Health care reform due to the Patient Protection and Affordable Care Act, technological innovations, and cost-cutting trends are expected to accelerate the shift in the locus of care from the hospital to the community setting (Domrose, 2010; O’Neil, 2009). The ability of the nursing profession to help shape the future U.S. health care system depends on its capacity to envision its future outside acute care settings (Institute of Medicine, 2010). Nursing should identify opportunities to redefine the traditions of public health nursing of the early 20th century, developing and expanding roles such as health coach, care coordinator, informaticist, primary care provider, and health team leader in community-based settings (Institute of Medicine, 2010).
Approximately 60% of all RNs currently work in acute care settings (Health Resources and Services Administration, 2010). An even greater proportion of new RN graduates (88%) are employed in inpatient settings, which is the traditional first step in a nursing career path (Domrose, 2010; Kovner et al., 2007). Transition programs for new nursing graduates in this setting are well established and result in improved competency and better retention (Rush, Adamack, Gordon, Lilly, & Janke, 2013). However, limited documentation is related to transition programs that prepare new graduates for ambulatory settings.
Opportunities and choices for new nurses after graduation influence the evolution of nursing practice. These positions are often constrained by student or new graduate expectations and preferences, faculty views, employers, and, in some cases, regulations. A continuing focus among new RN graduates on the acute care setting for models of career development and professional fulfillment inhibits the emergence of new community-based models of nursing practice. Nursing faculty can help shape student expectations, but educators must fully understand and support the transition to community-based practice before students follow (O’Neil, 2009). Community-based employers often expect new RN graduates to first pursue a traditional inpatient nursing career path; 1 year of professional nursing experience before employment in home care is required by some regulatory bodies, further constraining opportunities for new RN graduates.
The purpose of this article is to describe the implementation of academic–practice collaborative transition programs in community settings for new RN graduates who had not yet found employment in nursing. We focus on the lessons learned with the goal of facilitating the transformation of practice models for new RN graduates and, more broadly, for nursing.
Collaborative Transition Programs
The four transition programs were collaborative partnerships between one or more academic nursing programs in the San Francisco Bay Area (SFBA) and multiple practice sites spanning inpatient, ambulatory care, home care, and school settings. The programs arose in response to a request for proposals from the California Institute for Nursing & Health Care (CINHC) and were funded by grants and in-kind contributions from the participating schools and organizations. A consortium was created to link area schools of nursing, CINHC, and SFBA health care agencies. The target population included licensed RN graduates of any SFBA academic nursing program within the previous 18 months who had not yet found employment in nursing, despite efforts to do so; a confluence of factors in the SFBA resulted in a very tight job market for new nursing graduates (West et al., 2014). The dual goals of all programs were to retain these nurses in the profession and increase their confidence, competence, and employability. The application process for all programs consisted of submitting a résumé, goal statement, history of efforts to find employment as a nurse, and letters of recommendation from faculty of the degree-granting program. Individual programs had additional requirements. Participants had completed associate, bachelor’s, or entry-level master’s in nursing degrees. At least three qualified new graduates applied for each program opening.
Between January 2010 and August 2011, programs at each of four sites were provided to two to four cohorts of 14 to 53 new RN graduates; a total of 345 new RN graduates enrolled. Each program lasted 12 to 16 weeks and consisted of 4 or 8 hours per week of classroom, online, simulation, and skills laboratory instruction provided by clinical faculty and 16 to 24 hours per week of precepted clinical practice with clinical faculty oversight. Each program exercised flexibility in implementation to best tailor educational experiences to their participants.
Transition Program for New RN Graduates in Community Settings
Three of four transition programs provided either in-patient experiences only or a combination of acute care and community-based settings. This article describes the experience of one academic–practice partnership that focused exclusively on providing new RN graduates with professional experience in community settings that included schools and high school–based clinics, ambulatory care clinics, home health and hospice, and transitional care. Forty participants enrolled in two cohorts during the initial grant-funded period in 2010–2011; an additional 35 participants enrolled in two additional cohorts when the program was continued after the initial grant funding ended. A fifth cohort of 20 participants enrolled in August 2013.
Practice sites selected their participants from a list of candidates prepared by the program director from the school of nursing. The program director conducted all the initial onboarding of program applicants, such as health clearance, background checks, and licensure and qualifications verification. (Participants also received worker’s compensation and liability insurance under student coverage.) The director provided summary information on all program applicants, which included demographics, qualifications, experience, degrees, and school performance. Practice site leaders, such as clinic nursing managers or school health administrators, reviewed the summaries, interviewed prospective participants, and made the final selection of new RN graduates for their sites.
The classroom portion of the program included content elements specific to community settings. For example, participants learned a model of care that emphasized communication and helping patients to self-manage their health. Specific topics included care and case management, a team approach, patient-driven focus, integrated care, transitional care, behavior change, and self-management. Additional classroom content included scope and standards of practice for various community settings, communication, documentation, regulatory issues, end-of-life care, quality improvement and assurance, health care payment sources, and diagnostic and procedural coding issues, as well as reviewing the selected skills. Participants completed a total of 320 clinical hours during the transition program.
Providing community-based transition programs for new RN graduates resulted in important insights. In particular, they relate to changing the nursing culture about new graduate career paths, addressing regulatory issues as needed, new graduates’ potential to help transform nursing, and advancing academic–practice partnerships and supporting clinical placement sites. The learnings gleaned are broadly generalizable.
Changing the Nursing Culture
The community-based transition program sought to change the prevailing view within nursing that new graduates must spend at least 1 year in an inpatient setting before moving into more independent roles. Several factors enabled this culture change. The first was a series of meetings convened by CINHC to discuss the possibility of offering transition programs for new nursing graduates who had not yet found employment in nursing. Nursing leaders from throughout the state (and beyond) were invited. Although the initial meetings focused predominantly on inpatient practice sites, later discussions engaged nursing leaders in exploring how to develop transition programs in ambulatory care settings, such as clinics and schools, and evolved to include adding specialty sites, such as transitional care, home health, and hospice settings. Senior leaders from practice sites attended the meetings, setting the stage for a top-level partnership to provide a community-based transition program with a wide variety of care delivery sites.
The school had a history of innovation, and the transition program director had the benefit of existing contacts and credibility when working with agency and program staff. Given the school platform, the transition program director invested heavily in personal communication about the feasibility and benefits of providing precepted clinical hours to new nursing graduates. The program aimed to revise the prevailing stereotype among community agencies that a new RN graduate is a younger adult with little life experience. Many participants in the community-based transition program entered nursing as a second career, with prior undergraduate or graduate degrees across a range of disciplines. Even younger new graduates often have an expansive worldview that can enable them to function effectively in nontraditional settings.
The school of nursing’s clinical placement coordinator provided information about existing relationships with clinical sites and assisted with the formal arrangements for students. The initial cohort of 20 participants required the most intensive time investment to secure placements. The new graduates were placed at 10 public schools and 10 ambulatory care clinics. Developing these placements required approximately 6 months of effort by the program director.
Individuals at practice sites reported that several factors led to a positive experience with the transition program. They had a large selection of candidates from which to choose, and the initial review of applicants by the program director provided a clear summary of each potential participant. Preceptor training and support were pivotal, as was the school’s provision of insurance coverage for participants. In addition, they perceived the curriculum to address gaps between nursing education and community-based practice as essential.
The only negative experience reported by individuals at the practice sites related to participants who discovered that ambulatory care was not a good fit; this occurred infrequently and only among those who were not interviewed by individuals at the site before beginning the program or those who recruited their own practice site to increase the likelihood of acceptance into the transition program. This can be mitigated by adhering to the school’s selection of practice sites and the consistent use of interviews by agencies when selecting among potential participants.
Troubleshooting Regulatory Issues
A key source of reluctance on the part of some community-based practice sites was a California Department of Public Health regulation requiring that all nurses have 1 year of professional nursing experience before being hired to provide nursing services though a home care agency. Although employment was not promised to program participants, agencies were concerned that if they wanted to hire a participant who had completed the program, they would be unable to do so. CINHC and the school of nursing worked with the state to develop a waiver process for the home care regulation requiring 1 year of professional nursing experience.
As a result, home health practice sites could obtain waivers at the organizational level, which were renewable annually, or for individual new nursing graduates. Agencies were required to document the following: (a) individuals’ previous nursing experience or participation in the community-based new RN graduate transition program; (b) agency staff RN orientation; (c) agency competency evaluations and training or skills assessment for new nurses employed under the waiver process; and (d) agency quality assurance and assessment review processes (California Department of Public Health, 2012). Agencies that wanted to hire a program participant were also required to prepare and submit a post-hire plan demonstrating ongoing support and oversight for 8 months. The waiver process took approximately 6 weeks and was initiated by practice sites when they wanted to offer employment to a participant after program completion. The school of nursing assisted practice sites with the process, helping to assure that key features were included.
New Graduates Can Help to Transform Nursing
In addition to the model of precepted practice augmented with class and simulated clinical experiences, each transition program participant completed a quality improvement project in the clinical setting. Each project began as the preceptor and the participant explored quality improvement and assurance projects at the practice site. These projects related to agency-specific needs to help improve system outcomes, patient outcomes, staff outcomes, or a combination of the three. Working with a preceptor and others at the practice site, the participant identified measures for assessing improvement, an evidence base for developing the project, interdisciplinary team approaches, and the participant’s part in the quality improvement project. Including quality improvement underscored that the primary goal of the transition program was professional development, not skills acquisition, even though participants had opportunities to enhance hands-on skills in simulation laboratories and actual practice environments.
Practice site managers or preceptors perceived participants’ roles in quality improvement and assurance as highly beneficial, and the prospect of having assistance with quality improvement was one motivator for participating in the transition program. The value of this element of the program is best reflected in eight non-participating practice sites that contacted the program director about being included in a future cohort so they could reap the benefits of having a transition program participant share in quality improvement work. Practice site managers or preceptors often found the energy and enthusiasm of new RN graduates to be infectious, increasing the willingness of staff to mentor and learn.
A tool used in the transitions program assessed pre- and postprogram preceptor perceptions of participant professional development in terms of the Quality and Safety Education for Nurses (QSEN) competencies (Berman et al., 2014). This increased the familiarity of practice sites with the knowledge, skills, and attitudes associated with the six QSEN competencies of patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
Develop Academic–Practice Partnerships by Supporting Practice Sites
Until new nursing graduates are commonplace in ambulatory and home care settings, practice sites need support. In our experience, few nursing staff had extensive experience precepting new RN graduates, and many questions arose during the course of the program. The school of nursing program director provided active support to practice site preceptors and managers. Strategies included preceptor workshops and training, printed program guidelines and weekly learning activities (Figure), and monthly preceptor conference calls. Preceptors, located at many different sites and who sometimes may be the only RN at a school or clinic, were invited to the school of nursing campus for a dinner and interactive presentation, which gave them an opportunity to network, feel part of the larger effort, and better understand their role (Richards & Bowles, 2012). Preceptors reported feeling that their extra effort was worthwhile for engaged participants who wanted clinical experience at that site. Management support of preceptors and the transition program was also pivotal.
Example of weekly learning activities.
The school of nursing offered a modest financial incentive to practice sites. This proved to be an important strategy for recruiting the participation of many sites. The incentive was paid to the preceptor or to a fund or foundation for staff development if agency policies prohibited payments to individuals.
Finally, the program director was readily available by e-mail and telephone for questions and problem solving. Providing sufficient support to practice sites and preceptors requires a substantial time commitment. However, this is time well spent, both for the immediate benefit of program participants and over the long term in the form of closer ties between academic and clinical settings. Developing ongoing academic–practice partnerships removes barriers that often exist between educational and practice settings and can facilitate clinical placements for prelicensure students, as well as those for transition program participants.
Academic–Practice Partnerships Can Help to Transform Nursing Practice
Academic–practice partnerships in community-based settings are essential to transforming health care and advancing nursing education. The transition program described in this article influenced the culture within the school of nursing, successfully changing faculty perceptions about the relevance of community-based practice opportunities and potential career trajectories for new RN graduates.
All participants who completed the community-based transition program gained employment in nursing. Although employment by the practice site was not an explicit assumption of the program, some participants were hired by their practice sites. Other settings had no open position or had other restrictions, such as strict hiring protocols. In those cases, participants were hired by other ambulatory care agencies or returned to inpatient care. For example, participants with school nursing experience became employed in pediatric inpatient settings, underscoring the value of their community-based experiences. Some participants elected to pursue higher education in nursing, rather than become employed.
Academic–practice partnerships also make community-based capstone experiences possible for prelicensure students, which is a change essential to transforming nursing education to align with health care reform and the future of nursing. Equally essential to transforming nursing education is fully embracing a community-based model of nursing care that is patient directed and interdisciplinary team based. As students and faculty view preparation for practice in community settings as an essential part of prelicensure education, this model of care, which aligns with that envisioned in the report on the future of nursing, will become widely disseminated (Institute of Medicine, 2010).
The four community-based transition programs began as an effort to support new RN graduates who had not yet found employment in nursing. The program that focused on community-based nursing led to a substantial shift in culture and thought. It proved to be effective at meeting program goals for individual new RNs and, more importantly, prompted a reconceptualization of the way to advance essential changes in health care. Indeed, community-based nursing is a key component of the emerging shifts in health care, and making this practice setting a valid option for new RN graduates is both possible and advantageous. Nursing education and nursing practice share an opportunity to embrace change and plan for success.
- Berman, A., Beazley, B., Karshmer, J., Prion, S., Van, P., Wallace, J. & West, N. (2014). Competence gaps among unemployed new nursing graduates entering a community-based transition-to-practice program. Nurse Educator, 39, 56–61. doi:10.1097/NNE.0000000000000018 [CrossRef]
- California Department of Public Health. (2012). Program flexibility for home health agencies (HHA) nursing experience requirements. Sacramento, CA: Author.
- Domrose, C. (2010). A new era in nursing: Community health and aging population shift RN employment. Retrieved from http://news.nurse.com/article/20100912/national01/109130045/-1/frontpage
- Health Resources and Services Administration. (2010). The registered nurse population: Findings from the 2008 national sample survey of registered nurses. Rockville, MD: Author.
- Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.
- Kovner, C.T., Brewer, C.S., Fairchild, S., Poornima, S., Kim, H. & Djukic, M. (2007). Newly licensed RNs’ characteristics, work attitudes, and intentions to work. American Journal of Nursing, 107(9), 58–70. doi:10.1097/01.NAJ.0000287512.31006.66 [CrossRef]
- O’Neil, E. (2009). Four factors that guarantee health care change. Journal of Professional Nursing, 25, 317–321. doi:10.1016/j.profnurs.2009.10.004 [CrossRef]
- Richards, J. & Bowles, C. (2012). The meaning of being a primary nurse preceptor for newly graduated nurses. Journal for Nurses in Staff Development, 28, 208–213. doi:10.1097/NND.0b013e318269fde8 [CrossRef]
- Rush, K.L., Adamack, M., Gordon, J., Lilly, M. & Janke, R. (2013). Best practices of formal new graduate nurse transition programs: An integrative review. International Journal of Nursing Studies, 50, 345–356. doi:10.1016/j.ijnurstu.2012.06.009 [CrossRef]
- West, N., Berman, A., Karshmer, J., Prion, S., Van, P. & Wallace, J. (2014). Preparing new nurse graduates for practice in multiple settings: A community-based academic–practice partnership model. The Journal of Continuing Education in Nursing, 45, 252–256.