Designing Evidence-Based Models for Transitioning New Nurses to Practice Nancy Spector, PhD, RN...

Designing Evidence-Based Models for Transitioning New

Nurses to Practice

Nancy Spector, PhD, RNDirector of Education

Suling Li, PhD, RNAssociate Director of Research

Mission of NCSBN

The National Council of State Boards of Nursing (NCSBN), composed of

Member Boards, provides leadership to advance regulatory excellence for public protection.

Transition of New Graduates to Practice

Background of Transition Initiative

• Context of practice: “frenzy”• Health care becoming more

complex• Nursing shortage• Computerized NCLEX,

making results available simultaneously

Background of Transition Initiative (Cont’d)

• Two NCSBN studies (2001 & 2003) of nurse employers found:– More than 50% of employers perceive that new

graduates provide safe and effective care.– Employers reported the following weaknesses:

• Recognizing abnormalities• Deficits supervising unlicensed personnel• Lacked psychomotor skills• Unable to respond effectively to emergencies

Background of Transition Initiative (Cont’d)

• 2002-03 developed the following evidence-based recommendations:– Placement - While immersion programs offered by

nursing programs are valuable, posthire, structured transition programs are crucial.

– Knowledge type - Transition programs should include general knowledge, but it should also include specialty content.

– Same mentor/preceptor – New nurses benefit most when they work together with one preceptor, following the preceptor’s schedule.

Literature• Nursing satisfaction

• Nurse retention/turnover

• Nurse confidence

• Cost-benefit of transition programs

NCSBN’s New Transition Research (2006-2007)

Goals of the Study• To describe the transition experience of

newly licensed RNs

• To identify factors that influence transitions into practice

• To examine the impact of the transition experience on clinical competence and safe practice issues of newly licensed RNs

OutcomesPrimary Outcomes

• Clinical competency

• Practice errors and risks for practice breakdown

Secondary Outcomes

• Stress level

• Job turnover

New Nurse-Preceptor DyadTwo assessments:

- New RN self-assessment– Corresponding preceptor/mentor

assessment

Results: Transition Experience

%

No orientation or internship 2.0

Routine orientation only 24.3

Internship or plus 73.8

Results: Internship Experience

HospNon-hosp

Ro

utin

e o

rie

nta

tion

with

inte

rnsh

ip

100%

90%

80%

70%

60%

50%

40%

30%

20%

ADN

BSN

Results: Duration of TransitionNon-hosp

10%

81%

>12 w ks

12 w ks

8-11.9 w ks

<8 w ks

Hosp

20.9%

24.9%

21.5%

32.8%

>12 w ks

12 w ks

8-11.9 w ks

<8 w ks

Results: Transition and Clinical Competence

• During first 3 months of practice, those who had a primary preceptor performed at a higher competent levels, especially in the areas of communication and interpersonal relationships, as well as recognizing limits and seeking help.

• Without preceptor, new RNs (3-6 months) practiced at LESS competent levels during this phase of independent practice

Results: Clinical Competence

9.1-12m

6.1-9 m

3.1-6m

3m or less

Me

an

clin

ica

l co

mp

ete

nce

sco

res

3.5

3.4

3.3

3.2

3.1

3.0

2.9

2.8

35-item measure

1-item measure

Results: Clinical Competence and Practice Errors

• New nurses who were more competent (r= -.35), especially in the areas of clinical reasoning ability (ß=-.38) and communication and interpersonal relationships (ß=-.33), made less practice errors.

Results: Transition and Turnover

Internship

YesNo

40.0%

30.0%

20.0%

10.0%

19.2

33.1

Results (Cont’d)• Perceived Stress (almost always)

– Felt overwhelmed with patient care responsibilities – 24%

– Experienced fear of harming patient due to inexperience – 2.8% (25.5% - sometimes)

– Felt expectations unrealistic – 15.6%

– All were significantly related to practice errors

Results: Perceived Stress During 1st Year

9.1-12m

6-9 m3.1-6m

3 m or less

Me

an

ra

ting

(sc

ale

0-3

)1.4

1.2

1.0

.8

.6

.4

.2

Felt overw helmed

Feared harming pts

Expecta. unrealistic

Results: Clinical Competence and Stress

9.1-12m

6-9 m3.1-6m

3m or less

Me

an

clin

ica

l co

mp

ete

nce

sco

res

3.5

3.4

3.3

3.2

3.1

3.0

2.9

2.8

35-item measure

1-item measure9.1-12m

6-9 m3.1-6m

3 m or less

Me

an

ra

ting

(sc

ale

0-3

)

1.4

1.2

1.0

.8

.6

.4

.2

Felt overw helmed

Feared harming pts

Expecta. unrealistic

Results: Transition and Stress• New RNs who had an internship were

less likely to feel expectations were unrealistic

• New RNs who had a transition programs that addressed specialty knowledge were less likely to feel expectations were unrealistic

2007 Transition Forum

• February 22, 2007• 200 participants, 41 states, 5 countries • Discuss vision of transitioning new graduates from

broad perspective• Examine national and international perspectives

of transitioning new nurses• Seek input from stakeholders and participants

about effective transition models

Themes – Transition Forum

• Do the right thing for the right reasons• The context of the workplace: Frenzy!• A national, standardized transition program is

desired• Preceptors need to be acknowledged and educated• Articulate the evidence to the practice arena• Collaborate extensively for buy-in

Vision

• Transition program of 6-12 months• Standardized• National• Collaboration of practice, education, regulation

Premises of Transition Model(s)

• Failure to transition new nurses is a public safety issue

• Transition is facilitated by active engagement of the new nurse and the preceptor

• Transition programs will improve practice and decrease errors

• A standardized, national transition program will help the formation of professional nurses

• A standardized, national transition program will increase nurse retention

Conceptual Framework

• Structure, including type, duration, setting, preceptor involvement

• Content, including theoretical, clinical experiences, and learning lab/simulation

• Characteristics/qualifications of preceptors• Expectations for competencies• Development of new nurse/preceptor partnership• Institutional support of new nurse/preceptor

Some Thoughts• Flexible• Robust: include all settings and all levels of

education• National Web site?• Preceptor education?• Relate to license?

• How do we gain consensus?• Pilot study of states?

Next Steps

•NCSBN will look at feasibility of a national, standardized model

Questions

nspector@ncsbn.org sli@ncsbn.org www.ncsbn.org