In the past several years, an increased supply of new RN graduates and the impact of economic trends on nursing employment have made it difficult for new RN graduates in California to find employment despite a statewide nursing shortage. Since 2005, in response to a projected shortfall in California by 2030 of more than 193,000 RNs (Juraschek, Zhang, Ranganathan, & Lin, 2012), a partnership between the state, educational institutions, and private organizations invested more than $100 million to increase nursing education capacity (California Labor and Workforce Development Agency, 2010). Between 2002 and 2012, the number of California nursing programs grew by 36% and the number of nursing students graduating annually grew by 92%, an increase of approximately 5,000 RNs (Waneka, Bates, & Spetz, 2013).
Beginning in 2009, an economic recession created overall unemployment rates in California at or above 10.5%, a rank fluctuating between 48th and 49th of the country’s 50 states in terms of employment (Bureau of Labor Statistics, 2013). Nearly half of California’s nursing workforce is older than the age of 50, and many nurses have delayed retirement or worked more shifts to cope with the recession (California HealthCare Foundation, 2010; Dave, 2011). More nurses between the ages of 50 and 59 reactivated lapsed licenses in 2009 and 2010 than did nurses in any other decade of life (Spetz, 2011). With an abundant supply of experienced nurses and facing a tightening reimbursement environment, hospitals—the traditional setting of a first nursing job—have hired fewer new graduates (Buerhaus, Auerbach, & Staiger, 2009; California Institute for Nursing and Health Care [CINHC], 2009). In January 2013, 46% of new RN graduates in California had not found jobs in nursing 6 or more months after graduation (CINHC, 2013). Some found non-nursing employment, leaving the profession, at least temporarily, without having entered it. Others sought unpaid internships to keep nursing skills current, enrolled in baccalaureate or graduate nursing programs, or remained unemployed (Dave, 2011).
As of 2011, California had 664 RNs per 100,000 population compared to a national average of 874 (Kaiser Family Foundation, 2011). Economic recovery and an exodus of older nurses from the workforce, coupled with outmigration of younger nurses unable to find work in California, could cause the nursing shortage in California to persist or worsen (Buerhaus, 2009; Buerhaus, Auerbach, Staiger, & Muench, 2013).
Concurrent efforts also were under way to help new graduates bridge the gap between education and practice. A 2008 CINHC white paper identified nursing residencies as a key strategy for creating a well-prepared nursing work-force (Boller & Jones, 2008). In June of 2009, CINHC convened statewide meetings to raise awareness of the situation faced by new graduates and gather input from regional stakeholders about possible solutions. The leading recommendation was to create community-based programs to help transition newly graduated and licensed, but unemployed, RNs into professional practice (CINHC, 2009). A landmark Institute of Medicine (2010) report later identified nursing residencies as one of eight recommendations for preparing nurses for effective professional practice.
Nursing residencies are typically employer-provided and address several identified issues among new graduates: clinical, organizational, and critical thinking skills insufficient for safe independent practice in high acuity settings, high job turnover, and low job satisfaction (Goode & Williams, 2004; Krugman et al., 2006). Best practices include establishing a program infrastructure, creating a phased, evidence-based program, and increasing sustainability through evaluation and dissemination of results (Meyer Bratt, 2013). Nursing residences result in improved retention and competency (Goode, Lynn, McElroy, Bednash, & Murray, 2013; Rush, Adamack, Gordon, Lilly, & Janke, 2013). The University HealthSystem Consortium and American Association of Colleges of Nursing residency program is well known and currently offered in 92 practice sites in 30 states (four in California); more than 26,000 nurses have completed this residency program nationwide since 2002 (American Association of Colleges of Nursing, 2013).
However, the target population for the pilot programs described in this article consisted of unemployed new RN graduates. In light of reduced inpatient hiring of new graduates and the shifting of care to other settings under health care reform, the authors also sought to provide transition programs in both acute and nonacute care settings.
Transition Program Collaboratives
Beginning in November 2009, CINHC received funding to establish transition programs in the San Francisco Bay Area. CINHC distributed a request for proposals to create regional collaboratives and establish transition programs. Four collaboratives were developed:
- A private health sciences university in partnership with an integrated health care delivery system and multiple hospitals.
- A private university in partnership with a consortium of community health centers and a statewide organization for school nurses.
- A campus within the state university system in partnership with 10 hospitals and six nonacute care sites.
- A private health sciences university, a state university, a community college, and a workforce development institute in partnership with three hospitals and one hospice.
Each collaborative represented a joint effort between academic and practice settings. Academic–practice partnerships operate from a common belief that it is the mutual responsibility of academia and clinical settings to create programs that will ensure a quality nursing workforce (Bratt, 2009). Collaboratives included a mix of nonacute care settings, such as hospice, clinics, school districts, and skilled nursing facilities, as well as hospitals that ranged from smaller community facilities to large medical centers within multihospital systems.
Each collaborative had the flexibility to create programs to best meet the unique needs of its regional partners, but all shared core requirements:
- Programs were offered through schools of nursing with liability and workers’ compensation coverage provided based on the student status of enrolled RN participants.
- Programs included classroom, simulation, e-learning, skills laboratories, and clinical components.
- Programs developed curricula based on the Quality and Safety Education for Nurses (QSEN) competencies (Cronenwett et al., 2007; QSEN Institute, 2013).
- Participants were required to have passed the NCLEX-RN® and be licensed.
- Participants were assigned to preceptors who had access to training and resource materials.
All of the programs were built on the QSEN competencies, and general knowledge domains were consistent across all of the programs: cultural competence, communication, patient safety, pain management, and wound care. In addition, programs tailored content to the sites where participants completed clinical hours. Acute care nursing, community-based nursing, and skills laboratory topics are listed in the Table. Each program followed general guidelines for content and structure but the curriculum was customized to meet the needs for participant skills at practice sites.
Examples of Collaborative Program Topics
Each collaborative independently promoted its program via social media, e-mail campaigns, and workplace advertising. Referrals across programs occurred if programs were full or if applicants had specific clinical interests. Programs used a variety of application and selection criteria, including online applications and in-person interviews. Two programs provided stipends. Three programs charged nominal registration fees. CINHC provided standardized evaluation and completion certification.
Most of the RNs selected as preceptors had previous training and experience in that role. On the advice of a statewide advisory committee, CINHC purchased a nationally recognized online training course with an interactive component, which was completed by 19 (6%) preceptors. One program developed and provided preceptor training internally.
Between January 2010 and August 2011, each program enrolled two to four cohorts of 14 to 53 new RN graduates. Programs lasted 12 to 16 weeks and consisted of 4 or 8 hours per week of classroom, online, simulation, or skills laboratory instruction provided by clinical faculty and 16 to 24 hours per week of precepted clinical practice with clinical faculty oversight. A total of 345 grant-funded new RN graduates enrolled.
Due to variation across programs, the goal of evaluation was modest: to identify general trends in participants’ confidence, competency, and employment that could justify further study. Participants completed a modified version of the Casey-Fink Graduate Nurse Experience Survey (2006 revision) at program start and end (Casey, Fink, Krugman, & Propst, 2004). Preceptors completed a pre- and postprogram New Graduate RN Transition Program Competency Assessment for their assigned participants; this tool was developed by a statewide evaluation advisory committee and focused on the six QSEN competencies. Preceptors rated participant competencies on a four-point scale: 0 = not applicable, 1 = beginning competency, 2 = developing competency, and 3 = advanced competency. CINHC also completed program cost analysis for each collaborative and for the transition program initiative as a whole. Changes in average total Casey-Fink and Transition Program Competency Assessment scores were assessed using a two-tailed t test.
A total of 262 participants completed at least 50% of a transition program; most of the participants who did not complete the program left because they became employed. Completed pre- and postprogram Casey-Fink surveys were available for 153 (58%) participants. The average total score increased from 59.3 to 66.6 (p < .001). Participants reported substantial increases in confidence about communicating with physicians and other health care providers, delegating tasks or asking for help, feeling prepared and completing patient care assignments on time, making changes to the nursing plan of care, and feeling supported by staff. They also disagreed more strongly with negative statements regarding prioritizing patient care needs and feeling overwhelmed by their responsibilities and workload. The average item score on the preceptor-completed Transition Program Competency Assessment increased from 1.97 to 2.73, an aggregate shift from high-level beginning competency to high-level developing competency. The average total score increased from 65.3 to 85.9 (p < 0.001).
Of the participants completing at least 50% of a transition program, 188 responded to a postprogram employment survey for a response rate of 72%. Two months after completing the program, 73% of respondents were employed as RNs; the proportion of each cohort employed at 2 months ranged from 25% to 100%. Three months after completion, 84% of respondents were employed; the proportion of each cohort employed ranged from 69% to 100%. Participants became employed at their practice sites or elsewhere. Two medical centers that did not serve as practice sites contacted transition program coordinators and requested information about RNs who had completed the program; six participants subsequently were hired.
Costs per participant ranged from $2,246 to $3,300 and averaged $2,823. Variability related primarily to the number of participants in each cohort and the number and location of clinical sites. Cost components included planning, facilitation, and administration; personnel (faculty, site coordinators, and support staff); indirect costs; participant stipends; materials and supplies; clinical preceptor training and replacement staff; facilities (classrooms and simulation laboratories); and liability insurance.
Transition-to-practice program collaboratives achieved positive results in terms of improved confidence, competence, and employment of participating new RN graduates. One strength of this report is that it describes the first collaborative, comprehensive effort between multiple academic nursing programs and practice settings to address new RN graduate unemployment and build proficiency.
A limitation of this report is the inability to identify or isolate critical program elements. However, across settings, participants had significant immersion experiences as a nurse, spending 16 to 24 hours per week in clinical practice; total clinical hours required ranged from 240 to 360. All of the programs provided specific content addressing QSEN competencies and clearly communicated that education for successful nursing practice continued after graduation. Preceptors guided clinical experiences, and all of the participants received mentoring from faculty.
Academic–practice partnerships hold the potential to be an effective solution to bridge the nursing student-to-professional gap, in addition to employer-based nursing residencies. Transition programs like those described in this article can be collaboratively and flexibly designed by academic and practice partners to meet the needs of specific practice settings. Although they facilitate the transition to practice of new RN graduates, these programs are not intended to supplant employer-based residencies.
Interest in establishing transition-to-practice programs for RNs is increasing throughout California. Of the four initial collaboratives, three continued to offer the programs after the period reported in this article to approximately 175 additional new RN graduates. Similar transition programs also have been offered in four additional areas of California: the Central Valley, Los Angeles/Ventura, Orange County/Inland Empire, and San Diego. Sixteen additional active and pending programs offer similar experiences for unemployed new RN graduates, based on the San Francisco Bay Area pilot. To date, nearly 1,000 new graduate RNs have enrolled. In addition, transition programs have expanded into the home health setting, as well as to practicing RNs transitioning into care coordination, an increasingly important role as health care reform proceeds.
Needs for future studies include aggregating data from and evaluating impact of the additional active and pending programs in California, replicating the transition programs in other settings, identifying effective practices and program elements, and quantifying the results of immersing new RN graduates in the nursing role without attendant responsibilities for a patient care load. In addition, the 84% 3-month employment rate observed for the new RN transition program participants exceeded the 64% 6-month employment rate for all new RN graduates in California; additional qualitative data from employers would explicate the impact of the program on hiring decisions. A related area of inquiry is the impact of transition program participation on retention rates and professional performance among employed new RN graduates. The preliminary findings from the San Francisco Bay Area transition-to-practice collaboratives indicate that this may be an effective way to help address unemployment among new nursing graduates and help them move from the role of student to competent novice nurse.
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Examples of Collaborative Program Topics
|Acute care nursing topics|
| Professional nursing role|
| Team-based care|
| Management of changing/emergency patient situations|
| Evidence-based practice|
| Central line care|
| Quality improvement|
| Stress management/self-care|
| Advance directives|
|Additional community-based nursing topics|
| Care and case management|
| Multidisciplinary team approach|
| Patient-driven focus|
| Integrated care|
| Transitional care|
| Behavior change|
|Skills laboratory topics|
| Patient safety|
| Intravenous lines and medications|
| Foley catheter insertion and care|
| Blood draws|
| Infection control|