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Transitioning New Nurses to Practice: The Importance of Collaboration Nancy Spector, PhD, RN, Director of Education

Transitioning New Nurses to Practice: The Importance of Collaboration Nancy Spector, PhD, RN, Director of Education. 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.

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Transitioning New Nurses to Practice: The Importance of Collaboration Nancy Spector, PhD, RN, Director of Education

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  1. Transitioning New Nurses to Practice: The Importance of CollaborationNancy Spector, PhD, RN, Director of Education

  2. 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.

  3. 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

  4. Transition of New Graduates to Practice

  5. 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

  6. Literature • This is not new • M. Kramer’s Reality Shock: Why Nurses Leave Nursing…1974!

  7. Literature (Cont’d) • Benner’s work (over 20 years) • Feedback & reflection • Coaching • Support to get to competent stage

  8. 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

  9. 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

  10. 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

  11. 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

  12. Literature (Cont’d) • Studies on retention and satisfaction • Altier & Krsek, 2006; Krugman et al., 2006 • Halfer, 2007 • Pine & Tart, 2007

  13. 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)

  14. Literature (Cont’d) • Design and length is variable • Boyer, 2002 • Kenward & Zhong, 2006

  15. 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

  16. 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%

  17. NCSBN Transition StudyKenward & 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%

  18. 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”

  19. NCSBN’s New Transition Research (2007)Dr. Suling Li

  20. Goals of StudyDr. 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

  21. Measurement Instrument (Cont’d)Dr. Suling Li Primary Outcomes • Clinical competency • Practice errors and risks for practice breakdown Secondary Outcomes • Stress level • Job turnover

  22. 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)

  23. ResultsDr. Suling Li • No internship or orientation – 2% • Routine orientation only – 24.3% • Internship or plus – 73.8%

  24. Most Competent AreasDr. Suling Li

  25. Results (Cont’d) Least Competent Areas

  26. 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.

  27. 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.

  28. 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%

  29. 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

  30. Results (Cont’d) Perceived Stress During 1st Year

  31. Joint Commission Validation

  32. 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).

  33. Results: Transition and Turnover Dr. Suling Li

  34. Summary of Transition 2007 StudyDr. 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

  35. 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

  36. 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

  37. Panel – Transition Forum • AACN • ANA • AONE • NAPNES • NLN

  38. 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

  39. 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

  40. Vision • Transition program of 6-12 months • Standardized • National • Collaboration of practice, education, regulation

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

  42. 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.

  43. Next Steps

  44. 2007-2008 • NCSBN Board of Directors has charged our Practice, Regulation and Education Committee with studying the feasibility of a national, standardized transition model.

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

  46. Framework (Cont’d) • Expectations (QSEN competencies) • Development of new nurse/preceptor partnership • Institutional support of new nurse/preceptor

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

  48. 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

  49. Questions ?

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