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. 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

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
AACN
ANA
AONE
NAPNES
NLN

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 ?