The Transition from Student Nurse to Clinical Nurse Nicole McDonald NURS 450 Ferris State University

Objectives Discuss the difficulties of the transition into nursing Look at the implications of a difficult transition on nursing retention Examine theories related to the transition Assessment of the healthcare environment related to the transition Implications and consequences of this problem on patients and new nurses Examine policies related to the transition Perform a root cause analysis on the issue Recommendations for quality and safety improvement Examine QSEN competencies and ANA standards related to the transition

The Problem Up to half of new RNs consider leaving within the first year (MacKusick & Minick, 2010). 30-50% of new RNs change jobs or leave nursing in the first 3 years (MacKusick & Minick, 2010). Less than 50% of practicing nurses would recommend it as a career (Duscher, 2009) 25% of practicing nurses would actively discourage someone from going into nursing (Duscher, 2009)

Why is this an issue? Transition Shock/Reality Shock Bullying High patient to nurse ratios Orientation & Preceptors Lack of support Exhaustion Staffing The Nursing Shortage Transition: perception vs. reality Reasons: fast-paced, constantly changing, lack of support by peers, preceptor or supervisors, short & inadequate orientation periods, feeling unprepared for decision-making responsibilities, bullying by peers, hostility from physicians, fatigue, exhaustion, feeling alone, staffing The nursing shortage is expected to surpass 500,000 by the year 2025, so retention is vital. Accelerated programs are useless if they’re pumping out new nurses quickly, but they’re turning around and quitting within a few years. If this doesn’t change, this transition will continue to be difficult and retention levels will remain low. Will look into some of these more specifically later.

Transition Shock Theory Dr. Judy Boychuk Duchscher Nursing the Future Initiative Moves the new nurse through developmental, professional, intellectual, emotional, skill, role-relationship changes Intensity is felt more or less depending on experiences, history and situations encountered; more intense first 1-4 months after orientation Important to the experience for the new nurse is the contrast between relationship, roles, responsibilities and knowledge in the familiar academic environment to those required in the professional practice setting Feelings of doubt, confusion, disorientation & loss Expressions of the transition shock experience Canadian university

Schlossberg’s Transition Theory Situation Self Support Strategies 4 S’s – four factors that influence one’s ability to cope with change Situation: Expected? Controlled? Does it come with complications? At a time of multiple stressors? (marriage, move, health problems), viewed as positive or negative? Role change? Permanent or temporary? Self: Stage in life, state of health, outlook, personality, commitment, and resilience Support: Family? Friends? Spouse? Peers? Supervisor? Organization? Typical support utilized for this change? Will it be adequate? Strategies: how well have you coped with change in the past? previous strategies? Transition will have a big effect on psychological health and well-being, have to be aware of what the change means and be prepared to cope. Dr. Nancy Schlossberg Professor of Counseling Psychology

Assessment of the Health Care Environment Transition Shock/Reality Shock Expectations vs. Reality Unfriendly environment Emotional distress Fatigue and exhaustion Lack of comfort in challenging situations Shock: differing perceptions & reality of adjustment and practice, differences between cohorts & generational differences, mixed emotions. Expectations vs. reality: huge discrepancies, “profession but not treated like professionals,” expected to feel appreciation, respect & support & have adequate resources but did not; no feelings of success or satisfaction, feelings of clinical deficiency, “wish someone would have prepared me for the let down after school,” consuming documentation & lack of time with pts Unfriendly environment: feeling alone & helpless, being bullied and harassed, dread coming to work, doing just enough to get by, lack of positive reinforcement, fear of retaliation for reporting, Never thought going in to the career they had worked so hard for would be unwelcoming or negative Emotional stress: lack of collaboration, not abiding by fam wishes, asking fams to leave room, loss of respect, keeping alive sicker pts – false hope to fams Fatigue & exhaustion: no time to eat, sit, bathroom, mind constantly going – even after you leave (my take days after difficult shift), couldn’t answer phone, high patient:nurse ratios, holistic care is demanding, fast paced, off orientation early, pressure not to stay late & accrue overtime OR mandatory overtime Lack of comfort/experience: EOL care, communication with physicians, ethical issues

Implications, Inferences & Consequences For patients: Decreased quality of care Decreased safety Delayed care, increased time in hospital Negative outcomes Decreased confidence in nursing staff High pt nurse ratio, high acuity pt needs, excessive documentation – lack of time with pts; Pts that have one more thing needed to be done by the nurse & it doesn’t get done so they have to stay another day Short orientation, decreased confidence in clinical decision-making, decreased support – negative outcomes, decreased confidence

Implications, Inferences & Consequences For new nurses: Increased risk for errors Decreased job satisfaction Helplessness Staffing High turnover rates High costs Errors: low support, bullying and criticism, anxiety, not thinking clearly - mistakes Dec job satisfaction: lack of positive reinforcement– decreased confidence Helpless: lack of support, lack of voice, high patient to nurse ratios Staffing: increased call-ins, more work hours & overtime for others – burnout, shortened orientation or taken off early, full patient load from day 1,

Spectrum Health Policies Code of Excellence Non-retaliation policy, p. 6 Disclosure of potential conflicts, p. 11 Building relationships with colleagues, p. 14 Maintaining respectful treatment, p. 15 Preventing workplace violence, p. 16 Signed agreement by all new employees

Spectrum Health Initiatives Leadership training Relationship-based Care Model Shared Governance Model EXCEL Nursing Professional Development Model RBCM: helps nurses work as a team to provide better care to pts, 3 relationships: nurse-pt & family, nurse-staff, nurse-self; promotes teamwork - increased staff satisfaction leads to increased pt satisfaction, SGM: EBP model of shared leadership & decision-making, encourages input from staff, helps advance nursing at all levels, nurses make decisions affecting their own practice, supports professional practice – improves pt outcomes & increases staff satisfaction EXCEL: improving & advancing nursing practice; 1. professional environment, 2. facilitates accountability, autonomy & collaboration, 3. opportunities for advancement while promoting pt care

Low Retention of New Nurses Root Cause Analysis Lack of Support Staffing Bullying Peers Call-ins Isolation Supervisors ↑Pt load Low Retention of New Nurses Physical Lack of experience Judgment Cut short Emotional ↑ acuity Preceptor Fatigue Confidence Orientation High Stress

Recommendations for Quality & Safety Improvements Program emphasis on leadership, communication, conflict management, collaboration in final semester (Casey et al., 2011) Simulation experiences (Casey et al., 2011) Intensive preceptor-guided clinical (Casey et al., 2011) Novice Nurse Leadership Initiative (Dyess & Sherman, 2011) Nurse Residency Programs (Bratt, 2013) New nurse networking programs Education on new nurse support - peer and supervisor Performance evaluations Program: small amount of leadership at clinical, conflict management Clinical: research shows it provides increased confidence in new nurses, consistency?, requests for more skills practice & clinical time NNLI: started in 2006, South Florida, 10 months/20 sessions (information & activities), support transition in first year, considered part of work schedule & pay, nurse mentor (dec isolation), develop evidence based interventions for problems, 3 outcomes – 1. bigger perspective of nursing, 2. leadership skills development & use, 3. increased confidence; communication & conflict resolution; Findings – consistent preceptors, extended orientations, opps to meet with other new grads & nurse leaders, highly recommended by nurse managers & mentors, Institute of Medicine & American Org of Nurse Execs NRP: Wisconsin, started in 2005, addition to orientation (phase 1), phase 2: 12 months – education & psychosocial support, active learning, focused on role integration & professional identity, ; sessions on clinical judgment, core clinical topics, when to call physician; Results - higher rates of new nurse retention, decreased nurse vacancy & cost savings; improved environments, formation of relationships, decrease reality shock Look up information about these programs at places you apply, ask during interviews, utilize them if they are there, seek out other new nurses & network

Nurse Residency Programs in Michigan Children’s Hospital of Michigan – Detroit Medical Center St. Joseph Mercy Health System Beaumont Health Systems Sparrow Health System Munson Medical Center – Critical Care Internship DMC: 6 mo SHS: 12 wk MMC: 5 months

QSEN Competencies Teamwork & Collaboration Quality Improvement Teamwork & Collaboration: open communication, mutual respect – know strengths/weaknesses, know role on team, utilize collaboration, ask for help, communicate with peers & disciplines, initiate conflict resolution, assert opinions Quality improvement: monitor outcomes & utilize improvement methods to continuously improve quality – research outcomes & participate in improvement projects, follow policies on care modalities, utilize measurements of performance to improve, identify gaps in practice and modify, evaluate change effectiveness

ANA Standards Communication Leadership Professional Practice Evaluation Standard 11: Communication – communicate effectively in variety of settings (peers, families, patients, physicians), improvement on communication & conflict resolution, accuracy of information, questions rationales for care processes, contributes professional opinions Standard 12: Leadership – accountability, abide by care plan, continuing education & improvement, respect peers, communication & conflict resolution, participate in professional organizations, advance autonomy/ accountability, participate in efforts to modify policies for improvement Standard 14: Professional Practice Evaluation – evaluate own practice according to standards & guidelines, population-appropriate care, ID strengths & weaknesses, obtain feedback from peers & supervisors, methods to improve in weak areas, apply EBP & be able to defend decisions, utilize peers to expand practice, provide feedback for peers

References American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Springs, MD: Nursebooks.org Anderson, M. L., Goodman, J., & Schlossberg, N. K. (2012). Counseling adults in transition: Linking Schlossberg’s Theory with practice in a diverse world (4th ed.). New York, NY: Springer Publishing Company LLC. Boychuk Duchscher, J. E. (2009). Transition shock: The initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing, 1103-1113 Bratt, M. M. (2013). Nurse residency programs: Best practices for optimizing organizational success. Journal for Nurses in Professional Development, 29(3), 102-110. Casey, K., Fink, R., Jaynes, C., Campbell, L., Cook, P., & Wilson, V. (2011). Readiness for practice: The senior practicum experience. Journal of Nursing Education, 50(11), 646-652. Dyess, S. & Sherman, R. (2011). Developing the leadership skills of new graduates to influence practice environments: A novice nurse leadership program. Nursing Administration Quarterly, 35(4), 313-322. MacKusick, C. I. & Minick, P. (2010). Why are nurses leaving? Findings from an initial qualitative study on nursing attrition. Medsurg Nursing, 19(6), 335-340 Pellico, L. H., Brewer, C. S., & Kovner, C. T. (2009). What newly licensed registered nurses have to say about their first experiences. Nursing Outlook, 57(4), 194-294 Quality and Safety Education for Nurses (2014). Competencies. Retrieved from http://qsen.org/competencies/pre-licensure- ksas/ Spectrum Health (2014). For nurses: Nursing excellence providing world class care. Retrieved from http://www.spectrumhealth.org/nursing