The Impact of Transition Experience on Practice of Newly Licensed

Registered Nurses

Suling Li, PhD, RNAssociate Director of Research

NCSBN

Background• New RNs struggling with transition into

practice

• Shortened gap between taking NCLEX and being licensed

• High job stress and high turnover rates in new RNs

• Complexity of health care environment

• Increased workload due to acute nursing shortage

Goals• To describe the transition experience of

newly licensed RNs

• To identify factors that influence transitions into practice

• To examine the impact of the transition experience on clinical competence and safe practice issues of newly licensed RNs

Conceptual Framework on Transition

• Structure of transition• Content of transition• Characteristics of preceptors • Characteristics of the new nurse• Partnerships between the new nurse and

the preceptor• Institutional support for both the new

nurse and the preceptor

OutcomesPrimary Outcomes

• Clinical competency

• Practice errors and risks for practice breakdown

Secondary Outcomes

• Stress level

• Job turnover

Assessing OutcomesTwo perspectives:

– Perspective of the new RN– Perspective of his/her

preceptor/mentor

Outcome Measures• Clinical competence (35 items):

– Clinical reasoning and judgment

– Pt care delivery and management skills

– Communication and interpersonal relationships

– Recognizing limits and seeking help

• Practice errors and risks for practice breakdown

Design• Survey of nurse-preceptor dyad

Sample Profile – Demographics

New RNs Preceptors

N: RN 560 231

BSNs 32.8% 31.5%

ADNs 60.7% 49.7%

Age (yrs) 32.4 42.2

Female 94.4% 92.2%

White 81.2% 88%

Characteristics of the New RNs

• Hospital 86.4%

• Full time 91.2%

• English first language 92.6%

• Graduates of USA programs 99.0%

• With LPN experiences 19.9%

• Employed in urban area 47.3%

• Months of working experience 11.4

Characteristics of Preceptors

Experience in nursing

Experience in current position

>1 year experience on the unit

As preceptor for this nurse

As a preceptor for any nurse

Standardized training

Took courses on their own

Recommended by supervisor

13.7 yrs

8.6 yrs

81%

3.6 months

3.9 yrs

49%

11%

74%

Workload of Preceptors

Client care assignment:

• Yes, regular load 45.8%

• Yes, reduced load 31.7%

• No 22.5%

Pre-Graduation Synthesis Experience

ADNs BSNs (n=335)

(n=181)Synthesis course required 33.8% 68.2%Length of the course (wks) 7.0 9.9

Transition Experience

%

No orientation or internship 2.0

Routine orientation only 24.3

Internship or plus 73.8

Internship Experience

HospNon-hosp

Ro

utin

e o

rie

nta

tion

with

inte

rnsh

ip

100%

90%

80%

70%

60%

50%

40%

30%

20%

ADN

BSN

Duration of TransitionNon-hosp

10%

81%

>12 w ks

12 w ks

8-11.9 w ks

<8 w ks

Hosp

20.9%

24.9%

21.5%

32.8%

>12 w ks

12 w ks

8-11.9 w ks

<8 w ks

Preceptor Involvement

Hosp.Non-hosp.

%

80

70

60

50

40

30

Designated preceptor

for every shift

Primary preceptor as

signed

Shared assignments

w ith preceptor

Preceptor w orked the

same schedule

60

46

68

37

62

37

56

42

Content of Transition Programs

Non-Hosp.

25.4%

13.4%

61.2%

Both

Specialty know ledgeGeneral know ledge

Hospital

47.7%

8.1%

44.3%Both

Specialty know ledge

General know ledge

Days Before First Patient Care Assignment

HospNon-hosp

Me

an

da

ys b

efo

re 1

st a

ssig

nm

en

t

60.0

50.0

40.0

30.0

20.0

10.0

0.0

1st indep. assig.

1st dep. assig.

49.7

25.6

6.15.1

Patient Care Assignment

HospNon-hosp

Me

an

# o

f p

atie

nts

ass

ign

ed

50.0

40.0

30.0

20.0

10.0

0.0

1st indep. assig.

1st dep. assig.

4.1

23.2

2.8

16.2

Patient Care Assignment

HospNon-hosp

Me

an

# o

f p

ts in

ass

ign

me

nt

60.0

50.0

40.0

30.0

20.0

10.0

0.0

Experienced

New

4.9

25.2

4.1

23.4

Clinical Competence: Overall

PreceptorNew RN

Me

an

of

clin

ica

l co

mp

ete

nce

35

ite

ms

(0-4

)

3.60

3.50

3.40

3.30

3.20

3.10

3.00

3.50

3.46

Clinical Competence: Subconcepts

Recog. limit

Comm

. & relation

Pt care deliv & Mana

Clin reasoning

Me

an

(sc

ale

0-4

)

3.60

3.50

3.40

3.30

3.20

3.10

3.20

3.44

3.52

3.27

Most Competent AreasAlmostAlways (%)

Administer medications accurately 92.3

Maintain safe & respectful environment 83.6

Accurately perform client assessment 80.2

Perform technical skills accurately 79.7

Do what is right for clients no matter what 73.4

Least Competent areasAlmost always %

Appropriately utilize research findings 32.7

Meet clients cultural needs 41.5

Strategically delegate and supervise others 41.7

Recognize when demands exceed capability 47.4

Manage time and workload effectively 49.1

Use info. technology to enhance care 49.3

Synthesize data from multiple sources 50.0

Clinical Competence During 1st YearOverall

9.1-12m6-9 m3.1-6m3m or less

Me

an

co

mp

ten

cy b

y p

rece

pto

rs (

tota

l sco

re)

3.60

3.58

3.56

3.54

3.52

3.50

3.48

3.46

3.44

3.42

3.40

New RNs Preceptors

9.1-12m

6.1-9 m

3.1-6m

3m or less

Me

an

clin

ica

l co

mp

ete

nce

sco

res

3.5

3.4

3.3

3.2

3.1

3.0

2.9

2.8

35-item measure

1-item measure

Clinical Competence During 1st YearSubconcepts

9.1-12m6.1-9 m3.1-6m3m or less

Me

an

sco

re (

0-4

)

3.7

3.6

3.5

3.4

3.3

3.2

3.1

3.0

Clinical reasoning &

judgment

Pt care delivery &

management skills

Communication &

Interpersonal relati

Recognizing limit &

seeking help

Clinical Competence and Work Setting

9.1-12m6.1-9 m3.1-6m3m or less

Me

an

Clin

ica

l Co

mp

ete

nce

To

tal S

core

(0

-4)

3.50

3.40

3.30

3.20

3.10

3.00

2.90

Non-hosp

Hosp

3.44

3.39

3.33

3.37

3.16

3.26

3.01

3.29

Transition and Clinical Competence

During first 3 months of practice, those who had a primary preceptor performed at a higher competent levels (B=0.45), especially in the areas of communication and interpersonal relationships (B=.51), as well as recognizing limits and seeking help (B=.49).

Practice Errors  Only

once %

More than once %

Total %

Medication errors 30.4 12.8 43.2

Client falls 22.8 12.1 34.9

Contribute to treatment delays 14.1 25.2 39.3

Charted on wrong client record 30.8 14.3 55.2

Missed physician/provider order 26.7 11.8 38.5

Misinterpreted physician/provider order

18.8 5.0 23.8

Error in performance of skills 18.0 10.2 28.2

Avoidable client death .4 .7 1.1

Client elopement 9.6 3.7 13.3

Practice Errors Index

PreceptorNew RN

Me

an

Err

or

Ind

ex

(0-2

).40

.30

.20

.10

.15

.32

Transition and Practice Errors

HospNon-hosp

Me

an

err

or

ind

ex

ba

sed

0-2

sca

le.5

.4

.3

.2

Specialty Knowledge

No

Yes

Clinical Competence and Practice Errors

• New nurses who were more competent (r= -.35), especially in the areas of clinical reasoning ability (ß=-.38) and communication and interpersonal relationships (ß=-.33), made less practice errors.

New RN Turnover*

*Either changed position or plan to leave, 40.0%

Changed position since being licensed.

21.2%

Planning to leave current position within 6 months

23.0%

Transition and Turnover

Internship

YesNo

40.0%

30.0%

20.0%

10.0%

19.2

33.1

Perceived StressAlmost Never %

Some-times %

Often/Always %

Felt overwhelmed with pt care responsibilities

19.4 56.7 24.0

Fear of harming the pt due to inexperience

71.7 25.5 2.8

Felt expectations unrealistic

45.8 38.6 15.6

Perceived Stress During 1st Year

9.1-12m

6-9 m3.1-6m

3 m or less

Me

an

ra

ting

(sc

ale

0-3

)1.4

1.2

1.0

.8

.6

.4

.2

Felt overw helmed

Feared harming pts

Expecta. unrealistic

Clinical Competence and Stress

9.1-12m

6-9 m3.1-6m

3m or less

Me

an

clin

ica

l co

mp

ete

nce

sco

res

3.5

3.4

3.3

3.2

3.1

3.0

2.9

2.8

35-item measure

1-item measure9.1-12m

6-9 m3.1-6m

3 m or less

Me

an

ra

ting

(sc

ale

0-3

)

1.4

1.2

1.0

.8

.6

.4

.2

Felt overw helmed

Feared harming pts

Expecta. unrealistic

Transition and Stress• The longer the work experience the less the fear

experienced by graduates about harming the patients (B=-.11)

• Graduates who had an internship (B=-.11) were less likely to feel expectations were unrealistic

• Graduates who had a transition programs that addressed specialty knowledge (B=-.10) were less likely to feel expectations were unrealistic

Stress and Practice Errors Beta

Felt overwhelmed by care responsibilities

.158

Feared harming client due to inexperience

.208

Felt expectations unrealistic .137

Summary of Findings• Transition experiences of new RNs vary across

practice settings• New RNs are more competent in the areas of pt

care delivery and management, compared to the areas of clinical reasoning and judgment skills, as well as recognizing limits and seeking help

• During the first 3 months of practice, new RNs who had a primary preceptor practiced at higher competent levels

• Without the assistance of preceptors, new RNs practiced at less competent levels during their initial phase of independent practice

Summary of Findings• New RNs with preparation for specialty

practice in transition programs made less errors

• Less competent and/or stressed new RNs made more practice errors

• New RNs who had an internship experience were less likely to leave their current position within the next 6 months

AcknowledgementsAdvisory Group: 2006 & 2007 NCSBN PR&E Committee• Nancy Spector, NCSBN Director of Education• Gino Chisari (Chair, 2006)• Brenda S. Jackson (Chair, 2007)• Mary Blubough (Board Liaison)• Connie Brown• Barbara Knopp• Barbara Newman• Cynthia Van Wingerden• Debra Werner• Lepaine McHenry• Marcy Echternacht• Therese Shipps• Mary Calkins• Mary Doherty, NCSBN Practice, Regulation, & Education AssociateResearch Support• Data Collection: Lindsey Gross• Statistical Support: Richard Smiley

Contact InformationSuling Li, PhD, RN

Tel: (312) 525-3658

sli@ncsbn.org