2008 - Nurse Residency Programs/Transistioning Newly Licensed Nurses

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Oklahoma Nurses Association Position Statement on Residency Programs/ Transitioning Newly Licensed Registered Nurses to the Workplace

Newly licensed registered nurses leave their first professional nursing position at an alarming rate with over half leaving in less than one year. (McNeese-Smith 2000) Newly licensed registered nurses chose to leave the nursing profession due to role overload, job dissatisfaction, stress, low self-efficacy, and physician-staff relationships. Retention of newly licensed registered nurses is a vital part in ameliorating the critical nursing shortage. (Charnley, 1999; McNeese-Smith, 2000; Oermann & Moffitt-Wolf, 1997). The loss of newly licensed registered nurses has a ripple effect throughout the entire healthcare system (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002).

The Oklahoma Nurses Association position on transitioning newly licensed nurses into practice is to:

Support Initiatives that facilitate the successful integration of new nurse graduates in the work environment, including but not limited to, residency programs.

  • Appropriate orientation, support, and continuing education experiences should be planned and provided
  • Nursing managers are encouraged to use research/ information to develop guidelines for evaluating the progress and providing feedback to nurses during the first year of practice.
    • Benner’s 1984 model, From Novice to Expert: Excellence and power in clinical nursing provides a detailed analysis of the competencies expected at each level of practice.
  • Nurses own reflection on experiences from advanced beginner to competent nurse can be used to provide possible strategies for reducing turnover and enhancing support during the transition.
    • Advanced beginners are curious about new experiences and enthusiastic to learn. They often experience reality shock because of the disparity between the structured educational environment and the reality of chaotic clinical practice (Kramer, 1974).
    • Advanced beginners are able to recognize recurrent patient care situations in a predictable environment; they lack the flexibility to adapt prior knowledge to rapidly changing patient care situations.
  • Patient assignment based upon the skill level of the nurse.
    • The progress from advanced beginner (level 2) to competent (level 3) will assist in developing guidelines for appropriate patient assignments to nurses at the advanced beginner and competent levels.
  • Promote the role of the Preceptor and look at ways to develop Preceptors for those that may be in workplaces that do not have an adequate supply or one that may not be available.
  • Support other transition models that may evolve in the future such as the NCSBN Transition Model
  • The newly licensed nurse must also take ownership and be accountable for the development of their practice and continued competency.

Encourage and support nursing research efforts to identify principles/parameters/ components for new nurse orientation programs and support research efforts to demonstrate the effectiveness of those identified components, for the successful integration of new nurses into the work environment.

Participate in efforts of collaboration between faculty and service managers to develop Newly Licensed Registered Nurse Residency Programs. Nursing education and nursing service to co-teach in the Newly Licensed Registered Nurse Residency Programs.

Support collaborative research studies between the nursing programs and nursing service to demonstrate effectiveness of Newly Licensed Registered Nurse Residency Programs.

Support collaborative efforts between service managers and nursing faculty to plan the transition from education to practice for Newly Licensed Registered nurses in the first year of employment.


Background:

Newly licensed registered nurses leave their first nursing position at an alarming rate. In a study examining the turnover rate of Newly Licensed Registered nurses, McNeese-Smith (2000) reported that over half of Newly Licensed Registered nurses left their first professional nursing assignment in less than one year. Some neophyte nurses chose to leave the nursing profession due to role overload, job dissatisfaction, stress, low self-efficacy, and physician-staff relationships (Charnley, 1999; McNeese-Smith, 2000; Oermann & Moffitt-Wolf, 1997). It has been projected that approximately six percent of Newly Licensed Registered nurses become so discouraged during the first year of practice that they choose to leave the nursing profession completely (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002).

Retention of newly licensed registered nurses is a vital part in ameliorating the critical nursing shortage. The loss of newly licensed registered nurses has a ripple effect throughout the entire healthcare system. First, turnover has a large financial impact on healthcare institutions. Buerhaus, Staiger, and Auerbach (2000) estimated the cost of recruiting, hiring, and training a replacement nurse ranges between $42,000 and $64,000 per nurse, or approximately 100 percent of the nurse’s annual salary. Second, the failure of neophyte nurses is disconcerting to the nurses themselves (Thomka, 2001). Student nurses spend a considerable amount of time, money, and effort preparing for a nursing career.

The most alarming outcome of nursing turnover, however, is the effect on patients. According to The Joint Commission on Accreditation of Healthcare Organizations (2001), organizations with nursing turnover rates greater than 22 percent per year have higher rates of patient mortality, compared with organizations reporting less than 12 percent nursing turnover per year. Retaining nurses has a positive effect on patient outcomes.

The shortage of nursing staff and lack of support during the transition period has the potential to increase stress and pressure for neophyte nurses (Thomka, 2001). The orientation period is usually a limited amount of time replete with new experiences, procedures, and policies, placing additional pressure on the new nurse to perform. After the orientation period, neophyte nurses are expected to take the same patient assignment as an experienced, competent nurse, leading to potential overload and ultimately frustration with nursing as a career (Charnley, 1999).

Benner’s From novice to expert: Excellence and power in clinical nursing (1984) describes Newly Licensed Registered nurses as advanced beginners. Advanced beginners are curious about new experiences and enthusiastic to learn. They often experience reality shock because of the disparity between the structured educational environment and the reality of chaotic clinical practice (Kramer, 1974). While advanced beginners are able to recognize recurrent patient care situations in a predictable environment, they lack the flexibility to adapt prior knowledge to rapidly changing patient care situations.

Understanding the transition from advanced beginner to competent nurse is important for several reasons. First, hospital nursing educators need to plan appropriate orientation, support, and continuing education experiences. Second, nursing managers can use the information to develop guidelines for evaluating the progress and providing feedback to nurses during the first year of practice. Third, the nurses themselves can reflect on their experiences from advanced beginner to competent nurse and provide possible strategies for reducing turnover and enhancing support during the transition. Fourth, the assignment of patients should be based upon the skill level of the nurse. Benner’s 1984 model provides a detailed analysis of the competencies expected at each level of practice. Understanding the progress from advanced beginner (level 2) to competent (level 3) may assist in developing guidelines for appropriate patient assignments to nurses at the advanced beginner and competent levels. Nurse residency programs provide a structured, mentored environment that facilitates the new nurse graduates progression from advanced beginner to competent nurse with minimal stress and anxiety.

REFERENCES

Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of American Medical Association, 288(16), 1987–1993.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing,. Menlo Park, CA:

Addison-Wesley. Buerhaus, P., Staiger, D. O., & Auerbach, D. (2000). Implications of an aging RN workforce. Journal of the American Medical Association, 283(22), 2948–2954.

Charnley, E. (1999). Occupational stress in the newly qualified staff nurse. Nursing Standard, 13(29), 32–36.

Joint Commission on Accreditation of Healthcare Organizations (2001). Healthcare at the Crossroads. Strategies for improving the medical liability system and preventing patient injury. Retrieved April 22, 2008, from http://www.jointcommission.org/NR/rdonlyres/3F1B626C-CB65-468B-A87118 488D1DA66B06/0/medical_liability_exec_summary.pdf

Kramer, M. (1974). Reality shock: Why nurses leave nursing. St Louis, MO: Mosby.

McNeese-Smith, D. (2000). Job stages of entry, mastery, and disengagement among nurses.Journal of Nursing Administration, 30(3), 140–147.

Oermann, M., & Moffitt-Wolf, A. (1997). Newly Licensed Registereds’ perceptions of clinical practice. Journal of Continuing Education in Nursing, 28(1), 20–25.

Thomka, L. A. (2001). Graduate nurses’ experience of interactions with professional nursing staff during transition to the professional

Resolution Adopted by the ONA House of Delegates 10/2008

Position Statement approved by the ONA Board of Directors 07/25/2009

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