Transitions: Pathways for Nurse Entry to Practice

Transitions: Pathways for Nurse Entry to Practice October, 2015 Developed by the Ohio Action Coalition Transition to Practice Work Group 1

Table of Contents I. Introduction Page 1 II. Why worry about transition to practice? Page 4 A. Concern for quality and safety Page 4 B. Cost of turnover Page 5 C. Need to acquire skills Page 5 IV. The process Page 6 A. Results Page 7 B. Framework for practice Page 8 VII. Strategies for implementation Page 9 A. Key Components Page 9 B. Implementation Page 11 VIII. Conclusion and next steps Page 11 Tables and Figures: I. OAC TTP questionnaire results Page 6 II. NCSBN model Page 8 III. Ohio s Nurse Competency Model Page 9 IV. Key Components Page 9 2

Introduction This toolkit was developed to assist educators and those in practice environments in developing programs for transitioning the new nurse from academe into practice. A recommendation for action in the Institute of Medicine Report (IOM, 2011) Future of Nursing: Leading Change, Advancing Health is to develop nurse residency programs (NRPs) as a method for transition to practice (TTP). The Commission on Collegiate Nursing Education (CCNE, 2008, p.4) states that NRPs support nurse residents to do the following: 1. Transition from entry-level, advanced beginner nurse to competent professional nurse who provides safe, quality care; 2. Develop effective decision-making skills related to clinical judgment and performance; 3. Develop strategies to incorporate research-based and other evidence into practice; 4. Develop clinical leadership skills at the point of patient care; AND 5. Formulate an individual career plan that promotes a life-long commitment to the profession of nursing. The need for effective TTP programs is of particular urgency, given the available evidence related to the supply of nurses projected for the next 20 years. Recent information suggests that registered nurse (RN) shortages are projected to grow until 2030 (Juraschek, Zhang, Ranganathan, & Lin, 2012). Many factors affect these projections including an aging nursing workforce, health care reform, and influences of economic trends. With an increased need, and a decreased supply due to retirements, it is extremely important that new nurses are effectively transitioned and retained in the workforce. Throughout the process, an eye to partnering education and practice is important during the education and transition of the RN into professional practice. The purpose of this tool kit is to provide background information and resources for agencies to develop effective TTP programs in a variety of health care settings. The Ohio Nurse Competency Model provides a framework for understanding and in identifying key knowledge, skills, and attitudes necessary for safe and effective nursing practice. Additional resources are available through the National Council of State 3

Boards of Nursing (NCSBN) website. Why worry about transition to practice? Concern for quality and safety Quality and safety are of prime concern, particularly during the period when the nurse is transitioning from the academic to the work environment. Benner (2001) recognized that the newly licensed nurse, as an advanced beginner, has not yet fully developed the ability to think critically and is not yet prepared to reliably make clinical decisions. It has been reported that 25% of new graduates do not recognize clinical problems, nor are they able to safely prioritize care and implement independent nursing interventions (Fero, Witsberger, Wesmiller, Zullo & Hoffman, 2009). These inabilities have implications for both the new graduate and the experienced nurses providing mentorship and supervision. The process of on-boarding should occur without any gaps in the quality of the patient care delivered. The National Council of State Boards of Nursing (NCSBN) explored the problem of TTP as it relates to quality of patient care. Research completed at the time highlighted areas of concern for hospitals. According to their report, 40% of newly licensed nurses reported making medication errors. It was observed that 50% of new graduates would not recognize life-threatening complications in their patients. Since 2007, the NCSBN called for a national, standardized TTP model to mitigate this situation. NCSBN convened a committee to develop a TTP model, utilizing information from more than 35 nursing and health care organizations (Spector, et al., 2015b). The program was piloted in a mixed-methods study of newly licensed registered nurses hired from July through September 2011, in a multi-state area, including sites in Ohio. The study followed nurses throughout the first year of employment. Findings indicated that a formal, structured transition-to-practice program helped decrease errors and negative safety practices, increased confidence on the part of the new graduate, led to less workrelated stress, and indicated that participants in such a program were less likely to leave their position during the first year post-graduation (Spector, et al., 2015b). 4

Cost of turnover While some turnover is beneficial to an organization, higher rates of turnover can be costly to an organization. In one study, the estimated cost of replacing one RN was estimated at $70,200 (Fiedler, Read, Lane, Hicks, & Jegier, 2014). The nurse turnover in long-term care is estimated at nearly 65% in some studies (Spector, et al. 2015a). The financial burden to recruit and train replacements is staggering. The cost of turnover, combined with the expectation of an increasing gap between supply and demand for nurses in long-term care settings, underscores the urgency for the development of TTP programs in areas outside of acute care. The U.S. has an aging population, with about 70% requiring some type of long-term care during their lifetime (Hodgin, Chandra, & Weaver, 2010). Ultimately, a low supply of nurses negatively impacts the quality of care for residents, often resulting in higher use of restraints and catheters, increases in error, and a disruption in continuity of care (Chu, Wodchis, & McGilton, 2014). Need to acquire skills Since it is difficult to perfect skills when making frequent clinical rotations, the recommendation is that advanced beginners be limited in the range of patient conditions in which they work. This practice allows new nurses time to develop competency; indepth clinical knowledge is enhanced by keeping the advanced beginners in a situation where they can start to recognize patterns within a similar patient population (Benner, 2001). Frequent feedback is important for new nurses who have been used to receiving such constructive comments from instructors during their education. Positive feedback builds confidence. Providing feedback also gives the advanced beginner an opportunity to reflect on specific aspects of patient care that might be more challenging or confusing the new graduate can lean on the wisdom of the more experienced nurse if that senior nurse provides such feedback in a constructive, supportive environment (Oermann, Moffitt-Wolf, 1997; Laschinger, Grau, Finegan, & Wilk, 2010). To provide the supports needed for effective transition, Benner (2001) and many educators recommended a new-graduate residency program of at least one year. The program should include coursework, mentoring, and use of clinical narratives to help 5

nurses reflect on and learn from their experiences. Clinical narratives are similar to journaling about a clinical situation encountered with regard to how the nurse managed the situation and the subsequent outcomes. Such narratives are another opportunity for reflection, allowing the nurses to review and analyze the situation as well as share their experience with others. The Process The Ohio Action Coalition Transition to Practice Task Group (OAC TTP) is comprised of representatives from practice and from education. From the outset, the group identified that the solutions to difficulties in regards to effective transition to practice will require a cooperative effort. The group attempted to contact representatives of health care agencies in acute care, long-term care, and in home health and public health settings across the state. Seven of 13 agencies responded, all but one of which were acute care providers. Question Response summary Do you have a transition to practice 5 yes; 2 no - traditional orientation program? program How long has the program been in place? 14 months to >8 years What model was used as a basis for the UCH/AACN-1; Literature/other-4; Inst. program? Needs-2 What is the length of the program? 3 mos. To 5 years Is there a mentor or preceptor? All used preceptor except one coaches Is there training provided to the All but 2 provided training for preceptors. preceptor/mentor? Does the program use simulation? All but 2 used hi-fidelity simulation; 1 used an arm for injections; the other agency said no sim was used Does the program use classes? All but one program used classes. Who participates in the program? New RNS: All New Hires: All 6

Does the program use any other innovative teaching strategies besides simulation? What measures of success do you use? Do you have a comparison of turnover rates? Have you seen a difference? Transfers: 4 stated transfers receive unitspecific orientation; others stated no program for transfers APRNs: One program stated APRNs received some sort of transition to practice program Case studies, Problem-based learning, QI experience, committee experience, FEMA training Four agencies stated they measured turnover rates, but did not share data. The other reporting agencies stated they had no measure of program success. OACTTP Questionnaire Results This information was compared to information in the literature and the results of the NCSBN study (Spector, et al. 2015a). The full NCSBN study can be located at NCSBN study. Results The results of our informal interviews reflected the results of the larger NCSBN study in many ways. The most striking result is that TTP programs outside of acute care are not generally available. There are likely a variety of reasons for this, but these remain unclear and are good issues to address in future research. Another point that was evident in the survey results is that larger acute care organizations already have well-organized TTP programs/nrps. However, this was not necessarily the case with smaller organizations. In talking with representatives of smaller organizations, cost was frequently cited as a reason for not having a clear TTP/NRP. A final important point identified in the survey is that while most facilities have TTP/NRP 7

programs for new graduates and new hires, relatively few reported having anything other than unit orientation for internal transfers, and only one agency reported having any kind of TTP program for new Advanced Practiced Nurses (APRNs). It is important to note that The Campaign for Action recommends that TTP programs include any nurse transitioning to a new role or specialty area. Framework for practice The NCSBN has developed a model for transition to practice: In addition to the model, the NCSBN has resources available for use in the development of a nurse residency program. These resources are available by clicking: Resources. Ohio s TTP recommendations are based upon the Ohio Nurse Competency Model, which was developed using both Quality and Safety Education in Nursing (QSEN) (Thornlow & McGuinn, 2010), and the Massachusetts Nurse of the Future (NOF) model. Knowledge, skills, and attitudes in each of the seven competency areas are further defined by the Ohio Action Coalition (2014). A TTP program in any setting must address these competencies to help ensure higher levels of quality of care. A detailed description of each of the competencies is provided here. 8

Ohio s Nurse Competency Model Strategies for Implementation Key Components Key components of a successful transition to practice program are threefold: 9

Mentor support Different from a preceptor, which focuses primarily on the skills needed to work day-today on the assigned unit, a mentor is a longer-term relationship with the aim of helping the new nurse adjust to the role of the RN. A mentor provides the new RN with support during the critical first year of transition. Even after the formal orientation program is completed, new nurses may benefit from having a mentor to whom they can turn for advice and guidance. Mentors can either be assigned through a formal process or may occur through informal relationships. In either case, administrative support for such a relationship is important. Such support includes offering potential mentors some sort of preparation on mentoring techniques. The most successful programs have mentor education as a key component (Wilson, Sanner, &McAllister, 2010). Additionally, mentors should be of the same peer or ethnic group whenever possible, as this provides an understanding of the challenges facing the new nurse, especially for nurses from minority groups (Banister, Bowen- Brady, and Winfrey, 2014). Ongoing education Ongoing education to the specific clinical area is important through the transition process. Didactic content designed to build upon preparatory education allows the new nurse to think through potential clinical situations and apply information to case studies before encountering them in the clinical area (Garity, 2009; Gibbs, Trotta, & Overbeck, 2014). Content can be offered in face-to-face sessions or in an online format. While both methods have benefits, the online format does offer an added benefit of time flexibility, an important consideration of most nursing schedules. Clinical Experience While experience with actual patients is valuable, simulation is also useful in TTP. Simulation, combined with clinical experience during the TTP process allows new nurses to make links between information learned in the classroom to practice without the risks associated with caring for an actual patient. Simulation also provides experience for situations that are low-frequency and high risk, such as cardiac arrest. 10

Implementation It is recognized that there is still a gap in availability of transition to practice programs, especially in non-acute care settings. Smaller acute care facilities, community-based organizations, and long-term care facilities may lack the resources to provide all of the components of an effective transition to practice program alone. However, there are resources available to agencies looking to develop a TTP program. NCSBN Resources In order to support TTP programs in all areas of practice, the NCSBN offers an on-line group of Modules. Also included are preceptor training modules. American Association of Colleges of Nursing Resources (AACN) Another source of information for the development of an effective TTP program is the AACN. With the University of Wisconsin Health System, the AACN developed an effective nurse residency program. Resources for this program can be access via this link: AACN Ohio Resources Many larger health care agencies offer nurse residency programs to RNs. The following link offers information to some central and southern Ohio nurse residency programs: Ohio NRP Other Partnerships Academic-practice partnerships also offer possible solutions to the transition to practice barriers. Such partnerships can offer support for organizations with limited resources by offering innovative, mutually beneficial opportunities to support both pre-licensure education and transition to practice initiatives. Lists of educational programs in the State can be found at OLN. Conclusion and Next Steps More support is needed for TTP in all areas, but especially in areas outside of acute care settings and in smaller organizations. These settings face special challenges in regards to staffing, resources, and care settings that make TTP particularly perplexing. It is recognized that one model may not meet the needs of all practice settings. However, development of programs based upon the seven key components of the Ohio Model is key to ensuring a safe, knowledgeable nursing workforce. The key 11

components of mentor support, ongoing education, and clinical experience can be used in a variety of settings and can be adapted to the environment of care. There is opportunity for education and practice to partner in order to support the transition of nurses to new work environments and roles. The next step is to begin dialogue between education and practice in order to create transition programs for nurses at all levels and in all practice environments that meet the recommendations outlined in The Future of Nursing (IOM, 2011) report. It is through these partnerships that nursing can ensure a well-prepared, safe, and effective workforce to meet the demands of the changing health care landscape. 12

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