1. Implementing a QSEN Focused Transition to Practice Program
QSEN Conference - May 31, 2017, Chicago, IL 1

2. NCSBN’s Mission
The National Council of State Boards of Nursing (NCSBN) provides education, service and research through collaborative leadership to promote evidence-based regulatory excellence for patient safety and public protection.

3. Background
2001 NCSBN Employer’s study: Fewer than 50% of employers report newly licensed nurses are “safe and effective” in their practice.
Replicated in 2003 with similar results.
NCSBN BODs convened a TTP Committee, charged to design an evidence-based TTP model

4. Background Reviewed the evidence for a year (2009-2010)
Literature review
Gaps in education/practice
Berkow (2008)
Benner (2004)
Patient safety
Stress linked to errors (Elfering, 2007)
Discipline reports (MA BON, 2007; Chicago Tribune, 2000)
Missed care (Kalisch, 2006)
Just a few examples from the literature: Areas of improvement from Berkow: Follow up, initiative, quality improvement, time management, tracking multiple responsibilities, conflict resolution and delegation. Benner emphasizes that new nurses think concretely, rather than more broadly being able to clinically reason, especially in stressful situations. BONs, when there was discipline (collected from MA BON study; Chicago Tribune comprehensive look at all discipline in Illinois and one relationship was with new nurses)

5. Background Patient safety (cont’d) Competence
Ebright, 2004 (near misses)
Del Bueno, 2005 (COPA model)
Competence
Bjork & Kirkvold, 1999
Dartmouth Hitchcock transition program, 2007
Dartmouth Hitchcock did simulation for high-risk/ low frequency. COPA Competency Outcomes and Performance Assessment

6. Background Retention Kovner, 2009 – 26% in two years
Before economic downturn: 35%-60%
What’s next? (Auerbach et al., 2011)

7. Reviewed Successful Programs (2009-2010)
UHC/AACN’s Residency (now Vizient/AACN)
Versant Residency Program
Wisconsin Residency Program
Mississippi Residency Program

8. Successful International Programs (2009 – 2010)
Flying Start - Scotland
Canada’s Preceptorship Program
Australia’s Risk Management Program for new nurses
Portugal’s regulatory transition program

9. Evidence-Based Model Competencies
Specialty content
Communication
Safety
Clinical reasoning
5. Prioritizing/organizing
Evidence-based practice
Role socialization
Delegating/supervising

10. Threads
To be integrated throughout:
Feedback
Reflection

11. Collaborative Model
More than 35 stakeholders made suggestions on the model, including AACN, NLN, NOADN, ANA, AONE, HRSA, AHRQ, CMS, QSEN, etc.
QSEN suggested crosswalking with their competencies with goal of consistent national model.

12. QSEN Re-Categorizing
Specialty content Communication Safety Clinical reasoning
Patient Centered Care Communication & Teamwork Threaded throughout

13. Patient Centered Care Evidence Based Practice Communication & Teamwork
Re-Categorizing
Prioritizing/organizing Evidence based practice Role socialization Delegating/supervising
Patient Centered Care Evidence Based Practice Communication & Teamwork

14. Four Consistent Threads
Safety Clinical Reasoning Feedback Reflection

16. Multisite, Randomized, Controlled Study (JNR, 2015)
How effective is NCSBN’s TTP program in terms of safety, competence, stress, satisfaction and retention when compared to control group?
A Post Hoc Question Arose:
2. Do transition programs make a difference in new graduate outcomes in terms of safety, competence, stress, job satisfaction and retention?

17. Procedure State and site coordinators for study integrity
Online modules and surveys in integrated website
All sites either went through their own IRB or Western IRB
All preceptors trained before the study

18. Outcome Measures
Baseline, 6, 9, and 12 months; all established for validity and reliability:
Overall Competency (preceptors and nurses)
Specific Competencies (preceptors and nurses)
Safety Practices (nurses)

19. Outcome Measures (Cont’d)
Work Stress (nurses)
Job Satisfaction (nurses)
Preceptor Evaluation (preceptors and nurses)
Retention (data directly from the employers)

20. Results
No clear differences – so post-hoc question was asked: Do Transition to Practice Programs make a difference in new graduate outcomes in terms of safety, competence, stress, satisfaction and retention?

21. Results: Evidence-Based Components
Patient-centered care
Communication and teamwork
Evidence-based practice
Informatics
Safety
Clinical reasoning
Feedback
Reflection
Preceptorship
Specialty content

22. Results: Categories TTP Program – n=43 (577 new nurses)
Established Program – employ 6 components n=29 (300 new nurses)
Limited Program – employ fewer than 6 components – n=22 (186 new nurses)

23. Results Summarized Established programs significantly increased:
Overall competency
Job satisfaction
Established programs significantly decreased:
Work stress
Reports of errors
Use of negative safety practices (did not use universal precautions)
TTP in middle; Limited on bottom

24. TTP vs. Established vs. Limited Turnover
Transition Program
New Nurses Leaving
TTP
14.7%
Established Programs
12.0%
Limited Programs
24.8%

25. QSEN Competencies
All three groups significantly improved over the yearlong period
Implication: QSEN is being consistently integrated into the academic curriculum

26. TTP Courses Based on TTP study results: Communication and Teamwork
Patient and Family-Centered Care
Evidence Based Practice
Quality Improvement
Informatics
Preceptor Training

27. Key Features Assess – Begin courses with branching scenario
Learn – Information on a wide variety of topics is presented
Sustain – Real-world scenarios shared for application

28. Key Features (Cont’d) Interact – Preceptor and peer discussions
Evaluate – Preceptor feedback at every step
Modalities – Scenarios, quizzes, videos, critical thinking activities, discussion opportunities with preceptors and peers
Branching Scenarios – Beginning of each course

29. This is the plan of how these courses work together to allow new nurses to achieve a successful transition from education to their careers in nursing.

30. Communication and Teamwork: The primary goal of this course is to help new nurses understand the relationship between patient safety, collaboration, and teamwork. This course allows the new nurse to learn about providing safer and more effective care through situational awareness and using positive workplace behaviors. TeamSTEPPS strategies are emphasized (e.g., safety huddles, checkback, handoffs, etc.

31. An example of a scenario where the nurses use an SBAR.

32. Patient and Family Centered Care: The primary goal of this course is to help you understand the importance of including patients, their families, and significant others as integral members of the health care team. The course uses the 8 Picker Institute Principles of Patient-Centered Care. Areas such as linguistic & cultural competency, informed consent, culture of safety and medication errors are presented.

33. Quality Improvement: Primary goal is to understand how QI is used to facilitate change and how nursing quality initiatives can improve patient care. 
Learn how to study a problem, no matter how small. Learn about specific QI tools, eg fishbone diagram, flowcharts, etc.

34. Informatics: The primary goal of this course is to help you understand how nursing informatics supports a learning health care system. Nurses assess their informatics competencies. They learn about data management systems to improve patient care. E.g., what is the future of medical records? Documentation integrity.

35. Evidence Based Practice - The primary goal of this course is to help you understand the relevance of evidence-based practice (EBP) in nursing practice. The students learn about how evidence improves patient care, how to access the databases for questions, asking burning questions, etc.

36. The primary goal of the Preceptor Course is to facilitate the new nurses’ transition to practice. The course will teach the preceptors with their responsibilities as a coach, evaluator, facilitator, protector, role model, socialization agent and teacher and how to fulfill these responsibilities.

37. “ The synergy inspired by the Quality and Safety Education for Nursing (QSEN) project over the past decade is leading the transformation of nursing education and practice to improve Quality and safety of health care.” ~ Sherwood & Barnsteiner, 2017
Contact Information:
Nancy Spector, PhD, RN, FAAN: