Transition and pathway programs from second to first level nursing: A scoping review

BACKGROUND

Second-level nurses comprise a large proportion of the nursing workforce in many countries. Despite differences in nomenclature, these nurses work under the supervision of first-level registered nurses and possess a more restricted scope of practice. Transition programs facilitate second-level nurses upgrading their qualifications to become first-level nurses. Globally, the impetus for transition of nurses to higher levels of registration has been to increase the skill mix demands in health care settings. However, no review has sought to explore these programs internationally and experiences of those making the transition.

OBJECTIVES

To explore what is known about transition and pathway programs from second to first level nursing.

DESIGN

Scoping review informed by the work of Arksey and O'Malley.

DATA SOURCES

Four databases were searched, CINAHL, ERIC, Proquest Nursing and Allied Health and DOAJ, using defined search strategy.

REVIEW METHODS

Titles and abstracts were uploaded into the online program Covidence for screening, followed by full-text screening. Two members of the research team screened all entries at both stages. Quality appraisal was performed to assess overall quality of research.

RESULTS

Transition programs are often undertaken to open up career pathways, job and financial advancement. These programs can be challenging as students seek to maintain dual identities, grapple with academic requirements and juggle work, study and personal demands. Despite their prior experience, there is a need for students to receive support as they adjust to their new role and scope of practice.

CONCLUSION

Much of the existing research around second to first-level nurse transition programs is dated. There is a need for longitudinal research to examine students' experiences as they transition across the roles.

Factors that influence scope of practice of the five largest health care professions in Australia: a scoping review

INTRODUCTION

A well-functioning health system delivers quality services to all people when and where they need them. To help navigate the complex realm of patient care, it is essential that health care professions have a thorough understanding of their scope of practice. However, a lack of uniformity regarding scope of practice across the regulated health professions in Australia currently exists. This has led to ambiguity about what comprises scope of practice in some health care professions in the region.

OBJECTIVE

The objective of this review was to explore the literature on the factors that influence scope of practice of the five largest health care professions in Australia.

METHODS

This study employed scoping review methodology to document the current state of the literature on factors that influence scope of practice of the five largest health care professions in Australia. The search was conducted using the following databases: AMED (Allied and Complementary Medicine Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Library, EMBASE (Excerpta Medica Database), MANTIS (Manual, Alternative and Natural Therapy Index System), MEDLINE, PubMed, and SCOPUS. Additional data sources were searched from Google and ProQuest.

RESULTS

A total of 12 771 publications were identified from the literature search. Twenty-three documents fulfilled the inclusion criteria and were included in the final analysis. Eight factors were identified across three professions (nursing & midwifery, pharmacy and physiotherapy) that influenced scope of practice: education, competency, professional identity, role confusion, legislation and regulatory policies, organisational structures, financial factors, and professional and personal factors.

CONCLUSION

The results of this study will inform a range of stakeholders including the private and public arms of the healthcare system, educators, employers, funding bodies, policymakers and practitioners about the factors that influence scope of practice of health professions in Australia.

Exploring the role of the second-level regulated nurse in the Australian nursing workforce: An integrative review

BACKGROUND

The enrolled nurse is the second-level regulated nursing role in Australia, with similar roles in other Organisation for Economic Co-operation and Development countries. A plethora of reports and research papers indicate that this role is seen as integral but under scrutiny by the nursing profession and government bodies. Despite changes such as national accreditation and registration requirements there is a lack of role clarity and delineation, especially between the registered nurse and enrolled nurse roles. As a key nursing role there is the need to ensure it is understood and used to its potential in the nursing workforce.

AIM

To explore key issues that may impact the role of the EN in the Australian nursing workforce.

DESIGN

An integrative review.

METHODS

A seven-step framework was used to review peer-reviewed research papers, scholarly and published government documents, grey literature and government data.

RESULTS

The review identified three themes from 24 documents: understanding the enrolled nurses' scope of practice, standardised practice, and career development.

DISCUSSION

It is posited that a lack of understanding of the enrolled nurses' scope of practice creates confusion between the nursing roles and a lack of standardised practice. There is also an expectation that the enrolled nurses' career progression is to become a registered nurse, which is supported by the high dual registrations. Collectively these factors contribute to the enrolled nurse not feeling valued. Similar challenges to the equivalent role are found internationally.

CONCLUSION

The literature demonstrates a lack of understanding of the enrolled nurse role by the nursing profession. Further work is required to better understand the role and its place in the Australian nursing workforce.

IMPACT STATEMENT

Better understanding of the enrolled nurses' role and its place in the nursing workforce is needed to progress this role.

Four-hour swallow screening target for stroke - from guidelines to practice: A mixed methods knowledge translation study

Purpose: To conduct systematic analysis of compliance with swallow screening against a 4-hour target timeframe and determine barriers and facilitators to compliance.Method: Knowledge translation approach using mixed methods. Quantitative data from a medium sized metropolitan hospital was extracted from 12-months of medical records to review timing of swallow screening from stroke admission using descriptive and inferential statistics. Qualitative data involved 14 semi-structured interviews of speech-language pathologists, registered nurses and medical officers and were analysed using the Theoretical Domains Framework.Result: 74% of eligible patients (271/365) received a swallow screen by trained nursing staff; 189 (52%) were within the 4-hour target. Screening was facilitated by quality training of nurses, strong belief in the benefits for patients and availability of the specialist stroke nurse. Quantitative analysis, confirmed through participant interviews as barriers, revealed that the strongest predictors of not meeting the 4-hour target were overnight admissions and not being admitted to the dedicated stroke unit.Conclusion: 52% of swallow screenings were performed within the 4-hour target timeframe recommended as best practice in the Australian and UK stroke guidelines. Barriers identified may assist other institutions improve compliance with the 4-hour timeframe that will likely be adopted internationally.

Impact of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries: a systematic review

OBJECTIVE

The objective of this review was to determine the effect of nurse staffing on patient and nurse workforce outcomes in acute care settings within low- and middle-income countries.

INTRODUCTION

Health care systems in low- and middle-income countries experience a high proportion of the global burden of disease, which is aggravated by several health care constraints. The high rates of both communicable and non-communicable diseases, low numbers in the workforce, poor distribution of qualified professionals, and constraints in medical supplies and resources make the provision of quality health care challenging in low- and middle-income countries. Health care systems in low- and middle-income countries, however, are still expected to address universal health care access and provide high-quality health care. Systematic reviews examining nurse staffing and its effect on patient and nurse workforce outcomes are largely from the perspective of high-income countries. There is a need to understand the evidence on nurse staffing and its impact in the context of low- and middle-income countries.

INCLUSION CRITERIA

Empirical studies that addressed acute care nurse staffing levels, such as nurse-to-patient ratio or nurses' qualifications, experience, and skill mix, and their influence on patient and nurse workforce outcomes were included in the review. Studies conducted in a low- or middle-income country were included. Outcomes must have been measured objectively using validated tools.

METHODS

Studies published until July 2019 were identified from CINAHL, PubMed, Scopus, Embase, PsycINFO, Cochrane Library, Web of Science, and ProQuest Dissertations and Theses. The JBI approach to critical appraisal, study selection, data extraction, and data synthesis was used for this review. Narrative synthesis was conducted due to high heterogeneity of included studies. The level of evidence was determined using GRADEpro.

RESULTS

Twenty-seven studies were included in this review and the level of evidence was low, mainly due to the design of included studies. Low nurse-to-patient ratio or high nurse workload was associated with higher rates of in-hospital mortality, hospital-acquired infection, medication errors, falls, and abandonment of treatment. Findings on the effect of nurse staffing on length of hospital stay and incidence of pressure ulcers were inconsistent. Extended work hours, less experience, and working night or weekend shifts all significantly increased medication errors. Higher nurse workload was linked to higher levels of nurses' burnout, needlestick and sharps injuries, intent to leave, and absenteeism.

CONCLUSIONS

Lower nurse-to-patient ratios and higher nurse workload are linked to in-hospital mortality, hospital-acquired infections, and medication errors among patients, and high levels of burnout, needlestick and sharps injuries, absenteeism, and intention to leave their job among nurses in low- and middle-income countries. The results of this review show similarities with the evidence from high-income countries regarding poor outcomes for patients and nurses. These findings should be considered in light of the lower nurse-to-patient ratios in most low- and middle-income countries.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018119428.

Healthcare professionals' views of a new second-level nursing associate role: A qualitative study exploring early implementation in an acute setting

AIM

The study aimed to establish the views of a range of stakeholders about their experiences of the newly implemented nursing associate role in England and its potential to contribute to patient care.

BACKGROUND

Second-level nursing roles are increasingly used internationally within the healthcare workforce. In response to registered nurse workforce deficits, a new nursing associate role has been introduced in England to augment care provided by registered nurses and enable career progression of support workers.

DESIGN

Qualitative descriptive design.

METHODS

Semi-structured interviews and a focus group were conducted with a range of healthcare professionals in a large inner city acute secondary care healthcare organisation in England. Interviews were guided by the Consolidated Framework for Implementation Research and analysed using Framework Analysis. The study was reported according to COREQ guidelines.

RESULTS

33 healthcare professionals were interviewed-directors of nursing, ward managers, nursing associates and multidisciplinary team members. Participants perceived the role was broadly adaptable to different healthcare settings and provided a positive professional development mechanism for healthcare support workers. Managers felt training commitments made implementing the role complex and costly. Participants argued the role had limitations, particularly with intravenous medicine management. Implementation was impeded by rapid pace and consequent lack of clear communication and planning.

CONCLUSIONS

The nursing associate role was perceived as an inclusive pathway into nursing but with limitations when working with high-acuity patients. Further evaluation is needed to investigate how the role has embedded over time.

RELEVANCE TO CLINICAL PRACTICE

The role should be seen as both a stepping stone into registered nursing positions and valued as part of the nursing workforce. Consideration must be given to how the role can be safely implemented in different settings. Findings have relevance to healthcare leaders internationally, who continue to work in a climate of economic pressure and staffing shortages.

Healthcare professionals' perspectives on enrolled nurses, practical nurses and other second-level nursing roles: A systematic review and thematic synthesis

BACKGROUND

Significant workforce shortages and economic pressures have led to the expanded scope and reintroduction of new roles for second-level nurses in many Organization for Economic Co-operation and Development countries. Given this, there is a need to understand the emic and etic perspectives of second-level nurses, to ensure collaborative teamwork and safe patient care.

OBJECTIVE

This review aimed to systematically identify, appraise, and synthesize qualitative research evidence on healthcare professionals' perspectives on second-level nursing roles in the healthcare workforce. These findings inform recommendations that would influence the development and implementation of these roles in healthcare organisations.

DESIGN

A systematic review and thematic synthesis of qualitative research was conducted. Six databases were systematically searched and forward and backwards searching completed. Included studies focused on healthcare professionals' perspectives (including views of second-level nurses themselves) on second-level nursing roles. All included articles were from Organization for Economic Co-operation and Development countries. The Critical Appraisal Skills Programme checklist for qualitative research was used to assess the evidence quality. The results section of each included article was coded and descriptive themes were developed. An interpretative and iterative process led to the final analytic themes.

FINDINGS

Twenty-six qualitative studies were identified from five countries over 26 years. Four analytic themes were identified: undifferentiated role; efficient but limited; subordinated task-doers; and broadening scope and strengthened identity. The synthesis demonstrated dichotomies wherein some second-level nursing roles were devalued, and others had increasing scope and responsibility. Role and boundary confusion was evident and had not decreased over time. Hierarchies in nursing practice underlined the split between critical thinking and hands-on approaches to care which, in some cases, debased the second-level nursing role because of its association with practical hands-on care.

CONCLUSIONS

The analytic themes in this synthesis suggest that second-level nurses have faced the same issues over decades with little change. Perceptions of second-level nursing roles are primarily influenced by meso (organisational level) factors and micro (individual, behavioural) factors. The synthesis concludes that a cultural shift in valuing the hands-on care provided by second-level nursing is necessary, along with systems-level shift that clarifies the role of second-level nursing within healthcare teams to enhance collaborative practice. Further research should attend to macro-level influences on perceptions of second-level nurses, the work they do, and how this is valued or institutionally embedded. Tweetable abstract: Healthcare professionals' perspectives on second-level nursing roles: a systematic review and thematic synthesis.

Impact of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to demonstrate the effect of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries.

ENsCOPE: Scoping the Practice of Enrolled Nurses in an Australian Community Health Setting

INTRODUCTION

A continuing shift of healthcare delivery from hospital to the community has increased the acuity and complexity of care provided in the home. Global financial crises and nursing shortages have prompted policies supporting two tiers of nursing and expansion of the licensed practical nurse, second level or enrolled nurse role and evoked debate surrounding roles traditionally undertaken by registered nurses. Community nursing offers unique challenges for enrolled nurses wanting to enact their full scope of practice.

AIM

To compare and describe registered and enrolled nurse opinions of their current and potential enrolled nurse scope of practice in the community health setting.

METHODS

A cross-sectional survey of 136 nurses (115 registered and 21 enrolled nurses) was undertaken within a large community nursing team in Australia. Participants reported their opinions of enrolled nurse scope of practice based on 27 core community nursing skills.

RESULTS

Although substantial agreement was evident, there were statistically significant differences between registered nurse and enrolled nurse opinions in core skill areas; 'Patient Education' and 'Clinical Observation'. Registered nurses identified some specialized skills-catheter and gastrostomy care-that could be undertaken by enrolled nurses with further education.

CONCLUSION

We confirm that registered nurses do agree with extending the skills of enrolled nurses. Education approaches that build shared confidence in enrolled nurse advanced skills are recommended.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

The future supply of nurses is at risk. There are limited resources and increasing demand for quality health care where people live and work. While there may be opportunities internationally to improve productivity through advanced nursing roles, these policies should prioritize efficiency by firstly promoting the full enactment of nursing skills in these settings.

EN2RN - transitioning to a new scope of practice

BACKGROUND

In Australia, newly graduated registered nurses enter the workforce and a number of these have previous experience as enrolled nurses. For all newly graduated registered nurses, transitioning to the new role can be challenging.

AIM

The aim of this study was to explore the experiences of enrolled nurses transitioning to the role of registered nurses to support the development of effective transition programs.

DESIGN

An exploratory qualitative design.

METHODS

In-depth interviews with a purposive sample from one health service in South East Queensland, Australia. Data were analysed thematically.

FINDINGS

The three main themes emerging from analysis: a new scope of practice, perceptions of capability, building on experience and knowledge.

CONCLUSIONS

We recommend assessment of individual learning needs and support during the transition period which acknowledges previous experience and recognises learning required to effectively transition to the role of a registered nurse.