From enrolled nurse to registered nurse in the rural setting: the graduate nurse experience

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Introduction

This article reports the findings of a hermeneutic phenomenological study into enrolled nurse (EN) to registered nurse (RN) transition in two South Australian rural settings. As state and federal governments seek improvement in the recruitment and retention of nurses and other health professionals in rural areas, this study is timely¹. A higher proportion of ENs than RNs currently work in rural settings resulting in a specific, willing rural nursing workforce^2-4. Hegney et al.⁴ confirmed that ENs are attracted to rural work because of the advanced scope of practice expected in comparison with metropolitan contexts. This increased responsibility is primarily due to RN shortages⁴. However, these rural ENs are increasingly undertaking nursing degrees, and accordingly it is in the best interests of managers and educators to encourage and support the effective transition from EN to RN. Effective transition will impact positively on nursing retention rates and, ultimately, on the provision of a high quality rural healthcare system.

Literature review

Rural RNs are required to be multi-skilled generalists, capable of providing a wide range of nursing care to a diverse range of clients. This care is delivered in contexts of minimum peer, medical and specialist support^5,6. Budgetary constraints and other limited resources also impact on work conditions and outcomes¹. Consequently there are anomalies between metropolitan and rural health units and life styles. In conjunction with the diverse multi-skilled role of rural nurses, this significantly impacts on the rural EN to RN transition.

However, the main focus of the available literature is on the transition from student nurse to RN in the USA and the United Kingdom. The Australian perspective is significantly under-represented and what is available concentrates on the EN to RN transition in metropolitan contexts.

A number of factors influence the transition to RN, including the impact of work force and work place reality⁷, the knowledge and skills expected of a new RN⁸, the available support systems⁹, and adjusting to RN levels of responsibility and accountability¹⁰. These factors are intensified for the EN transitioning to RN because clinicians and mangers have higher expectations that the EN requires little or no support in their graduate year¹¹, role boundary confusion arises¹² and the likely reluctance of peers and superiors to accept the new RNs increase in knowledge and role change¹³.

While the transition of EN to RN in the Australian metropolitan area has been addressed^11,13, the transition experience in the rural setting is yet to receive equal attention. The aim of the study reported on here was to increase the understanding of this unique transition process and raise awareness of the specific needs of these graduates.

Methods

Research methodology

Hermeneutic phenomenology is both a philosophical movement and human science that uses the processes of description and interpretation to examine lived experiences. Phenomenology allows in-depth insight into an individual's experiences, where hermeneutics goes beyond the description of those experiences to uncovering their meaning¹⁴. Combined these form a suitable methodology to understand the meaning of the lived experiences of the EN transitioning to RN in the rural context.

After receiving ethics approval from the University of South Australia, the Directors of Nursing from four South Australian rural hospitals were contacted to support the study and provide access to potential participants. These hospitals were chosen for their proximity and, combined, they provide health care to a population of approximately 45 000 people. Following this, purposeful and network sampling through discussions with transitioning RNs were used to elicit contact from four individuals who had experiences relevant to the research focus¹⁵. These individuals were contacted by letter and formally asked if they would be willing to participate in the research. The four participants, one from each hospital, were ENs who had just completed the transition year, or were currently in the process of the first year of their RN transition. The researcher then met with each participant to discuss the study purpose and process. Pseudonyms were used to protect the identity of each participant whose ages ranged between mid-twenties and early fifties. All participants had undergone EN to RN transition in the rural setting and all had been ENs for a period greater than 3 years, with the mean average being greater than 13 years.

Consistent with the phenomenological approach, the data source was an unstructured interview with each participant^14,16 at a mutually agreeable time, lasting approximately 60 min and held in a quiet room at the participant's workplace. A phenomenological interview does not aim to explain, predict or generate theory. Consequently the phenomenological approach to interviewing combines both listening and narratives to gain deep insight into each participant's experiences¹⁴. Prior to each interview the participants were given the opportunity to clarify queries before signing a consent form.

Participants were asked 'What was it like making the EN to RN transition in the rural setting?' All participants were able to describe their experiences with little prompting. The researcher then transcribed the content of each audiotape verbatim. The participants each received a copy of their verbatim transcript to ensure accurate representation of their experiences. All transcripts were returned with no further comments or alterations. The credibility and dependability of this study are demonstrated by the participants' recognition of the findings as representative of their experiences, and the audit trail which provides a record of activities that others may follow¹⁵.

The data were analysed using van Manen's¹⁴ holistic and selective approaches in conjunction with Hycner's¹⁷ more structured approach to analysing phenomenological data. Van Manen describes the reflection that occurs in phenomenological research as thematic analysis. Hycner complements this process by providing clear steps that mirror van Manen's ideas but offers greater clarity. Significant phrases or units of meaning relevant to the study were then identified, coded and placed within a relevant theme.

While the study has been successful in providing insight into the experiences of ENs who transition to RNs in rural settings, it makes no claim to be generalisable to the experiences of all such graduates. Phenomenology aims to understand the experiences of a small number of participants through the generation of in-depth, quality data. Further research is required to determine how widespread such experiences are and to examine the effectiveness of strategies used to assist transition in the rural context.

Results

Analysis of the participants' accounts of their transition experience revealed the following three themes:

1. Great expectations - self-expectations; adjusting to the new role; other's expectations.
   
2. Support: sink or swim - peer, managerial and medical staff support.
   
3. Jacks and Jills of all trades - coping with the scope; proficiency equals specialising; positives of rural transition.

These three themes have units of meaning that are pertinent to more than one theme. Given the nature of the phenomenon being studied, the overlapping of these units of meanings is necessary to produce structure and understanding. This reiterates van Manen's view that the 'meaning' or 'essence' of a phenomenon is never straightforward or basic. Therefore, the identified themes and their units of meaning cannot be seen simplistically from a single view point; rather, together they form the meaningful whole of these participants' transitional experiences.

Great expectations

This first theme is made up of three units of meaning: self-expectation, adjusting to the new role and others' expectations. The theme draws attention to the participants' expectations that their previous EN experience would make their RN transition easier. They explained that, in reality, this was not the case. Kilstoff and Rochester¹¹ confirm that the expectations of individuals undergoing transition may not meet with reality. While these participants acknowledged the value of their previous nursing experience in assisting them to cope with general nursing care, on the other hand it resulted in ambiguity when adjusting to the more advanced demands of RN work. This uncertainty mainly resulted from their own high expectations about their performance in the new role. One participant stated:

My expectations of being an RN were extremely high as I think I was a good EN, as an EN you are usually the run-about person ... get this, get that, but as an RN you are actually thrust into doing the procedure.

The final unit of meaning in this theme, other's expectations, highlights management and work colleagues' expectations that previous EN experience made the EN to RN transition easier. Kilstoff and Rochester¹¹ verify that administrators and managers also hold this view. There was also the belief that these new RNs would manage at a more experienced RN level. As a result participants felt they did not receive the support they needed throughout their RN transition. This proved to be even more problematic when the transition was occurring in the venue where the new RN had worked as an EN. The following participant quote confirms this.

Because I went to work at the same place that I had previously worked as an EN ...they just presumed I knew things.

This last unit of meaning is closely interlinked with the next theme, Support: sink or swim. The high expectations of others often meant the new RN was left to cope in situations beyond their knowledge and experience level.

Support: sink or swim

This theme also encompasses three units of meaning: peer support, managerial support, and medical staff support. Study participants explained that they felt insecure and frustrated at limited management and peer support because their previous EN experience suggested to others that their transition would be unproblematic. Studies confirm that appropriate support is an issue for all nursing graduates making their transition^9,18. Such absence of consideration left these new RNs in many situations that increased their anxiety. Further, the allocation of responsibility was inconsistent and occurred when other staff were not available, or taking tea breaks. This repeated absence of supervision by senior staff could be viewed as systematic malpractice¹⁹. One participant explained:

The hierarchy in the hospital...presumed that you were OK so they sort of left you to your own devices and thought you were capable because you had worked there before as an EN.

You would say to ... who ever was in charge, .. 'you know that I haven't worked in here and you don't normally let me work in here, so why am I [here] now?'... They would say 'Oh you'll be right we are just in the office... and you can ring us'.

Goh and Watt⁹ stress the importance of nursing graduates receiving timely open communication and constructive feedback about their performance. These actions raise a graduate's confidence, enabling them to learn and settle into their new role¹⁹. Unfortunately the participants in this study spoke of lack of constructive communication and feedback from senior nurses, doctors and ward managers. They believed this impacted negatively on their ability to acclimatise to their new role and, therefore, hindered their professional development. Other staff are likely to continue to see the new RN in their EN role and omit support for their development. As one participant said:

Being an EN my transition was that I was expected to know more than I did [as a new RN] and I was questioned when I did not know.

The participants explained that anxiety and frustration increased when they were left unsupported in situations beyond their capabilities because of the assumption they would cope. The participants reported that the educational benefits of mentoring and constructive feedback were rare. Clare et al.⁸ question the preparedness of the new graduate to function in rural health settings because of the anomalies rural nurses encounter in their daily practice. In the absence of constructive feedback, these already disadvantaged graduates may continue to struggle.

Jacks and Jills of all trades

This theme includes three units of meaning: coping with the scope, proficiency equals specialising and the positives of rural transition. The theme draws attention to the impact of rural practice on these participants' transition experiences and their subsequent professional future. Participants explained they were not prepared to cope with the extensive knowledge and skills required of the 'generalist' rural RN role. A participant explained the situation.

[The] expectation [is] that you will be capable in all areas in a country hospital. People seem to think you know...something about everything, and you might know little bits and pieces [as a new RN] but you...don't know exactly the correct thing to do, especially if you get sent to outpatients [accident and emergency] . Expectations are fairly high that you will be able to function in any situation and I don't think that's actually possible when you're a first year RN.

Novice RNs are usually fragile and, when placed in situations that prevent them operating effectively, their confidence can be negatively influenced⁸. This is compounded by the fact that rural RNs are expected to function in multi-dimensional roles, providing nursing care to a diverse range of clients with different health needs. One participant explained:

One day you are in surgical the next day you could be out in casualty with somebody with chest pain, and then you back on the ward and you are looking after a mental health patient...mastering this diversity as a new RN.

Such diversity of practice meant participants did not receive the repeated exposure to situations that would increase their skills, knowledge and confidence, a concept that is supported by Hoffman and Elwin¹⁰. Subsequently participants identified a delay in the 'gelling' of deeper understandings of RN practice, less than expected levels of confidence in their RN role, and later onset of professional autonomy. One participant explained that the repeated exposure to new situations meant consistent uncertainty about how she would cope.

As a [previous] EN I think a certain level of care and knowledge is expected at a higher level, that you know what you're doing so you don't need quite as much support. [But] ... you have never been exposed to certain things; until you are you don't know how you are going to function.

All participants expressed the desire to gain experience and confidence in their RN role and be seen as 'specialists' with advanced nursing skills. They believed this was necessary to cope with the vast range of circumstances that arise in the rural health setting. However, they believed they could only become specialists if they gained experience elsewhere, such as the city, and completed specialised courses. The unpredictability of the rural health environment may make it difficult for RNs to feel they have control and to see that they are specialists in their own right. They did, however, recognise the knowledge growth gained from their rural nursing experiences.

It would be good to specialise and I would love to do some critical care stuff...but I wouldn't want to stay in that environment forever.... But I've learnt heaps as a country nurse and love it... I would shrivel up... as a city nurse. I like the trauma side of things, you never know what's coming through the door but you learn heaps [in the country setting].

So the graduates also saw the challenges of rural practice in a positive light. They believed the vast array of clinical experiences they were exposed to in the rural setting assisted their professional development, even though it may take time to have repeated exposure to situations and feel fully competent. They believed the key to positive professional development rested in learning in circumstances that foster job satisfaction and professional autonomy. Hegney et al.⁴ confirm that many rural nurses enjoy the diversity, challenges, and autonomy of their role.

Implications for practice

The transition from one nursing role to another is fraught with challenges and opportunities. Hermeneutic phenomenology has been used to gain insight into this transition process and to propose change. The findings of this study have implications for nurse educators, nurse managers, organizational administrators, policy-makers, nurse clinicians, and future graduates

Education: This study confirms the findings of research evidence that a general bachelor of nursing degree does not adequately prepare undergraduates making their RN transition in the rural context to managing the diversity and challenges of rural practice. Even graduates with previous EN training may not feel any better prepared for these challenges²⁰. Francis et al.²¹ believed the level of expertise required by the rural RN can take years to achieve. Therefore there is a need for undergraduate educators and rural nurse managers to collaborate on strategies that facilitate an improved undergraduate educational preparation for graduates making their RN transition in the rural context.

Nurse educators, nurse managers, and administrators need to recognize it is not merely the undergraduate preparation that is an issue for a nursing graduate's RN transition in the rural context. The provision of appropriate educational support must continue throughout a graduate nurse's transitional journey from novice to competent nurse, then proficient nurse and finally expert nurse. Such support needs to be readily available within a work place which also identifies the need for appropriately educated mentors. These mentors need both clinical experience and the ability to identify the support needs of individual graduates, to foster learning and increased autonomy.

Nurse managers: Nurse managers need an awareness of the process individuals undergo when making role transition within the workplace. This is essential because the way new RNs manage the variances of the healthcare environment is instrumental in influencing their decisions to stay in nursing^18,20. Nurse managers must acknowledge that although a graduate's previous EN education and experience may assist with practical nursing work, the new RN role requires a different level of critical thinking and practical application. Subsequently RN graduates with EN training require a similar degree of guidance, support, and understanding to that provided for other nursing graduates entering the healthcare sector¹¹.

It is in nursing managers' interests to understand how the anomalies of a rural practice impact on a graduate nurse's transition, and to ensure that the appropriate infrastructure is available to support nursing graduates cope with the challenges. Managers also have a responsibility to ensure mentors have the skills, knowledge and time to do their job of supporting new graduates¹⁸. The response, 'You'll be right just ring if you need anything' is not what nursing graduates need when faced with the prospect of a patient with chest pain coming through the accident and emergency door, nor is it legally acceptable. The provision of appropriate orientation and suitably educated mentors who are regularly rostered with graduates (especially during the initial months of a graduate nurse's transition) is important. Shift rostering must consider appropriate skill mix and workload allocation to ensure continued job satisfaction and retention and to foster increased professional autonomy. Jones and Cheek²² point out that practice development is a concern for all, and that it is a complex system of learning support and nurturing requiring the combined efforts of administrators, clinicians, and educators.

Organisational administrators: Health administrators are increasingly aware of the difficulties and problems caused by the current reluctance of RNs to practice in the rural setting. Presently there is a greater proportion of ENs than RNs practising in the rural context^2-4. These ENs seeking RN qualifications are a new and willing workforce. Therefore it is advantageous for health administrators and policy developers to encourage and support the EN to RN transition in order to increase the number of practising RNs. This transition needs to occur under circumstances that foster job satisfaction and so is likely to positively impact on staff morale, retention and recruitment, and on patient care. Ultimately this means that health budget planning and implementation must support appropriate staffing levels in order to foster educational support, job satisfaction, and professional autonomy of the rural RN.

Nurse clinicians: Nurse clinicians must remember that role transition creates ambiguity and conflict, and that it has the potential to generate feelings of insecurity and unfamiliarity for individuals undergoing this process. The expectation that graduates with previous EN training require less support than other graduates is best addressed through appropriate staff development. Work colleagues must align their expectations with individual graduate's abilities and ensure consistent mentoring²³. Recognition that this role is new to these graduates, and that the resulting unfamiliarity can impact on professional development and practice, should be considered by those working with the transition RN²⁰. The learning of another role within the same work context can be unnerving, requiring added understanding and support. Graduates need to be able to freely communicate concerns and feel they will be responded to appropriately. They need to be given time to develop their clinical practice and to increase in confidence and autonomy at their individual pace. The provision of positive constructive feedback is also important to successful professional development. Job satisfaction will occur in a work environment that provides encouragement - not humiliation.

Future graduates: While the findings of this study cannot be applied to all nursing graduates, these participants' experiences are none-the-less important, for they can assist future graduates and those responsible for their transition to recognise that the RN role is not a mere extension of an EN qualification. The education and experience of the EN will assist a new RN with general nursing duties involving clinical dexterity and work place familiarity; EN to RN transitions can also create challenges concerning role ambiguity, self-expectation, and others' expectations. A new graduate RN's previous EN status is likely to lead to workplace assumptions of better coping and the need for less support. Therefore, these new RNs need to develop the ability to clearly articulate concerns and needs to educators and workplace managers. In addition graduates will need to be proactive in regard to professional development needs and developing support systems, which include work mentors, colleagues, and friends that will assist and support them throughout their RN transition.

Further research will determine what is needed, what resources are available and the ideal process for implementing or encouraging these changes. Clare and van Loon²⁴ recognise that the first 3 to 6 months of a new graduate's transition are the most crucial in terms of positive professional adjustment and nursing career commitment. Therefore positive interventions at this time are essential.

Conclusion

Phenomenology seeks to discover what a phenomenon means and how it is experienced. The aim of this study was to explore the lived experiences of ENs making their RN transition within rural contexts. Currently there is a shortfall of RNs prepared to practice in the rural setting. However, there is a higher proportion of ENs to RNs working in rural health care, with many of these ENs undertaking nursing degrees. This identifies a nursing workforce prepared to practise in the rural context, and one possible means of addressing the RN shortage. For example, RN shortages could be reduced if healthcare units and policy-makers encouraged and supported the EN to RN transition in this unique setting.

This study has achieved its objective through the identification and discussion of three essential themes which were identified from the participants' descriptions of transitioning from EN to RN in a rural setting. While the experiences of these participants cannot be applied to all rural RN graduates with previous EN status, one cannot dispute its strengths in drawing attention to the needs of such new graduates. Appropriate actions taken by nurse administrators, managers and educators who oversee practice and staff development in rural venues will result in a better prepared and more stable workforce. Perhaps the most important change agents are the new RN graduates themselves, who must voice their needs to their managers and educators, and participate in strategies and further research to ensure beneficial transition processes for future graduates.

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