http://orcid.org/0000-0001-9016-8840
Figures
Abstract
Objective
Shortages in the speciality nursing workforce, both nationally and internationally are driving the need for the development of an evidence-based model to inform recruitment and retention into speciality nursing practice. This study aimed to identify the factors influencing rapid and early career transition into speciality nursing practice.
Methods
A comprehensive systematic review of the literature was undertaken using a convergent qualitative synthesis design where results from qualitative, quantitative and mixed methods studies were transformed into qualitative findings. Databases included CINAHL, Medline, Scopus and PsycINFO. Search terms were: nurse, early career, rapid career, transition, specialty, and Medical Subject Heading terms included: professional development and educational, nursing, and continuing. Using validated tools, papers were independently assessed by a minimum of two reviewers.
Results
Twenty-three research articles were included. There were no randomized control trials. Through thematic analysis and matrix mapping of the results, the TRANSPEC model was developed. The model outlines three phases of transition: pre-entry, incomer and insider. There has been little focus on pre-entry with programs being designed at the incomer and insider phases. Impacting on these phases are three concepts: the self (professional and personal), the transition processes (informal and formal) and a sense of belonging. The overarching theme influencing the phases and concepts is the context of practice. Enablers and inhibitors influence successful transition and therefore impact on recruitment and retention. Each nurse’s transition is influenced by time.
Conclusions
For successful transition, the enablers and inhibitors impacting on the three concepts, phases and the context of practice need to be considered when developing any program. It is apparent that while previous studies have focused on the transition processes, such as curricula, the development of the self and a sense of belonging are also essential to successful transition. Further studies should include the pre-entry phase.
Citation: Hegney D, Chamberlain D, Harvey C, Sobolewska A, Knight B, Garrahy A (2019) From incomer to insider: The development of the TRANSPEC model – A systematic review of the factors influencing the effective rapid and early career TRANsition to a nursing SPECiality in differing contexts of practice. PLoS ONE 14(5): e0216121. https://doi.org/10.1371/journal.pone.0216121
Editor: Heather Cuevas, University of Texas at Austin, UNITED STATES
Received: January 16, 2019; Accepted: April 14, 2019; Published: May 1, 2019
Copyright: © 2019 Hegney et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: Initial of authors who received award: DH, CH, DC, BK. Grant Number: HE2755. Funder: Queensland Health. URL: www.qld.gov.au/health. A partner investigator, AG was the Partner Investigator. The partner investigator had the following role: a) Design of the project and call for tender and awarding the competitive grant tender to Hegney’s team. A requirement of the project was that at least two papers be published in a peer reviewed journal to ensure any new knowledge was shared with the wider community. b) Discussion of any proposed changes with the University research team. c) Assistance with the recruitment of participants to part B of the study (interviews with nurses who had completed a specialist transition program) - not the focus of this paper d) Assistance with the recruitment of participants into Part C of the study (the Delphi study) – not the focus of this paper. e) Input into any recommendations made from the full study (not the focus of this paper). AG was not involved in any data analysis nor did they have access to any raw identifiable data – just commented on the draft paper and provided input from a government perspective.
Competing interests: The authors have declared that no competing interests exist.
Introduction
The need to re-examine the numbers and the types of nurses, and their role within the health workforce arises due to many factors including population drivers; economic considerations such as increased costs of medical advances and the use of technology to provide services; and problems with health workforce supply and mal-distribution [1]. Population drivers include an increased demand on health services driven by the increased life expectancy of populations, particularly in developed countries, alongside the rising number of people living with chronic conditions who require more complex and long term treatment [2–4]. In Australia, a major driver of the change in health service delivery has been the 50% of the population with at least one chronic condition, as 40% of all preventable hospital admissions are related to chronic conditions [5]. Servicing the need for this population alone has driven up the cost of provision of services. Described as a “growing health crisis” [6], the increased cost for treatment has resulted in an increased acuity of patients in the acute care system, with a flow on effect of earlier discharge in an attempt to reduce the length of hospitals stays. The flow on effect has meant that patients who are sicker are being cared for in their homes by multidisciplinary teams from numerous specialty areas and service providers [6]. The cost of medical devices, particularly the increase in availability and use of technology for diagnosis and treatment [1] and Tele-health provision, particularly to populations in rural and remote areas, has also driven the cost of delivery [2]. These changes have resulted in a need to re-examine traditional ways that health professionals provide services within hospitals and the community.
Complicating this role redefinition, has been workforce supply and mal-distribution. Similar to its population, Australia has an ageing health workforce, many of which have reduced their working hours as they prepare for retirement [5]. The preference of many health professionals, particularly medical practitioners, to work in metropolitan areas, has resulted in a mal-distribution of that workforce. While this mal-distribution has been the focus of the Australian Government for many years, it is now increasingly evident that, while the mal-distribution of medical practitioners may continue, driving a shortage in rural and remote areas, there is now a growing overall shortage of nurses in all geographical areas as well as in specific areas of speciality nursing practice [5, 7]. The overall response of the Australian government to address the mal-distribution and shortage has been to increase supply [8]. Similar shortages have occurred in other countries such as the United States of America and the United Kingdom, for several decades [9, 10]. However, Buchan and Aiken [11] also suggest that the reasons for the shortages are complex and not limited to actual numbers entering the profession.
In Australia there are three levels of nurses. Two levels are regulated by the National Body: Australian Health Practitioner Agency (AHPRA),–the registered nurse (RN) and the enrolled nurse (EN). The RNs complete a university degree (Master or Bachelor), while the ENs mostly graduate with a diploma obtained from a technical college. The third level are unregulated care providers known as assistants in nursing (AIN) or Personal Care Workers (PCWs), who may or may not have certificate qualifications. The three levels of nurses work across all care settings, with the registered nurse held responsible for the care that is delegated to ENs/AINs. There are also nurse practitioners (NP) who were introduced to the workforce in 2001. NPs are experienced RNs who work as advanced clinicians following the completion of a specialised master’s degree. NPs are endorsed through AHPRA, have limited prescribing rights and manage their own caseload.
In Australia, it is predicted that there will be a shortfall of 85,000 nurses by 2025 mostly due to increased work intensification coupled with recruitment and retention issues [2]. The shortages have been noted in all areas of nursing, and in particular at the RN level, in specialities such as critical care, neonatal, aged care, emergency nursing, rural and remote areas and mental health nursing [4, 12, 13]. Internationally, the World Health Organization has predicted a global shortage of 7.6 million by 2030 [14].The focus on supply has resulted in more newly graduated RNs than places for their employment, and, as several years of nursing experience is normally a pre-requisite for entry into specialised practice this creates a delay in recruitment in areas where there are already shortages [11]. Thus, there is a need to examine the factors influencing recruitment and retention into speciality nursing practice.
RNs in Australia, similar to other countries, work as either generalists or specialists. For the purpose of this study, generalist RN practice has been defined as:
Encompassing a comprehensive spectrum of activities. It is directed towards a diversity of people with different health needs. It takes place in a wide range of health care settings and it is reflective of a broad range of knowledge and skills. Generalist practice may occur at any point on a continuum from beginning to advanced [15].
Speciality practice has been defined as a practice that follows and builds on generalist practice.
It focuses on a specific area of nursing and is directed towards a defined population or a defined area of activity and it is reactive of depth of knowledge and relevant skills. Specialist practice may occur at any point on a continuum from beginning to advanced [15, 16].
To enable a RN to move from generalist to specialist, transition programs have been developed. These programs are taken post-registration as either formal degrees or as continuing development programs. The latter may articulate into a formal degree. The programs can be taken within five years of completing a pre-registration or after some time within the workforce [17]. These programs are designed to: “assist the newly graduated or transferred nurse/midwife to acquire further general and speciality knowledge and skills in a logical, sequenced supported approach to effectively transition to work expectations” [18].
Transition programs are often delivered by employers as a way of ‘growing their own’ specialists. In the current climate of projected and real shortages, many employers have therefore designed and delivered their own programs. Thus, a transition program into peri-operative nursing, for example, can vary considerably from one employer to another as there are no national standards to regulate the content of the program.
This study was commissioned by the State Government of Queensland’s Health Department. The need for this study was a growing shortage of experience registered specialist nurses in several areas, specifically pre-operative, paediatrics, neonatal, critical care, mental health and rural and remote area nursing. To overcome the current and projected future shortages, this study sought to understand the factors that influence recruitment into and retention within these nursing specialities from both an early career (defined as within 5 years of registration) and rapid transition (after 5 years) perspectives [19]. This study was designed, therefore, to gather evidence-based data to support the rapid and early career transition of a RN from a generalist to a specialist role.
Methods
The overall study aimed to provide an evidence-based model for early career and rapid specialisation to nursing specialities. The project contained three studies: a systematic review of the literature, interviews with RNs who had participated in a recent transition to speciality practice program and a Delphi study to confirm findings of stages 1 and 2 and to provide a model on which to base policy and education programs. The aim of study one, the systematic review, was to identify, assess and summarize available evidence relating to early or rapid career transitioning into a specialty area of nursing practice. The specialty areas considered for this review were peri-operative, mental health, neonatal, critical care, rural and remote area and emergency nursing. The primary outcome of the review was to establish a model or framework for successful early and rapid transition into speciality practice. As a secondary outcome, the review was designed to inform the healthcare and education industry of the inhibitors and enablers, influencing an effective transition into specialty areas.
Design
This systematic review was designed and reported in accordance with international guidelines: the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [20]. Full details of the overall search strategy can be found in the research protocol, registered with the International Prospective Register of Systematic Reviews (PROSPERO) [19]. A convergent qualitative synthesis design, as outlined by Pluye and Hong [21], was used where results from qualitative, quantitative and mixed methods studies were transformed into qualitative findings.
Search strategy
The search of the literature was undertaken from February to May, 2018. Articles were identified through a search of CINAHL, Medline, Scopus and PsycINFO databases. The search terms employed were nurse, early career, rapid career, transition, specialty, and Medical Subject Heading (MeSH) terms related to professional development, educational, nursing and continuing. Studies undertaken within Australia, New Zealand, United Kingdom, Canada, United States and Europe were included in the search. The results from the search were imported into EndNote X8 to remove duplicates and manage the references through the different stages of the review (full title, abstract, and full text). Titles and/or abstracts of studies were retrieved using the search strategy. Hand searching was also used to screen and identify studies that may have been missed. All papers were screened independently by two review authors to identify studies that potentially met the inclusion criteria. Inclusion criteria were: critical care, peri-operative, mental health, rural and remote, neonatal and emergency nursing, early career, rapid transition, nursing, published in English from 2007–2018. While it is recognised that nursing shortages have been a foci for several decades, the ten year time frame was selected as the shortages within nursing specialities, particularly in Australia, have accelerated, particularly influenced by the anticipated retirement of the aged workforce. Systematic or literature reviews were excluded from the study as were articles from the grey literature and research papers involving transition to general nursing (specifically new-graduate transition to generalist nursing) and all other nursing specialities.
Risk of bias (quality) assessment
The quality of the relevant literature was appraised by two authors who independently assessed for risk of bias. Due to the lack of randomized controlled trials, and the predominance of surveys, quantitative papers were critically appraised using the Critical Appraisal Questions for Surveys (CAQS) tool [22]. Qualitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) [23]. Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer. Three qualitative manuscripts that did not demonstrate Human Research Ethical or International Review Board Clearance were excluded from the study.
To avoid publication bias, each of these studies were assessed for overlap between sub-studies, however, none of the data appeared to repeat. Disagreements between appraisal scores were resolved through discussion and an acceptable quality appraisal. A cut-off score of 6 out of 10 for quantitative studies using the CAQS tool was adopted. Reasons for exclusion were: insufficient information on recruitment processes; measurement bias unclear; confounding factors in design and/or analysis unclear; results flawed; insufficient discussion of implications for transferability or generalizability [22]. For qualitative studies a cut-off score of 7 out of 10 was adopted. Reasons for exclusion were: lack of congruity between the research methodology and the methods used to collect the data; lack of congruity between the research methodology and the interpretation of results; the influence of the researcher on the research and vice versa were addressed; participants and their voices are adequately represented; conclusions drawn in the research report flow from the analysis, or interpretation, of the data [24]. Mixed methods studies were included if the quantitative and qualitative sub-study scored above the identified appraisal cut-off. The results of the literature search uncovered 23 articles to be included in the review (12 quantitative, 8 qualitative, 3 mixed methods) (Fig 1 and Table 1). The PRISMA flowchart (Fig 1) was used to summarise the selection process with reasons for exclusion of the study [20]. The data were analysed using matrix code analysis.
Data synthesis
The quantitative and mixed method full text papers could not be used for a quantitative pooled analysis due to the diverse range of results and small sample sizes. We used a qualitative coding template thematic analysis [48] where extracts were coded into broad themes and uploaded electronically into NVIVO 11 [49] for matrix code analysis. This revision of coding produced templates that were flexibly structured as a result of emergent and unanticipated data [50] into a matrix code analysis and frequencies. This formed a framework for the model, which was confirmed and then expanded by the qualitative meta-synthesis.
Independently to the matrix code analysis and frequencies, qualitative research findings were pooled using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) [23]. This involved the synthesis of findings to generate a set of statements that represented aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories were then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that were formulated into an over-arching theme, three phases and three concepts. The early findings were discussed by the quantitative and qualitative teams and from this discussion, the over-arching theme, the three phases and three concepts further emerged. The over-arching theme, phases and concepts were then plotted conceptually and from this aggregation, the TRANSPEC Model was developed which is discussed in detail in the following section.
Results
Overall
As described in Table 1, there were twelve quantitative papers [25, 28–30, 32, 35–39, 42, 45, 47], eight qualitative papers [26, 27, 30, 31, 33, 34, 44, 46] and two mixed method studies [40, 41, 43].
Model development
The thematic analysis and matrix mapping that identified the over-arching theme (context of practice), the three phases (pre-entry, incomer and insider) and three concepts (the self, transition processes and sense of belonging) were then mapped conceptually to form the TRANSPEC model (see Fig 2).
As we can see from Fig 2, central to successful transition are the concepts of the self (both personal and professional) and the development of a sense of belonging within the speciality and the context of practice. The formal and informal transition processes such as mentoring, shadowing, formal curricula, continuing professional educational short courses are a necessary part of the transition as this is the theoretical and clinical content required for speciality practice. Influencing all of this is the over-arching theme of context of practice, which can be a combination of: the geographical location; the health service type, policies and procedures; the speciality; and the links that the nurse has to other members of the multi-disciplinary team and the community in which the health service is located.
In the context of this model, the transitioning clinician goes through three distinct phases: pre-entry, incomer and insider. At each phase of the transition, the enablers and inhibitors influence the transition and therefore recruitment and retention. For example, pre-entry experiences such as a positive clinical placement in pre-registration programs may affect how attractive the speciality appears to the nurse and will affect steps to move into or away from the specific speciality. The TRANSPEC model (Fig 2) demonstrates the interactive nature of the overarching theme, the phases and concepts.
The findings from Tables 2, 3 and 4 are now discussed. Table 2 presents the matrix mapping which resulted in the over-arching theme and the three concepts being identified by individual papers. Within these papers, it is noted at what phase or phases these arose. Additionally, Table 2 shows the count or frequency that the over-arching theme and/or the concept or concepts were identified within each paper. Tables 3 and 4 add to the quantitative findings demonstrating the over-arching theme (Table 3) and concepts (Table 4) and findings within each phase. The enablers and inhibitors identified in each qualitative manuscript are also provided from this analysis (Tables 3 and 4). Thus the qualitative data have further informed the quantitative findings allowing for an understanding of specific inhibitors and enablers that are influencing the concepts at each phase as well the context of practice.
Overarching theme: Context of practice
In this model, the term context of practice is used to describe the interconnected factors, experiences, and opportunities, which enable or inhibit a nurse’s progress across the continuum of speciality practice within the working environment. Therefore, the context of specialty nursing practice is framed by professional and organisational elements. The professional element is based on a core body of nursing knowledge that is continually developed and refined by practice, research and innovation. Organisational elements impacting on specialty nursing practice include the geographical location, size and capability of the health service, policies and procedures that influence the scope of practice, the community in which the health care facility is located and the diversity of health care delivered by the health service to that and other communities [15, 51–53].
The frequency of codes for the over-arching theme ‘context of practice’ ranged from 17 to 178 [45, 47]. Spence et al. [47] maintain that a context of practice underpinned by an active learning environment, strong educational processes, and contemporary engineered models of care is important for specialist practice. Further, nurses prefer to acquire specialist knowledge and skills in the practice environment and need support to optimise this learning [47].
At the pre-entry phase, there were no identified inhibitors or enablers in the literature. As an incomer, there were several inhibitors including: economic cutbacks that limited the scope of experience [31] and the information and communications technology (ICT) environment [34], which were seen as a major challenge to care delivery in a new context. Specifically, nurses noted how they struggled with the technology and different ICT systems. This was particularly the case in critical care environments. One enabler at the incomer phase was the presence of trust of the incomer [46], and this was particularly important in the mental health environment. As an insider, the major influence, seen as an inhibitor was the lack of positions to retain nurses who had completed their transition process/program [40].
Concept one: The self
The concept of ‘the self’ is seen as a complex system steeped in philosophical, psychological and sociological arguments. Thagard [54: 2] argues that the self is:
A multilevel system consisting of social, individual, neural and molecular mechanisms… Each of these levels can be understood as a sub-system consisting of environmental influences, component parts, interconnections between parts, and regular changes in the properties and relations of the parts.
Thagard [54] goes on to note that each of these levels are influenced by additional phenomena such as ‘self-presentation, self-esteem, self-enhancement; self-regulation; self-expansion and self-development’. For the purpose of this study the concept of ‘the self’ is defined as an individual who is constantly changing and adjusting. These changes are driven by self-preservation, self-esteem, self-enhancement, self-regulation, self-expansion and self-development at two levels. For the professional nurse, these can be described as changes to the personal and the professional self.
Frequency of the codes for the concept ‘the self’ ranged from four [32] to 120 [39, 41]. As reported by Morphet et al. [41], enhancement of the personal and professional self occurs by the use of an evidence-based transition to speciality practice framework to guide the structure, process and outcomes of speciality practice. Morphet et al. [39] reported that a dedicated “career development year” enriches the development of the personal and professional self and translates into greater recruitment and retention of speciality nurses.
Personal self.
At the pre-entry phase, confidence was seen as both an enabler and an inhibitor [43], while at the incomer stage willingness to learn [31], self-care [26], and confidence [26, 30, 34] were seen as both inhibitors and enablers. Coping [26], being overwhelmed by the environment [41] and concealing lack of experience in the speciality [44] were inhibitors. In contrast, motivation and commitment [30] and job satisfaction [44] were seen as enablers. There were no enablers or inhibitors identified for the personal self at the insider phase.
Professional self.
There were no enablers or inhibitors identified in the pre-entry phase. At the incomer phase, willingness to learn [26] was an enabler and the level of knowledge was seen as an inhibitor [33]. At the insider phase, competence [26, 27, 34] was seen as both an inhibitor and enabler. Keeping up to date [31], willingness to learn [31] and confidence [34] were seen as enablers.
Concept two: Transition processes
For the purpose of this paper, transition processes refer to the processes or period of changing from one phase to another. The time to complete the transition processes will vary from one nurse to another as will the transition processes they undertake. Influences will include the context of practice, the beginning level knowledge and skills, the nature of the processes being undertaken and the availability of support [55]. Transition processes can be formal and/or informal. In some instances, both formal and informal processes were used, and in other cases only one was used.
Formal processes.
Formal transition processes are defined as processes that involve educational and clinical support and are designed to facilitate the transition [56]. The inhibitors and enablers identified related to these formal processes and the nurse’s ability to access them.
This concept had the highest frequencies of quantitative matrix coding as most of extracts described outcomes from transition programs or educational interventions. In the highest matrix coding frequency extract, 154 codes [47], found that nurses with less than one year speciality experience typically had the lowest ‘critical’ knowledge essential for safe practice, with the majority of novice nurses showing a preference for experiential ‘on-the-job’ learning. Gillespie’s [32] paper with a matrix coding frequency of 141, reported that although both years of experience and specialty education contributed to nurses’ perceived competence, experience was the strongest contributor.
The transition processes [40] were regarded as an enabler at the pre-entry phase. At the incomer phase, preparation processes embedded in the reality of practice, the way the program prepared the nurse for further education and feedback on performance were identified as enablers [41]. Additionally, the quality of the processes was also seen as an enabler [41, 43]. The volume of knowledge to be learnt [27, 41] and the ability to access the transition processes [31] were both enablers and inhibitors. Insider enablers were the way that they processes had enhanced successful transition [40], the accreditation of the processes into post-graduate programs [40], embedding learning into practice [27] were all enablers. There were no inhibitors found at the insider phase.
Informal processes.
No inhibitors or enablers were found at the pre-entry phase. For insiders, supportive staff [31, 44] and role models [31, 34] were both enablers and inhibitors. Observational learning [46] was an enabler and conflicting information was an inhibitor [34]. Support for continuing professional education was both an enabler and inhibitor [31] at the incomer phase.
Concept three: Sense of belonging
Baumeister and Leary [57] define a sense of belonging as the degree to which an individual perceives as being accepted, included and supported by others in their environment. When people feel they belong, positive emotional and cognitive outcomes occur [58]. A sense of belonging can be experienced in many contexts [59]. It relates to the inclusiveness of all participants where a culture of connection is built through relationships to promote a sense of belonging [60]. The within this concept three sub-concepts emerged as important to a successful transition. These were: were the culture of the organisation, the working conditions and the level of support. The over-arching theme of the context of practice, also influenced this concept and the enablers and inhibitors within it.
Culture.
Culture is defined as the totality of the relationships formed within the culture, and shapes how those relationships are structured [61]. The highest frequency of matrix codes was found in Morphet et al. [41], 35 codes [41], followed by Halfer [35] and Hussein [36], both 29 codes. From these studies, it was reported that speciality graduates are eager to establish goals for lifelong learning, specialty-nursing certification, postgraduate study, clinical ladder advancement, clinical governance participation, and professional organizational membership [35]. Also, it is imperative for nursing management to create opportunities for new speciality nurses and more experienced staff to develop closer working relationships, and improve retention through team projects and other department ‘bonding’ activities as these engender a sense of ‘belongingness’ among the new speciality nurses [35]. There were no identified inhibitors or enablers at the pre-entry phase. As an incomer, job satisfaction [31] and resource investment [41] were enablers while feedback on performance was an inhibitor [44]. Staff personalities [26, 34] and team support [30, 44] were both inhibitors and enablers. The culture of the organisation at the insider phase was enabled by positive feedback [44] team support/acceptance [44, 46] and promoting professional development [31].
Working conditions.
Nurses, in the majority, are in paid work. Working conditions for paid work normally are considered to include working time (hours of work, rest periods and work schedules), remuneration and the physical conditions and mental demands that exist in the workplace. Working conditions for the purpose of this study include: skill-mix, staffing ratios, remuneration, role clarity, support, sufficient staff, workload allocation and role clarity. There were no matrix codings for this sub-concept. In the pre-entry phase the inability of organisation to pre-empt staff shortages was identified [31]. At the incomer phase, remuneration and staffing levels [31] were inhibitors, whereas workload allocation was an enabler [33]. There were no inhibitors or enablers identified at the insider phase.
Level of support.
Support, for the purpose of this study, was defined as support within the workplace and was provided by colleagues and management. There were no matrix codes for this sub-concept. At the pre-entry phase there were no enablers or inhibitors. At the incomer phase, support from colleagues [30, 41] was an enabler, while perceptions of competent management of a ward or unit [27] was an inhibitor. Management support for their role [26, 31] was both an inhibitor and an enabler. At the insider phase, the opportunities to become a leader [31] were seen as an inhibitor and being supported, valued and accepted [31] and empowered [43] were enablers.
Discussion
The main concepts identified in the transition process included: the Self (personal and professional), the Transition Processes (formal and informal), and a Sense of Belonging. The data also clearly identified three phases to the transition: Pre-entry, Incomer and Insider. Influencing successful transition at each phase and within each theme were the identified enablers and inhibitors. It was apparent from the data analysis that at each phase, the three major concepts of the Self, Transition Processes and the Sense of Belonging occurred. It was possible therefore to map these conceptually (hence TRANSPEC model emerged). It was also apparent that the over-arching theme of the Context of Practice, particularly the geographical location and the speciality, influenced the transition. Thus it was possible to enclose the phases and concepts within an over-arching theme of the Context of Practice. To inform the development of a transition program, it was possible also to identify enablers, inhibitors or both in each phase and concept. Thus the model developed from the data analysis.
Context of practice
The model acknowledges the importance of the context of practice in both early career and rapid transition to specialty practice. There are many ways that the context can impact on the scope of practice on a nurse and therefore the level of professional and personal experience, skills, knowledge and competence required for practice. For example, geographical location of the health service has been found previously to influence: a) access to health services; and b) the scope of practice of the nurse [62]. Additionally, while there were many similarities in the influence of the context of practice across specialities, there were also differences that needed to be taken into consideration. For example, mental health specialities saw the need for personal and team safety [46], whereas nurses working in the critical care environment highlighted the complexity of practice caused by the technology used [34]. A third major influence on the context of practice, which has been well documented previously, are the organisational influences (e.g. funding, scope of practice restrictions, management styles) [63].
The TRANSPEC model acknowledges the importance of context of practice and allows for each speciality within a discipline to identify specific enablers, inhibitors or both that limit recruitment and then retention. It therefore allows for the different contexts of speciality practice.
The self (professional and personal)
The professional self.
Nationally and internationally, speciality practice has been described in terms of the movement from novice to expert [15, 16, 56, 64]. Benner’s model in particular has provided clear guidance for what is needed to advance professional practice. However, to date research has focused on specific specialities, for example, critical care, emergency department, mental health, neonatal, paediatric, rural and remote and so on. This has resulted in research and standards of practice for specialities being developed in silos. Additionally, transition to speciality practice research has focused on nurses at the incomer and insider phase. The model demonstrates that entry to professional speciality practice begins when the speciality practice is being considered as a career path (pre-entry). The importance of experience during pre-registration clinical placements and its impact on recruitment into speciality practice has been highlighted by this review [40, 65]. This review and one recent study demonstrate the importance of enablers and inhibitors at pre-entry. Yet, these have received limited attention in research [66].
The personal self.
The findings demonstrate how the personal self is influenced by confidence, anxiety about a new working environment and coping within it [26, 34, 43]. Attention to self-care was seen as an important way to cope with the new environment [26]. Previous research and policies have focused on building the competence (skills and knowledge) of the nurse as they transition within that speciality [56]. Recent work highlights the importance of individual well-being of nurses and how factors such as burnout and resilience can not only influence retention within the workforce, but also the quality of patient care delivered [67].
Transition processes (formal and informal)
Nursing has been acknowledged as a practice profession, with a combined theoretical knowledge (science of nursing) and the practice (art of nursing), being equally important [68]. Experiential learning, where the application of the theoretical knowledge informs practice, is important, with most health-related professions acknowledging the importance of on-the-job-training, mentorship and ongoing learning [69]. Life-long-learning (LLL) has become an important element of nursing practice through a requirement by AHPRA that all registered health practitioners provide evidence of continuing practice development, stipulating the annual minimum hours required for the continuance of registration [70]. LLL is a combination of self-directed learning, organisational learning through in-service sessions, required competence sign-offs, and required skills and knowledge acquisition in accordance with the profession or practice [71]. It requires a practitioner to take control of their learning, to engage with their profession and to actively support quality improvement initiatives that support personal and service adaptation and flexibility through evidence-based practice [71]. When a practitioner is transitioning to practice, whether it be a new area of practice, or gaining experiential knowledge as a new practitioner, both the practitioner and the service employing them have an obligation to access and provide learning opportunities within the field of practice the employment occurs. These can be divided into formal and informal processes.
Formal processes.
The formal curricula, on the whole, began when the nurse started in the new role. Few curricula focus on developing the nurse before they enter the speciality–in the recruitment or pre-entry phase. Procter et al. [65] note the importance of a positive experience during entry-to-practice clinical placements as this experience has the potential to influence how attractive the student may see the speciality in the longer term.
Formal processes include targeted educational programs that are offered at tertiary institutions, and may be at Certificate, Diploma, Bachelor or higher degree level. For specialty practice areas, these are general postgraduate qualifications that build on existing general practice knowledge to support transition to speciality practice [40, 56]. An important feature identified was that of processes of being embedded in the reality of practice [43, 65]. The importance of the preceptor and/or mentor was emphasised with other studies into transition, for example Hooper et al. [72] noted that they were important to assist with building and maintaining resilience and self-development. Conversely, the quality and level of support from preceptors and mentors can vary and thus impede the transition process [73].
Informal processes.
Informal processes noted in this study, employed during the transition processes included: role modelling which could be an enabler [34] or an inhibitor [31]; observational learning [46] and general supportive staff (nurses or other health care professionals) [44]. Similar to pre-entry exposure, the behaviour of staff already established in the area could be either an enabler or an inhibitor depending upon the characteristics of the individual staff member [31, 44]. Importantly, encouragement to pursue further education in the speciality was seen as an enabler [31].
Sense of belonging
The TRANSPEC model emphasises the importance of the development of a sense of belonging within the speciality, within the health service, within the multidisciplinary team and within the community. Hospitals, just like schools and other organizations do not exist in a vacuum. They respond to the social contexts in which they are immersed. Opportunities for participation, respect for and from participants in the work as well as general community as well as being valued and accepted, can aid in realising an individual’s psychological need to belong. Such support provides a sense of belonging and a connectedness, in which social and cultural facets shape the individual and community identity [58]. When people feel they belong, positive emotional and cognitive outcomes occur [58]. There were three sub-concepts that impacted on the sense of belonging: the culture, the working conditions and the level of support provided. Additionally, was the over-arching theme of the context of the specialisation. The personalities of current employees within the organisation and their interaction with the new nurse were both inhibitors and enablers. The culture of the workplace, particularly leadership, has been shown in many previous studies to impact on transition entry to practice as well as retention within practice [74]. The importance of other staff in the transition processes have also been highlighted by previous studies noting that promotion of a working environment that encouraged ‘inter-professional collaboration’ [72] and was seen to be an enabler, while ‘maltreatment, abuse and neglect’ were seen to be inhibitors [72]. In line with these findings, this study has highlighted the importance of positive feedback and team support and acceptance [31, 44]. This is at the core of a sense of belonging as this increases mutual trust and therefore respect, wellbeing and self-esteem. The impact of working conditions such as remuneration, workload allocation, staffing levels and lack of role clarity [75] have been raised previously as well as in this study [31, 33, 72, 73]. The impact of workload and the working environment on the personal self has also been documented previously [76, 77]. The time spent in the speciality is also seen as an enabler with insiders having a successful transition if allowed time to do so [73].
Support from colleagues and management also impacted on the sense of belonging. Leadership was demonstrated by either example [26] or by opportunities [31]. Successful leadership within healthcare organisations highlights the importance of emotional intelligence for insight into the “self’ of the nurse transitioning through change [78]. Emotional intelligence involves skills that are learnt and enhanced. Developing a sense of belonging and competence in the speciality happens over time, and depends on the individual (self).
Limitations
The review was limited to the specialities of critical care, mental health, neonatal, peri-operative and it is acknowledged that the inhibitors and enablers outlined in this review may vary from one speciality to another. However, the findings of this study are similar to those undertaken in a parallel transition to community and midwifery practice systematic review which has further developed this model for that specific content [79] and suggests that the TRANSPEC model can be applied to other nursing and non-nursing speciality contexts.
Conclusions
The TRANSPEC model provides a foundation for effective recruitment and retention for both early career and rapid transitions to speciality practice. It shows that transition begins prior to entry to the speciality (pre-entry) and then continues to be developed over time. A successful transition relies on, at each phase, enablers to the professional and personal self, the formal and informal transition processes and a sense of belonging developing. This transition is influenced by the context of practice and the transition time will vary from one nurse to another.
The TRANSPEC model brings new knowledge to speciality transition in that it acknowledges the importance of the pre-entry phase, which has not been a focus previously. It also acknowledges that recruitment and retention into speciality nursing practice involves both the professional and personal self. The importance of personal well-being is increasingly being recognised, particularly its effects on quality patient care and patient safety.
The TRANSPEC model is designed to be used as a basis from which inhibitors and enablers can be considered. While this review has outlined some inhibitors and enablers, and recognising that there will be many of these that are not unique to a particular speciality, it is recommended that when developing a transition program using this model, the focus should be on enablers at all three phases for each individual speciality.
Acknowledgments
We wish to acknowledge the work of Dr. Lisa Wirihana, formally of the School of Nursing, Midwifery, and Social Science, Central Queensland University, Noosa campus, Queensland, Australia for her work on this systematic review.
References
- 1. Armstrong BK, Gillespie JA, Leeder SR, Rubin GL, Russell LM. Challenges in health and health care for Australia. Medical Journal of Australia. 2007;187(9):485–9. pmid:17979607
- 2. Doughty K, Mulvihill P. Digital reablement-a personalised service to reduce admissions and readmissions to hospitals and nursing homes. Journal of Assistive Technologies 2013;7:228–34.
- 3. Duckett SJ. Health workforce design for the 21st century. Australian Health Review. 2005;29:201–10. pmid:15865571
- 4.
Health Workforce Australia. Australia's Future Health Workforce-Nurses Detailed. Canberra: Department of Health; 2014.
- 5.
Australian Institute of Health and Welfare. Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2011. Canberra: AIHW; 2016.
- 6. Davy C, Bleasel J, Liu H, Tchan M, Ponniah S, Brown A. Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review. BMC health services research. 2015;15(1):194.
- 7. O'Sullivan BG, Stoelwinder JU, McGrail MR. Specialist outreach services in regional and remote Australia: key drivers and policy implications. The Medical Journal of Australia. 2017;207(3):98–9. pmid:28764622
- 8.
Productivity Commission. Australia's health workforce. In: Australia Go, editor. Research Reports. Canberra2006.
- 9. Anonson J, Walker ME, Arries E, Maposa S, Telford P, Berry L. Qualities of exemplary nurse leaders: perspectives of frontline nurses. Journal of Nursing Management. 2014;22(1):127–36. pmid:23822100
- 10. Goodin HJ. The nursing shortage in the United States of America: an integrative review of the literature. Journal of advanced nursing. 2003;43(4):335–43. pmid:12887349
- 11. Buchan J, Aiken L. Solving nursing shortages: a common priority. Journal of clinical nursing. 2008;17(24):3262–8. pmid:19146584
- 12.
Australian Health Workforce Advisory Committee. The critical care nurse workforce in Australia, 2001–2011 Australian Health Workforce Advisory C, editor. North Sydney: Australian Health Workforce Advisory Committee; 2002.
- 13.
Commonwealth of Australia. The National Review of Nursing and Nursing Education 2002: our duty of care. Canberra: Commonwealth of Australia; 2002.
- 14.
World Health Organization. Global health observatory data: Density of nursing and midwifery personnel. Geneva: World Health Organization; 2019.
- 15.
National Nursing Organisations. Criteria for Specialities in Nursing/Principles of Credentialling for Nurses. Kingston: National Nursing Organisations; 2004.
- 16. Australian Nursing and Midwifery Federation. Nursing Speciality. 2016.
- 17. Mills J, Woods C, Harrison H, Chamberlain-Salaun J, Spencer B. Retention of early career registered nurses: the influence of self-concept, practice environment and resilience in the first five years post-graduation. Journal of Research in Nursing. 2017;22(5):372–85.
- 18.
Queensland Health. Transition Support Programs User Guide (Adapted for MNHHS Context). Brisbane: Queensland Health; 2012.
- 19.
Hegney D, Harvey C, Chamberlain D, Wirihana L, Sobolweska A, Garrahy A. A systematic review of the factors influencing the effective early career transition to a nursing speciality in differing contexts of practice. International Prospective Register of Systematic Reviews (PROSPERO). 2018.
- 20. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS medicine. 2009;6(7):e1000097. pmid:19621072
- 21. Pluye P, Hong QN. Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews. Annual review of public health. 2014;35:29–45. pmid:24188053
- 22. CASP UK. CASP (Critical Appraisal Skills Program) Checklists. 2018.
- 23.
Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual: 2014 edition. Adelaide: 2014.
- 24.
Joanna Briggs Institute. Checklist for qualitative research. Adelaide: JBI, 2018.
- 25. Boyer SA, Valdez-Delgado KK, Huss JL, Barker AJ, Mann-Salinas EA. Impact of a nurse residency program on transition to specialty practice. Journal for nurses in professional development. 2017;33(5):220–7. pmid:28891876
- 26. Bromley P. Capability: How is it recognised in student nurses undertaking postgraduate studies in neonatal intensive care? Journal of Neonatal Nursing. 2018;24(3):142–7.
- 27. Bromley P. Using eDelphi to identify capability requisites for postgraduate certificate in Neonatal Intensive Care Nursing. Journal of Neonatal Nursing. 2015;21(6):224–36.
- 28. Castro E, Click E, Douglas S, Friedman I. The professionalism of critical care nurse fellows after completion of the critical care nurse fellowship program. Journal for Nurses in Professional Development. 2016;32(2):87–93. pmid:26985753
- 29. Cleary M, Matheson S, Happell B. Evaluation of a transition to practice programme for mental health nursing. Journal of Advanced Nursing. 2009;65(4):844–50. pmid:19243464
- 30. Cleary M, Horsfall J, Mannix J, O'Hara‐Aarons M, Jackson D. Valuing teamwork: Insights from newly‐registered nurses working in specialist mental health services. International Journal of Mental Health Nursing. 2011;20(6):454–9. pmid:21676136
- 31. Coughlan LM, Patton D. A qualitative descriptive exploration of the educational and career plans of early career neonatal nurses and midwives: an Irish perspective. Nurse Education in Practice 2018;28:182–8. pmid:29102854
- 32. Gillespie BM, Chaboyer W, Wallis M, Werder H. Education and experience make a difference: results of a predictor study. AORN journal. 2011;94(1):78–90. pmid:21722773
- 33. Glynn P, Silva S. Meeting the needs of new graduates in the emergency department: A qualitative study evaluating a new graduate internship program. Journal of Emergency Nursing. 2013;39(2):173–8. pmid:22513187
- 34. Gohery P, Meaney T. Nurses’ role transition from the clinical ward environment to the critical care environment. Intensive and Critical Care Nursing. 2013;29:321–8. pmid:23886780
- 35. Halfer D, Graf E, Sullivan C. The organizational impact of a new graduate pediatric nurse mentoring program. Nursing Economics. 2008;26(4):243. pmid:18777973
- 36. Hussein R, Everett B, Hu W, Smith A, Thornton A, Chang S, et al. Predictors of new graduate nurses’ satisfaction with their transitional support programme. Journal of nursing management. 2016;24(3):319–26. pmid:26178039
- 37. Klingbeil C, Schiffman RF, Ziebert C, Totka JP, Schmitt CA, Doyle L, et al. Transition of experienced and new graduate nurses to a pediatric hospital. Journal for nurses in professional development. 2016;32(4):198–204. pmid:27434319
- 38. Krapohl G, Manojlovich M, Redman R, Zhang L. Nursing specialty certification and nursing-sensitive patient outcomes in the intensive care unit. American Journal of Critical Care. 2010;19(6):490–8. pmid:21041193
- 39. Morphet J, McKenna L, Considine J. The career development year: responding to the emergency nursing shortage in Australia. Australasian Emergency Nursing Journal. 2008;11(1):32–8.
- 40. Morphet J, Kent B, Plummer V, Considine J. The effect of Transition to Specialty Practice Programs on Australian emergency nurses’ professional development, recruitment and retention. Australasian Emergency Nursing Journal. 2015;18(4):204–11. pmid:26372251
- 41. Morphet J, Plummer V., Kent B., Considine J. A framework for transition to speciality practice programmes. Journal of Advanced Nursing. 2017;73:1970–81. pmid:28205248
- 42. Munroe B, Curtis K, Murphy M, Strachan L, Considine J, Hardy J, et al. A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: a pre–post study using full immersion simulation. Journal of clinical nursing. 2016;25(15–16):2262–74. pmid:27135203
- 43. Patterson B, Bayley E.W., Burnell K., Rhoads J. Orientation to emergency nursing: perceptions of new graduate nurses. Journal of Emergency Nursing. 2010;36:203–11. pmid:20457314
- 44. Saghafi N, Asamen J, Rowe D, tehrani R. The relationship of religious self-identification to cultural adaptation among Iranian immigrants and first-generation Iranians. Professional Psychology: Research and Practice. 2012;43(4):328–35.
- 45. Samedy K, Griffin MTQ, Capitulo KL, Fitzpatrick JJ. Perceptions of structural empowerment: differences between nationally certified perinatal nurses and perinatal nurses who are not nationally certified. The Journal of Continuing Education in Nursing. 2012;43(10):463–6. pmid:22390162
- 46. Schwartz L, Wright D, Lavoie-Tremblay M. New nurses' experience of their role within interprofessional health care teams in mental health. Archives of Psychiatric Nursing. 2011;25(3):153–63. pmid:21621729
- 47. Spence K, Sinclair L, Morritt ML, Laing S. Knowledge and learning in speciality practice. Journal of Neonatal Nursing. 2016;22(6):263–76.
- 48.
King N. Doing template analysis. In: Symon G, Cassell C, editors. Qualitative organizational research: Core methods and current challenges. London: Sage; 2012. p. 426–50.
- 49.
QSR International. NVIVO. 2018.
- 50.
Nadin S, Cassell C. Using data matrices. London: Sage; 2004.
- 51.
COAG Health Council. Guidance for National Board Submission re Specialist Registration. Canberra: Commonwealth of Australia; 2014.
- 52.
Nursing and Midwifery Board of Australia. Code of Conduct for Nurses. Melbourne: NMBA. Melbourne: Nursing and Midwifery Board of Australia, 2018.
- 53.
Queensland Health. Clinical Services Capability Framework for Public and Licensed Private Health Facilities (CSCF) v3.2. Brisbane: Queensland Government Department of Health; 2014.
- 54. Thagard P. The self as a system of multilevel interacting mechanisms. Philosophical Psychology. 2014;27(2):145–63.
- 55.
Queensland Health. Framework for Lifelong Learning for Nurses and Midwives. Queensland: Queensland Health; 2018.
- 56.
New South Wales Health Nursing and Midwifery Office. Transition to Intensive Care Nursing Project: Steering Group Report. Sydney: NSW Health; 2008.
- 57. Baumeister RF, Leary MR. The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin. 1995;117(3):497–529. pmid:7777651
- 58. Prince EJ, Hadwin J. The role of a sense of school belonging in understanding the effectiveness of inclusion of children with special education needs. International Journal of Emotional Education. 2013;17:238–62.
- 59. Roffey S. The ASPIRE principles and pedagogy for the implementation of social and emotional learning and the development of whole school well-being. International Journal of Emotional Education. 2017;9(2):59–71.
- 60. Good C, Rattan A, Dweck C. Why do women opt out? Sense of belonging and women's representation in mathematics. Journal of Personality and Social Psychology. 2012;102(4):700–7017. pmid:22288527
- 61. Oehlert K. Reflecting on Holistic Relationships: A definition of culture. Beginnings. 2017;37(2):6–7. pmid:29772146
- 62. McCarthy S, Hegney D, Brown L, Gilbar P, Brodribb TR, Swales J. Characteristics of chemotheraphy practice in rural and remote health facilities in Queensland. Australian Journal of Rural Health. 2003;11:138–44. pmid:12950397
- 63. Gibson T, Heartfield M. Australian enrolled nurses have their say—Part 2: Scope of practice. Contemporary Nurse. 2005;19:126–36. pmid:16167442
- 64.
Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice (Commemorative ed.). New Jersey: Prentice-Hall; 2001.
- 65. Procter N, Beutel J, Deuter K, Curren D, de Crespigny C, Simon M. The developing role of transition to practice programs for newly graduated mental health nurses. International Journal of Nursing Practice. 2011;17(3):254–61. pmid:21605265
- 66. Wareing M, Taylor R, Wilson A, Sharples A. Impact of clinical placements on graduates' choice of first staff-nurse post. British Journal of Nusing. 2018;27:1180–5.
- 67. Hegney D, Rees C, Eley R, Windsor C, Osseiran-Moisson R, Breen L, et al. Workloads and contributing factors, and their impact on implicit care rationing. Journal of Nursing Management. 2019;27:371–80. pmid:30221436
- 68. Henry D. Recovering the Art of Nursing to Enhance Nursing Practice. Nursing Science Quarterly. 2018;31:47–54. pmid:29235959
- 69. Bridges SJ. Professional identity development: Learning and journeying together. Research in Social and Administrative Pharmacy. 2018;14:290–4. pmid:28363381
- 70. Australian Health Practitioner Regulation Agency. Continuing Professional Development. 2018.
- 71. Cadorin L, Suter N, Dante A, Williamson SN, Devetti A, Palese A. Self-directed learning competence assessment within different healthcare professionals and amongst students in Italy. Nurse Education in Practice. 2012;12:153–8. pmid:22112861
- 72. Hooper ME, Browne G, O'brien AP. Graduate nurses' experiences of mental health services in their first year of practice: An integrative review. International Journal of Mental Health Nursing. 2016;25(4):286–98. pmid:26887915
- 73. Kinghorn GR, Halcomb E.J., Froggatt T., Thomas S.D. Transitioning into new clinical areas of practice: an integrative review of the literature. Journal of Clinical Nursing. 2017;26:4223–33. pmid:28793382
- 74. Perreira TA, Berta W, Herbert M. The employee retention triad in health care: Exploring relationships amongst organisational justice, affective commmitment and turnover intention. Journal of Clinical Nursing. 2018;27:e1451–e61. pmid:29322579
- 75. Mohr LD, Coke LA. Distinguishing the Clinical Nurse Specialist from other graduate nursing roles. The Journal for Advanced Nursing Practice. 2018;32(3):139–51.
- 76. Cusack L, Smith M, Hegney D, Rees CS, Breen L, Witt R, et al. Exploring environment factors in nursing workplaces that promote psychological resilience: Constructing a unified theoretical model Frontiers in Psychology. 2016;7:600. pmid:27242567
- 77. Rees C, Wirihana L, Eley R, Ossieran-Moisson R, Hegney D. The Effects of Occupational Violence on the Well-being and Resilience of Nurses. Journal of Nursing Administration. 2018;48(9):452–8. pmid:30134377
- 78.
Turner P. Succession Planning and Leadership Development. In: Turner P, editor. Talent Management in Healthcare Exploring How the World’s Health Service Organisations Attract, Manage and Develop Talent. Cham: Palgrave MacMillan; 2018. p. 157–87.
- 79.
Harvey C, Hegney D, Chamberlain D, Wirihana L, Sobolewska A, Wake T, et al. Facilitating pathways to community nursing and midwifery: a systematic review. PROSPERO. 2018.