Desired attributes of new graduate nurses as identified by the rural community

Introduction: Preparing nurse graduates for practice is challenging because of the diversity of skills expected of them. Increasingly consumers are more informed and expect quality care. Objective: To identify the attributes a rural community expect in new graduate nurses in order for them to provide quality care. Methods: A questionnaire was designed to assess the importance attached to a set of attributes of graduate nurses expected by a rural community. The community included a range of professionals working with government and hospitals, community volunteers and retired people. After pilot testing, the questionnaire was distributed using a cluster sampling technique. A total of 656 completed questionnaires were returned, giving a response rate of 69%. The respondents were asked to rate the importance of each item for the community on a five-point Likert scale (5 = extremely important, 4 = very important, 3 = moderately important, 2 = possibly importantly, and 1 = not important at all). Exploratory factor analysis was performed on the 38 items using SPSS (SPSS inc; Chicago, IL, USA). Principal Components Analysis was applied to identify the number of factors followed by Oblimin rotation. Results: The sample of 656 respondents consisted of 68% females and 30% males (2% did not identify their gender). The majority of the respondents (75.6%) were born in Australia, while 3.2% were born in the UK Kingdom. Principal Components Analysis identified five factors with eigenvalues above one, explaining 47.4% of the total variance. Items that loaded greater than + or 0.3, (approximately 10% of the common factor variance) was associated with the factor in question. Component 1 was labelled Sympathetic/ Patients’ welfare with the item ‘Nurses should be sensitive to the emotional needs of patients’ showing the highest loading. Component 2 was called Contextual knowledge/ Interpersonal skills. It contained items indicating that nurses should have good personal skills and possess a broad contextual knowledge of issues associated with the practice of their profession, including financial, legal, economic, resources and social matters. Component 3 was titled Professionalism and contained items relating to professional behaviour, including the application of theory to daily nursing practice, ability to work in a team, and to accept the


Introduction
The health needs of rural communities have changed over time for a number of reasons including the ageing population, the ebbs and flows of market competition, and often rapid changes in the availability and application of information technology, and the 'passive patients' who have become active consumers 1 .
Consumers are becoming more informed of health and health service options and expect quality care. According to Swanson 2 these changes must be considered when preparing nurses for the future. Additional skills are required to cater for the ever-increasing range of tasks expected of a nurse 3 . In turn, the changing needs in the community places additional requirements on universities to produce nurses who are able to match the growing demands.
An important part of this developmental process involves consideration of the views of stakeholders. One such important group of stakeholders in a rural setting is the local community.
The rural community, as consumers of health services, are in the best position to report their preferred type of new graduates 4 who will best meet their specific needs. Sharpe 5 states that patients should be able and allowed to comment on the quality of care they expect, and that this information should be used by health providers to guide the development of services. The focus of the current study concerns the rural community's perception of nurses and nurses' attributes. It identifies the kind of nurses the consumers expect.
According to Kulig et al 6  Australian research 6,7 suggests nurses practicing in rural settings are different from those employed in metropolitan settings. Special issues for those in rural areas include a lack of anonymity; isolation from support services; knowledge of the community; and the requirement to care for relatives and friends. Due to the limited number of healthcare providers, rural nurses are required to have a very broad knowledge base, and often must extend their practice into other professionals' domains 8 . This view is not shared by Offredy 9 who does not see metropolitan practitioners as different to rural. Offredy 9 perceives that remote and rural practice is part of advance nursing practice and, therefore, the generic attributes include competencies, accountability, diagnostic pathology, prescribing medications, and referral procedures.
The definition of the term 'rural' is very contextual 25  The aim of this article was to develop a questionnaire to be used to identify the key attributes (qualities and skills) that rural consumers expect in new nurse graduates in a RRMA 3 classified regional city.

Methods
The study was approved by the University of Melbourne Human Research and Ethics committee.
A questionnaire was designed to identify the importance attached to a set of attributes expected in nurse graduates.
The items included in the questionnaire were derived from eight focus groups conducted with residents from rural communities in Victoria, Australia.

Focus groups
Thirty participants from four social organizations were

Questionnaire
The questionnaire was piloted with a separate nonprofessional focus group in another rural town in Victoria, and was modified following feedback from participants.
The final version of the questionnaire contained 38 items.
Participants were asked to rate the importance of each item for the community on a five-point Likert scale

Procedure
One per cent of the 94 600 adults (≥16 years) of a regional city was surveyed using cluster sampling technique. The Australian regional city for the study is classified as RRMA 3 with some restriction to accessibility of some

Statistical analyses
Exploratory factor analysis was performed on the 38 items using SPSS (SPSS inc; Chicago, IL, USA), after first confirming that the data were suitable for factor analysis.
Principal components analysis (PCA) was used to extract the factors, followed by oblique rotation of the factors using Oblimin rotation (delta = 0). The number of factors to be retained was guided by Kaiser's criterion (eigenvalues above 1), inspection of the scree plot, and the interpretability of the items. Cronbach's alpha was used to assess the internal consistency of the subscales identified from the PCA.

Results
The majority of the 656 people who returned the questionnaire were female (68%), 30% were male, while 2% of the respondents did not identify their gender. There were 66.5 % of respondents between the ages of 21 and 60 years.  Cronbach alpha reliability coefficients were computed for each of the sub-scales identified from the PCA ( Table 2).
Four of the sub-scales recorded Cronbach alpha values exceeding .7, indicating satisfactory internal consistency.
The Accountability subscale, fell below this value (alpha = .58) due to small number of items (n = 3).

Discussion
The aim of the study was to identify the key attributes in new nurse graduates according to the community consumers.
Psychometric analysis found support for five factors:

Implications of the study for nursing in rural settings
According to Lee 21  To deliver quality service in a rural community experienced nurses working in rural areas must have independence and self-direction 24 , unlike new graduates who still need to 'accept guidance from colleagues' and 'recognize their own limitations'. With the lack of rural workforce 59 , appropriate guidance for the new nurse graduate is not possible, unless they are supported by large centres. The nurse is required to function in several capacities, including supervisor, administrator, educator, care giver 24 and, therefore, needs to have a broad range of qualities, as identified in this study.
Although, these expectations may be over-optimistic at times and difficult to fulfill, it is important to understand that this is the consumer's perspective. In order to enable nurses to fulfill their clients' expectations, universities and employers need to capture these views through a client feedback system and promote and foster development of those qualities that are feasible.

Limitations of the study and further research
Although this study provides a useful rural consumer perspective, there are a number of factors that limit its generalizability. The rural community in this study is a large rural centre that has some restrictions to accessibility of some goods, services and opportunities for social interaction, and therefore may not truly reflect the issues of all rural places with smaller populations. Further investigation of this issue is needed in other rural and remote settings; and for comparative purposes, also in urban areas. The approach adopted here could also be expanded to explore community