Background to study
Western Australia (WA) has approximately 10% of Australia's 19 million people but it covers nearly one-third of the Australian landmass1. Population densities of regional towns can be illustrated by the fact that most Western Australians (1.45 million) live in the greater metropolitan area of Perth1. This pattern is similar in other Australian states with approximately 30% of Australia's population living in large and small rural or remote centres2. Accordingly, as the distance between towns increases, services and infrastructure decreases. In particular, the lack of educational services for rural nurses is a problem3. Compounding the problem of distance between sparsely populated towns and regional cities is the publicly acknowledged shortage of division 1 registered nurses (RNs) in Australia4, including rural areas5,6. Although 28% of WA nurses work in rural areas7 the greater percentage of these are enrolled nurses (ENs)3. Similar shortages of rural nurses occur elsewhere internationally8,9.
In WA the existence of rural campuses that offer an internal program has not provided enough graduates to offer a solution to the nursing shortage in rural areas10. Concomitantly, there is an unmet demand for ENs working outside metropolitan areas who want to become an RN6. In Australia, only bachelor-level degree courses lead to registration as a division 1 nurse with the relevant state nurses board. That is, there are two levels of registration and conversion from division 2 to division 1 register requires the completion of a bachelor degree program.
The context for this study is the externally delivered Bachelor of Science (Nursing) conversion degree program. The 3.5 year Bachelor of Science (Nursing) degree is shortened to 2 years for the EN-to-RN pathway, in recognition of their clinical experience and understanding of the socially embedded knowledge of nursing practice in general. It is acknowledged that the EN who wants to convert to RN already has a positive attitude to nursing, and has knowledge of the reality of nursing, including rural nursing6, and we also know that ENs can relate new knowledge to previous clinical experience11,12. However, their experience with external tertiary study is not well documented.
The strategies put in place to assist the EN-to-RN student cope with the isolation of external study and the expectations of tertiary study include an eight-day foundation study program, the use of web-based units, a chat room, and six local learning centres spread across the state13. Each learning centre provides learning resources and a local point of contact with an academic RN mentor. Mentors are likely to model effective coping attitudes and strategies for managing problem situations, demonstrate the value of persistence, and assist in the identification of appropriate social support or resources for efficacious coping14-16. The mentor is also responsible for the EN-to-RN students' clinical preparation and country clinical placements. In the clinical setting the EN-to-RN students have two types of clinical supervision: either an RN clinical tutor whose sole responsibility is student supervision, usually a 1:10 ratio, or a preceptor. The preceptor is an experienced RN who has agreed to teach a student as they work together on the RN's caseload. The considerable and positive effect on student nurses of the RN preceptor as a clinical area mentor has been established elsewhere17. The types of clinical supervision the students have depend on the clinical placement versus the learning needs. For example, the paediatric and psychiatric placements have a clinical tutor because they require new skills, but the two clinical placements in the final semester use a preceptor. Apart from two of the seven clinical units in their course, the designated rural academic mentors would arrange clinical placements in school-approved health-care agencies situated locally or in nearby towns. This later strategy avoids the necessity for students to relocate to the metropolitan area or larger towns to complete all of the clinical components of the course.
Several studies6,9,18 suggest that students from rural areas are more committed to remaining in rural locations after graduation. Rural graduates, however, have fewer choices, if any at all, of entering a graduate nurse program (GNP) because of distance from a metropolitan or regional health centre where the programs are located. The existing year-long GNPs in Australia are generally well received by graduates with no previous nursing experience19. These programs, for tertiary qualified nurses, are aimed at addressing the problems of lack of confidence, a non-supportive work environment and insufficient orientation to the workplace20-22. The usefulness of existing GNPs for the EN-to-RN graduate has yet to be explored.
The primary purpose of this paper is to describe the transition experiences of rural and metropolitan enrolled nurses undertaking an external tertiary level course after receiving considerable advanced standing, regardless of educational background. The external option for the EN-to-RN pathway program was selected because of the rural ENs needs. Findings from a study of EN background students enrolled internally at a rural campus and participating in an on-line focus group confirms the worth of the EN conversion course6. However, the transition experience of ENs given considerable advanced standing based entirely on EN experience and studying by external mode has not been explored. When searching the home pages of universities offering a nursing degree, the amount of recognition of prior learning given to ENs varies considerably. The amount is often dependent upon the type of EN course undertaken: hospital based or technical college. The nursing literature is silent on the experiences of externally enrolled EN conversion students.
The secondary purpose of this paper is to describe the transition experiences for EN-to-RN graduates as novice RNs. Others have explored the transitional experiences of graduates with5,23 and without20,24 an EN background, but they did not refer to graduates from an external course. Would the transition experience for rural EN conversion graduates who completed their course without having to relocate to a larger town or city have the same problems returning to the same work place, but now as an RN, as previously identified25-27?
This descriptive qualitative study used a volunteer sample of recent graduates from the EN-to-RN pathway to explore their course experience and adjustment to the RN experience. Ethics committee approval to complete the study was obtained from the university. Written consent to participate and audiotape the interviews was obtained. The National Health & Medical Research Council guidelines were followed to protect participants' confidentiality.
Email or letter was used to recruit participants. The 10 mature-aged, female participants in this study graduated from the Bachelor of Science (Nursing) two-year conversion degree program that commenced in 2000. Five were from the metropolitan area and five from rural areas. Their ages ranged from 33 to 53 years with a mean of 42 years. Their educational background included hospital-based certificate or technical college Associate Diploma. One student had completed one year of a university course several years before enrolling in the pathway course. Students with a hospital-based certificate had to pass a mature age university entry test (special tertiary admission test or STAT).
The data for this study were collected through face-to-face interviews using open-ended questions. Ten graduates were interviewed before saturation occurred and the recruitment of further participants ceased. The interviews took approximately 60 min. The questions included: 'Tell me about your experience as a student in the EN pathway'; 'Tell me about your clinical learning during the course'; and 'Tell me about your experience as a newly graduated RN'. All interviews were audiotape recorded and transcribed verbatim. All participants formally interviewed completed a demographic data sheet.
Data from the transcripts were analysed using a grounded theory approach28: Coding, finding categories and clustering. Two of the researchers reviewed each transcript of the interview line-by-line and assigned codes to significant words and phrases. The coded data were sorted into larger categories, which were further sorted into pertinent themes. Together, the researchers returned to the transcript to verify exemplars of the themes that then became the findings of the research. Returning to the data to verify themes and categories, clarifying data with participants and verifying categories with all members of the research team ensured trustworthiness of the data.
Of the 10 females who participated in this study, five were from the rural areas. Analysis of the interviews revealed that both metropolitan and rural students had similar experiences related to being external students. There were, however, some experiences pertinent to either the metropolitan or rural students. The data analysis revealed the following four categories:
- adjusting to higher education
- achieving academically
- becoming critical thinkers
- adjusting to the RN role: accepting responsibility.
Adjusting to higher education
The participants gave several reasons for applying to commence the EN-to-RN course, all of which may have influenced their adjustment to the higher level of study. Reasons given included frustration with the EN role and little scope to branch out to other areas of nursing. They reported external study provided an opportunity not previously available because of distance from a university, and it also provided the opportunity to study around the commitments of family and or work.
Some participants reported the two-week orientation to the course made them very quickly realise that they did not know as much as they thought they knew and that 'theory' was going to be challenging. Others still believed that their previous knowledge and experience would mean the course would not be too difficult. The need to learn computing skills to access online learning and tests was reported by four participants to be a significant hurdle to adjusting to studying. Learning how to study and to write at the required academic level was also reported as a hurdle to adjustment with one participant stating she finally felt ready to study by the time she completed the course.
Adjustment also meant finding a time and space to study. All participants spoke of needing to be disciplined to manage study time. They explained that finding time for family was hard with one participant explaining that she revised her study time to very early morning to make more space for family interaction.
Most participants reported the on-campus orientation as being helpful in adjusting to study by providing an opportunity to meet others and establish student networks that allowed a sharing of experience. Rural participants described using email or the electronic bulletin board to communicate with other rural or metropolitan students, which helped maintain a sense of being part of a group. Internet connection also gave rise to incorrect information being easily disseminated, which one participant described as causing unnecessary concern. Another rural participant recounted that she did not contact fellow students by email or bulletin board because she was 'not good with computers'. She described feeling very isolated, particularly when telephoning academics was unsuccessful, stating 'these guys have very busy schedules as well'. Metropolitan participants described their inclusion in study groups created by students living in the same metropolitan area. This strategy helped them adjust to the rigour required for university study.
Adjusting to the clinical demands of the course was also difficult for some participants. There were comments about difficulties with the need to request annual leave early to ensure they had the appropriate leave needed to complete the clinical requirements of the course. Adjusting to the student role was also difficult for most participants with some stating that working with a hospital RN preceptor was most difficult as the preceptor did not have clear guidelines for what was expected of them as a student and nor did they. Adjustment to the student role was described as easier for some students when they were either placed away from their hospital of employment and or worked with a clinical tutor. Although clinical placements away from their place of employment benefited the participants' learning, it created some problems for rural participants with young families, as they had to relocate to the metropolitan area from 2 to 4 weeks at a time. One participant described her anger when she had to travel to the city for her final clinical placement. She remembered thinking 'not again, not going away again!'.
Achieving academic success
Participants described achieving academic success in various ways. Several participants were surprised at the amount of reading required to be successful in both tests and assignments, describing it as a challenge. The participants outlined various strategies to meet this challenge, including learning to skim read and to use the abstracts to determine usefulness of journal articles. Their recounting of these strategies was as a form of discovery learning rather than a strategy that they had been taught. Writing at the required academic level was reported as being achieved by using resources such as their academic mentor, hospital colleagues and feedback from assignments. Several participants reported that late return of assignments created great anxiety, because they needed the feedback before the next assignment was due. They also spoke about their anxiety in completing exams using the internet to access webCT with one participant describing her experience of being disconnected in the middle of an online test. Although she knew that she could telephone a designated academic to complete the test without penalty, it was unsettling. By contrast, another participant described the convenience of being tested in the comfort of her own home even recalling the casualness of being in her pyjamas to do an online test.
Academic success was also reflected in the description given by a rural participant able to use her assignment as a vehicle for a significant contribution to the community. She described being able to complete her community nursing placement in her rural community and how her community academic assignment could also be implemented with guidance from her community nurse preceptor. She described doing all the 'behind the scene organising' as a good learning experience. The student expressed not only a sense of academic achievement but also a feeling of community recognition.
All participants reported their academic success would not have been as achievable without the support of their families, colleagues, peers and employers. Some employers were supportive in practical ways such as granting leave when clinical placements needed to be completed. Their support also gave participants the courage to disregard negative comments from some nurses. One participant reported being very upset by a colleague's comments but also encouraged by another who helped her gain insight into possible reasons for such negative comments.
It was actually the older RNs who were hospital trained - and then after a while somebody sat me down and I was quite distressed this day and said 'Well actually, the problem is not yours. The problem is theirs. They have to deal with you doing something that they probably should have done'.
Mentors were reported by some metropolitan participants to be a useful addition to the program stating that their mentor helped them with academic writing and group problem solving. Conversely, rural participants reported that the mentor was of little value to them in achieving success, reporting the mentor's value was mainly in organising the clinical component of the course. Only one rural participant stated her mentor helped her with academic learning, thus contributing to her academic achievement.
Some participants confided that they had considered applying for further exemptions from clinical units if they had EN experience in that area but decided it was important being supernumerary so that they could ask questions and act in the student RN role. All participants remarked on clinical practice away from their home hospital and the positive experience of having a clinical teacher rather than a preceptor. They described the advantage of having clinical teacher led tutorials where they could discuss their experience and thus gain insight into what they were observing and why they were undertaking certain procedures.
Ultimately, graduation for all the participants was a time of pride and celebration with family members. Gaining registration and wearing the RN uniform for the first time was their extrinsic reward and confirmation of a significant achievement. Most reported it was a time of closure. In general, participants spoke of the realisation of career doors that were open to them. Two participants took graduation as an opportunity to change the focus of their clinical practice and several were looking at the possibilities of doing further study.
Becoming critical thinkers
Critical thinking, although not labelled by most participants, was clearly evident as a major component of their change in nursing practice as a result of the process of completing the course. The journey to critical thinking was at times challenging. The external learning packages were described as being daunting with expressions like 'you'd have a heart attack' when they arrived. They were also described as being well organised and gave the knowledge that could be applied in practice with one participant remarking:
You are putting into practice everything you had learnt ... and the reasons why you had to learn all that physiology ... I understand what the problems are.
For some participants, the insight was remarked on because they had performed the procedure many times as an EN without any insight into the purpose or rationale. An example given by one participant was becoming aware of her biases and how they affected her nursing care. Another gave an example of gaining an understanding of a certain drug and why some patients developed skin problems. A third participant spoke about giving a patient a drug and not only thinking about the expected amount of urine output but also about how the drug acted on the kidney.
A rural participant demonstrated understanding of her change in knowledge level and how it might change her nursing practice:
You are given some credit for knowledge you've gained and also able to impart some knowledge to them [staff at home hospital]. I think that's a bonus.
Another participant considered the change through the course in the following way:
Once you start this journey at the end of it you are going to be maybe not a different person but you are going to be a better person, a more educated person.
Transition to the RN role: accepting responsibility
Participants referred to a time of anticlimax when study was complete but registration not attained. Hence, those who returned to work as an EN during this time found it difficult because they felt ready for the RN responsibilities but were not legally authorised.
The participants described their transition to RN as a period they thought would be reasonably easy but found that it was not the case. To walk in the shoes of the RN brought home the reality of the role difference. One participant explained the workload difference was not great but 'responsibility differences really hit home once I was registered'. Another participant stated that after thinking the transition was going to be a 'piece of cake' she realised:
You are the one responsible for making the clinical decisions and whatever decision you make whether it be right or wrong you are the one that's got to live with it.
Paradoxically, one of the rural participants who returned to her home hospital explained the transition period was difficult for her in giving away her EN role. She explained it as follows:
I think at the beginning when I first became a registered nurse, if I worked with an enrolled nurse they were glad to see the back of me by the end of it because I was trying to be an enrolled nurse and I was trying to be a registered nurse. ... enrolled nurses they kind of brought that to a bit of a front. They said, 'Go and do the registered nurse job. Just leave me alone'.
Other rural students who returned to their home hospital reported that colleagues accepted their transition to RN. One stated the doctors took a little while to realise they could talk to her as an RN and they were very helpful in teaching her skills if she were not confident. Conversely, a few participants decided to change to another hospital because they foresaw that they would continue to be perceived as an EN after RN registration even though they would be in the RN uniform. In one case, with the approval of the rural director of nursing, the rural participant chose to complete a GNP elsewhere returning to the home hospital once completed. Rural participants who had more limited employment opportunities tried to at least change the ward or area in which they had previously worked as an EN in order to take on the RN responsibilities.
While accepting the need for a GNP for graduates without prior nursing workplace experience, some of the metropolitan participants had difficulty accepting that they needed to complete a graduate program. One participant stated the GNP was a waste of time, as she knew most of the information. Another participant became proactive in submitting to management a case for an accelerated assessment for the EN-to-RN conversion graduates that was commensurate with expectations in role responsibility. Although she achieved an accelerated assessment, another participant at the same hospital stated that she was glad she had not received an accelerated assessment and had the time to understand the RN responsibilities at the same rate as other new graduates.
Participants in this study overcame the fear of embarking on tertiary study reported by others as a reason for not furthering their education20,29. A reconsideration of the effort necessary for tertiary study was, however, made by several participants during orientation to the course. Consistent with other studies18,30, participants described the need to be disciplined when trying to adjust study to other commitments. Others showed that cost, time constraints and family commitments were important considerations when undertaking tertiary studies while continuing to work12,31. As was the case for the participants in the current study, responsibilities for aging parents, child-care and domestic responsibilities in general were significant competing roles that had to be fitted around the student role32-35. This is also consistent with the literature on mature-age female students in general undertaking tertiary studies6,36,37.
Although participants in this study did not experience the problems of inflexible timetables or lack of child care experienced by other mature females undertaking internal tertiary studies36,38, they did have other difficulties when completing clinical units. Of most concern was negotiating leave entitlements from existing EN employment to complete clinical requirements of the course. The need to arrange annual or study leave well in advance was a common problem. Additional difficulties and stress occurred when rural participants had to move away from the family home to complete clinical placements.
The clinical placement itself was also identified by many of the participants in this study as being problematic with the potential to be stressful, especially for students in the rural areas where the participants were known as ENs. Several participants referred to their student status being ignored during their clinical practice and that they were 'used' for their EN expertise. In situations where hospital RN preceptors rather than clinical tutors were used, they felt that the lack of the preceptor's awareness of their learning needs was compounded by their own lack of clear guidelines as to what was expected of them. That level of ambiguity was similar to findings from an EN-conversion group studying at a rural university in another Australian state6. By contrast, when participants had a placement with a clinical tutor, the clinical experience was more positive with less role confusion. Nevertheless, all participants reported difficulty separating their EN nursing experience from the expectations of the student-RN role. For the rural EN at least, greater consideration of the more diverse expectations of the EN in rural areas6, and how this impacted on their adjustment to RN-student status, could take place in the preparation of educational material and guidelines.
This study also found that using webCT and the internet is challenging, especially if students have never used a computer before. Meeting the challenge offered students the opportunity to readily consult with peers, regardless of their geographic location. There is a large body of evidence suggesting undergraduate students not only learn best in like-minded groups, but also when they have time to focus on the learning task, when they are given feedback and when they have access to an academic advisor39.
The provision of an academic mentor as a resource to the EN-to-RN pathway students had mixed success. Metropolitan participants had easy access to their academic mentor while a few rural participants had difficulty with access because of distance and apparent apathy. As a result, student-selected mentors from the clinical area proved to be of greater assistance to participants achieving success. The value ascribed to an RN as a mentor for nursing students is consistent with findings from other studies16,40.
Clinical teachers were reported as not only supportive, but also as pivotal in allowing participants to change in their thinking about their practice. The participants' experience as ENs, their new knowledge and the challenge by clinical teachers to reflect on what they observed in the clinical area facilitated their change in thinking. Their insight as to how the course changed their perspective of nursing care is informative for nursing educators because it supports the difference in educational outcomes of ENs and RNs. This study provides evidence that these participants have achieved some of the graduate attributes expected of students graduating from a university; particularly discipline knowledge, thinking creatively and reflectively and the ability to access, evaluate and synthesise information41. Such scholarly activities are necessary for the development of nursing knowledge and its application to practice. As former ENs, these novice RNs have the clinical background to consolidate their empirical knowledge while developing new conceptualisations.
Concomitantly, a feeling of frustration with the GNP was also evident in participants' comments. Most participants entered a GNP after completing their course. Since GNPs focus on workload prioritisation and problem anticipation42,43 these graduates were familiar with the workplace milieu and how to prioritise. Similarly, the majority of participants in this study did not experience a lack of confidence. A few participants, however, felt that the GNP did not acknowledge their ability to take on higher responsibilities earlier than graduates without EN experience. There was an intuitive sense to the notion that the phenomenon 'reality shock'24,44 was less for the EN-to-RN graduate with consequent faster transition from novice practitioner to advanced beginner. Their experiences are consistent with the views of others that have recommended a review of the GNP content19,22.
Although the British experience of providing a pathway from EN to RN indicates that graduates improve their career prospects in most instances, there is evidence that nurses who return to their former workplace are disadvantaged in adjusting to the new role and obtaining promotion26,45,46. A change in title did not necessarily mean a change in duties25-27. Furthermore, ENs in New South Wales who returned to the same hospital after graduation felt former superiors or peers did not readily accept them as RNs5. This finding concurs with the views of participants in this study: They feel more acceptance as an RN in clinical areas where they are not seen as a former EN.
In most country towns of WA, the opportunity for individuals to 'start again with a clean slate' and new graduate status is rare. Consistent with the literature, rural participants from this study who remained at the hospital where they worked as an RN refer to the RN transition as having some difficulties, but staff, including doctors, are supportive with former EN peers encouraging them to take on the RN responsibilities - even if it was just to leave them alone.
There is recognition of the need for a more collaborative transition program approach from education and practice areas21,24. More specifically, the national review of nursing education4 suggests that the Australian Nursing Council develops minimum standards for transition programs. Hence, if the transition experience of the EN-to-RN graduate is different, information is needed to support such recommendations. The best practice principles for a supportive environment21 would appear to be appropriate for all graduates23 but should the EN-to-RN group continue to be considered novice RNs for 12 months? Health services could benefit from fast-tracking those EN-to-RN graduates with appropriate nursing experience into specialty areas where there is a shortage of staff12.
As with all exploratory studies, the findings cannot be generalised to other EN conversion programs. The participants' educational and graduate transition experiences would be different for other courses. Also, the impact of gender on course experience could not be explored. Given the prevalence of females in nursing in general, gender may not be a significant problem but family structures have the capacity to fundamentally change the findings. For example, differences in extended families have the potential for positive and negative impacts. Extended families provide opportunities for more support but they could also involve greater responsibilities for some members of the family, especially mature females who are likely to enrol in EN-to-RN conversion courses.
Participants in the study were from the first EN-to-RN conversion program and interviewed within 6 months of completion. Hence, although the transition to RN experience was contemporary, the course experience findings relied upon retrospective data. By limiting the inclusion criteria to those who had completed the course, we are not able to comment on the reasons for or experiences of those who withdrew from the course. A further study is warranted to explore the very different experiences of students who withdrew.
The transition experiences for participants in the external conversion degree program are generally positive although, as with other studies, the transition to student status was reported as being stressful. The study establishes that the external mode allowed these rural and metropolitan ENs to undertake study that they would not have embarked on if the course was only offered internally.
Offering advanced standing has challenged participants academically more than clinically. Nevertheless, they have described their transition in a way that suggests the course has provided knowledge and opportunities for the development of critical thinking appropriate for baccalaureate nurses. Also, findings suggest that a clinical teacher or preceptor who has the time to explain clinical situations in relation to new knowledge is as important to this group as it is for nursing students without an EN background. Of concern for some rural participants is the necessity to relocate for clinical practicum. Relocation for clinical practice can be stressful but has given participants the experience of a different perspective needed to initiate reflection.
The study also indicates that rural ENs can gain the recognition needed to make a successful transition to RN in their home community, even though it requires a change in attitude for themselves and their colleagues. The rural community has gained novice RNs with knowledge of the local community, hospital nursing procedures and the workplace milieu. For the graduate, the achievement of a long-held goal has provided the opportunity for career advancement.
Strategies to provide career opportunities for health-care professionals in rural areas are always a challenge. As one such strategy, the external mode EN-to-RN conversion program has proven to be effective for these experienced ENs regardless of their educational background. In addition, participants' post-graduation experiences suggest that consideration be given to more flexibility in the way the graduate program for the EN-to-RN graduate is structured. The degree to which the EN pathway graduate can move beyond novice RN faster than the usual pre-registration student after graduation is yet to be explored.
The authors would like to thank the participants of this study and acknowledge the Nurses Memorial Charitable Trust who provided financial support.
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