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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 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

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 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

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

8 Benners work (over 20 years) –Feedback & reflection –Coaching –Support to get to competent stage Literature (Contd)

9 Santucci (2004) Employers 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 (Contd)

10 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 (Contd)

11 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 (Contd)

12 Bjørk & Kirkevold, (1999) (Contd) –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 (Contd)

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

14 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 (Contd)

15 Design and length is variable –Boyer, 2002 –Kenward & Zhong, 2006 Literature (Contd)

16 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 ( )

17 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)

18 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

19 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)

20 NCSBNs New Transition Research (2007) Dr. Suling Li

21 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 Study Dr. Suling Li

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

23 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

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

25 Almost Always (%) Administer medications accurately92.3 Maintain safe & respectful environment83.6 Accurately perform client assessment80.2 Perform technical skills accurately79.7 Do what is right for clients no matter what73.4 Most Competent Areas Dr. Suling Li

26 Results (Contd) Least Competent Areas Almost always % Appropriately utilize research findings32.7 Meet clients cultural needs41.5 Strategically delegate and supervise41.7 Recognize when demands exceed capability47.4 Manage time and workload effectively49.1 Use info. technology to enhance care49.3 Synthesize data from multiple sources50.0

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

28 Relationship to practice errors: More competent in clinical reasoning, significantly fewer errors. More competent in communication and interpersonal relationships, significantly fewer errors. Results (Contd) Dr. Suling Li

29 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 (Contd) Dr. Suling Li

30 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 (Contd) Dr. Suling Li

31 Results (Contd) Perceived Stress During 1 st Year

32 Joint Commission Validation

33 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 (Contd) Dr. Suling Li

34 Results: Transition and Turnover Dr. Suling Li

35 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 Study Dr. Suling Li

36 February 22, 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

37 Dr. David Leach, ACGME Transition to Practice: A Journey to Authenticity Cathy Krsek – report of UHC/AACN yearlong residency Carol Dobson – report of Scotlands Flying Start Program Suling Li – NCSBNs report linking transition programs to safety Susan Boyer and Patty Spurr – statewide initiatives Speakers – Transition Forum

38 AACN ANA AONE NAPNES NLN Panel – Transition Forum

39 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

40 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 (NCSBNs and UHC/AACNs), different sample, different tools, different goals…yet findings consistent: Validating! NCSBNs first study to link practice errors to lack of transition Evidence at the Transition Forum

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

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

43 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

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

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

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

49 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 (Contd)

50 Questions ?

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