Introduction and historical context: fire and light
In 1860, the first Nightingale training school opened at St Thomas Hospital, London and enrolled
the initial cohort of student nurses. Student selection was based on their social status and
character. Uniforms reflected the dress of Victorian servants and required them to live in a nurses
home as a necessity of their contract (Nicholson 2000). Their accommodation was carefully
managed to replicate that of their status within the hierarchical structure. To minimise social
contact and regulate their private lives, students were subject to strict curfews and close
supervision by the nurses’ home sister or matron. Visitors were also discouraged (Nicholson 2000).
To further reduce the necessity for exposure to the outside world, the nurses’ home had a lecture
theatre for educational purposes. Such socialisation also reinforced their obligation to submit to the
authority of doctors and senior nurses. The apparent success of this strategy resulted in the
concept of nurses’ homes being adopted more broadly within the United Kingdom and Australia. In
the local context, the first nurses’ home in South Australia was constructed at the Royal Adelaide
Hospital in 1882, and subsequently, others arose throughout the state. Such conditions for student
nurses continued to flourish until the late 1960s (Nicholson 2000).
History and my beginning nursing career coalesced on 10 January 1972, when I enrolled in a
hospital-based apprenticeship training program in the mid-north of South Australia. Surprisingly, I
learnt that very little had changed throughout nursing education in Australia since the 1860s.
Female nursing students were still selected on the basis of their social status, and were required to
live in a strictly supervised nurses’ home environment (Nicholson 2000). As a male, I was an outlier and
permitted to reside in the community. In such a nursing education program, students were apprentices
who undertook short blocks (4-6 weeks) of study distributed over a three year period. For the remainder
of the time, student nurses were low-paid employees servicing the 24 hour needs of the hospital. This
period of indentured servitude culminated in being privileged to sit a qualifying registration examination
prepared by the Nurses Board of South Australia. Remuneration was far below the basic wage and
student supervision was minimal, with only one registered nurse to vicariously oversee student nurses
taking care of 18 to 20 patients. Care provision was dominated by the scientific management theory of
Frederick Taylor (Spender & Kijne 1996, p.
139). Student nurses provided the majority of hands-on care and often supervised each other. As a
consequence of their inexperience, there was highly prescriptive task assignment and little discretionary
judgement permitted. Students were not to ask questions about any aspect of care, but to follow orders
as per the military. The nurse was definitely not permitted to show any critical thought, but to follow the
directions of those in authority, thereby depersonalising and marginalising their patients (Lagerwey
2010). Doctors were still considered to be gods, and matrons remained monastic. This experience was
daunting for student nurses, including myself at the age of 16-17 years, not considered old enough to
live independently outside of a nurses’ home, but considered mature enough to be nurses. For
example, I recollect providing the hygiene needs for a stroke patient without any prior education of how
to provide appropriate care. The person was dependent, disabled, and incontinent of bowels and
bladder. He also exhibited paradoxical emotions. To the inexperienced novice, it was a confounding
and traumatic experience.
While the apprenticeship model required many hours of hands-on care (learning on the job as an
employee), there was still an appreciable gap between the day-to-day practice of student nurses
and that of the qualified registered nurse. As a consequence, my initial interest in transition to
practice stemmed originally from graduation as a nurse from the ‘apprenticeship’ model in 1975. I
distinctly remember remarking to a fellow student, “we have been perfectly prepared to be a
student, but not a registered nurse”. On reflection, this insight was an epiphany. I began to search
for answers to questions such as “Was this experience unique to myself, or was it a phenomenon
familiar to new nursing graduates as a whole?” At the time, I was unaware that Kramer (1974) had
also identified the “chasm” between nurse education and the reality of practice. Simultaneously,
the early 1970s found the education of nurses within the tertiary education sector to be an
emerging force in Australia. Initially, there was limited community and government support for
nurses to be educated in universities or advanced education; however, with fire and light, the
movement continued and gradually expanded to acceptance throughout Australia.
Preparing nurses through a system in which they had full student status was deemed to have
educational advantages not possible in the traditional ‘apprenticeship’ system. For example,
students from early on in their education [Tertiary approach] may be involved in the total care of
patients carefully selected so that their needs are able to be met at that level of experience,
rather than [Hospital apprenticeship approach] meeting only certain needs for a large
number of patients and thus becoming task rather than person-focused (Pickhaver et al.
1985, p. 1).
Nurse Education and transition to practice: radical transformation
In 1978, I was personally appointed to the role of nurse educator, and later in 1981, I undertook the
role of Principal Nurse Educator at the Lower Northern School of Nursing (LNSN - Port Pirie). 1984
was an exciting year as in late August, I received a telegram from the Australian Nursing
Federation confirming that all registered nurse education was going to be transferred nationally to
the tertiary education sector by 1993 (Francis 1999, p. 87). I now had an enhanced impetus to
explore transition theory and the critical interface between education and the reality of practice. My
first task involved the development of a theoretical framework around the transition needs of
nurses in the rural community.
The proposed transfer of nurse education to the tertiary sector became imminent in 1988, and the
foreseeable implications of closing the local school of nursing encouraged me to transfer to the
Modbury Hospital School of Nursing. Within the first few months of my new tenure, reports of
university graduates struggling without a supported transition were being voiced throughout the
nursing profession. It was at this juncture when my past informal research and curriculum
development experience proved invaluable, for later that year, I assumed the newly created role of
Staff Development Consultant (Graduate Nurse Programs).
Soon after my appointment, a forum was convened with the title ‘Delights and Dilemmas’ where
nurse graduates and nursing staff from Modbury and Lyell McEwin Hospitals gave personal
accounts of their metropolitan transition experience. The dialogue was recorded for analysis,
and the results provided further confidence in the Pickhaver, Young and Goldsworthy (1985)
study, ‘They seem different somehow’. It soon became apparent that a positive organisational
culture was fundamental to the successful transition of the newly graduated registered nurse
(Mooney 2007). Accordingly, I developed a conceptual model known as ‘the circle of
willingness’. The ‘circle of willingness’ is a cultural expectation of the organisational climate
(Mellor 2009). It makes a request of all persons/sectors that interface with graduate nurses to
welcome them to the organisation and contribute to their success. For example, the nurse
manager must be willing to schedule preceptors to work with the novice together on the same
shift (Figueroa, Bulos & Judkins-Cohn 2013). In a successful preceptorship relationship, there is
a willing and shared responsibility for patient outcomes. In an unwilling environment, this
scheduling and positive support does not occur. Overwhelmingly, it was identified that there
were deficiencies in the organisational climate experienced by graduate nurses. Where
“willingness” is absent with regard to staff support and prioritisation of resources, the outcomes
for the graduate nurse is diminished (Kirkpatrick & Kirkpatrick 2006).
As a result of a positive evaluation of the Modbury Hospital Graduate Nurse Program, I was invited to
present at a Nurses Board of South Australia (NBSA) open forum entitled, ‘The future of the novice
graduate nurse in South Australia’. The presentation, based on “the circle of willingness” (Mellor 2009),
was viewed very favourably and, as a result and on behalf of the NBSA, I invited all sections of the
professional nursing community as a cooperative to develop a position statement on transition to
professional practice programs, focusing on their structure and content. Two new committees of the
Board were created and I was invited to be chairperson for both of them. The first committee was the
Graduate Nurse Program Working Party (Cross Section), comprising representatives from all sections
of the nursing community, including the university sector. The second committee was the Graduate
Nurse Program (GNP) Coordinators Working Party. The first draft statement on the ‘Elements of a
Graduate Nurse Transition Program’ and the ‘Position Statement on Preceptorship’ (Circular No:
26/93) were sent for comment to Directors of Nursing, educators, health units, and universities in 1993
by the NMBA CEO/Registrar (Ms. Elizabeth Percival). In the intervening period (1994-1995), further
drafts were modified and developed for the profession. In response to the perceived needs, funding of
$11,000 per graduate nurse was provided (South Australian Health Commission 1995) to assist with
transition to professional practice in 1995. Disappointingly, the zest for support of graduate nurses has
waned significantly since then, and the dollar amount of $11,000 per graduate, which is woefully
inadequate, remains unchanged after 26 years (South Australian Department for Health and Wellbeing
2019, p. 7).
Transposition of thought and new research question: the radiance
of wisdom
In 2001, I returned to rural nursing, and in 2003, assumed the role of student
coordinator/facilitator for local SA universities, and for Johns Hopkins and Saskatchewan
Universities. I also had the opportunity to observe the nature of the support provided by the
local graduate nurse transition program. It was concerning that much of the promised clinical
support did not occur.
In 2006, I was appointed Casual Lecturer (Nursing) at the Flinders University Rural Clinical
School (FURCS), and concurrently enrolled in the Master of Clinical Education. Owing to my
prior concerns with transition programs, I completed a formal research thesis focused on the
nature of professional support given to graduate nurses in rural areas (Mellor 2009; Mellor &
Greenhill
2014). Focus groups were undertaken in three locations of rural South Australia.
Overwhelmingly, the responses from the focus groups indicated that the transition program was
not conceived to be an integral part of everyday clinical practice. It was experienced by
graduate nurses as a separate entity (an external program with study days) to the clinical
environment (Mellor 2009).
Preceptorship was rudimentary and, in many instances, did not occur. Graduate nurses stated
that they received clinical support only if they were assertive and initiated the process. Self-
support proved to be the beginnings of an evolving theme.
In 2008, I had the additional role of transition coordinator for the regional health service;
however, my attempts to mobilise the required supports for graduate nurses were not very
fruitful. I wrote a new curriculum and attempted to reduce the abandonment, but with limited
success. I clearly remember one stand-off where a graduate nurse (with 2-3 months
experience since graduating) was left in charge of the Accident & Emergency Department on
an afternoon shift. The Director of Nursing was not willing to make any concessions; however,
she stated that the graduate nurse could contact her at home if needed. It was apparent that
employment of graduate nurses and the financial benefits of exploiting them with fixed
contracts was the primary focus. History was repeating itself. It was disturbingly apparent that
the organisational willingness to clinically support the graduate nurse was of a low priority. A
utilitarian approach was again clearly evident.
In early 2013, I consulted with Professor Jennene Greenhill (Associate Dean and Director of Flinders
University Rural Clinical School) and duly made an appointment with SA Health, naively proposing
that an observational study along the lines of ‘Are graduate nurses safe?’ be undertaken to quantify
the risk that unsupervised graduate nurses posed to patient safety. A mixed approach was to be
proposed comprising a root cause analysis of patient safety incidents involving graduate nurses,
triangulation of reported data with the Australian Health Practitioners Registering Authority, and
interviews with graduate nurses. A meeting was arranged with Debra Pratt (Principal Nursing and
Midwifery Adviser, SA Health) for Tuesday 16 April 2013 to discuss the possibility of setting up a
plan, framework, and the appropriate ethical considerations. As might be expected, we were
nformed that this research was not going to happen. I was advised that SA Health firmly
believed the responsibility for ensuring graduate nurses attain a safe level of competence rested
entirely with the university sector. The prevailing mindset was that graduate nurses are
registered and therefore competent, and do not need support of any kind. Supporting and
nurturing graduate nurses was not perceived to be a health sector responsibility, and we left the
meeting feeling quite uncomfortable about the SA Health commitment to graduate nurses. This
perspective lead me to the conclusion that efforts to persuade organisations to willingly provide
an appropriate environment for graduate nurses was a fraught expectation. It was clearly
evident that willingness to clinically support the graduate nurse within local health organisations
and at the highest levels of government was a low priority (Masso et al. 2019). This prompted a
response which embraced the challenge, and created an impetus for pursuing new and different
understandings.
In order to cater to this new understanding, I undertook a critical review of transition programs
worldwide (Mellor, Gregoric, Atkinson & Greenhill 2017), seeking a problem-based solution;
however, the study only served to reinforce the SA Health perspective. Overall, a lack of
development and resourcing of transition programs was revealed. For example, the reporting
and evaluation of transition programs was rudimentary, and it was difficult to see any progress
being made, or likely to be made, in the near future. In addition, most of the manuscripts
reviewed were self-reported and little innovation was apparent. Elements such as preceptorship
had not been fully tested for their sustainability. While it is possible to have successful instances
of preceptorship, sustainability is problematic for a number of reasons, including burnout, the
need for adequate preparation for the role, ongoing education, and willingness to fulfill the role.
These findings converge with my overall experience, and articulate the need to embrace and
explore a transposition of thought, an alternative ideation, one which has the objective of
preparing nursing students for the reality of transition to professional practice. This alternative
ideation emanating from my prior research was subsequently explored as a new paradigm, and
the research question ‘How do nursing students successfully transition to graduate nurse?’
evolved. This question resulted in three publications, Mellor and Gregoric (2016); Mellor,
Gregoric and Gillham (2017); and Mellor and Gregoric (2019). For a full version of the
manuscripts presented, please refer to Chapter 4.
