Table 2 Nurses' perceptions of incentives and disincentives

Salary/Income

Salary was not perceived spontaneously as an economic incentive/disincentive and was most often not considered in career moves. Exceptions were identified involving jobs offering similar working conditions (e.g. hours) and changes in civil status (e.g. married to divorced).

In London, comments on salary relativities were restricted to nursing team members. In Geneva, poor relativities in salary/hourly rates between nurses and other workers were often highlighted.

It was suggested that the poor salary progression within a given pay grade (comparison of starting and retirement salary) may undermine nurses' commitment to their profession as a long-term career.

Clinical grading

Clinical grading (career structure) in London was said to perpetuate promotional opportunities in management as opposed to clinical nursing and failed to reward individual areas of expertise and professional development. The autonomy required in community nursing was, however, recognized in the overall grading resulting in higher pay.

In Geneva, clinical grading recognized the global vision and public health expertise of nurses with post-basic qualifications as well as clinical specialities. Clinical grading did not exist for nurses operating within the fee-for-service/fee-for-time system and the for-profit setting.

Car access

Personal cars were required as a condition of employment. With one exception, car pools had been eliminated as a cost-containment measure. Recent subsidized public transport was reported in the two public-funded agencies. Allowances for car maintenance were granted by one employer although claimed inadequate. The purchase of a car was considered a significant personal investment for nurses. Vandalism was also mentioned as a financial disincentive

Petrol

A set allowance was provided to compensate for petrol expenses. There was consensus at both research sites that these allowances did not cover the total cost.

Parking

Parking fees were paid for the salaried nurses, although parking fines most often were not. Parking discs were provided to General Practitioners (GPs) but not for nurses.

Uniform/laundry

Nurses were no longer required to wear uniforms. Aprons were provided to the salaried nurses, while independent nurses could purchase disposable aprons at bulk rate. Several London nurses felt that using personal clothes represented important personal initial purchase and ongoing maintenance costs, as their clothing allowance was considered to be inadequate. This issue was mentioned only twice by Geneva nurses, although no allowances were provided.

Subsidised cafeteria

No subsidized cafeterias were available to nurses in either setting. Although meals represented a significant additional cost (in comparison with a hospital setting), this was not spontaneously mentioned by interviewees.

Unsocial hours

Shift differentials (i.e. extra pay for working nights and weekends) were considered to be insignificant and not a motivating factor in the workplace. There is, however, an indirect economic advantage for community nurses working more regular hours with regard to better access and lower fees for child care (mentioned only once).

Overtime

Overtime was compensated by time in lieu for salaried nurses and in general did not constitute a major issue. Although not strictly overtime, the time spent by independent nurses on indirect care (i.e. liaison duties) was not recognized by the reimbursement system and considered a major financial burden as well as concern.

Pension

One London respondent mentioned improved pension rights, while another claimed lower benefits. Several salaried Geneva nurses noted equal benefits for private and public-sector nurses. Independent nurses were obliged to contribute to the government basic pension scheme.

Cost-of-living

London nurses were entitled to cost-of-living increases. The budget freeze applied in Geneva eliminated these automatic allowances for salaried nurses. Independent nurses were tariff-dependent and these were not linked to a cost-of-living scale. Nurses working for the Swiss for-profit agency did not benefit from cost-of-living increases.

Geographic-specific allowances

London nurses benefited from Inner and Outer London Weighting allowances. Such allowances did not exist in the Geneva setting.

Bonuses

Nurses working at the for-profit agency were entitled to productivity and merit bonuses, although the criteria applied were unknown. Salaried (non-profit employer) nurses were eligible for "loyalty" bonuses after 5 years of service. London nurse managers received performance-related pay, merit and productivity bonuses, although community nurses did not.

Miscellaneous cash disbursements

In addition to the above financial incentives, Geneva salaried (non-profit employer) nurses were granted child support supplements, partial payment of health insurance premiums and an allowance for the purchase of a diary. These incentives were not mentioned by nurses from other workplaces.

Staff coverage

The London facility was reported to experience chronic staff shortages, high turnover and high absenteeism. In both settings, access to temporary nurses was felt to depend on the Area Manager's personal priorities.

Access to supplies and equipment

Access to supplies, while considered adequate, was perceived to be more difficult than previously. As a cost-containment measure, stocks had been reduced and orders needed to be justified with greater rigour.

Job contracts

Although short-term contracts were widely introduced during a certain period as a cost-containment measure, this was no longer the practice. The number of part-time jobs was also being reduced. Many of the London nurses were contracted out to GP fundholders, their duties largely being determined by contract negotiation.

Access to continuing education

All employers were perceived to support continuing education and a lifelong learning approach.

Access to professional support

The elimination of Team Leaders was experienced by London nurses as a loss of professional support, while the development of the nurse manager hierarchy and the introduction of Clinical Specialists were seen to increase the professional support available to Geneva nurses. Respondents, however, were aware of the risk of professional isolation due to the working conditions specific to community nursing.