Transitioning New Nurses to Practice: The Importance of Collaboration

Nancy Spector, PhD, RN, Director of Education

The National Council of State Boards

of Nursing (NCSBN), composed of

Member Boards, provides leadership

to advance regulatory excellence for

public protection.

Mission of NCSBN

www.ncsbn.org

Go to Programs and Services and then to Education• Position paper on clinical experiences• White paper on PN scope of practice• Evidence-based nursing education for regulation

(EBNER)• Systematic review of nursing education outcomes• White paper on state of art of approval

Transition of New Graduates to Practice

• Computerized NCLEX, making results available simultaneously

• 2001 & 2003 NCSBN studies showing that fewer than 50% of employers perceived new nurses prepared to provide safe and effective care

• Health care is more complex – Practice frenzy

• Nursing shortage• Data showing transition

programs protect the public

Background of Transition Initiative

• This is not new

• M. Kramer’s Reality Shock: Why Nurses Leave Nursing…1974!

Literature

• Benner’s work (over 20 years)

– Feedback & reflection

– Coaching

– Support to get to competent stage

Literature (Cont’d)

• Santucci (2004)Employer’s Bill of Rights:

– Constructive Feedback

– Adequate resources

– Safe and trusting environment

– Elements of transition programs:

Areas of Growth from Experience– Role integration

– Clinical and interpersonal skills

– Reshaping of values

Literature (Cont’d)

• Beecroft, Kunzman & Krozek, (2001)– Facilitate transition to a professional nurse

– Prepare nurse to provide safe and competent care

– Increase commitment and retention of new graduate

Literature (Cont’d)

• Bjørk & Kirkevold, (1999)

– Longitudinal, videotaped study from 8-14 months after licensure

– Interviews of patients and nurses

– Practicing skills of dressing changes; ambulation

– Had short orientation of 3 weeks; no opportunities for reflection or feedback

Literature (Cont’d)

• Bjørk & Kirkevold, (1999) (Cont’d)

– Same omissions and faults after 14 months of practice• Contaminated wounds

• Misuse of gloves

• Failed to wash hands

• Dangerous tube removal

• Decreased caring

• Inadequate physical support during ambulation

• Privacy not provided

Literature (Cont’d)

• Studies on retention and satisfaction

– Altier & Krsek, 2006; Krugman et al., 2006

– Halfer, 2007

– Pine & Tart, 2007

Literature (Cont’d)

• Studies on cost benefit

– Pine & Tart, 2007 – cost savings of $823,680 (n=48)

– Halfer, 2007 – cost savings of $707,608 (n=17)

– Beecroft, Kunzman & Krozek, 2001 – cost savings of $543,131 (n=21)

Literature (Cont’d)

• Design and length is variable

– Boyer, 2002

– Kenward & Zhong, 2006

Literature (Cont’d)

• Knowledge type – General knowledge + specialty knowledge

• Placement – posthire transition programs had better outcomes

• Consistency – Work same schedule as preceptor

- Drs. June Smith & Linda Crawford

Past NCSBN evidence-based recommendations (2002-03)

• 2004 data• N=628 RNs • Orientation only – 27.1%• Internship, externship, preceptorship, mentorship –

31%• Both orientation and “ship” – 38.9%• None – 3%

NCSBN Transition Study Kenward & Zhong (2006)

• Specialty design – 38.8%• Designed to increase knowledge – 47.0%• Worked same schedule with preceptor – 48%• Shared assignment with preceptor – 47.8%• Assigned to preceptor for help – 50.2%• Participated after licensure – 27%• Participated after graduation – 36.8%

NCSBN Transition Study Kenward & Zhong, 2006

• LPNs assigned to care for patients earlier and caseload heavier

• 38.9% of RNs participated in “ships” + orientation• 16.2% of LPNs participated in “ships” + orientation• Graduates of ADN programs were more likely than

BSN graduates not to have a “ship”

LPNs versus RNs(Kenward & Zhong, 2006)

NCSBN’s New Transition Research (2007)Dr. Suling Li

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

Goals of StudyDr. Suling Li

Primary Outcomes

• Clinical competency

• Practice errors and risks for practice breakdown

Secondary Outcomes

• Stress level

• Job turnover

Measurement Instrument (Cont’d)Dr. Suling Li

• Similar results – validation

• N=560 new RNs

• N=231 preceptors

• 11.4 months in practice (new RNs)

• 13.7 years in practice (preceptors)

New Nurse – Preceptor Dyad Dr. Suling Li

• No internship or orientation – 2%

• Routine orientation only – 24.3%

• Internship or plus – 73.8%

ResultsDr. Suling Li

AlmostAlways (%)

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

Most Competent Areas Dr. Suling Li

Results (Cont’d) Least Competent Areas

Almost always %

Appropriately utilize research findings 32.7

Meet clients cultural needs 41.5

Strategically delegate and supervise 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

• Without preceptor, new RNs (3-6 months) practiced at LESS competent levels.

• This points to need for longer transition programs.

Results (Cont’d) Dr. Suling Li

Relationship to practice errors:

• More competent in clinical reasoning, significantly fewer errors.

• More competent in communication and interpersonal relationships, significantly fewer errors.

Results (Cont’d)Dr. Suling Li

• Practice Errors– Medication – 43.2%– Client falls – 34.9%– Treatment delays – 39.3%– Chart on wrong client record – 55.2%– Missed physician/provider order – 38.5%– Misinterpreted order – 23.8%– Error in performing skills – 28.2%– Avoidable death – 1.1%– Client elopement – 13.3%

Results (Cont’d)Dr. Suling Li

• Perceived Stress (almost always)– Felt overwhelmed with patient care responsibilities

– 24%– 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 (Cont’d)Dr. Suling Li

Results (Cont’d) 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

Joint Commission Validation

• Internship programs were significantly less likely to feel expectations were unrealistic (and therefore fewer practice errors).

• Transition programs that addressed specialty knowledge, nurses were significantly less likely to feel expectations were unrealistic (and therefore fewer practice errors).

Results (Cont’d)Dr. Suling Li

Results: Transition and Turnover Dr. Suling Li

Internship

YesNo

40.0%

30.0%

20.0%

10.0%

19.2

33.1

• Transition experiences vary• New RNs competent in patient care; less competent in clinical

reasoning and recognizing limits• Practiced at higher competent level in first 3 months when they

had a preceptor• Practiced at less competent level in 3-6 months when

independently practicing• Prepared with specialty practice in transition programs, made

fewer errors• Less competent or more stressed, made more practice errors• Transition programs improve retention

Summary of Transition 2007 StudyDr. Suling Li

• February 22, 2007• 41 states, 5 countries, 200 participants• 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

2007 Transition Forum

• Dr. David Leach, ACGME “Transition to Practice: A Journey to Authenticity”

• Cathy Krsek – report of UHC/AACN yearlong residency

• Carol Dobson – report of Scotland’s Flying Start Program

• Suling Li – NCSBN’s report linking transition programs to safety

• Susan Boyer and Patty Spurr – statewide initiatives

Speakers – Transition Forum

• AACN

• ANA

• AONE

• NAPNES

• NLN

Panel – Transition Forum

• Do the right thing for the right reasons• The context of the workplace: Frenzy!• A national, standardized transition program is desired• The transition program should last 6 months to 1 year• Preceptors need to be acknowledged and educated• Articulate the evidence to the practice arena• Collaborate extensively for buy-in

Themes – Transition Forum

• Krsek: on UHC/AACN 1-year program – stress decreased – leveled out in 1 year

• Krsek: control over practice and satisfaction started high, plunged to 6 mos., and then rose from 6 mos. to 1 year

• Krsek: Organization and prioritizing & communication and leadership gradually rose

• 2 studies (NCSBN’s and UHC/AACN’s), different sample, different tools, different goals…yet findings consistent: Validating!

• NCSBN’s first study to link practice errors to lack of transition

Evidence at the Transition Forum

• Transition program of 6-12 months

• Standardized

• National

• Collaboration of practice, education, regulation

Vision

• Practice (cost benefit)

• AHA

• Joint Commission

• Centers for Medicaid and Medicare Services

Creating Consensus

• Failure to transition new nurses is a public safety issue.• Transition is facilitated by active engagement of new

nurse to preceptor.• Transition programs will improve practice and decrease

errors.• A standardized, national transition program will benefit

the profession.• A standardized, national transition program will

increase nurse retention.

Premises of Model

Next Steps

NCSBN Board of Directors has charged our Practice, Regulation and Education Committee with studying the feasibility of a national, standardized transition model.

2007-2008

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

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

• Characteristics/qualifications of preceptors

Literature Supported Framework

• Expectations (QSEN competencies)

• Development of new nurse/preceptor partnership

• Institutional support of new nurse/preceptor

Framework (Cont’d)

• National Web site

• Flexible

• Robust: include all settings and all levels of education

• Preceptor education

• How do we gain consensus?

Some Thoughts

• Relate to license?

• Pilot study of states

• Program developed collaboratively with practice, education and regulation

• New nurse will work under supervision

• Use QSEN competencies

Thoughts (Cont’d)

Questions ?