Registered Nurses Perceptions of the Transferability of New Graduate Registered Nurses Skills across Healthcare Settings

Aims and Objectives: This paper describes Registered Nurses’ (RN’s) perceptions of the transferability of New Graduate Registered Nurses (NGRN’s) skills across settings: one aspect of a larger study exploring RN’s perceptions of NGRN’s work-readiness. Background: There is evidence RN’s do not consider NGRN’s as adequately prepared for practice. However, there does not appear to be consensus on what characterizes work-readiness. Methods: An adapted online questionnaire was sent to RNs in a range of clinical settings. They rated NGRNs’ skills and the applicability of those skills to their clinical setting using a 5-point Likert scale. Results: Perceptions of transferability of skills across settings varied. In the skills grouping of routine assessment, basic clinical skills, advanced clinical skills the percentage rated as “not applicable” was over 40% in 75% of the skills. The low or zero non-applicable responses to communication skills indicate this skill group contains transferable skills regardless of the setting. The zero non-applicable responses for preparedness for practice for all but two skills indicate these groups contain transferable skills across settings. Conclusion: There appears to be some alignment between expectations from RNs and current NGRN preparation. The lack of transferability of more advanced technical skills raises questions about the role of education in preparing the NGRN versus that of industry-based graduate programmes. The increase in nursing roles and the increased emphasis on aged care and primary health care dictates that generalist preparation of NGRNs emphasising the attributes of an RN should be the focus rather competency in advanced technical skills.


Introduction
Over the last two decades concerns about the adequacy of nursing programmes to prepare work-ready graduates have been widely reported in the international nursing literature [1]. In the local context of Northland, New Zealand anecdotal evidence, such as discussions between education and the clinical providers at clinical contract meetings, suggest that Registered Nurses (RNs) have mixed perceptions about the work readiness of new graduate registered nurses (NGRNs).
Additionally, there appears to be no overall consensus with respect to the particular skills in which the NGRN should be competent.
A large mixed-method study using exploratory sequential design was undertaken by Missen et al. [1] [2] [3] in Victoria, Australia investigating the work readiness of NGRNs. Phase 2 of this study [1] examined the perceptions of qualified nurses (including Enrolled Nurses) about NGRN's preparedness in a range of technical and non-technical skills. These included: routine assessment; basic and advanced clinical skills; medication administration; emergency procedures; communication skills; preparedness for practice; and coping with work environment. This paper reports the findings of a study in Northland, New Zealand (NZ) related to transferability of skills across settings which is one aspect of a larger project which replicated the research of Missen et al. [1]. The intention of the larger study was to provide evidence of any key concerns around competency so nurse educators from the local education provider and local employers including the District Health Board could better prepare NGRN's to be ready for work.

Background
Bakon et al. [4] report the increasing global concern that NGRNs are under pressure to transition quickly from the student role in a health care environment that is highly stressed. The reasons for an increasingly stressed healthcare environment and the impact on NGRNs have been documented elsewhere in the literature [5]. Certainly, over the last several decades some key stressors in the healthcare environment and the delivery of nursing care have been the increased use of technology, higher numbers of admissions with increased acuity, and an ageing population and increasing prevalence of chronic disease [1]. These trends, along with an ageing nursing workforce and a predicted global shortage of nurses [6], highlight the importance of NGRN's being able to quickly transition into the workforce and competently perform the requisite clinical skills.
Although there is limited research in the New Zealand setting with respect to the work readiness of new graduates, being underprepared has been reported by many NGRN's themselves. A research pilot of new graduate first year of clinical practice nursing programme found that only one third of NGRNs felt confident at commencement of the programme [7].
A requisite for rapid transition must be adequate preparation; however, there is considerable evidence internationally that nurses do not perceive their new graduate nursing colleagues as adequately prepared for practice [

Methods
This study utilised a descriptive quantitative design using an online question-

Results
The data obtained from the questionnaires were analysed using an excel statistics package. As per the approach used by Missen et al. [1] ordinal data is presented with numbers and frequencies with medians (range of 1 -5) and interquartile ranges. To promote readability the Likert-type items are presented in collapsed form (3 instead of 5) amalgamating "very good" and "good" and "poor" and "very poor".
Sixty-four questionnaires were completed. All participants completed Part One (Likert-type questions) but only 75% completed Part Two (demographic information). The demographic characteristics of the participants are summarised in Table 1 were also asked to rate their preparedness in terms of preparedness for practice and coping with the work environment.
A breakdown of "not applicable responses" was undertaken to compare across community, hospital and aged care settings. There was variability in transferability of skills across different settings (community, aged care and acute hospital) depending on their skill groups with the largest number of "not applicable" being recorded in the "advanced skills category" ( Table 2). Across the three skill groupings in Table 2 (routine assessment,    skills) the percentage of respondents rating skills as "not applicable" was higher than 40% in 75% of the listed skills, indicating that those skills were not deemed relevant to these clinical settings and indicating lack of transferability across settings. From Table 2 it can be seen that "suicide risk assessment was viewed by many as "not applicable" (31%) closely followed by 'mental status assessment'.
The latter was across all the settings: community, aged care and acute hospital". Table 3 presents the non-applicable responses for the skills groupings "medication administration", "emergency procedures" and "communication". Nonapplicable choices for medication administration indicate a degree of transferability although there are obvious skills which do not transfer well, for example, administering intravenous medication (see Table 3). The non-applicable responses for the skills in the "emergency procedures" grouping were mixed but appear to have some transferability depending on the actual skill and setting involved. The low or zero non-applicable responses to communication skills indicate that this skill group contains transferable skills regardless of the setting.
The zero non-applicable responses for preparedness for practice for all but two skills-caring for full patient load and working independently-indicate that these groups contain transferable skills regardless of the setting although there was quite a large amount of missing data (see Table 4). Non applicability ranges with the skills group of "coping with the work environment" were mixed and obviously had some transferability depending on the actual skill and the setting involved.

Discussion
The aim of the larger study was to explore the perceptions of RNs on the practice readiness of NGRNs. In their original report [14], it was found that the more technical the skill is, the fewer participants perceived that they were adequately performed or applicable to their practice settings.  variability in transferability of skills across different settings (community, aged care and acute hospital) depending on their skill grouping. Advanced skills scored most highly in the non-applicable rating (45%) which is to be expected as the majority are setting specific. This was followed by basic clinical skills (20%) indicating lack of transferability across settings for these categories. Non applicability responses with the skills groups of "emergency procedures" (Table 3) and "coping with the work environment" (Table 4)     indicate that these groups contain transferable skills regardless of the setting.
The results presented here raise concern about participants' perceptions of skills not being applicable to their practice setting when there are those which should in fact be applicable across settings. The NCNZ (2010) [13] requires undergraduate nursing programmes to prepare students for comprehensive health consumer assessment skills. The results of this study indicate that skills around mental health (suicide risk assessment, "mental status assessment" and "delivery of calming & restraint techniques") are either viewed as not applicable or that students are only adequately or poorly prepared. This is a concern when suicide rates are increasing [15]. According to Davison, Mackay and McGivern [16], New Zealand nurses are at the forefront of health services and are well placed to conduct suicide risk assessment within many settings and undergraduate programmes have a responsibility to prepare nursing students for this life saving skill. Therefore it is disappointing to note that such a high percentage of respondents' viewed this skill and that of mental status assessment as not applicable to their setting.
There appears to be some alignment between expectations from RNs in clini-

B. Mackay. T. Harding
of NGRNs particularly with respect to "communication skills" and "preparation for practice" being seen as applicable across all settings. However, the lack of transferability of more advanced technical skills raises the question of the role of the education provider in preparing the NGRN and the role of the industry-based graduate programme. There are many challenges for NGRNs in their first year of practice but perhaps the biggest, and largely unacknowledged challenge, is that they are caught in the tension between industry and education with respect to how of NGRNs should be prepared for entry into practice [1] [10] [17] [18]. Education and industry are influenced by different system drivers. On the one hand industry is requiring NGRNs to perform in the role of the RN in the setting in which they are employed, versus the education requirement to prepare a generalist nurse who is able to function at a competent level regardless of the setting [10] [18].
Although there is acceptance of the place of the first year in practice in developing confidence and competence within the clinical setting the reality is that often acuity levels and staff shortages negatively impact on support for NGRNs [19]. Both this study and the study by Missen et al. [1] demonstrated that registered nurses perceive that NGRNs are not prepared for advanced skills. The question must be raised of the expectation of advanced skills on entry to practice. It needs to be questioned whether these should be expected on entry to practice or whether these should be introduced in the first year of practice. According to El Haddad et al. [10], there needs to be more collaboration between industry and education providers to develop a shared understanding of the expectations of NGRN's in regard to readiness for practice.
In the past, most new graduate programmes were based in a hospital setting [7]. However, it is apparent that there is a shift from the dominance of secondary services towards a greater emphasis on community services with an associated requirement for more nurses including NGRNs and undergraduate programmes should prepare them for these settings [20] [21] [22]. There is now potential for extension into the community with NETPE and NESP programmes [23], but opportunities are still limited [24].

Current competency in New Zealand is assessed in undergraduate education
and in nursing practice against the NCNZ competencies. There is also an expectation from NCNZ [13] of demonstration of competency across all settings, evidenced in the requirement that students experience a range of settings in preparation for entry to practice; including: primary health care and community settings, acute care including medical and surgical settings, continuing care settings including rehabilitation/disability care settings and mental health care including acute and rehabilitation/continuing care settings (p. 62).
In addition, students are required to meet RN domains of practice before entry to practice. These include: professional responsibility, provision of nursing care, interpersonal relationships and inter-professional healthcare and quality

Implications for Practice
It is apparent that the increase in nursing roles and the increased emphasis on aged care and primary health care [22] [23] dictates that generalist preparation of NGRNs should be the focus rather than preparation in setting specific or with competency in advanced technical skills. The future of nursing is changing in response to increasing demand for technology and in complexity, therefore, we need to prepare nurses for lifelong nursing. According to the World Health Organisation [25]: Education standards should ensure that education programmes prepare graduates who are capable of critical thinking and problem-solving, and capable of functioning as competent, ethical care providers. In addition the educational experience should promote the capacity to become a self-directed, life-long learner (p. 7).
In response to this demand, there is increasing literature arguing for preparing NGRN's according to the attributes of a registered nurse rather than skill preparation [17], and the importance of non-technical or "soft" skills and their impact on clinical performance [26]. According to Laker and Powell [27], "soft" skills are those relating to intrapersonal and interpersonal skills whereas hard skills are "the technical expertise and knowledge needed for a job" (p. 453) [28].
There is also a third category, that of cognitive skills which Robles [28] deems just as important as soft skills. Some sort of balance between these sets of skills is required within curricula.
The professional confidence of NGRNs on entry to the workforce impacts on their readiness to practice [29]. The disconnect between the clinical and undergraduate nursing environment is one factor in the influence on confidence. Re-  [31]. Preparing students for reality shock in undergraduate education is essential and developing professional confidence is a process that needs to carry on in the first year of practice, but could be expedited through strategies for preparation for entry to practice in undergraduate education [29]. These include a focus on soft skills such as interpersonal interaction and communication which could be achieved through simulation or from an emphasis on this in clinical settings (with clinical teaching support). Additionally, Baldwin et al. [17] also suggest that the graduate attributes of nursing students include: "Resilient, reflective, resolute, reliability, resourceful, confident, contemporary, communicative, courageous, compassionate, competent, robust" (p. 10) and that curricula should be designed to allow development of these attributes.
If we are to have work-ready practitioners for the future in a health care that is increasingly dynamic and complex then there needs to be better alignment between the goals of education and practice. In order to enhance the support for NGRNs a necessary first step must be collaboration between the two groups to

Limitations
This study represents the findings from one small regional study, therefore, the results cannot be generalised and it is also likely that the results represent the views of those nurses within clinical practice most interested in new graduates.
However, many of the findings support the results of previous research in Victoria, Australia indicating that there is some potential for transferability of these findings to other regions in New Zealand and Australia.

Conclusion
This study explored the perceptions of RNs on the practice readiness of NGRNs