June 24, 2024

New Graduate Nurse Transition to Practice and Retention in Rural Settings

When I went into nursing school back in 2016, I only ever knew about rural nursing and healthcare. I grew up in a small rural town in Northern Ontario called New Liskeard. I thought I was familiar with the concepts of rural healthcare. In my eyes, it was only distance. We had to drive 2 hours to get an MRI, we had to drive anywhere from 2-6 hours to seek professionals who could perform a complicated surgery, or we had to drive 5 hours for a consultation with a pediatrician. But I didn’t realize just how different urban nursing was until 2020 when I returned home to work as a New Grad RN. Living and studying in Ottawa for 4 years with all of the fancy specialty areas and resources, and then returning to the bare bones of rural nursing was a whole different ball game for me.

I did my training in the capital, where there were things like RACE (Rapid Assessment of Critical Events) and SPOT (Critical Care Response Team) teams, Residents, Respiratory Therapists, Pharmacists and support staff on-site around the clock, always a phone call away. We were who these small, rural hospitals would call when they needed help with a complicated case. But now, all of a sudden, things took a shift. I was the one in a small rural hospital begging for help, wishing I had a button I could press to have two ICU nurses, an ICU resident and an RT at my fingertips in seconds to help me assess my patient when things weren’t quite severe enough for a code blue, but not good enough to handle on my own with my new grad level of knowledge and novice skills. When me and my group of nursing friends graduated, it was easy to compare our experiences. The majority of my classmates were transitioning within established urban hospitals, where they had completed their consolidations. However, here I was, starting my first RN job in an unfamiliar hospital, unaware of how the organization ran and unfamiliar with the paper charting system, the med carts and the resources (or lack of) that were available to me. I quickly noticed that my city friends had formal orientation programs with regular check-ins with their leadership team, regular compensated in-class learning opportunities, and were being welcomed as a cohort of New Graduate Nurses (NGNs), where they would have the opportunity to bond and create friendships which would help them during their transition period.

I was enrolled to start my Master’s of Science in Nursing program in the fall of 2020 and quickly realized that I wanted to dive further into this huge gap I had observed. During the winter 2022 semester, I had the opportunity to complete a clinical placement as a part of a course where I further explored the front-line issue of retention among NGNs in their first 3 years of practice at my local hospital. During this placement, I was able to identify several factors that contributed to NGN’s low retention rates in these settings, such as an overload of patients with high levels of acuity, an inability to accommodate patient’s needs, a lack of materials to implement training, a lack of sense of belonging, and negative workplace morale. Following this experience, I decided to make the leap to the thesis stream to further explore this topic and help fill the gap in literature.

When starting my thesis, one finding from my placement study stood out for me in particular, the NGN’s sense of belonging. With this, I found two models to base my thesis study from. The first was the Job Embeddedness Model (Mitchell & Lee, 2001) which describes the reasons why people stay at a job. This model focuses on the nurse’s attachment to the clinical and community settings (Mitchell & Lee, 2001). Second was Judy Boychuk Duchscher’s Transition Stages Model (2008) which highlights the various transition phases that NGNs experience during their first 12 months of practice.

Three main themes emerged from my thesis study: 1) Being a NGN in a rural setting, 2) Lack of support in rural settings, and 3) NGN sense of belonging in the workplace and community. The first theme, Being a NGN in a rural setting, developed following participants’ expressed difficulties during their orientation due to a lack of consistency of staff on their work line, orientation being completed with agency nurses or staff with a different scope of practice (e.g., RPNs) and being pulled from orientation on multiple occasions to help staff the units. Half (50%) of participants expressed having 4 or more preceptors during their orientation, in a study conducted by Casey et al. (2004), it was found that NGNs having three or more preceptors did not progress as seamlessly in their orientation process.

The second theme focused on a lack of support in rural settings where 62.5% of participants expressed having acted as charge nurse and 25% having had acted as a preceptor in their first year of practice, despite The Ontario Ministry of Health & Long-Term Care’s (2023) recommendation that preceptors have a minimum of 3-5 years of nursing experience. The participants also expressed fears during their transition from student to RN which encompassed patient safety and role expectations due to their high levels of autonomy in these settings. Some nurses reported working independently in high acuity settings (e.g., Emergency Department and Intensive Care Unit) on night shifts and 75% of participants noted a need for increased support in order to feel more supported and integrated into their unit. Focus group participants identified little to no content coverage on rural nursing throughout their undergraduate education. According to the National Nursing Education Framework (CASN, 2022), only primary healthcare principles are required to be covered during nurses’ undergraduate education and not necessarily the skills that “generalist” nurses in rural settings may be required to perform.

Finally, the third theme of NGN sense of belonging and quality of life confirmed the nurse’s ties to the community through relationships with family and friends. The nurses in this study chose to work in rural areas, having been from the area themselves and/or to be with family or within commuting distance from them. The participants also reported working with at least 3 coworkers regularly, creating attachments in their workplace. The literature states that positive work relationships are associated with a better connection outside of work (Mitchell & Lee, 2001). In the questionnaire, the NGNs identified their intent to find a comparable job in a different city as 2.3 on a 5-point Likert scale. This moderately-low score can be attributed to the NGNs perceived quality of life living in a rural setting with the short travel times, the nurses’ ties in their communities, and the proximity of their families and friends. In contrast, during the focus group, participants described their experience with the use of agency nursing staff and the barriers they pose to having long-term co-worker relationships. The participants expressed a lack of consistency in coworkers with the presence of agency nursing staff.

In terms of future considerations, I hope that NGNs can read this and reflect on which areas of their practice they’ll likely need to advocate for when starting their careers in rural settings. They may use this knowledge to familiarise themselves with the difficulties that may arise and be prepared to seek strategies to engage with the leadership team. I hope that nursing staff supporting NGNs may read this and see the importance of seeking funding opportunities to secure thorough orientation programs for NGNs to ensure their continued growth. This orientation should include 1-2 consistent full-time mentors with 3-5 years of experience who are assigned to NGNs for orientation. Nurse leaders must also advocate for better preparation during the baccalaureate programs for rural settings and offer placements to other regions in order to increase awareness and recruitment to these locations. Likewise, hospitals can highlight their rural incentives which go beyond financial, and also include rural lifestyle incentives that many people seek (Molanari et al., 2011). Finally, nurse leaders are some of the first faces that NGNs will see when they begin their careers, these leaders need to prioritize the NGN’s sense of belonging by connecting them with like-minded individuals and highlighting optional committee and engagement activities at work and in the community.

References:

Boychuk Duschscher, J. (2008). A process of becoming: The stages of new nursing graduate professional role transition. The Journal of Continuing Education in Nursing, 39(10), 441-450.

Canadian Association of Schools of Nursing (CASN). (2022). National Nursing Education Framework. https://www.casn.ca/wp-content/uploads/2023/04/National-Nursing-Education-Framework_2022_EN_FINAL.pdf

Casey, K., Fink, R., Krugman, M., & Propst, J. (2004). The Graduate Nurse Experience. The Journal of Nursing Administration, 34(6), 303–311. https://doi.org/10.1097/00005110-200406000-00010

Ministry of Health. (2023). 2023-24 Guidelines for Participation in the Nursing Graduate Guarantee Program. https://www.health.gov.on.ca/en/pro/programs/hhrsd/nursing/docs/NGG_Guidelines.pdf

Mitchell, T., & Lee, T. (2001). The unfolding model of voluntary turnover and job embeddedness: Foundations for a comprehensive theory of attachment. Research in Organizational Behavior23, 189–246. https://doi.org/10.1016/S0191-3085(01)23006-8

Molanari, D., Jaiswal, A., & Hollinger-Forrest, T. (2011). RURAL NURSES: LIFESTYLE PREFERENCES AND EDUCATION PERCEPTIONS. Online Journal of Rural Nursing and Health Care: The Official Journal of the Rural Nurse Organization.11(2), 16–26.

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Emily Reynolds is from New Liskeard, a small town in northern Ontario. She graduated from the University of Ottawa with her BScN in 2020 and has been working as a nurse since. Based on her personal new graduate nurse experience in rural healthcare, Emily decided to focus her thesis on New Graduate Nurses experiences of transition and retention in rural settings, she completed her MScN in the spring of 2024. Emily has worked in a variety of rural settings, including med-surge, special care unit (acute care) and now works as a public health nurse. 

Emily’s full thesis can be accessed here: https://ruor.uottawa.ca/items/02b86aee-53d0-4a25-aa64-f8571312d28b

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