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Transitioning New Nurses to Practice: The Importance of Collaboration
Nancy Spector, PhD, RN, Director of Education
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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
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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
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Transition of New Graduates to Practice
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• 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
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• This is not new
• M. Kramer’s Reality Shock: Why Nurses Leave Nursing…1974!
Literature
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• Benner’s work (over 20 years)
– Feedback & reflection
– Coaching
– Support to get to competent stage
Literature (Cont’d)
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• 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)
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• 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)
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• 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)
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• 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)
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• Studies on retention and satisfaction
– Altier & Krsek, 2006; Krugman et al., 2006
– Halfer, 2007
– Pine & Tart, 2007
Literature (Cont’d)
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• 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)
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• Design and length is variable
– Boyer, 2002
– Kenward & Zhong, 2006
Literature (Cont’d)
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• 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)
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• 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)
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• 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
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• 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)
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NCSBN’s New Transition Research (2007)Dr. Suling Li
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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
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Primary Outcomes
• Clinical competency
• Practice errors and risks for practice breakdown
Secondary Outcomes
• Stress level
• Job turnover
Measurement Instrument (Cont’d)Dr. Suling Li
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• 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
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• No internship or orientation – 2%
• Routine orientation only – 24.3%
• Internship or plus – 73.8%
ResultsDr. Suling Li
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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
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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
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• 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
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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
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• 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
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• 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
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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
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Joint Commission Validation
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• 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
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Results: Transition and Turnover Dr. Suling Li
Internship
YesNo
40.0%
30.0%
20.0%
10.0%
19.2
33.1
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• 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
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• 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
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• 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
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• AACN
• ANA
• AONE
• NAPNES
• NLN
Panel – Transition Forum
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• 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
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• 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
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• Transition program of 6-12 months
• Standardized
• National
• Collaboration of practice, education, regulation
Vision
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• Practice (cost benefit)
• AHA
• Joint Commission
• Centers for Medicaid and Medicare Services
Creating Consensus
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• 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
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Next Steps
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NCSBN Board of Directors has charged our Practice, Regulation and Education Committee with studying the feasibility of a national, standardized transition model.
2007-2008
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• Structure, including type, duration, setting, preceptor involvement
• Content, including theoretical, clinical experiences, and learning lab/simulation
• Characteristics/qualifications of preceptors
Literature Supported Framework
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• Expectations (QSEN competencies)
• Development of new nurse/preceptor partnership
• Institutional support of new nurse/preceptor
Framework (Cont’d)
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• National Web site
• Flexible
• Robust: include all settings and all levels of education
• Preceptor education
• How do we gain consensus?
Some Thoughts
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• 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)
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Questions ?