Graduate Nurse Education Programs: Transition Pathway for Registered Nurse Employment

In Australia, graduate nurse programs (GNP) are formalised transition programs provided by employers for graduate registered nurses (GRN) in their first year of practice...

In Australia, graduate nurse programs (GNP) are formalised transition programs provided by employers for graduate registered nurses (GRN) in their first year of practice following successful completion of an entry to practice degree. An analysis of nursing education in Australia highlighted a lack of data about student to graduate transition (Australian Government Department of Health and Aged Care, 2019). Statistics provided by the Nursing and Midwifery Board of Australia (NMBA) and equivalent international organisations, provide registration numbers but fail to account for those who do not register. They also do not distinguish between those successful in attaining employment and those choosing to leave the profession (NMBA, 2022).

Sustainability in the nursing profession requires an understanding of current issues followed by planned action...

Sustainability in the nursing profession requires an understanding of current issues followed by planned action to secure the health workforce recommended for growing population groups, such as mental health, aged care and rural and remote areas (Australian Government Department of Health and Aged Care, 2015). Furthermore, the World Health Organisation (WHO) report, “State of the World’s Nursing 2020: Investing in Education, Jobs and Leadership” highlights the threat posed by an ageing nurse workforce and international recruitment overreliance (WHO, 2020a). This document also purports that nurse graduates need assistance with improved employment opportunities and retention for nursing workforce sustainability (WHO, 2020b).

“The Nursing Workforce Sustainability: Improving Nurse Retention and Productivity” report (Australian Government Department of Health and Aged Care, 2015) in Australia identified the lack of congruence between availability of employment for graduate nurses and the number of graduating nurses. The report recommended an “increase in the breadth of graduate nurses employment opportunities” (Australian Government Department of Health and Aged Care, 2015, p. 17). However, the Department of Health, Nursing and Midwifery Office in Western Australia (WA) estimated that in 2018 only 35% of the graduating registered nurses obtained a position through Graduate Nurse Connect, the largest employment agency for graduate programs in the state (C. Barrett, personal communication, May 17, 2019). This unemployment trend has been increasing over recent years, with 40% in 2016 not obtaining a graduate program and 37% in 2015 (O’Leary, 2016).

What is known is that graduating nurses [are] unable to obtain employment, even with many having applied for multiple positions...

The authors of this study, like others recently (Cottle-Quinn et al., 2021), found that there is a dearth of literature that addresses factors that assist (specifically) graduating nurses to gain their first positions. Gilmore et al. (2017) purported that “increased nursing education enrolments to cater for possible future nursing shortages, (ii) decreased state expenditure on health services and, (iii) graduate employment dictated by staff vacancies rather than ensuring sustainability of the future workforce” (p. 251) are contributing factors. What is known is that graduating nurses are unable to obtain employment, even with many having applied for multiple positions, resulted from their lack of nursing experience, lack of nursing positions for new graduates and no jobs without the completion of a nursing graduate program (Australian Nursing and Midwifery Federation [ANMF], 2014). The latter is of concern because the significant issue is that the actuality of employment opportunities available to graduates continues to reduce and there is also limited realistic prospect of a supported post entry degree graduate program for future graduates.

Study Methods

Study Aim
Given predicted shortfalls in the global nursing workforce (HWA, 2014; WHO, 2020b), this pilot study aimed to describe the graduating nursing students’ experience of engagement with their chosen profession when attempting to gain employment. The study was undertaken to describe the enablers and barriers of engagement with nursing experienced by graduating registered nurses to better understand graduate pathways, which may influence nursing education and workforce planning. It is envisaged that findings from this study will support a wider state or national study.

Sample and Data Collection
Convenience sampling technique was used, and to ensure sufficient data sampling, two cohorts of graduating students were invited to participate. The research team presented the research to the two graduating student groups (graduating end of Semester 1 and Semester 2, 2020) at the commencement of the semester to outline the study, followed by emails with links to the survey after end of semester student exams. Ethics approval was obtained from The University of Notre Dame Australia Human Research Ethics Committee.

The online survey data collection incorporated closed and opened ended questions about participant engagement with the profession of nursing.

The study consisted of an online survey developed using Survey Monkey (SurveyMonkey Inc., 2022) that included 27 questions. Face validity was achieved through input and review of the survey by multiple members of the research team as well as a group of recently graduated nurses (n = 5). The online survey data collection incorporated closed and opened ended questions about participant engagement with the profession of nursing.

Data analysis was conducted on the survey, embedded in Survey Monkey, which provided quantitative data, and open-ended questions. This enabled descriptive statistics to summarise the patterns of responses of participants. Cross tabulation for data of interest was used to further understand patterns and relationships (Punch & Oancea, 2014).

Study Findings

Participants were asked to complete the survey only if they were about to graduate from the Bachelor of Nursing. Study data were collected from the 194 returned, completed in full surveys. Of the study participants there was a total of 40 graduates who had previously completed the Diploma of Nursing (a two-year qualification leading to registration as an enrolled nurse [EN] who works under the supervision of the registered nurse) and returned to study to become a registered nurse. The majority of these nurses did not engage with the profession as enrolled nurses. All study participants, including the graduates with a previous Diploma of Nursing, provided a 100% response rate to their intention to register with the Nursing and Midwifery Board as a registered nurse (RN).

For group 1 (G1) participants graduating in 2020 semester 1, to account for the Western Australian Health nurse recruitment strategy to manage the COVID-19 pandemic, the survey was altered to include the additional statement “prior to the outbreak of Coronavirus/COVID-19).” This was included so that employment statistics could be reported on, in consideration of the impact of this recruitment drive. As outlined in Table 1, of the G1 (47.5%) almost 50% did not gain employment in a formalised graduate transition program for registered nurses; G2 fared slightly better with just over 41% not gaining employment in a formalised graduate transition program. Of note, no participants in G1 gained an employment contract as a result of the WA Health COVID-19 recruitment. The question was removed for G2 as there was no active recruitment drive in response to COVID-19. This was a direct result of the WA Government strict border policy resulting in no community acquired COVID-19. (Government of Western Australia, 2020)

Table 1. Have you been offered a Graduate RN position in a graduate program?

Participants were asked, if offered a GRN position did they accept the position, to determine the acceptance rate of graduate programs and why a student may decline a position offered. Three participants did not accept a graduate nurse position. Two respondents had received two offers each and therefore accepted one and declined the other; one other respondent accepted a Medical Degree program.

Of the 84 of 194 participants who did not gain employment in a GRN program, only nine participants gained an independent level one position as a RN (i.e., an offer of employment without the support of a formalised transition program). To further understand those participants who gained a position outside of a GRN program, the study sought to determine if this was their preference. One participant indicated this was by preference, whilst for the other participants this was only as a result of not gaining a graduate RN role. For those not gaining a position, when asked if they have obtained a position outside of nursing in which their Bachelor of Nursing assisted them, five participants indicated that they had obtained a position in residential care as a support worker; this role is a non-registered healthcare worker in Australia, typically requiring about 6 months training.

Advertised RN positions usually sought one year plus experience, making the available graduate openings very competitive.

The central focus on the challenges faced by the respondents in trying to obtain a RN position (graduate or level one RN) was the lack of graduate positions. Advertised RN positions usually sought one year plus experience, making the available graduate openings very competitive. Exemplars of respondents’ comments included:

• “Other than graduate programs, there are minimal opportunities available for graduate RNs in WA, most advertised positions require 2-5 years experience”
• “Lack of positions for RN graduates- competing against a significant number of other graduates for the few gradate positions offered”
• “Competition for the position and not having a clear idea of which hospital would be the best fit for me”
• “High level of competition and trying to ensure a high application level”
• “Extremely stressful knowing that there is not enough graduate positions for the amount of students that graduate”
• “Disappointed that the uni [university] over accepts students knowing full well the lack of jobs available to us as a graduate”
• “The system fails us in that they need more nurses in the future but refuse to put more funding into graduate programs”

The challenge of competing for limited graduate openings was followed closely with having difficulties in writing a selection criterion to ensure a high-quality application and failure in the interview process. Personally, some respondents felt frustrated in that they do not perform well in interviews (finding the interview process anxiety provoking), whilst others commented that they were not being prepared for interviews and not having enough time to prepare for them was a challenge. The theme of stress was prominent throughout. One respondent provided a reflective summation of the challenges the graduating nurses face that was common throughout participant responses:

When I received feedback from my first hospital choice, they said my selection criteria was very good and if I had applied to a larger hospital that had more positions available, they thought I would've had no problem in getting a grad program. Since not receiving a grad program, I have applied for MANY RN level 1 positions. However, I have still been unsuccessful, despite my experience as a support worker. It is extremely hard to obtain a level 1 RN position as all of the jobs I have applied for state they require a minimum of 3 years nursing experience. I still apply for the positions, but am not very hopeful as I don't fit the criteria that they ask for in a nurse due to having zero RN experience. Also, a lot of the applications required a selection criteria to be completed, but I am only able to answer based on practice experience, not RN experience, which isn't as good as nurses applying who have previous RN experiences.

Personally, some respondents felt frustrated in that they do not perform well in interviews (finding the interview process anxiety provoking), whilst others commented that they were not being prepared for interviews...

Discussion

The findings indicated that approximately half of the group gained employment, and half did not. Despite the initial call out for nurses at the commencement of the COVID-19 pandemic, due to its successful control within WA there were no additional employment contracts provided. Outside of the WA graduate programs, three graduates were successful in gaining a position overseas (English National Health Service). No positions were gained outside of WA within Australia, and nine participants were successful in obtaining a position outside of a formalised graduate program as a level one RN. A further five participants obtained employment as non-registered careers/support staff. These findings support the Australian Government Department of Health and Aged Care report (2015) that highlighted the lack of congruence between the availability of employment for graduate nurses and the number of graduating nurses. Further, our findings supported the recommendation of an “increase in the breadth of graduate nurse’s employment opportunities” (Australian Government Department of Health and Aged Care, 2015, p. 17).

The findings indicated that approximately half of the group gained employment, and half did not.

Reliance of graduating students on gaining a traditional graduate program position was evidenced in their responses. Moreover, this report is reflective of the continuing low graduate nurse unemployment rate, with the graduating nurses in this pilot study rates being 47.5% and 41% respectively, and with only a further 3% and 5% respectively gaining a position as a RN (outside of GRN program). These rates do not meet the recommendation of the WHO (2020b), in relation to the looming nursing shortage gap, where “an absorption rate of 70% of graduates into the labour market” (p.65) would be needed for workforce sustainability. Of concern for future nursing workforce sustainability is the high number of graduating nurses in this pilot study who have not gained employment as a GRN nor as an RN. Hence, with some taking up further studies and others seeking opportunities outside health; it is concerning when taking into account the cost and time taken to gain the qualifications as an RN that these graduates are lost to the nursing workforce and health industry if this trend continues.

Of note was the importance placed by the study respondents on gaining a graduate nurse education program to enhance their ongoing career success. This is driven by the known bottleneck of Australian graduating nurses vying for limited graduate nurse program (GNP) positions, knowing that without a program place, any employment opportunity is limited (HealthTimes, 2020). This is concerning when literature suggests that professional practice experience enhances the graduates’ confidence and competency (Hawkins et al., 2019; Spector et al., 2015).

...it is concerning when taking into account the cost and time taken to gain the qualifications as an RN that these graduates are lost to the nursing workforce and health industry if this trend continues.

Further, structured GNPs where clinical decision-making and nurse judgements are supported provide relevant socialisation within the health field (Ankers et al., 2018; Fowler et al., 2018) and reduce clinical practice incidents (Spector et al., 2015). This GNP support enhances graduate nurse practice readiness that links to patient safety and wellbeing when supported by appropriate resources (Murray et al., 2018; 2020). Resources such as career pathway progression and nursing education investment in developing the nursing workforce is purported in the United Nations Sustainable Development Goals (SDG), SDG 3 ‘Ensure healthy lives and promote well-being for all at all ages’ with its reliance on a competent nursing workforce (WHO, 2020b).

Conclusion

Findings from the pilot study have highlighted a significant gap between graduating student numbers and employment gained in Western Australia.

Findings from the pilot study have highlighted a significant gap between graduating student numbers and employment gained in Western Australia. Further data collection from future graduating groups and their long-term engagement with the profession is required. This will assist with understanding student career pathways and workforce planning. To support global healthcare workforce predictions, and the WHO (2020b) Sustainable Development Goal 3, an international understanding of nursing graduates and their place of work and the impact of graduate nurse education programs can further support global strategic planning and workforce sustainability.

Author Note

With changes to Western Australian Government policy on border control in early 2022, an increase in COVID-19 cases and hospital demand is inevitable. The impact of this short-term demand has seen a rapid employment of all health professionals in late 2021, after the data collection period of this study. This change of recruitment strategy, in the midst of COVID-19, requires close monitoring to understand the long-term impact on nurse recruitment.

Authors

Kylie Russell, PhD
Email: Kylie.russell@nd.edu.au
ORCID ID: 0000-0001-9737-8533

Bachelor of Nursing, Graduate Certificate Human Resource Management, Master in Health Science (Education), PhD.

Kylie is a Professor in the School of Nursing & Midwifery, and School of Medicine at The University of Notre Dame Australia.

Tracey Coventry, PhD
Email: Tracey.coventry@nd.edu.au
ORCID ID: 0000-0003-3228-6448

Bachelor of Science (Nursing), Master of Nurse Education, PhD.

Tracey is a Senior Lecturer in the School of Medicine at the University of Notre Dame Australia.

Sheralee Tamaliunas, PhD
Email: sheralee.tamaliunas@health.wa.gov.au

Sheralee Tamaliunas: Bachelor of Science (Nursing), Diploma Project Management, Graduate Diploma Clinical Nursing (ICU), Master of Clinical Nursing, PhD.

Sheralee is the Clinical Director Workforce and Innovation at the Department of Health Western Australia and an Adjunct Associate Professor at the University of Notre Dame Australia.

Dianne Juliff, PhD, MSc(Nsg), BSc(Nsg), RM, RN, GradCertMgmt(Leadership)

Di is a sessional Senior Lecturer, Research Associate and HDR Supervisor for the University of Notre Dame Australia.