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Transition to Practice: The North Carolina Initiative
Transition to Practice: The North Carolina Initiative Joyce Wolf Roth, MSN, RN, NE-BC, SWP, and Mary P. Johnson, MS, RN, FAAN Successful transition of newly licensed nurses into practice is essential for safe nursing practice. North Carolina has completed three phases of a transition-to-practice project. This article describes the results of Phase I, which studied the competence and confidence development of newly licensed registered nurses in acute-care hospitals. A key finding was a statistically significant relationship between the preceptor–new nurse relationship and the new nurses’ self-reported competence scores.
T
he first 6 months of practice for newly licensed nurses are stressful, but their successful transition into practice is essential for safe patient care. An estimated 33% to 69% of new nurses change positions within a year of graduating, and 57% leave their first job within 2 years (Beecroft, Kunzman, & Krocek, 2001; Ellertin & Gregor, 2003; Goode & Williams, 2004; Newhouse, Hoffman, Suflita, & Hairston, 2007). The stress new nurses experience results from adjusting to the workplace, developing competence and confidence, and making errors (Boychuck Duchscher, 2001; Oerman & Gavin, 2002). A recent study for the Advisory Board Company found that 90% of nurse faculty members, but only 10% of nurse executives, believe that new graduate nurses are prepared to provide safe, effective patient care (Berkow, Virkstis, Stewart, & Conway, 2008). Benner and colleagues found that “a significant gap exists between today’s nursing practice and the education for that practice, despite some considerable strengths in nursing education.” This study supports implementing nurse residencies for new nurses (Benner, Sutphen, Leonard, & Day, 2010). A planned transition that includes specific activities to develop competence and confidence, promote socialization into the profession and the workplace, and provide support to the new nurse will promote safe patient care and help address some retention issues. North Carolina has completed three phases of a multiphase project to develop an evidence-based, transition-to-practice model for all newly licensed nurses. Phase I focused on development of competence and confidence of newly licensed registered nurses (RNs) in acute-care hospitals in North Carolina and preceptor characteristics that contribute to that development. Phase II focused on identifying the best and most promising practices related to new-nurse transition and preceptor preparation, determining current practices related to each in North Carolina, and developing online preceptor preparation modules and simulation activities on the preceptor’s critical role of helping new nurses transition into practice. Phase III focused on testing and evaluating the strategies and tools developed in Phase II. This article reports the findings of Phase I. 56
Journal of Nursing Regulation
Driving Forces A number of factors prompted the decision to develop a formal transition-to-practice model for newly licensed nurses. ⦁⦁ The North Carolina Institute of Medicine Task Force on the North Carolina Nursing Workforce issued a report with a priority recommendation urging the state board of nursing (BON) to convene a group to study options for improving school-to-work transitions. The specific priority was to develop interventions that enhance the new nurse’s application of knowledge into clinical practice in a way that supports safe, effective care and the nurse’s growth and retention (North Carolina Institute of Medicine, 2004). ⦁⦁ The BON considered factors that affect the new nurse’s ability to provide safe, effective nursing care, including the increased complexity of the health care environment, increased acuity and complexity of patient needs, decreased lengths of stay, and a nursing shortage that is predicted to worsen. ⦁⦁ The existing gap between the educational experience and the work setting can adversely affect the provision of safe patient care. This gap can be diminished, but it cannot be eliminated. ⦁⦁ Computerized adaptive testing for the national licensing examination has decreased the time between graduation and licensure. Today, a person can obtain a nursing license just days after graduation. In the past, the time between obtaining examination results and obtaining a license was about 3 months. During that period, unlicensed graduates could gain competence and confidence under the direct supervision of an experienced licensed nurse. Along with today’s quick entry into practice, the variance among transition experiences from setting to setting creates the potential for new nurses to face situations beyond their knowledge and ability without the guidance of an experienced nurse. North Carolina currently has no legal requirement regarding orientation or workplace transition. Thus, new nurses depend on their employers to determine the extent and type of orientation and transition experiences.
⦁⦁
⦁⦁
High nursing turnover rates create an increased risk for patients and increased costs for employers. Estimates on the cost of hiring a new nurse range from $20,000 to $80,000, depending on the clinical practice area (Contino, 2002; Jones, 2008; Kosel & Olivo, 2002). The risk to patient safety and the financial and human costs are compounded when new nurses leave not only their employers but also the nursing profession. Effective January 2008, the BON requires that all generic nursing education programs in North Carolina include a patientfocused experience designed to begin the transition before the end of the curriculum (North Carolina Administrative Code 21 NCAC 36.0321 (e) (f)). This addresses the education side of the gap, but does not address the new nurse’s first employment experience.
Phase I Overview The Foundation for Nursing Excellence (FFNE), a nonprofit organization created in 2002 by the BON and now an independent organization, took the lead on the transition-to-practice project. The North Carolina Center for Nursing and the North Carolina Area Health Education Centers agreed to collaborate with the FFNE. The steering committee has representatives from the three collaborating groups, the BON, and practice and education arenas in North Carolina. A broader group of stakeholders, representing educators, employers, practitioners, trade associations, professional associations, and newly licensed nurses, serves as an advisory panel to the steering committee. A variety of studies and reports were reviewed to provide background information for the steering committee of this project. ⦁⦁ Literature addressing new-nurse transition (American Organization of Nurse Executives, 2000; Beecroft et al., 2001; Benner, 1984/2001; Blanzola, Linderman, & King, 2004; Clare & van Loon, 2003; Ellertin & Gregor, 2003; Hayes, 1990; Marcum & West, 2004; Messmer, Jones, & Taylor, 2004; Rosenfeld, Smith, Iervolino, & Bowar-Ferres, 2004) ⦁⦁ North Carolina transition models ⦁⦁ National and other state transition models—the Vermont Nurse Internship Project, the Kentucky Clinical Internship Regulation, and the American Association of Colleges of Nurses/ University Health System Consortium Residency Program ⦁⦁ International transition models—the Flying Start Program from Scotland and the New Graduate Initiative from Ontario, Canada In 2005, the three collaborating organizations sponsored an invitational research development conference supported by the Agency for Healthcare Research and Quality. Conference attendees reached consensus on core competencies for new nurses in the North Carolina transition-to-practice project. The core competencies were as follows: ⦁⦁ Perform accurate assessments. ⦁⦁ Communicate effectively. ⦁⦁ Recognize imminent threats. Volume 2/Issue 3 October 2011
Recognize limits of competence and ask for help. Evaluate patient response and modify intervention appropriately. ⦁⦁ Prioritize to provide care in a timely manner. ⦁⦁ Perform medication administration and patient education. ⦁⦁ Create a safe work environment. ⦁⦁ Use critical thinking to develop action plans. ⦁⦁ Collaborate to optimize outcomes. In 2006, BlueCross BlueShield Foundation of North Carolina awarded a 2-year grant to the FFNE for study on the role of transition programs in the development of new nurses. The goals of Phase I were to examine the perceived development of competence and confidence of new nurses in three types of orientation programs in North Carolina hospitals and to identify preceptor characteristics that aid the development of competence and confidence of new nurses. ⦁⦁ ⦁⦁
Research Questions
The four research questions were as follows: 1. What is the relationship between the preceptor-new nurse relationship and the development of competence among newly licensed RNs in North Carolina hospitals? 2. What is the relationship between the type of transition-topractice experience and practice errors among newly licensed RNs in North Carolina hospitals? 3. What is the relationship between the type of transition-topractice experience and the risk of practice breakdown among newly licensed RNs in North Carolina hospitals? 4. What is the relationship between preceptor characteristics and the development of competence among newly licensed RNs in North Carolina hospitals? Methodology
The longitudinal design used repeated measures at 2, 4, and 6 months of employment. The project director sent invitations to all newly licensed RNs, defined as those within the first 6 months of first employment as an RN, and their preceptors in 29 acute-care hospitals. Hospitals were selected to represent various sizes, geographic locations in the state, and urban/suburban/rural settings. Participation was voluntary, and Institutional Review Board approval was obtained. Participants were assigned to three comparison groups based on the orientation or formal transition experience offered by the employing hospital. Each orientation or transition experience was reviewed based on predetermined criteria and assigned to group A, B, or C: ⦁⦁ Group A: Hospitals with a standardized, nationally utilized competence assessment and development system ⦁⦁ Group B: Hospitals with an individual, employer-developed, formal transition-to-practice program for new nurses ⦁⦁ Group C: Hospitals that included orientation to the hospital and the job the nurse was hired to do, but did not formally include activities designed to facilitate transition into practice www.journalofnursingregulation.com
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Participants were asked to complete surveys that had been modified from the National Council of State Boards of Nursing Competency Assessment Scale and Practice Errors and Risk for Practice Breakdown Survey. Newly licensed RNs were asked to complete the Newly Licensed RN Survey, and preceptors were asked to fill out the Preceptor Survey after 2 months (round 1), 4 months (round 2), and 6 months (round 3) of new-nurse employment. The new RNs rated their performance on 35 items, using a five-scale measurement, with “1” indicating “almost never” and “5” indicating “almost always.” Preceptors were asked to rate the new graduate’s performance on the same items using the same scale. Both preceptors and new RNs were asked to rate the quality of the preceptor/new-nurse partnership on a five-point scale, with “1” indicating “poor” and “5” indicating “excellent.” Reminders were sent 2 weeks after the survey was distributed for each round. The following statistical analysis methods were used: The self-reported competency index was compiled using the average score of the 35 items evaluated. ANOVA analyses were performed to test if there were any statistically significant differences in each of the 35 items related to self-reported competence among the three comparison groups. An independent t-test and one-way analysis of variance were used to determine if there was a statistically significant difference between self-reported competency scores of those new RNs who had experience as an aide or licensed practical nurse and those without such experience. A binary correlation analysis was used to determine statistically significant correlations between the self-reported competency scores and the partnership ratings. A paired t-test was used to determine significance in the risk score given by newly licensed nurses and their preceptors. Correlation analysis was used to determine the effect of preceptor/new-nurse relationship on the new RN’s perceived competence. Response Rates
The respondents were evenly distributed among groups A, B, and C and among urban, suburban, and rural settings. The response rates for new nurses were 31.4% (160 of 510) for round 1, 17.1% (87 of 510) for round 2, and 17.9% (83 of 463) for round 3. The response rates for preceptors were 38.8% (198 of 510) for round 1, 21.0% (107 of 510) for round 2, and 17.5% (81 of 463) for round 3. A total of 188 newly licensed nurses participated in one, two, or three of the data collection rounds, and 42 new nurses completed all three rounds. A total of 242 preceptors participated in one, two, or three of the rounds, and 39 preceptors completed all three rounds. The data from all nurses and preceptors who participated in any round of the survey were analyzed even if a nurse subsequently left his or her position. In this study, 29 (5 from group A, 15 from group B, and 9 from group C) newly licensed nurses resigned from their positions and left the hospital, and another 15 (1 from group A, 3 from group B, and 11 from group C) were terminated within the first 6 months of employment. One of the 29 new nurses who left the hospital also left the nursing profession.
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Phase I Findings and Discussion Phase I provided longitudinal data on the new nurse’s development in the areas of interpersonal relationships, knowledge integration into practice decisions, technical skills, clinical judgment, ability to recognize competence limits and seek help, and ability to confront ethical issues. Longitudinal data were also gathered on practice errors and the risk of practice breakdown during the first 6 months of employment. “Practice error” was defined as incidents or occurrences that resulted in harm to clients or had the potential to place the client at risk for harm. Risk for practice breakdown relates to unsafe practices that could lead to an error or patient harm. Demographics
General demographic data obtained from round 1 of the Newly Licensed RN Survey revealed that 93% of respondents were female and 86.7% were white. The average age was 30 years. Among the new nurses, 73.4% had an associate degree, 24.7% had a baccalaureate degree, and 1.9% had a diploma. Also, 53.2% had worked as a nurse aide or licensed practical or vocational nurse (LPN/LVN). These nurses were evenly distributed in groups A, B, and C. General demographic data obtained from round 1 of the preceptor survey revealed that 90.2% of respondents were female and 90.2% were white. The average age was 38.7 years. Among the preceptors, 62.8% had an associate degree; 32.2% had a baccalaureate or higher degree; and 2.2% had a diploma. The average length of time in their current positions was 6.29 years, and the average length of time as a preceptor was more than 7 years. Preceptor–New Nurse Relationship
A key finding was a statistically significant relationship between the preceptor–new nurse relationship and the new nurses’ selfreported competence scores in all three rounds. Higher positive ratings for the preceptor–new nurse relationship correlated with higher levels of self-reported competence by the new nurse. Equally important, the study found that higher competence scores correlated with fewer practice errors at 4 and 6 months. Length and Type of Transition Experience
No one type of transition or orientation program was superior to the others in fostering competence and confidence. The average length of time for programs was 8 weeks. Among new nurses, 83.8% worked the same schedule as their preceptor, and 51.3% had one primary preceptor. The average number of days before a new nurse had an independent assignment was 25 in group A, 38 in group B, and 30 in group C. There were no significant differences among the three groups regarding the number of days before an independent assignment or the number of patients in the first independent assignment.
Transition to Practice and Competence
The average overall self-reported competence scores of new nurses revealed no statistically significant differences between groups. On average, new nurses reported slightly higher competence scores in round 2 but overall slightly lower competence scores in clinical reasoning and judgment. The study revealed statistically significant differences in round 1 regarding the new nurses’ self-reported ability to perform technical skills safely and accurately as well as statistically significant differences in round 3 among the three groups in five areas: ⦁⦁ Recognizing when the care demands of patients exceed the ability of new nurses ⦁⦁ Managing time and organizing workload effectively ⦁⦁ Recognizing the implications of clinical presentations ⦁⦁ Appropriately utilizing research findings in providing care ⦁⦁ Fully understanding assignments, including physician’s orders. (See Table 1.) In all three rounds, new nurses felt relatively less competent in the area of clinical reasoning and judgment than in the areas of patient-care delivery, communication, and ability to recognize limits and seek help. The study found no significant difference in the overall self-assessment or in the subscales among the nurses with previous experience as nurse aides or LPN/LVNs and those with no such experience. Transition to Practice and Errors
In round 1, the study found no significant relationship between self-reported error scores and self-reported competence scores. However, in rounds 2 and 3, statistically significant negative relationships existed between these scores: The higher the competence score, the fewer self-reported errors. More than 75% of new nurses in all three rounds reported at least one instance of risk for practice errors in the previous 30 days. Interestingly, in round 1, the new nurses reported a risk that was statistically significantly higher than that reported by their preceptors. In rounds 2 and 3, the study found no statistical difference between new nurses and their preceptors regarding risk ratings. In all three rounds, more than 19% of new nurses reported that they “often” or “always” felt overwhelmed by patient-care responsibilities. Preceptor Characteristics and Competence
Analysis revealed a negative—though statistically insignificant— correlation between the perceived competence of new nurses and the number of new nurses the preceptor was responsible for at one time: The more new nurses per preceptor, the lower the new nurses’ competence. As noted, the quality of the relationship between new nurse and preceptor significantly affected the new nurse’s perceived competence.
Volume 2/Issue 3 October 2011
Table 1
Round 3: Self-Reported Competency Scores Ability to Recognize Care Demands Exceed Capability N
Mean
SD
Group A
27
4.30
0.67
Group B
28
4.14*
0.97
Group C
26
4.69*
0.47
Overall
81
4.37
0.77
*Statistically significant difference with df = 2, F = 3.93, p = .02.
Ability to Manage Time and Organize Workload Group A
N
Mean
SD
27
4.41*
0.69
Group B
28
3.96
0.74
Group C
27
3.85*
0.77
Overall
82
4.07
0.77
*Statistically significant difference with df = 2, F = 4, p = .02.
Ability to Recognize Implications of Clinical Presentations Group A
N
Mean
SD
28
4.53*
0.64
Group B
28
4.32
0.67
Group C
27
4.07*
0.73
Overall
83
4.31
0.69
*Statistically significant difference with df = 2, F = 3.18, p = .047.
Ability to Use Research Findings to Provide Care N
Mean
SD
Group A
28
4.11*
1.10
Group B
28
3.21*
1.31
Group C
26
3.46
1.27
Overall
82
3.60
1.28
*Statistically significant difference with df = 2, F = 3.91, p = .02.
Ability to Understand Assignments N
Mean
SD
Group A
28
4.46*
0.79
Group B
28
3.79*
0.96
Group C
27
4.03
0.90
Overall
83
4.09
0.92
*Statistically significant difference with df = 2, F = 4.21, p = .02.
Confidence
The study found no statistical difference in confidence development related to the type of orientation or transition program. In round 1, statistically significant correlations existed between the confidence of new nurses and the length of nursing practice, showing that selfreported confidence increased with practice experience. No similar statistically significant relationships appeared in rounds 2 and 3.
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Study Limitations Participation in this study was voluntary, providing a selfselecting group of participants that may have affected the data. In addition, new-nurse and preceptor participation varied from round to round and decreased with each round. Some new nurses worked with multiple preceptors; determining if this experience altered the developmental path was impossible. Data analysis also reveals that some respondents were confused about the type of transition or orientation they experienced and about the official length of the experience. This confusion may have affected how new nurses responded to some questions.
Conclusions Although the sample size was limited, Phase I of this multiphase study revealed information on new-nurse competence and confidence over the first 6 months of employment. No one type of orientation or transition program was more effective than the others, but the quality of the preceptor–new nurse relationship significantly affected the new nurse’s self-reported competence in all three rounds. Equally important, this study found that a higher self-reported competence score correlated with fewer practice errors at 4 and 6 months.
Implications and Future Research The statistical results among the three groups in several areas have implications for patient safety and thus for nursing regulation. Those areas include recognizing when care demands exceed the ability of new nurses; managing time and organizing workload effectively; recognizing the implications of clinical presentations; appropriately utilizing research findings in providing care; and fully understanding assignments, including physician’s orders. The following areas require more research: ⦁⦁ The relationship between formal transition-to-practice programs and safe patient care ⦁⦁ The number of new nurses who leave their first practice position and the reasons they leave ⦁⦁ The amount of time needed before a new nurse can provide safe, independent care ⦁⦁ The effect of the preceptor–new nurse relationship on the development of competence and confidence
References American Organization of Nurse Executives. (2000). Perspectives on the nursing shortage: A blueprint for action. Washington, DC: Author. Beecroft, P. C., Kunzman, L., & Krocek, C. (2001). RN internship— Outcomes of a one-year pilot program. Journal of Nursing Administration, 31(12), 575–582. Benner, P. (1984/2001). From novice to expert—Excellence and power in clinical nursing practice (commemorative ed.). Upper Saddle River, NJ: Prentice Hall.
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Journal of Nursing Regulation
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Berkow, S., Virkstis, K., Stewart, J., & Conway, W. (2008). Assessing new graduate nurse performance. Nurse Educator, 34(1), 17–22. Blanzola, C., Linderman, R., & King, M. L. (2004). Nurse internship pathway to clinical comfort, confidence, and competency. Journal for Nurses in Staff Development, 20(1), 27–37. Boychuck Duchscher, J. E. (2001). Out in the real world—Newly graduated nurses in acute care speak out. Journal of Nursing Administration, 31(9), 426–438. Clare, J., & van Loon, A. (2003). Best practice principles for the transition from student to registered nurse. Collegian, 10(4), 25–31. Contino, D. S. (2002). How to slash costly turnover. Nursing Management, 32(2), 10, 12–13. Ellertin, M. L., & Gregor, F. (2003). A study of transition: The new nurse graduate at 3 months. Journal of Continuing Education in Nursing, 34(3), 103–107, 136–137. Goode, C., & Williams, C. (2004). Post-baccalaureate nurse residency program. Journal of Nursing Administration, 34(2), 71–77. Hayes, J. M. (1990). Comprehensive orientation: The road to retention. Journal of Healthcare Education and Training, 7(1), 12–15. Jones, C. (2008). Revisiting nurse turnover costs: Adjusting for inflation. Journal of Nursing Administration, 38(1), 11–18. Kosel, K., & Olivo, T. (2002). The business case for workforce stability (VHA Research Series, Vol 7). Retrieved from http://www.vha. com/research/public/stability.pdf Marcum, E., & West, R. (2004). Structured orientation for new graduates. Journal for Nurses in Staff Development, 20(3), 118–126. Messmer, P. R., Jones, S. G., & Taylor, B. A. (2004). Enhancing knowledge and self-confidence of novice nurses: The “Shadow-A-Nurse” ICU Program. Nursing Education Perspectives, 25(3), 131–136. Newhouse, R. P., Hoffman, J. J., Suflita, J., & Hairston, D. P. (2007). Evaluating an innovative program to improve new nurse graduate socialization into the acute healthcare setting. Nursing Administration Quarterly, 31(1), 50–60. North Carolina Administrative Code 21 NCAC 36.0321(e)(f). Retrieved from www.oah.state.nc.us/rules/register/Volume20Issue01.pdf North Carolina Institute of Medicine. (2004). Task force on the North Carolina nursing workforce report: 2004. Durham, NC: Author. Oerman, M., & Gavin, M. F. (2002). Stress and challenges for new graduates in hospitals. Nurse Education Today, 22(3), 225–230. Rosenfeld, P., Smith, M. O., Iervolino, L., & Bowar-Ferres, S. (2004). Nurse residency program: A 5-year evaluation from the participants’ perspective. Journal of Nursing Administration, 34(4), 188– 194.
Joyce Wolf Roth, MSN, RN, NE-BC, SWP, is associate director for Organizational Development, North Carolina Board of Nursing in Raleigh. Mary P. Johnson, MS, RN, FAAN, is president and CEO, Foundation for Nursing Excellence in Raleigh.
T
he first 6 months of practice for newly licensed nurses are stressful, but their successful transition into practice is essential for safe patient care. An estimated 33% to 69% of new nurses change positions within a year of graduating, and 57% leave their first job within 2 years (Beecroft, Kunzman, & Krocek, 2001; Ellertin & Gregor, 2003; Goode & Williams, 2004; Newhouse, Hoffman, Suflita, & Hairston, 2007). The stress new nurses experience results from adjusting to the workplace, developing competence and confidence, and making errors (Boychuck Duchscher, 2001; Oerman & Gavin, 2002). A recent study for the Advisory Board Company found that 90% of nurse faculty members, but only 10% of nurse executives, believe that new graduate nurses are prepared to provide safe, effective patient care (Berkow, Virkstis, Stewart, & Conway, 2008). Benner and colleagues found that “a significant gap exists between today’s nursing practice and the education for that practice, despite some considerable strengths in nursing education.” This study supports implementing nurse residencies for new nurses (Benner, Sutphen, Leonard, & Day, 2010). A planned transition that includes specific activities to develop competence and confidence, promote socialization into the profession and the workplace, and provide support to the new nurse will promote safe patient care and help address some retention issues. North Carolina has completed three phases of a multiphase project to develop an evidence-based, transition-to-practice model for all newly licensed nurses. Phase I focused on development of competence and confidence of newly licensed registered nurses (RNs) in acute-care hospitals in North Carolina and preceptor characteristics that contribute to that development. Phase II focused on identifying the best and most promising practices related to new-nurse transition and preceptor preparation, determining current practices related to each in North Carolina, and developing online preceptor preparation modules and simulation activities on the preceptor’s critical role of helping new nurses transition into practice. Phase III focused on testing and evaluating the strategies and tools developed in Phase II. This article reports the findings of Phase I. 56
Journal of Nursing Regulation
Driving Forces A number of factors prompted the decision to develop a formal transition-to-practice model for newly licensed nurses. ⦁⦁ The North Carolina Institute of Medicine Task Force on the North Carolina Nursing Workforce issued a report with a priority recommendation urging the state board of nursing (BON) to convene a group to study options for improving school-to-work transitions. The specific priority was to develop interventions that enhance the new nurse’s application of knowledge into clinical practice in a way that supports safe, effective care and the nurse’s growth and retention (North Carolina Institute of Medicine, 2004). ⦁⦁ The BON considered factors that affect the new nurse’s ability to provide safe, effective nursing care, including the increased complexity of the health care environment, increased acuity and complexity of patient needs, decreased lengths of stay, and a nursing shortage that is predicted to worsen. ⦁⦁ The existing gap between the educational experience and the work setting can adversely affect the provision of safe patient care. This gap can be diminished, but it cannot be eliminated. ⦁⦁ Computerized adaptive testing for the national licensing examination has decreased the time between graduation and licensure. Today, a person can obtain a nursing license just days after graduation. In the past, the time between obtaining examination results and obtaining a license was about 3 months. During that period, unlicensed graduates could gain competence and confidence under the direct supervision of an experienced licensed nurse. Along with today’s quick entry into practice, the variance among transition experiences from setting to setting creates the potential for new nurses to face situations beyond their knowledge and ability without the guidance of an experienced nurse. North Carolina currently has no legal requirement regarding orientation or workplace transition. Thus, new nurses depend on their employers to determine the extent and type of orientation and transition experiences.
⦁⦁
⦁⦁
High nursing turnover rates create an increased risk for patients and increased costs for employers. Estimates on the cost of hiring a new nurse range from $20,000 to $80,000, depending on the clinical practice area (Contino, 2002; Jones, 2008; Kosel & Olivo, 2002). The risk to patient safety and the financial and human costs are compounded when new nurses leave not only their employers but also the nursing profession. Effective January 2008, the BON requires that all generic nursing education programs in North Carolina include a patientfocused experience designed to begin the transition before the end of the curriculum (North Carolina Administrative Code 21 NCAC 36.0321 (e) (f)). This addresses the education side of the gap, but does not address the new nurse’s first employment experience.
Phase I Overview The Foundation for Nursing Excellence (FFNE), a nonprofit organization created in 2002 by the BON and now an independent organization, took the lead on the transition-to-practice project. The North Carolina Center for Nursing and the North Carolina Area Health Education Centers agreed to collaborate with the FFNE. The steering committee has representatives from the three collaborating groups, the BON, and practice and education arenas in North Carolina. A broader group of stakeholders, representing educators, employers, practitioners, trade associations, professional associations, and newly licensed nurses, serves as an advisory panel to the steering committee. A variety of studies and reports were reviewed to provide background information for the steering committee of this project. ⦁⦁ Literature addressing new-nurse transition (American Organization of Nurse Executives, 2000; Beecroft et al., 2001; Benner, 1984/2001; Blanzola, Linderman, & King, 2004; Clare & van Loon, 2003; Ellertin & Gregor, 2003; Hayes, 1990; Marcum & West, 2004; Messmer, Jones, & Taylor, 2004; Rosenfeld, Smith, Iervolino, & Bowar-Ferres, 2004) ⦁⦁ North Carolina transition models ⦁⦁ National and other state transition models—the Vermont Nurse Internship Project, the Kentucky Clinical Internship Regulation, and the American Association of Colleges of Nurses/ University Health System Consortium Residency Program ⦁⦁ International transition models—the Flying Start Program from Scotland and the New Graduate Initiative from Ontario, Canada In 2005, the three collaborating organizations sponsored an invitational research development conference supported by the Agency for Healthcare Research and Quality. Conference attendees reached consensus on core competencies for new nurses in the North Carolina transition-to-practice project. The core competencies were as follows: ⦁⦁ Perform accurate assessments. ⦁⦁ Communicate effectively. ⦁⦁ Recognize imminent threats. Volume 2/Issue 3 October 2011
Recognize limits of competence and ask for help. Evaluate patient response and modify intervention appropriately. ⦁⦁ Prioritize to provide care in a timely manner. ⦁⦁ Perform medication administration and patient education. ⦁⦁ Create a safe work environment. ⦁⦁ Use critical thinking to develop action plans. ⦁⦁ Collaborate to optimize outcomes. In 2006, BlueCross BlueShield Foundation of North Carolina awarded a 2-year grant to the FFNE for study on the role of transition programs in the development of new nurses. The goals of Phase I were to examine the perceived development of competence and confidence of new nurses in three types of orientation programs in North Carolina hospitals and to identify preceptor characteristics that aid the development of competence and confidence of new nurses. ⦁⦁ ⦁⦁
Research Questions
The four research questions were as follows: 1. What is the relationship between the preceptor-new nurse relationship and the development of competence among newly licensed RNs in North Carolina hospitals? 2. What is the relationship between the type of transition-topractice experience and practice errors among newly licensed RNs in North Carolina hospitals? 3. What is the relationship between the type of transition-topractice experience and the risk of practice breakdown among newly licensed RNs in North Carolina hospitals? 4. What is the relationship between preceptor characteristics and the development of competence among newly licensed RNs in North Carolina hospitals? Methodology
The longitudinal design used repeated measures at 2, 4, and 6 months of employment. The project director sent invitations to all newly licensed RNs, defined as those within the first 6 months of first employment as an RN, and their preceptors in 29 acute-care hospitals. Hospitals were selected to represent various sizes, geographic locations in the state, and urban/suburban/rural settings. Participation was voluntary, and Institutional Review Board approval was obtained. Participants were assigned to three comparison groups based on the orientation or formal transition experience offered by the employing hospital. Each orientation or transition experience was reviewed based on predetermined criteria and assigned to group A, B, or C: ⦁⦁ Group A: Hospitals with a standardized, nationally utilized competence assessment and development system ⦁⦁ Group B: Hospitals with an individual, employer-developed, formal transition-to-practice program for new nurses ⦁⦁ Group C: Hospitals that included orientation to the hospital and the job the nurse was hired to do, but did not formally include activities designed to facilitate transition into practice www.journalofnursingregulation.com
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Participants were asked to complete surveys that had been modified from the National Council of State Boards of Nursing Competency Assessment Scale and Practice Errors and Risk for Practice Breakdown Survey. Newly licensed RNs were asked to complete the Newly Licensed RN Survey, and preceptors were asked to fill out the Preceptor Survey after 2 months (round 1), 4 months (round 2), and 6 months (round 3) of new-nurse employment. The new RNs rated their performance on 35 items, using a five-scale measurement, with “1” indicating “almost never” and “5” indicating “almost always.” Preceptors were asked to rate the new graduate’s performance on the same items using the same scale. Both preceptors and new RNs were asked to rate the quality of the preceptor/new-nurse partnership on a five-point scale, with “1” indicating “poor” and “5” indicating “excellent.” Reminders were sent 2 weeks after the survey was distributed for each round. The following statistical analysis methods were used: The self-reported competency index was compiled using the average score of the 35 items evaluated. ANOVA analyses were performed to test if there were any statistically significant differences in each of the 35 items related to self-reported competence among the three comparison groups. An independent t-test and one-way analysis of variance were used to determine if there was a statistically significant difference between self-reported competency scores of those new RNs who had experience as an aide or licensed practical nurse and those without such experience. A binary correlation analysis was used to determine statistically significant correlations between the self-reported competency scores and the partnership ratings. A paired t-test was used to determine significance in the risk score given by newly licensed nurses and their preceptors. Correlation analysis was used to determine the effect of preceptor/new-nurse relationship on the new RN’s perceived competence. Response Rates
The respondents were evenly distributed among groups A, B, and C and among urban, suburban, and rural settings. The response rates for new nurses were 31.4% (160 of 510) for round 1, 17.1% (87 of 510) for round 2, and 17.9% (83 of 463) for round 3. The response rates for preceptors were 38.8% (198 of 510) for round 1, 21.0% (107 of 510) for round 2, and 17.5% (81 of 463) for round 3. A total of 188 newly licensed nurses participated in one, two, or three of the data collection rounds, and 42 new nurses completed all three rounds. A total of 242 preceptors participated in one, two, or three of the rounds, and 39 preceptors completed all three rounds. The data from all nurses and preceptors who participated in any round of the survey were analyzed even if a nurse subsequently left his or her position. In this study, 29 (5 from group A, 15 from group B, and 9 from group C) newly licensed nurses resigned from their positions and left the hospital, and another 15 (1 from group A, 3 from group B, and 11 from group C) were terminated within the first 6 months of employment. One of the 29 new nurses who left the hospital also left the nursing profession.
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Phase I Findings and Discussion Phase I provided longitudinal data on the new nurse’s development in the areas of interpersonal relationships, knowledge integration into practice decisions, technical skills, clinical judgment, ability to recognize competence limits and seek help, and ability to confront ethical issues. Longitudinal data were also gathered on practice errors and the risk of practice breakdown during the first 6 months of employment. “Practice error” was defined as incidents or occurrences that resulted in harm to clients or had the potential to place the client at risk for harm. Risk for practice breakdown relates to unsafe practices that could lead to an error or patient harm. Demographics
General demographic data obtained from round 1 of the Newly Licensed RN Survey revealed that 93% of respondents were female and 86.7% were white. The average age was 30 years. Among the new nurses, 73.4% had an associate degree, 24.7% had a baccalaureate degree, and 1.9% had a diploma. Also, 53.2% had worked as a nurse aide or licensed practical or vocational nurse (LPN/LVN). These nurses were evenly distributed in groups A, B, and C. General demographic data obtained from round 1 of the preceptor survey revealed that 90.2% of respondents were female and 90.2% were white. The average age was 38.7 years. Among the preceptors, 62.8% had an associate degree; 32.2% had a baccalaureate or higher degree; and 2.2% had a diploma. The average length of time in their current positions was 6.29 years, and the average length of time as a preceptor was more than 7 years. Preceptor–New Nurse Relationship
A key finding was a statistically significant relationship between the preceptor–new nurse relationship and the new nurses’ selfreported competence scores in all three rounds. Higher positive ratings for the preceptor–new nurse relationship correlated with higher levels of self-reported competence by the new nurse. Equally important, the study found that higher competence scores correlated with fewer practice errors at 4 and 6 months. Length and Type of Transition Experience
No one type of transition or orientation program was superior to the others in fostering competence and confidence. The average length of time for programs was 8 weeks. Among new nurses, 83.8% worked the same schedule as their preceptor, and 51.3% had one primary preceptor. The average number of days before a new nurse had an independent assignment was 25 in group A, 38 in group B, and 30 in group C. There were no significant differences among the three groups regarding the number of days before an independent assignment or the number of patients in the first independent assignment.
Transition to Practice and Competence
The average overall self-reported competence scores of new nurses revealed no statistically significant differences between groups. On average, new nurses reported slightly higher competence scores in round 2 but overall slightly lower competence scores in clinical reasoning and judgment. The study revealed statistically significant differences in round 1 regarding the new nurses’ self-reported ability to perform technical skills safely and accurately as well as statistically significant differences in round 3 among the three groups in five areas: ⦁⦁ Recognizing when the care demands of patients exceed the ability of new nurses ⦁⦁ Managing time and organizing workload effectively ⦁⦁ Recognizing the implications of clinical presentations ⦁⦁ Appropriately utilizing research findings in providing care ⦁⦁ Fully understanding assignments, including physician’s orders. (See Table 1.) In all three rounds, new nurses felt relatively less competent in the area of clinical reasoning and judgment than in the areas of patient-care delivery, communication, and ability to recognize limits and seek help. The study found no significant difference in the overall self-assessment or in the subscales among the nurses with previous experience as nurse aides or LPN/LVNs and those with no such experience. Transition to Practice and Errors
In round 1, the study found no significant relationship between self-reported error scores and self-reported competence scores. However, in rounds 2 and 3, statistically significant negative relationships existed between these scores: The higher the competence score, the fewer self-reported errors. More than 75% of new nurses in all three rounds reported at least one instance of risk for practice errors in the previous 30 days. Interestingly, in round 1, the new nurses reported a risk that was statistically significantly higher than that reported by their preceptors. In rounds 2 and 3, the study found no statistical difference between new nurses and their preceptors regarding risk ratings. In all three rounds, more than 19% of new nurses reported that they “often” or “always” felt overwhelmed by patient-care responsibilities. Preceptor Characteristics and Competence
Analysis revealed a negative—though statistically insignificant— correlation between the perceived competence of new nurses and the number of new nurses the preceptor was responsible for at one time: The more new nurses per preceptor, the lower the new nurses’ competence. As noted, the quality of the relationship between new nurse and preceptor significantly affected the new nurse’s perceived competence.
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Table 1
Round 3: Self-Reported Competency Scores Ability to Recognize Care Demands Exceed Capability N
Mean
SD
Group A
27
4.30
0.67
Group B
28
4.14*
0.97
Group C
26
4.69*
0.47
Overall
81
4.37
0.77
*Statistically significant difference with df = 2, F = 3.93, p = .02.
Ability to Manage Time and Organize Workload Group A
N
Mean
SD
27
4.41*
0.69
Group B
28
3.96
0.74
Group C
27
3.85*
0.77
Overall
82
4.07
0.77
*Statistically significant difference with df = 2, F = 4, p = .02.
Ability to Recognize Implications of Clinical Presentations Group A
N
Mean
SD
28
4.53*
0.64
Group B
28
4.32
0.67
Group C
27
4.07*
0.73
Overall
83
4.31
0.69
*Statistically significant difference with df = 2, F = 3.18, p = .047.
Ability to Use Research Findings to Provide Care N
Mean
SD
Group A
28
4.11*
1.10
Group B
28
3.21*
1.31
Group C
26
3.46
1.27
Overall
82
3.60
1.28
*Statistically significant difference with df = 2, F = 3.91, p = .02.
Ability to Understand Assignments N
Mean
SD
Group A
28
4.46*
0.79
Group B
28
3.79*
0.96
Group C
27
4.03
0.90
Overall
83
4.09
0.92
*Statistically significant difference with df = 2, F = 4.21, p = .02.
Confidence
The study found no statistical difference in confidence development related to the type of orientation or transition program. In round 1, statistically significant correlations existed between the confidence of new nurses and the length of nursing practice, showing that selfreported confidence increased with practice experience. No similar statistically significant relationships appeared in rounds 2 and 3.
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Study Limitations Participation in this study was voluntary, providing a selfselecting group of participants that may have affected the data. In addition, new-nurse and preceptor participation varied from round to round and decreased with each round. Some new nurses worked with multiple preceptors; determining if this experience altered the developmental path was impossible. Data analysis also reveals that some respondents were confused about the type of transition or orientation they experienced and about the official length of the experience. This confusion may have affected how new nurses responded to some questions.
Conclusions Although the sample size was limited, Phase I of this multiphase study revealed information on new-nurse competence and confidence over the first 6 months of employment. No one type of orientation or transition program was more effective than the others, but the quality of the preceptor–new nurse relationship significantly affected the new nurse’s self-reported competence in all three rounds. Equally important, this study found that a higher self-reported competence score correlated with fewer practice errors at 4 and 6 months.
Implications and Future Research The statistical results among the three groups in several areas have implications for patient safety and thus for nursing regulation. Those areas include recognizing when care demands exceed the ability of new nurses; managing time and organizing workload effectively; recognizing the implications of clinical presentations; appropriately utilizing research findings in providing care; and fully understanding assignments, including physician’s orders. The following areas require more research: ⦁⦁ The relationship between formal transition-to-practice programs and safe patient care ⦁⦁ The number of new nurses who leave their first practice position and the reasons they leave ⦁⦁ The amount of time needed before a new nurse can provide safe, independent care ⦁⦁ The effect of the preceptor–new nurse relationship on the development of competence and confidence
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Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Berkow, S., Virkstis, K., Stewart, J., & Conway, W. (2008). Assessing new graduate nurse performance. Nurse Educator, 34(1), 17–22. Blanzola, C., Linderman, R., & King, M. L. (2004). Nurse internship pathway to clinical comfort, confidence, and competency. Journal for Nurses in Staff Development, 20(1), 27–37. Boychuck Duchscher, J. E. (2001). Out in the real world—Newly graduated nurses in acute care speak out. Journal of Nursing Administration, 31(9), 426–438. Clare, J., & van Loon, A. (2003). Best practice principles for the transition from student to registered nurse. Collegian, 10(4), 25–31. Contino, D. S. (2002). How to slash costly turnover. Nursing Management, 32(2), 10, 12–13. Ellertin, M. L., & Gregor, F. (2003). A study of transition: The new nurse graduate at 3 months. Journal of Continuing Education in Nursing, 34(3), 103–107, 136–137. Goode, C., & Williams, C. (2004). Post-baccalaureate nurse residency program. Journal of Nursing Administration, 34(2), 71–77. Hayes, J. M. (1990). Comprehensive orientation: The road to retention. Journal of Healthcare Education and Training, 7(1), 12–15. Jones, C. (2008). Revisiting nurse turnover costs: Adjusting for inflation. Journal of Nursing Administration, 38(1), 11–18. Kosel, K., & Olivo, T. (2002). The business case for workforce stability (VHA Research Series, Vol 7). Retrieved from http://www.vha. com/research/public/stability.pdf Marcum, E., & West, R. (2004). Structured orientation for new graduates. Journal for Nurses in Staff Development, 20(3), 118–126. Messmer, P. R., Jones, S. G., & Taylor, B. A. (2004). Enhancing knowledge and self-confidence of novice nurses: The “Shadow-A-Nurse” ICU Program. Nursing Education Perspectives, 25(3), 131–136. Newhouse, R. P., Hoffman, J. J., Suflita, J., & Hairston, D. P. (2007). Evaluating an innovative program to improve new nurse graduate socialization into the acute healthcare setting. Nursing Administration Quarterly, 31(1), 50–60. North Carolina Administrative Code 21 NCAC 36.0321(e)(f). Retrieved from www.oah.state.nc.us/rules/register/Volume20Issue01.pdf North Carolina Institute of Medicine. (2004). Task force on the North Carolina nursing workforce report: 2004. Durham, NC: Author. Oerman, M., & Gavin, M. F. (2002). Stress and challenges for new graduates in hospitals. Nurse Education Today, 22(3), 225–230. Rosenfeld, P., Smith, M. O., Iervolino, L., & Bowar-Ferres, S. (2004). Nurse residency program: A 5-year evaluation from the participants’ perspective. Journal of Nursing Administration, 34(4), 188– 194.
Joyce Wolf Roth, MSN, RN, NE-BC, SWP, is associate director for Organizational Development, North Carolina Board of Nursing in Raleigh. Mary P. Johnson, MS, RN, FAAN, is president and CEO, Foundation for Nursing Excellence in Raleigh.