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

2. 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

3. 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)

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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,

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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, Bratt, M. M. (2013). Nurse residency programs: Best practices for optimizing organizational success. Journal for Nurses in Professional Development, 29(3), 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), 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), MacKusick, C. I. & Minick, P. (2010). Why are nurses leaving? Findings from an initial qualitative study on nursing attrition. Medsurg Nursing, 19(6), 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), Quality and Safety Education for Nurses (2014). Competencies. Retrieved from ksas/ Spectrum Health (2014). For nurses: Nursing excellence providing world class care. Retrieved from