An Analysis of the Experience of the Rural Registered Nurse Entering Practice

Transcription

1 Alberta Rural Development Network Research Project REPORTING Form Requests $10,000 and under 215, 50 Brentwood Boulevard Sherwood Park, AB T8A 2H5 Tel: / Fax: An Analysis of the Experience of the Rural Registered Nurse Entering Practice Project # RU-019 ARDN Contribution: $8, Contact Information Principal Investigator/ Contact Person Institution City Dr. Monique Sedgwick University of Lethbridge monique.sedgwick@uleth.ca Lethbridge Please indicate where this type of project fits (check all that apply) Aboriginal Environment Training Agriculture Community Business Development Education Employment Governance Health & Wellness Seniors Tourism Water Youth Other Please List Please note boxes will expand as you type. Section 1 Executive Summary (approximately one page) including project rationale, and collaborations (including details about collaborations with rural communities, other post-secondary institutions, and other partners). Include a list of outcomes (in accordance to the original proposal). Reporting form $10,000 and less, updated March 16,

2 Rural nursing practice has been described as multidimensional requiring nurses to have an extensive depth and breadth of knowledge (MacLeod, 2008). This description however, undervalues the multifocal nature of rural acute care nursing practice (MacLeod, Kulig, Stewart, & Pitblado, 2004) as well as the relational component of rural nursing that adds a level of complexity rarely seen in urban practice (Crooks, 2007). Presently, few undergraduate nursing programs in Canada prepare nurses for the realities of rural acute care practice (Kulig et al., 2003). In Alberta, only two nursing programs currently thread the concept of 'rural health' and 'rural nursing practice' throughout the curriculum. Available anecdotal that was available at the beginning of this study suggested that many graduates feel ill prepared for the unique nature of rural nursing practice. The lack of preparation at the undergraduate level is compounded by the increasing lack of post-graduate professional development opportunities. In addition, continuing education programs specific to rural health care provision are often inconsistently implemented throughout the province resulting in marginalization of rural registered nurses as well as the general rural population. Using a mixed methods approach, we sought to assess the current state of the knowledge gaps and learning needs amongst novice Registered Nurses in rural Alberta. Novices were described as Registered Nurses who had graduated from a nursing program within five years of the start of the project, were employed in a 50% or higher full-time equivalency position, and were working in a hospital designated as rural by Alberta Health Services. Data collection: A survey tool specific to rural nursing skill sets was adapted for use in this project. Two hundred and fifty seven surveys were mailed out to potential participants across the province to yield a response rate of 32.5%. Thirteen individual in-depth qualitative interviews were conducted with novice Registered Nurses. These participants were located in areas throughout the province according us with a comprehensive perspective. The majority of the participants were between the ages of years of age. Thirty six percent of the participants had between two and three years of work experience. One male participant responded to the survey and one male participant participated in an interview. Seventy one percent of the participants were baccalaureate prepared, 18% of the participants were diploma prepared, and eight percent were second degree prepared. Three focus group interviews with health professionals that work alongside rural novice Registered Nurses were conducted. Two focus group interviews were conducted in northern Alberta and the third was conducted in southern Alberta. Major findings: The Likert survey measured four areas of clinical competency: clinical/technical; critical thinking; communication/interpersonal; and management/organizational. Generally, if participants felt they were competent for one factor within a clinical competency area, there was a strong correlation with feeling competent across all factors within that area. The same is true across the four clinical competency areas. If overall the participant felt competent in his/her technical skills, there was a strong correlation with feeling competent across the remaining three categories of competencies. The qualitative data that came from the individual and focus group interviews revealed the complex nature of rural hospital nursing practice as well as the intricate and often times difficult work novices engaged in to create order and to make sense of their experience. The major categories were: how novices prepared for rural hospital nursing practice; the multiple factors influencing their experience (for example, impact on their personal life); how novices make sense of their experience (for example, learning in the rural environment) and; what made them stay. Outcomes: 1. To identify knowledge gaps so that novice Registered Nurses can provide safe, competent care: Quantitative data analysis suggests that novice Registered Nurses feel they possess the necessary psychomotor, organizational, communication, and critical thinking skills needed to be able to provide safe, competent care. 2.To identify what novice Registered Nurses require to feel confident in the care they provide: Our analysis reveals that Reporting form $10,000 and less, updated March 16,

3 novice Registered Nurses feel ill-equipped to deal with the complex nature of rural nursing practice. They lack skills in navigating the relational component of rural practice. They also lack skills in 'sophisticated thinking' ability - being able to quickly and easily move between widely differing patient care needs. 3. To identify how best to meet novice Registered Nurses' learning needs: Participants in this study clearly indicated that current orientation practices (these vary from facility to facility and range from hours) are insufficient. They suggested more in-depth orientation is required. They also identified that ongoing support from clinical educators and more experienced Registered Nurses is essential in helping them make the transition from novice to competent practitioner (Benner, 2001). In addition, while novice Registered Nurses expressed a desire to obtain additional skills sets quickly, seasoned Registered Nurses suggested more fundamental elements must be solidified first. Last, the novices we interviewed repeatedly stressed the importance of mentoring, preceptoring, and buddying as essential in being able to meet their learning needs. 4. Generalizability of findings to other healthcare professional groups (Physiotherapy, Licenced Practical Nurses, Pharmacists, etc.): While this research was specific to novice Registered Nurses, similarities in context will provide generalizability to other healthcare professionals as we work to disseminate our findings. 5. Generalizability of findings to other 'rural' settings: The term rural is ambiguous. For this study, we used Alberta Health Services' (AHS) definition of 'rural' to identify our participants. We found this definition produced a limitation to the generalizability of our findings since according to participants the size of the facility varies widely across what AHS defined rural. Further, the geographic location what AHS defines rural is vague resulting in the possibility of capturing suburban experiences as well as 'rural' experiences. Recommendations: 1. We recommend the content provided in orientation for new hires be re-examined. There needs to be a balance between pathophysiology and procedural knowledge, and the opportunity to develop greater ease in retrieving knowledge about varying patient conditions across the life-span at a moment's notice. 2. We also recommend that health services authorities consider instituting a mentorship program. Such a program would help novices develop skills to be able to navigate the relational component of rural nursing practice. This type of program would help with sustaining the workforce - nurses would have greater job satisfaction. Last, this type of program would meet the learning needs of not only novices but more experienced nurses as well. 3. Future research is needed to examine the notion of "sophisticated thinking" as well as strategies that would support the development of this skill. Section 2 a) What was the desirable direction of change anticipated at the start of the project (please refer to your original application)? Was this achieved? What was the actual direction of change, if different? What lessons were learned? Desirable direction of change: Identification of the knowledge gaps and learning needs of novice Registered Nurses practicing in rural facilities in Alberta. Novice Registered Nurses have identified the strengths and weaknesses of current orientation and professional development opportunities. We believe that modifications in undergraduate nursing education, orientation and ongoing professional development programs and/or experiences that effectively address these gaps will prepare novice nurses for success in rural practice. Further time and resources are required in order to ensure that these needs are effectively addressed. b) Please describe how project results were disseminated. Especially include knowledge translation (plain language) and mobilization to and with rural communities. Canadian Rural Health Research Society 10th conference, Oct 20-22, podium presentation Reporting form $10,000 and less, updated March 16,

4 MHC Innovates Symposium, Oct, podium presentation c) What are the impacts of the project on rural development (use of bullets is encouraged). Explain how this project is making or will make a difference to rural Alberta. Short term? Long term? The anticipated benefits of this project include: 1. Support for current and future Registered Nurses learning needs specific to rural health care: By effectively addressing the knowledge gaps and learning needs identified by the participants in this study, more confident competent nurses will be responsible for the provision of care to rural Albertans. We have met with representatives for AHS (rural programs) with the goal of sharing with them what we learned. These discussions are in the very early stages. We hope to be able to guide nurse educators in determining the type of the content needed to address the learning needs and gaps identified by novice Registered Nurses. 2. Production of distance continuing education courses to meet the needs of novice Registered Nurses: Rural contextual content is essential in facilitating the adaptation of the novice nurse to healthcare in rural Alberta. Discussions are taking place with MHC to adapt its present rural nursing course to a distance learning format. 3. Enhanced patient outcomes for Albertans: "Healing in place" is recognized as a means to improve patient outcomes. A stable and continuous registered nursing workforce is essential for this to happen. This project demonstrates the existing knowledge gaps, required skill sets and necessary relational elements to assist in achieving this outcome in rural Alberta. Consequently, meeting the learning needs of novice nurses may improve their confidence and thus impact retention in rural facilities. 4. Provision of a quality assessment of novice rural hospital Registered Nurses learning needs: Robust empirical data were generated from this project. This data begins to address the gap in identifying the knowledge gaps and learning needs of novice Registered Nurses practicing in rural Alberta. 5. Provide educational insights to undergraduate nursing programs: The data support the need for including rural nursing practice curricular content in undergraduate nursing programs. d) What are the next steps from this project? Short term? Long term? Who will undertake these activities? Please give their name & contact information so we can discuss the next steps with. 1. We are interested in exploring the impact of healthcare centralization on rural nursing practice. 2. We are interested in comparing novice rural Registered Nurses' sophisticated thinking abilities in graduates who have been exposed to rural nursing practice content during their undergraduate nursing program with those who have not. Section 3 Please fill out all relevant sections below. a) Please include the details about community collaboration (if applicable) This study was a survey of novice registered nurses working in rural facilities across the province of Alberta. Three focus group interviews were also conducted with registered nurses who work with novices in rural hospitals. Focus group interviews brought together 7-9 participants in each interview. As can be expected with this type of interview, the participants were able to hear about their colleagues' experiences working with novices and discuss novices learning needs as well as strategies they might engage in to support their novice colleagues. b) Please include the details about collaboration with ARDN members (if applicable) A Medicine Hat College researcher has been instrumental in all phases of this project. She collaborated in the development of the original study project proposal as well as the final project report. She also assisted with the ethics application. She further assisted in the adaptation of survey, data collection i.e. conducting individual interviews, and data analysis (both qualitative and quantitative). She presented the findings of the study at the MHC Innovates Symposium in Reporting form $10,000 and less, updated March 16,

5 October, 2011 and she continues investigate other avenues for dissemination of the findings including meeting with Alberta Health Services representatives. c) Please include the details about collaboration with other partners (if applicable) Hope Health Initiative reviewed the original study project proposal and offered suggestions. They also offered suggestions for the survey. Senior Researcher for Alberta Health Services assisted the research team in establishing linkages with various rural sites for recruitment of potential participants. They also provided feedback on the survey instrument. Section 4 a) Did this project further the goals of science? If so, how? List publications, actual and planned. From this project, empirical evidence exists that extends our understanding of novice Registered Nurses experience of rural nursing practice. Four manuscripts are currently being developed: 1. The reciprocal nature of relationships in rural nursing practice 2. The role of sophisticated thinking in novice rural registered nurse practice 3. Novice Registered Nurse competencies required for safe, competent practice 4. Making sense of the rural nursing practice experience Section 5 a) Provide a list of key learnings; what worked and what didn t? Include recommendations for others planning to initiate similar projects in rural Alberta. What worked: The ability to work with CARNA to access the network of rural novice Registered Nurses practicing in Alberta. Access to their database of key contacts resulted in a great response rate to our survey. Using Survey Monkey (an online program for survey completion) was also successful: it was easy to set up and use, relatively inexpensive, and accessible to potential participants. Having said this, we also mailed out hard copies of the survey. This yielded a very good response as well. What didn't work as well: The survey itself needs to be clarified. We experience some difficulty in gaining commitment from participants for some of the focus group interviews. The difficulty we experienced might be in part to the difficulty in being able to coordinate five or six key people during 'offduty' time when staffing in rural hospitals is generally a challenge. As noted above the term 'rural' needs to be more clearly defined. We suggest that facility size (maximum of 25 in-patient hospital beds) and services offered be used to help describe rural hospitals. That is, some rural hospitals have designated units for particular services (for example a surgical unit) while others do not (rather they have rooms where patients who have undergone a particular treatment might be assigned to the same room). Some rural facilities offer a wide range of medical services (for example obstetrical services) while others have more limited medical services. Consequently, some larger rural hospitals have designated units and staff to provide care in these areas (for example some rural registered Reporting form $10,000 and less, updated March 16,

6 nurses work only in the emergency department). To help advance our knowledge and understanding of rural hospital nursing a more precise definition would be helpful. That is, while there may be commonalities across rural hospitals, having a more precise definition would help identify important differences. Recommendation: Sharing of our findings and developing the next steps in terms of dissemination is more difficult. We recommend that contact with the Rural Nurse Educator group (these are registered nurses employed by AHS to function in a nurse educator role. As a result, their primary role is to address the learning needs of rural registered nurses) be made in the initial development of any project so that the dissemination of findings and recommendations is facilitated through this group. Reporting form $10,000 and less, updated March 16,