Graduate nurses' experience of postgraduate education within a nursing entry to practice programme.
Abstract: The first year of practice is usually a challenging time for nursing graduates. In New Zealand most undertake a Nursing Entry to Practice (NETP) programme aimed at socialising them into their new role and work environment. Some of these programmes now have embedded postgraduate courses. This means that graduates undertake higher education while at the same time adjusting to a new role and work environment. Using a cross-sectional survey design the purpose of this study was to explore graduate nurses' experiences of postgraduate education within a NETP programme. Overall, participants felt well prepared for postgraduate studies at academic, personal and professional levels, although most suggested that NETP programmes could allow for a stand-down period of three to four months before postgraduate education is introduced. This would give the graduate an opportunity to adjust to the clinical environment. They also highlighted the importance of making expectations clear from the outset. This study revealed that the number and nature of postgraduate courses offered in a NETP programme requires further investigation.

Key Words: Graduate nurse; nursing entry to practice programme; postgraduate education; cross-sectional survey.
Article Type: Report
Subject: Nurses (Education)
Nurses (Surveys)
Nurses (Beliefs, opinions and attitudes)
Universities and colleges (Graduate work)
Universities and colleges (Surveys)
Authors: McDonald, Stuart
Willis, Gail
Fourie, Willem
Hedgecock, Bronwyn
Pub Date: 11/01/2009
Publication: Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2009 Nursing Praxis in New Zealand ISSN: 0112-7438
Issue: Date: Nov, 2009 Source Volume: 25 Source Issue: 3
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 291894326
Full Text: Introduction

Various District Health Boards within New Zealand offer postgraduate courses within their Nursing Entry to Practice ( NETP) programmes. Graduates are therefore expected to perform the role of a beginning practitioner as well as embark on postgraduate education during their first year of practice. As yet there is little evidence available to substantiate the efficacy and impact of such embedded courses. The purpose of this study was to explore graduate nurses' experience of postgraduate education within a NETP programme. This was undertaken through a collaborative research project between a District Health Board and local nursing tertiary providers.

Background

International research has shown that new graduates are anxious about their practical skills as beginning practitioners (Beecroft, Santner, Lacy, Kunzman & Dorey, 2006; Roud, Giddings, & Koziol-McLain, 2005). The transition period from undergraduate student nurse to registered nurse can be stressful and challenging as the graduate attempts to cope with the new expectations of the registered nurse role. Combined with this is the employer expectation that graduates will perform competently after a brief orientation period (Hayman-White, Happell, Charleston & Ryan 2007). However, health care providers are encouraged to provide a supportive environment for graduates in which they can pursue their postgraduate studies. Evans (2001) suggested that employers who do not offer this, run the risk of failing to attract and retain graduates. Halfer, Graf, and Sullivan, (2008) in a descriptive study of 84 graduates, who completed a paediatric internship programme, found that job satisfaction was greatly improved and that graduate turnover decreased from twenty to twelve percent. They suggested that postgraduate education is valuable but can also be resource intensive, and that more research is required to evaluate the impact on retention, job satisfaction and competency.

Within the New Zealand context the first year of graduate practice has been of some concern for at least a decade. In 1998, the New Zealand Ministry of Health initiated a taskforce on nursing which recommended the development of a national framework for the first year of clinical practice for new graduate nurses (Ministerial Taskforce on Nursing, 1998). Subsequently, NETP programmes were introduced countrywide. These programmes are designed specifically to support the graduate in developing the knowledge and skills required to progress from a new graduate registered nurse to a competent registered nurse (Nursing Council of New Zealand (NCNZ), 2005). The programme's learning framework is linked to the Competencies for Registered Nurses (NCNZ, 2007), and the Standards for Nursing Entry to Practice Programme (NCNZ, 2005).

The District Health Board in this study established its NETP programme in 2001. While it is recognised as an integral component facilitating transition from undergraduate student to registered nurse, this programme was resource-intensive and did not contribute to any formal qualification. In late 2005 a decision was made to formalise this education into the tertiary sector by including postgraduate courses within the programme. Consequently, in February 2006 new graduates were required to undertake two postgraduate courses while on the Graduate Nurse programme. These were: New Graduate Practice and Health Assessment and Diagnostic Reasoning. It was an expectation that all the graduates would complete these courses in their first year.

It is important to take into consideration the context in which the research took place. Although graduates were informed that the extra study was a requirement for completion of the graduate nurse programme, initially this condition was not linked to their employment contract for fear that it might evoke resistance to entering the programme. However, it was proposed that this condition would be stipulated in future employment contracts. In the event both the newly appointed Nurse Co-ordinator and the graduates had limited time to prepare for the introduction of the postgraduate courses. As a result, guidelines and expectations related to these courses were developed throughout the year. It was therefore timely to determine the new graduates' experience of postgraduate education within their first year of practice within the NETP programme.

Methodology

The study adopted a cross-sectional survey design. This design focuses on examining data at one point in time (Taylor, Kermode, & Roberts, 2006). It was particularly appropriate for this study as the researchers wished to discover the graduates' experiences of postgraduate education while the experiences were still fresh in their minds.

The cross-sectional survey design combined both closed and open ended questions which allowed the participant to comment on their experience: for example, 1.2: On commencement did you feel fully informed about the expectations of postgraduate studies within the NETP programme? 2.2: In what way has your practice changed as a result of postgraduate education? Questions (refer to Table 1) were formulated by the researchers based on the three broad objectives of the study:

* To explore the level of preparedness of graduates doing postgraduate education with in a NETP programme

* To explore the perceived benefits and challenges of postgraduate education with in a NETP programme

* To identify to what extent the graduates' expectations of postgraduate education within the NETP programme were met.

The questionnaire consisted of 27 items, including one section dedicated to general comments for example, what could be done to improve graduates experience of postgraduate education in their first year of practice?

At a meeting with the graduates the research was explained by the primary researcher who explained that participation was entirely voluntary. There were 51 graduates involved in the programme, and as there were no exclusion criteria all were given the opportunity to participate. Forty completed the questionnaire resulting in a response rate of 82%.

Ethical Considerations

This study was approved by the tertiary educational institution's Ethics Committee. A Participant Information Sheet that explained the research, including voluntary participation, was provided to all participants. All those in the NETP programme were informed of the study by an independent person who had no relationship with the NETP programme. A time lapse between recruitment and completion of the questionnaire allowed opportunity for possible participants to consider whether or not they wished to participate. Data collection was through an anonymous questionnaire. Completion and return of the questionnaire implied consent.

Data Analysis

The closed questions were analysed via frequency counts and proportions. The results of this analysis were then presented visually, typically using pie graphs. Analysis of the open-ended questions was done in a multi-step fashion. Firstly, all answers were transcribed in full and ordered by question. Secondly, all answers for each question were then content-analysed by the researchers. Effectively the researchers were exploring all answers relating to each question and grouping similar responses together under a common theme. This was done until all responses were appropriately grouped for each open-ended question.

Results

The aim of the research was to explore how graduates perceived and coped with postgraduate education within a NETP programme. In relation to the first objective for the study the majority of the students felt well prepared for postgraduate education. At an academic level (95% indicated satisfactory or better), personal (82% indicated satisfactory or better) with respect to professional (87% indicated satisfactory or better) level. The preparation was lowest at the practical level with 25% rating this as unsatisfactory.

The majority of participants (75%) were aware their NETP programme involved postgraduate courses, but 41% were unclear as to the amount of work and time this would involve. Overall the most frequent time suggested was between one and two hours per week, yet many respondents were doing eight.

In relation to the second objective benefits and challenges of postgraduate education within the NETP programme, over three quarters of the participants (78%) felt their nursing skills had improved due to the programme and this positive experience had encouraged them to continue with their education (Refer to Figure 1.) "I feel I have deeper knowledge of anatomy and physiology and in doing a full head to toe assessment." Others mentioned having an increased knowledge and understanding of nursing practice and procedures especially in terms of being better informed on nursing procedures. "It has helped me to make my practice more evidence-based." Postgraduate education was deemed most useful in the area of examinations and assessments such as wound care and dialysis care (44%). "Highlighting/refreshing practical nursing skills in first semester i.e. IVL[Intravenous Line], wound care, dialysis and physical assessment ... health assessmentpaper\course] made me more confident doing everyday health assessments."

In this study 41% of the participants identified time management as a challenge.

"Time constraints and the work load was difficult, found it tough fitting it all in as well as doing shift work. "Almost half of the participants (47%) found it extremely demanding to balance, work, study and life issues in a shift work environment.

"I'm under stress because I am still adjusting myself into the new job position and environment, it also puts stress on my personal life."

The third objective focused on the expectations that graduates had of postgraduate education within a NETP programme. Participants expected postgraduate education to enhance their knowledge and understanding of nursing practice. Almost half (48%) of participants felt these expectations were met, however participants identified the need for a more supportive environment. "Need more support from ward.... the papers [courses] should have more practical application ... this puts extra strain on us when we are trying to get used to being a RN."

Some participants (18%) expected a greater degree of flexibility around assignments and extensions considering they were both working and studying. Other participants (31%) suggested more communication about the course requirements at the commencement of the course and clarification of how to access support would have been beneficial.

The majority (61%) of participants felt postgraduate education was appropriate in the first year of practice as reflected in Figure 2. "Yes, beneficial, as it measured my confidence and knowledge and made me well informed about nursing practice and skills." Choice also appears to be a common theme from the data with 32% recommending one postgraduate course and 52% recommending two courses in the first year of practice. "Maybe not to start post-grad education so soon. Maybe delaying it for a couple of months would give new grads time to adjust and do orientation and prepare themselves for further studies/3 Ultimately it is the student who wants to make the decision.

Discussion

Over three quarters of the respondents felt that their nursing skills had improved due to postgraduate courses being embedded in their NETP programme and that this positive experience had encouraged them to continue with their education in the future.

One of the biggest challenges participants experienced was time management. In this study, 41% identified time management as an issue. The majority of respondents found it extremely demanding to balance, work, study and life stresses in a shift environment. Participants on the NETP programme had to learn time management skills and seek out support wherever they could, be it family, friends or colleagues. Participants commented that their own support networks such as family were under stress while on the NETP programme as their families had already been supporting them for the previous three years as undergraduate students. Another year of academic study had the potential to add further stress to such relationships.

A common theme throughout the results was that of adjustment. New graduates focus on orientation and being accepted into the nursing profession as a peer. Having just completed a three-year degree they are ambivalent about commencing further study so soon. This, along with the expectation that they must successfully complete the NETP programme as it may be linked to their employment contracts, requires further research due to the stress that this now places on graduates. Participants suggested a settling in period was required before commencing study and postgraduate courses should not commence until the second rotation. This study concurs with other studies where graduates had a strong desire to be viewed as being competent and reliable clinicians and that postgraduate study could impact on this perception (Heslop, McIntyre & Ives, 2001; Kelly, 1998). A similar viewpoint is expressed by industry (Charnley, 1999).

While 65% of graduates expected the NETP programme would enhance their knowledge and understanding of nursing practice and 61% felt it was appropriate in the first year of practice, only 48% felt that these expectations were met. The main barrier to having their expectations fully met was identified as requiring a more supportive environment. Studies have highlighted the important role of supporting the new graduate by effective mentoring/preceptorship and clinical supervision (Beecroft et al., 2006; Fourie, McDonald, Connor & Barlett, 2005; Gray & Smith, 2000; Kelly, Simpson, & Brown, 2002). It has been suggested that support is what graduates consider the most important aspect of the new graduate year, and that a graduate-friendly clinical environment with access to competent role models is as much valued as academic study (Beecroft et al.).

Respondent comments also highlighted the difficulty that some graduates experienced with having to take responsibility for their learning and having to work within the parameters of study at a higher level. Literature does identify the need for learners to take responsibility, along with the course and the workplace, to promote clinical effectiveness of education (Hardwick & Jordon, 2002). The Strategic review of undergraduate nursing education: Final report to the Nursing Council, (KPMG Consulting, 2001) suggested that the first year of practice is the point at which professional registration occurs and the accountabilities and responsibilities embedded in that registration become a reality for the graduate and for the industry.

Many students expected a greater degree of flexibility with assignments and extensions, given that they were both working and studying. Respondents suggested that more communication on the course requirements at the commencement of the course and clarification on how to access support would have been helpful. If postgraduate study is an expectation in the first year of clinical practice then there is a responsibility for educators to ensure that students are aware of what this entails before they commence. In particular more information is needed about the choice of courses graduates might be offered and the academic expectations required. Graduates would then be better informed and prepared for industry, and realise that postgraduate education is a component of the transition from student to registered nurse.

Recommendations

The following recommendations were put forward for consideration by the District Health Board.

* Graduates should be given the option of commencing postgraduate studies on the NETP programme in either the first or the second semester.

* Clear expectations and guidelines should be made available to the graduates before the programme commences.

* Graduates should be made aware of how they will be supported throughout the programme, and how to access support.

* That the study be replicated in other District Health Boards.

Conclusion

The appropriateness of postgraduate education in the first year of practice requires further investigation. Although 56% of participants felt it was appropriate, 41% did not, with three percent being undecided. This research has shown that graduates require a period of socialisation into the role of the registered nurse before feeling confident to embark on postgraduate studies and that a 'stand down' period of three to four months could make a difference. Graduates valued the postgraduate studies as part of the NETP programme but they want to be able to choose their pathway into the course. To achieve this clear guidelines and expectations should begin at recruitment therefore allowing the applicant the freedom to make an informed choice. Flexibility on the number of courses taken in the first year of practice was important to participants. This may give them a greater sense of commitment and enable them to plan their study more effectively.

This study has given some insights into graduates' experiences but further research is required on this topic. Replicate studies with other District Health Boards who include postgraduate study would enable comparisons to be made that in turn may inform a national curriculum on NETP programmes. This could improve graduate outcomes and provide standards that would be consistent throughout the country, making graduate skills more transferable and better supported during their transition from new graduate to registered nurse.

References

Beecroft, P., Santner, S., Lacy, M., Kunzman, L., & Dorey, F. (2006). New graduate nurses' perceptions of mentoring: Six-year programme evaluation. Journal of Advanced Nursing, 55, 736-747.

Charnley, E. (1999). Occupational stress in the newly qualified staff nurse. Nursing Standard, 13(29), 33-36.

Evans, K. (2001). Expectations of newly qualified nurses. Nursing Standard, 15(41), 3338.

Fourie, W., McDonald, S., Connor, J., & Bartlett, S. (2005). The role of the registered nurse in an acute mental health setting in New Zealand: Perceptions versus reality. International Journal of Mental Health Nursing, 14(2), 134-141.

Gray, M., & Smith, L. (2000). The qualities of an effective mentor from the student nurses' perspective: Findings from a longitudinal qualitative study. Journal of Advanced Nursing, 32, 1542-1549.

Halfer, D., Graf, E., & Sullivan, C. (2008). The organizational impact of a new graduate paediatric nurse mentoring programme. Nursing Economics, 26, 243-250.

Hardwick, S., & Jordan, S. (2002). The impact of part-time post-registration degrees on practice. Journal of Advanced Nursing, 38, 524-35.

Hayman-White, K., Happell, B., Charleston, R., & Ryan, R. (2007). Transition to mental health nursing through specialist graduate nurse programs in mental health: A review of the literature. Issues in Mental Health Nursing, 28, 185-200.

Heslop, L., McIntyre, M., & Ives, G. (2001). Undergraduate student nurses' expectations and their self-reported preparedness for the graduate year role. Journal of Advanced Nursing, 36, 626-634.

Kelly, B. (1998). Preserving moral integrity: A follow-up study with new graduate nurses. Journal of Advanced Nursing, 28, 1134-45.

Kelly, D., Simpson, S., & Brown, P. (2002). An action research project to evaluate the clinical practice facilitator role for junior nurses in an acute hospital setting. Journal of Clinical Nursing, 11 (1), 90-98.

KPMG Consulting. (2001). Strategic review of undergraduate nursing education: Final report to the Nursing Council. Wellington: Nursing Council of New Zealand.

Ministerial Taskforce on Nursing. (1998). Report of the Ministerial Taskforce on Nursing: Releasing the potential of nursing. Wellington: Ministry of Health.

Nursing Council of New Zealand. (2005). Standards for nursing entry to practice programme. Wellington: Author.

Nursing Council of New Zealand. (2007). Competencies for the registered nurse. Wellington: Author.

Roud, D., Giddings, L., & Koziol-McLain, J. (2005). A longitudinal survey of nurses' self-reported performance during an entry to practice programme. Nursing Praxis in New Zealand, 21(2), 37-47.

Taylor, B., Kermode, S., & Roberts, K. (2006). Research in nursing and health care: Evidence for practice. Victoria: Thomson.

Stuart McDonald, RN, MHSc, Senior Lecturer, Department of Nursing and Health Studies, Manukau Institute of Technology, Auckland

Gail Willis, RN, PGDip (Health Science), Nurse Co-ordinator: Nurse Entry to Practice Programme (NETP) and Undergraduate Placements, Counties Manukau District Health Board, Auckland

Willem Fourie, RN, PhD, FCNA(NZ), Deputy HOD and Research Leader, Department of Nursing and Health Studies, Manukau Institute of Technology, Auckland

Bronwyn Hedgecock, RN, MHlth. Sci. Ed., Lecturer, School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland
Table 1.

Questions included in the Questionnaire.

To explore the level of preparedness of graduates doing
postgraduate education within the Graduate Nurse Programme

1. Rate your level of preparation for postgraduate education in
your first year of practice at an academic level; a personal level;
a professional level; a practice level.

2. Prior to commencement did you know that postgraduate
courses/papers were part of the Graduate Nurse Programme?

3. Where did you obtain information on the postgraduate courses in
the Graduate Nurse Programme?

4. On commencement did you feel fully informed about the
expectations of postgraduate studies within the Graduate Nurse
Programme?

5. How many hours per week did you anticipate committing to the
postgraduate courses in the Graduate Nurse Programme?

To explore the perceived benefits and challenges of postgraduate
education within the Graduate Nurse Programme

1. In what way has your practice changed as a result of
postgraduate education?

2. Which aspects of postgraduate education were the most useful to
your practice?

3. Which aspects of postgraduate education were most useful to you
personally?

4. Has this encouraged you to continue with postgraduate education?

5. In what way has this encouraged you to continue?

6. Did you find postgraduate education beneficial?

7. Which aspects of postgraduate education were the least useful to
your practice?

8. What, if any challenges did you encounter in your first year of
practice undertaking postgraduate education?

9. What strategies did you employ to address those challenges?

10. What would have made it easier for you to deal with those
challenges?

To identify to what extent the graduates expectations of
postgraduate education within the Graduate Nurse Programme were met

1. What were your expectations of postgraduate education at the
commencement of the Graduate Nurse Programme?

2. How were these expectations in relation to postgraduate
education on the Graduate Nurse Programme met?

3. In what way, if any did your expectations change through-out the
Graduate Nurse Programme?

4. What were the barriers to having your expectations met in
relation to postgraduate education on the Graduate Nurse Programme?

5. Did you make it known that your expectations in relation to
postgraduate education on the Graduate Nurse Programme were not
being met?

6. Describe the response of those you made this known to.

7. What could have been done to improve/ensure your expectations on
the Graduate Nurse Programme were being met?

General Questions

1. Do you think postgraduate education in the first year of
practice within a NETP programme is appropriate/beneficial? Please
comment.

2. What could be done to improve graduates' experience of postgraduate
education in their first year of practice?

3. Is it preferable to undertake postgraduate papers within your
first year of practice?

4. If yes, how many would you like to do?

5. Please add any further comments regarding postgraduate education
in the first year of practice.

Figure 1. Ways in which practice changed as a result
of postgraduate education

Deeper knowledge                         22%
and understanding

More critical thinking                   14%
and reflection

Improved practical nursing skills        36%

Not much change                          19%

Bring all my experience and               3%
knowledge together

Standard of care decreased due            3%
to burn out

Greater confidence                        3%

Note: Table made from pie chart.

Figure 2. Appropriateness of post graduate
education in first year of practice

Furthers education while still in        29%
study mode

Mainly for single people--not             5%
appropriate for people with
families

Appropriate as it makes you               5%
research evidence-based
practice

Not appropriate as there is a            34%
lot of pressure to postgraduate
education with a lot of stress

Beneficial but more support              11%
needed from ward

Beneficial but need a choice of          16%
when to start postgraduate
education--it should not be
compulsory

Note: Table made from pie chart.
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