103-13. · 1.44 Impact Factor
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    ABSTRACT: Using data from a sample of 169 patients, this study evaluates the acceptability and feasibility of telehealth videoconferencing for preclinic assessment and follow-up in an interprofessional memory clinic for rural and remote seniors. Patients and caregivers are seen via telehealth prior to the in-person clinic and followed up at 6 weeks, 12 weeks, 6 months, 1 year, and yearly. Patients are randomly assigned to in-person (standard care) or telehealth for the first follow-up, then alternating between the two modes of treatment, prior to 1-year follow-up. On average, telehealth appointments reduce participants’ travel by 426 km per round trip. Findings show that telehealth coordinators rated 85% of patients and 92% of caregivers as comfortable or very comfortable during telehealth. Satisfaction scales completed by patient–caregiver dyads show high satisfaction with telehealth. Follow-up questionnaires reveal similar satisfaction with telehealth and in-person appointments, but telehealth is rated as significantly more convenient. Predictors of discontinuing follow-up are greater distance to telehealth, old-age patient, lower telehealth satisfaction, and lower caregiver burden.
    Journal of Applied Gerontology 01/2011; 30(3):304-331. · 0.97 Impact Factor
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    ABSTRACT: The purpose of this study was to identify key concepts in dementia care from the perspective of registered nurses working in the Canadian north. Interviews were conducted with RNs employed in small, remote northern communities about their experiences with dementia assessment and caregiving and their perceptions about dementia care resources. The grounded theory method used in analyzing the interview data led to the development of a theory about dementia awareness in northern nursing practice.The study identified 3 categories of conditions that influence northern RNs' awareness of dementia: dementia care and community caregiving, characteristics of the northern RN, and northern nursing worklife. The findings suggest the need for educational programs and health-care policies that increase awareness of dementia in northern nursing practice and thereby improve the care provided to northern people.
    The Canadian journal of nursing research = Revue canadienne de recherche en sciences infirmières 03/2010; 42(1):56-73.
  • Mary Ellen Andrews, Debra G. Morgan, Norma J. Stewart
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    ABSTRACT: The purpose of this study was to identify key concepts in dementia care from the perspective of registered nurses working in the Canadian north. Interviews were conducted with RNs employed in small, remote northern communities about their experiences with dementia assessment and caregiving and their perceptions about dementia care resources. The grounded theory method used in analyzing the interview data led to the development of a theory about dementia awareness in northern nursing practice. The study identified 3 categories of conditions that influence northern RNs' awareness of dementia: dementia care and community caregiving, characteristics of the northern RN, and northern nursing worklife. The findings suggest the need for educational programs and health-care policies that increase awareness of dementia in northern nursing practice and thereby improve the care provided to northern people. French Cette étude a pour objectif de cerner les concepts clés en matière de soins aux personnes souffrant de démence, selon le point de vue des infirmières autorisées œuvrant dans le Nord canadien. Des entrevues ont été réalisées auprès d'IA en poste dans de petites communautés nordiques isolées, portant sur leurs expériences de dépistage de la démence, la prestation de soins liée à cette maladie et leurs perceptions concernant les ressources disponibles. La méthode de théorisation ancrée utilisée dans l'analyse des données d'entrevues a mené à l'élaboration d'une théorie portant sur la connaissance des troubles de démence dans le cadre de la pratique infirmière en région nordique. Les auteures de l'étude ont cerné trois points qui influencent les connaissances des IA œuvrant en région nordique relativement à la démence : les soins aux personnes atteintes de démence et la prestation de soins communautaires; les caractéristiques de l'IA œuvrant en région nordique; et la vie professionnelle des infirmières en milieu nordique. Les résultats indiquent un besoin de mettre en place des programmes et des politiques de santé qui sensibilisent le personnel infirmier nordique aux troubles de démence, une mesure qui permettrait d'améliorer les soins prodigués aux populations nordiques.
    The Canadian journal of nursing research = Revue canadienne de recherche en sciences infirmières 02/2010; 42(1):56-73.
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    ABSTRACT: BACKGROUND: The organizational context in which healthcare is delivered is thought to play an important role in mediating the use of knowledge in practice. Additionally, a number of potentially modifiable contextual factors have been shown to make an organizational context more amenable to change. However, understanding of how these factors operate to influence organizational context and knowledge use remains limited. In particular, research to understand knowledge translation in the long-term care setting is scarce. Further research is therefore required to provide robust explanations of the characteristics of organizational context in relation to knowledge use. AIM: To develop a robust explanation of the way organizational context mediates the use of knowledge in practice in long-term care facilities. DESIGN: This is longitudinal, in-depth qualitative case study research using exploratory and interpretive methods to explore the role of organizational context in influencing knowledge translation. The study will be conducted in two phases. In phase one, comprehensive case studies will be conducted in three facilities. Following data analysis and proposition development, phase two will continue with focused case studies to elaborate emerging themes and theory. Study sites will be purposively selected. In both phases, data will be collected using a variety of approaches, including non-participant observation, key informant interviews, family perspectives, focus groups, and documentary evidence (including, but not limited to, policies, notices, and photographs of physical resources). Data analysis will comprise an iterative process of identifying convergent evidence within each case study and then examining and comparing the evidence across multiple case studies to draw conclusions from the study as a whole. Additionally, findings that emerge through this project will be compared and considered alongside those that are emerging from project one. In this way, pattern matching based on explanation building will be used to frame the analysis and develop an explanation of organizational context and knowledge use over time. An improved understanding of the contextual factors that mediate knowledge use will inform future development and testing of interventions to enhance knowledge use, with the ultimate aim of improving the outcomes for residents in long-term care settings.
    Implementation Science 09/2009; 4:53. · 2.37 Impact Factor
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    ABSTRACT: The availability, accessibility and acceptability of services are critical factors in rural health service delivery. In Canada, the aging population and the consequent increase in prevalence of dementia challenge the ability of many rural communities to provide specialized dementia care. This paper describes the development, operation and evaluation of an interdisciplinary memory clinic designed to improve access to diagnosis and management of early stage dementia for older persons living in rural and remote areas in the Canadian province of Saskatchewan. We describe the clinic structure, processes and clinical assessment, as well as the evaluation research design and instruments. Finally, we report the demographic characteristics and geographic distribution of individuals referred during the first three years.
    Aging and Mental Health 02/2009; 13(1):17-30. · 1.68 Impact Factor
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    ABSTRACT: To describe community satisfaction and attachment among rural and remote registered nurses (RNs) in Canada. Cross-sectional survey of rural and remote RNs in Canada as part of a multimethod study.The sample consisted of a stratified random sample of RNs living in rural areas of the western country and the total population of RNs who worked in three northern regional areas and those in outpost settings. A subset of 3,331 rural and remote RNs who mainly worked in acute care, long-term care, community health, home care, and primary care comprised the sample. The home community satisfaction scale measured community satisfaction, whereas single-item questions measured work community satisfaction and overall job satisfaction. Community variables were compared across practice areas using analysis of variance, whereas a thematic analysis was conducted of the open-ended questions. Home care and community health RNs were significantly more satisfied with their work community than RNs from other practice areas. RNs who grew up in rural communities were more satisfied with their current home community. Four themes emerged from the open-ended responses that describe community satisfaction and community attachment. Recruitment and retention strategies need to include mechanisms that focus on community satisfaction, which will enhance job satisfaction.
    Public Health Nursing 01/2009; 26(5):430-9. · 0.78 Impact Factor
  • The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 12/2008; 35(5):669-71. · 1.33 Impact Factor

Publication Stats

380 Citations
45.56 Total Impact Points


  • 1999–2014
    • University of Saskatchewan
      • • Department of Psychiatry
      • • College of Nursing
      Saskatoon, Saskatchewan, Canada
  • 2008
    • University of Lethbridge
      Lethbridge, Alberta, Canada
  • 2005
    • Laurentian University
      • Centre for Rural and Northern Health Research
      Greater Sudbury, Ontario, Canada