Adaptation of a Transition to Practice

Program for New Graduates in Acute and

Long-term Care Facilities in Urban and Rural

Nebraska

Project Director: Peggy Hawkins, RN, PhDpeggyhawkins1@creighton.edu

Sheila.Exstrom@nebraska.gov

Statistics: June Smith, RN, PhD

Grant from Center for Regulatory Excellence to study educational needs of RNs and LPNs in rural and urban Nebraska including both long-term care and acute care facilities.

Project launch Spring 2010 Conclusion Spring 2012

Background

Phase One: ◦ Determine educational needs

Phase Two: ◦ Quasi-experimental study of new graduates◦ Purpose to determine whether educational

modules and preceptor development made a difference in new graduate transition to practice

Phase Three: ◦ Analysis of data

Three Phases to Project

Representatives from the 5 nursing organizations

Nebraska Board of Nursing Nebraska Assembly of Deans and Directors Licensed Practical Nursing Association of Nebraska Nebraska Organization of Nurse Leaders Nebraska Nurses Association

Task Force as Oversight

Baseline data: 2009 new nursing graduates by mailed questionnaires plus interviews and expert panel Delphi study

Determined which modules to develop for the educational intervention

Phase One Activities

Do new nursing graduates who have online educational modules and preceptors who attended a preceptor development program have greater satisfaction, higher confidence, and less errors than new graduates who have regular orientation programs?

Secondary question was to estimate costs.

Phase Two: Primary Research Question

Control ◦ Surveys

Managers Preceptors New nursing graduates

◦ Observational studies Interventions introduced

◦ Educational Modules◦ 8 Preceptor programs (n = 239 at 22 facilities)

Treatment ◦ Surveys

Managers, Preceptors New grads

◦ Observational studies

Phase Two

Control Group Treatment Group

New GraduateInterimConclusion

9740

6045

PreceptorsInterimConclusion

11881

5657

Managers 30 29

Results - Sample

Significant Items <.05 Control Treatment

New Graduate: % Satisfied• Assigned classes• Length of transition

83%85%

96%97%

New Graduate: % Prepared• Make patient care decisions 76% 93%

Preceptor perception: % of new grads prepared• Delegate Tasks• Make patient care decisions• Administer meds to large groups• Provide care to 6 or more

35%43%54%25%

46%75%77%

*17%

Results – Perceptions about New Grads

Preparedness Items <.05 Control Treatment Felt prepared to precept 68% 81%Develop coaching plans 47% 58%Develop new grad critical thinking 54% 78%Understand learning styles 55% 78%Evaluate new grad competence 59% 81%Utilize variety of teaching strategies

56% 65%

Assuring new grad gave safe care 86% 92%

Results – Preceptors Preparedness

Items <.05 Control TreatmentDevelopment of critical thinking in new grads

83% 93%

Resolution of issues/conflicts 92% *80%Acting as a role model for my facility 100% *98%Evaluating the competency of new graduates

81% 92%

Planning meaningful experiences for new graduates each work day

78% 92%

Results – Satisfaction of Preceptors

Items <.05 Control TreatmentSatisfied with new grads 88% 96%

Manager satisfaction with self 60% 100%

Results – Manager Satisfaction

Percentages of Control Group Rating New Grads ‘Prepared’ or ‘Very Prepared’

Administer Medications by Common Routes

Administer Medications to Large Groups*

Make Patient Care Decisions *

Perform Psychomotor Skills

Provide Direct Care for 2 to 5 Clients*

Provide Direct Care for 6 or More Clients*

Supervise Care Provided by Others*

Delegate Tasks*

Know When and How to Call a Physician*

Document a Legally Defensible Record of Care Provided*

Teach Clients*

Work Effectively within a Health Care Team*

Manage and Organize Own Time*

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

*Statistically Significant at P < .02

New Grad Manager Preceptor

Percentage of Treatment Groups Rating New Graduates as ‘Prepared’ or ‘Very Prepared’

Administer Medications by Common Routes

Administer Medications to Large Groups*

Make Patient Care Decisions *

Perform Psychomotor Skills

Provide Direct Care for 2 to 5 Clients*

Provide Direct Care for 6 or More Clients

Supervise Care Provided by Others*

Delegate Tasks*

Know When and How to Call a Physician*

Document a Legally Defensible Record of Care Provided*

Teach Clients

Work Effectively within a Health Care Team*

Manage and Organize Own Time*

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

*Statistically Significant at p < 0.02

New Grad Manager Preceptor

Control TreatmentNew Graduates n=47 n=45 Number and % of new graduates reporting errors 32 (68%) 29 (64%) Total errors reported by new grads 97 88

Preceptors n=84 n=66 Number and % of preceptors reporting new grad errors 51 (61%) 34 (52%) Total errors reported by preceptors 258 120

Managers n=30 n=29 Number and % of managers reporting new grad errors 19 (63%) 17 (59%) Total errors reported by managers 206 144

Results - Errors

Control TreatmentEstimated cost per manager $1128 $634Estimated cost per preceptor $5900 *$3932

Estimated total cost: $7028 $4566

Results – Costs *does not include preceptor

conference fee

Control Group Treatment Group New Graduate

RuralUrban

4856

2733

PreceptorsRural

Urban5464

3438

ManagersRural

Urban1811

919

Rural Urban Comparison: Sample

Item Control Treatment

Preparation documenting care Urban Rural

72.7%81.3%

77.8%*30%

Preparation of preceptors (major/minor issue) Urban Rural

45.6%*93.4%

58.9%55.5%

Satisfaction with transition program Urban Rural

90%*40%

100%100%

Client falls Urban Rural

*80% 40%

57.1%25.0%

Treatment delays Urban Rural

77.8%*26.7%

46.2%37.5%

Costs estimate per new grad Urban Rural

$417.65*$1754.6

$546.59$799.92

Comparison of Control and Treatment Manager Groups by Location: Items with Significance

Item Control Treatment

Yes, enough time in transition Urban Rural

71.7%*93.5%

93.9%88.5%

Yes, each day unofficial preceptor Urban Rural

7.3%*27.7%

9.7%0%

Yes, courses improved general nursing knowledge in program Urban Rural

87.0%*68.9%

87.9%80.0%

Yes, courses improved specialty nursing knowledge in program Urban Rural

76.9%61.9%

87.9%*60.0%

Dissatisfaction with length of time Urban Rural

20.0%*6.5%

3.0%3.8%

Comparison of Control and Treatment New Graduate Groups by Location: Items with Significance

Item Control Treatment

Very satisfied with preceptor classes Urban Rural

31.3%*8.1%

33.3%19.0%

Very satisfied with ability to assist new grad decision making Urban Rural

54.7%*34.0%

54.5%43.5%

Very satisfied with developing critical thinking in new grad Urban Rural

31.5%*10.0 %

48.5%20.8%

Very satisfied with collegial support Urban Rural

42.3%*17.8 %

40.6%*27.3 %

Comparison of Control and Treatment Preceptor Groups by Location: Items with Significance

Control (n = 7) Treatment (n = 10)

Category f Field Note Examples f Field Note Examples

Safety 52 Lack of proper identification (n=23)Lack of infection control (n=19)Improper hand hygiene (n=8)Hazards (n=2)

56 Lack of proper identification (n=16)Lack of infection control (n=22)Improper hand hygiene (n=10)Hazards (n=8)

Medications 16 Prep (n=12)Administration (n=4)

10 Prep (n=7)Administration (n=3)

Privacy 4 Enter without knocking (n=3)Patient information left out (n=1)

3 Patient information left out (n = 3)

Cares 4 Missed weight ac (n=1)Omitted bruise assessment (n=1)Improper technique BG (n=1)Did not know how to transfer (n=1)

4 Omitted assessment (n=2)Improper technique BG (n=2)

Communication 10 Failed to inform or report (n=10) 7 Fail to inform, report or chart timely manner (n=7)

Total 86M=12

80M=8

Observational Studies

New graduates ◦ Higher satisfaction◦ More Prepared◦ Fewer errors

Preceptors◦ More prepared to precept

Managers◦ Higher satisfaction

Costs estimates reduced

Findings

New graduates need mentoring Education assists in transition Modules and trained preceptors reduce

errors Internships in programs of study are valued

and positively impact transition Preceptors educated in role are essential Financial opportunities exist Rural and urban patients deserve an equal

opportunity to receive safe care

Implications

The likelihood to provide safe, timely, effective, efficient, equitable, and patient-centered care to Nebraska patients during new graduate transition to practice improves when focused, standardized, and evidence-based educational modules are available/mandated for new graduates, and new graduates are paired with a consistent, formally educated preceptor.

Implications

Lack of LPNs

Long-term care underrepresented

Limited generalization as pilot study

Limitations