1. Transition to Practice Regulatory Model: Implementing Change Nancy Spector, PhD, RN June, 2008

2. Mission of NCSBN The National Council of State Boards of Nursing (NCSBN), composed of Member Boards, provides leadership to advance regulatory excellence for public protection.

3. Background of the Problem

4. Benners work over 20 years Benners work over 20 years Kramers Reality Shock, from 1974 Kramers Reality Shock, from 1974

5. Background of the Problem NCSBN 2001 Employers study Yes definitely to new graduates providing safe and effective care: 45% - diploma graduates 45% - diploma graduates 40% - BSN graduates 40% - BSN graduates 35% - ADN graduates 35% - ADN graduates 30% - PN graduates 30% - PN graduates

6. Background of the Problem: Not About Blame

7. Background of the Problem Computerized NCLEX, allowing for almost immediate licensure Context of practice: frenzy Health care becoming more complex Nursing shortage

8. Background of the Problem Turnover rates (2006 Nurse Executive Center: Transitioning New Graduates to Hospital Practice) One Year – 36% Two Years – 75% Three Years – 50%

9. Background of the Problem Underinvestment of Novice Nurses (2006 Nurse Executive Center): CMS Funds American Council for Graduate Medical Education American Society of Health-System Pharmacists Association for Clinical Pastoral Education

10. Background of the Problem NCSBN Hosted Transition Forum: February 22, 2007 Speakers from other disciplines and countries all came together Various research findings showed need for transition programs

11. Background of the Problem NCSBN Hosted Transition Forum: February 22, 2007 Stakeholders agreed to a standardized regulatory model (AACN, AONE, ANA, NAPNES, NLN) Buy-in is so important

12. Charge from Board of Directors Recommend an evidence-based regulatory model for transition to practice.

13. Barriers Time Constraint – October 2007 – April 2008 Committee make up States are autonomous

14. Evidence 5 International Projects Canadian Nurses Association Canadian Nurses Association Scotland Scotland Ireland Ireland Portugal Portugal Australia Australia

15. Evidence 16 National Projects/Studies: 2002 American Health Care Association 2002 American Health Care Association Behrens (investigative reporter) (2000) Behrens (investigative reporter) (2000) Carnegie study of nursing education (preliminary) Carnegie study of nursing education (preliminary) EBNER (2006) EBNER (2006) Joint Commission 2002 White Paper Joint Commission 2002 White Paper

16. Evidence National: Hofler: synthesis of national reports (2008) Hofler: synthesis of national reports (2008) HRSA (2007) HRSA (2007) NCSBN analysis of discipline data (2007) NCSBN analysis of discipline data (2007) NCSBN employer studies (2004) NCSBN employer studies (2004) NCSBN post-entry study (preliminary) NCSBN post-entry study (preliminary)

17. Evidence National: NCSBNs Transition Study (2006)NCSBNs Transition Study (2006) NCSBNs Transition Study (unpublished)NCSBNs Transition Study (unpublished) RNRN PNPN National Survey of Nursing Home Workforce Satisfaction (2006)National Survey of Nursing Home Workforce Satisfaction (2006)

18. Evidence National: University HealthSystem Consortium/American Association of Colleges of Nursing (2007) University HealthSystem Consortium/American Association of Colleges of Nursing (2007) Versant (2001) Versant (2001)

19. Evidence 7 Statewide Projects/Studies: California – In process; White paper California – In process; White paper Kentucky – Legislation Kentucky – Legislation Massachusetts – Preliminary data Massachusetts – Preliminary data Mississippi – Office of Workforce Nurse Residency Program Mississippi – Office of Workforce Nurse Residency Program

20. Evidence Statewide: North Carolina North Carolina Vermont Nurse Internship Program Vermont Nurse Internship Program Wisconsin Residency Program Wisconsin Residency Program

21. Evidence 12 Individual Studies/Projects: Bjørk & Kirkevold (1999) – Empirical evidence Bjørk & Kirkevold (1999) – Empirical evidence Childrens Memorial, Chicago (2007) – Cost/Retention Childrens Memorial, Chicago (2007) – Cost/Retention Dartmouth-Hitchcock (2007) - Simulation Dartmouth-Hitchcock (2007) - Simulation Del Bueno (2005) – Novice nurses judgment Del Bueno (2005) – Novice nurses judgment

22. Evidence Individual: Ebright, Urden, Patterson & Chalko (2004) – Near misses and adverse events in novice nurses Ebright, Urden, Patterson & Chalko (2004) – Near misses and adverse events in novice nurses Johnstone & Kanitsaki (2006) – Clinical risk management in new graduates Johnstone & Kanitsaki (2006) – Clinical risk management in new graduates Johnstone & Kanitsaki (2008) – Novice nurses integration of patient safety Johnstone & Kanitsaki (2008) – Novice nurses integration of patient safety

23. Evidence Individual: Johnstone, Kanitsaki & Currie (2008) – Support Johnstone, Kanitsaki & Currie (2008) – Support Keller, Meekins & Summers (2006) – Cost/Retention Keller, Meekins & Summers (2006) – Cost/Retention Pine & Tart (2007) - ROI Pine & Tart (2007) - ROI

24. Evidence Individual: Orsolini-Hain & Malone (2007) – Excellent review citing impending gap in clinical expertise Orsolini-Hain & Malone (2007) – Excellent review citing impending gap in clinical expertise Sir Charles Gairdner Hospital Centre for Nursing Education – Australia Sir Charles Gairdner Hospital Centre for Nursing Education – Australia

25. Once Evidence was Collected Developed DefinitionsDeveloped Definitions Core Elements of ModelCore Elements of Model PreceptorshipPreceptorship Feedback and ReflectionFeedback and Reflection Across Settings and EducationAcross Settings and Education

26. Summary of the Evidence How much evidence is enough? Our perspective is on public protection Safety Competence Retention

27. The Model

28. Considerations Cost ROI 67.3% (Versant); 884.7% (Methodist Hospital in Houston) Money saved on decreased turnover and fewer replacement nurses What about cost to Boards?

29. Considerations Collaborations Legislators AHA Nursing practice Nursing education Joint Commission CMS

30. Considerations Link to license Link to license Enforcement? Enforcement? Compromise Compromise

31. Next Steps National Web site National Web site Identify strategies for implementation, e.g., pilots? RNs/acute first? Identify strategies for implementation, e.g., pilots? RNs/acute first?

32. The Future in Nursing