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Transitioning New Nurses to Practice: The Importance of Collaboration Nancy Spector, PhD, RN, Director of Education.

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Presentation on theme: "Transitioning New Nurses to Practice: The Importance of Collaboration Nancy Spector, PhD, RN, Director of Education."— Presentation transcript:

1 Transitioning New Nurses to Practice: The Importance of Collaboration Nancy Spector, PhD, RN, Director of Education


3 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.

4 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

5 Transition of New Graduates to Practice

6 Background of Transition Initiative
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

7 Literature This is not new
M. Kramer’s Reality Shock: Why Nurses Leave Nursing…1974!

8 Literature (Cont’d) Benner’s work (over 20 years)
Feedback & reflection Coaching Support to get to competent stage

9 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

10 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

11 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

12 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

13 Literature (Cont’d) Studies on retention and satisfaction
Altier & Krsek, 2006; Krugman et al., 2006 Halfer, 2007 Pine & Tart, 2007

14 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)

15 Literature (Cont’d) Design and length is variable Boyer, 2002
Kenward & Zhong, 2006

16 Past NCSBN evidence-based recommendations (2002-03)
Knowledge type – General knowledge + specialty knowledge Placement – posthire transition programs had better outcomes Consistency – Work same schedule as preceptor - Drs. June Smith & Linda Crawford

17 NCSBN Transition Study Kenward & Zhong (2006)
2004 data N=628 RNs Orientation only – 27.1% Internship, externship, preceptorship, mentorship – 31% Both orientation and “ship” – 38.9% None – 3%

18 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%

19 LPNs versus RNs (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”

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

21 Goals of Study 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

22 Measurement Instrument (Cont’d) Dr. Suling Li
Primary Outcomes Clinical competency Practice errors and risks for practice breakdown Secondary Outcomes Stress level Job turnover

23 New Nurse – Preceptor Dyad 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)

24 Results Dr. Suling Li No internship or orientation – 2%
Routine orientation only – 24.3% Internship or plus – 73.8%

25 Most Competent Areas Dr. Suling Li
Almost Always (%) 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

26 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

27 Results (Cont’d) Dr. Suling Li
Without preceptor, new RNs (3-6 months) practiced at LESS competent levels. This points to need for longer transition programs.

28 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.

29 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%

30 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

31 Perceived Stress During 1st Year
Results (Cont’d) Perceived Stress During 1st Year

32 Joint Commission Validation

33 Results (Cont’d) Dr. Suling Li
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).

34 Results: Transition and Turnover Dr. Suling Li

35 Summary of Transition 2007 Study Dr. Suling Li
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

36 2007 Transition Forum 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

37 Speakers – 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

38 Panel – Transition Forum

39 Themes – 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

40 Evidence at the 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

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

42 Creating Consensus Practice (cost benefit) AHA Joint Commission
Centers for Medicaid and Medicare Services

43 Premises of Model 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.

44 Next Steps

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

46 Literature Supported Framework
Structure, including type, duration, setting, preceptor involvement Content, including theoretical, clinical experiences, and learning lab/simulation Characteristics/qualifications of preceptors

47 Framework (Cont’d) Expectations (QSEN competencies)
Development of new nurse/preceptor partnership Institutional support of new nurse/preceptor

48 Some Thoughts National Web site Flexible
Robust: include all settings and all levels of education Preceptor education How do we gain consensus?

49 Thoughts (Cont’d) Relate to license? Pilot study of states
Program developed collaboratively with practice, education and regulation New nurse will work under supervision Use QSEN competencies

50 Questions ?

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