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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
