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I-Kiribati nursing graduates experience of transition from university to residential aged care facilities in Australia
Nurse Education Today 36 (2016) 463–467
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Nurse Education Today journal homepage: www.elsevier.com/nedt
I-Kiribati nursing graduates experience of transition from university to residential aged care facilities in Australia Elisabeth Coyne a,⁎, Hazel Rands a, Santi Gurung b, Ursula Kellett a a b
School of Nursing and Midwifery, Centre for Health Practice Innovation, Menzies Health Institute, Griffith University, Logan Campus, University Drive, Meadowbrook, Qld, 4131, Australia School of Nursing and Midwifery, Griffith University, Logan Campus, University Drive, Meadowbrook, Qld, 4131, Australia
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Article history: Accepted 20 October 2015 Keywords: International nursing students Graduate transition Phenomenology Residential aged care I-Kiribati
s u m m a r y Objective: To explore the experience of international nursing graduates from Kiribati transitioning into practice in RACFs, upon completion of their bachelor of nursing degree in Australia. Design: This study used an interpretive phenomenology design with two focus groups. A thematic analysis of the transcripts from the focus groups generated themes relating to the graduates personal journey through transition. Setting: This study was conducted with graduates working in residential aged care facilities [RACF]. Subjects: I-Kiribati nursing graduates (N = 6) who have been practicing for 1 year in RACF. Results: The experience of transition for the I-Kiribati graduates related to challenges faced during this time. Three themes were developed from the analysis: being unsure of expectations, understanding responsibilities of practice, and stepping up to the RN role. The influence of culture was apparent within the three themes. Conclusion: Overall, the transition to RACFs for the participants was difficult; however, students described increased confidence to work through professional and cultural challenges. They became more reliant on their own knowledge and skills as they matured as practitioners. Recommendations for improving the transition experience include transitional support and educational workshops related specifically to working in RACF. Tailoring workshops to the specific needs of international graduate nurses would assist their transition in relation to cultural differences. © 2015 Elsevier Ltd. All rights reserved.
Introduction
Kiribati Australia Nursing Initiative (KANI)
International nursing graduates in Australia increasingly seek employment in residential aged care facilities (RACFs), mostly due to difficulties finding employment in the acute sector related to English language requirements and visa restrictions (Nursing and Midwifery Board of Australia, 2014). These graduates have unique cultural, professional, and educational needs that are different to domestic graduate nurses and international graduates often feel challenged in the workplace due to language and expectation differences (Pokharel and Anichukwu, 2012). In addition, the transition into the RACF brings challenges that contrast to the acute setting. Challenges experienced during this transition have been found to increase anxiety in graduates, often leading to frustration and early burnout (Laschinger, 2012).
This study explored the experiences of nursing graduates from the Republic of Kiribati transitioning to practice in RACFs. These students completed their bachelor of nursing (BN) as part of an AusAID scholarship scheme offered through the Kiribati Australia Nursing Initiative (KANI) project. The KANI project provided I-Kiribati youth with an opportunity to acquire a bachelor nursing (BN) degree to enable them to seek national registration with Australian Health Practitioner Regulation Agency (AHPRA) and employment in Australia as registered nurses. The bachelor of nursing programme aims to develop competent and professional nurses to with general knowledge to commence practice in any nursing area.
Literature Review
⁎ Corresponding author at: School of Nursing and Midwifery, Griffith University Logan Campus, Meadowbrook, Queensland 4131, Australia. E-mail addresses: e.coyne@griffith.edu.au (E. Coyne), h.rands@griffith.edu.au (H. Rands), santi.gurung@griffithuni.edu.au (S. Gurung), u.kellett@griffith.edu.au (U. Kellett).
http://dx.doi.org/10.1016/j.nedt.2015.10.020 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
The transition from graduate nurse to competent practitioner is a complex experience (Bisholt, 2012; Clark and Springer, 2012). Clark and Springer (2012) propose that the first year of practice is critical to job satisfaction and retention of graduate nurses. Bisholt (2012) argued that graduate nurses practicing in acute care settings lack theoretical
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and clinical skills to manage complex cases and receive little supervision from senior colleagues. Graduates are often inadequately prepared for the clinical environment, despite prior exposure as a student nurse (Kelly and Ahern, 2009). The clinical environment, which is constantly changing in terms of organisation and social dynamics, can further complicate the graduate transition (Parker et al., 2012). Research has identified that transition from student to RN is a dynamic time which involves challenges to personal and professional identify (Phillips et al., 2014). The graduate period is a time for development of skills, social integration, and role changes, with the new graduate often struggling with balancing personal and work place expectations (Casey et al., 2004; Wangensteen et al., 2012). The graduate transition into RACF has received less exploration; however, transitional difficulties are noted to be similar with the added concerns of less senior staff to assist with support and supervision (Baldwin, 2013; Foley, 2013). RNs in RACFs are faced with challenges related to workload, organisational and supervisory responsibilities that are different to acute hospital care setting (Heath, 2010). Supervisory responsibilities in RACFs include being in charge of unlicensed carers and being accountable for the welfare of the residents and the staff (Carryer et al., 2010; Hunter and Levett-Jones, 2010). Despite a range of studies exploring the transitional challenges, there is scant research examining the transitional challenges experienced by international nursing graduates in Australia. Focus has been primarily on the internationally qualified nurse transitioning to work in acute care settings such as hospitals (Liou and Cheng, 2011; Thekdi et al., 2011). Thekdi et al. (2011) reported that international qualified nurses faced communication barriers and experienced feelings of isolation, often struggling with being assertive and feeling uncomfortable about asking questions during training and classes. Similarly, cultural and language differences were found to hinder international students from fitting in with university life and communicating effectively with staff (Liou and Cheng, 2011; McDermott-Levy, 2011). Junious et al. (2010) discussed cultural differences with RNs, finding that foreign-born nursing students struggled with working with other staff due to inherent cultural respect for elders, especially aspects such as eye contact with their supervisors. RACFs in Australia provide services for residents with a wide range of care needs, including low-care, high-care, and dementia-specialised units (Aged Care Reform, 2014). Residents are older, frailer, and present with multiple co-morbidities (Bedin et al., 2013; LerRoy et al., 2010). Despite having to provide care for such a specialised and complex group, RACF employees are paid less and have lower levels of qualifications in comparison to staff from other health care settings (AIHW, 2011). Workforce issues such as staff shortage, recruitment, and retention are commonplace, leading to challenges related to management and delegation concerns due to being the sole registered nurse on the shift (Baldwin, 2013; Carryer et al., 2010). Graduate education provides a baseline of understanding for caring for the older adult but often fails to develop the specialised skills for aged care including management skills (Smith and Barry, 2013). Transition into RACF has a range of challenges different from transition into the acute sector. Coupled with the increasing number of international graduates who are now beginning work in this sector, it is timely to explore their experience. The purpose of this study was to explore the transitional experience of I-Kiribati graduates. This group of graduates were chosen to develop a better understanding of the transition to RACF practice. Method An interpretive phenomenological research approach was used to understand the transitional experience of the I-Kiribati participants practicing in RACFs. Use of interpretive phenomenological methods specifically allows new insights, meanings, and understandings to
be discovered and placed in the practice context of the participants' world (Holloway and Wheeler, 2010). Interpretive phenomenology was chosen, as the researcher was an international student completing her masters with honours while practicing in a RACF. This ability to personally reflect on transition into practice allowed for shared experiences and a deeper engagement with the participants.
Sample A purposive sample of I-Kiribati graduates, currently practising in RACFs [N = 36], were emailed with the study information and invited to participate in the study. Six graduates [four female, two male] volunteered and participated in a focus group. Follow-up phone calls yielded no further participants. Graduates identified working as a reason for not participating in the study, but also the culture of participants influenced recruitment (George et al., 2014). The participants were all registered nurses [aged between 25 and 29 years] and have been working in RACFs for a year since graduating. Data Collection Two focus groups were completed with six participants using openended questions. A follow-up semi-structured interview with two students was then undertaken to clarify points from the first two focus groups. The third author [SG] conducted all focus groups. The focus groups began by asking participants about their experiences of beginning their nursing practice in a RACF. All questions were supported with follow-up probes encouraging participants to provide richer descriptions and allowing them to describe their opinions and feelings. While the questions asked related to their practice in RACF, the use of the term working was a purposeful decision. This ensured the participants understood that the focus groups were related to working in aged care rather than practicing as a student. Focus groups took place at a time and place convenient for the participants lasting between 35 and 45 minutes and were tape-recorded with participants' permission and transcribed verbatim. See Table 1.
Data Analysis Transcripts were analysed using thematic analysis as articulated by Braun and Clarke (2006). The analysis began by reading the transcripts several times to gain a comprehensive understanding of the participants' experiences. During these readings, similar opinions about topics were highlighted as initial content categories. Themes developed from analysis of the initial focus group were then explored in the follow-up focus group, providing an opportunity to explore themes further. Emerging issues were discussed with the supervision team and following consensus; the data were classified into themes. All participants were offered the opportunity to review the transcripts, so that they were given an opportunity to validate the transcripts (Braun and Clarke, 2006). Table 1 Focus group questions. Focus groups questions 1) How would you describe your experience of working in residential aged care facilities? 2) What was it in your bachelor of nursing that helped you to prepare you for work in an aged care setting? 3) What do you enjoy about working in aged care? 4) Can you describe the challenges you experience in your everyday practice in residential aged care facilities? 5) What help, have you received as a new registered nurse working in residential aged care facilities?
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Ethical Considerations Ethics approval was granted for this study from Griffith University Human Research Ethics Committee [GU Ref No:NRS/ 41/ 13/ HREC]. Prior to the focus group interviews, the study was explained and participants were provided with an opportunity to ask questions. The interviewer then outlined the ground rules that apply to the conduct of focus group interviews and gained written informed consent from each participant. Participants were reminded of their right to withdraw from the study should they wish to do so. Confidentiality of participants was guaranteed by the development of a master list kept by the first author [EC] that identified participants by an assigned code. The list was kept separately in a locked filing cabinet away from the transcripts and audio-records. Findings While numerous themes emerged from the transcripts, the themes presented in this paper focused on the experience of the transition to practice in RACFs. During the transition period, participants described their competence as RNs developing through being exposed to a range of challenging experiences. Findings were grouped into three themes which reflected this journey of professional development: being unsure of expectations, understanding responsibilities of practice, and stepping up to the role of being a RN. The influence of culture was apparent within these three themes. See Table 2. Theme: Being Unsure of Expectations All participants described feeling unsure of what was expected of being an RN. The first few months of practice were reported to be especially stressful, as participants struggled to deal with challenges in the workplace. Participants having just begun their professional nursing practice described being looked up to as ‘leaders’ and were being relied on to make decisions about clinical situations to which they had never been previously exposed. Sometimes you don't even know yourself, what you are expected to do, or what they are asking; you don't know the answer to most things. Participants spoke of ‘needing to assess them [residents] and come up with a decision on what to do next.’ Participants described this responsibility as stressful; their anxiety increased when they were unsure about how to manage varied clinical situations and needs of elderly residents, particularly without senior staff to assist. Participants also spoke of the challenge of working in residential aged care with little supervision or having few senior staff to support them. If you're in a hospital setting . . . you have somebody to turn to . . . but in aged care during afternoon or night shift, you don't have that. Language and cultural differences were considered to be another challenge for the participants who expressed personal fear because of their lack of comprehension, being misunderstood, or being laughed Table 2 Themes and sub-themes. Themes
Sub-themes
Being unsure of expectations
• • • • • • • •
Understanding responsibilities of practice. Stepping up to the RN role
Unsure of role Being the sole clinician Cultural differences—Asking for help Linking theory to practice Taking on supervisory role Challenges of delegation being aware of your own culture Increasing confidence in their nursing practice Appreciating the need to be knowledgeable and skilful
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at. ‘They tell jokes, they laugh, but we were like, sorry?’ Language and cultural difficulties were more challenging when dealing with death and dying. Participants expressed difficulty related to informing family members about their deceased relative, as they were unsure of the right words to use. I know in my own language, but like in the language, like in English, what is the proper way to say it? Experience of dealing with dead bodies also invoked fear: ‘It’s a feeling of like you're scared. The first time you're going to handle the death.’ The participants described their cultural experiences in Kiribati where only the elders dealt with death so as a young person it was very foreign. Participants spoke with uncertainty about their first experience of dealing with death as an RN, regardless of whether they had experienced this as a student nurse. I think it's just up to someone [else] . . . it's related to our culture. In particular, participants found the RN's responsibility for confirming the death of a resident challenging, as this was totally new to them. Dealing with the death of a resident was very personal due to their cultural background; in Kiribati, younger people were not involved with this aspect of society. I am the one supposed to do all the assessment and stuff, like to confirm the death, beside the doctor. So I have to touch, like feel the pulse and close his eyes. I'm just scared. Participants expressed comfort with practices that they felt familiar with, giving the example of medication administration, which they often practised, during their student clinical placements. However, due to large resident-to-nurse ratios, time was primarily spent administering medications, rather than trying to gain a better understanding of the residents' medical history and care needs. Participants were concerned that the RN role kept them away from the resident's bedside, leaving little time for ‘hands-on care.’ When someone wants to go to the toilet, I don't know how to mobilise him. So I have to go and check their care plan, because all I do is like the medication round. So it's not a good practice at all, like you don't know their history. All participants agreed that working in RACFs had a different focus to working in a hospital. In RACFs, nursing practice was focused more on managing the situation to ensure quality of life rather than attempting to fix the problem. Like, here is this massive ulcer. I can't fix it, but what sort of things can I do to actually manage it [ulcer]? You do things differently . . . you're not going to fix them, you're trying to give them a quality [of life] until the time comes. Theme: Understanding Responsibilities of Practice. Participants were acutely aware of their lack of clinical experience as RNs, especially when dealing with new incidents and numerous clients with dementia. Despite being taught in class about how to deal with challenging situations, applying this knowledge in practice was often difficult. One of the participants commented: We always freaked out. Like, we know in theory but in practice it's really different, and sometimes when there's a [challenging] scenario we forget all our teaching and theories. All participants agreed that this challenge was further complicated because of their culture, which had embedded relationship rules concerning elders from their community. Participants viewed elders as
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anyone who was older than them. In the I-Kiribati culture, listening to their elders, never saying no, or challenging their elders demonstrated deference and respect. As a consequence, participants expressed difficulty in balancing respect and concern for the individual elderly resident with their professional responsibility to effectively and efficiently manage time across multiple residents. They struggled to tell residents that they could not attend to their needs, which in their culture would be seen as very disrespectful. Our culture, it's tracking us as we're on the floor, it's hard for us to abandon someone—not to abandon, but just to move on to the next thing. We're more hooked up on one person than the other one, and we run out of time, because it's so hard for us to just leave—leave one person who needs more time. Participants talked of staying back to complete work, as they felt it was their responsibility. Sometimes we just have to stay after work . . . just to complete our paperwork, just to finish up everything. Being a RN in RACF included inherent supervisory roles and responsibility for delegating tasks to carers. However, due to the participants' culture, delegating tasks to staff that were often older was challenging; ‘coming from a background where we don't talk, especially to people who are older than us . . . it's really hard for us. . .’ Similarly, due to their culture, participants were not used to seeking help and strived to manage clinical situations independently, despite their lack of practice experience. Help was only sought when participants felt that the situation was beyond their control. ‘We tend to do things on our own . . . when it's really serious, we ask for help, but otherwise, we try and manage things on our own.’ Participants learnt to be self-reliant so as to avoid being burdensome on the other staff: ‘You don't want to ask every five minutes. . . So that's sort of the hard bit.’ The culture of the students clearly reflected a strong sense of respect for their elders, taking care of your elders, even though they're becoming very difficult you still have that respect for them. Theme: Stepping Up The participants described how they felt they had achieved a new level of working as a RN in RACF. After working for 6 months, participants felt more confident about their practice and experienced a greater sense of accountability, stating; You feel like you're the only one who can answer their [the residents'] calls, provide for their needs and manage them using your nursing skills. And the families, they all rely on you, too. Participants described feeling satisfied of having been able to step up to the challenges they initially faced, more confidence in providing care as they learned more about medications, understanding routines and being able to communicate with the family. Now it's pretty amazing, like how you know their medications. I just can't believe that I know their routine, medications, and stuff. Participants discussed the need to be knowledgeable and skilful to practise in a RACF, due to the acuity and complex level of care needed by the residents. Most of our residents now are coming down with basically everything; they've got heart condition, kidney condition, you do need a lot of skills to care for them. Overall, the participants described a sense of pride in their achievements as an international graduate working in a RACF and their ability to provide appropriate safe care for the residents.
Discussion The findings from this study revealed that the I-Kiribati participants' transitional experience was challenging and stressful, which is similar to all graduates but the participants accentuated the influence of their culture on this transition. However, they learnt to overcome their challenges and ultimately described a sense of pride in their practice in RACFs. In finding their way to becoming competent RNs, graduates encountered different learning experiences. Participants learnt to manage the expectations of working in RACF by gaining an understanding of their role as sole clinician in the facility. The RNs were in charge of administering medications to all residents and supervising other cares provided by unlicensed care assistants. A consequence of this was that the majority of the participant's time was dedicated to activities that removed them from direct resident care. This resulted in participants experiencing stress and frustration when they had limited opportunities to gain even a minimal understanding of the residents' history. Similar findings were reported by Heath (2010), who argued that RNs were kept away from the resident's bedside in RACFs. Practice was prioritised by supervision, nursing activities (medication round, wound dressings), and management resulting in extended amounts of time away from the bedside with limited opportunities to provide basic nursing care (Heath, 2010). RNs in RACFs are responsible for supervising and delegating tasks to unlicensed carers. In the current study, participants struggled with directing unlicensed carers, as they had little experience of delegation, and it was culturally difficult for them. Participants also experienced difficulties dealing with complex scenarios with little professional support. Similar findings were reported by Carryer et al. (2010), who found that despite being enthusiastic about their practice, RNs struggled to deliver quality care for their residents. Much time was dedicated to supervising tasks undertaken by unlicensed carers who had minimal levels of education (Carryer et al., 2010). Having to supervise unlicensed carers required the participants in the current study to have good time management skills. Participants discussed how the culture they had been brought up with influenced the way they delegated work tasks. Concerns such as the need to be knowledgeable to practise in RACFs were expressed, and related to the graduates ability to prioritise and organise their workload effectively. Similarly, Hunter and Levett-Jones (2010) found that RNs in RACFs need management skills to manage a range of unlicensed carers to ensure that their responsibilities were completed. The RNs role in aged care was described as a continual balancing act of managing clinical activities with documentation and other managerial responsibilities (Hunter and Levett-Jones, 2010). Participants also described feelings of stress and frustration when dealing with language and cultural difficulties. Consistent with previous studies, issues related to differences in language were a significant stressor during the transitional experience for international RNs (Junious et al., 2010; Liou and Cheng, 2011). Participants in the current study also spoke of the challenge of understanding jokes and the use of colloquialisms, particularly in relation to differences in their personal culture. McDermott-Levy (2011) found that Arabic nursing students in America did not feel confident in their ability to communicate clearly in English, which lead to increased stress when working. Liou and Cheng (2011) described the international RN as being confident about relaying patient information to doctors in their native language, but struggling to do the same in English. Similarly, participants in the current study experienced difficulties in maintaining cultural dignity when informing families about their deceased relatives or changes in condition of residents in English. The influence of culture for the participants was apparent throughout their transitional journey. Junious et al. (2010) also discussed the international graduates' experiences of cultural differences. Respect to their elders often hindered the participants' ability to supervise and delegate. Respect in Kiribati was demonstrated by following directives
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given by their elders; therefore, participants struggled with approaching older colleagues for help. In addition, death and dying was handled by the elders in I-Kiribati families, meaning that the participants had never been previously exposed to or had to deal with death. Although, scarce research has been undertaken to look at cultural challenges, respect for elders has been noted as a challenge, particularly aspects such as displaying respect to their elders, eye contact, and working with instructors (Junious et al., 2010). Similar concerns were voiced by the participants in the current study. Strengths and Limitations Findings of the current study should be interpreted within the context of its participants, which allows for the voices of the I-Kiribati graduates to be heard. The study provides a platform for further exploration of international nursing graduates, particularly their transition to working in a RACF. This study also provides an understanding of the transitional challenges faced by international nursing graduates who commence their practice in RACFs. Recommendations This study demonstrates the importance of providing graduate transition programmes for graduates who begin work in RACF. These programmes should include topics such as delegation responsibilities, time management, communicating with families, and dealing with dementia and death. The provision of transitional education could reduce retention problems and improve practice readiness in RACF. Workshops delivered online or face to face on a regular basis would increase the graduates' knowledge about gerontology and help to reduce transition anxiety. The workforce of RACF increasingly has less registered nurses and more enrolled and assistant nurses, making the provision of transitional support for RN graduates more difficult. A preceptor model of transitional support which could be used in the RACF for the first 6 months would provide the international graduate guidance and emotional support. External support could be made available to graduate nurses after hours via telephone or email assistance to answer any questions, discuss concerns, and reduce anxiety. The bachelor of nursing programmes need to promote aged care as a positive learning environment which will improve the graduates' understanding and engagement of aged care. The inclusion of cultural workshops both within the BN and graduate transition programmes would prepare graduates for working with different cultural groups. Further research is needed to explore the current level of transitional support provided in RACFs. Conclusion The aim of this study was to investigate the transitional experience of I-Kiribati graduates practising in RACFs. Findings resulted in three main themes: being unsure of expectations, understanding responsibilities of practice, and stepping up. Although challenges experienced varied slightly between individuals, all participants identified common meanings when facing similar experiences in RACFs. The transitional experience for the participants was described as a period of being unsure, yet beginning to understand what was expected. In summary, despite the challenges, participants reported that they had become more selfreliant and continued to have a positive attitude towards caring for the elderly.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
I-Kiribati nursing graduates experience of transition from university to residential aged care facilities in Australia Elisabeth Coyne a,⁎, Hazel Rands a, Santi Gurung b, Ursula Kellett a a b
School of Nursing and Midwifery, Centre for Health Practice Innovation, Menzies Health Institute, Griffith University, Logan Campus, University Drive, Meadowbrook, Qld, 4131, Australia School of Nursing and Midwifery, Griffith University, Logan Campus, University Drive, Meadowbrook, Qld, 4131, Australia
a r t i c l e
i n f o
Article history: Accepted 20 October 2015 Keywords: International nursing students Graduate transition Phenomenology Residential aged care I-Kiribati
s u m m a r y Objective: To explore the experience of international nursing graduates from Kiribati transitioning into practice in RACFs, upon completion of their bachelor of nursing degree in Australia. Design: This study used an interpretive phenomenology design with two focus groups. A thematic analysis of the transcripts from the focus groups generated themes relating to the graduates personal journey through transition. Setting: This study was conducted with graduates working in residential aged care facilities [RACF]. Subjects: I-Kiribati nursing graduates (N = 6) who have been practicing for 1 year in RACF. Results: The experience of transition for the I-Kiribati graduates related to challenges faced during this time. Three themes were developed from the analysis: being unsure of expectations, understanding responsibilities of practice, and stepping up to the RN role. The influence of culture was apparent within the three themes. Conclusion: Overall, the transition to RACFs for the participants was difficult; however, students described increased confidence to work through professional and cultural challenges. They became more reliant on their own knowledge and skills as they matured as practitioners. Recommendations for improving the transition experience include transitional support and educational workshops related specifically to working in RACF. Tailoring workshops to the specific needs of international graduate nurses would assist their transition in relation to cultural differences. © 2015 Elsevier Ltd. All rights reserved.
Introduction
Kiribati Australia Nursing Initiative (KANI)
International nursing graduates in Australia increasingly seek employment in residential aged care facilities (RACFs), mostly due to difficulties finding employment in the acute sector related to English language requirements and visa restrictions (Nursing and Midwifery Board of Australia, 2014). These graduates have unique cultural, professional, and educational needs that are different to domestic graduate nurses and international graduates often feel challenged in the workplace due to language and expectation differences (Pokharel and Anichukwu, 2012). In addition, the transition into the RACF brings challenges that contrast to the acute setting. Challenges experienced during this transition have been found to increase anxiety in graduates, often leading to frustration and early burnout (Laschinger, 2012).
This study explored the experiences of nursing graduates from the Republic of Kiribati transitioning to practice in RACFs. These students completed their bachelor of nursing (BN) as part of an AusAID scholarship scheme offered through the Kiribati Australia Nursing Initiative (KANI) project. The KANI project provided I-Kiribati youth with an opportunity to acquire a bachelor nursing (BN) degree to enable them to seek national registration with Australian Health Practitioner Regulation Agency (AHPRA) and employment in Australia as registered nurses. The bachelor of nursing programme aims to develop competent and professional nurses to with general knowledge to commence practice in any nursing area.
Literature Review
⁎ Corresponding author at: School of Nursing and Midwifery, Griffith University Logan Campus, Meadowbrook, Queensland 4131, Australia. E-mail addresses: e.coyne@griffith.edu.au (E. Coyne), h.rands@griffith.edu.au (H. Rands), santi.gurung@griffithuni.edu.au (S. Gurung), u.kellett@griffith.edu.au (U. Kellett).
http://dx.doi.org/10.1016/j.nedt.2015.10.020 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
The transition from graduate nurse to competent practitioner is a complex experience (Bisholt, 2012; Clark and Springer, 2012). Clark and Springer (2012) propose that the first year of practice is critical to job satisfaction and retention of graduate nurses. Bisholt (2012) argued that graduate nurses practicing in acute care settings lack theoretical
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and clinical skills to manage complex cases and receive little supervision from senior colleagues. Graduates are often inadequately prepared for the clinical environment, despite prior exposure as a student nurse (Kelly and Ahern, 2009). The clinical environment, which is constantly changing in terms of organisation and social dynamics, can further complicate the graduate transition (Parker et al., 2012). Research has identified that transition from student to RN is a dynamic time which involves challenges to personal and professional identify (Phillips et al., 2014). The graduate period is a time for development of skills, social integration, and role changes, with the new graduate often struggling with balancing personal and work place expectations (Casey et al., 2004; Wangensteen et al., 2012). The graduate transition into RACF has received less exploration; however, transitional difficulties are noted to be similar with the added concerns of less senior staff to assist with support and supervision (Baldwin, 2013; Foley, 2013). RNs in RACFs are faced with challenges related to workload, organisational and supervisory responsibilities that are different to acute hospital care setting (Heath, 2010). Supervisory responsibilities in RACFs include being in charge of unlicensed carers and being accountable for the welfare of the residents and the staff (Carryer et al., 2010; Hunter and Levett-Jones, 2010). Despite a range of studies exploring the transitional challenges, there is scant research examining the transitional challenges experienced by international nursing graduates in Australia. Focus has been primarily on the internationally qualified nurse transitioning to work in acute care settings such as hospitals (Liou and Cheng, 2011; Thekdi et al., 2011). Thekdi et al. (2011) reported that international qualified nurses faced communication barriers and experienced feelings of isolation, often struggling with being assertive and feeling uncomfortable about asking questions during training and classes. Similarly, cultural and language differences were found to hinder international students from fitting in with university life and communicating effectively with staff (Liou and Cheng, 2011; McDermott-Levy, 2011). Junious et al. (2010) discussed cultural differences with RNs, finding that foreign-born nursing students struggled with working with other staff due to inherent cultural respect for elders, especially aspects such as eye contact with their supervisors. RACFs in Australia provide services for residents with a wide range of care needs, including low-care, high-care, and dementia-specialised units (Aged Care Reform, 2014). Residents are older, frailer, and present with multiple co-morbidities (Bedin et al., 2013; LerRoy et al., 2010). Despite having to provide care for such a specialised and complex group, RACF employees are paid less and have lower levels of qualifications in comparison to staff from other health care settings (AIHW, 2011). Workforce issues such as staff shortage, recruitment, and retention are commonplace, leading to challenges related to management and delegation concerns due to being the sole registered nurse on the shift (Baldwin, 2013; Carryer et al., 2010). Graduate education provides a baseline of understanding for caring for the older adult but often fails to develop the specialised skills for aged care including management skills (Smith and Barry, 2013). Transition into RACF has a range of challenges different from transition into the acute sector. Coupled with the increasing number of international graduates who are now beginning work in this sector, it is timely to explore their experience. The purpose of this study was to explore the transitional experience of I-Kiribati graduates. This group of graduates were chosen to develop a better understanding of the transition to RACF practice. Method An interpretive phenomenological research approach was used to understand the transitional experience of the I-Kiribati participants practicing in RACFs. Use of interpretive phenomenological methods specifically allows new insights, meanings, and understandings to
be discovered and placed in the practice context of the participants' world (Holloway and Wheeler, 2010). Interpretive phenomenology was chosen, as the researcher was an international student completing her masters with honours while practicing in a RACF. This ability to personally reflect on transition into practice allowed for shared experiences and a deeper engagement with the participants.
Sample A purposive sample of I-Kiribati graduates, currently practising in RACFs [N = 36], were emailed with the study information and invited to participate in the study. Six graduates [four female, two male] volunteered and participated in a focus group. Follow-up phone calls yielded no further participants. Graduates identified working as a reason for not participating in the study, but also the culture of participants influenced recruitment (George et al., 2014). The participants were all registered nurses [aged between 25 and 29 years] and have been working in RACFs for a year since graduating. Data Collection Two focus groups were completed with six participants using openended questions. A follow-up semi-structured interview with two students was then undertaken to clarify points from the first two focus groups. The third author [SG] conducted all focus groups. The focus groups began by asking participants about their experiences of beginning their nursing practice in a RACF. All questions were supported with follow-up probes encouraging participants to provide richer descriptions and allowing them to describe their opinions and feelings. While the questions asked related to their practice in RACF, the use of the term working was a purposeful decision. This ensured the participants understood that the focus groups were related to working in aged care rather than practicing as a student. Focus groups took place at a time and place convenient for the participants lasting between 35 and 45 minutes and were tape-recorded with participants' permission and transcribed verbatim. See Table 1.
Data Analysis Transcripts were analysed using thematic analysis as articulated by Braun and Clarke (2006). The analysis began by reading the transcripts several times to gain a comprehensive understanding of the participants' experiences. During these readings, similar opinions about topics were highlighted as initial content categories. Themes developed from analysis of the initial focus group were then explored in the follow-up focus group, providing an opportunity to explore themes further. Emerging issues were discussed with the supervision team and following consensus; the data were classified into themes. All participants were offered the opportunity to review the transcripts, so that they were given an opportunity to validate the transcripts (Braun and Clarke, 2006). Table 1 Focus group questions. Focus groups questions 1) How would you describe your experience of working in residential aged care facilities? 2) What was it in your bachelor of nursing that helped you to prepare you for work in an aged care setting? 3) What do you enjoy about working in aged care? 4) Can you describe the challenges you experience in your everyday practice in residential aged care facilities? 5) What help, have you received as a new registered nurse working in residential aged care facilities?
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Ethical Considerations Ethics approval was granted for this study from Griffith University Human Research Ethics Committee [GU Ref No:NRS/ 41/ 13/ HREC]. Prior to the focus group interviews, the study was explained and participants were provided with an opportunity to ask questions. The interviewer then outlined the ground rules that apply to the conduct of focus group interviews and gained written informed consent from each participant. Participants were reminded of their right to withdraw from the study should they wish to do so. Confidentiality of participants was guaranteed by the development of a master list kept by the first author [EC] that identified participants by an assigned code. The list was kept separately in a locked filing cabinet away from the transcripts and audio-records. Findings While numerous themes emerged from the transcripts, the themes presented in this paper focused on the experience of the transition to practice in RACFs. During the transition period, participants described their competence as RNs developing through being exposed to a range of challenging experiences. Findings were grouped into three themes which reflected this journey of professional development: being unsure of expectations, understanding responsibilities of practice, and stepping up to the role of being a RN. The influence of culture was apparent within these three themes. See Table 2. Theme: Being Unsure of Expectations All participants described feeling unsure of what was expected of being an RN. The first few months of practice were reported to be especially stressful, as participants struggled to deal with challenges in the workplace. Participants having just begun their professional nursing practice described being looked up to as ‘leaders’ and were being relied on to make decisions about clinical situations to which they had never been previously exposed. Sometimes you don't even know yourself, what you are expected to do, or what they are asking; you don't know the answer to most things. Participants spoke of ‘needing to assess them [residents] and come up with a decision on what to do next.’ Participants described this responsibility as stressful; their anxiety increased when they were unsure about how to manage varied clinical situations and needs of elderly residents, particularly without senior staff to assist. Participants also spoke of the challenge of working in residential aged care with little supervision or having few senior staff to support them. If you're in a hospital setting . . . you have somebody to turn to . . . but in aged care during afternoon or night shift, you don't have that. Language and cultural differences were considered to be another challenge for the participants who expressed personal fear because of their lack of comprehension, being misunderstood, or being laughed Table 2 Themes and sub-themes. Themes
Sub-themes
Being unsure of expectations
• • • • • • • •
Understanding responsibilities of practice. Stepping up to the RN role
Unsure of role Being the sole clinician Cultural differences—Asking for help Linking theory to practice Taking on supervisory role Challenges of delegation being aware of your own culture Increasing confidence in their nursing practice Appreciating the need to be knowledgeable and skilful
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at. ‘They tell jokes, they laugh, but we were like, sorry?’ Language and cultural difficulties were more challenging when dealing with death and dying. Participants expressed difficulty related to informing family members about their deceased relative, as they were unsure of the right words to use. I know in my own language, but like in the language, like in English, what is the proper way to say it? Experience of dealing with dead bodies also invoked fear: ‘It’s a feeling of like you're scared. The first time you're going to handle the death.’ The participants described their cultural experiences in Kiribati where only the elders dealt with death so as a young person it was very foreign. Participants spoke with uncertainty about their first experience of dealing with death as an RN, regardless of whether they had experienced this as a student nurse. I think it's just up to someone [else] . . . it's related to our culture. In particular, participants found the RN's responsibility for confirming the death of a resident challenging, as this was totally new to them. Dealing with the death of a resident was very personal due to their cultural background; in Kiribati, younger people were not involved with this aspect of society. I am the one supposed to do all the assessment and stuff, like to confirm the death, beside the doctor. So I have to touch, like feel the pulse and close his eyes. I'm just scared. Participants expressed comfort with practices that they felt familiar with, giving the example of medication administration, which they often practised, during their student clinical placements. However, due to large resident-to-nurse ratios, time was primarily spent administering medications, rather than trying to gain a better understanding of the residents' medical history and care needs. Participants were concerned that the RN role kept them away from the resident's bedside, leaving little time for ‘hands-on care.’ When someone wants to go to the toilet, I don't know how to mobilise him. So I have to go and check their care plan, because all I do is like the medication round. So it's not a good practice at all, like you don't know their history. All participants agreed that working in RACFs had a different focus to working in a hospital. In RACFs, nursing practice was focused more on managing the situation to ensure quality of life rather than attempting to fix the problem. Like, here is this massive ulcer. I can't fix it, but what sort of things can I do to actually manage it [ulcer]? You do things differently . . . you're not going to fix them, you're trying to give them a quality [of life] until the time comes. Theme: Understanding Responsibilities of Practice. Participants were acutely aware of their lack of clinical experience as RNs, especially when dealing with new incidents and numerous clients with dementia. Despite being taught in class about how to deal with challenging situations, applying this knowledge in practice was often difficult. One of the participants commented: We always freaked out. Like, we know in theory but in practice it's really different, and sometimes when there's a [challenging] scenario we forget all our teaching and theories. All participants agreed that this challenge was further complicated because of their culture, which had embedded relationship rules concerning elders from their community. Participants viewed elders as
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anyone who was older than them. In the I-Kiribati culture, listening to their elders, never saying no, or challenging their elders demonstrated deference and respect. As a consequence, participants expressed difficulty in balancing respect and concern for the individual elderly resident with their professional responsibility to effectively and efficiently manage time across multiple residents. They struggled to tell residents that they could not attend to their needs, which in their culture would be seen as very disrespectful. Our culture, it's tracking us as we're on the floor, it's hard for us to abandon someone—not to abandon, but just to move on to the next thing. We're more hooked up on one person than the other one, and we run out of time, because it's so hard for us to just leave—leave one person who needs more time. Participants talked of staying back to complete work, as they felt it was their responsibility. Sometimes we just have to stay after work . . . just to complete our paperwork, just to finish up everything. Being a RN in RACF included inherent supervisory roles and responsibility for delegating tasks to carers. However, due to the participants' culture, delegating tasks to staff that were often older was challenging; ‘coming from a background where we don't talk, especially to people who are older than us . . . it's really hard for us. . .’ Similarly, due to their culture, participants were not used to seeking help and strived to manage clinical situations independently, despite their lack of practice experience. Help was only sought when participants felt that the situation was beyond their control. ‘We tend to do things on our own . . . when it's really serious, we ask for help, but otherwise, we try and manage things on our own.’ Participants learnt to be self-reliant so as to avoid being burdensome on the other staff: ‘You don't want to ask every five minutes. . . So that's sort of the hard bit.’ The culture of the students clearly reflected a strong sense of respect for their elders, taking care of your elders, even though they're becoming very difficult you still have that respect for them. Theme: Stepping Up The participants described how they felt they had achieved a new level of working as a RN in RACF. After working for 6 months, participants felt more confident about their practice and experienced a greater sense of accountability, stating; You feel like you're the only one who can answer their [the residents'] calls, provide for their needs and manage them using your nursing skills. And the families, they all rely on you, too. Participants described feeling satisfied of having been able to step up to the challenges they initially faced, more confidence in providing care as they learned more about medications, understanding routines and being able to communicate with the family. Now it's pretty amazing, like how you know their medications. I just can't believe that I know their routine, medications, and stuff. Participants discussed the need to be knowledgeable and skilful to practise in a RACF, due to the acuity and complex level of care needed by the residents. Most of our residents now are coming down with basically everything; they've got heart condition, kidney condition, you do need a lot of skills to care for them. Overall, the participants described a sense of pride in their achievements as an international graduate working in a RACF and their ability to provide appropriate safe care for the residents.
Discussion The findings from this study revealed that the I-Kiribati participants' transitional experience was challenging and stressful, which is similar to all graduates but the participants accentuated the influence of their culture on this transition. However, they learnt to overcome their challenges and ultimately described a sense of pride in their practice in RACFs. In finding their way to becoming competent RNs, graduates encountered different learning experiences. Participants learnt to manage the expectations of working in RACF by gaining an understanding of their role as sole clinician in the facility. The RNs were in charge of administering medications to all residents and supervising other cares provided by unlicensed care assistants. A consequence of this was that the majority of the participant's time was dedicated to activities that removed them from direct resident care. This resulted in participants experiencing stress and frustration when they had limited opportunities to gain even a minimal understanding of the residents' history. Similar findings were reported by Heath (2010), who argued that RNs were kept away from the resident's bedside in RACFs. Practice was prioritised by supervision, nursing activities (medication round, wound dressings), and management resulting in extended amounts of time away from the bedside with limited opportunities to provide basic nursing care (Heath, 2010). RNs in RACFs are responsible for supervising and delegating tasks to unlicensed carers. In the current study, participants struggled with directing unlicensed carers, as they had little experience of delegation, and it was culturally difficult for them. Participants also experienced difficulties dealing with complex scenarios with little professional support. Similar findings were reported by Carryer et al. (2010), who found that despite being enthusiastic about their practice, RNs struggled to deliver quality care for their residents. Much time was dedicated to supervising tasks undertaken by unlicensed carers who had minimal levels of education (Carryer et al., 2010). Having to supervise unlicensed carers required the participants in the current study to have good time management skills. Participants discussed how the culture they had been brought up with influenced the way they delegated work tasks. Concerns such as the need to be knowledgeable to practise in RACFs were expressed, and related to the graduates ability to prioritise and organise their workload effectively. Similarly, Hunter and Levett-Jones (2010) found that RNs in RACFs need management skills to manage a range of unlicensed carers to ensure that their responsibilities were completed. The RNs role in aged care was described as a continual balancing act of managing clinical activities with documentation and other managerial responsibilities (Hunter and Levett-Jones, 2010). Participants also described feelings of stress and frustration when dealing with language and cultural difficulties. Consistent with previous studies, issues related to differences in language were a significant stressor during the transitional experience for international RNs (Junious et al., 2010; Liou and Cheng, 2011). Participants in the current study also spoke of the challenge of understanding jokes and the use of colloquialisms, particularly in relation to differences in their personal culture. McDermott-Levy (2011) found that Arabic nursing students in America did not feel confident in their ability to communicate clearly in English, which lead to increased stress when working. Liou and Cheng (2011) described the international RN as being confident about relaying patient information to doctors in their native language, but struggling to do the same in English. Similarly, participants in the current study experienced difficulties in maintaining cultural dignity when informing families about their deceased relatives or changes in condition of residents in English. The influence of culture for the participants was apparent throughout their transitional journey. Junious et al. (2010) also discussed the international graduates' experiences of cultural differences. Respect to their elders often hindered the participants' ability to supervise and delegate. Respect in Kiribati was demonstrated by following directives
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given by their elders; therefore, participants struggled with approaching older colleagues for help. In addition, death and dying was handled by the elders in I-Kiribati families, meaning that the participants had never been previously exposed to or had to deal with death. Although, scarce research has been undertaken to look at cultural challenges, respect for elders has been noted as a challenge, particularly aspects such as displaying respect to their elders, eye contact, and working with instructors (Junious et al., 2010). Similar concerns were voiced by the participants in the current study. Strengths and Limitations Findings of the current study should be interpreted within the context of its participants, which allows for the voices of the I-Kiribati graduates to be heard. The study provides a platform for further exploration of international nursing graduates, particularly their transition to working in a RACF. This study also provides an understanding of the transitional challenges faced by international nursing graduates who commence their practice in RACFs. Recommendations This study demonstrates the importance of providing graduate transition programmes for graduates who begin work in RACF. These programmes should include topics such as delegation responsibilities, time management, communicating with families, and dealing with dementia and death. The provision of transitional education could reduce retention problems and improve practice readiness in RACF. Workshops delivered online or face to face on a regular basis would increase the graduates' knowledge about gerontology and help to reduce transition anxiety. The workforce of RACF increasingly has less registered nurses and more enrolled and assistant nurses, making the provision of transitional support for RN graduates more difficult. A preceptor model of transitional support which could be used in the RACF for the first 6 months would provide the international graduate guidance and emotional support. External support could be made available to graduate nurses after hours via telephone or email assistance to answer any questions, discuss concerns, and reduce anxiety. The bachelor of nursing programmes need to promote aged care as a positive learning environment which will improve the graduates' understanding and engagement of aged care. The inclusion of cultural workshops both within the BN and graduate transition programmes would prepare graduates for working with different cultural groups. Further research is needed to explore the current level of transitional support provided in RACFs. Conclusion The aim of this study was to investigate the transitional experience of I-Kiribati graduates practising in RACFs. Findings resulted in three main themes: being unsure of expectations, understanding responsibilities of practice, and stepping up. Although challenges experienced varied slightly between individuals, all participants identified common meanings when facing similar experiences in RACFs. The transitional experience for the participants was described as a period of being unsure, yet beginning to understand what was expected. In summary, despite the challenges, participants reported that they had become more selfreliant and continued to have a positive attitude towards caring for the elderly.
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