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JULY/AUGUST 2011 :: 72(4)
Future of Nursing in North Carolina

The policy forum of this issue takes as its point of departure an April 2011 summit of North Carolina nurse leaders, who met to review and discuss recommendations from The Future of Nursing: Leading Change, Advancing Health, a report recently published by the Institute of Medicine of the National Academies. Commentaries from experts across the state affirm the importance of ensuring that an effective, educated nursing workforce is present; that nursing education involves a seamless process; that nurses can practice to the full extent of their education and training; that nurses are full partners in redesigning health care; and that an effective, comprehensive health care workforce planning system is in place. Also in this issue, original articles address the use Charlotte-area emergency departments for primary care services and the presence of defibrillators in North Carolina public schools.


Evidence-Based Transition to Practice: Developing a Model for North Carolina

Mary P. "Polly" Johnson, Joyce W. Roth, Pamela R. Jenkins

N C Med J. 2011;72(4):282-284.PDF | TABLE OF CONTENTS

To enhance patient safety and increase retention of new nurses, structures and processes should be developed to ensure that newly licensed nurses are afforded the opportunity to gain confidence and competence as they enter the workforce. This commentary provides an overview of the work performed to date in North Carolina to build an evidence-based transition-to-practice model.

Successful transition of newly licensed nurses into practice is essential for safe patient care. Unlike for most other health professions, there is no formalized internship or required residency period to support the transition of a newly licensed nurse from student learner to competent and confident health care professional. The first 6 months of practice for new nurses is a time of high stress related to adjustment to the workplace, development of competence and confidence, and risk for errors [1]. It is also when health care agencies can have the greatest impact on retaining newly licensed nurses. Before the current economic downturn, national studies estimated that 33%-69% of new nurses changed positions within a year after graduating and that more than 50% changed jobs within the first 2 years of initial employment as a licensed nurse [2-4]. One issue is how best to transition newly licensed nurses into the work setting in a manner that safely supports development of their competence and confidence and retains them in the workforce. North Carolina has no standardized approach to the preparation of nurse preceptors, who guide these new nurses during the critical first weeks and months of their employment, and orientation programs vary greatly in time and content from one employment setting to another.

The need to study the options to improve this school-to-work transition period was identified by the North Carolina Institute of Medicine in 2004 as a priority recommendation [5]. The report acknowledged that the existing gaps between the educational experience of the student and real-world work expectations have potentially detrimental effects on the provision of safe patient care, as well as on the retention of nurses.

Following the North Carolina Institute of Medicine report, the Foundation for Nursing Excellence (FFNE), a nonprofit organization created by the North Carolina Board of Nursing and now an independent entity committed to enhancing the practice of nursing, convened a group of key nursing leaders to study how improvements could be made in the transition from school to work for newly licensed nurses.

Phase I: Gathering Evidence About Current Transition-to-Practice Activities in North Carolina
Background. Representatives from the North Carolina Center for Nursing, the North Carolina Area Health Education Centers, and the North Carolina Board of Nursing, as well as experts in nursing education and practice, formed the steering committee for the FFNE’s evidence-based transition-to-practice project. An advisory panel composed of North Carolina health care employers, staff development specialists, educators, regulators, professional associations, philanthropic foundations, newly licensed registered nurses (RNs), and the public offered unique perspectives from across the state. Generous funding for the project was provided by the Blue Cross Blue Shield of North Carolina Foundation, The Duke Endowment, and the Kate B. Reynolds Charitable Trust.

An invitational research development conference, held in 2005 with support from the Agency for Healthcare Research and Quality, was the first step in our journey to build a transition-to-practice model for North Carolina. Consensus was reached on 32 core competencies needed by newly licensed nurses. These became the basis for a competency-assessment scale developed by the National Council of State Boards of Nursing and further refined for use in our North Carolina transition-to-practice project. The conference report and the list of these competencies are posted on the FFNE Web site (available at:

The next step was to gather information on current orientation practices across North Carolina health care systems. A survey was designed to examine the perceived development of competence and confidence among newly licensed RNs in 3 different types of orientation programs currently offered in North Carolina hospitals and to identify preceptor characteristics that affect the development of competence and confidence for new nurses. Twenty-nine hospitals agreed to participate and were placed in 1 of the following 3 comparison groups, according to the type of transition support they offered their newly licensed nurse employees: a standardized, nationally used competence assessment and development system (group A); an individual, employer-developed, formal transition-to-practice program (group B); and an employer-developed orientation program that does not include a formal transition-to-practice program (group C).

The survey on newly licensed RNs provided self-reported and preceptor-reported information related to competence development, practice errors, risk for practice breakdown, and confidence development among the new nurses. The sample consisted of newly licensed nurses and their preceptors, who were surveyed in 3 rounds of data collection, at 2-month intervals, during the first 6 months of the new nurses’ employment, between August 2007 and February 2008.

Survey findings. One hundred eighty-eight newly licensed RNs participated in this study in 1, 2, or 3 of the data-collection rounds, with 42 completing all 3 rounds of the survey. A total of 73.4% of these new RNs held an associate’s degree in nursing (ADN), 42.7% held a baccalaureate in nursing (BSN), and 1.9% held a diploma in nursing. A total of 242 preceptors participated in 1, 2, or 3 of the data-collection rounds, with 39 preceptors completing all 3 rounds. On average, preceptors had more than 7 years’ experience in precepting, with 62.8% holding an ADN, 32.2% holding a BSN or higher degree, and 2.2% holding a diploma in nursing.

The one statistically significant finding across all 3 rounds of data collection was the relationship between the quality of the partnership with the preceptor and the new nurse’s self-reported competency score. The better the quality rating of the new nurse–preceptor relationship, the higher the perceived competence of the new nurse. Of equal importance was the finding that a higher competency score reported by the new nurse correlated with fewer practice errors 4 and 6 months after initial employment. The data indicated a low competence score in clinical reasoning and judgment by the new nurses in all 3 rounds of data collection; across all 3 data-collection points, more than 75% of the responding new nurses (ie, 123 of 158 in round 1, 62 of 82 in round 2, and 63 of 83 in round 3) reported that risks for practice breakdown occurred at least once during the previous month. At each survey round, more than 19% of the new nurses reported that they “often” or “always” felt overwhelmed by client care responsibilities. The average overall self-reported competency scores for the new RNs revealed no significant differences between the 3 comparison groups. Thus, no single group was superior for the development of the new nurses. Twenty-nine newly licensed nurses resigned their positions and left the agency (1 left nursing altogether), and another 15 were terminated within the first 6 months after employment. The average length of the orientation program across all comparison groups, as reported by the new nurses, was 8 weeks [6].

Phase II: The Role of the Preceptor in Transitioning Newly Licensed Nurses into Practice
On the basis of the findings in phase I and an extensive literature review of role development among preceptors and its impact on transitioning the new nurse into practice, 2 invitational working conferences were convened in 2009. The first conference focused on the preparation and development of preceptors, and the other addressed use of simulation to assess new-nurse competence. Participants identified essential content and concepts that should be included in a preceptor preparation program (Table 1).

On the basis of evidence from the literature and the feedback obtained from the invitational conferences, new-nurse focus groups, and a review of the few currently available preceptor educational programs, the steering committee decided to create a preceptor educational program that used the most-current concepts and delivery modalities. The preceptor package consists of 3 Web-based modules and 3 low-fidelity simulation experiences. The learning modules were developed by staff educators who prepare preceptors in both rural and urban health care facilities and address (1) dimensions of the preceptor role, (2) communication in the preceptor role, and (3) the transition process of new nurses. These self-paced learning tools are interactive, integrate reflective exercises, and include Web links for supplementary resources, such as TeamSTEPPs [7]. The simulated scenarios, which are intended to reinforce, through role play, the basic preceptor concepts addressed in the Web-based modules, focus on patient handoffs, response(s) to an adverse event, interprofessional communication, prioritization of care, and generational differences. The operational framework for the preceptor learning package is based on the core competencies for all health professionals outlined in a 2001 report from the Institute of Medicine of the National Academies [8], the pioneering work of the Quality and Safety Education for Nurses project [9], and the team-development initiatives set forth by the Agency for Healthcare Research and Quality. The goal of this structured learning program was to provide the preceptor with the basic knowledge and skills needed to effectively support the development of competence and the retention of newly licensed nurses during their initial period of transition from school to work.

Phase III: Piloting Preceptor Development Tools
Nine hospitals, representing both rural and urban regions and ranging in size from 58 to 712 in-patient beds, were selected to help evaluate the effectiveness of the preceptor educational tools and the impact of preceptor development on the safe transition of new nurses into practice. Before the initial employment of newly licensed RNs in 2010, 180 preceptors in these facilities completed the Web-based modules. Seventy-five of these preceptors then participated in an additional day of on-site learning, using the simulated scenarios. Evaluation data were collected from preceptors on completion of each learning module and by both facilitators and participants in the simulation experiences, to identify the effectiveness and gaps in both the structure and the content of the learning modalities. Additional evaluative data were collected from the trained preceptors, their preceptees, and nurse managers 2 months into the employment of the new nurse. Similar to the structure of phase I, data were also collected during the first 6 months of the new nurse’s employment, to assess the perceived development of competence and confidence, risk for error, and retention of the new nurse in the workplace.

Although a full analysis of the data for phase III will not be completed until September 2011, initial evaluation of the Web-based modules and the simulation experiences indicated that they were effective development tools for preceptors. Both new and experienced preceptors reiterated the value of the modules’ content, instructional methods, and simulation experiences.

Minor revisions were made to the Web-based learning tools on the basis of initial feedback, and, in February 2011, an electronic preceptor training package was made available for use by individual nurses, as well as by health care systems, as a cost-effective, easily accessible, standardized learning tool for preceptors. The steering committee is currently considering how best to package the simulated scenarios, which may be easily accessed by a broad base of users as an effective adjunct to the Web-based modules. Future refinements of these learning tools will be based on the full analysis of phase III data, as well as on ongoing feedback from users and on key findings from other similar projects across the country.

Next Steps
It is the intention of the FFNE to develop a set of recommendations for best practices in transitioning newly licensed nurses into competent members of the health care workforce, using evidence from this and other studies across the country. In particular, much information has been gained through the University HealthSystem Consortium–American Association of Colleges of Nursing Residency Project [10], as well as through the Vermont Internship Project: Evidence Based Preceptor Development [11]. Additional information will be gained from the National Council of State Boards of Nursing transition project, which is being piloted in North Carolina and 2 other states during the next year. How these transition programs affect patient safety and outcomes; new-nurse turnover, satisfaction, and competency; and the effectiveness of preceptor training will help formulate the recommendations for an evidence-based transition-to-practice model for nursing in North Carolina.

Potential conflicts of interest. All authors have no relevant conflicts of interest.

1. Oerman M, Gavin MF. Stress and challenges for new graduate in hospitals. Nurse Educ Today. 2002;22:222-230.

2. North Carolina Trends in Nursing Education 2004-2009. North Carolina Board of Nursing Web site. Accessed May 5, 2011.

3. Goode C, Williams C. Post-baccalaureate nurse residency program. J Nurs Adm. 2004;34(2):71-77.

4. Newhouse RP, Hoffman JJ, Suflita J, Hairston DP. Evaluating an innovative program to improve new nurse graduate socialization into the acute healthcare setting. Nurs Adm Q. 2007;31(1):50-60.

5. North Carolina Institute of Medicine (NCIOM). Task Force on the North Carolina Nursing Workforce Report. Durham, NC: NCIOM; 2004. Accessed September 6, 2011.

6. National Council of State Boards of Nursing Research Department. Progress Report: Phase I Study of North Carolina Evidence-based Transition to Practice Initative Project. Foundation for Nursing Excellence Web site. Accessed May 5, 2011.

7. TeamSTEPPS Web site. Accessed May 5, 2011.

8. Institute of Medicine of the National Academies (IOM). Crossing the Chasm: A New Health System for the 21st Century. Washington, DC: IOM; 2001. Accessed May 5, 2011.

9. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook. 2007;55(3):122-131.

10. UHC/AACN Nurse Residency Program. American Association of Colleges of Nursing Web site. Accessed May 5, 2011.

11. Intern and preceptor development. Vermont Nurses in Partnership Web site. Accessed May 5, 2011.

Mary P. “Polly” Johnson, MSN, RN president and chief executive officer, Foundation for Nursing Excellence, Raleigh, North Carolina.
Joyce W. Roth, MSA, RN, NE-BC manager, Organizational Development, North Carolina Board of Nursing, Raleigh, North Carolina.
Pamela R. Jenkins, EdD, RN program director, Foundation for Nursing Excellence, Raleigh, North Carolina.

Address correspondence to Ms. Mary P. “Polly” Johnson, NC Foundation for Nursing Excellence, PO Box 31824, Raleigh, NC 27622 (