Valuing Enrolled Nurses – A study to better understand the investment education and training have on the retention of Enrolled Nurses

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Valuing Enrolled Nurses – A study to better understand the investment education and training have on the retention of Enrolled Nurses Rebecca J. Leon ∗,1,2,3,4,5 , Jaimie H. Tredoux 1,2,3,4,5 , Suzanne M. Foster 1 South West Sydney Centre for Education and Workforce Development, Corner of Elizabeth and Goulburn Streets, Liverpool Hospital Eastern Campus, Liverpool NSW 2170, Australia

a r t i c l e

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Article history: Received 4 September 2017 Received in revised form 21 June 2018 Accepted 1 July 2018 Available online xxx Keywords: Enrolled nurse Scope of practice Retention Role Professional development Career

a b s t r a c t Background: Despite the investment in education and training, a Health Service in Australia continues to experience a shortage of enrolled nurses. Aim: The aim of this study was to understand the investment education and training have on the retention of enrolled nurses in the Health Service. Methods: An explanatory sequential mixed methods design was used. The study was divided into three phases: 1. Separate surveys to enrolled nurses and stakeholders (nursing managers and educators); 2. Focus groups for enrolled nurses and stakeholders; 3. Analysis of recruitment and retention data from the graduating Diploma of Nursing cohorts. Results: Phase 1 and 2 identified that enrolled nurses participated in education and training for selfsatisfaction and personal interest. A professional development pathway was identified as something that would retain enrolled nurses. Inconsistent standards and confusion in their scope of practice, together with a lack of respect for the enrolled nurse, contributed to them leaving. Phase 3 identified poor recruitment processes for the graduating Diploma of Nursing cohorts negatively impacted on their retention. Discussion: Retention of enrolled nurses was influenced by inconsistent standards of practice, confusion in their scope of practice, and a lack of career progression. Phase 3 demonstrated that changes made to the recruitment process resulted in improved retention. Conclusion: Limited opportunities for professional development, confusion in their scope of practice and feelings of being undervalued influenced the retention of enrolled nurses. The results also indicated a well-structured recruitment program favourably impacted on retention. © 2016 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Summary of relevance This paper adds to the literature examining the role of the enrolled nurse (EN) in the Australian healthcare context. The results of this study identified that an EN professional development pathway would support retention of the EN. Factors impacting

∗ Corresponding author at: Liverpool Hospital Eastern Campus, Locked Bag 7279, Liverpool NSW, BC 1871, Australia. E-mail address: [email protected] (R.J. Leon). 1 Bankstown-Lidcombe Hospital Address: 68 Eldridge Rd, Bankstown NSW 2200. 2 Bowral and District Hospital Address: 97-103 Bowral St, Bowral NSW 2576. 3 Camden and Campbelltown Hospitals, Address: Therry Rd, Campbelltown NSW 2560. 4 Fairfield Hospital Address: Prairievale Rd & Polding St, Prairiewood NSW 2176. 5 Liverpool Hospital Address: Corner of Elizabeth and Goulburn Streets, Liverpool NSW 2170.

negatively on their retention included inconsistent standards and confusion in their scope of practice, feelings of being undervalued and limited opportunities for professional development. Further research is needed to address the confusion in their scope of practice; and the feelings of lack of respect felt by the EN. The study also identified that the ageing workforce appears to be starting with mature-aged graduates. 1. Background Enrolled Nurses (ENs)6 are members of the health care team and play an integral role within the nursing workforce. They are a regulated workforce and work under the supervision of Registered

6 Enrolled Nurses are also known as Registered Practice Nurses, Licensed Practical Nurses, Division 2 Nurses.

https://doi.org/10.1016/j.colegn.2018.07.001 1322-7696/© 2016 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Please cite this article in press as: Leon, R. J., et al. Valuing Enrolled Nurses – A study to better understand the investment education and training have on the retention of Enrolled Nurses. Collegian (2018), https://doi.org/10.1016/j.colegn.2018.07.001

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Nurses (Australian Nursing & Midwifery Accreditation Council, 2017). A Health Service (HS) in Australia employs approximately 12,500 staff of which approximately 500 are ENs. The HS, of which the researchers are employed, invests significant resources into education and training, including delivering the entry level program for ENs, the Diploma of Nursing. Despite this investment there continues to be a shortage of ENs. The Australian Institute of Health and Welfare (2015) identified a decreasing trend in EN’s registrations, with an overall –0.8% change from 2011 to 2015. The Australian Government Department of Jobs and Small Business (2017) also identified a decreasing trend over the last five years for ENs, with the forecast that this workforce will stabilise by May 2022. However, in their 2017 Labour Market Research report they identified a 1% increase from December 2015 to December 2016 in the EN workforce (Australian Government Department of Employment, 2017). With these differing perspectives, only time and further scrutiny of this workforce will identify if the trend has reversed. A research study was conducted to understand the investment education and training has on the retention of ENs in the HS. The results of the study will inform recommendations for ongoing investment into education to ensure a sustainable EN workforce.

2. The literature A comprehensive analysis of the literature was conducted. There was an initial search within a ten year window to establish contemporary knowledge and information. This was then expanded to be open ended to identify older references relevant to the topic. Any literature that did not explicitly indicate that the nurses were ENs was excluded. The EN role was first introduced in Australia in the 1950 s to improve the supply of nursing-related services (Dewdney, 1972). Since the introduction of the role, there has been increasing diversity in their scope of practice. This has been driven by factors including retention of ENs, an ageing workforce, administration of medication and the complexity of rural and aged care settings (Cusack et al., 2015; Dalton, Levett-Jones, & Gee, 2018, ND; Jacob, Barnett, Sellick, & McKenna, 2013). The increasing diversity in their scope of practice has resulted in confusion between the roles of the RN and the EN (Gibson & Heartfield, 2003; Jacob, Sellick, & McKenna, 2012; Jacob, McKenna, & D’Amore, 2016; Milson-Hawke & Higgins, 2004). This confusion is a result of perceived similarities between these two roles (Gibson & Heartfield, 2003; Kenny & Duckett, 2005). Chaboyer et al. (2008), p. 1283) conducted an observational study of the activities performed by ENs and RNs, and identified that ‘the actual activities undertaken by ENs and Level 1 RNs are not particularly different, suggesting a blurring of roles.’ A key professional development strategy for ENs is on providing career progression that is tied to the EN to RN transition (Allan & McLafferty, 2001; Birks, Al-Motlaq, & Mills, 2010; Dearnley, 2006; Iley, 2004; Kenny & Duckett, 2005; Ralph, Birks, Chapman, Muldoon, & McPherson, 2013; Rapley, Nathan, & Davidson, 2006; Rapley, Davidson, & Nathan, 2008). Reasons for an EN to become a RN were identified as ‘push’ rather than ‘pull’ factors (Ralph et al., 2013). Push factors are described as negative emotions towards the role of the EN, limited opportunities for professional development and career advancement, confusion around their scope of practice, ambiguity about their role, lack of encouragement and role erosion (Allan & McLafferty, 2001; Dearnley, 2006; Kenny & Duckett, 2005; Ralph et al., 2013; Rapley et al., 2006). In contrast ‘pull’ factors are described as factors that entice. There was little evidence for ‘pull’ factors with only one study by Allan and McLafferty in 1999 that

reported financial incentives as the EN’s reason for becoming a RN (as cited in Ralph et al., 2013). Combined, these factors resulted in an EN workforce with ongoing concerns about job security, job satisfaction and lack of professional opportunities (Dalton, Levett-Jones, & Gee, 2016; Hoodless & Bourke, 2009; Jacob et al., 2013; Kenny & Duckett, 2005). With this evidence, this study focussed on the investment education and training has on the retention of ENs in the HS. Understanding this would assist in the development of future education and training that supports a satisfied and sustainable EN workforce. 3. Aim The aim of this study was to understand the investment education and training has on the retention of ENs in the HS. The following questions were designed to explore the aim: • What education and training opportunities currently exist for ENs working in the HS? • What level of uptake occurs within the education and training offered? • What areas across the HS employ ENs? • What new opportunities could be made available for ENs, including specialty skills or other areas of interest? • What education and training do ENs require, to meet the expectations of management? 4. Method This study used an explanatory sequential mixed methods design. This methodology was chosen as it provided the opportunity to capture a breadth of data through the quantitative phase, which informed the qualitative phase capturing a depth in the data. This combination of quantitative and qualitative approaches resulted in a more comprehensive body of evidence than using either method alone (Creswell & Plano Clark, 2018). The study was divided into three phases: Phase one involved surveying two cohorts. Cohort one were the ENs and cohort two were the Stakeholders (nursing managers and educators) employed in the HS. Completion of the surveys was anonymous and participants were asked to complete the survey once only. Representatives from the Executive Nursing and Midwifery Office, Facility Directors of Nursing, Educators, and Enrolled Nurses participated in the development and pilot of the survey questions. The EN survey consisted of 20 questions in the styles of yes/no, open responses, multiple-choice and Likert scales. ENs were asked questions relating to de-identifiable demographic details; their motivations for becoming and staying an EN; their participation in education and training; their career development; and their perception on the RNs understanding of the EN scope of practice. The EN cohort was sent a hard copy survey through internal mail due to inconsistent access to staff email. Completed surveys were confidentially returned. The Stakeholder survey consisted of 13 questions in the styles of yes/no, open responses, multiple-choice and Likert scales. Stakeholders were asked questions relating to de-identifiable demographic details; if they employed ENs in their department; education and training for ENs; opportunities that could be made available for EN career development; and their perception of the RNs understanding of the ENs’ scope of practice. The Stakeholders were sent an electronic survey through staff email. Phase two was conducting focus groups. The focus group questions were designed and based on the results and recurring themes identified from phase one. An invitation and information about

Please cite this article in press as: Leon, R. J., et al. Valuing Enrolled Nurses – A study to better understand the investment education and training have on the retention of Enrolled Nurses. Collegian (2018), https://doi.org/10.1016/j.colegn.2018.07.001

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Table 1 Focus Group Questions. Enrolled Nurse Focus Group 1 What do you consider essential on an EN Development Pathway? 2 What do you consider as nice to have on an EN Development Pathway? 3 What barriers do you have in accessing education and training? 4 What helps you access education and training? 5 Should education and training be EN specific or can you join in other training? Why/Why not? 6 If yes, what sort of education and training specific to ENs do you think we should consider? 7 What additional roles could be created to support your professional development? 8 From the survey the perception was that % RNs understood the ENs’ current scope of practice? Is it EN or RN education that is needed to improve this understanding? Stakeholder Focus Group 1 What do you consider essential on an EN Development Pathway? 2 What do you consider as nice to have on an EN Development Pathway? 3 What barriers do ENs have in accessing education and training? 4 What helps the ENs access education and training? 5 Should education and training be EN specific or can they join in other training? Why/Why not? 6 If yes, what sort of education and training specific to ENs do you think we should consider? 7 What additional roles could be created for ENs to support their professional development? 8 From the survey the perception was that % RNs understood the ENs’ current ENs’ scope of practice? Is it EN or RN education that is needed to improve this understanding?

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participants were provided a Participant Information Sheet detailing the study, and clearly indicating that participation was voluntary. Consent was assumed on returned receipt of a completed survey. Written consent was obtained from all participants before the commencement of each focus group. All focus groups were conducted by the researchers, digitally recorded and then transcribed verbatim. No identifiable data was collected. All researchers came from the HS and had professional relationships with participants through the provision of education and training. Authors do not believe this relationship influenced the data, or created a bias. 4.3. Study limits A number of study limits were identified. A small sample size from both cohorts resulted in the inability to develop statistically significant conclusions. Inconsistent email access for the ENs resulted in the inability to use electronic surveys for this cohort. This limit was addressed with the use of hard copy surveys. Only one focus group per cohort was held at each site across the HS. While participants could attend any focus group location, there was potential for this to limit their ability to attend. Finally this study was limited to one public HS. Further analysis would be required to identify if the results from this study are representative of other public HS, and also of private organisations which employ ENs. 4.4. Data analysis

the focus groups was included with the respective surveys. Focus groups where scheduled for 45 min, but, in reality, ran from 30 to 90 min. Focus groups were chosen as the means to collect data, as it has been demonstrated that discussion within a group generates data the researcher might not obtain otherwise (Connelly, 2015). As the focus groups were used to explain the quantitative results a semi-structured approach was used. The focus group questions for each cohort are in Table 1: Focus Group Questions. Phase three focused on identifying graduating Diploma of Nursing students who were employed by the HS as an EN. This was done through the HS’ staffing database. The initial results led to a review of the recruitment processes for this specific cohort. The staffing database was able to identify how many graduates were employed by the HS on graduation, and whether or not they were still employed in the HS as an EN. 4.1. Setting and participants Participants were recruited from across a HS, which has five hospitals. Two cohorts were defined and their relevant details obtained from the staffing database. Recruitment strategies included the circulation of a memo from the HS Director of Nursing and Midwifery to all nursing and midwifery staff, and hard copy flyers placed in tea rooms and notice boards. Cohort one was currently employed ENs. There were 502 ENs invited to participate in the study. Cohort two, for the purposes of the study, were called stakeholders. This group were defined due to their involvement in approving, supporting and providing education for ENs. They were currently employed nursing staff in the positions of Clinical Nurse/Midwifery Educator, Nursing/Midwifery Unit Manager, Nurse/Midwifery Manager, and Director of Nursing and Midwifery. There were 410 Stakeholders invited to participate in the study. 4.2. Ethical considerations Research approval was obtained through the HS Ethics Committee, Valuing our Enrolled Nurses LNR/16/LPOOL/141. All

Data from the hard copy surveys was entered into Survey Monkey. Survey Monkey was used as an analysis tool. EN age, motivators, and satisfaction results generated inferences but due to the study limits there was the inability to generate a statistical significance. Data from the focus groups was coded and analysed. An inductive approach to thematic analysis was undertaken to determine latent themes within the data. Initial codes were generated separately for each focus group. These initial codes were then grouped into key themes. Integrating the data from phase 1 and 2 allowed key themes to be compared and consolidated. Each researcher conducted an independent thematic analysis to ensure validity. 5. Results 5.1. Phase 1: survey The demographic results from each cohort are presented, followed by the EN responses to their motivators, and education and training opportunities. The stakeholder responses to education and training opportunities are then presented; with the final results from phase one being the comparative results between the two cohorts. 5.1.1. Demographics – EN responses Of the 502 surveys circulated, 141 were returned, a response of 28.1%. No EN survey responses were excluded. Of the respondents, 11.3% identified as Male (n = 15), 88.7%, as Female (n = 118) and 5.67% skipped the question (n = 8), see Table 2 for age demographics of the ENs. The majority of ENs, 61.2% (n = 82) have a Certificate IV in Nursing, 45.5% (n = 61) have a Diploma of Nursing (of which 41.9% trained in the HS program) and 0.7% (n = 1) were hospital trained. Participants were asked which department they were currently employed. All departments were represented by the ENs.

Please cite this article in press as: Leon, R. J., et al. Valuing Enrolled Nurses – A study to better understand the investment education and training have on the retention of Enrolled Nurses. Collegian (2018), https://doi.org/10.1016/j.colegn.2018.07.001

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Table 4 What would keep the EN in their role.

Age bracket

Response

Answer Options

Response

Skipped ≤ 21years 22-36 years 37-50 years 51-70 years

0.7% 3.6% 29.3% 29.3% 37.9%

EN development pathway Recognition as an EN Other (personal satisfaction, finance) Nothing, I had no intention of staying as an EN

36.9% 36.9% 26.4% 9.7%

Table 3 When considering leaving the EN role. Why they would leave the role of the EN Transition to RN Limited career progression for EN 42.9% Other 21.4% - Financial - Stigma/Recognition 21.4% - Personal 14.3% circumstances - Progression to specialty area

Response 54.5% 48.1% 37.9%

Increased responsibility as an EN Workload issues Retirement

35.1% 35.1% 10.4%

5.1.2. Demographics – stakeholder Of the 410 surveys circulated to the stakeholders, there was a return rate of 17.6% (71 surveys), with 62.9% respondents identified as a Manager and 37.1% as an Educator. Seven (7) Stakeholder survey responses were excluded as they were incomplete. There were respondents from all departments except the rehabilitation department. 5.1.3. Stakeholders – ENs in their departments 85.71% identified they currently have ENs in their departments. Of those that said No, 82% see a role for an EN within their departments. 5.1.4. EN responses – motivators To the question ‘why did you choose to become an EN?’ 47.48% identified that they wanted to pursue a nursing career as an EN. 38.85% identified that they chose to be an EN as a pathway to becoming a RN. When analysed by age group, the following inferences could be made: • More ENs in the 22–36 age group had chosen to be an EN as a pathway to becoming a RN than those in the 37–50 and 51–70 age groups. • ENs in the 37–50 age group were more likely than those in the 51–70 age group, but less likely than those in the 22–36 age group to identify using the EN role as a pathway to becoming a RN. Other responses for becoming an EN included that it was shorter than the nursing degree 28.06%, financial reasons 27.34%, get a job faster 17.99%, and other 17.99%. Other was clarified in free text as Personal Circumstances (health, personal circumstances); Personal Satisfaction; Australian Health Practice and Regulatory Authority – RN oversees qualification recognised at EN level; and Pathway into Nursing Career. These respondents didn’t specify EN or RN pathway – just noted they wanted a career in nursing. When the ENs were asked ‘have you considered leaving your role as an EN?’ 58.2% said Yes and 41.8% said No. Analysis of Satisfaction responses by age, inferred that ENs in the 22–36 age group were more likely to say ‘yes’ than those in the other age groups. The reasons identified by the yes respondents are identified in Table 3.

The ENs were asked ‘what would keep them in the role of an EN?’ There was no difference across age groups or departments when asked what would keep them in their role, refer to Table 4. When asked about ‘what would motivate you (the EN) to participate in additional education and training? The responses were 23.7% self-satisfaction, 23.2% personal interest, 13.4% potential to increase money, 12.1% required for current role, 9.6% identified a change in role, 7.5% promotion, 4.6% seek future employment as an EN, 3.5% seek future employment NOT as an EN, and 2.4% identified other. It was at this point that free text comments identified feelings of being undervalued, and not being respected in the role of an EN. Statements included: • Maybe respect • To increase my salary and increase respect When comparing responses on motivators against age groups to participate in additional education and training, the following inferences could be made, those in the: • 22–36 and 37–50 age groups were more likely to participate in education and training to facilitate a change in roles than those aged 51–70 years. • 37–50 and 51–70 age groups were more likely to complete education and training for self-satisfaction and personal interest than those aged 22–36 years. • 37–50 age group identified they were more likely to seek promotion and increase income than those in the 22–36 and 51–70 age groups. 5.1.5. EN responses – education and training opportunities The ENs were asked ‘what ongoing education and training is specifically for ENs?’ The ENs responses included: Online, Unsure, None, Many but not for ENs, There are a few education and training programs but nothing that is recognised as a qualification for more (increase) wages, and . . .there are few opportunities for us. Everything requires you to be an RN. The ENs were asked if they had had opportunity to participate in education and training in the HS. 78.9% said Yes and 21.1% said No. There was no difference across age groups or departments ENs work in when analysed against opportunities to participate in education and training. A number of the ENs identified they were studying to be a RN because that was expected of them or it was their only opportunity to have career progression. Although, their comments identified they would have preferred to stay as an EN. EN participant comments included: • A lot of people say to me oh when you get to be an RN there are so many doors that open to you, so I am doing part time studies for that because I don’t see any doors here. • It’s expected, everyone’s like ‘oh you’ve done your EN, when are you starting RNs’ . . . I’m, ‘oh well I wasn’t going to’ • Why can’t I just be an EN?

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Table 5 Comparison of what the ENs and Stakeholders identified as current and potential roles for the EN. ENs in Roles other than Clinical roles Teaching Mentoring Management Clinics Quality initiatives Evidence based practice guidelines Other

Currently participate

Potential to participate

EN response

Stakeholder response

EN response

Stakeholder response

20.6% 31.7% 4.8% 6.3% 17.5% 5.6% 13.5%

3.1% 15.4% 0.0% 15.4% 29.2% 0.0% 16.9%

18.9% 22.2% 12.6% 19.9% 13.6% 9.9% 3.0%

40.6% 59.4% 3.1% 42.2% 56.3% 28.1% 9.4%

Table 6 Support for the expansion of knowledge and skills of the EN.

5.1.6. Stakeholders – education and training opportunities The Stakeholders were asked ‘what ongoing education and training is specifically for ENs?’ Of the 75% who responded, the most repeated free text comment was Not specifically for ENs. Other free text comments included: • Only excluded if training specifically targets RNs; EN assessments • Encourage ENs to have a portfolio & specialise e.g. wound care champion • I have developed a specific career pathway for EEN. 5.1.7. ENs and stakeholders – comparative responses Both cohorts were asked about ENs currently working in roles other than clinical roles, and what roles other than clinical the EN could potentially participate. Table 5 provides this comparison. A key point of difference in regard to mentoring was that over 30% of ENs identified they are mentoring, as opposed to only 15% of the Stakeholders. However 59% of the Stakeholders identified it was a role that could be performed by the EN. Further clarification would be required on what each cohort understands as ‘mentoring’. Both cohorts were asked if they would support the expansion of knowledge and skills of the EN. This was positively responded to by both cohorts, as identified in Table 6. Both cohorts were asked if RNs have a clear understanding of the ENs’ scope of practice, see Table 7. 5.2. Phase two: focus groups In total eleven (11) focus groups were conducted and facilitated by the researchers. A focus group per cohort was held at five locations. An additional stakeholder focus group was held with the Directors of Nursing and Midwifery. In total 34 EN and 44 Stakeholders participated in focus groups. Focus group participants were provided with the focus group questions, refer to Table 1. Saturation in themes was observed at the third focus group per cohort, but the decision was made to continue with the focus groups as advertised. This decision was made based on equity of access to a focus group and ensuring there was opportunity for all staff who

Table 7 The RN has a clear understanding of the ENs’ scope of practice.

Table 8 Enrolled Nurse and Stakeholder Focus Group Themes. RANK

EN Response

Stakeholder Response

1 2 3 4 5

Education and Training EN Scope of Practice Lack of Respect Support Preceptor

EN Scope of Practice Education and Training Teamwork Culture Lack of Respect

felt they wanted to participate to have the opportunity to voice their opinions. Table 8 lists the top five themes from each cohort. These were determined by the highest number of responses. Analysis of free text comments in the survey and discussion in the focus groups identified the theme of ENs being undervalued and not being respected, with these comments: • Minimal respect and stigma of being ONLY an EEN (not a Real Nurse ie. RN)!! • Get treated like @#$%! Because I am ‘only’ an EEN. • . . .attitude to EN’s is that we are second rate citizens. . ..sometimes the NUMs treat you like that too. So it is also their attitude. • I felt that I was being dismissed because I was an Enrolled Nurse. A perception from the EN was that they do the same work as a RN, so being paid less also undervalued them. As indicated by the following comments: • Less money than RN, doing just as much. • Poor pay as opposed to RN’s when workload is the same and responsibilities. • Where I am working not much different to RN. 5.3. Phase 3: recruitment & retention of graduating ENs On analysis of the recruitment process of the locally trained ENs, it was identified that since 2011 five Diploma of Nursing cohorts graduated from the HS training program. There was no coordinated

Please cite this article in press as: Leon, R. J., et al. Valuing Enrolled Nurses – A study to better understand the investment education and training have on the retention of Enrolled Nurses. Collegian (2018), https://doi.org/10.1016/j.colegn.2018.07.001

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Table 9 Recruitment and retention rates for the graduating EN, 2011–2016 cohorts. Year Commenced

Year Graduated

No. of ENs Graduating

Recruitment No. of ENs employed as ENs in HS on graduation

% of ENs recruited

Retention No. of ENs employed as ENs in the HS as at November 2017

Retention % of ENs employed as ENs in the HS as at November 2017

a

2012

34

7

20.6

8.8

2014 2015 2016 2017 TOTAL

36 34 31 21 156

9 16 27 19 78

25.0 47.0 87.1 90.5 50.0

3 (4 employed as RN) 4 11 27 b 20 65

2011

a 2013 2014 2015 2016

a b

11.1 32.3 87.1 95.2 41.6

As a result of the 2011 class commencing later in the year, there was no 2012 commencing class therefore no graduating class in 2013. A graduate returned to the HS and was employed.

approach to the recruitment of the graduating classes in 2012 and 2014. The students were provided a professional development day within their course, but then left to seek out vacancies and employment opportunities on their own accord. This resulted in 20.6% and 25% recruitment respectively from these graduating classes to the HS. In 2015, a centralised bulk recruitment process was trialled where the graduates were interviewed and asked to provide their priority listing against vacant positions across the HS. This process increased the recruitment rate to 47%. Further refinement of subsequent recruitment processes involved changing the timing of when the interviews were conducted, and recruitment panels including nursing managers and educators from across the HS. This resulted in a recruitment rate of 90.5% in 2017. The recruitment and retention rates for the graduating ENs are presented in Table 9. 6. Discussion The discussion from the focus groups complimented the results of the survey, from both cohorts, as well as supported the findings from the literature review. The results identified key themes that showed why ENs were leaving their role, however, what would keep them in their role was an EN professional development pathway and recognition. The key themes from the results are discussed after the demographics of the ENs. 6.1. Demographics of the ENs The gender and age demographics of the ENs who participated in the study was consistent with the Australian Institute of Health and Welfare (AIHW) data of 2015, where males made up 9.4% of the EN workforce and the average age of an EN was 46.3 years old, and 47.7% over the age of 50 years (Australian Institute of Health & Welfare, 2015). The graduating ENs are older, as demonstrated by the age demographics and entry level qualification, see Table 2. This results in less time in the workforce before retiring. The ageing workforce starts with mature-aged graduates.

address this frustration is the development of a standardised EN professional development pathway. 6.3. Lack of respect and culture When exploring why ENs choose to become a RN, the results were consistent with the ‘push’ factors as described by Ralph et al. (2013). Patricia Evans (1994), p. 26), an EN stated ‘We are valuable members of the nursing profession, and we would like to be taken seriously’. In 2016, over 20 years later, in this study, one of the EN study participants stated ‘I felt that I was being dismissed because I was an Enrolled Nurse’. This was also reflected by Iley (2004) who identified that those ENs who converted to RNs were less likely to be satisfied with their work. The perception that an ENs only professional pathway is to become an RN and that the EN role is of lesser value needs to be challenged. The culture that continues to support this perception needs to be changed if the nursing profession is going to Value Enrolled Nurses and retain them. 6.4. Scope of practice Confusion and lack of clarity around the ENs scope of practice was a concern for safe and quality person centred care, and negatively impacted retention of the EN. This study supports the continuing evidence in the literature in regards to the confusion and inconsistencies surrounding their scope of practice. This confusion is not new and was documented as early as 1995 (Chang & Twinn, 1995) and continues to be documented (Jacob et al., 2013). Jacob et al. (2013), p. 155) states Significant changes to the scope of practice for enrolled nurses have occurred in Australia over the past decade. These changes. . .have resulted in increased role confusion and overlap between enrolled and registered nurses in Australia. The challenge now is to identify what would effect a change so the same discussion is not happening in another 20 years.

6.2. Education and training

7. Recruitment and retention of graduating ENs

EN’s participated in education and training for self-satisfaction and personal interest, not for their career progression. EN’s shared their frustration around education and training, as they had attended training, been assessed and allowed to perform a task or skill only to have a change in manager, or change the facility in which they worked and their scope was changed. The lack of standardised practice across the HS contributed to their feelings of being undervalued and underutilised. Both cohorts identified that there is minimal education and training available specifically for the EN. They did identify that an EN Professional Development Pathway would keep them in their role, see Table 4. One approach to

As a HS which trains its own ENs, the recruitment and transition process for the newly qualified EN did not exist in anything but an ad hoc process up to 2015. A review of the process and a coordinated response demonstrated a significant improvement in recruitment, which translated to an improvement in retention. An analysis of the earlier graduating cohorts identified ENs now employed as RNs. A standardised transition program for the EN in their first 12 months of practice was developed and implemented in 2017. Currently under development are specialty pathways to further support the professional development for the EN as well as standardise practice across the HS.

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7.1. Recommendations As a result of this study the HS is now: • Standardising competencies for ENs across the HS– recognition and transferability of skills. • Defining and communicating the ENs’ Scope of Practice to all nursing staff. • Implementing a Transitioning into Practice Program for the EN in their first 12 months of practice as the beginning of the EN Professional Development Pathway. • Implementing EN Specialty Professional Development Pathways – this will support standardised practice as well as provide further professional development opportunities. • As RNs are those staff that are required to supervise the EN (Nursing & Midwifery Board of Australia, 2016) the logical progression is to explore the role of the EN as perceived by the RN, and how they work together as a nursing team. 8. Conclusion This study set out to identify if the HSs’ investment into education and training for ENs had any impact on their retention. Limited opportunities for professional development were identified as a factor in retention. However it became very evident there were other factors which influenced EN retention. These were described as ‘push’ factors and included ENs’ feeling undervalued, confusion in their scope of practice and an expectation that their career progression was based on becoming a RN. These results are consistent with the literature and previous studies. The results also indicated that a well-structured recruitment program was a favourable retention factor. Further research is needed to address the continued confusion in the EN scope of practice; and the feelings of lack of respect felt by the ENs. There is also an opportunity to explore that the ageing workforce appears to be starting with mature-aged graduates. Acknowledgements Funding was received from the NSW Ministry of Health Nursing and Midwifery Office to support the appointment of a project officer at a Nurse Educator Grade 3 part-time for six months. Executive support was provided by the HS Director of Nursing and Midwifery. References Allan, I., & McLafferty, I. (2001). The perceived benefits of the enrolled nurse conversion course on professional and academic advancement. Nurse Education Today, 21(2), 118–126. Australian Government Department of Employment. (2017). Labour Market research - Nurses. Australia: Australian Government.

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Australian Institute of Health and Welfare. (2015, 9 June 2016). Nurses and midwives: division 2011-2015. Retrieved 12 November, 2017, from https:// www.aihw.gov.au/reports/workforce/nursing-and-midwifery-workforce2015/data. Australian Nursing and Midwifery Accreditation Council. (2017). Enrolled nurse accreditation standards 2017. Canberra, ACT: Australian Nursing and Midwifery Accreditation Council. Birks, M., Al-Motlaq, M., & Mills, J. (2010). Pre-registration nursing degree students in rural Victoria: Characteristics and career aspirations. Collegian, 17(1), 23–29. Chaboyer, W., Wallis, M., Duffield, C., Courtney, M., Seaton, P., Holzhauser, K., et al. (2008). A comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: An observational study. International Journal of Nursing Studies, 45(9), 1274–1284. Chang, A. M., & Twinn, S. (1995). Role determination in nursing – Implications for service provision. Journal of Nursing Management, 3(1), 25–34. Connelly, L. M. (2015). Focus groups. MEDSURG Nursing, 24(5), 369–370. Creswell, J. W., & Plano Clark, V. L. (2018). Designing and conducting mixed methods research (3rd ed.). Los Angeles: SAGE Publications Inc. Cusack, L., Smith, M., Cummins, B., Kennewell, L., Dennett, L., & Pratt, D. (2015). Advanced skills for enrolled nurses: A developing classification. Australian Journal of Advanced Nursing, 32(4), 40–46. Dalton, L., Levett-Jones, T., & Gee, T. (2016). Using clinical reasoning and simulation-based education to’ flip’ the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing, 33(2), 28–34. Dalton, L., Levett-Jones, T., & Gee, T. (2018). Using clinical reasoning and simulation-based education to ’flip’ the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing, 33(2), 28–34. Dearnley, C. A. (2006). Knowing nursing and finding the professional voice: A study of enrolled nurses converting to first level registration. Nurse Education Today, 26(3), 209–217. Department of Jobs and Small Business. (2017). Enrolled and mothercraft nurses Retrieved 25 January, 2018, from http://joboutlook.gov.au/Occupation.aspx?search=Industry&Industry=Q&code=4114. Dewdney, J. C. H. (1972). Australian health services. Sydney, Australia: Wiley. Evans, P. (1994). The voice of one, and many enrolled nurses. Australian Nursing Journal, 1(7), 26. Gibson, T., & Heartfield, M. (2003). Contemporary enrolled nursing practice: Opportunities and issues. Collegian, 10(1), 22–26. Hoodless, M., & Bourke, L. (2009). Expanding the scope of practice for enrolled nurses working in an Australian rural health service – Implications for job satisfaction. Nurse Education Today, 29(4), 432–438. Iley, K. (2004). Occupational changes in nursing: The situation of enrolled nurses. Journal of Advanced Nursing, 45(4), 360–370. Jacob, E. R., Barnett, A., Sellick, A., & McKenna, L. (2013). Scope of practice for Australian enrolled nurses: Evolution and practice issues. Contemporary Nurse, 45(2), 155–163. Jacob, E. R., McKenna, L., & D’Amore, A. (2016). Educators’ expectations of roles, employability and career pathways of registered and enrolled nurses in Australia. Nurse Education in Practice, 16(1), 170–175. Jacob, E. R., Sellick, K., & McKenna, L. (2012). Australian registered and enrolled nurses: Is there a difference? International Journal of Nursing Practice, 18(3), 303–307. Kenny, A. J., & Duckett, S. (2005). An online study of Australian Enrolled Nurse conversion. Journal of Advanced Nursing, 49(4), 423–431. Milson-Hawke, S., & Higgins, I. (2004). The scope of enrolled nurse practice: A grounded theory study. Contemporary Nurse, 17(1-2), 44–62. Nursing and Midwifery Board of Australia. (2016). Standards of practice: Enrolled nurses. Canberra, ACT: Nursing and Midwifery Board of Australia. Ralph, N., Birks, M., Chapman, Y., Muldoon, N., & McPherson, C. (2013). From EN to BN to RN: An exploration and analysis of the literature. Contemporary Nurse, 43(2), 225–236. Rapley, P. A., Davidson, L., & Nathan, P. (2008). Enrolled nurse to registered nurse: Is there a link between initial educational preparation and course completion? Nurse Education Today, 28(1), 115–119. Rapley, P. A., Nathan, P., & Davidson, L. (2006). EN to RN: The transition experience pre- and post-graduation. Rural and Remote Health Research, 6, 1–13, online.

Please cite this article in press as: Leon, R. J., et al. Valuing Enrolled Nurses – A study to better understand the investment education and training have on the retention of Enrolled Nurses. Collegian (2018), https://doi.org/10.1016/j.colegn.2018.07.001