Early graduate program outline

for Bachelor of Midwifery/

Bachelor of Nursing dual
degree graduates

Nursing and Midwifery Policy

Early graduate program outline for
Bachelor of Midwifery/Bachelor of
Nursing dual degree graduates

Nursing and Midwifery Policy

Acknowledgements
Nursing and Midwifery Policy would like to thank the nursing and midwifery education and training
team at The Royal Women;s Hospital for sharing their knowledge and experience in the development
of this outline. In addition, the contribution by the Directors of Nursing and Midwifery and the
education providers to the statewide stakeholder meetings is also acknowledged.

If you would like to receive this publication in an accessible format please phone 9096 7528 using
the National Relay Service 13 36 77 if required, or email: [email protected]

This document is also available in PDF format on the internet at: www.health.vic.gov/nursing

© Copyright, State of Victoria, Department of Health 2013

This publication is copyright, no part may be reproduced by any process except in accordance with
the provisions of the Copyright Act 1968.

Authorised and published by the Victorian Government, 50 Lonsdale St, Melbourne.

February 2013 (1210022)

Contents
Background 3

Contemporary issues 4

Statewide consultation 5

Marketing your graduate program 6

Recruitment 9

Induction and orientation 13

Learning outcomes 16

Rotations 17

Rostering 23

Graduate education, competencies and study days 24

Preceptoring and mentoring 31

Facilitating continuing professional development 36

Evaluations 37

Further information 39

References 40
Background
This early graduate program (EGP) outline for Bachelor of Midwifery and Bachelor of Nursing
graduates has primarily been developed to support rural and regional health services, however,
will benefit all health services that offer combined EGPs for midwifery/nursing graduates.

Rural health service provision and workforce are important areas of focus for the Victorian
Government, in particular in rural maternity care. To assist, the government has committed
$5 million over four years to enhance rural midwifery clinical supervision.

The funding focuses on three key areas:

• attracting new midwifery graduates to work in rural settings

• supporting existing rural registered nurses to undertake midwifery postgraduate studies
• retaining existing rural midwives and increasing clinical connections.

The suite of activities being funded is based on consultation with the sector about the particular
issues and drivers they experience in providing maternity services.

To assist in attracting new graduates to work in rural settings, targeted funds have been committed
to support health services to provide EGPs for dual-registered nursing and midwifery graduates to
rural Victoria. The aim of this funding is to specifically recognise and address the unique issues of
maternity services and the midwifery workforce within rural and regional health settings.

More than half of Victorian regional/rural public health services that provide intrapartum maternity
care had fewer than 200 birth separations in 2011–12; the majority of these health services had
fewer than 100 birth separations (or between two and four births a week). In these health services
dual registration in both nursing and midwifery are essential to be able to provide a cost-effective
workforce. It is recognised that smaller, often rural health services have difficulty attracting midwifery
graduates to undertake graduate years when needed, largely due to a perception that the exposure
to clinical opportunities in a small service are limited and may have an impact on a graduate’s
consolidation of practice and future employability.

In 2011 the majority of EGPs for graduates of Bachelor of Midwifery or combined Bachelor of
Nursing and Bachelor of Midwifery (BN/BM) were in the metropolitan area. Only 12 of the 139.5
(8.6 per cent) positions were rural or regional. To support the employment and career planning for
combined BN/BM graduates, health services may benefit from having access to a program outline/
template for a combined EGP.

The Department of Health’s Nursing and Midwifery Policy unit commissioned The Royal Women’s
Hospital to develop this EGP outline for combined BN/BM graduates, recognising that rural and
regional health services have particular needs, including:

• requiring nursing and midwifery staff with an extended scope of practice and flexible skill set
• requiring employees to hold dual registration as a necessary cost-effective workforce model
• facing challenges in recruiting and retaining graduates.

This EGP outline meets the department’s current Early Graduate Nurse Program guidelines (2009)
and is suitable to implement at a range of public health services in Victoria. In addition, it reflects the
national professional practice framework for health professionals.

3
Contemporary issues
Literature review
As part of the project to develop this outline The Royal Women’s Hospital conducted reviews of
current literature and of Victorian healthcare services, both of which are highlighted throughout this
document. The reviews highlighted the following points that require consideration when exploring
workforce issues.

General staffing
• Ageing workforce
• High incidence of part-time employment
• High incidence of qualified nurses and midwives who have left the profession or have not
maintained their registrations in one or both profession groups
• Increased requirements of registered nurses and midwives to supervise enrolled nurses and
healthcare assistants
• Limited opportunities for clinical career pathways in nursing and midwifery, particularly in rural
and regional health services
• High proportion of graduating student nurses and midwives with a combined BN/BM qualification

Rural staffing
• Low turnover of staff in rural health services
• Advanced scope of practice required by rural nurses and midwives
• Limited preparedness of graduates to live and work in rural communities
• Ongoing challenges recruiting nurses and midwives to work in rural communities
• An estimated 25 per cent of Aboriginal and Torres Strait Islanders living in rural and remote
communities in Australia with poorer health outcomes when compared with other Australians
• Decreased access to healthcare services for rural populations

Maternity services
• There is increasing demand for public birthing services in Victoria and Nationally.
(AHMAC 2011; Francis & Mills 2011; HWA 2011; Lea & Cruikshank 2005; Mills 2010; Preston
2009; Tracey et al. 2000)

In the box below, identify any of the issues listed above that apply to your health service.

4
Statewide consultation
In order to ensure this outline meets the needs of health services in Victoria, the project team
undertook a series of statewide stakeholder meetings.

Five departmental regions were consulted: Gippsland, Grampians, Barwon-South Western, Loddon
Mallee and Hume. A meeting was conducted in each region, with all relevant health services invited
to participate. In addition a metropolitan meeting was held to consult with relevant metropolitan
health services, in particular those that currently run EGPs for midwifery and nursing/midwifery
graduates.

Following a review of demographic data it was evident that the opportunities and needs of health
services varied and were often related to their number of birthing separations per year. In an effort to
provide an EGP outline to support the majority of health services across Victoria the first outcome of
the stakeholder meetings was to categorise information by birth rate.

Most health services with a birth rate over 200 per year offered an EGP (nursing) and many offered
the employment model for postgraduate diploma of midwifery students. There were varying numbers
of health services in each region that provided a combined EGP or an EGP for midwifery graduates.
The project team was also interested to know at what full-time equivalent (FTE) they offered their
graduate positions as this had bearing on the numbers of positions they could offer. Most services
employed graduates at 0.6–1.0 FTE, with 0.8 FTE being the most common model for employment,
which helps address work/life balance requirements.

From the statewide consultation it became evident that:

The fundamental goal of the graduate program is being one

of entry and introduction to the profession of nursing and
profession of midwifery rather than the mastering of all nursing
and midwifery clinical skills in the first year of practice.

This principle underpins the EGP outline.

5
Marketing your graduate program
The demands faced in evolving healthcare systems require graduating health professionals who
are knowledgeable, competent and professional (Williams et al. 2012). Current nursing graduates
describe themselves as being:

• self-aware
• self-directed
• capable and competent
• critical thinkers
• patient advocates
• engaged in evidence-based holistic practice
• interdisciplinary team members
• able to take on leadership roles
• able to handle conflict (Clare & van Loon 2003; Williams et al. 2012).

These are all attractive qualities when considering recruitment strategies.

McCall et al. (2009) suggest that aside from clinical placements being essential for midwifery
preparation, they also play a significant role in career decision making and employment choice.
This is supported by Scanlon (2009), whose Victorian research found that a positive student clinical
experience is strongly associated with choice of graduate year. Other factors that influence which
program and health service a graduate chooses include:

• previous positive experiences on student clinical placements

• positive promotion of the graduate program and health service by current graduates
• opportunities for specialist care (emergency care, mental health or practice contexts such as
caseload midwifery)
• further study opportunities
• encouragement from others
• flexibility of start dates and rotations
• career opportunities and development
• observing nursing and midwifery leadership and management during student clinical placements
(Baillie et al. 2003; McCall et al. 2009; McGillion 2003; Scanlon 2009; Ullrich 2009).

Marketing strategies
Graduate nurses and midwives are the future of the profession, with research clearly demonstrating
a link between graduate programs, staff retention and job satisfaction (Almada et al. 2004; Gaynor et
al. 2007). The ability to effectively market your graduate program will help recruit the right graduates
for your health service. This begins with having robust and well-supported student clinical placement
environments and continues with providing information to graduates who have not had the
experiences of placement at your health service.

Marketing strategies used by healthcare organisations for marketing to potential BN/BM graduates
include the following.

Year 10 school work experience program: exposure to and promotion of the nurse/midwifery role
and career opportunities.

6
Undergraduate student clinical placement program: Offering rural and regional midwifery
placements for BN/BM students will enable organisations to showcase their health service and
enable potential graduates to make informed choices about rural and regional career options.

Attending the ‘Life as a Grad’ event: This event is conducted by the Australian College of
Midwives (Victorian Branch) in the first week of July. Graduate midwifery program coordinators
across Victoria are invited to attend and provide a brief overview of their graduate programs. Further
information can be obtained by emailing <[email protected]>.

Nursing and Midwifery Expo: Held annually at the Royal Exhibition Buildings by the College of
Nursing Australia (CNA), this expo is attended by many health services, universities and affiliated
services. Further information can be found at <http://rcna.org.au/WCM/RCNA/Events/nursing-and-
health-expos/VIC/rcna/events/nursing-and-health-expos/victoria.aspx>.

Directly contacting education providers: current universities graduating BN/BM students include,
Deakin University, La Trobe University and Monash University. Many universities have open days and
invite prospective employers.

Hosting an information evening at your health service.

Your health service website. An example of this can be found at <http://www.thewomens.org.au/

ClinicalEducationNursesAndMidwives>.

Using employment websites such as Seek (see <www.seek.com.au>).

Distributing written information such as postcards and brochures.

Advertising in the Postgraduate Medical Council of Victoria (PMCV) online handbook.

At The Royal Women’s Hospital

The Women’s incorporates a number of the above methods to market its EGP including:

• advertising on the hospital website, PMCV website and seek.com.au

• presenting at the Nursing and Midwifery Expo
• presenting at ‘Life as a Grad’
• holding nursing and midwifery information nights.
– The information night includes a presentation from the graduate midwife and graduate nurse
coordinator, with specific discussion about rotations, study days, support and the application
process. This is followed by a short presentation from current graduates and tours of the
hospital.

The rural context

Rural and regional health services have noted various challenges in recruiting graduates. The
concerns raised during the project team’s consultative meetings included:

• graduates’ perception of learning opportunities available in rural/regional hospitals

• travel expenses associated with exchange programs
• challenges to retain graduates past the graduate year due to available FTE
• the proportionately higher number of learners at the beginning of each year: graduates, students,
junior medical staff.

7
There are demonstrated factors (that influence graduates seeking rural graduate positions)
to consider when marketing your EGP:

• having rural connections such as family, returning ‘home’

• wanting to explore a rural lifestyle
• having experienced rural healthcare as a student
• opportunities to connect with the community, for example, sports teams, young professional
groups and social clubs. (Lea & Cruikshank 2005).

What marketing strategies do you currently employ to attract graduates to your health
service?

What other marketing strategies could you employ to attract graduates to your health
service?

8
Recruitment

The right graduate for your health service, the right health
service for each graduate.

Recruitment is the process of attracting a large pool of suitably qualified applicants from which to
interview and select for an offer of employment. We acknowledge that each health service will have
its own human resource processes, policies and procedures to follow.

Graduate Nurse Midwife Program Computer Matching Service (GNMP Match)

GNMP Match is the computer matching system administered by the PMCV on behalf of the
Department of Health. It utilises a mathematical algorithm to match graduate candidates with
health services according to the preferences of the candidates and health services (PMCV 2012).
Participating in GNMP Match is one component of the eligibility criteria to apply for the training and
development grant funding for an EGP (nursing and midwifery) from the Department of Health.

Further information can be found at <www.computermatching.pmcv.com.au>.

Nursing and midwifery graduate jobs portal

For health services that have unmatched graduate positions Health Workforce Australia (HWA) has
established a nursing and midwifery graduate jobs portal as another vehicle for employment. The
aim of the portal is to complement employer recruitment processes by providing another avenue to
advertise jobs across public, private and aged care sectors for newly graduated registered nurses
and midwives in Australia (HWA 2011a).

This can be accessed via <www.nmgj.org.au>.

Using internet-based graduate recruitment through portals such as PMCV is congruent with current
human resources practice in Australia and international trends. Portals provide a consistent and
systematic way of processing applicants and providing information about graduate programs and
health services (Carless 2007).

Selection process
The selection process involves filtering the applicants to determine who are best qualified or suited
to your health service and who will progress to the interview phase.

• You may consider using pre-screening questions where applicants are asked to write a short
piece (half to one page) in response to two set questions. The purpose of these questions is to
provide an opportunity for graduates to demonstrate documentation skills, reflective practice,
critical thinking and professional engagement. Sample questions are:
– Outline an aspect of nursing or midwifery that has contributed to your interest in working in
a rural health service.
– Describe a significant moment with a childbearing woman when you, as a student midwife,
made a difference. Please include details of your response, actions and the outcome of the
situation.
– Describe a clinical situation in nursing or midwifery that you found challenging. Please include
details of your response, actions and the outcome of the situation.

9
 – Describe the attributes and clinical practice of a midwife or nurse that has inspired you as
a student. Please remember to keep the identity of the nurse/midwife anonymous.
– How have the professions of nursing and midwifery complemented each other in your clinical
practice as a student? (Carless 2007; Doelling et al. 2010).

Write a question that you could use in your selection process.

Recruiting Aboriginal and Torres Strait Islander graduates

The need to increase opportunities for Aboriginal people in the health workforce across Victoria has
been well documented. Increasing Aboriginal representation in employment and reducing the overall
level of disadvantage among Aboriginal and Torres Strait Islander Australians is a key element of the
Australian Government’s ‘Closing the Gap’ initiative. HWA discusses the need for an increase in the
number of Aboriginal health professionals, particularly within midwifery and nursing (HWA 2011b).
An increased Aboriginal maternity workforce is also supported by the National maternity services
plan action.

An Aboriginal nursing and maternity workforce that is supported by culturally aware work
environments is integral to providing culturally competent, evidence-based maternity care for
Aboriginal women and babies. Although the Aboriginal health workforce is increasing in Australia,
this population continues to be under-represented among nurses and midwives. Within nursing and
midwifery there are few Aboriginal students, with accompanying high rates of attrition and failure to
complete training (Usher et al. 2005; West et al. 2010).

The following are important points for health services to consider (AIHW 2012; AHMAC 2011; DPCD
2010; HWA 2011, 2009; Usher 2005):

• pathways to nursing and midwifery – measures to assist and support Aboriginal secondary
school students and Aboriginal health workers to enter a career in nursing or midwifery
• financial supports available to Aboriginal nursing and midwifery students – measures to
mitigate the financial barriers to the study of nursing or midwifery
• challenges to completing nursing and midwifery education – measures to help Aboriginal
tertiary students deal with the challenges and barriers to the successful completion of their
education

10
• nursing and midwifery student clinical placements – measures to assist Aboriginal students
in finding clinical placements and support for consistency of clinical placements
• graduate year pathways – measures to assist graduates to enter into graduate programs once
they have graduated
• attracting and retaining Aboriginal staff – measures to attract and retain Aboriginal staff and
meet the target set by Karreeta Yirramboi (the Victorian Aboriginal public sector employment and
career development action plan 2010–2015)
• improving retention – measures to improve retention such as mentoring, support groups, and
flexible work arrangements and family support
• cultural awareness and cultural safety – measures to create a culturally safe environment
for Aboriginal students and staff. There is significant research and evidence demonstrating the
importance of cultural safety in hospitals. Creating a culturally safe environment for Aboriginal
students and staff is crucial to attract, support and retain Aboriginal students and health
professionals.

The following resources provide further information:

Koolin Balit – Victorian Government strategic directions for Aboriginal health 2012–2022
http://www.health.vic.gov.au/aboriginalhealth/koolinbalit.htm

Cultural resource guide

http://docs.health.vic.gov.au/docs/doc/Cultural-resource-guide-October-2012

Karreeta Yirramboi: An employment toolkit to grow Aboriginal employment in your organisation

http://www.ssa.vic.gov.au/products/view-products/karreeta-yirramboi.html

Victorian Aboriginal affairs framework 2013–2018

http://www.dpcd.vic.gov.au/indigenous/about/taskforce-on-aboriginal-affairs

Interviews
Many nursing and midwifery interviews include scenario-based questions to screen for theoretical
and clinical knowledge and competency. This style of question can also assess both nursing and
midwifery knowledge. A clear and easy-to-use marking guide is important for consistency when
assessing responses to the question(s).

The rural context

Using technology to conduct interviews assists with geographically dispersed employers and
applicants, reduces travel costs and time for applicants, and provides employers with ease of access
to a wider pool of graduates.

These styles of interviews are often associated with a lower ranking for applicants as opposed to
those who have a face-to-face interview, probably due to a combination of factors such as a lack of
visual cues and non-verbal communication (Chapman et al. 2003; Silvester et al. 2000). Using online
technology such as Skype™ and Facetime™ may allow distance interviews to be more consistent
with face-to-face interviews. Alternatively, rural health services may wish to consider conducting
interviews in metropolitan or regional centres.

11
An example of a midwifery scenario-based question is:

You are working on the maternity ward caring for Kelly, a 15-year-old who has just had
her first baby. Kelly has had a long labour, a second-degree tear and has recently been
transferred from the labour ward. Kelly had skin-to-skin contact with her baby at birth
and is documented has having a good breastfeed. Although Kelly has said that she
hopes to breastfeed, she calls you and asks for a bottle of formula because her baby
is crying and hungry. When you meet Kelly you realise that she goes to school with
your sister, who has been asking you if Kelly has had her baby yet.

What do you see as your key responsibilities when providing care for Kelly in this scenario?

Write a scenario-based question that would suit your health service and graduate program.

12
Induction and orientation
Definitions
Induction – The organisation’s initial welcome and introduction to new staff members.

Orientation – The longer term process of entering an organisation or workplace and developing
a practical overview of and socialisation to the organisation, staff, culture and workplace practices
(Malouf & West 2011).

The benefits of an effective induction and orientation program are numerous and include:

• developing a sense of belonging to an organisation or workplace

• developing social bonds
• reducing anxiety and stress for the graduate
• reducing clinical errors, such as medication errors, because of effective orientation to hospital
protocols
• enhancing recruitment and retention strategies
• graduates feeling valued by the organisation (Kennedy et al. 2012; Malouf & West 2011; Squires
2002; Squires & McGinnis 2001).

In order to understand the landscape of existing EGP orientation programs, the project team asked
Victorian health services about their existing induction and orientation programs for staff and whether
they offered anything different for the EGPs. The results are listed below.

• All health services provide at least a half-day organisational induction for all new staff.
• Most health services offer an induction afternoon specific to new nursing and midwifery staff,
and usually cover basic life support, back care and basic competencies.
• Induction and orientation programs specific to EGP (nursing and midwifery) vary with the size of
the health service. There is a general consistency of topics covered in the extra orientation days.
• All health services offer specific orientation and supernumerary days to each clinical area for
graduates.
• The amount of supernumerary days offered varies regarding both the area (birth centre,
emergency, postnatal care) and the availability of dedicated clinical support nurses or clinical
support midwives.

Orientation strategies commonly employed in health services include reviewing policies and procedures,
performing competencies and assessments, and computer and medication testing (Kennedy et al.
2012). Acknowledging different learning styles, strengths or weaknesses and life skills when planning
an EGP orientation program will help support the acquisition and retention of information.

Strategies to consider when designing an induction and orientation program include:

• an active, learner-focused approach

• integration of cognitive, technical and behavioural skills
• use of simulations, drills, scenarios and case studies
• team-based learning to promote working within multidisciplinary settings
• fostering the use of critical thinking skills
• allowing space for debriefing, particularly when using simulation-based teaching
• use of independent study and online learning and assessments
• providing an orientation manual for each graduate (Altimier 2009; Kennedy et al. 2012; Patterson
et al. 2010; Squires & McGinnis 2001).

13
Specific considerations for graduates
Most graduate programs commence in late January or early February. Even though the graduates
have completed their course by December, time must be allowed for universities to complete their
marking processes and submit student requirements to the Australian Health Practitioner Regulation
Agency (AHPRA). The graduate must also apply for registration and any delays can impact on the
registration of the graduate and therefore when they are able to commence employment.

This means that when they begin employment most graduates have not been in a clinical situation
for some months and many fear they have lost clinical skills. This fear was confirmed during the
stakeholder meetings. In response, most EGPs include a specific skills day in their orientation
program to refresh the graduate, reduce their stress and familiarise them with the health service’s
specific processes, equipment and protocols.

At The Royal Women’s Hospital

A combined inter-professional maternity update is offered for the new medical officers and the
new EGP BN/BM and BM. The morning session includes lectures covering current clinical practice
and guidelines pertinent to normal labour and birth, with strategies to reduce perineal trauma. The
afternoon session includes skills-based workstations covering normal birth, obstetric emergencies,
and core skills required when supporting a woman in labour (for example, vaginal examination
and neonatal resuscitation). Having an interdisciplinary format for education helps develop peer
relationships and teamwork.

The rural context

The Northern Rivers collaborative EGP (nursing) offers meet and greet sessions in the November
prior to beginning the EGP. This allows graduates to meet each other and health service staff,
reducing the graduates’ anxiety about their new working and living environment. In addition they are
able discuss their concerns, for example, accommodation, rotations, rosters and clinical support.

What does your health service do to bridge the gap between clinical placement and
employment?

14
Proposed induction and orientation process for a BN/BM EGP
Ward induction is standard across most hospitals for all new nurses and midwives commencing in
a new ward or area. Graduates also receive some supernumerary shifts to support their integration
into the ward routine. At the stakeholder meetings it was revealed that some hospitals offered more
supernumerary days than others; this appeared to correlate with the number of clinical support staff
who were available to support the graduate and financial constraints.

The orientation and induction process continues during the year as graduates move from one
rotation to the next.

15
Learning outcomes

Best practice EGPs are planned learning and professional

development experiences that address both early graduate
and workplace needs (Department of Health 2009).

The theoretical and clinical learning outcomes for a graduate year have the possibility of becoming
an exhaustive list of competencies, learning tools, study days and assessments. It is important to
consider that these BN/BM graduates have completed four years of theory and clinical practice prior
to beginning the EGP.

In order to clarify the learning outcomes for graduates at your health service, it is essential to identify
the aims of your program.

Which of the following apply to your health service and graduate program?

• To facilitate the transition from student to beginning nurse and midwife.

• To have graduates practice within the core national competency standards as outlined by the
Australian Nursing and Midwifery Council.
• To provide a supportive learning environment.
• To develop graduates that provide evidence-based healthcare through lifelong learning and
professional development.
• To provide a program that will assist the graduate to consolidate and develop practical skills
and theoretical knowledge (Colac Area Health, personal communication).

What aims do you have for the graduates within your program?

During regional stakeholder meetings in Victoria, it was noted that the fundamental goal of the
graduate program was one of entry and introduction to the profession of nursing and/or profession
of midwifery rather than to master all nursing and midwifery clinical skills in the first year of practice.

16
Rotations
Each health service has unique needs and rotations are tailored according to organisational and
patient requirements.

For a combined EGP the learning needs and rotations around nursing and midwifery practice
need to be considered. The challenge is to develop a program that supports the consolidation
and growth in both nursing midwifery skills and knowledge equally, and to focus on areas that
are complementary to each other. It is worthwhile considering that many nursing skills can and
are consolidated during midwifery rotations (for example, caring for women post Caesarean and
general assessment and observations); however, this does not work in the reverse (birthing and
breastfeeding experience can not happen in an acute medical/surgical ward).

Rotation options are unique to each organisation and some existing combined EGPs include:

• three-month rotations in four clinical settings

• four-month rotations in three clinical settings
• six-month rotations in two clinical settings
• a blended placement in a combined medical/surgical/maternity ward.

The rural context

Some EGPs include rotations from smaller health services to regional or metropolitan health
services, providing exposure to increased acuity and birth separations. Supporting these graduates
with a travel allowance and accommodation may be an attractive option for graduates during the
recruitment process.

Current literature on rotations

Australian research into the nursing graduate year found that graduates have a strong need to ‘fit in’
to the workplace, organisational culture and team. Multiple clinical rotations during the graduate year
increase stress and limit the chance to establish social and professional networks (Malouf & West
2011). Recent Victorian research on nursing graduates suggests that limiting graduate rotations
is important; all graduates experience insecurity leaving one rotation for another and take time to
assimilate into each new clinical area (Newton & McKenna 2007). Furthermore, multiple clinical
rotations, underpinned by the philosophy of providing a wide exposure to clinical experiences, may
hinder a beginning practitioner’s development due to constant change (Clare & van Loon 2003).

The literature search showed an absence of research on midwifery rotations during the graduate year,
suggesting scope for midwifery research in this area. With an absence of literature on this it is difficult to
comment on midwifery rotations during the graduate year, other than relating anecdotal experiences.

Challenges with nursing and midwifery rotations

The challenge with combining nursing and midwifery rotations is considering how to support the
learning within each profession. If the graduate does not get to the birth centre until the second six
months of the program, how are they going to reintegrate midwifery knowledge and skills? This is
similar to the graduate nurse who moves from aged care to acute care in the second six months of
the program. They are going to need targeted specific support to refresh their basic skills in these
areas, and programs need to reflect this planning. Without forethought and planning there is risk to
patient care and increased stress on the graduate and staff, with the potential loss of the graduate
from the profession.

17
The rural context
When planning the graduate rotations, identify what learning outcomes are going to be gained that
can be transferred and progressed in the next rotation. Consider the basic skills gained in the aged
residential wing that can be utilised in the acute wing, for example. These include but are not limited to:

• documentation
• communication
• basic medication administration
• teamwork
• time management skills
• safe lift and movement principles
• infection control principles
• vital signs
• urinalysis, diagnosis and management of urinary tract infections
• wound care – shared principles of care with perineal trauma or Caesarean section wounds,
aseptic technique, knowledge of wound dressing options
• blood glucose measurement and administration of insulin
• basic hygiene – sponge baths and supportive showering
• chronic illness management and knowledge.

By identifying these skills, the graduate can be reassured that they have a sound toolkit of
knowledge and experience that can be easily transferred to the acute care setting. They can then
focus on refreshing their midwifery knowledge and pre- and post-operative care.

A service with fewer than 200 births per year: The hospital may have an acute wing and an aged
residential wing. Maternity services may be combined within the acute wing or the health service
may provide antenatal and postnatal care, with birthing services provided by a larger regional health
service.

A service with fewer than 600 births per year: The ward configuration may be a medical
ward, surgical ward, emergency department, high dependency/intensive care unit, operating
rooms, renal dialysis unit, aged and residential care unit, paediatric unit and a midwifery unit. The
midwifery unit may contain a special care unit as well. Rotations in these hospitals may be easier to
structure; however, they usually already have a strong nurse EGP. Negotiations for rotations for the
combined EGP will need to occur to ensure the skill mix is maintained and the nursing EGP is not
disenfranchised.

Does your organisation have other campuses or sites that could be utilised for the nursing
rotation?

Is there a commitment from your closest regional health service to assist you to maintain and
develop your midwifery and nursing workforce?

Can you work with other health services to facilitate midwifery rotations and shared study
days?

Example:

Central Gippsland Health Service in Sale uses its Maffra Campus for nursing rotations.
This campus currently has nine acute/subacute beds and a 30-bed high-care

18
 residential aged care facility. The learning outcomes for the combined graduate on
this placement include physical assessment skills, triage, in-charge responsibilities,
medication administration and wound management.

Organisational mapping may assist with rotation planning in rural and regional health services.

Examples of organisational mapping may include:

• mental health – increasing numbers of pregnant women present with mental health conditions
including antenatal and postnatal depression, and women with drug and alcohol dependency
• emergency department – bleeding in early pregnancy, miscarriage, ectopic pregnancies, early
labour, trauma patients who are pregnant, migraine
• surgical/gynaecology unit – endometriosis, gynaecological surgery, pre- and post-operative care,
breastfeeding women undergoing surgery or mastitis for admission
• termination of pregnancies, IVF – ovarian hyperstimulation syndrome
• intensive care – eclampsia, fulminating pre-eclampsia, trauma patients, H1N1 in pregnant woman,
whooping cough in pregnant woman, stroke in pregnancy, chronic renal disease and pregnancy,
complicated diabetes in pregnancy, postpartum women requiring intensive care (requires
midwifery care and assistance with establishing breastfeeding or expressing, gaining experience
with intensive monitoring and ventilation support that can be transferable skills to the special care
nursery setting)
• paediatrics – babies with failure to thrive, continuity of care (many midwives go on to become
maternal and child health nurses).

The answers to the following questions may assist you in deciding what nursing rotations
would be the best to include in the combined EGP.

Where are midwives/nurses utilised if the maternity unit is quiet?

Which wards are you more likely to have a pregnant woman admitted to?

19
What core skills are most easily transferable to other wards?

Other considerations
Competition in the midwifery setting
In both the < 200 births per annum and < 600 births per annum health services the main challenge
is ensuring graduates gain enough midwifery and birth exposure. As identified at the stakeholder
meetings, there are plenty of health professionals in the maternity setting putting their hand up for
the next birth to maintain their confidence and recency of practice. This includes existing registered
midwives, medical staff, graduate diploma of midwifery students, undergraduate midwifery students
and medical students.

The main thing to remember is that the graduates are registered; they can and should be considered
for their share of night duty and weekends when most students are not rostered. The graduate
needs to consolidate skills in managing birthing women and their families, not necessarily birth every
one of them.

At The Royal Women’s Hospital

Graduates are given a core birth skills consolidation booklet to complete by the end of the graduate
year. The aim of the booklet is to ensure each graduate is supervised for a specific number of core
skills to ensure their technique is correct and they can interpret the findings appropriately. This
strategy has ensured graduates get time to consolidate core skills in the birth centre with specific
feedback regarding their performance. It has assisted the graduates to argue successfully for their
place in the birthing room when competition begins to impact on their opportunities to consolidate.

Antenatal and postnatal care

The birth centre is just one part of the midwifery continuum. Many combined units offer acute
antenatal and postnatal care in one ward. This is great experience for the graduate and helps
develop time management skills. Many units also offer antenatal clinic and postnatal care in the
home. Consider how you support graduates if only one registered midwife is allocated to this area.
Providing a rigorous policy and procedure manual with clinical practice guidelines is essential,
backed by a telephone hotline to the experienced midwives in the ward.

Often these rotations don’t occur until later in the graduate year when the graduate has had time to
develop assessment skills. Graduate study days assist with refreshing the clinical skills specific to the
antenatal clinic and can be timetabled just before the rotation begins.

20
An antenatal clinic is included one day a week in the second postnatal rotation and, if the graduate is
progressing well, postnatal care in the home is included in the final postnatal rotation. The combined
graduate may not get a rotation to postnatal care in the home in the graduate year if the nursing
rotation occurs in the second half of the year. Graduates may be offered this experience in the
following year. Supernumerary time is provided for both the antenatal clinic and postnatal care in
the home, regardless of whether it is undertaken in the graduate program or afterwards.

How can you develop a rotation planner?

The following questions may assist you in developing your EGP rotations:

• What are your nursing options and what are the learning outcomes for the graduate?
• What are your midwifery options?
• If you already offer a combined EGP, how did you organise your planner? Did your planner work?
Did the graduate enjoy the rotations? Did the planner work for the organisation?
• Do you have other campuses or wards that you have not considered yet for a graduate rotation?
• Can you identify some shared learning outcomes that may be gained by the graduate?
• Are there other ways of growing the program?

Identify nursing and midwifery rotations in your organisation.

Placement area Length of rotation

Example: Birth suite Three months

At The Royal Women’s Hospital

The midwifery rotations at The Women’s reflect a model of working across the continuum. Midwives
are not allocated to wards for a set rotation, but rather to teams that then allocate the midwife on a daily
basis in response to organisational workload and staffing requirements. The aim of this approach is to
enhance the continuity of care provided to patients and to maintain midwifery skills across practice.

Set rotations are provided across the main locations for midwifery and include high-risk antenatal
inpatients, antenatal outpatients and clinics, the birth centre, the postnatal ward and postnatal care
in the home. The graduates have rotations of varying lengths and once they have worked in an area
they can be sent back to that area for a shift if required; however, this is discouraged until the end
of the year. The rotation planner is developed at the beginning of each program and all graduates
receive an equal number of weeks in each area.

This model is not dissimilar to a rural practice model when a graduate is working on a combined
maternity unit offering all midwifery care in one ward and possibly a paediatric or gynaecology ward.
By tracking the days a graduate spends in each specific role (birth centre, postnatal, paediatric
nurse, gynaecology nurse), the graduate coordinator and unit manager can monitor and facilitate
a fair spread of experience for each graduate. This could be reviewed at the three-monthly
performance review as discussed later in this outline.

21
Nursing rotations throughout the combined program include the following areas for three- or
six-month rotations:

• gynae/oncology
• perioperative suites, (including scrub/scout and anaesthetics, and post-anaesthetic care units)
• reproductive services
• emergency department
• day surgery unit
• special care nursery.

In order to maximise the number of combined EGP placements. The Women’s has four FTE in
nursing rotations at any one time. It is important when recruiting to consider the available FTE and
to plan for positions beyond the graduate year.

The hospital’s placement planner is flexible and changes can occur throughout the year dependent
on organisational need. It evolves annually to meet preferences of graduates and organisational
needs.

22
Rostering

Best practice EGPs adopt a holistic approach that considers

professional, social and whole-of-life issues (Department of
Health 2009).

Graduate midwives and nurses aged 25 years and younger are less likely to work full time compared
with those in older age groups (Hammond et al. 2011). This is congruent with workforce data
showing that almost half of all nurses and midwives work part time (AIHW 2011).

With this is mind, offering graduates the choice between full-time employment and 0.8 FTE
could be worth considering.

Graduates often undergo a ‘grieving process’ as they enter paid employment; they no longer have
weekends and long summer and winter holidays. They often experience frustration with work/
life balance, alongside an adjustment to working in a profession that requires a commitment to
patients and families 24 hours a day, seven days a week (Halfer & Graf 2006). Challenges with full-
time shiftwork, feeling tired and social isolation are common experiences for graduate nurses and
midwives, leading to very high levels of dissatisfaction and attrition (Clare & van Loon 2003).

Rostering during the orientation period that allows for appropriate rest, social contact and family time
is important for graduates as they transition from student to registered nurse/midwife (Clare & van
Loon 2003).

The rural context

Offering a 0.8 FTE role will provide time for the graduate to return home if they are not from your
area. Travel time is a unique issue in the rural setting, so why not market your recognition of this via
flexible FTE?

What rostering and support strategies can your health service utilise during the graduate
year?

Example:

Encourage mentors to share stories about how to promote effective sleep during night
shift rotations or how to balance family time during holidays such as Christmas (Halfer
& Graf 2006).

23
Graduate education, competencies
and study days
Graduate education can be facilitated through formal study days, informal tutorials, in-service
education participation, reflective journalling, online learning packages and quizzes, online
competencies and practical assessment of core competencies such as resuscitation and no-lift
techniques. In the current literature, themes emerge that underpin graduate education (see Figure 1).
These themes can be used to plan education and study days and assist with preparing our next
generation of nursing and midwifery leaders to work in a rapidly changing healthcare system.

Figure 1: Graduate education themes from the literature

• Contextualising clinical skills and knowledge

• Incorporating organisational polices/procedures and clinical practice
Core clinical skill guidelines into practice
development
• Developing practice from novice to autonomous professional nurse/
midwife

• Professional accountability and scope of practice

Professional • Human resource use – nurse/midwife–patient ratios
behaviours and • Conflict resolution and negotiation
knowledge • Health polices – strategic planning, meeting with nursing/midwifery
senior management

Information • Victorian hand-held antenatal record

and healthcare • Healthcare software and monitoring systems
technology • eLearning
systems • Orientation to new equipment and processes

Research and • Graduate research presentations

evidence-based • Critical thinking and reflective practice – debriefing journalling
practice

• Cultural safety and diversity

• Meet with Aboriginal liaison officers (ALOs)
Family-centred • Transfers – NETS, PERS
care • Hospital in the Home (HITH) and Postnatal Care in the Home (PNCITH)
• Infection control
• Patient/family education and childbirth education

• Debriefing
• Grief and bereavement
• OHS, no lift policies
• Employee Assistance Program (EAP)
Self-care
• Rostering
• Work/life balance
• Socialisation – team building, debriefing, peer support, community
engagement

• Leadership skills
Advanced practice, • Organisational policies/procedures and clinical practice guidelines
knowledge and
• Advanced clinical practice
skills
• Midwifery skills – perineal repair

Adapted from: Aduddell & Dorman 2010; Beecroft et al 2004; Department of Health 2009

24
 On exiting an undergraduate program, nursing and midwifery
graduates are able to demonstrate entry-to-practice
competency. Ongoing education within the graduate year
bridges the gap between classroom and clinical placement
theory and practice and the requirements of a professional
and autonomous practitioner (Applin et al. 2011).

What essential technical skills do health services deem necessary to cover in the graduate
year?

From stakeholder consultation meetings, there was uniformity for what clinical/practical skills were
considered essential to be covered during the graduate year:

Nursing Midwifery
The deteriorating patient Breastfeeding education
Physical assessments CTG interpretation: FSEP or K2
IV cannulation Obstetric emergencies
Venipuncture Neonatal resuscitation
PiCCs/ports
Adult basic life support

Are there other essential technical skills that are required for your health service?

25
Graduate theoretical program elements
Delivering the theoretical components of the graduate year can comprise varied learning modalities
and study day formats, including shared regional study days and those specific to a health service.
Each of these will contribute to the graduate’s professional portfolio (Figure 2), and may be used to
demonstrate continuing professional development (CPD) and competency of practice.

Figure 2: Building a graduate’s professional portfolio

Core mandatory
competencies –
online theory and
assessments, practical
assessments

Online learning
resources – MeL,
Reflective learning packages,
journalling video clips, online
library

Graduate
professional
portfolio

Health service
Graduate and regional
study days inservices and
study days

External
education

26
Shared nursing and midwifery knowledge
The following examples for study days focus on clinical suggestions.

Combined programs offer the opportunity to provide shared study days with midwifery and nursing
graduates. Table 1 provides an example of how this could be developed.

Table 1: The benefits of combined nursing and midwifery EGPs

Topics for combined EGP Suggested learning outcomes

shared study day
Physical assessment skills Basic principles, including auscultation of a fetal heart

The deteriorating maternity Pathophysiology of pre-eclampsia, use of abbreviations in

patient: fulminating pre-eclampsia healthcare; intravenous cannulation; treating a fitting patient,
that progresses to eclampsia escalation of care protocol, inserting a indwelling catheter, fluid
management

Emergency Caesarean section Pre-operative care including checklist and consent,

haemodynamic stabilisation, transfer to theatre, neonatal
resuscitation

Post-partum haemorrhage Estimating blood loss, emergency management, blood

transfusions, ABO and rhesus considerations, transfusion protocol

Stillbirth/neonatal death Unexpected outcome, loss and bereavement, registerable births,

documentation

Strategies for self-care Organisational debrief, reflective journalling, employee assistance

programs, privacy and confidentiality issues

The rural context

Peer support and networking is very important in rural and regional areas. Graduates have gone from
a larger student cohort to perhaps being the only graduate at the health service, and the opportunity
to come together with others and hear their stories often help the transition to professional practice.

Social networking is emerging as one of the most popular methods of overcoming this isolation from
other graduates. Education regarding the ethics of discussing work and/or the workplace is required
for all graduates to help them avoid the dangers of breaching confidentiality and their contractual
obligation to their health services.

One Victorian rural health service uses a specific portal designed for graduates as a way of
connecting, regardless of shift or location.

Midwifery study days

All midwives across the state are entitled to study days to assist them to maintain their clinical
competence including fetal surveillance and interpretation of cardiotocography (CTG), obstetric
emergencies, and breastfeeding. Graduates sometimes attend regional education events as part of
their graduate study day program.

27
As an example, Southern Health uses the following midwifery study day outline:

Natural/normal birth study day

• ‘How do we conduct a normal birth?’ – this includes plenty of discussion time because graduates
often observe midwives conducting births with a wide variety of practice styles and techniques
• Discussion: hands poised versus hands on, checking for nuchal cord, episiotomy and so on using
a model for simulation and group discussion
• Guest speakers presenting on normal birth topics such as water births, ‘calm’ births or hypo-
birthing, intradermal water injections, positions for labour and birth
• Graduate research presentation: each graduate researches and presents a brief summary on
something that enhances the incidence of normal birth
• Why normal birth is important: looking at the statistics for Caesarean sections, postnatal depression
and maternal satisfaction

Obstetric emergencies study day

• Shoulder dystocia • Pre-eclampsia and eclampsia
• Breech • Fetal bradycardia
• Cord prolapse • Post-partum haemorrhage

• Topics explored through examining current literature, stations for simulation and drills, exploration
of emergency management (nominating a leader, keeping calm, documentation, debrief)
• Neonatal loss and stillbirth presentation by a bereavement or social worker
• Asking the graduate to present a reflective piece on an emergency they have witnessed or
participated in

Before and after study day

• Focusing on antenatal care provision and postnatal care, as well as postnatal care in the home.
• Presenting a ‘specialist panel’ of midwives with diverse experience such as in young women’s
health, drug and alcohol clinic work, from the fetal monitoring department, birth centre and lactation
services. All present on how they got to what they are doing now, challenges and rewards. This
provides an opportunity for graduates to explore career options.
• Graduates conduct an audit of three medical histories either antenatal or postnatal and outline the
care management including what was done well and what could have been done differently .

Nursing study days

The topics covered within nursing study days will vary according to patient demographics, nursing
specialities covered by each health service and the learning requirements of graduates. Some health
services encourage graduates to attend study days at other health services in order to address
particular areas of professional interest.

At The Royal Women’s Hospital

Study days include a combination of formalised education and researched graduate presentations,
as well as a debriefing session with the graduates. The following is an example agenda from a
women’s health study day.

• An introduction to the nursing graduate program

• Meeting with the executive directors of nursing and midwifery, nurse unit managers, educators
and previous graduates

28
• Acute pain team service and pain assessment
• Blood taking and IV cannulation theory and practical session
• Debrief and team building

The rural context

Collaborative study days with regional health services bring educators and graduates together to
share learning and knowledge while developing networks and support. This is an efficient way of
utilising resources and skills within a region. An example of this method of shared resources can be
seen in the Grampians region where educators meet every three months to plan regional study days
and their ‘highway’ model of education, and study days are shared across the region.

Central Gippsland Health Service

This health service offers a comprehensive clinical nursing study day program across the year that
is open to all nursing and midwifery graduates at their health service, with additional days offered to
the midwifery graduates only. All study days include a debrief session alongside formalised education
and developing professional behaviours, with topics such as telephone etiquette, rotations and
rosters, salary packaging, work/life balance and stress management. Examples of clinical content for
study days at Central Gippsland Health Service include:

• priming lines
• injections
• PICCs and ports
• aseptic technique
• wound management, dressing selection, stoma care, pressure ulcers
• insertion of a subcutaneous butterfly
• dangerous drug and medication management
• drug administration including Webster packs
• advanced skills in the emergency department and coronary care unit
• preparing a patient for surgery
• cardiac monitoring telemetry
• organ donation
• blood transfusions
• paediatric assessments.

Project case studies and research presentations

Many health services in Victoria include a project by graduates to be presented at study days. These
presentations can include a patient case study, research topic, quality assurance activity, reflect the
health service’s strategic plan or explore the community and patient demographics. Presentations
typically last 15–20 minutes and can be individual or in small groups.

These presentations are an opportunity for graduates to explore practice issues, evidence-based
practice, reflective practice and address deficits in knowledge.

29
At The Royal Women’s Hospital
At The Women’s the graduate first selects an area of their practice that they would like to research
further and to then present about to the group. The objective is to have the graduates appreciate
and explore different areas of their practice as well as presenting in a collegial atmosphere.

The presentations go for 20 minutes and include a literature search, relevant evidence-based
research and an exploration of the topic. Graduates are free to be as creative as they choose
with presentation styles but most will choose a PowerPoint presentation, leading into discussion.
Graduates often interview more senior staff in the area to present an anecdotal perspective, as well
as giving their own personal account.

Each of the graduates liaises with the graduate coordinator when they make their choice to ensure
there is no clash with other presenters.

Past presentations have included: female genital mutilation; natural methods of induction of labour;
the role of the infertility nurse and exploring a related case study; water injections in labour; and
neonatal abstinence syndrome.

The rural context

Colac Area Health

The graduate nurse or midwife is required to complete and present a 15-minute case study.
The presentation must include:

• an introduction to the case study

• an overview of the patient’s condition
• details of the patient’s assessment and findings
• the signs and symptoms of the patient
• an outline of medications used
• a discussion of comorbidities and their effects on the patient’s condition
• a discussion of the nursing care plan
• researched and referenced evidence
• submission of case study notes.

30
Preceptoring and mentoring

Best practice EGPs are based on the understanding that

early graduates have been prepared through their tertiary
qualifications for beginner level practice. As such, early
graduates require access to more experienced nurses and
midwives as preceptors for supervision, direction and
instruction (Department of Health 2009).

What are preceptors and mentors?

The terms preceptor and mentor are often used interchangeably. While they have similar
characteristics of being senior clinicians who act as teachers and resource people, there are
key differences.

A preceptor:

• orientates new staff to responsibilities, polices and procedures, and clinical practice guidelines
• sets learning goals in clinical practice
• teaches and directs clinical learning experiences
• develops clinical competencies, time management and prioritising of work.
• A graduate may be assigned to many different preceptors during the orientation period.
• A mentor:
• develops a nurturing relationship with the graduate and helps him/her develop as a professional
• role models professionalism, attitudes and behaviours
• assists with transitions into the social culture of work environments
• offers guidance and constructive feedback, and shares knowledge, past experiences and advice
• meets regularly with the graduate.
– Research suggests the relationship continues for at least one year. Successful mentoring
relationships are where the graduate chooses their own mentor (Firtko et al. 2005; Persaud 2008).

Introduction to preceptoring and mentoring

A review of current literature supports the principle of providing preceptorship or mentorship to
graduates. It is clear that graduates require some level of support in the first year of employment,
but there is little evidence as to what is best practice for supporting graduate nurses and midwives
(Cubit & Ryan 2011; Evans et al. 2006).

Research demonstrates that new graduates want preceptorship; providing such support assists
in improving patient care through graduates developing skills and encouraging workforce retention
(Almada et al. 2004; National Nursing Research Unit 2009). This is confirmed by the high number of
students asking about preceptor support when researching graduate programs.

Support is most critical in the first four weeks of a graduate program and again at the beginning
of each rotation. The support required for each graduate will be individual, taking into account the
clinical areas of practice (Johnstone et al. 2008).

• Preceptoring is embedded into the department’s Early Graduate Nurse Program guidelines
(Department of Health 2009).

31
• Best practice EGPs provide supportive environments with mentors and preceptors.
• Mentors and preceptors assist the graduate in exhibiting professional behaviours.
• Mentoring increases professional behaviours exhibited by graduates and gives graduates the
confidence to transition beyond beginner level practice.
• Mentoring assists graduates to identify opportunities to take leadership and to expand their role
in the organisation.
• Preceptoring increases the retention of graduates in the current workplace.
• Mentors and preceptors assist graduates to appropriately choose ongoing professional
development (Department of Health 2009).
Compliance with the guidelines is included in the eligibility criteria for training and development
grant funding.

The rural context

During the consultation, rural and regional stakeholders highlighted some issues regarding using
preceptorship and mentorship models to support graduates. The predominant issue was matching a
part-time preceptor roster to a new graduate’s full-time roster. However, one health service believed
that ‘everyone has a responsibility to be a preceptor’, taking a team-based approach.

Mentoring within rural communities can be described as an experience of cultivating and growing
new and novice nurses and midwives. Here mentors and graduate nurses and midwives need to be
able to identify similar values and interests in order to develop sustainable, meaningful relationships
that develop into mentoring. Mentoring in a rural setting is particularly complex due to nurses and
midwives living and working in the same community and where graduates have additional needs
regarding assimilation into a workplace due to the complex social issues, culture and structures
embedded within rural communities (Lea & Cruikshank 2007; Mills et al. 2008).

Successful mentorship relationships appear to develop when the mentor and mentee form an
informal and mutually negotiated partnership. In the rural setting this will often extend beyond the
workplace into the community. Many rural nurses and midwives provide community education or
work through groups like St John First Aid, the Australian Breastfeeding Association, Country Fire
Authority and the Victoria State Emergency Service. Participation in these community groups can
help develop supportive networks and mentorship for graduates.

No formal graduate mentorship programs were identified in stakeholder meetings, which may
indicate an area for future development.

Rural and regional preceptor programs

In order to train, educate and support preceptors, many rural and regional health services utilise
online or e-learning packages and training systems. Examples from Gippsland can be seen online
at <http://www.gha.net.au/nurseed/viewresources.asp> and from Grampians and Loddon Mallee at
<http://www.grhc.org.au/glm-elearning-portal/elearning-progress-report>.

These challenges with aligning shift workers’ rosters are universal to preceptor programs. Latrobe
Regional Hospital nominates two preceptors to each graduate in order to address this challenge.
In acknowledgement of the time and energy given by preceptors, some health services in Victoria
reward and support their preceptors through strategies such as a ‘thank you’ afternoon tea, credits
towards study days, time in lieu and designated time away from the ward to support graduates.

32
Preceptoring can also be promoted as a career development strategy for staff.

Developing a preceptoring/mentoring model

Drawing on comments at the stakeholder meetings and on current literature, there are a variety
of strategies that can be utilised to support the graduate (see Figure 3). Workload, staffing and
relationships can all impact on how support is provided (National Nursing Research Unit 2009).

Figure 3: Strategies to support graduates

• organisational commitment to preceptoring and mentoring

• providing preceptoring training to all staff who work as preceptors
or mentors
Planning • work force planning for staff to attend preceptor training
• development of preceptor/mentor programs
• appoint a senior nurse/midwife to manage and coordinate the
program – usually a graduate coordinator or clinical educator.

• ensure provision of preceptoring is robust with strategies to cover

absences or staff changes
• establish strategies for addressing any difficulties or conflict in
preceptor and mentor relationships
• having allocated preceptor/s for the first weeks/shifts of each clinical
Organisation
rotation
• recognise the demands of assisting a graduate during a shift with a
reduction in workload
• have frameworks that recognise flexibility for the provision of
preceptors, i.e. a graduate requiring additional support.

• fortnightly or monthly informal lunch meetings with the nurse/midwife

in charge of the preceptor/mentor program
• regular debrief sessions scheduled into the graduate year
• monthly meetings with a mentor: these can be formal or informal,
in the workplace or a neutral location such as a cafe
Implementation • developing peer support networks and peer team building through
organised social events and study days
• value the role of the preceptor/mentor/s with a ‘thank you’ morning/
afternoon tea at the conclusion of the graduate year
• evaluation of the preceptor/mentor program by graduates, preceptors
and mentors and the coordinator.

33
Group debriefing

Programs should encourage peer support; groups can be

internet-based or face-to-face facilitated groups. These groups
provide an opportunity for debriefing and provide useful
psychological support (Department of Health 2009).

In nursing and midwifery, debriefing is a process whereby group members can take a step back from
events and situations to reflect on practice through the discussions of feelings and concerns in a
critical way (Mangone & King 2005). Debriefing has many benefits:

• provides support, including peer support

• helps develop a sense of belonging within an organisation
• improves interpersonal communication skills
• encourages the sharing of skills, knowledge and experiences with peers
• develops confidence in nursing and midwifery skills
• reduces the experience of ‘reality shock’
• develops reflective and critical thinking skills
• encourages the development of a supportive relationship with educators.

At The Royal Women’s Hospital

Debriefing sessions have been integrated into EGP study days at The Women’s, with a positive
response from graduates and educators. Regular weekly or monthly debrief sessions can be
integrated into an EGP, with demonstrated benefits to graduates and the organisation.

The rural context

Colac Area Health

Graduate support sessions are held weekly for an hour in order for graduates to meet with an
educator and foster a supportive peer network. During these support sessions there may also
be an education session, an opportunity to discuss an experience, submission or completion of
assessments and the opportunity to practise skills.

Clinical support
At the regional stakeholder meetings, it became evident that there are many names and roles
assigned to the more formalised providers of clinical and educational support for nursing and
midwifery graduates. These roles can be shared by more than one nurse/midwife or combined,
particularly in rural and regional health services where educators often hold multiple portfolios.

The educator is responsible for the overall coordination and management of the EGP in accordance with
Department of Health guidelines (2009). Clinical support is generally provided by clinical support midwives
and nurses, with the extent of this support being dependant on available FTE hours; however, in a
rural/regional setting the educator may also provide the graduate with most of their clinical support.

34
Clinical support nurses/midwives have an important role to play in fostering the education and
development of graduates. They are experienced nurses and midwives who provide clinical and
mentoring support and act as a resource, and are acknowledged as role models in the context
of contemporary nursing and midwifery practice. The position is primarily aimed at fostering
the professional role of the nurse and midwife while working collaboratively within the broader
multidisciplinary team. They:

• promote evidence-based care

• work with nursing and midwifery management, other educators and clinical staff
• ensure that professional, comprehensive and accountable midwifery care, consistent with the
values and objectives of the health service, are practised
• orientate graduates to clinical areas
• provide clinical support at the bedside to support skill development
• assess compulsory graduate competencies
• conduct graduate performance reviews
• provide mentoring and debriefing
• act as a resource person who can be called upon to assist with the direct care of women, specific
procedures, or to simply advise
• act as a liaison between graduates and ward staff.

At The Royal Women’s Hospital

Preceptors are allocated to all graduates at the beginning of their maternity and nursing rotations
and are matched as much as possible in the first month of practice. Following this initial month of
rostering, the graduate and preceptor are not intentionally matched unless the graduate is identified
as requiring additional support. Last-minute shift changes, sick leave and the movement of a
preceptor to other work areas due to organisational need all impact on the success of this program.

The model of maternity care at The Women’s allows midwives to move between all areas of clinical
practice on a daily basis. This challenges the consistency of preceptor support for the graduate and
is reflected in the varying feedback received from graduates regarding the ongoing support they
receive from their preceptor.

In nursing areas where they team-nurse, one nurse is responsible for the graduate’s initial orientation
day, then all staff are jointly responsible for preceptoring the graduates and contributing to the
graduate’s appraisal at the end of their placement. Most preceptors attend a preceptorship course
run by the hospital.

At The Women’s a full-time clinical support midwife (CSM) is allocated to each of the four maternity
teams. CSMs provide consistency in support for the individual graduates and other midwives in the
team throughout the year. Together with the preceptors and the graduate coordinator, the graduates
often remark positively on the level of support available.

35
Facilitating continuing professional
development

‘Continuing professional development is the means by which

members of the profession maintain, improve and broaden
their knowledge, expertise and competence, and develop the
personal and professional qualities required throughout their
professional lives. The CPD cycle involves reviewing practice,
identifying learning needs, planning and participating in
relevant learning activities, and reflecting on the value of
those activities’ (AHPRA 2010).

Nurses and midwives are expected to maintain 20 hours of CPD per annum per registration,
therefore dual-registered practitioners require 40 hours per annum, unless part of that education falls
under both nursing and midwifery (breastfeeding education and epidural management competency),
in which case it can be included under both. Participating in CPD ensures practice is current, safe
and competent, and enhances job satisfaction and staff retention (Gould et al. 2007; James &
Francis 2011). Health services have an obligation to facilitate and support nursing and midwifery staff
to fulfill CPD requirements.

Further information about CPD can be found at <http://www.nursingmidwiferyboard.gov.au/

Registration-Standards.aspx>.

At The Royal Women’s Hospital

Graduates are given a professional practice portfolio when they commence at the hospital. This
portfolio includes all the initial information they receive about the hospital and the program, the
hospital’s expectations and professional practice guidelines. This portfolio can then be added to
over the year with all their additional education and achievements. At one of their study days a full
session is dedicated to their CPD requirements to use in the future as they develop lifelong skills in
maintaining CPD.

All graduates are expected to write a reflective journal that is submitted regularly to the graduate
coordinator.

The Women’s provides all staff, including graduates, with an extensive variety of educational
opportunities. These range from online competencies, seminars, lectures, workshops,
multidisciplinary meetings, in-services, study days, online portfolios and journal clubs in order
to meet CPD requirements.

36
Evaluations
Feedback and performance evaluations are designed to monitor standards of competency,
protect the public from harm through risk management and as a developmental tool to encourage
nurses and midwives to reach their full potential (Fereday & Muir-Cochrane 2004). Regular and
objective feedback regarding performance is also essential to ensure graduates receive timely and
appropriate support strategies. Utilising national competency standards is considered to be the ideal
measurement tool of safe practice (Berkow & Virkstis 2008).

It is important to be aware that despite best intentions, nurses and midwives can describe the
evaluation process as one of being judged or something to be feared, and they can feel let down
with unexpected outcomes. They highly value verbal, spontaneous, less formal feedback, which can
come from peers, managers, patients or medical staff (Fereday & Muir-Cochrane 2004; Spence &
Wood 2007).

Effective performance evaluations are believed to:

• promote the development of practice improvements

• improve job satisfaction
• improve morale
• provide regular feedback
• formally recognise the work done by a nurse/midwife
• assist in career development (Spence & Wood 2007).

National competency standards for registered nurses and midwives can be found at <http://www.
anmc.org.au/userfiles/file/competency_standards/Competency_standards_RN.pdf> and <http://
www.anmc.org.au/userfiles/file/Midwifery%20Competency%20Standards%20August%202008%20
(new%20format).pdf>.

37
Suggested performance evaluation process
Figure 4 provides a suggested structure for three-monthly performance evaluations, which are
designed to be conducted in conjunction with the graduate.

Figure 4: Structure for three-monthly performance evaluations

Three-month Six-month Nine-month 12-month

evaluation evaluation evaluation evaluation

• Brief • Full graduate • Full graduate • Brief

evaluation evaluation evaluation evaluation
using criteria using criteria
• Performance • Performance
• Performance evaluation evaluation • Performance
evaluation algorithm algorithm evaluation
algorithm followed followed algorithm
followed followed
• Completed • Completed
• Completed by educator by educator • Completed
by educator in conjunction in conjunction by educator
in conjunction with the with the in conjunction
with the graduate graduate with the
graduate graduate
• Graduate • Graduate
• Graduate to identify to identify • Graduate
to identify personal personal to identify
personal learning goals learning goals personal
learning goals for the next for the next learning goals
for the next three months three months for the next
three months Communicate three to six
• Communicate
Communicate outcome with months
outcome with
outcome with manager
manager • Communicate
manager
• Outcome outcome with
• Outcome
• Outcome recorded manager
recorded
recorded
• Outcome
recorded

Brief evaluation: uses criteria based on Australian Nursing and Midwifery Accreditation Council
(ANMAC) competencies standard domains. These domains are: professional practice; critical
thinking and analysis; provision and coordination of care; and collaborative and therapeutic practice.

Full graduate evaluation: assessment of clinical skills, with both the graduate and educator
completing this evaluation. Learning goals are then developed with the educator, along with
identifying strategies for achieving these goals within the next three months. This process is ideally
one of structured guidance and support. It models critical thinking, reflective practice and the
continual development of clinical skills.

38
Further information
For EGP resources from The Royal Women’s Hospital please email the graduate nursing and/or
midwifery educator at <[email protected]>.

For training and development grant guidelines for early graduate programs from the Department
of Health, see <http://www.health.vic.gov.au/__data/assets/pdf_file/0006/506580/Training-and-
development-grant-nursing-and-midwifery-2011-12-guidelines.pdf>.

Karreeta Yirramboi: An employer toolkit to grow Aboriginal employment in your health service
provides a collection of practical materials to help increase the numbers of Aboriginal employees in
organisations. See <http://www.ssa.vic.gov.au/products/view-products/karreeta-yirramboi.html>.

39
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