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Transition-to-practice programs may contribute to new grad success

Monday April 22, 2013
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The transition from nursing student to RN often is rocky. Aside from being challenged clinically by the minute, newly licensed nurses also must adjust to demanding institutional cultures. These stresses can contribute to clinical errors and employee turnover.

More than 40% of new graduate nurses report making medication errors, and 50% said they would not recognize life-threatening complications that require intervention, according to data collected by the National Council of State Boards of Nursing. The council also found average turnover rates for nurses in their first year on the job range from 35% to 60%.

"Newly graduated nurses tend to be exhausted that first year," said Patricia Benner, RN, PhD, FAAN, distinguished visiting professor at Seattle University and professor emeritus at the University of California, San Francisco. "Theyíre having to be more vigilant than theyíll ever have to be again."

Benner, who developed the Novice to Expert model of nursing skill development, recognizes that nursing education can do a better job of closing the gap between education and clinical practice. "Itís too much to ask that you just learn this in a class and then know how to recognize clinical aspects of the situation when you see it," she said.

Situational clinical coaching or guided clinical decision-making for new graduate nurses is key to a good transition program, Benner said. But equally important is an institutional culture that welcomes new graduate nurses and appreciates the stresses of the graduatesí first year. "The organization needs to provide support groups, coaching and a welcoming environment," she said.

Proficient practice

"Evidence suggests that new nurses are safer, more confident and have less stress when they have a model of transition to practice," said Nancy Spector, RN, PhD, director of regulatory innovations at NCSBN. "We think they will get into fewer problems and feel more competent as they go forward, which will increase job satisfaction and retention."

Thatís why the NCSBN launched a two-phase, longitudinal study to examine the effect a standardized transition-to-practice model would have on patient safety and quality outcomes in hospital and nonhospital settings. By collecting patient outcome data, such as length of stay, medication errors and other markers, the study will assess the relationship between an in-depth transition-to-practice program and patient outcomes.

If proven successful, the NCSBN model could become accessible nationwide, even for institutions that donít have the funding to develop their own programs. The study, which is ongoing at 150 sites across Illinois, North Carolina and Ohio, is in its second phase, and results will be reported at the NCSBN annual meeting in 2014.

Keeping skills current

Nikki West, MPH, director of the California Institute for Nursing and Health Care, saw a need for a transition-to-practice program for a specific segment of newly graduated RNs — those who canít find employment. After California spent 10 years increasing its nursing school capacity, the economic downturn left many new graduates with no job prospects.

"We worked with the hospital council to conduct a survey of hospitals to really get a sense of and quantify what we were hearing anecdotally, that new grads werenít getting hired," West said. "We found out that about 40% to 43% of new grads would likely not be able to find hospital positions."

Taking that data to nursing school deans, CNOs and private funders with an interest in California healthcare, the CINHC warned of a looming state crisis. Partnering with nursing schools and clinical sites, the institute developed a transition-to-practice model to help nurses continue to build their skills while they look for employment.

The CINHC transition model includes classroom learning, a clinical experience with a preceptor and a skills lab component. Though the 24-hour-per-week program is unpaid, participants get to practice their skills until they find employment. The program has enrolled 330 nurses, and the outcome has been promising. "We are at about 80% employment for people who went through our program," West said.

The projectís funding is coming to an end, but West is optimistic about the future. "Our initial data shows that these programs have a positive impact," she said. "The challenge is in finding a way to make them self-sustaining."

Transition-to-practice pioneers

Emily Read, RN-BC, MSN, MPH, an education quality coordinator at Rush University Medical Center in Chicago, has seen firsthand how a transition-to-practice program pays off. Since the medical center began its new graduate residency program in 2008, new graduate turnover rates during the first year are at 4.9%.

Throughout the nine-month program, the new graduate nurses develop critical thinking and clinical judgment skills while honing in on the needs of the specific patient populations for which they care. They participate in classroom learning, small group discussions and a clinical experience guided by a preceptor.

"We split into approximately six to eight people, and with facilitators we have constructive venting sessions," Read said. "What happens in the room stays in the room, kind of like Vegas. Itís not a time for us to solve their problems. Itís a time for peer-to-peer support."

Read is collecting long-term data on the program, and she expects to find that new graduate nurses who go through a residency program have higher rates of leadership positions and more advanced degrees.

Legacy Health in Portland, Ore., has found that embracing a transition-to-practice program can change the culture of an institution to be more supportive of new graduatesí needs.

"We were concerned that we were losing this young early talent and felt that we were not sensitive enough to the transition from the academic environment to the practice setting," said Carol Bradley, RN, MSN, senior vice president and CNO of Legacy Health.

After partnering with Versant, an independent nurse residency education and training system company based in Southern California, Legacy started its first residency cohort in July 2010. Since the program began, the new graduate turnover rate has dropped from 30.09% in 2009 to 7.89% in January 2013.

Bradley outlines what she thinks sets the Legacy program apart from others: a network of support built around each new grad, with an emphasis on professional development. New grads learn from three different preceptors on the clinical level, and are assigned a mentor and a "debriefer" who help support the nurses as they grapple with new responsibilities.

"Itís not just being comfortable with a diagnosis or a certain patient problem," Bradley said. "Itís realizing and socializing a new graduate to what it is to have professional responsibilities and what their responsibilities are within the context of a larger organization."

That focus on professionalism, Bradley said, is the key to grooming not only clinicians but also nurse leaders. "Some of my residents from year one have turned into some of our most active shared governance participants," she said. "Itís exciting to see these nurses blossom." •

Meaghan O'Keeffe, RN, BSN, is a freelance writer.Write to editor@nurse.com or post a comment below.
Key transition-to-practice program components

According to experts interviewed by Nurse.com, qualities of a successful transition-to-practice program are:

Invested preceptors: An institutional culture that welcomes new nurses and views training as a means to molding more competent and capable co-workers is essential.
Just as important is good training and support. As part of its model, the National Council of State Boards of Nursing has developed modules to help train and support nurse preceptors.

Social and emotional support: New graduates need peer-to-peer support with the guidance of seasoned professionals, including chaplains, social workers, clinical nurse specialists and mental health professionals, to support them through the first year.

Classroom learning: Whether through case studies, discussions or clinically related education, classroom learning is a chance to help nurses assimilate and reinforce the knowledge theyíre rapidly acquiring.

Institution-specific knowledge: Each patient population has unique needs, and each institution has unique systems and cultures. An emphasis on local, in-depth knowledge that takes those factors into account is key.