Transitioning Newly Licensed Registered Nurses into Practice

Submitted by: Suling Li, Ph.D., RN • Associate Director of Research • National Council of State Boards of Nursing (NCSBN)

The National Council of State Boards of Nursing (NCSBN) is responsible for assisting its members, the boards of nursing in the United States and the four territories, in their mission of public protection through safe nursing practice.

Successfully transitioning newly licensed nurses into entry-level practice is a long-standing issue. With the ever-increasing complexity of the health care system and the continuing nursing shortage, newly licensed nurses are struggling with mastery of clinical skills, managing and organizing an increased and complex patient care assignment, communicating with physicians and delegating tasks during the transition period.

Given that transition period is a vulnerable time for new nurses and the initial learning curve is steep, it is an obligation of regulation working collaboratively with education and practice to develop proper transition models for all new nurses.

From a regulatory perspective, the ultimate goal of transition programs is to increase competence of new nurses and consequently augment the quality and safety of healthcare provided to all patients. Currently, there is no national standard for transitioning new nurses into practice following graduation from a nursing program, and very few states have regulations for the development of nurses during the first year of practice. In addition, the most common form of transition programs is within the employment setting, which is a corporate model. The lack of standardized transition programs and the continuing use of corporate models may hamper competence development of new nurses.

The ultimate goal of transition programs is to increase Competence of new nurses and consequently augment the quality and safety of healthcare provided to all patients.

In an effort to establish a regulatory model on transitioning newly licensed nurses to practice, NCSBN recently completed a study on transition with Dr. Suling Li as the Principal Investigator. The purpose of this study was to describe the transition experience of newly licensed registered nurses (new RNs), identify factors that influence the transition experience, and examine the impact of transition experiences on clinical competence and safe practice of new RNs.

The study employed a non-experimental, comparative, nurse-preceptor dyad survey design, in which 560 new RNs and 230 preceptors participated. Since the mission of state boards of nursing is to protect the public, the primary outcomes of interest were clinical competence and safe practice, including practice errors and risks for practice breakdown. The secondary outcomes included perceived stress levels and job turnover rate. Studying clinical competence and safe practice of new RNs addresses a regulatory concern compared to a number of transition studies in the literature that examined the nurse turnover/retention, nurse satisfaction and nurse confidence. Recognition of factors useful in indicating and/or predicting clinical competence and safe practice help improve transition programs.

Major findings of the study are listed below. It is important to note that the following findings were generated based on the newly licensed RN’s self-assessment, as there were no significant differences in the clinical competence rated by the newly licensed RN’s self-assessment and by the corresponding preceptor.

1. Transition experiences of new RNs vary across practice settings; new RNs in hospital settings were more likely to receive internship experiences, and the duration of transition experience tended to be longer compared to those in non-hospital settings.

2. In general, the new RNs felt they were more competent in the areas of patient care delivery and management, compared to the areas of clinical reasoning, judgment skills, recognizing limits, and seeking help.

3. Within the first three months of practice, those new RNs who had a primary preceptor were more likely to perceive that they practiced at higher competency levels.

4. During the initial phase of independent practice (three to six months of practice), new RNs practiced at less competent levels.

5. The new RNs who were provided with preparation for specialty practice within transition programs were more likely to indicate they made fewer errors compared to the other periods of the first year of practice.

6. The new RNs who felt they were less competent and/or more stressed tended to indicate they make more practice errors.

7. The new RNs who had an internship experience were less likely to leave their current position within the next six months.

8. The more competent the new RN, the fewer errors he/she reported making.

In conclusion, this study demonstrates that internship experiences have a positive impact on the clinical competence and safe practice as reported by new RNs. Internship programs may benefit the new RN and his/her organization by decreasing nurses’ stress and nurse turnover. Incorporating preceptors in the internship program may help integrate the new nurse into the organizational system and nursing profession faster. Transition programs that are six months or longer and that address specialty knowledge appear beneficial.