Associate Director of Research The Impact of Transition Experience on Practice of Newly Licensed Registered Nurses Suling Li, PhD, RN Associate Director of Research NCSBN

Background New RNs struggling with transition into practice Shortened gap between taking NCLEX and being licensed High job stress and high turnover rates in new RNs Complexity of health care environment Increased workload due to acute nursing shortage

Goals 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

Conceptual Framework on Transition Structure of transition Content of transition Characteristics of preceptors Characteristics of the new nurse Partnerships between the new nurse and the preceptor Institutional support for both the new nurse and the preceptor

Outcomes Primary Outcomes Clinical competency Practice errors and risks for practice breakdown Secondary Outcomes Stress level Job turnover

Assessing Outcomes Two perspectives: Perspective of the new RN Perspective of his/her preceptor/mentor

Outcome Measures Clinical competence (35 items): Clinical reasoning and judgment Pt care delivery and management skills Communication and interpersonal relationships Recognizing limits and seeking help Practice errors and risks for practice breakdown

Design Survey of nurse-preceptor dyad

Sample Profile – Demographics New RNs Preceptors N: RN 560 231 BSNs 32.8% 31.5% ADNs 60.7% 49.7% Age (yrs) 32.4 42.2 Female 94.4% 92.2% White 81.2% 88%

Characteristics of the New RNs Hospital 86.4% Full time 91.2% English first language 92.6% Graduates of USA programs 99.0% With LPN experiences 19.9% Employed in urban area 47.3% Months of working experience 11.4

Characteristics of Preceptors Experience in nursing Experience in current position >1 year experience on the unit As preceptor for this nurse As a preceptor for any nurse Standardized training Took courses on their own Recommended by supervisor 13.7 yrs 8.6 yrs 81% 3.6 months 3.9 yrs 49% 11% 74%

Workload of Preceptors Client care assignment: Yes, regular load 45.8% Yes, reduced load 31.7% No 22.5%

Pre-Graduation Synthesis Experience ADNs BSNs (n=335) (n=181) Synthesis course required 33.8% 68.2% Length of the course (wks) 7.0 9.9

Transition Experience % No orientation or internship 2.0 Routine orientation only 24.3 Internship or plus 73.8

Internship Experience

Duration of Transition

Preceptor Involvement

Content of Transition Programs

Days Before First Patient Care Assignment

Patient Care Assignment

Patient Care Assignment

Clinical Competence: Overall

Clinical Competence: Subconcepts

Most Competent Areas Almost Always (%) Administer medications accurately 92.3 Maintain safe & respectful environment 83.6 Accurately perform client assessment 80.2 Perform technical skills accurately 79.7 Do what is right for clients no matter what 73.4

Least Competent areas Almost always % Appropriately utilize research findings 32.7 Meet clients cultural needs 41.5 Strategically delegate and supervise others 41.7 Recognize when demands exceed capability 47.4 Manage time and workload effectively 49.1 Use info. technology to enhance care 49.3 Synthesize data from multiple sources 50.0

Clinical Competence During 1st Year Overall New RNs Preceptors

Clinical Competence During 1st Year Subconcepts

Clinical Competence and Work Setting

Transition and Clinical Competence During first 3 months of practice, those who had a primary preceptor performed at a higher competent levels (B=0.45), especially in the areas of communication and interpersonal relationships (B=.51), as well as recognizing limits and seeking help (B=.49).

Practice Errors Only once % More than once % Total % Medication errors   Only once % More than once % Total % Medication errors 30.4 12.8 43.2 Client falls 22.8 12.1 34.9 Contribute to treatment delays 14.1 25.2 39.3 Charted on wrong client record 30.8 14.3 55.2 Missed physician/provider order 26.7 11.8 38.5 Misinterpreted physician/provider order 18.8 5.0 23.8 Error in performance of skills 18.0 10.2 28.2 Avoidable client death .4 .7 1.1 Client elopement 9.6 3.7 13.3

Practice Errors Index

Transition and Practice Errors

Clinical Competence and Practice Errors New nurses who were more competent (r= -.35), especially in the areas of clinical reasoning ability (ß=-.38) and communication and interpersonal relationships (ß=-.33), made less practice errors.

New RN Turnover* Changed position since being licensed. 21.2% Planning to leave current position within 6 months 23.0% *Either changed position or plan to leave, 40.0%

Transition and Turnover

Perceived Stress Almost Never % Some-times % Often/ Always % Felt overwhelmed with pt care responsibilities 19.4 56.7 24.0 Fear of harming the pt due to inexperience 71.7 25.5 2.8 Felt expectations unrealistic 45.8 38.6 15.6

Perceived Stress During 1st Year

Clinical Competence and Stress

Transition and Stress The longer the work experience the less the fear experienced by graduates about harming the patients (B=-.11) Graduates who had an internship (B=-.11) were less likely to feel expectations were unrealistic Graduates who had a transition programs that addressed specialty knowledge (B=-.10) were less likely to feel expectations were unrealistic

Stress and Practice Errors Beta Felt overwhelmed by care responsibilities .158 Feared harming client due to inexperience .208 Felt expectations unrealistic .137

Summary of Findings Transition experiences of new RNs vary across practice settings New RNs are more competent in the areas of pt care delivery and management, compared to the areas of clinical reasoning and judgment skills, as well as recognizing limits and seeking help During the first 3 months of practice, new RNs who had a primary preceptor practiced at higher competent levels Without the assistance of preceptors, new RNs practiced at less competent levels during their initial phase of independent practice

Summary of Findings New RNs with preparation for specialty practice in transition programs made less errors Less competent and/or stressed new RNs made more practice errors New RNs who had an internship experience were less likely to leave their current position within the next 6 months

Acknowledgements Advisory Group: 2006 & 2007 NCSBN PR&E Committee Nancy Spector, NCSBN Director of Education Gino Chisari (Chair, 2006) Brenda S. Jackson (Chair, 2007) Mary Blubough (Board Liaison) Connie Brown Barbara Knopp Barbara Newman Cynthia Van Wingerden Debra Werner Lepaine McHenry Marcy Echternacht Therese Shipps Mary Calkins Mary Doherty, NCSBN Practice, Regulation, & Education Associate Research Support Data Collection: Lindsey Gross Statistical Support: Richard Smiley

Contact Information Suling Li, PhD, RN Tel: (312) 525-3658 sli@ncsbn.org