Practice protocol

Transition to community nursing practice revisited

Irene Ellis
Coordinator Child & Family Health Nursing, RMIT University, School of Health Sciences, Division of Nursing & Midwifery, Bundoora VIC

Keri Chater
RMIT University, School of Health Sciences, Division of Nursing and Midwifery, Bundoora VIC

Abstract

The purpose of this paper is to explore and describe the process of transition that nurses experience when moving from the acute sector to a specialist area of community nursing. Issues explored include the increased movement of nurses into the community sector, the experience of culture shock and changes in nursing roles. Transition issues including the need for effective management and infrastructure support, mentoring and preceptorship, skills acquisition and continuing education will be examined. Joint implementation of what is successful at both university and industry levels can improve the transition to community nursing.

Keywords

Transition, community nursing, culture shock, preceptorship, mentoring

Article Text

Challenges of the transition into clinical practice that the newly graduated nurse is faced with, whether at the undergraduate level as a novice nurse or at the postgraduate level as a specialty nurse, are well documented (Benner 1984; Zerwekh & Claborn 2000). Kramer (1974) reported that this is a time of major adjustment and she introduced the term "culture shock" to describe common experience. Novice nurses face a myriad of problems, including issues of confidence with their newly acquired clinical skills as well as fear in making incorrect clinical decisions. Rosser and King (2003) argued that "(t)ransitions create change in identities, role, relationships, abilities, and behaviours and are associated with stress, upheaval and disruption" (p.207).

Transitions are made within the tertiary hospital sector between acute, chronic or rehabilitation care and from the tertiary hospital sector into the community sector. New graduates and experienced nurses have many choices when considering their future roles in the workforce. This in part is due to the broad array of clinical areas and health care settings available to them. In addition there are many postgraduate courses available to nurses who plan to consolidate their knowledge in their current area of practice (general or specialist) or to diversify into another field of nursing.

Hospitals function to "heal the sick", their clientele are in-patients with varying degrees of dependence on nursing and medical staff. Nursing and other hospital staff work as part of a team with strong organisational support. Nurses usually work a roster and have set and specific shifts with four to six patients to care for. If difficulties arise in such a setting they have the backing and support of their colleagues and the hospital management. The hospital team is well recognised and the roles and responsibilities of the team members are clearly defined.

Traditionally, most acute care was undertaken in the hospital sector. However, economic conditions, an aging population and research supporting the value of home-based care for clients (Swaidek, K 2009) has led to a change in the patterns of care over the last 10 years. There are increasing health care costs relating to length of stay as well as advances in medical technology which have put pressure on the existing acute-care system. This, coupled with a nursing workforce shortage across the country has created a burden on the acute care sector (Duke and Street, 2003). Some of the biggest impacts on acute care have been the changing demographic and disease patterns such as a sudden increased birth rate, and a continued increase in obesity in addition to an ageing population with co-morbidities.

Australia, like most western countries has an ageing population and it is predicted that by 2016, 16% of the population will be over the age of 65 (Courtney, Abbey and Abbey 2004). This has put strain on the public acute care system as older people are living longer and needing services to manage chronic conditions and co-morbidities. The Federal Government has acknowledged this and has identified priority areas such as asthma, cancer, diabetes, mental health, arthritis, cancer control and injury prevention as national priorities (Crisp & Taylor 2005). It is noticeable that all these conditions can be managed in the community sector as has been evidenced by a shift in the nursing workforce to post-discharge programs such as hospital in the home (Street, 2004).

The most recent demographic change in Australia has been the surprise increase in the birth rate. This was not factored into public policy and the result is that existing services are stretched to the limit. This is resulting in mothers being sent home within the first 24 hours following the birth of their baby (ABS 2009). Births in Australia are at a 25-year high with around 296,600 babies born in 2009, reflecting an estimated total fertility rate of 1.97 babies per woman.

Because of the changing landscape of health care Zurmlehy (2007) argued that "by 2010, it is anticipated that 70% of all nursing care will be performed in the community setting with increases in the level of technology and range of interventions provided in the home setting (p. 162). This paper presents a discussion on the role transition of the nurse from the acute to the community sector and presents recommendations to overcome the stress and disruption of role transition.

Role Transition

Many nursing leaders have examined the transition of new graduates into the work place (Kramer 1974; Benner 1984; Chick and Meleis 1986; Shumacher and Meleis 1994). Benner traced the movement from the transition of novice nurse to expert whereas Norma Chick and Afaf Meleis (1986) conceptualised transitions in nursing to include the process, movement over time and the individual's perception. Both of these works acknowledge that transition can be a time of disruption and 'shock'. Other studies undertaken have focused on transitions of nurses moving into hospice care (Rosser and King, 2002) or enrolled nurses undertaking their degree (Kilstoff and Rochester, 2003). However, few have examined the transition of experienced registered nurses from acute care settings to the community (Bryan et al 1997; Edgecombe and Chater, 2008; Hartung 2005; Hope 2001; Kralik and van Loon, 2006; Zurmlehy, 2007).

The transition into community nursing is reported by practitioners as being difficult and challenging and potentially as dislocating and confronting to the experienced nurse as it is to the newly graduated nurse. Separation from the old discipline of hospital-based nursing can lead to a period of chaos (Bridges & Mitchell 2000; Kimball 2005) as the new community nurse experiences confusion before redefining and embracing the new role. Nurses move from an environment where there is routine, security and familiarity to an environment where there is a lack of routine (Castledine 2002). They need to let go, or as Bridges & Mitchell (2000) put it, say goodbye to their past identity before moving forward. Further confounding this period of chaos and role redefinition, are the issues of confidence and competence. Disch (2002) aptly described this as moving from "expert to novice" (p310).

Community-based nursing practice is "a setting specific practice whereby care is provided for clients and families where they live, work, and attend school" (Stanhope & Lancaster 2008; 16). Not only is the nursing environment different but the underlying philosophy of community health nursing (Keleher, 2007) as well as the culture (Kimball 2005) is substantially different to that of hospital based nursing. The community nurse often has flexible working hours in sometimes difficult or inadequate buildings including the care recipient's home (Hitchcock 2003) and a different management structure. The nurse will be expected to work as a sole community practitioner and/or within a small multidisciplinary team. The scope of care may range from the individual to groups of people or sub-populations (Stanhope & Lancaster 2008) as well as inner city and rural/remote area communities. In addition, community nurses are expected to be able to see the bigger health picture (Keleher 2007) and be involved in policy development (Edgecombe 2006).

There may be real concerns about one's ability to perform newly learnt skills while engaging in health promotion strategies, recognising the need for intervention and referring appropriately. This transition is different for each individual with some moving forward rapidly, others gradually accepting the change in both role and identity, and some never taking that final step and returning, disillusioned and angry to their former role or by leaving the profession.

With the increasing focus on community based nursing there is an urgent need to examine this transition and report on the issues and attempts to improve the experience. The following section examines the need for orientation, mentoring and preceptorship, skills acquisition, and continuing education and career advancement.

Orientation

Nursing in the community by its nature is very diverse with organisations ranging from large, complex state run facilities with large infrastructures to very small, locally run agencies with community based committees of management which reflect the communities that are served. For community nurses to function there ought to be "...supportive, well structured organisations that have clear strategic directions and appropriate quality frameworks" (Ryan, Shaban & St John 2007:310). For a new community health nurse there needs to be a very clear period of induction or orientation into the organisation. Ideally, during this time the new community nurse needs to be supernumerary. St John and Shaban (2007) acknowledge that "(a)ppropriate induction and orientation maximises experiences, minimises culture shock and contributes to a smooth transition into a new role" (p.334).

The novice community nurse would benefit from the opportunity to become acquainted with the philosophy, policy and procedural aspects of the organisation. This includes information on the demography of the community being serviced, including age range, ethnicity and the major health issues related to this community. In addition the nurse needs to become acquainted with the other services and resources serving the community (Edgecombe & Chater 2008).

The nurse making the transition from the acute sector is used to working as a team member. Although the majority of the team members will have been nurses she/he will also have worked with the medical staff as well as other allied health staff including social workers, physiotherapists, occupational therapists and others. In the community sector the concept of 'team' becomes broadened to include staff working for other agencies in that community (Crooks, Griffiths, and Brown, A: 2010). It is imperative for the new community nurse to understand the connection between these agencies and their role as well as meeting the staff from these agencies. These contacts will become part of the formal and informal support networks for the newly transitioning nurse. Long term trusting professional working relationships will be forged.

All staff, particularly new staff benefit from regular team meetings. For the sole practitioner their meetings may be with colleagues from different venues who meet on a regular basis in both formal and informal networks. For those nurses working in larger organizations team meetings may be made up of nurses only or multidisciplinary team members. Such teams may meet for specific client groups, for example, child care or aged care teams or even illness specific issues such as diabetes or hypertension teams (Ryan, Shaban & St John 2007). The nurse making the transition into the community sector will benefit from the support of such teams.

Some agencies such as the Royal District Nursing Service will focus on primary, secondary and tertiary prevention and respond to the needs of the recovering individual. Larger community health services will incorporate this within their doctor's clinics. As well at this there will be a strong focus on illness prevention through campaigns and health related groups such as obesity, diabetes management or seniors exercise groups. Again there may also be a third layer of service provision which is directly related to community development. All this information should be made available to the transitioning nurse during a formal, defined orientation or induction. Honey and Walton (2008) suggest that the induction package includes 'signposts' to direct the new health visitor to resources as well as mentorship and preceptorship to assist in settling into the organization and from their research suggest that this formal induction reduces 'reality shock'.

Preceptorship and Mentoring

Preceptoring and mentoring are often used interchangeably (Borbasi, S. Jones, J and Gatson, C, 2004). However, there is a qualitative and quantitative difference. The term mentor is derived from the classic Greek legends. Mentor was a loyal and wise friend of Odysseus and was entrusted with the care of Telemachus, son of Odysseus when he went to war (McCloughen, O'Brien and Jackson, 2006). The goddess Athena disguised as Mentor would not show Telemachus where his father was. Instead, Mentor directed him to search in a particular area. Mentoring within nursing is similar in that it is not prescriptive and does not give answers, instead mentors focus on broader learning and facilitation of professional growth. Preceptorship (which doesn't have the ancient reference) on the other hand is specific to individual one to one guidance in professional practice. This is usually done with student nurses who 'buddy' with a preceptor. The nursing literature tends to conflate these two concepts and they are often used interchangeably.

Preceptoring and mentoring and can be done together or individually but it would appear logical for preceptorship to help start the period of transition and then for mentorship to follow. In the preceptorship model there is a definite time frame where there are set goals to be achieved. This would begin at orientation and the preceptor would assist the new community nurse through induction into the centre and community (Pickens & Fargotstein 2006). The major task of the preceptor is to provide constructive support within a planned framework to assist with the transition period (Borbasi et al, 2004). Preceptorship programs have been proven to work in assisting with recruitment and retention of nurses in community settings (Pickens and Fargotstein, 2006).

On the other hand mentorship can become an ongoing longer term role to support the newly transitioning nurse. The role of mentor appears less formalised and can often grow out of the preceptor model. Often times the role of mentor can be personality driven when the experienced community nurse and the new community nurse develop an ongoing professional relationship. The role of the mentor will be to continue to guide and direct the new community nurse giving constructive feedback so that the new nurse can grow and develop professionally (Borbasi, et al, 2004). This relationship is based on a mutual understanding of improving standards of care as well as the profession (Hall 2006).

Neither preceptorship nor mentorship works unless there is management support for these roles. This means that management has to value the time commitment taken by the experienced nurse to undertake the role of either preceptor or mentor. The experienced nurse needs to have her or his workload adjusted in a formalised manner. This could be a reduction in case load as well as formal acknowledgement in relation to the mentorship role being part of the position description. (Di Ciccio 2008; Hall 2006).

Skills Acquisition

Some of the skills a new community nurse will need to adjust from acute care sector roles are time management and personal professional accountability. Transitioning from an acute health service to a community service the nurse leaves behind the sense of security in knowing that s/he is part of a larger team in a highly regulated organisation. Although this can be daunting for the new graduate in relation to time management the new nurse has to learn the existing routine. In community health nursing this type of routinisation often does not exist. The nurse transitioning into the community has to learn to regulate her/his own workload and manage the time allocation accordingly. Some specific aspects of time management include prioritizing goals, planning, delegation and communication. As well as this community nurses need to be able to work to a deadline deal with crises and learn to say 'no' to avoid becoming overloaded (Grohar-Murray and DiCroce, 2003). A supportive work environment which includes preceptorship will help in developing these skills.

Newly transitioning nurses have to develop personal and professional accountability. Again this may be daunting as community nurses often do not have immediate back up and support for the decisions they make. Community nurses are expected to make independent decisions about a range of issues relating to client education and support, clinical care and medication management, all of which can be daunting. Rosser and King (2003) found that the anxiety that transitioning nurses experience diminishes with mentoring and time. Because of these inbuilt supports nurses gained more confidence which led to them developing a wider range of skills including treatment decisions as well as client, family and community advocacy.

In each state in Australia there is a branch of the Australian Nursing Federation. The Federation supports special interest groups such as the community health nurses' special interest group. These groups act as a link for nurses working in community health as a clearing house for information as well as developing professional support and peer accountability. Nurses working in the community can have access to their peers and can also have access to current journals as well as conferences and short courses. This assists in enabling the community nurse to develop personal and professional accountability and to establish peer networks.

Continuing education and career advancement

Nursing/midwifery academics and employing agencies recognise that to assist with the transition into the community sector nurses need to be educationally prepared. Smith and King (2008) acknowledge that this concept has been actioned by a number of universities in Australia who prepare postgraduate nurses to work with vulnerable and minority groups. This preparation includes the theoretical underpinnings and principles of community health, together with the development of research skills with an emphasis on epidemiology.

The community health agency needs to have a culture conducive to gaining clinical experience. In a synthesis of national reports undertaken in America and relating to nurses transition into the work environment Hofler (2008) asserted that in order to make the transition successful organisations need to include the opportunity of career development as part of a reward strategy. This also assists in recruitment and retention of nurses.

Of major issue here is that large hospital organisations have an educational infrastructure in place to support nurses with continuing education and clinical support. Pearson and Care (2002) argued that with continuing education it has been traditionally the role of managers to decide what type and content of education is needed for nurses. However, this model is not appropriate for community based nurses. They argue that self initiated learning is more conducive to community nursing. Becoming a member of a community nursing professional body will provide information on conferences and related continuing education opportunities.

There are many barriers that stand in the way of community nurses accessing continuing education opportunities. The size and location of the organisation for example rural and remote nurses, time, availability and cost all hinder this. Nurses have a full workload each day and in order to take time off during the working day to attend ongoing education can prove difficult. Barriers to participation (Penz et al 2007) particularly for remote nurses include financial constraints, time, support, isolation and having a trusted colleague to relieve them.

Continuing education is vital for the discipline of nursing as evidenced by the growing practice of recognising this through the allocation of Continuing Nursing Education (CNE) points. This is in its developmental stages in Australia and it is suggested that each registered nurse should gain at least 25 CNE points each year in order to maintain competence within the discipline.

Conclusions

In order to minimise culture shock that takes place when a nurse moves into the community sector there needs to be a focus on promoting a culture that both supports and fosters practice development. At the university level more community clinical hours at the undergraduate and postgraduate level would be desirable. This should be combined with formal theoretical courses addressing community health in all its diverse roles and practice settings. As well there needs to be a discrete 'transition to the work environment' course that focuses on differing types of management structures within the health domain and includes examples of differing types of service provision.

At the local level, when the new nurse enters the community health domain, committees of management need to have a formalised induction time where the new nurse is preceptored. The new community nurse needs to be supernumerary during this defined period. The transitioning nurse should have access to and become familiar with the role and scope of the organisation, its geographical area, demography and other service providers within that area.

Community nurses need to be introduced to existing professional networks and professional organisations. Involvement in these networks and organisations should be seen as a normal part of the nurses work load and recognised as essential for professional adjustment, development, confidence and competence. Computer technologies are as creative as we make them. The establishment of chat rooms and blog sites could potentially assist with ongoing support of community nurses particularly those in rural and remote areas.

To ensure that the transitioning nurse maintains his or her competencies there needs to be ongoing accessible continuing education which is acknowledged and supported by management. This could be managed through a clearing house based with a professional nursing organisation. As well as this there needs to be an increasing use of computer technologies to manage and distribute information regarding ongoing education.

With more health care being provided in the community setting there will be a greater number of nurses leaving the structured acute sector to work in a broad range of community settings. Leaders in nurse transitioning show this can be a wasteful and painful time of dislocation and culture shock. This paper presents a number of suggestions that, if implemented at both the university and community health care settings, may assist transitioning nurses to overcome their culture shock and feel more prepared and supported.

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