Necessity for Research on Work Engagement of Remote Island Public Health Nurses

Necessity for Research on Work Engagement of RemoteIsland Public Health Nurses– Based on literature review findings for research on
nursing profession work engagement and rural nursing
profession turnover and retention –Mako HIRATA1） and Kazunori OTSUKA2）

Abstract
Purpose: The turnover of public health nurses working on remote islands is presumably related tojob satisfaction and work environments. To assess the importance of applying the concept of work
engagement （WE） for research to investigate factors influencing the turnover of remote island
public health nurses（PHN）, we review domestic and international studies of PHN’WE and trends
in research investigating turnover and retention for rural nursing professionals. Methods: Using
PubMed we sought and reviewed reports of WE research investigating public health nurses andReports of turnover and retention of rural nursing professionals. Results: Reviewed Results indicatethat turnover and retention of rural nursing professionals are related to personal and job resources.
However, we found no report of a WE study investigating remote island PHN using the WE concept
related to personal and job resources. Therefore, the actual WE of remote island PHN remains unclear.
Conclusions: Clarification of the actual status of turnover among remote island PHN using the conceptof WE as it relates to turnover and retention is likely to be effective as a study to obtain measures toprevent turnover among remote island PHN. Also, it can be said that this research will lead to protect
the lives of island residents.
Key words: public health nurse, remote islands, retention, work engagement

Affiliation
1）Division of Human Health Science, Graduate School of Regional Design and Creation, Nursing, University of Nagasaki2）Department of Nursing Science, Faculty of Nursing and Nutrition, University of Nagasaki, Siebold−1−

長崎県立大学

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Introduction
Japan, which is said to have 14,125 islands1）,
has one of the largest sea areas in the world
by virtue of those islands 2）. The fundamental
policy of the Remote Islands Development
Act states clearly that remote islands havea key role in ensuring homeland security
because of their geographical characteristics
and because the lives of people living on
those islands must be compensated 3）. The 17
Sustainable Development Goals adopted by theUnited Nations in 154） include“Goal 3: Ensure
healthy lives and promote well-being for all
at all ages.” and “Goal 11: Make cities andhuman settlements inclusive, safe, resilient andsustainable.” In this way, local communities
must be sustained to protect people’s healthequally worldwide, whatever the environmentis, and allow people to continue living where
they want to live.
Moreover, the progressive decline and aging
of populations and disparities among regions
are regarded as challenges 5） . Maintaining
and improving quality of life（QOL）in areas
with restricted environments and resources,
such as remote islands and rural areas, posea universal challenge. The powerful voices ofislanders who want standards of medical care
to be improved suggest a need and role forthe nursing profession to turn its attention
to remote islands 5）. Medical and healthcare
professionals on remote islands can be key
persons as a valuable and reassuring presence
that supports local residents.
This study specifically examines publichealth nurses （PHN） working in thenursing profession in local communities. Theirmajor tasks of PHN in Japan include disease
prevention, health promotion, and community
development using regional characteristics 6）.
Japan has worked at establishing a communitybased, integrated care system for people tolive in the community in which they have lived
for a long time until the end of their days 7）.
Great importance is assigned to the role of−2−

第22巻 （2024）

public health nurses as a profession to play animportant role in the system8）.
However, the number of employed PHN
is 55,595 in Japan. That figure remains low
compared to the number of employed nurses:
1,280,911 9） . Of the employed PHN, thoseworking full time for local governments are
38,528 10） : nearly 70 percent of employed
PHN work as local government officials.
The turnover rate of full-time public healthnurses working for local governments is 4.7%
（based on results of the 21 Survey on PHN’
Activity by dividing the number of full-time
PHN who left their jobs by the total numberof PHN presented above）, which is not highcompared to the turnover rate of full-time nurses（11.6%）11）. Nevertheless, because burnout is
an important underlying cause of the turnoverof local government PHN 12）, earlier reports
have described that PHN are likely to havepoor mental health and high job stress13）. In
addition, high turnover rates of PHN in small
towns, villages, and remote islands in Okinawa
Prefecture have been drawing attention14）.
Research using the concept of “workengagement” has been increasing in recent
years for investigations related to burnout
and job satisfaction 15） . Work engagement（hereinafter, WE） is defined as “a positive,
fulfilling, work-related state of mind thatis characterized by vigor, dedication, andabsorption. Rather than a momentary andspecific state, engagement refers to a more
persistent and pervasive affective-cognitive
state that is not focused on any particular
object, event, individual, or behavior” 16）. In
fact, WE is regarded as intimately related toburnout and job satisfaction17）: Using the WE
concept to explore details of the backgroundand factors in the turnover of remote island
PHN is important to ascertain strategies forremote island PHN in Japan and to sustain
healthcare activities while regaining vigor andrenewed dedication. Nevertheless, the WE
concept validity and significance for research
have not been clarified.

Necessity for Research on Work Engagement of Remote Island Public Health Nurses

For this reason, our study reviews WE
research on PHN and research trends related
to turnover and retention of remote island
nursing professionals. Moreover, this study
assesses the value of applying the WE concept
for research to explore factors contributing
to the turnover of remote island public healthnurses. We use “remote islands” herein,
following the basic policy of the RemoteIslands Development Act3）.

papers, and other available papers wereselected as documents for analysis. However,for 2）, bulletins were included among
the target documents because only a few
applicable documents were found.
This paper describes the Results of theliterature search for the two themes anda discussion of each theme followed by an
integrated discussion of the two themes in theOverall discussion.

Methods

Results

1. Search and analysis methods for target

1. Results of a literature review for WE

1） Search and analysis methods for reports
describing WE research investigating publichealth nurses
Using PubMed, we sought documents
including the term “public health nurse
work engagement.” Although this search
was aimed at finding WE research aboutpublic health nurses, those keywords yielded
only one documents. Therefore, we again
searched after replacing the term with“nurse
work engagement.” Most of the obtained
documents were related to the nursing
profession. Accordingly, we consider the needand importance of WE research on publichealth nurses based on trends of WE research
examining the nursing profession.
2）Search and analysis methods for documents
describing the turnover and retention of
remote island public health nurses
Again with PubMed, we sought documents
using the keywords of “rural remote nurse
turnover retention.”No document was found.
Therefore, we made another attempt after
removing“turnover retention”from the first
keywords.
Considering the importance of turnover andretention of remote island PHN, we examinedfactors affecting the turnover and retention ofrural nursing professionals and future researchmethods.
For both 1）and 2）, original papers, review

When searching for documents including thewords“public health nurse work engagement,”
we found a document falling under the theme.
When trying a search again after changing
those words to “nurse work engagement,”
we obtained 1598 documents. An additional
search using the added search term“review”
identified 236 cases, 3 of which were of WE
research on the nursing profession. They
were chosen for analysis. Treating thepapers reviewing the literature publishedby May 2020 as the latest review papers 18）,
we searched for papers published during
2020–2023, except review papers, following
the procedures explained above. As a result,
770 documents were found. The abstracts of
those papers indicated 113 papers after those
not falling under the theme were eliminated.
We further eliminated studies not dealing with
the WE of the nursing profession. Thereby, we
selected 43 papers from those 113（Table 1）.
Additionally, we collected one highly relevant
paper from the cited references in key
literature. Eventually, we selected 48 papers
for analyses.
Although those review papers included
a paper describing a profession other thannursing 19） , the research encompassed WE
research in nursing and other fields. Moreover,it was the latest one among the review
papers obtained as literature related to WE

documents−3−

research on the nursing profession

長崎県立大学

Table1

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第22巻 （2024）

List of references analyzed（published between 2020- 2023）

No author
1 Gong et al., 2020
2 Lyu et al., 2020

objective
Demonstrate evidence that psychological empowerment becomes the mediator between trait emotional intelligence and job satisfaction and WE mediates the link
between traits of emotional intelligence and job satisfaction.
To explore the internal associations among organizational identity, psychological resilience, and nurses’ work engagement by applying the job demands-resources (JDR) model theory and structural equation model.

3 Wu et al ., 2020

Investigate how spiritual leadership influences WE through increased spiritual well-being and psychological capital.

4 Bartsch et al., 2021

Look into the relation between nurses and their WE during the second wave of the COVID-19 pandemic.

5 Bernburg et al., 2021

To investigate and describe the stress perception, sleep quality,pandemic-related worries and concerns, as well as the work engagement of outpatientnurses during the
COVID-19 pandemic.

6 Cussó et al., 2021

To assess the level of work engagement of Spanish nurses during the COVID-19 pandemic.

7 Fukuzaki et al., 2021

Examine how nurses’ work-life balance, job demands and resources, and organizational attachment influence nurses’ WE.

8 Hara et al., 2021

Assess how the attraction of working at nursing homes and autonomous clinical judgment influence affective occupational commitment and whether WE mediates thoserelations.

9 Hu et al., 2021

Consider the relation between nurses’ proactive personality and job performance.

10 Iglesias et al., 2021

To evaluate the work engagement, psychosocial risks, and psychological well-being of Spanish nurses, analyzing existing relationships, and their associations with selfreported mental health problems of nurses.

11 Martínez et al., 2021

Analyze relations among empathy, affect, personality, and WE components; then analyze the mediator role of variables susceptible to intervention.

12 Remegio et al., 2021
13 Sasaki et al., 2021
14 Sawada et al., 2021

Understand nurse leaders’ (NLs’) professional quality of life, WE, and efforts for work.
To examine the effects of a newly developed smartphone-based stress management program (ABC Stress Management) on improving work engagement among hospitalnurses in Vietnam, an LMIC.
This study observed the effects of a program called Civility, Respect,and Engagement in the Workplace (CREW) on social climate and staff work engagement in a
psychiatric ward of a Japanese hospital.

15 Wang et al., 2021

Measure Chinese dental nurses’ efforts for work, job stress, psychological flexibility, perceived social support, and subjective well-being.

16 Wu et al., 2021

Systematically assess the interaction patterns of nurses’ mental workload with more fatigue, WE, and COVID-19 exposure risks.

17 Zhang et al., 2021

Uncover both potential influencing factors and the reality of front-line nurses’ work engagement.

18 Ding et al., 2022

Explore correlations between character strengths, WE, and subjective well-being in nurses.

19 Dossary et ai., 2022

To examine how nurse managers' leadership styles, work engagement, and nurses' organizational commitment are related in Saudi Arabia.

20 Hu et al., 2022

To investigate the current situation of work engagement of nurses in emergency department, and to find out the impact of psychological violence on work engagement
and its impact path.

21 Jiang et al., 2022

To test a moderated mediation model that focuses on job resources mediating the relationship between organizational climate and nurse engagement in the long-term carefacilities and emotional intelligence moderates this mediated relationship.

22 Matsuoka et al., 2022 Clarify the relation between subjective organizational justice and WE for nurses.
23 Mohamed et al., 2022 To assess the mattering perceptions, feelings of burnout, and work engagement during the COVID-19 outbreak.
24 Nagai et al., 2022

To examine the causal relationship between the personal and professional resources for nurses to work vigorously (PPR-N) and work engagement among nurses in theearly stages of their careers, considering time as a key mediating factor.

25 Slåtten et al., 2022

Scrutinize whether WE is a key predictive factor to achieve desirable organizational goals.

26 Tang et al., 2022

investigate the interrelationship between nurses' sense of security, work engagement, and turnover intention during the normalization phase of the epidemic in China andto explore the impact of sense of security on turnover intention.

27 Topa et al., 2022

Using the concept of job crafting, provide empirical evidence of job crafting in nursing.

28 Wu et al., 2022

To investigate the effect of career identity on career success among Chinese male nurses and to examine the mediating role of work engagement in this relationship.

29 Yin et al., 2022

Find out the subgroups of WE for front-line nurses during the COVID-19 pandemic.

30 Zeng et al., 2022

Examine how nurses’ intrinsic and extrinsic working motivation influence WE in long-term care (LTC) facilities.

31 Zhang et al., 2022

To study the effect of role overload, work engagement and perceived organisational support on nurses’ job performance, including task performance, inter personal facilitation andjob dedication.

32 Aguilar et al., 2023

This study aimed to evaluate the mediating role of self-efficacy in the relationship between resilience and stress on work engagement in Peruvian nurses.

33 Alharbi et al., 2023

To evaluate the work engagement status of registered pediatric nurses and its relationship with personal- and work-related variables in selected hospitals.

34 Forster et al., 2023

To explore which job demands and resources exert a major influence on nurse managers’ work engagement.

35 Joneghani et al., 2023

To examine the role of mental health as a mediating factor in the influence of self-compassion and work engagement on ICU nurses’ job performance during the COVID-19
pandemic, as well as the moderating effect of gender on all model relations.

36 Kato et al., 2023

To explore the antecedents (i.e., job crafting and nursing practice environment) and outcomes (i.e., strength-oriented care attitudes, mental health, and turnover intention)of work engagement.

37 Liu et al., 2023

To explore the relationships among social network degree centrality, job satisfaction, work engagement and organizational citizenship behavior (OCB) among nurses.

38 Ren et al., 2023

To examine the status quo and influencing factors of sleep quality and work engagement of nurses participating in COVID-19 during the post-epidemic era and to study
the relationship between them.

39 Tanaka et al., 2023

To examine factors related to WE of industrial nurses from both workplace environmental and individual factors, to identify factors contributing to job satisfaction ofindustrial nurses.

40 Wu et al., 2023

To investigate the male nurses' engagement in nursing work and the influencing factors.

41 Xue et al., 2023

To evaluate the relationship between healthy work environment and work engagement considering the effect of psychological capital among ICU nurses.

42 Zhang et al., 2023

The mediating role of emotional disorders between conflict management styles and work engagement was explored based on constructing structural equation models in
paediatric nurses.

43 Zhang et al., 2023

To compare psychological capital, job satisfaction, and work engagement among nurse specialists and general nurses during the pandemic, as well as to test the role ofjob satisfaction as a mediator in the association between psychological capital and work engagement among nurses, and to examine whether the underlying mechanism of
the relationship between psychological capital and job satisfaction differs between nurse specialists and general nurses.

−4−

Necessity for Research on Work Engagement of Remote Island Public Health Nurses

research other than nursing. For this reason,
we included the paper among the target
documents to assess overall trends of WE
research.
1）Review papers（three documents）（1）Research theme classification[Job resources], [personal resources], and[outcomes] were common in two review papers
as research themes for WE18）19）. Although one
document took up [organizational antecedents]
and [individual antecedents] as its theme 20）,
we were able to perceive those antecedents
respectively as [job resources] and [personal
resources] based on its structure.“Teamwork”
was found only in WE research on theJapanese nursing profession as a new personal
resource18）. Apparently, teamwork is peculiar
to Japanese cultural values18）. Other research
themes included [nursing management’s
influence on engagement] 20） and [leadershiptraining]19）, suggesting that the characteristics
of nurse managers as leaders influenced WE20）.
Research on leadership has tended to increase
in WE research overall. By no means is it
limited to nursing professionals19）.
Applying the Job Demands – Resource
model （JD-R model） developed by Schaufeli
et al.（2004） 16）, we extracted [job demands]
as a theme18）. The JD-R model comprises dual
processes: The “health impairment process”
explains that job demands （job stressors）
engender stress responses, consequently
causing health problems. The “motivational
process” explains that job and personal
resources influence WE, having positive
a t t i t u d e s 17）. M a n y s t u d i e s o f W E h a v eemployed the model18）. Those falling under job
demands, such as overtime work, reduced WE
and therefore have negative correlation with
WE18）.
（2） Trends of WE research assessing thenursing profession
Three papers represented the few
longitudinal design studies which have beenreported. Because WE improves in nurses’
careers over time 20） , the process must be−5−

demonstrated through longitudinal design
research 20） . Few intervention studies havebeen conducted to verify what interventions are
effective at improving WE 18）20）. Particularly
few are intervention studies of the nursing
profession in Japan 18） . Intervention studies
are increasingly common in recent years,
including studies using“Mindfulness: paying
attention on purpose, in the present moment,n o n j u d g m e n t a l l y 2 1 ）” a n d “ J o b c r a f t i n g : aprocess to raise the significance of work whilechanging one’s work” 17）19） . As effective
intervention methods that influence WE,
findings must be increased while concurrently
using longitudinal design research in futurestudies 19） . Methods that intervene both injob resources and in personal resources are
expected to increase because they are more
effective 19）.
2）Literature review of 43 papers publishedbetween 2020 and 2023 and one describing
a WE study of public health nurses, and one
describing a WE study of nurses in remoteareas abroad.
Methods
Our search revealed 43 studies that wereconducted of nurses. The departments to which
the target nurses belonged varied, including
pediatrics 22）23） , emergency departments 24） ,psychiatry 25）, ICUs 26） and nurse leader 27）28）.
Some studies targeted male nurses 29）30） . In
addition to nurses, two studies targeted publichealth nurses12）31）. All used an applied crosssectional research design. The most commonlyused scale to measure WE was the Utrecht
Work Engagement Scale（UWES）（including
the short version）developed by Schaufeli et al.
（2004）16）（43 papers）.
（2）Recent trends of WE research
A distinctive feature of the papers publishedduring 2020–2023 was that they addressed[COVID-19] 32）- 42） . During the worldwide
COVID-19 pandemic, with wider effects startingin 2020, nurses’ mental workloads 32） andpsychological stress 38） increased drastically;長崎県立大学

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第22巻 （2024）

mental health declined33）. Although the average
WE score was moderate34）35）39）, it was higher
than before the pandemic34）, WE scores werereported as tending to be higher36）40）41）. Some
reports suggested a positive association
between mental workload and WE because
many nurses had high WE scores despitehigh mental workloads, suggesting a positive
association between mental workload andincreased subjective fatigue and WE32）37）. Thisfinding suggested that, in a crisis situationsuch as COVID-19, a high workload might
be regarded as positively rewarding 32） . In
terms of the three components of WE（vigor,
dedication, and absorption） 17） , differenceswere identified among nurses: some had ahigh level of“dedication” 34）; others showed
high levels of “vigor” and “absorption” 35） .

reportedly have positive correlation26）47）51）.
Furthermore, WE is positively associatedwith other detailed psychological factors inindividuals, such as emotional intelligence52）45）,
which is the ability to express and manage
one's own emotional reactions, psychologicalresilience 53）54）, which is the ability to handles t r e s s a n d r e c o v e r , s e l f - c o m p a s s i o n 33）,
which indicates compassion for oneself, andpsychological flexibility 47） . These findings
suggest the influence of an ability to manage
stress within oneself as a personal resource,
and that WE is linked to job satisfaction45） andmaintaining a high level of mental health33）.
（ii）Job resources
S o c i a l s u p p o r t 29）47）, l e a d e r s h i p 51）55）,
o r g a n i z a t i o n a l c o m m i t m e n t 55）56） a n daffective commitment 57） have been found

These differences might be attributable todifferences in the research scales used andthe departments in which the respondents
worked35）. Results demonstrated that different
findings in terms of the elements of WE
during the COVID-19 pandemic were likely
to be produced by different factors including
the scales used for research, the people anddepartments studied, national cultures, and thetiming of implementation.
（3）Antecedents of WE
Factors reported as improving WE include
job resources（e.g., support from bosses andco-workers and discretion over work） andpersonal resources （e.g., self-efficacy andoptimism） 17） . These resources constituteantecedents that influence WE. Reportedly,
greater abundance of job resources is related
to higher levels of WE. Moreover, greater
abundance of personal resources is related tohigher levels of WE17）. Consequently, for the
discussions presented herein, we classified thereported antecedents into personal resources
and job resources.
（i）Personal resources
Job satisfaction36）43）44）45）46）, subjective wellbeing47）, consistently proactive personality 48）49）,
cognitive empathy50）, and psychological capitalto share consistently positive correlation.
Transformational （transformation-type）
leadership, transactional （transaction-type）
leadership55）, and spiritual leadership increase
WE more than any other type of leadership51）.
By contrast, during the COVID-19 pandemic,
leadership did not have a positive effect on WE,
suggesting that other aspects of leadership
might be important as a work resource during
a crisis situation 37） . In addition, discomfortof personal protective equipment （PPE）,
infection control, and frustration during the
COVID-19 pandemic, which characterized
the corona virus pandemic, were reported ashaving negative correlation34）.
With regard to organizational justice, only
procedural justice showed positive correlation
related to organizational justice 58） . Thisfinding indicated that the fairness perceived
in the organizational decision-making process
was of particular importance, suggesting thatmanagers fully informing their organizations’policies and assessment processes and listening
to the opinions of individuals engenderimprovement of WE 58） . As described, somestudies investigated a single factor related to
WE in greater detail.
（iii）Outcomes of WE−6−

Necessity for Research on Work Engagement of Remote Island Public Health Nurses

Outcomes achieved by improving WE include
work-related and business-related outcomes（e.g., work performance and attitude） andindividual health-related outcomes（e.g., mental
and physical health） 15）17） . Burnout 28） andsecondary traumatic stress 28） were found tohave a negative correlation consistently as
outcomes of WE in the nursing profession. The
improvement of performance in nursing34）59）,
Sleep Quality60） and quality of service care44）
were found to have a positive correlation,
which was a similar finding to those of an
earlier study 20）. Administrative public healthnurses with scarce job resources were more
likely to be in a state of burnout12）. The only
study of remote nurses we found indicatedthat WE scores included high levels of burnout
scores, although remote nurses had highburnout scores and high occupational stress61）.
3）Discussion of a review of literature about
WE research on the nursing profession
Based on 1）and 2）, it is possible to discuss
trends of WE research into the future nursing
profession and to discuss the necessity andsignificance of studying PHN.
（1）WE studies examining the future of thenursing profession
As reported particularly from review
papers 18）19）20）, no longitudinal research but
three intervention studies were conductedduring 2020–2023 62）63）64）.
A recent trend of WE research is thegrowing movement to reconsider WE asa phenomenon that changes depending ont h e t i m e a n d c i r c u m s t a n c e s 65）. F i n d i n g s
demonstrating how the WE of nursing
professionals has been affected and how
it has changed must be improved throughthe accumulation of findings from increased
longitudinal research and intervention
research18）19）.
As the antecedents specific to Japanesenurses were reported18）, WE varies dependingon the cultural background and values of thecountry or region, so it is important to set the−7−

purpose, scale, and variables appropriately
when conducting WE research 18）65）66）. Then,in interpreting the results obtained, it isnecessary to consider the cultural backgroundand values as well. We need to prevent theincreasing number of nurses from leaving thenursing profession and guarantee the right toequal health for all by building on the findingsof WE research in the various environments
and situations in which nurses are placed.
（2）Significance of WE research of PHN
Although numerous studies have examined.
WE among nurses in various settings, andaccording to department and gender, few
WE studies of public health nurses havebeen reported worldwide. Research has
not well developed. As “job resources” foradministrative public health nurses, it isreportedly peculiar to PHN that the satisfaction
gained from interpersonal support is at the coreof their occupational satisfaction 67） and that
disregard of the health sector and involvementwith clerical staff within the organization
become job demands（stressors） 67）. In lightof those findings, there is a state of WE that is
peculiar to PHN, derived from their operationaland organizational characteristics. Clarifying
the WE of PHNs under various circumstances
helps elucidate factors preventing their
turnover and mental health deterioration.
To this end, accumulation of findings from
WE studies conducted solely with PHN isnecessary.
2. Results of a review of literature related tothe turnover and retention of rural nursing
professionals

The original purpose of this study was toreview the literature from studies of remoteisland PHN. Nevertheless, because only threedocuments specifically described studies ofremote islands 14）68）69） , this report presents
results of a review of the literature related
to the turnover and retention of nursing
professionals in rural areas.
A search conducted with the keywords長崎県立大学

看護栄養学部紀要“rural remote nurse turnover retention”
identified no document. After removing“turnover, retention”from those keywords, weagain conducted a search, which yielded 961
documents, 146 of which were review papers.
Eliminating papers with contents different
from the purpose of this study left five papers.
Eventually, two papers were selected foranalyses after eliminating three papers forwhich the contents overlapped.
The target documents included bulletins 14）
because only a few targeted documents were
found, and because their contents accordedwith our study’s purpose. One review paper14）
presented discussion of the relevant literature
published during 2009–2019. Using the review
paper as the latest literature review found forthe present study including remote islands,
we then searched the literature publishedafter 2020, which identified 10 papers. Of
them, three papers were selected for analysis
after eliminating one with contents different
from this study’s purpose. Additionally,
we collected 9 highly relevant papers fromthe cited references in key literature andspecialized books. Eventually, we selected 14
papers for analyses（Table 2）.
As a reference for analysis, we used aliterature review 70） conducted to examine thefactors influencing the retention of nursing
professionals in rural areas, deeming it theoldest review paper we found for this study.
Figure 1 presents the overall results obtained
from the study as “Factors influencing theretention of rural nursing professionals.”
Although the obtained documents, aside
from review papers, described examinationsof “rural areas” and “remote areas,” weuse “rural areas” for the present study byintegrating those areas based on the definitionof rural:“In mountainous areas, remote islands,
and other areas that are not favored by traffic
conditions and natural, economic, and social
conditions, areas which have difficulty securing
medical care and which meet the requirements
for a doctorless area and areas equivalent to−8−

第22巻 （2024）

it.”71）
1） Factors influencing the retention andturnover of rural nursing professionals（1）Characteristics of rural nursing practice
A challenge that influences nurses’
retention in rural nursing practice is thelimited availability of resources such as
drugs, specialized resources to care forpatients, scarce housing resources for nursing
professionals 72）73） , lack of anonymity 68）72） ,the blurred boundary between private andwork life72）, burnout68）, and difficulty obtaining
opportunities for growth68）. Practical support
for distinctive nursing practice in remote areas
is necessary, and support such as preceptors
and access to educational opportunities areimportant factors that influence retention74）.
（2） Relation between job satisfaction andnurse retention rates
Reportedly, numerous studies have assessed
the relation between job satisfaction anddecisions about whether or not to reside inrural areas70）. Rural nurses are more likely toleave their jobs when not satisfied with theirwork. The characteristics of nursing practicein rural areas influence job satisfaction.
Moreover, their job satisfaction influences theduration of retention in rural areas 70） . The
need for establishing some system to improve
job satisfaction has been pointed out because
many findings of studies have indicated thatrural nurses have low job satisfaction70）.
（3）Relationship with the organization
With regard to the relation between
nurses and organizations in rural areas, alower organizational commitment is related
directly to a higher probability of turnover
intention 75） . Organizational commitment isdefined as “an emotional attachment to anorganization characterized by the sharing of
the organization’s values and goals, a desire
to remain a member of the organization, anda willingness to exert considerable effort onbehalf of the organization.” 76） In addition
to studies of the field of nursing, those of

Necessity for Research on Work Engagement of Remote Island Public Health Nurses

Table2 Literature of literature related to the turnover and retention of rural nursing professionals
Noauthor

1

Roberge, 20092

Integrating current evidence to the effectiveness of the intervention to promote nurses’
Mbemba et al., 2013 retention in rural or remote areas, present a classification system for potential strategies for
improving their retention in those areas.

3

DeValpine, 2014

To ensure the unique stories of bush Alaska nurses are preserved and told; to foster astrong bush nursing tradition; and to inform recruitment, hiring, and retention practices inremote settings.

4

Bragg et al., 2014

Find out the reasons why registered nurses leave their jobs at local hospitals in New South
Wales, Australia.

5Catherine et al.,2018

how employment and rural-living factors impacted the turnover intention of early-career, ruralbased CMH professionals in their first few years of working.

6

Calleja et al., 2019

To investigate what transition support was reported for new graduate nurses to function
effectively in rural and remote settings.

7

Sellers et al., 2019

The purpose of this study is to examine the unique contributions that job satisfaction,
resilience, grit, engagement, and rural fit have on nurses’ intention to stay in their unit for the
next 6 months and intention to leave the institution in the next 3 years.

8

Zhao et al., 2019

Comparing the increase in the turnover rates of resident nurses and Aboriginal medical
professionals with the costs and influences of increased use of agency nurses, quantify the
relation between staffing patterns and health outcomes in remote primary care (PC) services.

9

Chinen et al., 2020

Clarify the factors and research trend of the turnover and retention of public health nurses andnurses working on remote islands and in rural areas.

10

Stewart et al., 2020

objective
Consider factors influencing the retention of nurses in rural areas.

Regarding registered nurses, or nurse practitioners (RNs/NPs), and licensed practical nurses(LPN), consider the determinants of their intention to leave the nursing profession in rural andremote areas by the end of the following year

11 Chinen et al., 2021

This study aimed to clarify that taking a job and turnover reasons, the event that they want toresign their job among public health nurses on remote islands.

12 MacKay et al., 2021

Using meta-integration of systematic reviews and qualitative studies by theme, clarify the
influence on the decision-making of nurses working at medical sites in rural and remote areas.

Nishimoto et al.,2022

Examine resilience to clinical nurses’ burnout and the influence of relevant factors.

14 Tamata et al., 2022

To explore the perception of health leaders on factors affecting the shortage of nursing
workforce in underserved areas in Vanuatu.

13

−9−

長崎県立大学

看護栄養学部紀要

other fields have found that organizational
commitment and occupational（job）satisfaction
correlate significantly 77） as a psychologicalattachment to an organization 77） . Because
nurses left their jobs when failing to readjust
their values to changes in the organization’svalues, the blending of personal andorganizational values is expected to be a
strategy for retention78）.
（4）Factors influencing the length of working
years
The satisfaction of rural nurses with
community activities and life, including
awareness as a team member, a sense of
belonging to society, and their friends’
presence in the community, constituted factors
influencing retention in rural areas70）72）79）.
（5）Individual attributes and experiences asfiltering factors
Even when nurses satisfy their jobs andcommunity life, a family member’s schooling,care, and other life events can constitutereasons for turnover intention 68）. Experiencesof living, being raised, and training in rural
areas, family members living in rural areas,and educational opportunities for family
members available in rural areas served as“filtering factors”and influenced whether one
chooses to continue residing in the rural area,
or not 80）.
2）Discussion of a review of literature related
to the turnover and retention of rural nursing
professionals（1）The importance of research investigating
the turnover and retention of public healthnurses on remote islands
Because the turnover of rural medical
professionals directly influences increases
in hospital expenses and medical costs 81）, it
strongly influences the health of community
residents. Similarly, local residents of remoteislands invariably worry about healthemergencies in an environment where
medical, health, and welfare resources are
scarce 82） . Remote islands, which present− 10 −

第22巻 （2024）

various difficulties associated with population
decline that is occurring more rapidly thanon the mainland and in other rural areas 83）,
can serve as an example to be followed inunderpopulated areas and can therefore be thesubject of important research84）.
（2）Matters common to factors influencing
the turnover and retention of nursing
professionals in rural areas
Factors influencing the turnover andretention of nursing professionals in rural areas
were classified as [Responses to tasks withdiversity and responsibility] and [Adaptation to
the environments peculiar to rural areas andremote islands]. Matters common to those twoare personal resources and job resources74）.
（i） Responses to tasks with diversity andresponsibility
For medical and healthcare services in rural
areas, the workload is immense because oflabor shortages. Medical care professionals
are under psychological and physical stressbecause of responses to support of various
kinds85）. Moreover, working at tasks that are
difficult to improve on remote islands influences
PHN’turnover intentions68）. To continue theiroccupation as nursing professionals in such anenvironment, a strong adventurous spirit andan optimistic perspective86） constitute personal
resources, as well as a system to support andeducate individuals as an organization 87） andthe blending of personal and organizationalv a l u e s 78） f r o m j o b r e s o u r c e s 17）. T h o s eresources improve job satisfaction 77）, leading
to prevention of turnover intention75）.
（ii）Adaptation to environments peculiar torural areas and remote islands
Some environments, such as environmentswith a blurred boundary between work andprivate life72）, are peculiar to rural areas andremote islands 70） . Even in such a negative
situation, an active coping style that includes
exchanges with the community and coworkers with an optimistic perspective 86）
and satisfaction with the local community
through a sense of belonging to society 72）

Necessity for Research on Work Engagement of Remote Island Public Health Nurses

become personal resources 17） and constitutefactors to adjust and settle in the community.
Furthermore, because family life events
influence turnover 68） , organizations must
establish a system to achieve individual work–
life balance as a job resource70）.
Both （i） and （ii） above indicate that“personal resources”and“job resources”arethe common factors influencing the turnoverand retention of nursing professionals in rural
areas and remote islands 74）. Therefore, thosefactors can be expected to be reflected in theliterature describing future studies.
（iii）Future research for retention in rural
areas and remote islands
When considering a concept model for theturnover and retention of nursing professionals
in remote islands and rural areas, the relation
between turnover and retention can beclarified by including the two aspects ofwork and private life14）, and by incorporating
indicators that might be outcomes of job
satisfaction and burnout 14）. Environments inwhich nursing professionals work vary withdifferences in the population size and social
resources in rural areas and remote islands75）,
which influences analysis84）. Consequently, thedefinition of remote islands used for researchshould be considered carefully 72）.

Overall discussion
Based on 1. Results of a literature review
for WE research on the nursing profession and
2. Results of a review of literature related tothe turnover and retention of rural nursing
professionals, we discuss the importanceof adopting the WE concept as research to
explore turnover factors affecting PHN on
remote islands.
The role of public health nurses in the local
community is to promote healthy community
development that is sustainable and whichtakes advantage of regional characteristics6）.
Consequently, community development that− 11 −

secures the lives of people living on islands
and which allows them to continue living
without undue worry can be a duty of PHN
working on remote islands. As the basic
policy of the Remote Islands Development
Act clearly states, remote islands assume
national and citizenry roles3）. They also servein important roles in the administration of thecountry, prefectures, and municipalities3）. For
public health nurses who are specialists andadministrative officers to carry out their duties
for maintaining and improving residents’
QOL and those for sustainable community
development, they themselves must engage
in healthcare activities energetically withoutleaving their job.
The literature reviews conducted for thisstudy revealed the association of personaland job resources with turnover of nursing
professionals in rural areas and remoteislands 74） . However, no WE research has
been conducted of remote island publichealth nurses using the WE concept, which
has strong relations with personal and job
resources. Because the WE study of nurses
in remote areas reported differences fromearlier studies61）, it is probable that the realityof WE on remote islands differs from thaton the mainland. Personal and job resourcesof remote island public health nurses havenot been clarified, or their relation to WE, ortheir influences on turnover and retention. A
strategy for using the WE concept to prevent
turnover and to retain public health nurses
working on remote islands, which involves
personal and job resources, can be importantresearch to support nurses as they fulfill theirduties.

Limitations of this study
The WE studies obtained for analyses inthis study specifically targeting public healthnurses were few: two papers. It can hardly
be claimed that our search encompassed all
publications because PubMed alone was used

長崎県立大学

看護栄養学部紀要

to search the available literature. Moreover,very few reports of relevant literature
have included discussion of studies of theturnover and retention of remote island publichealth nurses. For this reason, we inferredsome factors influencing the turnover andretention of remote island PHN from studiesof the turnover and retention of the nursing
professionals in rural areas. Future studies
must clarify the actual state of turnover andretention of remote island PHN, which was
the original purpose of this study. Such studies
can accumulate empirical research on those
PHN, and can consider strategies for retention
based on the circumstances of PHN working
on remote islands today.

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