The author has disclosed no potential conflicts of interest, financial or otherwise.
The long-awaited results of phase I (RNs in hospitals) of the National Council of State Boards of Nursing’s (NCSBN) multisite, randomized, controlled Transition to Practice study have been released (Spector et al., 2015). This large, national study is the only transition-to-practice research that randomly assigned sites to a control group (they used their existing onboarding strategies) or to NCSBN’s evidence-based transition to practice (TTP) program. The study investigated whether a transition-to-practice program for new graduates made a difference in several outcomes related to quality and safety. We (i.e., the researchers) collected detailed information on the control sites’ programs so that they eventually were divided into three groups: NCSBN’s TTP program, those with an established program with institutional support (established program), and those with a very limited program (limited program) with little support. Then the outcomes were compared among the TTP and the established and limited programs.
The results are promising for nursing, although other areas needed improvement. Many of the control group hospitals had excellent, “homegrown” programs (national programs such as the Versant or University HealthSystem Consortium/American Association of Colleges of Nursing residency programs were excluded from the study) that incorporate evidence-based components and support new graduates. However, some of the transition programs were sparse, with little or no support for the new graduate. We found that outcomes (competence, which was reported by the new graduate and preceptor; self-reports of errors, the use of safety practices, stress, and job satisfaction; and hospital data on retention) were significantly better when the transition program had the following characteristics:
- A formalized program that is integrated into the institution, with support from the chief nursing officer and other administrators.
- A preceptorship, as well as a preceptor who was educated for the role.
- A program length of 9 to 12 months.
- Content in patient safety, clinical reasoning, communication and team-work, patient-centered care, evidence-based practice, quality improvement, informatics, feedback, and reflection.
- Time for new graduates to learn and apply the content and to obtain feedback and share their reflections.
- Time for the preceptors to work with and connect with the newly graduated nurses.
- Customization so that the new graduates learn specialty content in the areas where they are working.
Some interesting findings about new graduates’ first year in practice were noted. In all three groups, whether or not they had additional didactic content, the new nurse’s overall competency and Quality and Safety Education for Nurses (QSEN) competencies significantly improved over the year-long study. This suggests that educators are adequately preparing their students for practice and particularly that the national initiative to integrate QSEN competencies into undergraduate programs seems to be working.
Another pattern identified was that the new graduates had a spike in reported errors, a decrease in job satisfaction, and an increase in work stress at the 6-month period, which is typically when the new graduates became more independent. By the 12th month in practice, work stress and reported errors decreased and job satisfaction increased. This finding supports the need for ongoing support of the new graduate during the entire first year of practice. That first 6- to 9-month period of practice seems to be the most vulnerable time for new graduates.
Turnover, which has been linked to adverse events in some studies (Bae, Mark, & Fried, 2010) and can lead to chaos in the workplace (Duffield, Roche, O’Brien-Pallas, & Catling-Paull, 2009), was significantly higher in the limited program group, with nearly a 25% turnover over the year-long period, compared with the TTP group (14.7%) or the established program group (12%). Nurse educators can arm their students with information about the types of supportive, evidence-based transition programs they should be looking for when interviewing for their first jobs. This could go a long way toward decreasing the turmoil that new graduates sometimes experience in their first year of practice.
Another finding of the Transition to Practice study that could inform hospital administrators and educators is preliminary evidence on the type of preceptorship that promotes significantly better new nurse outcomes. Previous preceptor research focused on preceptor training, evaluations, perceptions and personal characteristics, or new graduate perceptions toward the preceptor. Very little research has focused on the arrangement of the preceptorship itself. We compared hospitals with high support to those with low support of the preceptorship, defining the high support preceptorship as a one-on-one relationship, where the preceptor shared assignments with the new nurse and worked many of the same shifts with the new nurse. In the low-support preceptorship, more than one new nurse was with a preceptor, and the preceptor was available for questions but did not share assignments with the new nurse. We found that the new nurses in the high-support preceptorship had significantly higher preceptor competence ratings and a significantly lower turnover rate than those in the low support preceptorship. These are promising results for providing evidence to practice facilities for designing the preceptorship experience, and this is an excellent area for collaborative research among educators and practice leaders.
This new evidence provides nurse educators with an opportunity to collaborate with practice leaders and inform them of these findings. Educators could partner with practitioners to design effective, evidence-based transition programs and preceptorships, using their expertise in teaching–learning strategies.
Nurse educators are well positioned to begin this transition-to-practice journey for students. Incorporating the QSEN competencies into the curriculum, along with clinical reasoning, opportunities for reflection, and provision of constructive feedback, prepares students for effective transitioning from education to practice.
Nancy Spector, PhD, RN, FAAN
Director, Regulatory Innovations
National Council of State Boards of Nursing
111 E. Wacker Drive, Suite 2900
Chicago, IL 60601
- Bae, S.H., Mark, B. & Fried, B. (2010). Use of temporary nurses and nurse and patient safety outcomes in acute care hospital units. Health Care Management Review, 35, 333–344. doi:10.1097/HMR.0b013e3181dac01c [CrossRef]
- Duffield, C., Roche, M., O’Brien-Pallas, L. & Catling-Paull, C. (2009). The implications of staff ‘churn’ for nurse managers, staff, and patients. Nursing Economic$, 27, 103–110.
- Spector, N., Blegen, M.A., Silvestre, J., Barnsteiner, J., Lynn, M.R., Ulrich, B. & Alexander, M. (2015). Transition to practice study in hospital settings. Journal of Nursing Regulation, 5(4), 24–38.