Transition of Nurses from Education & Practice

Nancy Spector, Director of Education

• Strategic initiative that seeks excellence in regulation

• Board needs: Unintended consequence of CAT

• PERC’s recommendations

Background

• January – March 2002

• Stratified random 1000 RNs (focus on RNs)

• 3 stage mailing

• 633 usable surveys

2002 Practice & Professional Issues Survey (Spring)

Surveys – Drs. Smith & Crawford

• Self reports

• Questions

– Work environment– Education and transition– Involvement in errors and difficulty with

assignments– Demographics

Outcome 1: Involvement in errors – 49%– Definition: incidents or

“occurrences that resulted in harm to clients or had the potential to place a client at risk for harm. You may have been involved as the one making the error, the supervisor of others making errors, or as the one discovering errors made by others.”

Outcomes

Types of Errors/Occurrences

1.3

11

0.3

37

40

75

2

13

1.7

36

47

71

0 10 20 30 40 50 60 70 80

Care povided by impaired Professional

Client elopement

Avoidable death

Delays in care/treatment

Falls

Medication

Percent

RN LPN/VN

Work Place Causes of Errors

0 10 20 30 40 50 60 70 80

RN

LPN/VN

Inadequate staffing

Lack of adequatecommunicationLong work hours

Lack of support from otherdepartmentsPoorly understood policiesand proceduresInadequate orientation

Lack of supplies orequipmentOther

Inappropriate use of UAP

Lack of adequate referencematerialLack of CE classes

• Problems understanding English & non English speaking clients & staff

• Problems reading or understanding MD orders

• Prior work as NA – more likely• Prior work as PN – less likely• OT – more likely• Age – younger more likely

Other Factors Related to Errors

• 20% too difficult

• Average days to first assignment: 8 days

• 13% said first assignment too challenging

Outcome 2:Difficulty of Current Assignment

• Self report of perceptions

• Definition of error

Study Limitations

Secondary Analysis of Data for Transition Models Multiple chi squares and t-tests on variables

%Before graduation 35.1Before licensure 52.8Part of post hire orientation 63.8Paid for work performed 76.7Paid tuition to be in program 12.5Voluntary 19.5Mandatory 55.3Assigned same nurse as preceptor/mentor 49.7Assigned preceptor/mentor worked the same scheduled I worked 48.3Designed to increase general knowledge and skills 62.0Designed to increase specialty knowledge and skills 62.4

Internship/Externship, Preceptorship, Mentorship Descriptors - RN

• Knowledge type: General versus Specific

– General includes core information

– Specific includes specialty knowledge

– Mixed results

Evidenced-Based Models for Successful Transition

• Specific knowledge – Fewer errors (p=.000)

– Better prepared for current assignment (p=.047)

• Core knowledge

– More prepared to function as a team (p=.036)

– More prepared to provide teaching (p=.024)

Evidenced-Based Models for Successful Transition (Con’d)

Evidenced-Based Models for Successful Transition (Con’d)

• Provide a transition program with core knowledge and also specialty knowledge.

* Best Practice Recommendations

Evidenced-Based Models for Successful Transition (Con’d)

• Placement of transition programs

– Before or after graduation

– Pre hire versus post hire

– Pre licensure versus post licensure

Evidenced-Based Models for Successful Transition (Con’d)

• Placement of transition programs

– Fewer errors with post graduate programs (p=.004)

– Better prepared for current assignment with post graduate programs (p=.015)

Evidenced-Based Models for Successful Transition (Con’d)

* Best Practice Recommendation:

•Post hire/pre licensure transition programs

–Kentucky Model

Evidenced-Based Models for Successful Transition (Con’d)

• Mandatory versus Voluntary Programs

– Mixed results

– Mandatory – more errors (p=.044)

– Voluntary – less prepared to administer meds (p=.027)

No recommendation– bears watching

Evidenced-Based Models for Successful Transition (Con’d)

• Same mentor with same schedule– More confidence (sum score) (p=.000)

– Evidence supports increase confidence

* Best Practice Recommendation:

• Same mentor with same schedule

Evidenced-Based Models for Successful Transition (Con’d)

* Best Practice Recommendation:• For regulators the following are key aspects of

education:

– Making decisions– Providing direct care to 2 clients– Knowing when and how to call the physician– Supervising care– Working effectively within a health team

• 2003 Employers Survey(Drs. Crawford & Smith)

– 1189 employer responses

– 41.9% said new RN (BSN & ADN) provide safe, effective care

Other Research

• 2003 Employers Survey (Drs. Crawford & Smith)

– 69.1% said their transition programs last 6.7 weeks– Longterm care offered the least– Employers rated these skills as most important:

1. Critical thinking or clinical decision-making

2. Therapeutic relationships

3. Medication administration

4. Management leadership

5. Psychomotor skills

Other Research (Con’d)

• Experienced and new nurses July 2002 – June 2003• N=592

Design• 56% standardized transition• 36% customized transition

Type• 62% preceptorship• 21% orientation

Survey Spring 2003 (Drs. Smith & Crawford)

1. Critical thinking and clinical decision-making

2. Medication administration

3. Psychomotor

4. Therapeutic relationship

5. Management/leadership

Most Important Skills (Students)

• Collaborate with VNIP

• Investigate HRSA work with residencies

• Study on outcomes– Vermont

– Kentucky

– National

• Develop model based on outcomes

NCSBN Future

The art of progress is to preserve order amid change and to preserve

change amid order.

Alfred North Whitehead