Transition to Practice Regulatory Model: Implementing Change Nancy Spector, PhD, RN June, 2008.

Transition to Practice Regulatory Transition to Practice Regulatory Model: Implementing ChangeModel: Implementing Change

Nancy Spector, PhD, RNNancy Spector, PhD, RN

June, 2008June, 2008

Mission of NCSBNMission of NCSBN

The National Council of State Boards of The National Council of State Boards of

Nursing (NCSBN), composed of Member Nursing (NCSBN), composed of Member

Boards, provides leadership to advance Boards, provides leadership to advance

regulatory excellence for public protection.regulatory excellence for public protection.

Background of the ProblemBackground of the Problem

Background of the ProblemBackground of the Problem

• Benner’s work over 20 yearsBenner’s work over 20 years

• Kramer’s “Reality Shock,” from 1974Kramer’s “Reality Shock,” from 1974

Background of the ProblemBackground of the Problem

NCSBN 2001 Employer’s study NCSBN 2001 Employer’s study

““Yes definitely” to new graduates providing Yes definitely” to new graduates providing safe and effective care:safe and effective care:

• 45% - diploma graduates45% - diploma graduates• 40% - BSN graduates40% - BSN graduates• 35% - ADN graduates35% - ADN graduates• 30% - PN graduates30% - PN graduates

Background of the Problem:Background of the Problem:

Not About BlameNot About Blame

Background of the ProblemBackground of the Problem

• Computerized NCLEX, allowing for almost immediate licensure

• Context of practice: “frenzy”

• Health care becoming more complex

• Nursing shortage

Background of the ProblemBackground of the Problem

Turnover rates (2006 Nurse Executive Center: “Transitioning New Graduates to Hospital Practice”)

• One Year – 36%

• Two Years – 75%

• Three Years – 50%

Background of the ProblemBackground of the Problem

Underinvestment of Novice Nurses(2006 Nurse Executive Center):

CMS Funds•American Council for Graduate Medical

Education

• American Society of Health-System Pharmacists

• Association for Clinical Pastoral Education

Background of the ProblemBackground of the Problem

NCSBN Hosted Transition Forum:• February 22, 2007

• Speakers from other disciplines and countries all came together

• Various research findings showed need for transition programs

Background of the ProblemBackground of the Problem

NCSBN Hosted Transition Forum:• February 22, 2007

• Stakeholders agreed to a standardized regulatory model (AACN, AONE, ANA, NAPNES,

NLN)

• Buy-in is so important

Charge from Board of DirectorsCharge from Board of Directors

Recommend an evidence-based regulatory model for transition to practice.

BarriersBarriers

•Time Constraint – October 2007 – April 2008

•Committee make up

•States are autonomous

EvidenceEvidence

5 International Projects5 International Projects• Canadian Nurses AssociationCanadian Nurses Association• ScotlandScotland• IrelandIreland• PortugalPortugal• AustraliaAustralia

EvidenceEvidence

16 National Projects/Studies:16 National Projects/Studies:

• 2002 American Health Care Association2002 American Health Care Association• Behrens (investigative reporter) (2000)Behrens (investigative reporter) (2000)• Carnegie study of nursing education Carnegie study of nursing education

(preliminary)(preliminary)• EBNER (2006)EBNER (2006)• Joint Commission 2002 White PaperJoint Commission 2002 White Paper

EvidenceEvidence

National:National:• Hofler: synthesis of national reports (2008)Hofler: synthesis of national reports (2008)• HRSA (2007)HRSA (2007)• NCSBN analysis of discipline data (2007)NCSBN analysis of discipline data (2007)• NCSBN employer studies (2004)NCSBN employer studies (2004)• NCSBN post-entry study (preliminary)NCSBN post-entry study (preliminary)

EvidenceEvidence

National:National:• NCSBN’s Transition Study (2006)NCSBN’s Transition Study (2006)• NCSBN’s Transition Study (unpublished)NCSBN’s Transition Study (unpublished)

• RNRN• PNPN

• National Survey of Nursing Home Workforce National Survey of Nursing Home Workforce Satisfaction (2006)Satisfaction (2006)

EvidenceEvidence

National:National:• University HealthSystem University HealthSystem

Consortium/American Association of Colleges Consortium/American Association of Colleges of Nursing (2007)of Nursing (2007)

• Versant (2001)Versant (2001)

EvidenceEvidence

7 Statewide Projects/Studies:7 Statewide Projects/Studies:• California – In process; White paperCalifornia – In process; White paper• Kentucky – LegislationKentucky – Legislation• Massachusetts – Preliminary dataMassachusetts – Preliminary data• Mississippi – Office of Workforce Nurse Mississippi – Office of Workforce Nurse

Residency ProgramResidency Program

EvidenceEvidence

Statewide:Statewide:• North CarolinaNorth Carolina

• Vermont Nurse Internship ProgramVermont Nurse Internship Program

• Wisconsin Residency ProgramWisconsin Residency Program

EvidenceEvidence

12 Individual Studies/Projects:12 Individual Studies/Projects:

• BjBjøørk & Kirkevold (1999) – Empirical evidencerk & Kirkevold (1999) – Empirical evidence

• Children’s Memorial, Chicago (2007) – Children’s Memorial, Chicago (2007) – Cost/RetentionCost/Retention

• Dartmouth-Hitchcock (2007) - SimulationDartmouth-Hitchcock (2007) - Simulation

• Del Bueno (2005) – Novice nurses judgmentDel Bueno (2005) – Novice nurses judgment

EvidenceEvidence

Individual:Individual:• Ebright, Urden, Patterson & Chalko (2004) – Ebright, Urden, Patterson & Chalko (2004) –

Near misses and adverse events in novice nursesNear misses and adverse events in novice nurses• Johnstone & Kanitsaki (2006) – Clinical risk Johnstone & Kanitsaki (2006) – Clinical risk

management in new graduatesmanagement in new graduates• Johnstone & Kanitsaki (2008) – Novice nurses Johnstone & Kanitsaki (2008) – Novice nurses

integration of patient safetyintegration of patient safety

EvidenceEvidence

Individual:Individual:

• Johnstone, Kanitsaki & Currie (2008) – SupportJohnstone, Kanitsaki & Currie (2008) – Support

• Keller, Meekins & Summers (2006) – Keller, Meekins & Summers (2006) – Cost/RetentionCost/Retention

• Pine & Tart (2007) - ROIPine & Tart (2007) - ROI

EvidenceEvidence

Individual:Individual:

• Orsolini-Hain & Malone (2007) – Excellent Orsolini-Hain & Malone (2007) – Excellent review citing impending gap in clinical review citing impending gap in clinical expertiseexpertise

• Sir Charles Gairdner Hospital Centre for Sir Charles Gairdner Hospital Centre for Nursing Education – Australia Nursing Education – Australia

Once Evidence was CollectedOnce Evidence was Collected

• Developed DefinitionsDeveloped Definitions

• Core Elements of ModelCore Elements of Model• PreceptorshipPreceptorship• Feedback and ReflectionFeedback and Reflection• Across Settings and EducationAcross Settings and Education

Summary of the EvidenceSummary of the Evidence

• How much evidence is enough?

• Our perspective is on public protection• Safety• Competence• Retention

The ModelThe Model

ConsiderationsConsiderations

• Cost• ROI 67.3% (Versant); 884.7%

(Methodist Hospital in Houston)• Money saved on decreased turnover and

fewer replacement nurses• What about cost to Boards?

ConsiderationsConsiderations

• Collaborations

• Legislators• AHA• Nursing practice• Nursing education• Joint Commission• CMS

ConsiderationsConsiderations

• Link to licenseLink to license

• Enforcement?Enforcement?

• CompromiseCompromise

Next StepsNext Steps

• National Web siteNational Web site

• Identify strategies for implementation, Identify strategies for implementation, e.g., pilots? RNs/acute first?e.g., pilots? RNs/acute first?

The Future in NursingThe Future in Nursing