Embed Size (px)
Citation preview
The Impact of Transition Experience on Practice of Newly Licensed
Registered Nurses
Suling Li, PhD, RNAssociate Director of Research
NCSBN
Background• New RNs struggling with transition into
practice
• Shortened gap between taking NCLEX and being licensed
• High job stress and high turnover rates in new RNs
• Complexity of health care environment
• Increased workload due to acute nursing shortage
Goals• 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
Conceptual Framework on Transition
• Structure of transition• Content of transition• Characteristics of preceptors • Characteristics of the new nurse• Partnerships between the new nurse and
the preceptor• Institutional support for both the new
nurse and the preceptor
OutcomesPrimary Outcomes
• Clinical competency
• Practice errors and risks for practice breakdown
Secondary Outcomes
• Stress level
• Job turnover
Assessing OutcomesTwo perspectives:
– Perspective of the new RN– Perspective of his/her
preceptor/mentor
Outcome Measures• Clinical competence (35 items):
– Clinical reasoning and judgment
– Pt care delivery and management skills
– Communication and interpersonal relationships
– Recognizing limits and seeking help
• Practice errors and risks for practice breakdown
Design• Survey of nurse-preceptor dyad
Sample Profile – Demographics
New RNs Preceptors
N: RN 560 231
BSNs 32.8% 31.5%
ADNs 60.7% 49.7%
Age (yrs) 32.4 42.2
Female 94.4% 92.2%
White 81.2% 88%
Characteristics of the New RNs
• Hospital 86.4%
• Full time 91.2%
• English first language 92.6%
• Graduates of USA programs 99.0%
• With LPN experiences 19.9%
• Employed in urban area 47.3%
• Months of working experience 11.4
Characteristics of Preceptors
Experience in nursing
Experience in current position
>1 year experience on the unit
As preceptor for this nurse
As a preceptor for any nurse
Standardized training
Took courses on their own
Recommended by supervisor
13.7 yrs
8.6 yrs
81%
3.6 months
3.9 yrs
49%
11%
74%
Workload of Preceptors
Client care assignment:
• Yes, regular load 45.8%
• Yes, reduced load 31.7%
• No 22.5%
Pre-Graduation Synthesis Experience
ADNs BSNs (n=335)
(n=181)Synthesis course required 33.8% 68.2%Length of the course (wks) 7.0 9.9
Transition Experience
%
No orientation or internship 2.0
Routine orientation only 24.3
Internship or plus 73.8
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
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
Preceptor Involvement
Hosp.Non-hosp.
%
80
70
60
50
40
30
Designated preceptor
for every shift
Primary preceptor as
signed
Shared assignments
w ith preceptor
Preceptor w orked the
same schedule
60
46
68
37
62
37
56
42
Content of Transition Programs
Non-Hosp.
25.4%
13.4%
61.2%
Both
Specialty know ledgeGeneral know ledge
Hospital
47.7%
8.1%
44.3%Both
Specialty know ledge
General know ledge
Days Before First Patient Care Assignment
HospNon-hosp
Me
an
da
ys b
efo
re 1
st a
ssig
nm
en
t
60.0
50.0
40.0
30.0
20.0
10.0
0.0
1st indep. assig.
1st dep. assig.
49.7
25.6
6.15.1
Patient Care Assignment
HospNon-hosp
Me
an
# o
f p
atie
nts
ass
ign
ed
50.0
40.0
30.0
20.0
10.0
0.0
1st indep. assig.
1st dep. assig.
4.1
23.2
2.8
16.2
Patient Care Assignment
HospNon-hosp
Me
an
# o
f p
ts in
ass
ign
me
nt
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Experienced
New
4.9
25.2
4.1
23.4
Clinical Competence: Overall
PreceptorNew RN
Me
an
of
clin
ica
l co
mp
ete
nce
35
ite
ms
(0-4
)
3.60
3.50
3.40
3.30
3.20
3.10
3.00
3.50
3.46
Clinical Competence: Subconcepts
Recog. limit
Comm
. & relation
Pt care deliv & Mana
Clin reasoning
Me
an
(sc
ale
0-4
)
3.60
3.50
3.40
3.30
3.20
3.10
3.20
3.44
3.52
3.27
Most Competent AreasAlmostAlways (%)
Administer medications accurately 92.3
Maintain safe & respectful environment 83.6
Accurately perform client assessment 80.2
Perform technical skills accurately 79.7
Do what is right for clients no matter what 73.4
Least Competent areasAlmost always %
Appropriately utilize research findings 32.7
Meet clients cultural needs 41.5
Strategically delegate and supervise others 41.7
Recognize when demands exceed capability 47.4
Manage time and workload effectively 49.1
Use info. technology to enhance care 49.3
Synthesize data from multiple sources 50.0
Clinical Competence During 1st YearOverall
9.1-12m6-9 m3.1-6m3m or less
Me
an
co
mp
ten
cy b
y p
rece
pto
rs (
tota
l sco
re)
3.60
3.58
3.56
3.54
3.52
3.50
3.48
3.46
3.44
3.42
3.40
New RNs Preceptors
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
Clinical Competence During 1st YearSubconcepts
9.1-12m6.1-9 m3.1-6m3m or less
Me
an
sco
re (
0-4
)
3.7
3.6
3.5
3.4
3.3
3.2
3.1
3.0
Clinical reasoning &
judgment
Pt care delivery &
management skills
Communication &
Interpersonal relati
Recognizing limit &
seeking help
Clinical Competence and Work Setting
9.1-12m6.1-9 m3.1-6m3m or less
Me
an
Clin
ica
l Co
mp
ete
nce
To
tal S
core
(0
-4)
3.50
3.40
3.30
3.20
3.10
3.00
2.90
Non-hosp
Hosp
3.44
3.39
3.33
3.37
3.16
3.26
3.01
3.29
Transition and Clinical Competence
During first 3 months of practice, those who had a primary preceptor performed at a higher competent levels (B=0.45), especially in the areas of communication and interpersonal relationships (B=.51), as well as recognizing limits and seeking help (B=.49).
Practice Errors Only
once %
More than once %
Total %
Medication errors 30.4 12.8 43.2
Client falls 22.8 12.1 34.9
Contribute to treatment delays 14.1 25.2 39.3
Charted on wrong client record 30.8 14.3 55.2
Missed physician/provider order 26.7 11.8 38.5
Misinterpreted physician/provider order
18.8 5.0 23.8
Error in performance of skills 18.0 10.2 28.2
Avoidable client death .4 .7 1.1
Client elopement 9.6 3.7 13.3
Practice Errors Index
PreceptorNew RN
Me
an
Err
or
Ind
ex
(0-2
).40
.30
.20
.10
.15
.32
Transition and Practice Errors
HospNon-hosp
Me
an
err
or
ind
ex
ba
sed
0-2
sca
le.5
.4
.3
.2
Specialty Knowledge
No
Yes
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.
New RN Turnover*
*Either changed position or plan to leave, 40.0%
Changed position since being licensed.
21.2%
Planning to leave current position within 6 months
23.0%
Transition and Turnover
Internship
YesNo
40.0%
30.0%
20.0%
10.0%
19.2
33.1
Perceived StressAlmost Never %
Some-times %
Often/Always %
Felt overwhelmed with pt care responsibilities
19.4 56.7 24.0
Fear of harming the pt due to inexperience
71.7 25.5 2.8
Felt expectations unrealistic
45.8 38.6 15.6
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
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
Transition and Stress• The longer the work experience the less the fear
experienced by graduates about harming the patients (B=-.11)
• Graduates who had an internship (B=-.11) were less likely to feel expectations were unrealistic
• Graduates who had a transition programs that addressed specialty knowledge (B=-.10) were less likely to feel expectations were unrealistic
Stress and Practice Errors Beta
Felt overwhelmed by care responsibilities
.158
Feared harming client due to inexperience
.208
Felt expectations unrealistic .137
Summary of Findings• Transition experiences of new RNs vary across
practice settings• New RNs are more competent in the areas of pt
care delivery and management, compared to the areas of clinical reasoning and judgment skills, as well as recognizing limits and seeking help
• During the first 3 months of practice, new RNs who had a primary preceptor practiced at higher competent levels
• Without the assistance of preceptors, new RNs practiced at less competent levels during their initial phase of independent practice
Summary of Findings• New RNs with preparation for specialty
practice in transition programs made less errors
• Less competent and/or stressed new RNs made more practice errors
• New RNs who had an internship experience were less likely to leave their current position within the next 6 months
AcknowledgementsAdvisory Group: 2006 & 2007 NCSBN PR&E Committee• Nancy Spector, NCSBN Director of Education• Gino Chisari (Chair, 2006)• Brenda S. Jackson (Chair, 2007)• Mary Blubough (Board Liaison)• Connie Brown• Barbara Knopp• Barbara Newman• Cynthia Van Wingerden• Debra Werner• Lepaine McHenry• Marcy Echternacht• Therese Shipps• Mary Calkins• Mary Doherty, NCSBN Practice, Regulation, & Education AssociateResearch Support• Data Collection: Lindsey Gross• Statistical Support: Richard Smiley
