Employment of New Graduate Registered Nurses into Rural Primary Health Care

Written by Brooke Stevenson

  Introduction

Sustainability of the primary health care workforce in New Zealand is under threat; ageing employees with an unidentifiable group of younger replacements will cause rural nursing shortage in the near future (Gordon et al., 2014). The PECOT model established by Jackson (2010) was used to develop this practice issue to the research question: ‘is it feasible to employ new graduate registered nurses into rural primary health care?’ Rural nursing is a unique specialty area of nursing practice and the literature covers a wide variety of registered nurse experience in this clinical setting. This review will focus on new graduate registered nurses and discuss evidence of new graduate experiences of transition to practice in rural primary health care. Patient safety, isolation, lack of readiness for the role, and professional boundaries and confidentiality are the main implications for nursing practice. Main themes emerged repeatedly from the literature which includes support of the new graduate, increased responsibility, expectations of the graduate and workplace, confidence, competence and scope of practice. Although the literature represents these themes in a variety of contexts, this paper will primarily focus on their application to new graduate registered nurses in the rural context of practice. This literature review identified recommendations in support, ongoing education in professional development, postgraduate study and the need for a rural primary health care New Zealand nurse entry to practice program.

  Clinical Issue

The long-standing shortage of health professionals wanting to work in rural areas is current, global and very relevant in New Zealand (Ministry of Health [MOH], 2014b, 2015; Molinari & Bushy, 2012; Gordon et al., 2014; Molinari, Jaiswal, &Hollinger-Forrest, 2011; Romyn et al., 2009; Gum, 2007). The MOH have identified the rural Primary Health Care (PHC) workforce as largely composed of mature age nurses, this is an issue due to an unidentifiable cohort of younger replacements for this specialty area of nursing practice (Gordon et al., 2014; MOH, 2002, 2014a). Traditionally, rural was the residual area not included in the urban definition; Statistics New Zealand (n.d.) classify rural areas according to the degree of urban influence on the community, measured by population density, geographic location and dependence on urban areas for employment (Bushy, 2012; Statistics New Zealand, n.d.).

Rural nursing is widely recognised as an advanced area of practice characterised by autonomy, interprofessional collaboration, scarce resources, complex management of personal and professional relationships, and accountability. Rural nurses require a wide range of knowledge and ability, are committed to practice, and are efficient in prevention, management, emergency and working with expansive age range and acuity levels in various clinical areas (Gordon et al., 2014; Mellor & Greenhill, 2014; Molinari & Bushy, 2012; Molinari et al., 2011; Scharff, 2006). My rationale for pursuing this practice issue is that I have a desire to work in rural health and am interested to research how attainable and appropriate this is for a New Graduate Registered Nurse (NGRN) with no previous nursing experience in the rural setting.

Current undergraduate nursing degrees educate the student as a beginning practitioner with a general set of skills and knowledge in preparation for ongoing study in a chosen are of practice. Employers expect NGRN’s to be ready to work in any clinical setting even though “new graduate nurses should be strengthening and consolidating their knowledge and clinical skills…and gaining confidence through the increased application of what has been learnt as an undergraduate” (MOH, 1998, p.52). The MOH (2002) acknowledge the diverse set of advanced skills a rural nurse must acquire to meet the needs of the community due to distance from immediate clinical and emergency support; “being rural means being a long way from anywhere and pretty close to nowhere” (Scharff, 2006, p.181). Nurses practicing in a rural setting must contend with the isolation from friends, family, colleagues, and continuing professional education that comes with their practice (Ross, 1996).

  PECOT Model

The practice issue of a rural nurse shortage has been identified as problematic due to an unidentifiable cohort of younger replacements. Jackson (2010) developed the PECOT model, an acronym used to refine research ideas to a searchable question. The PECOT model will be used to develop a specific research question related to the practice issue as shown in the following table.

PECOT Model Category

Information relating   to question

Rationale relating   to practice issue

P - population

New Graduate   Registered Nurses (NGRNs).

NGRNs are candidates   for transition to professional practice programs.

E – exposure or   environment

Rural Primary Health   Care.

The scope of   practice of rural nurses and the influences of working in a small population   with geographical isolation.

C- comparison

Reality and   expectations of NGRN performance in rural health.

NGRN exposure to   rural nursing in undergraduate degree related to expectations and reality of   NGRN rural practice.

O - outcome

NGRN supported in   rural employment.

The provision of   support is readily available for the NGRN in rural practice with the   opportunity for ongoing professional education relevant and attainable. A   NGRN program supporting the transition to practice period in rural primary   health care available in New Zealand.

T -time

NGRN from time of   nursing registration to first job as a professional registered nurse.

Inclusion of first   new graduate year and those already involved in transition to professional   practice programs for literature search.

 Through application of the PECOT model, the broad research idea was developed into the research question: ‘is it feasible to employ new graduate registered nurses into rural primary health care?’ The literature search included key words such as new graduate registered nurse, rural, remote, primary health care, workforce, transition, rural nurse, and scope of practice.

  Evidence-based discussion with implications for practice

According to the MOH (2014a), 8.84% of NGRN’s chose PHC as their first choice of employment area in the New Zealand Nurse Entry to Practice (NETP) program; this amounts to 109 out of a total 3696 NGRN candidates wanting to work in PHC compared with 11.46% of the current Registered Nurse (RN) workforce employed in this clinical setting. The aim of the NETP program is to support NGRN’s in the first year of transition to practice from student nurse to competent RN (Nursing Council of New Zealand [NCNZ], n.d.). NGRN’s supported through NETP programs with the opportunity for continued professional education in rural nursing are the potential replacements of the ageing rural PHC workforce (MOH, 2014a). Traditionally, the focus of health care has been on retaining the existing workforce and supporting transition of experienced acute care hospital nurses into PHC (Gordon et al., 2014; MOH, 2002). Gordon et al. (2014) discuss the benefit of transition to PHC programs for NGRN’s as a sustainable workforce strategy; it is agreed that the ageing workforce is contributing to future rural nursing shortage (MOH, 2002, 2014a). Gordon et al. (2014) suggest the PHC workforce will be stable in the long-term if retention of the existing workforce is focused on simultaneously with training a cohort of NGRN’s specialised in PHC through professional development and postgraduate study. Gum (2007) argues that nursing practice beginning and remaining in rural settings could affect the NGRN career path.

The NGRN beginning a career in rural PHC requires ongoing support as the experience gained in an undergraduate degree is not sufficient for preparing the nurse in independent, unsupervised practice (MOH, 1998; Ostini & Bonner, 2012). New Zealand undergraduate nursing degrees provide the opportunity for the majority of students to experience clinical placement in rural hospitals or communities, enabling students to have a beginning understanding of rural context to facilitate in rural nurse transition to practice (Ross, 2012). The transition period from student nurse to RN is recognised as an important and challenging time yet successful, within a supportive environment (Ostini & Bonner, 2012; Romyn et al., 2009).

Bennett, Barlow, Brown, and Jones (2012) believe high expectations, lack of support and heavy workloads are the main issues of the NGRN practicing in rural areas; “new graduate registered nurses have clear needs that are not being met as they transition from student to practitioner” (Bennett et al., 2012, p.488). Haggerty, McEldowney, Wilson, and Holloway (2009) support this notion as they found staff shortage, pressure to consolidate skills and knowledge, lack of support, and poor relationships between the NGRN and preceptor contributable to decreased confidence in clinical skills, decision-making and judgement. For successful transition to practice the new nurse needs a safe, trusting and positive work environment with available experienced staff willing to help in improving critical thinking, socialisation, stress management and problem-solving skills; NGRN’s require resources, support, clear expectations and constructive feedback (Haggerty et al., 2009).

The NGRN is expected to assume greater responsibility early in the transition period (Mellor & Greenhill, 2014; Bennett et al., 2012; MOH, 1998). Romyn et al. (2009) claim NGRN’s in rural settings are unprepared for the professional workforce as they are unable to ‘hit the ground running’. It is argued that graduate readiness has always been an issue regardless of whether it is the work environment they are unprepared for or actual readiness of the graduate for professional practice (Mellor & Greenhill, 2014; Molinari et al., 2011). Romyn et al. (2009) believe NGRN’s are incompetent in delivery of safe, unsupervised nursing practice at the beginning of the transition year; it is irrational to expect a NGRN to function as an experienced RN without time to develop confidence in applying the knowledge and skills learnt in the undergraduate nursing course. The expected level of proficiency of the NGRN is too high to be realistic in rural areas (Ostini & Bonner, 2012; Romyn et al., 2009; MOH, 1998).

High expectations with lack of support in a professional, geographical and socially isolated environment increase pressure on the NGRN, the level of responsibility and accountability with limited available staff impacts negatively on patient safety (Bennett et al., 2012; Ostini & Bonner, 2012). Undergraduate student nurses interested in rural practice should be encouraged to experience plentiful opportunities in rural placements (MOH, 2002, 2015). Increasing exposure to rural practice in undergraduate nursing degrees provide exposure to heavy workload, staff shortage and increased responsibility and will facilitate in preparing student nurses for the role of professional RN (Molinari et al., 2011; Romyn et al., 2009).

“New graduates in rural areas are not only under prepared to undertake the RN role but also have the added complication of requiring extensive knowledge and skills due to the requirements of rural clinical practice” (Ostini & Bonner, 2012, p.244). This can cause serious negative implications on practice when rural nursing involves unpredictable clinical presentations difficult for the NGRN to cope with; adaptability, leadership, autonomous practice and situational awareness are developed as the nurse gains experience in the clinical setting (Mellor & Greenhill, 2014). Adverse outcomes are more likely to occur with a vulnerable NGRN unable to anticipate possible complications. The need to develop skills in unpredictable environments was identified as an area for consideration as well as supervision as crucial for effective rural health care and patient safety (Mellor & Greenhill, 2014; Molinari & Bushy, 2012).

NGRN’s must be given the opportunity for guidance and supervision with more experienced nurses so they are able to work within their scope of practice consistent with their level of education and experience (Mellor & Greenhill, 2014; Molinari & Bushy, 2012). Romyn et al. (2009) found inexperience of NGRN’s to be a burden on more experienced nurses if they are needed to repeatedly complete tasks due to NGRN lack of confidence in applying skills. Trial and error is practiced when there is limited supervision available which can be damaging to the rural community as they will seek healthcare elsewhere if they are not satisfied with their local provider. This can have negative consequences on rural health and of the NGRN confidence to question their limitations in practice (Mellor & Greenhill, 2014; Molinari & Bushy, 2012).

Bennett et al. (2012) report that NGRN’s are aware of their limitations as new practitioners and in turn expect a supportive environment from employers and other staff to enable them to become proficient and valuable employees working within their professional limitations in new graduate rural nursing context. Benner’s (1984) novice to expert model in nursing theory and practice is relevant to expectations of the NGRN. Benner (1984) applied the model of skill acquisition developed by Stuart Dreyfus to nursing as the “five levels of proficiency: novice, advanced beginner, competent, proficient, and expert” (p.13). The novice displays structured, inadaptable practice as they have limited experience of the rural context they are expected to perform in; the novice is task-oriented, governed by rule and focused on acquiring skills (Benner, 1984). New graduates should not be expected to operate above their level of expertise other than that consistent with knowledge and skills acquired through the undergraduate degree (Romyn et al., 2009; Benner, 1984).

Mellor and Greenhill (2014) found that NGRN’s were often asked to work beyond their scope of practice in rural settings. “Rural nurses’ work well beyond the limits of what is conventionally thought to be the scope of professional nursing practice”, the level of expertise and responsibility of the rural nurse differs from that of the urban nurse (Ross, 1999, p.254). It is well supported that challenges exist in the rural setting that are not encountered in the urban area (Bennett et al., 2012; Ostini & Bonner, 2012). The nurse gains an ‘insider’ knowledge of the rural population by personal acquaintance; the implications of managing personal and professional boundaries that present with living and working in the same small community as clients impact the NGRN as they are challenged to become accepted and trusted as a health professional while it also impacts on client confidentiality and privacy (Ross, 2012; Howie, 2008; Scharff, 2006; MOH, 2002).

  Recommendations

Postgraduate study clarifies the level of responsibility, scope of practice and boundaries of the rural RN (Ostini & Bonner, 2012; Connor, Nelson, & Maisey, 2009; Ross, 1999). Postgraduate education is vital for the diversity of skills required for rural nurses; advanced clinical training is essential for high quality and safe nursing care for the rural population, supported by research evidence-based practice as it increases confidence and consolidates the expansion of clinical skills (Bennett et al., 2012; Connor et al., 2009; Haggerty et al., 2009; Gum, 2007). Ross (1996) believes the advanced role of rural nursing may have evolved over time as a necessity to meet the needs of the rural community, nursing potential is increasingly recognised as a diverse, adaptable, highly skilled and knowledgeable profession (Ross, 1999). Bennett et al. (2012) recognise postgraduate education as important for provision of quality and safe health care; postgraduate education specialising in rural nursing is highly recommended as it allows expansion of scope of practice and advancement of skills needed for complex nursing roles (Ross, 1999; MOH, 1998).

New Zealand District Health Boards require rural nursing staff to have several years of nursing experience prior to employment with training in primary response in medical emergencies; retention of general practitioners is an ongoing issue in New Zealand therefore up-skilling of rural nursing staff is crucial for rural population health (Haydon-Clarke, McKinlay, & Moriarty, 2011; Connor et al., 2009). Rural nursing practice requires advanced training as a necessity, Molinari et al. (2011) believe professional development through ongoing education relevant to the practice setting assists in attracting, preparing, and allowing the NGRN to progress in the rural nurse role. Attraction of younger nurses to rural PHC with specific rural training prior or soon after entry to rural practice is frequently recommended (Haydon-Clarke et al., 2011; MOH, 2002). Bennett et al. (2012) identify the need to develop a specifically planned course involving postgraduate study for rural health care professionals in transition to practice.

Haggerty et al. (2009) propose more research is needed around the impact of offering postgraduate education during the NETP program, the pressure of extra study above program requirements and expectations of working as a NGRN could be a burden due to accommodation of so many responsibilities such as “demands of the program, getting used to shift work and patient loads, and the postgraduate paper could blow them out of the water” (Haggerty et al., 2009, p.42). Transition to practice programs provide the opportunity to gain specialty skills; developing a tailored program specific to PHC would be beneficial by increasing employment opportunities and contribute to combat future rural nurse shortage by securing a skilled younger workforce (Gordon et al., 2014; Gum, 2007). Gordon et al. (2014) recognise NETP programs are traditionally designed for implementation in acute care hospital settings however suggest District Health Boards as ideal suitors to implement and coordinate a NETP program in PHC. Tieman (2012) presents a case for a rural facility NETP program identifying additional considerations of rural areas.

Molinari (2012) identifies a critical need to research rural nurse transition to practice programs. “The topic of developing rural transition to practice programs is widely discussed at this time” (Molinari, 2012, p.30). Overseas research indicates the development of rural training as a beneficial strategy in addressing the rural nurse shortage (MOH, 2014b). New Zealand has to compete with other countries which have established programs and more desirable incomes attracting NGRN’s into rural PHC (MOH, 2002, 2015). Australia has established transition to practice programs specific to the rural setting (Ostini & Bonner, 2012). Bennett et al. (2012) discuss Australian initiatives for support of new nurses; the Ocean to Outback Program offers rural nursing rotations in four remote hospitals within Western Australia for second year RNs as delivered by the Western Australian Country Health Service. Community-based placements including rural hospitals and postgraduate nursing courses are included in some New Zealand NETP programs (NCNZ, n.d.). An early publication of the MOH (1998) note that NGRN’s do not require experience in the acute hospital setting before entering community-based practice and that changes in health care focus should influence the development of NETP programs.

  Summary

In conclusion, ensuring a sustainable rural primary health care workforce and delivery of safe and effective nursing care by employing NGRN’s is feasible provided they are aware of their scope of practice and well supported in a positive work environment. Supporting NGRN’s into the professional role enhances critical thinking and clinical skills contributing to more confidence and higher job satisfaction, improving retention in the workplace for a long-term sustainable rural PHC workforce. Rural nurses have challenges and responsibilities unique to the clinical setting; limited access to health services, other health professionals, support and isolation are consistent problems in rural communities. Rural nurses are required to have advanced generalist skills and the ability to adapt in unpredictable situations to meet the needs of the client. Developing a specific nurse entry to practice program for rural primary health care in New Zealand requires more research, development and implementation of this program can be guided by review of established overseas transition to practice programs. International literature suggests new graduate transition to practice programs are successful if they include clinical and non-clinical support with realistic expectations of the NGRN ability in undertaking the role as a beginning practitioner. Increasing exposure to rural nursing in undergraduate nursing degrees and encouraging postgraduate study would benefit health of the rural population due to advanced health practitioners in a sustainable rural primary health care workforce.

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