Facilitating an early career transition pathway to community nursing: A Delphi Policy Study

Abstract Aim To further develop and validate a new model of the early career transition pathway in the speciality of community nursing. Design Delphi policy approach, guided by a previous systematic review and semi‐structured interviews. Methods Four rounds of an expert panel (N = 19). Rounds one, two and four were questionnaires consisting of a combination of closed (Likert response) and open‐ended questions. Round three comprised of a focus group conducted using virtual meeting technology. Results The final model demonstrated reliable and valid measures. There were deficiencies in “pre‐entry”—where the marketing of community nursing was negligible and the support around orientation informal and minimal, mainly due to tight budgetary concerns. Community practice holds a whole new dimension for nurses transitioning from acute care as the concept of “knowing your community” took time and support—time to be accepted reciprocally and develop a sense of belonging to the community.

career pathway model for Registered Nurses in the area of community care. The essence of the Delphi policy method is to provide a factual basis for an argument for or against an issue, policy or problem (Rayens & Hahn, 2000;Turoff, 1970). We used a Lockean philosophical approach for forming consensus, based on what is known or observed from data inductively and to find agreement on issues between different individuals (Mitroff & Turoff, 2002). The Delphi technique is applied when examining an area with a scant empirical research base where there may be no definitive answers (Keeney, Hasson, & McKenna, 2001).
The TRANSition to a Nursing SPECiality in differing contexts of practice (TRANSPEC; Chamberlain, Hegney, Harvey, Knight, & Tsai, 2019;Hegney et al., 2019) is a theoretical model developed from our previous work on early career and rapid transition to specialty practice. TRANSPEC includes the major concepts of "self;" "professional and personal," "transition processes;" "formal and informal;" a "sense of belonging;" and the "context of practice." Box contains the definitions of these concepts, and Figure 1 presents the preliminary model. As can be seen in Figure 1, in these concepts are three areas of transition: Preentry, Incomer and Insider. These transition areas incorporate enablers and inhibitors.A Delphi policy approach was appropriate to this study, as the published information was particularly negligible in the Pre-entry area of transition to community speciality nursing practice. Eliciting a divergence of opinions is pivotal in a Delphi policy approach. We chose a combination of a Delphi technique rounds and a focus group to explore divergence of opinions and the feasibility of the preliminary model. This combination also allowed for validating the credibility or internal validity of participants' views, narrations and importance ratings that were formulated through the study (de Loë, Melnychuk, Murray, & Plummer, 2016). The focus group also allowed for the enhancement of the original findings by bringing additional sources of evidence.

| Expert panel selection and recruitment
A regional health service office in Queensland, Australia, assisted with the identification and selection of key expert stakeholders in regional Queensland Health. As per the selection criteria, the participants were specialist community clinical nursing practitioners or nursing directors of community practice. This sample provided a blend of clinical care, expert speciality community practice and nursing policy expertise. This was a homogenous group of 19 experts who were invited and signed consent to take part.

| Questionnaire development
The electronic questionnaires were developed using the online survey platform Survey Monkey™. The questionnaires were piloted using a separate panel of clinicians and qualitative researchers to improve usability and validity and for quality control. Wording and format changes occurred over two iterative cycles before being distributed to the expert panel.
The survey was conducted in three of four rounds from August to September 2018. The objective of the study, the questionnaire content and the scoring method were explained to the experts, who F I G U R E 1 Preliminary model for the early and rapid transition pathway to specialist community nursing

Community
Nursing Pathway Pre-entry Incomer Insider Belonging Self Unknown

Transition Processes
TA B L E 1 Round 1 closed question ratings for the concepts of professional and personal self-stratified by enablers and inhibitors

| Delphi Round 1
Experts were presented with the preliminary model

| Delphi Round 2
Prior to the second round, the selected items, their first-round standardized group mean ± SD values and the newly added views were compiled and sent confidentially to each expert by email. Round two consisted of open-ended and closed Likert response questions and was designed using the generated items from round one.

| Round 3 focus group
Experts gave feedback in a face-to-face online meeting room. Focus group technique was used to facilitate interactions. Focus groups centre on the use of interaction among participants as a way of accessing data that would not emerge if other methods were used.
The data emerging from focus group interactions have a high level of face validity, because panel members confirm, reinforce or contradict the arising content (Keeney et al., 2001

| Delphi Round 4
The panel was presented with an updated theoretical model informed by round one, two and three where qualitative data were transformed into quantitative question items. The panel was asked to rate items using a 5-point Likert scale with the option of an open-ended response to their choice. Items with a group mean score of more than three were retained. Refer to Figure 1 for the Delphi pathway.

| Analysis
In round one, two and four, the resultant quantitative data tables generated by the electronic survey were exported to Stata 15 software for analysis. Standardized group means and standard deviations (SDs) were used to compare movement between Delphi rounds as a measure of both stability and convergence (Greatorex & Dexter, 2000). The group mean, as a measure of central tendency, "represents the group opinion of the panel" (Greatorex & Dexter, 2000, p. 1018. The standard deviation, as a measure of spread, "represents the amount of disagreement within the panel"  (Greatorex & Dexter, 2000, p. 1018. The median is also reported for comparison to the group mean as an indicator of the direction of the group response. Cronbach's alpha (α) was used during each round of the Delphi process to determine the internal consistency of survey questions or items. Cronbach's α was also used as a measure of homogeneity for the ratings. Increasing homogeneity was considered to be an indication of consensus among the panellists. An a priori α of .7-.9 was used to define consensus (Tavakol & Dennick, 2011).
The overall agreement among the experts was determined with the intra-class correlation coefficient (ICC), with consensus and stability tested by two-way random ANOVA with absolute agreement.
ANOVA use is based on the normality of the distribution of means rather than the data. As per the Central Limit Theorem, sample sizes >5 or 10 per group, the means are approximately normally distributed regardless of the original distribution (Norman, 2010). The ICC is interpreted as follows: ≤.40, poor consistency or large variation in opinion; .41-.74, acceptable consistency; and ≥.75, good consistency (Heiko, 2012).
Qualitative data were collated from round one and two as openended answers and three in the form of a transcribed audio recording of the focus group discussion provided by the participants.
Data were analysed using content analysis (Burnard, 1991). First, statements were identified that were either the same or very similar. These statements were grouped together and themes developed around statements that were in the same area of interest until nothing similar emerged. These were kept as worded and included directly in round 4 as transformed quantitative statement items.
TA B L E 2 Round 1 pre-entry narratives based on open-ended questions about strategic measures

Transition positions resourced
• "Ongoing support for training courses with dedicated training courses with replacement staff available … [and] maintain these courses" (P4) • "There should be identified positions that are specifically designated for new staff to develop into" (P9) • "Preceptors must be trained" (P5) • "Need to [have] base grade (entry level) positions" (P5) • "Absence of… careful selection of staff … and opportunities for … trial placements" (P9) • "There are limited positions available" (P1)

Marketing of Community
Nursing career • "Pathways into community may need to be flexible … need to match the values that are needed for the community setting … have clear pathway" (P5) • "More visible career pathway" (P6) • "Marketing the flexibility and autonomy of practice, that community nursing is relational and person-centred" (P7) • "Better marketing and promotion of community nursing as a speciality" (P8) • "Advertising the positives" (P10) • "Early career development must start early … market the work to the undergraduates" (P5) • "Embedding the recognition that community pathway is valued" (P2) Pre-entry placements • "Clinical placement with students [for successful recruitment]" (P1) • "Providing postgraduate qualification in community speciality area" (P2) • "Adequate, sufficient clinical placements during training in the community" (P11) • "More clinical experience in the community sector as undergraduate. Exposure to the different types of clinical positions" (P1) • "Universities must ensure PHC concepts and placements occur in undergraduate years" (P5) Positions available on completion of transition program • "At the moment, there's limited opportunities to progress upward" (P2) • "[A need for] opportunities for career growth" (P3) • "A lack of career aspirational opportunities in community practice has hindered recruitment" (P2) • "There should be identified positions that are specifically designated for new staff to develop into…This will, by necessity, mean that senior staff are upskilled in clinical supervision" (P10)

Funding
• "Paid training position with opportunity to gain further temporary or permanent positions" (P3) • "Funding models are a concern" (P7) TA B L E 3 Round 1 pre-entry narratives based on open-ended questions about the personal and professional self

Motivation & Passion
• "I wanted to practice in the community as soon as the right opportunity presented itself" (P10) • "Motivation is essential" (P2) • "Community nursing was where I felt most aligned with my professional ideals" (P7)

Resourcefulness
• "(Own) ability to gain the child health nursing skills and learning by uni courses and student placement" (P4) Transition reason positive • "Having exposure to community-based practice provides a greater understanding of roles and importance of these roles in the continuum of health care" (P2) Commitment high • "Sufficient hands on experience prior [to] making commitment" (P5) Resilience high • "Need life experiences to work in remote areas. Idealism is not an ideal pre-requisite" (P1) • "Training courses need to develop resilience" (P2) Self-care quality • "You need to be able to care for yourself -have good self-care practices because often you are on your own" (P1) • "The demands placed on you can be high and client expectation can often be unrealistic" (P1) Self-confidence • "Person needs to be able to be confident to work independently and confidently and make decisions. Good concept of self, ability to take leadership, think critically and have a reasonable level of social intelligence will have an impact on the success of the nurse" (P4) • "While self-confidence is desirable, [it] must not be excessive" (P2)

Professional
Previous experience in community • "Completion of an undergraduate nursing degree is the only amount of experience that is essential to pre-entry" (P9) • "New graduates should be able to work in community with sufficient and appropriate support" (P10) • "Depend[ing] on the role … some roles could take newly graduated nurses… if the model of care supported that" (P1) • "Nursing degree with some experience but no set time" (P5) • "Recognition of the completed course" (P4) Clinical decisionmaking & critical thinking • "Need some good concepts in primary health care and ability to problem solve well" (P5) • "Education on the complexity and challenges of the role and reward as a clinician" (P6) • "Many of the community nursing/ roles are largely autonomous … need 3 years (of) experience" (P1) • "At least 1 year to enable isolated practice and clinical decision-making with remote supervision" (P7) Teamwork ability • "Ideally, you would start with a team with more experience practitioners … recognition that community-based nursing services are valued members of the health care team" (P2) • "Sufficient staff on site for both staff safety and collaboration" (P4) • "Digital clinical decision-making tools [may be useful]" (P7) • "Team connection/network and community of practice options" (P7) • "Difficult to feel part of a team when your practice is in isolation. Take effort to be part of a team" (P1) • "Team structures provide clinical governance that ensures patient safety. An inability to function as a cohesive team member would compromise the nurses" practice" Competence, knowledge & skills-generalist • "Sufficient hands on experience prior to making commitment … realistic onsite experience as graduate" (P4) • "Broad experience across generalist nursing to have capacity to manage both specific conditions … [and] comorbidities" (P8) • "Skills and knowledge based on sole practitioner … ensuring nurses receive skills and knowledge required to fulfil their role" (P2) • "At least 2 years post-graduation to consolidate learning. Level of experience would depend on position" (P2) • "1-2 years post graduate (experience) before embarking on rural placement then supervision is required" (P4) • "Nurses concerned about losing acute care clinical skills" (P2) (Continues)

| Ethics
The study was approved by the Central Queensland University Human Research and Ethics Committee and the Queensland Health ethical committee.

| Round 1
In round 1, 12 of 19 experts completed the survey (65% response rate). Those who did not contribute were on leave or had left their positions. Panel members were recruited from community specialities and executives involved in mental health, midwifery, child, youth and family health, outreach Indigenous health, community nursing and community care for the older person. Only 20% of the panel members planned community practice as a career pathway. The qualifications of this panel focused more on their specialty of practice (i.e., mental health) rather than on community practice principles or community or primary health postgraduate education.
There were 59 items rated in the closed rating statement questions. Consensus and internal consistency between survey questions was strong except for the inhibitors in the theme of Self (Professional), in the time frame of Pre-entry (Cronbach's α = .673).
As this was an area deficient in published information, they were retained. Table 1 shows the mean rating, SD, median and Cronbach's alpha for enablers and inhibitors of the themes of Self (Personal

The self Enablers Inhibitors
Clinical placement to understand community practice principles • "Rotational experience programs when working within the sector" (P1) • "Gain the child health nursing skills and learning by courses and student placement" (P3) • "Lots of opportunities to do different parts of community work" (P5) Leadership for autonomous practice • "Many of the community nursing roles are largely autonomous therefore need 3 years' experience. However, some roles could take newly graduated nurses if the model of care supported that" (P2) Professional maturity • "Recruitment strategies need to match the values that are needed for the community setting and to work out if the candidates are good at problem solving and working independently or ability to work toward this" (P6) • "The recruitment process itself needs to be transparent and ro-bust… Questions need to be able to identify potential candidates who are flexible in their thinking, mature and robust enough to practice with developing autonomy" (P10) Self-reflection regarding scope of practice • "I knew after completing a community placement that community nursing was where I felt most aligned with my professional ideals as an entry nurse and it made the most sense. I completed midwifery studies three years later and again the model of health and wellness aligned with my values and ideals as a nurse" (P7)

Mentors/ Preceptors/ Supervision
• "Preceptor on board then supervision and mentoring models within the community organisation" (P7) • "Appropriate supervision of staff … preceptorship and mentorship … to challenge and grow" (P1) • "Support and mentoring from experienced RN/CN/CNC" (P6) • "Role model who can provide coaching and mentoring" (P8) • "Mentoring and supervision should be mandatory, with adequate time allowed" (P9) • "Clinical supervision and support and timely access to support for decision-making inputs" (P7)

TA B L E 3 (Continued)
TA B L E 4 Round 1 transitioning processes concept for the incomer category narratives based on open-ended questions focused on strategic measures

Transition programs & Orientation
• "Post graduate specialisation program … rotational programs between similar streams (e.g. paediatrics and child health)" (P1) • "Effective orientation" (P8) • "Individual learning and a transition support program … [should] matches or articulates with universities … contribute to a career in the community" (P5) Buddy system • "Need peer support network" (P3) Time frame tailored to individual needs • "Transition support needs to last beyond the first year" (P6) • "[Have] clearly identified professional development/educational goals" (P10) • "[Availability of] adequate relief time after stressful incidents" (P1) • "There may be the requirement for additional skills however we fail to recognise that a lot of skills are transferrable" (P1) Person, family & community centred assessment skills • "A true sense of holistic care -need to see the person as a whole and part of the community, to think about the needs of our patient beyond the hospital" (P2) • "Qualifications are required in area of work to ensure good understanding of what is happening to/for the client, to be able to conduct appropriate assessments and develop appropriate plan of action and evaluation. Having a holistic approach is important, understanding what factors are impacting your client or their condition" (P3) • "Ongoing study in theories and models of primary health care and patient centred care" (P7) • "Focus on specialty areas in tertiary level training…required for remote area nursing" (P2) Knowledge of community culture • "Connection to space or country" (P4) • "Primary source of contact for some communities" (P3) • "Site specific specialities especially in diverse roles e.g. Indigenous communities/graziers/station settings, rural townships" (P1) • "Community nursing in remote areas is not for faint hearted…persons should be aware of issues prior to accepting posi-tions… isolation etc" (P2) • "Need generalist training in rural areas including cultural awareness/safety/driving skills" (P2)

Knowledge of referral pathways
• "[The community nurse is a] repository of knowledge of where to go or how to solve a problem (health or lifestyle)" (P3) Practice in others personal space rather than hospital space • "Capacity to work both with hospital specialists, general practitioners, and within multidisciplinary team" (P8) Understanding role in a multidisciplinary service • "At least 3 years of nursing in variety of different roles … outside of the acute setting" (P6) • "Multidisciplinary practices where all teams work collaboratively with defined roles" (P3) • "Provide experience in working across community setting" (P8) • "Recognition that community-based nursing services are valued members of the health care team and are an important component of ensuring healthy people/community" (P3) • "The value of community-based nursing practice is under-recognised" (P1) Peer and community health Support systems • "Have a support network for community nurses including mentoring, clinical skills feedback/supervision, peer support network" (P2) • "Support is absolute necessity … needs to last beyond first year" (P5) • "[Having the] ability to recognise need for support/self-caring strategies in dealing with difficult situations" (P1) Clinical skills to match community needs • "[Community nurses need to] have ability to work across both community and acute care … role of health promotion and primary health care" (P2) • "[Need] a diploma in child health" (P3) • "Digital clinical decision-making tools" (P8) • "Clinical decision making is also very important -you are assessing your client and making decisions as to plan of care. You also need the clinical knowledge to know when this is beyond your scope of practice and need to refer on" (P2) • "In rural areas, nurses are often de facto allied health and this leads to resentment on return to city areas" (P4) • "Health practices change" (P2)

Strategic measures Enablers Inhibitors
Continuing education and lifelong learning support • "Have a career framework for nursing … include career pathway … provide opportunities for professional Development in the area of community-based nursing service … include updating on evidence based best practice" (P2) • "Ongoing study [is necessary]" (P6) • "Support for postgraduate pathways through scholarship programs" (P1) • "Ongoing professional development" (P7) • "Clearly identified professional development/educational goals … and access to appropriate postgraduate education" (P9) Workplace environment • "Workplaces need to understand concepts such as different generations … [need] good leaders who can manage diverse teams" (P5) • "Strong and competent leadership" (P8) • "Ensuring nurses receive skills and knowledge required to fulfil their role" (P3) • "Flexible working conditions, opportunities for career growth" (P4) • "Workplaces that are happy, provide clinical supervision and are fun, interesting and engaging" (P6) • "At present there is limited opportunity to progress upward" (P3) • "Higher level positions are scarce" (P1) • "Lack of recognition of previous knowledge and skills greatly inhibits professional concept of self" (P1) • "At present, most opportunities are in the acute care setting" (P2)

TA B L E 4 (Continued)
TA B L E 5 Open-ended questions exploring the concept of self, stratified by enablers and inhibitors

Self Enablers Inhibitors
Professional (incomer) • Clinical decision-making and reasoning • Problem-solving skills • Ability to ask guidance/seek out information as required • Self-confidence • Self-motivated, listen and adapt • Perceived myth and reality from consumers and staff, and social media and Professional). As can be seen in Table 1, the highest rating item for enablers was in the concept of Self (professional at incomer) "critical thinking ability" (standardized mean = 4.50). The highest rating item for inhibitors was in the concept of Self (professional at incomer) "lack of support" (standardized mean = 4.70).
The total Cronbach's Alpha for round 1 model was very strong .939.
The open-ended questions sought statements focused on enablers and inhibitors. The statements were organized into concepts

Concept Enabler Inhibitor
Transition processes TA B L E 6 (Continued) of strategic measures (see Table 2); Self, both personal and professional (see Table 3); and transitioning processes (see Table 4). New concepts emerged to inform the theoretical model. These included Funding ("funding models [are] a concern" and "paid training position with opportunity to gain further permanent positions"); Supervision and Support: ("mentoring and supervision should be mandatory with adequate time allowed"); and the Workplace Environment: ("need good leaders who can manage diverse teams").

| Round 2
Round 2  New concepts from round 2 were included. One of them, as presented in Table 7, was the choice of transition in Self narrated as follows: ("[professional needed to] define community roles") and ("[personal needed to] explore self-values and beliefs, cultural safety and cultural choice"). Another new concept was the amount of supernumerary experience in transitioning processes. This concept is presented in Table 8  There were 79 items rated in the closed rating statement questions. Consensus and internal consistency between survey statements was strong. The highest rating item for Self (professional) enabler was "satisfactory critical thinking ability" (standardized mean = 4.78) and for transitioning processes enabler "supportive staff and feeling as part of the team" (standardized mean = 4.78) and Transition processes inhibitor "lack of support" (standardized mean = 4.89). The mean rating, SD, median and Cronbach's alpha for enablers and inhibitors of the themes of Self (Personal and professional) are presented in Table 9; and for transitioning processes (formal and informal) and Belonging in Table 10.

| Round 3
The focus group had nine participating experts and was 2 hr long.
Additional themes and sub-themes were included in the model that emerged through the focus group. The new themes included "safety of self, clinicians and patients," "marketing," "scope of practice and time" and "professional development and life-long learning." Table 11 documents the focus group findings.
Each theme comprised of multiple sub-themes. For example, "safety of self, clinicians and patients" had three sub-themes: "prevention of hospital admissions," "social aspects in safety" and "having insight into self and reflective practice." Each sub-theme emerged "Getting to know your community" was a strong sub-theme related to attaining a sense of belonging. One participant elaborated: "relying on other people and relying on networks and understanding how communities work understanding family networks in small communities … knowing your community." Invisibility of the community nursing was also ubiquitous. The issue of community nursing being poorly understood was evident: "we're not visible they can't see what we're doing so they can't know unless they actually walk in our shoes." There was also a sense that the specialty is undervalued: "community looks very different to the style of nursing that you see in the acute sector and so being invisible means that we get undervalued." The new themes and sub-themes were converted to quantitative items for round 4 including the new concepts of "conditional requirements," "for safety" and "orientation requirements" for getting to know the community. Finally, the "specialist workforce retention TA B L E 7 Open-ended questions with narration by the concept of self

Self Enablers Inhibitors
Professional (incomer) • "Clinical decision making and reasoning. Good at problem solving. Not afraid to ask guidance, self-confidence" • "Self-motivated, listen and adapt. Analytic problem solving, self-reflection, communication, listening skills, team building, leadership skills, professional boundaries, strong scope of practice, knowledge, resilience" • "Organisational skills" • "Clinical competency with capacity to take initiative to ask for help/seek out information as required" • "Competent clinical practice, critical thinking and problem-solving skills … being proactive" • "Situational awareness" • "A sense of professional self needs to be fostered which includes have good role models and good feedback and the right fundamentals of professional knowledge … support of a skilled CNC who has knowledge in the area" • "Open to observing and learning from other work practices, being innovative … practical compassionate emotional intelligence to relate to both clients and staff … influencer" • "Defined career path … self-motivator" • "Use of informal networks." • "Lack of constructive feedback and guidance" • "Recognition of burnout and compassion fatigue" Personal (incomer) Choice of transition • "Important to connect to a team" • "Dealing with isolation is important" • "Explore self-values and beliefs, cultural safety and cultural choice" • "Good leadership and vision of community managers … Opportunity for performance feedback, clinical supervision, ability to work autonomously and manage work flow" • "Define community roles" • "Preconceived myth and reality from consumers and staff, and social media" activity" concept overarched the professional development and lifelong learning of the novice community practice specialist. The findings from the focus group formed the focus of the theme development for round 4.

| Round 4
Round 4 consisted of eight closed importance rating questions of 52 items. The results are shown in Tables 12 and 13. Table 12 shows that the highest rating items for the Self fell under Professional-Pre-entry: "Clinical placement to understand community practice principles and culture" (standardized mean = 4.83); and Personal-Pre-entry: "Commitment [is] high" (standardized mean = 4.67). trial and error … we had no one with previous experience" • "Networking, exploring available resources … and peer processes" • "Coaching by existing staff" • "Experienced peers, operational manuals and policies" • "Need orientation to health, driving/ survival skills, negotiating skills" • "Following a nurse around for few weeks is not orientation" Ideal orientation program • "Supernumerary for 1-2 weeks, mentorship, regular meeting to review practice and debrief" • "Formal process of supervision, allocated preceptor and mentorship, recognition within educational frameworks, mediation process" • "General orientation of community process followed by unit orientation.
Preceptor or buddy for initial period, performance agreement" • "Introduction to other health professionals in the area … referral processes, introduction to key stakeholders outside of practice, support networks, community … time sheet, payroll … shadow another clinician … technological programs and devise" • "Regular meeting post orientation" • "Review of local needs … self-awareness/personal health courses" Role of mentor • "Introduction into the role … boundaries and referral pathways … encourage progression of practice and experience … available for debrief … local community and culture" • "Past the incomer period" • "Navigate the system and culture" • "Identify strength and clinical knowledge and skill gaps … provide constructive feedback and support … assist incomer to develop confidence and abilities … guide the incomer in clinical practice reflection, assist in developing critical thinking and problem-solving skills" • "Coaching, role modelling, resource guidance" • "Provides structured program of regular contact with incomer, willing to work with incomer over 1-2 years … available via electronic media/phone … support tailored to the need of the nurse" Amount of supernumerary experience • "Depend on the role & prior experience. At least a week for experienced, 2-3 weeks for inexperienced" • "Depend on … the level of autonomy" • "More [than a week] in complex role … it is important to have more time" • "Ideally … at least 2 weeks minimum … but guided support" • "If it is limited, senior/expert clinician in community will provide guidance to gain skills" • "Up to one month in single/small remote communities" • "Not always possible, needs to build into work program, not all organisations can afford supernumerary experience" • "Need to understand the capacity of private employee to support supernumerary time" (Continues)

Concept Enablers Inhibitors
Strategies needed • "Effective mentorship, clear and effective and accepting referral pathways. Introduction to local community and culture" • "Clear orientation processes, policy, education framework, succession planning and peer support … scope of practice, review facilitate handover process, support with client care, consumer feedback, self-care boundaries and review" • "Planned program for upskilling" • "Coaching, communities of practice" • "Receive required training early" • "Professional boundaries and relational care" • "supported supernumerary practice, education on professional boundaries and relational care" • "remote mentorship … tailored learning packages, study days at intervals … ideal for about 6 months … healthy work place … good leadership … understand different generational needs and drivers" • "ensuring lunch breaks are allocated … resourced with equipment required for the role, team to belong to, allocated space to sit" • "educational and personal development… linking in with nursing groups … good teleconference access" Early career entry • "Undergraduate experience/exposure, effective mentorship, clear and effective referral pathways, introduction to local community and culture" • "Develop supported practice guidelines, case reviews, peer support, resilience, debriefing, self-reflection guidelines, develop pathways for continuity of care, preceptor" • "Regular clinical supervision" • "Good orientation, coaching" • "Clear career pathway, mentor, professional development" • "Structured orientation program with core competency development" • "Good leadership and management, clarity of processes and role expectations, positive feedback, ongoing education and training" • "Suitability for proposed role … self-motivation to improve nursing skills demonstrated" • "Peer support for extended transition programs. Need a workplace that is accepting, where preceptors have time, resources such as nurse educators, CNCs and clinical practice facilitators, transition learning package … regular study days and placements" • "Postgraduate pathway to specialisation" • "Opportunity for work experience in acute care facility" • "Mentor to support autonomous decision making, clinical decision-making tools/pathways" • "Services can 'grow our own' and bind staff long enough to gain their loyalty … provide a variety of different work to keep staff engaged and interested … flexible work conditions must be balanced with providing the services. Workloads need to be realistic, prevent burnout" • "Being validated for role and acknowledged, respect from wider staff for input.
Inclusion in planning and whole care of patient." • "[Need] interpersonal communication skills" • "feeling of isolation in practice" • "work/life balance" • "computer literacy" • "need life experience" • "the volume of work involved in transition program is too large [for new graduates]" • "programs that do not interact are time wasters" • "lack of placement opportunities in undergraduate is a concern however many placements are unsuitable to give outline of possible career choices" Insider Continuous Professional Development (CPD) • "I am able to access PD leave." • "Learning is always ongoing and obtained through a healthy workplace that knows how to develop high performance staff and keep us engaged and learning … encouragement to know what opportunities are available outside the workplace … engagement in a professional association … that reach out to new graduates" • "It is expected that the individual source appropriate CPD according to needs" • "Support for CPD is essential in remote areas requiring replacement staff to attend" other than … AHPRA commitment" • "I need to identify ways." • "Ability [for organisation] to support financially depends on staffing level" • "Time out to travel to regional centres adds to burden of role" (Continues)

TA B L E 8 (Continued)
The highest rating was for Transitional Processes (Conditional requirement) in the "Ability to provide safe practice in the community setting" (standardized mean = 5.0).
After the three rounds of Delphi, agreement between panel members remained strong (Tables 7 and 8)   and quality care (Stewart et al., 2017).

| The final theoretical model
This Delphi study has provided the knowledge and insight that was deficient in the preliminary model for the early career transition pathway to community nursing. We used the TRANSPEC model of "the effective rapid and early career TRANsition to nursing SPECiality in differing contexts of practice" . In this study, we found deficiencies in "pre-entry"-where the marketing of community nursing was negligible and the support around orientation informal and minimal, mainly due to tight budgetary concerns. We found that community practice holds a whole new dimension for nurses transitioning from acute care as the concept of "knowing your community" took time and support. It took time to be accepted in a reciprocal manner between self and the community, and to develop a sense of belonging within the community. Ashley, Brown, Halcomb, and Peters (2018), in their qualitative work of Registered Nurses transitioning from acute care to primary healthcare employment, dedicate a sizeable proportion of their discussion to orientation during transition. They report similar findings, where orientation was either minimal or non-existent.
The findings emphasize the assumption held by healthcare providers that community nursing is not different to acute hospital nursing, therefore, experienced Registered Nurses transitioning to community practice require minimal orientation. Transition programmes typically include a supernumerary orientation period, structured study days, preceptor or mentor support and access to a nurse educator who usually coordinates the programme (Rush, Adamack, Gordon, Lilly, & Janke, 2013). As highlighted in our study, similar transition to professional practice programmes in community nursing that incorporates a structured orientation

Concept Enablers Inhibitors
Strategies to retain community specialists • "Research and reporting, visibility of service to further build services and relationships, consumer engagement." • "Clinical supervision or feedback community with area of practice. Professional development supported and encouraged. Teamwork and culture fit" • "Recognition and development opportunities, remuneration" • "Opportunities to work across both community and tertiary settings" • "Coaching and development conversations … good leaders, inclusive workplaces, university programs that have clear pathways" Speciality specific • "You may need to approach the support differently (e.g. mentor/supervision may occur through video/phone)" • "More generalist training [in rural and remote community nursing]" • "Nurses are often sole practitioners … clinical practice network is [important]" • "Supervision strategies require community involvement and remote options" • "Need to become more innovate and independent in practice" • "Research is common to both to inform needs and services" Belonging • "Effective patient advocate … sense of community belonging" • "Life experience, empathy, ability to motivate"

TA B L E 8 (Continued)
TA B L E 9 Closed rating question items in the concept of self stratified by enablers and inhibitors "A sense of belonging" to the community relates to the reality that community nursing is grounded in the social model of health.
Community nursing practice entails working with individuals, families and community groups (Besner, 2004;Kemp, Anderson, Travaglia, & Harris, 2005). The practice involves coordinating care in multidisciplinary environments and provision of visiting services TA B L E 1 0 Closed rating question items in the concepts of transition processes and belonging stratified by enablers and inhibitors • Primary health care model … preventative care … chronic conditions or short-term conditions like whether they've comfortable with the post-acute care … continue to rehabilitate • We're very much working together with the client and having them at the centre of that care • Capturing where the gaps are • You take initiative, you see what the client's needs are • You carry that patient with you on the journey … often relationships that you have for a number of years • Advocating and championing for the services that your client needs Nobody knows what community nurses do-invisibility • Community looks very different to the style of nursing that you see in the acute sector and so the values • Being invisible means that we get undervalued • We're not visible, they can't see what we're doing so they can't know unless they actually walk in our shoes • Strong focus on the primary health care principles and the foundations Difficult to market prevention • Preventive health care… can be complex at times because people don't always well identify their needs • We're talking about prevention … most difficult things to market • People aren't always thinking of the cost of preventing disease, initially they're thinking of the cost of treating the disease • Trying to encourage clients to accept some services to help them maintain their independence • Unless we can demonstrate measurable outcomes and our KPIs to show that yes our different input into clients here has produced something at the end, that it's really hard to attract funding or support for those roles Acute nurses have limited understanding of community • Prevent and promote health care in the ED, I was on the wrong end of the scale • There's a whole lot of different digital platforms in every single Hospital and Health Service… so they miss people because they don't see them on their system • Tried to poach or coach people across from acute wards … look like they might feel fit the model of community quite well • I'm sure, sometimes undergraduates could see that you're having a very nice conversation with family but not picking out the nuances of how you know your probing and you are asking the right questions • We're so experienced, we forget that the nuts and bolts and having to point that out to some preceptors • The ability to talk through case studies • It's keeping them there, and I think it's keeping them there by providing the debrief sessions • I have somebody I can contact and talk the situation through with • Enabler is having a safe go to kind of clinical practice supervision • Just when you're thrown out on your own, I think you really need to be able to have that contact • Not common in there for nurses to get clinical supervision • Clinical supervision and the tele mentoring • Knowing who is it that I can go to, who is my network, who can I talk to, particularly in most isolated areas • Role modelling … I observed people having some wonderful discussions and seeing how they work around with families • How to support new learners • Mentoring is a really big part of precepting and I'm actually precepting somebody now and as we speak and she's been with me for three weeks and I'm quite protective of ensuring that she feels supported and that she's not given any task that is beyond her ability to manage yet until she's aware of all the systems and or checking in you know how do you feel about doing that • Prioritize what you feel that they're going to need first so that they're not going to sink. They can at least swim a little bit in some of those preliminary roles. And it's as sequential and gradual in terms of tasks responsibilities and taking them on board. So not setting people up to add something that's too complex to manage. If you're all brand-new to the service … you would be looking at tasks that you'd have to be able to be with someone that can assist with that, and then gauge what tasks would be appropriate to allocate Transition process-Specialist workforce retention activity Cronbach's alpha: .988 The Specialist nurse exhibits outcomes of practice that are professional, capable competent, sustainable and person focused on completion of transition processes to clients in complex situations that often require advanced problem-solving skills (Besner, 2004;Kemp et al., 2005). A "sense of belonging" is an achievement indicating that the community has embraced the practitioner into its privileged state. Attaining a "sense of belonging" is essential not only for optimum practice but also for the long-term retention of community nurses (Coughlan & Patton, 2018;Moseley, Jeffers, & Paterson, 2008). It also allows for the trust to develop between nurse and client and to establish interagency cooperation for the disclosing of relevant personal and private information (Dellemain, Hodgkin, & Warburton, 2017).
Our conceptual model of "the early career transition pathway to specialist community nursing" enhances the TRANSPEC model Hegney et al., 2019) and culminates with the novice community nurse specialist at the beginning of the progression from novice to expert (Benner, 2001).

| Relevance to clinical practice
This study has identified five key elements needed for effective recruitment, transition and retention of staff in community-based clinical practice,

1.
Marketing. There is a general view that community nursing is poorly understood. There is a sense that these professionals are secondary adjuncts to their acute care counterparts, making community nursing an undesirable career pathway. Marketing needs to raise the awareness to the diversity of the role, its autonomy in practice and its generalist-specialist focus. The diverse areas of practice in the community also need to be exposed positively as a professionally satisfying career pathway.
2. Pre-entry opportunities need to be provided. These opportunities should include more clinical placements for nursing students to what are currently available. These placements need to have structured learning activities, provide exposure to clinical activities and be sufficiently long, for students to gain a sound and positive understanding of community practice.
3. Orientation requirements. Orientation has been described as ad hoc and not addressing the real needs of a community nurse.
Orientation needs to be structured and include key elements of community nursing, rather than be an add-on to acute based practice. Moreover, orientation should incorporate some introduction to the broader community issues, available support services and referral pathways. For instance, this could include responding to issues such as domestic violence, housing and problematic substance use. In the study, basic operational budgeting was also seen as essential. The implication is that orientation also needs to be flexible enough to recognize the level of experience and practice of Incomers and the application of structured mentoring opportunities that last longer than the orientation timeframes.
F I G U R E 2 Final model for the early and rapid career transition pathway to specialist community nursing tings. Opportunity to grow and develop critical thinking and a sense of belonging in the community through access to activities in the broader community needs should also be offered.

Acceptance by community PROFESSIONAL SELF-ATTRIBUTES
Community-focused in-service and tertiary learning opportunities should be developed, in addition to existing specialist-focused learning.

| Limitations
In this study, specific limitations include a low participant number. The panel members were speciality experts and as such their group opinion is considered more "valid" and "reliable" than indi-

| CON CLUS ION
This Delphi study presents an emerging early career transition pathway in the speciality of community nursing. The five key elements needed for effective recruitment, transition and retention of staff in community-based practice included: marketing, formal orientation, personal and professional safety for clinicians and supported professional development. These elements can facilitate effective recruitment, transition and retention of staff in community-based practice. Future work building and testing this model is a research priority.

ACK N OWLED G EM ENTS
We wish to acknowledge the early work of Dr. Lisa Wirahana formally from Central Queensland University in the systematic review of part one of this study. We also acknowledge the input from our nurse experts and stakeholders who contributed to the development of the Delphi model.

CO N FLI C T O F I NTE R E S T
No conflicts of interest. AS, LT, CH, DH: Review and Editing.

PATI E NT CO N S E NT S TATE M E NT
This study did not require a patient consent.