ORIGINAL ARTICLE
The support needs of new graduate nurses making the transition to rural nursing practice in Australia Jackie Lea and Mary Cruickshank
Aims and objectives. The aim of this paper is to present the findings from the new graduate nurse participants of a larger study that explored the transitional experiences of newly graduated nurses making the role transition in rural health care facilities in Australia. Background. Evidence indicates that workload, skill mix and organizational pressures are still of concern for new nursing graduates within the Australian context and internationally. Many graduates are expected by employers to have high levels of independence, well developed problem solving abilities and be able to assume management and leadership responsibilities early in their graduate year. Design. An exploratory, descriptive, qualitative case study design was utilised to determine the particular support needs over time that would assist with a safe transition to the rural nursing workforce. The aims of the study were to: (1) Explore the new graduate nurses’ perceptions and experience of the nature and timing of support throughout their Transition to Practice Program in a rural setting; (2) Identify the functional elements of rural graduate nurse transition programs and develop guidelines that will assist in the design of Transition to Practice Programs that match the rural context and capacity. Methods. A purposive sample of 15 new graduate nurses who had commenced a 12 month Transition to Practice Program within a rural health facility from northern New South Wales, Australia, participated in this study. In-depth individual interviews with the new graduate nurses were conducted at time intervals of three to four months, six to seven months and 10 to 11 months. Results. One of the key findings of this study is that as the new graduate nurse making the transition to professional rural nursing practice moves along the transition continuum, there are particular and unique aspects of the rural nurse’s role and responsibilities for which the new graduate nurse will require specific learning support during their transition. Conclusions. When the new graduate moves from the role of the student to the less familiar role of professional practitioner, it is important that a rural Transition to Practice Program offers an incrementally staged workload and responsibilities that recognises the graduate’s beginning nurse status. Relevance to clinical practice. The study contributes new knowledge to the discussion of issues concerning support mechanisms for new graduate nurses as they make the transition to rural nursing practice.
What does this paper contribute to the wider global clinical community?
• Adds to the global literature on rural nursing practice.
• Informs policy makers of transi•
tional support needs for rural new graduate nurses. Adds to the breadth of knowledge on Transition Theory by contributing to furthering the understanding of the support needs of the new graduate nurse making the role transition in the rural practice context.
Authors: Jackie Lea, PhD, MN, RN, Senior Lecturer in Nursing, School of Health, University of New England, Armidale, NSW; Mary Cruickshank, PhD, MN, RN, Head of Nursing & Midwifery Disciplines, University of Canberra, Canberra, ACT, Australia.
Correspondence: Dr. Jackie Lea, Senior Lecturer, School of Health, University of New England, Armidale, NSW, 2351, Australia. Telephone: +61 67732974 E-mail: [email protected]
948
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 948–960, doi: 10.1111/jocn.12720
Original article
New graduate nurses entering rural nursing practice
Key words: new graduate nurses, qualitative, rural nursing practice, transition theory Accepted for publication: 10 September 2014
Introduction Evidence from Lea and Cruickshank (2007), Johnstone et al. (2008), Duchscher (2008), Parker et al. (2009), Bennett et al. (2012) and Ostini and Bonner (2012) indicates that workload, skill mix and organizational pressures are still of concern for new nursing graduates within the Australian context and internationally. This is particularly true for new graduate nurses who enter the rural nursing workforce where the diversity and complexity of nursing practice often prevent the new graduate from making an effective transition into the nursing workforce. The purpose of the study was to explore the transitional experiences of newly graduated nurses making the role transition in rural health care facilities in Australia. A specifc aim of the study was to determine the support needs that would assist with a safe transition to the rural nursing workforce.
Background Research findings from Lea and Cruickshank (2007) and Lea et al. (2008) indicates that new graduate nurses who enter the rural workforce enter a professional practice very different from metropolitan practice and also from what they have experienced as an undergraduate nursing student. The literature identifies unique characteristics of rural practice, including the unique clinical experiences associated with rural practice, greater autonomy enjoyed by rural health professionals, and the rewards of living in a small community (Wolfenden et al. 1996, Mills et al. 2006, Lea et al. 2008). The difference between rural and metropolitan nursing practice may be attributed partly to the scope and diversity of rural nursing practice whereby the level of responsibility and skills differs from that of their metropolitan peers. It is likely that new graduate nurses in rural practice settings will have to assume workload responsibilities that are vastly different from their metropolitan or regional peers. In addition, the context of rural practice means that rural nurses must be able to switch clinical focus quickly, possess a broad range of assessment and clinical skills (Lea et al. 2008) and have a broad understanding of referral services
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 948–960
(Kenny & Duckett 2003, Seright 2011). For example, staff ratios in rural areas can mean that the new graduate may be required to relocate to different clinical areas on a daily basis and also may be required to move between clinical units fairly constantly throughout one shift. It is not uncommon in rural health care facilities for the Accident and Emergency area to be attached to a general ward area where staff rostered to that ward are expected to also attend to the Accident and Emergency area should the need arise during the course of the shift (Lea & Cruickshank 2007). Also, it is not uncommon for paediatrics, maternity, and acute surgical care clinical areas to be a component of the general ward in rural agencies. In addition, many small rural hospitals have long term residential care facilities due to the lack of residential aged care facilities in the rural area. Lower registered staff to patient ratios than their urban peers means that the rural new graduate’s expectations of a supportive transitional experience are generally not met because many rural graduate nurses will be required to take on workload responsibilities, with limited supervision or guidance, that allows no time for familiarising or settling into the work environment (Lea & Cruickshank 2007, Seright 2011). In addition, many graduates in rural areas will be expected by employers to have high levels of independence, have well developed problem solving abilities and be able to assume management and leadership responsibilities, such as being in charge and delegating, as well as directing and co-ordinating roles very early on in their graduate year (Kenny & Duckett 2003, Lea & Cruickshank 2007, Lea et al. 2008, Bennett et al. 2012).
The transition to practice Historically, explanations for, and of the process, of transition from student nurse to professional practising nurse have been consumed by descriptions of the adjustment to new roles and socialisation to the role of practising nurse, influenced by concepts central to Role Theory, Reality Shock Theory (Kramer 1974) and Transitions Theory (Meleis et al. 2000). The Stages of Transition Theory arises from Transitions Theory (Schumacher & Meleis 1994) and
949
J Lea and M Cruickshank
subsumes elements of professional role socialisation as identified by Kramer (1974). The description and understanding of the phases and stages of transition for newly graduated nurses as posed by Kramer (1974) focuses on the new graduates’ responses during the initial stages of role transition as being primarily about the gap between the education and practice environments (Duchscher 2009). Kramer’s work suggested that new graduates experience a reality shock with the discovery that educational values concerning nursing practice instilled during undergraduate preparation conflict with work-world values (Duchscher & Cowin 2006). Since then, many authors (Goh & Watt 2003, Roberts & Farrell 2003; Casey et al. 2004, McKenna & Green 2004, Maben et al. 2006, Newton & McKenna 2007, Zinsmeister & Schafer 2009), have identified concerns or issues for the new graduates at specific points in time that have peripherally enhanced understanding of transitional stages and processes, however, none have ‘distilled out the nuances of the transition experience at various stages or have clarified the relationship of the stages of growth and change in the newly graduated nurse to the passage of time’ (Duchscher 2008, p. 443). In the Stages of Transition Theory, Duchscher (2008, p. 444) describes the initial 12 months of the transition to professional practice as ‘a process of becoming’ that is both a personal and professional journey for the new graduate nurse. Duchscher’s (2008) theory demonstrates that during the first 12 months of professional practice, new graduates will evolve through a continuum of three stages; doing, being and knowing. Encompassed in this journey are ordered processes of anticipating, learning, performing, concealing, adjusting, questioning, revealing, separating, rediscovering, exploring and engaging. According to this author, the stages are not linear, prescriptive or progressive, they are ultimately transformative and might be influenced by critical events such as practice situations or contexts and new events that may cause transient regressions along the continuum (Duchscher 2008).
Methods The purpose of this study was to investigate new graduate nurses’ transition into rural nursing practice within a Transition to Practice Program. The following research questions were formulated to assist in exploring the support required for graduate nurses and to identify issues related specifically to the provision of support within the rural practice context.
950
1 What are the new graduate nurses’ perceptions and experiences of support throughout a rural Transition to Practice Program? 2 What are the functional elements of a rural Transition to Practice Program? In this study a Transition to Practice Program is defined as structured support and assistance provided for graduate nurses in the transition from student to registered nurse throughout the first year of professional nursing practice. In exploring the phenomenon of support for new graduate nurses within a Transition to Practice Program, this study specifically aimed to investigate and describe the nature and timing of support required during the transition to rural nursing practice that is specific for the rural context and capacity. This study used the Stages of Transition Theory (Duchscher 2008) to determine the provision of support during the transition process from student nurse to registered practising nurse within rural practice settings. Utilising a qualitative case study approach, 15 new graduate nurses employed in Transition to Practice Programs within rural health services of northern New South Wales, Australia, participated in individual, semi-structured face to face and telephone interviews at time intervals of three to four months, six to seven months and 10–11 months, a timeframe consistent with Duchscher’s (2008) Stages of Transition Theory. This study was conducted in 14 rural towns of northern New South Wales and is therefore not representative of the new graduate nurse population in all rural areas of this State. However, the researcher was not interested in making statistical inferences or generalising the findings to the wider population. Rather, the purpose was to obtain rich and insightful data that would shed light on the barriers as well as the positive factors that impacted on the experiences of a sample of graduate nurses who made the role transition in rural practice settings. Thus this study also sought the views of experienced rural nurses who were employed in rural health agencies where the new graduate nurses were employed and the findings from these data are the subject of a second publication. Conducted in health services in rural towns of northern New South Wales (NSW), which, at the commencement of the study, had new graduate nurse positions available within a graduate nurse Transition to Practice Program, rural towns included in this study had a population base classified to be outer regional according to the Australian Government Department of Health and Ageing (2010) and/ or those whose population base is classified as rural, according to The Australian Bureau of Statistics, Australian Standard Geographical Classification Remoteness Areas Classification (ABS 2001, accessed 22nd April 2010) within © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 948–960
Original article
New graduate nurses entering rural nursing practice
one Area Health Service of Northern New South Wales, Australia. A total of 14 large rural and small rural health services met the criteria and intended to employ new graduate nurses on a 12-month graduate nurse Transition to Practice Program in 2011. Each program was independent of larger regional or metropolitan Transition to Practice Programs. Five of the large rural health services are located within large rural towns and provided similar medical and nursing services. According to the Australian Government Department of Health and Ageing (2010, p. 49) these large rural health services are located in outer regional areas and as such would be classified according to the number of admissions per year as ‘medium acute hospitals in regional areas’. At the time of this study, the staff ratios, skill mixes, and graduate nurse programs within these health services were very similar. These five large rural sites have between 2–6 new graduate positions each year. The remaining nine health services included in this study are located in outer regional areas. Five of these nine health services, according to the Australian Department of Health and Ageing (2010, p. 48), would be classified as ‘small regional acute hospitals (mainly small country town hospitals)’ because of their admissions per year and treating fewer than 2000 patients per year. Four of the nine health services were classified as Multipurpose Services or according to the Australian Government Department of Health and Ageing (2010, p. 48) ‘small non-acute hospitals’ with ‘patient throughput of
The support needs of new graduate nurses making the transition to rural nursing practice in Australia Jackie Lea and Mary Cruickshank
Aims and objectives. The aim of this paper is to present the findings from the new graduate nurse participants of a larger study that explored the transitional experiences of newly graduated nurses making the role transition in rural health care facilities in Australia. Background. Evidence indicates that workload, skill mix and organizational pressures are still of concern for new nursing graduates within the Australian context and internationally. Many graduates are expected by employers to have high levels of independence, well developed problem solving abilities and be able to assume management and leadership responsibilities early in their graduate year. Design. An exploratory, descriptive, qualitative case study design was utilised to determine the particular support needs over time that would assist with a safe transition to the rural nursing workforce. The aims of the study were to: (1) Explore the new graduate nurses’ perceptions and experience of the nature and timing of support throughout their Transition to Practice Program in a rural setting; (2) Identify the functional elements of rural graduate nurse transition programs and develop guidelines that will assist in the design of Transition to Practice Programs that match the rural context and capacity. Methods. A purposive sample of 15 new graduate nurses who had commenced a 12 month Transition to Practice Program within a rural health facility from northern New South Wales, Australia, participated in this study. In-depth individual interviews with the new graduate nurses were conducted at time intervals of three to four months, six to seven months and 10 to 11 months. Results. One of the key findings of this study is that as the new graduate nurse making the transition to professional rural nursing practice moves along the transition continuum, there are particular and unique aspects of the rural nurse’s role and responsibilities for which the new graduate nurse will require specific learning support during their transition. Conclusions. When the new graduate moves from the role of the student to the less familiar role of professional practitioner, it is important that a rural Transition to Practice Program offers an incrementally staged workload and responsibilities that recognises the graduate’s beginning nurse status. Relevance to clinical practice. The study contributes new knowledge to the discussion of issues concerning support mechanisms for new graduate nurses as they make the transition to rural nursing practice.
What does this paper contribute to the wider global clinical community?
• Adds to the global literature on rural nursing practice.
• Informs policy makers of transi•
tional support needs for rural new graduate nurses. Adds to the breadth of knowledge on Transition Theory by contributing to furthering the understanding of the support needs of the new graduate nurse making the role transition in the rural practice context.
Authors: Jackie Lea, PhD, MN, RN, Senior Lecturer in Nursing, School of Health, University of New England, Armidale, NSW; Mary Cruickshank, PhD, MN, RN, Head of Nursing & Midwifery Disciplines, University of Canberra, Canberra, ACT, Australia.
Correspondence: Dr. Jackie Lea, Senior Lecturer, School of Health, University of New England, Armidale, NSW, 2351, Australia. Telephone: +61 67732974 E-mail: [email protected]
948
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 948–960, doi: 10.1111/jocn.12720
Original article
New graduate nurses entering rural nursing practice
Key words: new graduate nurses, qualitative, rural nursing practice, transition theory Accepted for publication: 10 September 2014
Introduction Evidence from Lea and Cruickshank (2007), Johnstone et al. (2008), Duchscher (2008), Parker et al. (2009), Bennett et al. (2012) and Ostini and Bonner (2012) indicates that workload, skill mix and organizational pressures are still of concern for new nursing graduates within the Australian context and internationally. This is particularly true for new graduate nurses who enter the rural nursing workforce where the diversity and complexity of nursing practice often prevent the new graduate from making an effective transition into the nursing workforce. The purpose of the study was to explore the transitional experiences of newly graduated nurses making the role transition in rural health care facilities in Australia. A specifc aim of the study was to determine the support needs that would assist with a safe transition to the rural nursing workforce.
Background Research findings from Lea and Cruickshank (2007) and Lea et al. (2008) indicates that new graduate nurses who enter the rural workforce enter a professional practice very different from metropolitan practice and also from what they have experienced as an undergraduate nursing student. The literature identifies unique characteristics of rural practice, including the unique clinical experiences associated with rural practice, greater autonomy enjoyed by rural health professionals, and the rewards of living in a small community (Wolfenden et al. 1996, Mills et al. 2006, Lea et al. 2008). The difference between rural and metropolitan nursing practice may be attributed partly to the scope and diversity of rural nursing practice whereby the level of responsibility and skills differs from that of their metropolitan peers. It is likely that new graduate nurses in rural practice settings will have to assume workload responsibilities that are vastly different from their metropolitan or regional peers. In addition, the context of rural practice means that rural nurses must be able to switch clinical focus quickly, possess a broad range of assessment and clinical skills (Lea et al. 2008) and have a broad understanding of referral services
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 948–960
(Kenny & Duckett 2003, Seright 2011). For example, staff ratios in rural areas can mean that the new graduate may be required to relocate to different clinical areas on a daily basis and also may be required to move between clinical units fairly constantly throughout one shift. It is not uncommon in rural health care facilities for the Accident and Emergency area to be attached to a general ward area where staff rostered to that ward are expected to also attend to the Accident and Emergency area should the need arise during the course of the shift (Lea & Cruickshank 2007). Also, it is not uncommon for paediatrics, maternity, and acute surgical care clinical areas to be a component of the general ward in rural agencies. In addition, many small rural hospitals have long term residential care facilities due to the lack of residential aged care facilities in the rural area. Lower registered staff to patient ratios than their urban peers means that the rural new graduate’s expectations of a supportive transitional experience are generally not met because many rural graduate nurses will be required to take on workload responsibilities, with limited supervision or guidance, that allows no time for familiarising or settling into the work environment (Lea & Cruickshank 2007, Seright 2011). In addition, many graduates in rural areas will be expected by employers to have high levels of independence, have well developed problem solving abilities and be able to assume management and leadership responsibilities, such as being in charge and delegating, as well as directing and co-ordinating roles very early on in their graduate year (Kenny & Duckett 2003, Lea & Cruickshank 2007, Lea et al. 2008, Bennett et al. 2012).
The transition to practice Historically, explanations for, and of the process, of transition from student nurse to professional practising nurse have been consumed by descriptions of the adjustment to new roles and socialisation to the role of practising nurse, influenced by concepts central to Role Theory, Reality Shock Theory (Kramer 1974) and Transitions Theory (Meleis et al. 2000). The Stages of Transition Theory arises from Transitions Theory (Schumacher & Meleis 1994) and
949
J Lea and M Cruickshank
subsumes elements of professional role socialisation as identified by Kramer (1974). The description and understanding of the phases and stages of transition for newly graduated nurses as posed by Kramer (1974) focuses on the new graduates’ responses during the initial stages of role transition as being primarily about the gap between the education and practice environments (Duchscher 2009). Kramer’s work suggested that new graduates experience a reality shock with the discovery that educational values concerning nursing practice instilled during undergraduate preparation conflict with work-world values (Duchscher & Cowin 2006). Since then, many authors (Goh & Watt 2003, Roberts & Farrell 2003; Casey et al. 2004, McKenna & Green 2004, Maben et al. 2006, Newton & McKenna 2007, Zinsmeister & Schafer 2009), have identified concerns or issues for the new graduates at specific points in time that have peripherally enhanced understanding of transitional stages and processes, however, none have ‘distilled out the nuances of the transition experience at various stages or have clarified the relationship of the stages of growth and change in the newly graduated nurse to the passage of time’ (Duchscher 2008, p. 443). In the Stages of Transition Theory, Duchscher (2008, p. 444) describes the initial 12 months of the transition to professional practice as ‘a process of becoming’ that is both a personal and professional journey for the new graduate nurse. Duchscher’s (2008) theory demonstrates that during the first 12 months of professional practice, new graduates will evolve through a continuum of three stages; doing, being and knowing. Encompassed in this journey are ordered processes of anticipating, learning, performing, concealing, adjusting, questioning, revealing, separating, rediscovering, exploring and engaging. According to this author, the stages are not linear, prescriptive or progressive, they are ultimately transformative and might be influenced by critical events such as practice situations or contexts and new events that may cause transient regressions along the continuum (Duchscher 2008).
Methods The purpose of this study was to investigate new graduate nurses’ transition into rural nursing practice within a Transition to Practice Program. The following research questions were formulated to assist in exploring the support required for graduate nurses and to identify issues related specifically to the provision of support within the rural practice context.
950
1 What are the new graduate nurses’ perceptions and experiences of support throughout a rural Transition to Practice Program? 2 What are the functional elements of a rural Transition to Practice Program? In this study a Transition to Practice Program is defined as structured support and assistance provided for graduate nurses in the transition from student to registered nurse throughout the first year of professional nursing practice. In exploring the phenomenon of support for new graduate nurses within a Transition to Practice Program, this study specifically aimed to investigate and describe the nature and timing of support required during the transition to rural nursing practice that is specific for the rural context and capacity. This study used the Stages of Transition Theory (Duchscher 2008) to determine the provision of support during the transition process from student nurse to registered practising nurse within rural practice settings. Utilising a qualitative case study approach, 15 new graduate nurses employed in Transition to Practice Programs within rural health services of northern New South Wales, Australia, participated in individual, semi-structured face to face and telephone interviews at time intervals of three to four months, six to seven months and 10–11 months, a timeframe consistent with Duchscher’s (2008) Stages of Transition Theory. This study was conducted in 14 rural towns of northern New South Wales and is therefore not representative of the new graduate nurse population in all rural areas of this State. However, the researcher was not interested in making statistical inferences or generalising the findings to the wider population. Rather, the purpose was to obtain rich and insightful data that would shed light on the barriers as well as the positive factors that impacted on the experiences of a sample of graduate nurses who made the role transition in rural practice settings. Thus this study also sought the views of experienced rural nurses who were employed in rural health agencies where the new graduate nurses were employed and the findings from these data are the subject of a second publication. Conducted in health services in rural towns of northern New South Wales (NSW), which, at the commencement of the study, had new graduate nurse positions available within a graduate nurse Transition to Practice Program, rural towns included in this study had a population base classified to be outer regional according to the Australian Government Department of Health and Ageing (2010) and/ or those whose population base is classified as rural, according to The Australian Bureau of Statistics, Australian Standard Geographical Classification Remoteness Areas Classification (ABS 2001, accessed 22nd April 2010) within © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 948–960
Original article
New graduate nurses entering rural nursing practice
one Area Health Service of Northern New South Wales, Australia. A total of 14 large rural and small rural health services met the criteria and intended to employ new graduate nurses on a 12-month graduate nurse Transition to Practice Program in 2011. Each program was independent of larger regional or metropolitan Transition to Practice Programs. Five of the large rural health services are located within large rural towns and provided similar medical and nursing services. According to the Australian Government Department of Health and Ageing (2010, p. 49) these large rural health services are located in outer regional areas and as such would be classified according to the number of admissions per year as ‘medium acute hospitals in regional areas’. At the time of this study, the staff ratios, skill mixes, and graduate nurse programs within these health services were very similar. These five large rural sites have between 2–6 new graduate positions each year. The remaining nine health services included in this study are located in outer regional areas. Five of these nine health services, according to the Australian Department of Health and Ageing (2010, p. 48), would be classified as ‘small regional acute hospitals (mainly small country town hospitals)’ because of their admissions per year and treating fewer than 2000 patients per year. Four of the nine health services were classified as Multipurpose Services or according to the Australian Government Department of Health and Ageing (2010, p. 48) ‘small non-acute hospitals’ with ‘patient throughput of
