Supporting nurses moving into primary health care

With the threat of an impending nursing shortage it is widely recognised there is an urgent need to address recruitment and retention issues in the Australian primary health care nursing workforce.¹

Primary health care has been identified as the sector with the greatest potential to impact on the health challenges Australia faces with an ageing population and the growing burden of chronic illness.² It is therefore vital to develop an overall strategy where nurses are encouraged and supported in their transition to primary health care and assisted in remaining in the sector. Although the specific reasons for leaving the workforce are varied, it is widely recognised that, as with most jobs, new and experienced nurses are more likely to leave the sector if they do not have adequate support.³ 

This presents a significant challenge across all areas of primary health care in Australia. Due to the unique and often isolated environments and requirements of each primary health care setting, the level of support provided to transitioning nurses is quite varied.⁴ While all healthcare settings will develop appropriate strategies and processes to support their nurses, the needs and experiences of the nurses transitioning will also vary greatly.

Nurses who are moving into primary health care are doing so not only as experienced nurses from acute care settings, but also as recently graduated nurses from Australian universities. Nurses are entering at different points in their career and are diverse in their experiences and scopes of practice, which in turn requires varying levels of support. Both groups, however, require socialisation and introduction to the foundational elements of their chosen primary health care setting.

APNA conducted a literature review in November 2015 on Australian and international models of nursing preceptorship and mentorship and their role within transition programs. The purpose of this literature review was to inform the development of a 12 month pilot program of support for Australian nurses, both experienced and recently graduated, who are transitioning into various primary health care settings. APNA has been given funding by the Australian Government Department of Health under the Nursing in Primary Health Care Program. This program is called the APNA Transition to Practice Pilot Program.

Among the many findings of this literature review was that most Australian studies have looked at mentoring and preceptorship of nurses entering the acute healthcare sector — less work has been undertaken on nurses transitioning into the primary health care sector. This finding was also reflected in a 2016 paper by Ashely et al exploring the transition experiences of acute care nurses entering employment in primary health care settings. It noted that, while there is significant research relating to new graduate transition experiences, little is known about the transition experience from acute care into primary health care employment and observed that further research is required.⁴ 

Of interest, the 2014 study by Mellor and Greenhill looked at three South Australian rural transition to practice programs in 2008–2009.5 The study found that although new graduate registered nurses had an expectation of clinical support as they made the transition from novice to advanced beginner, this clinical support did not eventuate. As a result they reported feeling underprepared for practice and overwhelmed by responsibility, which could significantly impact safe patient care. 

The study concluded that graduate nurse transition programs need to have the physical and human resources necessary to deliver the clinical support to ensure patient safety. It also highlighted the need for three essential core elements — leadership support, clinical supervision, and effective interprofessional relationships — to be incorporated in all transition to professional practice programs.

These findings are not dissimilar to many observations and feelings expressed by nurses who have transitioned into primary health care — both experienced and recently graduated — who have participated in stakeholder engagement undertaken in preparation for the development of the APNA Transition to Practice Pilot Program. 

Where are we now?

In April 25 registered nurses who had recently transitioned into a variety of primary health care settings including general practice, residential aged care, Aboriginal health services and correctional health services, were selected from applications that met the essential criteria for tranche one of the APNA Transition to Practice Pilot Program.

(from left) Figure 1: An internal preceptor is available within the workplace of the transitioning nurse and supported by an external mentor and APNA. Figure 2: The transitioning nurse is supported by an external mentor/preceptor and APNA.

The 12 month structured but flexible support program aims to increase the confidence, competence, skill and knowledge of the transitioning nurse into their primary health care setting. Due to the varied needs of the transitioning nurses, motivated and experienced primary health care nurses with highly developed interpersonal skills are providing the transitioning nurses with preceptorship and mentorship in a variety of ways under the two distinct models of support as shown below.

Access to high quality, relevant, self-paced education is also a fundamental element of any transition program. Transitioning nurses enter the primary health care setting at different times in their career journey and have variable knowledge gaps, influenced by their previous work settings, duration in nursing and professional interests. Transitioning nurses are not a homogenous group, rather they have diverse needs and therefore diverse learning requirements. It was considered imperative that the Transition to Practice Pilot Program was developed using a strengths-based model that could accommodate inevitable variations in learning needs. 

An interactive decision support tool has been developed to assist transitioning nurses to identify, prioritise and record their learning needs. Selfassessment is integral to tailoring the educational element of the Transition to Practice Pilot Program to suit individuals. Transitioning nurses complete the assessment framework in collaboration with their nurse preceptor or nurse mentor/preceptor and together develop an education action plan for the following 12 months.

All aspects of the Transition to Practice Pilot Program are being continually evaluated to identify what works for whom and under what circumstances. All evaluation and feedback will inform progression to an improved model in tranche two, which will run from April 2017 to March 2018. Final findings and recommendations will follow.

Overall supporting nurses transitioning to primary health care requires a multifaceted approach, with education just being one facet of the support needed by the transitioning nurses. The support provided thus far has been well received by the participants, with one participant in Sydney saying that, ‘The support we receive is beyond my expectations. Thanks so much!’ Applications for tranche two will open towards the end of 2016. 

For more information visit www.apna.asn.au/transitiontopractice.

References
1. Health Workforce Australia 2014: Australia’s Future Health Workforce – Nurses Overview. 2014 [cited 10 August 2016]. Available from: www.health.gov.au/internet/main/publishing.nsf/Content/australias-future-health-workforce-nurses.
2. Australian Institute of Health and Welfare. Australia’s health 2014. Canberra: Australian Institute of Health and Welfare;2014.
3. Dawson A, Stasa H, Roche M, Homer C, Duffield C. Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies. BMC Nursing. 2014 [cited 10 August 2016] 13:11. Available from: www.biomedcentral.com/1472-6955/13/11.
4. Ashley C, Halcomb E, Brown A. Transitioning from acute to primary health care nursing: an integrative review of the literature. Journal of Clinical Nursing. 2016;25(15–16):2114–25. 
5. Mellor P, Greenhill J. A patient safety focused registered nurse transition to practice program. Contemporary Nurse. 2014;47(1–2):51–60.