Pre-registration paid employment choice: The views of newly qualified nurses
Article Outline
- Summary
- Introduction
- University student employment
- Transition to practice
- The study
- Discussion
- Limitations
- Conclusion
- References
- Copyright
Summary
In Australia, nurse education was transferred from hospital based nursing schools to the higher education sector. This transfer resulted in a change for students, from hospital employee to an unpaid, supernumerary role during professional placements. The majority of undergraduate nursing students now combine part time employment with their studies, working mainly within health settings or service sectors such as hospitality and retail. The aims of this study were to identify if newly qualified registered nurses engaged in paid employment during their final year of undergraduate studies, the types of employment they chose, reasons for that choice, skills acquired and their views on any link between employment choice and transition to practice. Focus group interviews involving sixty seven new graduates were conducted. From the data, four organising themes were identified; financial independence and autonomy, confidence and experience, future opportunity and ease of transition. The global theme maximising opportunity describes nurse's views about their decisions on student employment. Participants had differing views on employment choice and transition to practice. Further research is needed in the area to identify whether there is any link between student employment choice and transition to practice.
Keywords: Nursing student employment, Graduate nurse transition
Introduction
With the completion of the transfer of nurse education from hospitals to universities in 1992 (Heath, 2002), Australian nursing students' work experience changed from full time employment, in an apprenticeship model [approximately 5000
h], to approximately 1000h of supernumerary, unpaid, experience over a three to four year degree. This change had a significant impact on a student's financial situations and most nursing students now seek employment external to their studies (Australian Bureau of Statistics, 2006).
Only a small number of studies have explored university student employment and have focused on academic performance, the acquisition of professional skills and work experience (Curtis and Lucas, 2001, Lee et al., 1999, Ford et al., 1995). Moreau and Leathwood (2006) considered university study and employment and suggested that the student's academic performance may be negatively affected from working 15 or more hours per week.
Although the change to university education for nursing occurred almost two decades ago, even less is known about nursing students employment choices. Importantly, any relationship between undergraduate employment choice and transition to practice has not been adequately considered. This gap in knowledge extends beyond Australia to other countries, such as the United Kingdom, that have similar histories of nurse education.
This article reports on an Australian study with newly qualified nurses that considers reasons for student employment choice and views on any relationship between student employment and transition to practice.
University student employment
In Australia, government financial support for tertiary study is means tested with a personal and parental income test threshold applied. Youth Allowance or ABSTUDY [support for those from Australian Aboriginal or Torres Strait Islander descent] payments may be made to qualifying students (Commonwealth of Australia, 2010). As a guide, the maximum payment for a student with no children who is studying and living away from home is currently $AU377 per fortnight. Figures indicate that 90% of all Australian tertiary students engage in employment for at least 15h per week (ABS Education and Work, 2009) to supplement Youth Allowance or ABSTUDY payments or as a means of support if they fail to qualify for government assistance (Australian Tax Office, 2010). Students are required to pay for their university education, either upfront, or through the taxation system once they are in full time employment, with the average cost of a degree currently AU$24,000 (DWEEP HECS-HELP, 2010).
Internationally, there is some evidence to suggest that nursing students seek employment primarily in health-related settings (Salamonson and Andrew, 2006, Andrews et al., 2005, Lee et al., 1999). While a relationship between skills attained in employment and student's future career has been alluded to (Curtis and Lucas, 2001, Lee et al., 1999, Ford et al., 1995), researchers have not specifically commented on any relationship between employment choice and transition to registered nurse practice. The link between employment choice and transition to practice has relevance, particularly with regards to ‘work readiness.’
The development of specific paid employment programs
While students can seek health care employment, generally in assistant roles, internationally, there are reports of health services designing specific programs that employ undergraduate nursing students while they complete their degrees, often independent of universities (Alsup et al., 2006, Hoffart et al., 2006, Gamroth et al., 2003, Gamroth and Lougheed, 2002, Kee and Ryser, 2001). It is argued that students who engage in these programs are more ‘job ready’ for their transition to registered nurse (RN) practice, by virtue of greater clinical exposure and socialisation to a health care setting (Hoffart et al., 2006, Gamroth et al., 2003). A number of Australian health services have recently established specific employment programs for undergraduate students in acute care and midwifery. The programs promote opportunities for continuing employment following graduation (Kenny et al., 2007, Department of Health South Australia, 2004).
Transition to practice
Transition to RN practice has been described as a difficult time for graduates, with suggestions that new graduates are not work ready or fit for practice (Fox et al., 2005, Gerrish, 2000, Greenwood, 2000). Authors have suggested that graduate transition is difficult based on lack of clinical experience, poor assimilation into the workforce and poor institutional support (Heslop et al., 2001). Transition for new graduates has been described as “a shock state” (Goh and Watt, 2003).
Health service programs that involve paid employment of students report a positive impact on transition to practice with increased graduate confidence, reduced orientation time, familiarity with institutional culture and reduced graduate stress (Rochford et al., 2009, Nelson et al., 2004, Olsen et al., 2001). Authors indicate that feedback from students employed in hospital based programs is positive, with students reporting high levels of confidence as they are assimilated as members of a health care team, rather than the more limited exposure during their formal studies (Roymn et al., 2009, Gamroth et al., 2003).
The impact of paid employment choice and any link with transition to practice is relevant for key stakeholders including policy makers, health services, education providers and students.
The study
The aims of the study were to:
Design
An interpretive descriptive design (Thorne, 2008) was deemed appropriate to explore newly qualified registered nurses' views on paid employment during their undergraduate degrees. Thorne (2008) argues that interpretive description is useful for developing knowledge that is important to practice. In developing this study, focus groups were identified as a method of generating the type of knowledge sought, as we believed that capitalising on interaction (Krueger, 1995) would maximise opportunities for the exploration of a research area where little is known.
Participants
Following an invitation to participate that was distributed to South Australian health services; eight services expressed interest in the study. An information session for first year RNs was conducted and interested people were asked to contact the researcher. 67 first year RNs were recruited from acute and residential care sectors in metropolitan and regional areas.
Inclusion criteria included all first year registered nurses. This represented all those first year RNs who were employed and also those who did not work in their final undergraduate year. Former enrolled nurses (one year hospital or vocational training qualification), completing conversion to registered nurse, were excluded as it was considered that they may unduly bias the group due to their previous health care experience.
Ethical considerations
The study was approved by university and health services ethics committees. All participants were given a detailed information sheet and completed a consent form. Participants agreed to maintain confidentiality within the focus groups.
Data collection
Eight focus groups were conducted from April to September 2008 with 67 first year RNs. Numbers in each group ranged from 3 to 11 participants. Basic demographic information was collected and this is outlined in Table 1.
Table 1. Demographic and paid employment profile of undergraduate nursing students (n=67).
| Characteristic | |
|---|---|
| Gender% (n) | |
| Female | 94 (63) |
| Male | 6 (4) |
| Age in years (minimum–maximum) | 20–50+ |
| Type of undergraduate paid employment% (n) | |
| Health care setting | 79 (53) |
| Hospitality/retail | 18 (12) |
| Did not work in final undergraduate year | 3 (2) |
| Hours worked per week (minimum–maximum) | 15–30+ |
The focus groups were conducted by the first author (CP) and ranged in time from 60 to 90min. Questions included whether participants engaged in pre-registration paid employment, types of employment, hours worked and the reasons why they chose a specific employment type. Finally, participants were asked to consider the skills derived from their student employment and whether their employment choice impacted on their transition to practice.
Data analysis
Focus groups were audio-taped and transcribed verbatim. Transcripts were read several times and coded independently by three of the authors. Discussion and refinement of the themes occurred until consensus was achieved. Data were analysed utilising NVIVO 8 qualitative software package and themes from the text were extracted and categorised into basic themes, organising themes and finally a global theme. Consistent with the work of Attride-Stirling (2001) this is presented as a thematic network that summarises the main themes.
Findings
The global theme, maximising opportunity was identified and describes nurses views about their decisions on student employment. The global theme was derived from four organising themes; financial independence and autonomy, confidence and experience, future opportunity and ease of transition. The structure of the thematic network is illustrated at Fig. 1.
Fig. 1
The thematic network that was generated from the data.
Financial independence and autonomy
Over 90% of new graduates reported that they engaged in paid employment during their undergraduate education, the majority in either health related positions or hospitality and retail. Consistently, the primary motivating factor for employment as students was financial remuneration in order to meet daily living expenses:
Everybody needs money…..to eat, to live, pay rent, the mortgage I am a single parent, with a teenager, one at school and a mortgage. I needed to survive.
Participants argued that employment provided autonomy, opportunity and a sense of independence:
I have been working ever since I was 15 so for me it was more about independence [worked in non health setting].
Many participants indicated that their choice of employment was based on how much they could earn:
I wanted to……[work in health setting] but I was getting paid so well where I was……..[retail position] I stayed there because I couldn't afford to go down in wage even though the transition would have been easier if I [worked in a health service].
Confidence and experience
In all groups, there was a consistent theme that employment in health services as a student was a means of building confidence and experience:
You can see how they do things, not just medications but how they respond to different situations regarding clients, or families or other things going on around the hospital that they have to deal with…..You see things differently [worked in a health service].
There was general agreement that the confidence gained from health service employment would make transition to practice easier:
To get your basic nursing care down pat……I thought it might make it a bit easier for when you actually start working as a RN [worked in a health service].
For some, the experience of working in a health setting confirmed their career choice:
Say you hadn't done it [work] and you rock up to your first year and say this isn't me at all. That is 3years of your life wasted and all of a sudden you are thinking what am I going to do next. Yeah really I should have been a hairdresser [worked in a health service].
Many undergraduate nursing students were critical of the limited number of placements and time provided in their course to practice nursing skills and felt that paid employment in a health related setting assisted this:
I thought I need to do more to get my confidence and competence up [worked in a health service].
Participants argued that paid employment in a health setting offered them broad experience in challenging situations:
You get that experience of dealing with death and dying. So when you are the RN in charge you are not falling to pieces and thinking what do I do and how do we do this and you get that experience of listening to the RN. How they speak to family and how you speak to the family as well [worked in a health service].
Participants who worked in health settings stated that their student employment assisted them with time management, clinical skills, teamwork and being reliable:
Definitely time management because you had your 8 patients you had to shower and get ready for breakfast and get ready before the doctors round. It was team work with that as well [worked in a health service].
Participants who were in paid employment in non health settings, like hospitality and retail, identified the benefits of their employment choice. They argued that their skills, including leadership were transferable to their nursing careers:
My retail job. I was considered a senior person who made decisions [worked in a non health setting].
Participants who were employed in the hospitality and retail sector during their undergraduate studies reflected on how the skills that they developed assisted them as an RN:
Good customer skills which obviously can relate in this job to patients, families. I think if you have them when you start off as a grad, people are pretty impressed [worked in a non health setting].
One undergraduate nursing student who was not employed as a student argued that her broader life skill set has transferred to her current role:
I didn't work, but being a mum at home helps with skills that you need as a nurse like caring, intuition, organization, hygiene all that.
Future opportunity
Participants argued that a desire for health service employment was influenced by the opportunity and possibility of a graduate position in the same hospital where they worked. The following responses summed up the overwhelming views for the majority of undergraduate nursing students who were in paid employment in health settings:
I am not sure anyone will admit it…it [work in a health setting] virtually guaranteed that the hospital would want you to stay on because they had invested a year in you [worked in a health service].
However, those nurses who worked in hospitality and retail as students were ambivalent about an “employment guarantee” based on their undergraduate employment choice:
In the ward, the manager not only focuses on your clinical skills but also your personality as well. The clinical skills you can always [acquire], but your personality. Are you getting along well with others, or are you an isolated person [worked in a non health setting]?
For the undergraduate nursing students who did not work, they felt somewhat disadvantaged in terms of additional clinical exposure, but less so in terms of seeking a graduate nurse position:
Yes the only experience was through my placement and they were few and far between…so I was disadvantaged compared to the group [those who were employed] I just had my placements, but I felt comfortable enough with my placements to still go for a job here [was not in paid employment as a student].
Ease of transition
Nurses who worked in health settings as students believed that their choice of paid employment gave the best transition to RN practice:
I worked on the ward last year, so I had a good grounding of the ward…. I have only been there four months, but because I knew the ward and the staff the transition was quite easy [worked in a health service].
I found it [transition] extremely easy. I fell straight into it because I knew everyone and knew the expectations [worked in a health service].
Individuals who worked in the hospitality and retail sectors justified their paid employment choice:
I worked in a pub and retail …….I didn't really want to get sick of it before I even started and I thought getting the experience from my placements was enough [worked in a non health setting].
They argued that their experience also assisted with their transition to registered nurse:
I think retail does help with customer service and generally how you speak to people from all different walks of life. I was in charge of a of lot people in my retail management job, so this really helped with my transition [worked in a non health setting].
Some nurses argued that their paid employment choice during their studies was strategic and timely:
I have been given a really good position and they have put a whole lot of faith in me and I am really enjoying it. Because I worked there [residential care] as a carer I have stepped up from carer to RN in a senior position [worked in a health service].
A number of participants expressed criticisms about people who didn't work in health settings as students:
I don't know how people go from… [Department store] to an RN that would be horrible [worked in a health service].
I still had a retail job that I knew and had been doing for 2 ½ years. If I didn't go and do some work [in a health setting] it would have been so much harder because it would have been 100 % transition to new things as opposed to 20 % [worked in a health service].
Discussion
The high numbers of participants in this study who worked during their undergraduate degree is consistent with Australian Government figures on broader university student employment (ABS Education and Work, 2009). Participants reported that the predominant type of paid employment choice was in health and this is representative of other studies (Happell, 2002, Lee et al., 1999). Whilst most participants stated that their primary reason for undertaking paid employment was financial support (Lee et al., 1999, Ford et al., 1995), the experience of employment was an important consideration. In an earlier study, Ferguson and Cerinus (1996) acknowledge that remuneration was the primary reason for undergraduate students pursuing paid employment; however, consistent with our study their findings indicate that student's gain numerous “people and life” skills from a diversity of paid employment choices.
Nurses who undertook paid employment in a health setting as students indicated that increased clinical experience was a motivating factor for their employment choice. The increased level of clinical experience above their university clinical placement hours allowed development of decision making, proficiency of skills and the experience of team work within “real world” settings. This supports studies by Olsen et al., 2001, Nelson et al., 2004 who suggest that undergraduate students employed in health care are better prepared for transition to RN practice in terms of organisation, confidence, and knowledge and skill acquisition. Those who were employed in specific health service employment programs indicated the increased clinical experience assisted them in their orientation and socialisation to that particular institution which aided their transition. Researchers have argued that this process of socialisation leads to shorter times for orientation of new RNs and gives rise to graduates being more “work ready” (Alsup et al., 2006, Hoffart et al., 2006, Kee and Ryser, 2001).
Participants, who worked as students in the hospitality and retail sector, expressed a multitude of benefits of their work. They identified opportunities to develop interpersonal skills, professional skills in a wide range of roles such as a manager or business owner and argued they were valuable in assisting transition from student to an RN.
Participants who undertook paid employment in health settings stated that a primary reason for seeking this employment type was the possibility of a graduate nurse position at the same institution, however, those participants who chose employment in hospitality or retail, believed that their clinical placement reports, strong academic results and life experiences made them sound employee prospects as future RNs. It should be noted that all participants in this study, (regardless of whether they worked or not as an undergraduate nursing student), gained employment on completion of their university studies. All participants who worked, irrespective of type of employment argued they gained skills pertaining to time management, dealing with difficult people, conflict resolution, confidence and communication. Participants who chose paid employment in hospitality or retail argued they possessed higher order skills relating to customer service, autonomy and accountability. It has been argued (Curtis and Williams, 2002) that these qualities are transferrable to RN practice and are indeed universally favoured by future employers.
Participants who undertook paid employment in health settings tended to be critical of their colleagues who chose employment in non health settings. These criticisms were based on the belief that if an undergraduate nursing student sought paid employment outside health settings, they would be disadvantaged in their transition to RN practice, through having less clinical experience. Most participants implied that paid employment in a health setting was advantageous. Whilst this notion influenced a small number of participants to change their employment choice from the hospitality sector to a health setting in the final year of their university studies, approximately 20% of respondents were satisfied that working in hospitality and retail provided a suitable platform for their transition.
Limitations
The study took place in one Australian state so it is not known how generalisable the findings are. However, in relation to the primary reason why undergraduate nursing students work, being financial; this is represented in similar populations of tertiary students in other studies. Clearly there is a need to conduct further work in this area. A larger sample size may yield different results as it might provide a different mix of students, however, other literature supports the high number of students who work, and for nursing, in health settings. All of the graduates who participated in this study were working as registered nurses. The views of participants who did not gain employment following graduation were not sought as it was outside the scope of this study. It is acknowledged that their views may have been different and capturing this knowledge would be useful in further studies.
Conclusion
The global theme maximising opportunity reflects the major findings from this study. That is, nursing students seek employment during their studies to maximise their opportunities from the perspective of financial security, confidence and experience, future opportunity and ease of transition. Participants in this study expressed that these four parameters are gained from all paid employment types. Whilst the majority of new graduates in this study sought undergraduate employment in health settings, with the belief that it was strategic for their future careers, those who worked in hospitality and retail sectors also considered this choice as a solid foundation to graduate transition. In addition, the choice of undergraduate paid employment in a health setting was perceived as advantageous to securing a graduate nurse position. Those who were employed in the hospitality and retail sector held no such perceptions or concerns, or indeed, those graduates who did not work during their studies. Little is known about undergraduate nurse paid employment choices and the impact on graduate nurse transition. Further research is required to explore if any particular kind of relationship exists in both an Australian and international context.
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PII: S0260-6917(11)00020-7
doi:10.1016/j.nedt.2011.01.007
© 2011 Elsevier Ltd. All rights reserved.
