A patient safety focused registered nurse transition to practice
program
Publication 1 emerged from my first study. It highlighted the inconsistent support for graduate
nurses, the deficits identified, and the safety implications. Emerging is the beginning concept of
the graduate nurse need to self-initiate and facilitate their own transition. My contribution to
publication 1 as corresponding author is detailed below. (An authorship declaration is provided in
Appendix 5).
Citation
Mellor, P. & Greenhill, J. (2014). A patient safety focused registered nurse transition to
professional practice program. Contemporary Nurse, 47(1-2), 51-60. [10.5172/conu.2013.3614]
Journal Impact factor: 1.3 Citations: 50 (See Appendix 4 for details)
Authorship statement and publication background
My first publication represents the not uncommon scenario that exists in which graduates are
offered a transition program of support by an organisation. The graduate nurse accepts this offer of
support, but soon becomes aware that a huge chasm exists between support (educational) and
support (clinical). The results of study 1 (Mellor 2009), ‘The nature of professional support given to
new graduate registered nurses in rural areas’, demonstrated that the nature of clinical support for
graduate nurses was marginal. There were serious implications for patient safety and I was keen to
have the results published. I therefore approached Professor Jennene Greenhill who was happy to
assist as adviser, contributor, and co-author. The uniqueness of the approach was to frame the
results, implications, and recommendations in the context of patient safety. It was felt that framing
the results in this context would provide leverage with regard to improving the clinical support
provided to graduate nurses.
Table 1. Three core elements of a transition program (Mellor & Greenhill 2014)
Safety concerns of Three core elements of a safe Proposed graduate nurse
graduate nurses graduate program support outcomes
Underprepared for practice Clinical supervision Oversight of practice
Overwhelmed and Leadership support Allocation of resources to facilitate
abandoned clinical supervision and inter-
professional support, e.g.,
Preceptors mirror, and rostered to
work with, the graduate nurse
Need for clinical Inter-professional support Preceptor and inter-professional
supervision networks relationships cater to the graduate
nurse
Research design: The research design had an overarching grounded theory method (i.e.,
Glaser 52
1967; Glaser 1992) decided in consultation with Professor Jennene Greenhill. We traveled to
conduct three focus groups throughout the rural areas of South Australia. Our aim was to elicit the
nature of support given to graduate nurses in rural areas. Comprehensive detail of the research
design has been provided in Chapter 1.
Data collection and analysis: After some consideration, it was proposed that a solution-focused
approach be adopted to the safety concerns identified. I revisited the data and developed a patient
safety narrative around three major categories from my research, –‘under-prepared for practice’,
‘overwhelmed and abandoned’, and ‘need for clinical supervision’. In response to the three
categories and through further discussion with Jennene Greenhill, three core elements for an
effective (i.e., safe) transition to practice program were developed.
Writing and editing: I wrote the first manuscript draft for publication with the title, “A patient safety
focused transition to professional practice program”. In addition to the dialogue, I also designed all the
figures (1, 2, & 3). I also approached the “Contemporary Nurse” who accepted my publication with the
provision that I continue dialogue with the publisher and make the following adjustments:
• rewrite and update of the literature review
• adjustment to grammar and layout
• a greater emphasis on the international context/audience
• revisions of the discussion, methods, and ethics sections
As corresponding author, I was responsible for completion of the revision of each draft and making
adjustments to the manuscript in response to the reviewers. At all stages of preparing this
manuscript, I consulted and received helpful contributions and agreement from first co-author
Professor Jennene Greenhill. A complete version of this publication is included on the following
pages.
A patient safety focused registered nurse transition to practice program
Abstract
New graduate registered nurses (NGRNs) have an expectation of clinical support as they make
the transition from novice to advanced beginner. In this 2008-2009 study of three rural transition to
practice programs we found that clinical support did not eventuate. Consequently, NGRN’s
reported feeling underprepared for practice, overwhelmed by responsibility and often abandoned.
Against this background, many were concerned that their inexperience had implications for safe
patient care. Graduate nurse transition programs need to have the physical and human resources
necessary to deliver the clinical support as promised in their prospectus, to ensure patient safety.
This grounded theory study identified three essential core elements - leadership support, clinical
supervision, and effective inter-professional relationships. Recommendation is made to address
these deficits by mandating their inclusion in all transition to professional practice programs.
Key words: graduate nurse, transition, transition to practice, registered nurse,
professional support, preceptorship, failure-to-rescue, patient safety, scope of practice.
Introduction and Background
Formal transition to practice programs for new graduate registered nurses (NGRN’s) have been
provided for more than 70 years internationally in both metropolitan and rural areas (Spector &
Echternacht, 2010a). The effectiveness of these programs is now being questioned and
research is being undertaken regarding the nature of support actually provided.
Defining transition to practice as a period of adjustment
The focus of transition to professional practice programs in the past has been to assist the NGRN
through a period of adjustment while they become a productive member of the health care team.
Transition to professional practice refers to the process of becoming a professional. It is a
period of adjustment where the new graduate is required to bring together their theoretical
and professional knowledge. (Department of Human Services – Nursing, 2004, p. 6)
While this is an Australian perspective, the focus on transition as a “period of adjustment” during
which there is progression “from education to practice across all settings” is universal (Spector
& Echternacht, 2010a).
Transition to professional practice programs– the reality of support
In my own practice as a registered nurse I have noticed that the reality of the transition to practice
program for NGRN’s was often very stressful, with little clinical guidance provided and all too often
patients are put at risk. Concerns about patient safety provided the stimulus to undertake research into
the effectiveness of transition to practice programs for NGRN’s. Similar concerns are also evident in
United States studies which propose that a national standardized transition program be
54
implemented by regulation to ensure a focus on patient safety. Regulation is seen as
necessary because of the variable nature of support provided by existing transition to practice
programs (Spector & Echternacht, 2010a;Spector & Suling, 2007).
Research question and methodology
The research question ‘What is the nature of professional support given to new graduate
registered nurses in rural areas’, was undertaken as a substantive grounded theory study (Mellor,
2009) and is the source of data discussed. The underpinning belief was that a grounded theory
study would enable the nature of support to emerge from the data (Glaser, 1967,1992).
Literature Review
Transition from nursing student to registered nurse brings significant responsibility. The clinical
environment is unpredictable which is different to that of being a nursing student. As a
consequence, NGRN’s can experience high levels of stress as they attempt to provide safe
care (Mills, Birks, & Hegney, 2010; Wu, Fox, Stokes, & Adam, 2012). Studies also reveal that
new graduates, whether in rural or metropolitan settings, do not work with guidance and
supervision from experienced registered nurses (Duchscher, 2008; Etheridge, 2007). Within
transition to practice programs, Lea and Cruickshank (2005) discovered a significant difference
between the nature of support promised and the nature of support actually provided by northern
New South Wales rural health units.
The provision of a supportive environment with a focus on safe patient care is seldom stated as
a goal in transition to practice program curricula. This may influence the low priority given to
preceptorship within graduate programs (El Haddad, Moxham, & Broadbent, 2013).
In Australia, the National Competency Standards for the Registered Nurse were adopted by the
Nursing and Midwifery Board of Australia (NMBA, 2008a) and like other registering authorities
(NCSBN, 2007; Nursing & Midwifery Council, 2008; Nursing Council of Hong Kong, 2010) require
that nurses only be registered when considered safe. For example, the National competency
standards for the registered nurse (NMBA, 2008a, p.6) state that a registered nurse: “Provides
comprehensive, safe and effective evidence-based nursing care to achieve identified
individual/group health outcomes”. The Code of Professional Conduct for Nurses (NMBA, 2008b,
p. 2) states: “Nurses are personally accountable for the provision of safe and competent nursing
care. It is the responsibility of each nurse to maintain the competence necessary for current
practice” and “Nurses are aware that undertaking activities not within their scopes of practice may
compromise the safety of persons in their care.”
The assumption “they are registered so therefore they are safe” results in transition to practice
programs that are not fully functional (El Haddad, Moxham & Broadbent, 2013). Consequently there is
considerable variability in the level of clinical supervision of NGRN’s (Ethridge 2007;Lea &
55
Cruickschank, 2007;Levett-Jones & Fitzgerald, 2005; NCSBN, 2012).
In accordance with these leadership concerns, it is also well recognized that the scope of practice of
the registered nurse in the rural context is extended, variable and more complex than that of their
peers in urban areas (Francis & Mills, 2011; Mills, Birks, & Hegney, 2010; Ostini & Bonner, 2012).
There are unique skills required in rural practice such as having to manage serious high speed motor
vehicle accidents and farm injuries (Mills, et al., 2010). In addition, many rural hospitals do not have
resident medical staff and NGRN’s in rural areas are often asked to work beyond their scope of
practice (Lea & Cruickshank, 2007). Nursing duties of the NGRN often include undertaking a
management role or being required to triage and initiate treatment for patients with life-threatening
conditions in the emergency department, without support (Commonwealth Department of Education
Science and Training, 2002; Lea & Cruickshank, 2007).
Benner has consistently emphasized the need for new graduate registered nurses to work with
attending experienced staff (Benner, 2004; Benner, Tanner, & Chesla, 1996). Supportive inter-
professional relationships, consistent feedback and a preceptor working closely with NGRN’s in
the practice setting were identified as being essential (Boychuk Duchscher, 2009;Cubit & Ryan,
2010; NCSBN, 2012).
In fact, the most frequently reported reason for new graduates leaving their first position is
related to stress associated with acuity of clients, unacceptable patient/nurse ratios, and feeling
their patient care was unsafe (Hoffart, et al., 2011). New graduates are concerned about making
mistakes and identify patient safety as an issue that needs to be addressed (Clare & Vanloon,
2003). Further research and advocacy for NGRN’s is needed to design and deliver transition
programs based on evidence, leadership, supervision and support in the clinical environment
(Levett-Jones & Fitzgerald 2005; Morrow 2009).
Methods
Study Aim
To identify the nature of support provided within transition to practice programs to NGRN’s in
rural areas and identify the implications for rural health units, the community as consumers, the
nurse education sector and nurse registration authorities.
Setting
This 2008-2009 study was conducted in health services in three different regions of South Australia.
In Region 1 there were five NGRN’s originating from four rural hospitals, in Region 2 there were eight
NGRN’s originating from five rural hospitals and in Region 3, eight NGRN’s originating from five rural
hospitals. These 21 participants therefore represented 14 rural hospitals over a radius of 200 km
(125,000 km2). All hospitals offered acute inpatient services, had visiting
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specialists and provided outpatient and 24-hour emergency services. All of the hospitals
represented were from rural towns with medical services provided on an “on-call” basis. Acute
bed numbers ranged from 11 to 56 beds with a mode of 22 acute beds per hospital. The
remoteness of the hospitals within regions was consistent with few exceptions. For some
hospitals there was only one registered nurse on duty after hours, with staff “on-call” if needed.
Sample/Participants
Participants were NGRN’s, a purposive sample, located through consultation with the transition
to practice program coordinators in the three designated rural regions. All participants had
almost completed their 1-year transition to practice program. In order to maximize participation
and minimize disruption to the participants it was negotiated that focus groups would be held on
the final study day of each of the three transition to practice programs. All of the NGRN’s
consented to participate. In group 1 there were five participants, in group 2 there were eight
participants and in group 3, eight participants. The commitment of time was approximately 1
hour per focus group.
Study Tools
The focus group method was chosen as it is particularly suited to groups such as nursing and
has been used successfully to explore the experiences of NGRN’s (Newton & McKenna, 2007).
In this study the participants were NGRN’s from three different regions of rural South Australia.
There were two experienced facilitators for each focus group thus enabling recursive
enrichment of the data and writing of field notes (Kidd & Marshall, 2000).
Data Collection
Focus groups were conducted using recommended strategies to minimize possible facilitator
influence on the data collected (Fern, 2001; Taylor, Kermode, & Roberts, 2007). Preservation
of independent responses was critical to ensure validity of the data. As facilitators we also
ensured that each group member participated and that reluctant participants were
encouraged (Taylor, et al., 2007). The focus group questions were open ended and
encouraged dialogue.
Further credibility was provided by focus group members drawing upon authentic recent
experiences. Inaccuracies or exaggerations were moderated by the group to ensure
trustworthiness of the information provided. Each focus group was facilitated in a room free of
distraction; quiet, uninterrupted and away from the workplaces of all participants. The rooms
were comfortable, including the seating, lighting and temperature. All groups had refreshments
available. Focus group 1 was held in the lecture room of a community centre, focus group 2 was
held in the function room of a small convention centre, and focus group 3 was held in the lecture
room of a participating health service.
Data analysis
To ensure confirmability, the transcribed data from the focus groups was processed using
QSR Nvivo 7 software which enabled an audit trail. It also provided dependability as a vehicle
for grounded theory analysis. The facility for making memos made possible constant
comparative analysis and the transparent development of categories or concepts. The
concepts were linked to each of the coded texts and the QSR Nvivo 7 software enabled the
relationships to be made between variables to create a concept map. Themes also were
cross-checked with the co-facilitator to ensure dependability. Please see the example of
thematic analysis provided below.
Ethical considerations
Approval to conduct this research was sought from the Social and Behavioural Research Ethics
Committee of Flinders University, Adelaide, South Australia before any approach to participants
was made. Approval was obtained in accordance with the requirements of the National Statement
on Ethical Conduct in Human Research. Written approval was also sought from the Directors of
Nursing of regional health units and their individual ethics committees as required. Transition to
practice program coordinators were consulted for assistance with the practical aspects of
conducting the focus groups. Focus group participants were then provided with an introductory
letter providing authority from the university and ethics committee. They were also supplied with the
focus group questions and a confidentiality agreement to be signed. Participants were given
adequate time to consult with others, as appropriate, about their decision to be part of the study.
Confidentiality was important so that participants would provide the richness of data desired,
namely their true feelings, beliefs and points of view (White & Thomson, 1995). Participants
were advised that it was each person’s responsibility to maintain confidentiality; they could
withdraw from the focus group at any time, and decline to answer any questions. They were
also advised of the recording of the focus group and how the recording would be secured.
Pseudonyms were assigned to protect the identity of participants following transcription
(Newton & McKenna, 2007).
In focus groups, participants reveal information to other participants and not only to the
facilitator(s), which means there are not only privacy concerns but also stresses due to the
group dynamics of interaction. As such, facilitators discussed the need for confidentiality and
continuously monitored the stress level of each group. A debrief opportunity was provided at
the end of each session. The overall goal was avoidance of any harm, risk or wrong being
imposed on participants (Smith, 1995).
