3Mission of NCSBNThe National Council of State Boards of Nursing (NCSBN), composed of Member Boards, provides leadership to advance regulatory excellence for public protection.
4www.ncsbn.org Go to Programs and Services and then to Education Position paper on clinical experiencesWhite paper on PN scope of practiceEvidence-based nursing education for regulation (EBNER)Systematic review of nursing education outcomesWhite paper on state of art of approval
6Background of Transition Initiative Computerized NCLEX, making results available simultaneously2001 & 2003 NCSBN studies showing that fewer than 50% of employers perceived new nurses prepared to provide safe and effective careHealth care is more complex – Practice frenzyNursing shortageData showing transition programs protect the public
7Literature This is not new M. Kramer’s Reality Shock: Why Nurses Leave Nursing…1974!
8Literature (Cont’d) Benner’s work (over 20 years) Feedback & reflectionCoachingSupport to get to competent stage
9Literature (Cont’d) Santucci (2004) Employer’s Bill of Rights: Constructive FeedbackAdequate resourcesSafe and trusting environmentElements of transition programs:Areas of Growth from ExperienceRole integrationClinical and interpersonal skillsReshaping of values
10Literature (Cont’d) Beecroft, Kunzman & Krozek, (2001) Facilitate transition to a professional nursePrepare nurse to provide safe and competent careIncrease commitment and retention of new graduate
11Literature (Cont’d) Bjørk & Kirkevold, (1999) Longitudinal, videotaped study from 8-14 months after licensureInterviews of patients and nursesPracticing skills of dressing changes; ambulationHad short orientation of 3 weeks; no opportunities for reflection or feedback
12Literature (Cont’d) Bjørk & Kirkevold, (1999) (Cont’d) Same omissions and faults after 14 months of practiceContaminated woundsMisuse of glovesFailed to wash handsDangerous tube removalDecreased caringInadequate physical support during ambulationPrivacy not provided
13Literature (Cont’d) Studies on retention and satisfaction Altier & Krsek, 2006; Krugman et al., 2006Halfer, 2007Pine & Tart, 2007
14Literature (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)
15Literature (Cont’d) Design and length is variable Boyer, 2002 Kenward & Zhong, 2006
16Past NCSBN evidence-based recommendations (2002-03) Knowledge type – General knowledge + specialty knowledgePlacement – posthire transition programs had better outcomesConsistency – Work same schedule as preceptor- Drs. June Smith & Linda Crawford
17NCSBN Transition Study Kenward & Zhong (2006) 2004 dataN=628 RNsOrientation only – 27.1%Internship, externship, preceptorship, mentorship – 31%Both orientation and “ship” – 38.9%None – 3%
18NCSBN 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%
19LPNs versus RNs (Kenward & Zhong, 2006) LPNs assigned to care for patients earlier and caseload heavier38.9% of RNs participated in “ships” + orientation16.2% of LPNs participated in “ships” + orientationGraduates of ADN programs were more likely than BSN graduates not to have a “ship”
20NCSBN’s New Transition Research (2007) Dr. Suling Li
21Goals of Study Dr. Suling Li To describe the transition experience of newly licensed RNsTo identify factors that influence transitions into practiceTo examine the impact of the transition experience on clinical competence and safe practice issues of newly licensed RNs
22Measurement Instrument (Cont’d) Dr. Suling Li Primary OutcomesClinical competencyPractice errors and risks for practice breakdownSecondary OutcomesStress levelJob turnover
23New Nurse – Preceptor Dyad Dr. Suling Li Similar results – validationN=560 new RNsN=231 preceptors11.4 months in practice (new RNs)13.7 years in practice (preceptors)
24Results Dr. Suling Li No internship or orientation – 2% Routine orientation only – 24.3%Internship or plus – 73.8%
25Most Competent Areas Dr. Suling Li AlmostAlways (%)Administer medications accurately92.3Maintain safe & respectful environment83.6Accurately perform client assessment80.2Perform technical skills accurately79.7Do what is right for clients no matter what73.4
26Results (Cont’d) Least Competent Areas Almost always % Appropriately utilize research findings32.7Meet clients cultural needs41.5Strategically delegate and supervise41.7Recognize when demands exceed capability47.4Manage time and workload effectively49.1Use info. technology to enhance care49.3Synthesize data from multiple sources50.0
27Results (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.
28Results (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.
29Results (Cont’d) Dr. Suling Li Practice ErrorsMedication – 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%
30Results (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
31Perceived Stress During 1st Year Results (Cont’d)Perceived Stress During 1st Year
33Results (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).
35Summary of Transition 2007 Study Dr. Suling Li Transition experiences varyNew RNs competent in patient care; less competent in clinical reasoning and recognizing limitsPracticed at higher competent level in first 3 months when they had a preceptorPracticed at less competent level in 3-6 months when independently practicingPrepared with specialty practice in transition programs, made fewer errorsLess competent or more stressed, made more practice errorsTransition programs improve retention
362007 Transition Forum February 22, 2007 41 states, 5 countries, 200 participantsDiscuss vision of transitioning new graduates from broad perspectiveExamine national and international perspectives of transitioning new nursesSeek input from stakeholders and participants about effective transition models
37Speakers – Transition Forum Dr. David Leach, ACGME “Transition to Practice: A Journey to Authenticity”Cathy Krsek – report of UHC/AACN yearlong residencyCarol Dobson – report of Scotland’s Flying Start ProgramSuling Li – NCSBN’s report linking transition programs to safetySusan Boyer and Patty Spurr – statewide initiatives
39Themes – Transition Forum Do the right thing for the right reasonsThe context of the workplace: Frenzy!A national, standardized transition program is desiredThe transition program should last 6 months to 1 yearPreceptors need to be acknowledged and educatedArticulate the evidence to the practice arenaCollaborate extensively for buy-in
40Evidence at the Transition Forum Krsek: on UHC/AACN 1-year program – stress decreased – leveled out in 1 yearKrsek: control over practice and satisfaction started high, plunged to 6 mos., and then rose from 6 mos. to 1 yearKrsek: Organization and prioritizing & communication and leadership gradually rose2 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
41Vision Transition program of 6-12 months Standardized National Collaboration of practice, education, regulation
42Creating Consensus Practice (cost benefit) AHA Joint Commission Centers for Medicaid and Medicare Services
43Premises of ModelFailure 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.
45NCSBN Board of Directors has charged our Practice, Regulation and Education Committee with studying the feasibility of a national, standardized transition model.
46Literature Supported Framework Structure, including type, duration, setting, preceptor involvementContent, including theoretical, clinical experiences, and learning lab/simulationCharacteristics/qualifications of preceptors
47Framework (Cont’d) Expectations (QSEN competencies) Development of new nurse/preceptor partnershipInstitutional support of new nurse/preceptor
48Some Thoughts National Web site Flexible Robust: include all settings and all levels of educationPreceptor educationHow do we gain consensus?
49Thoughts (Cont’d) Relate to license? Pilot study of states Program developed collaboratively with practice, education and regulationNew nurse will work under supervisionUse QSEN competencies