Implementing a transition to practice program in Rural NY: Improving retention and satisfaction of New Graduate Nurses during the first year of practice.

The practice problem to be addressed in this evidence-based practice (EBP) project is the retention and satisfaction of new graduate RNs in a rural community hospital. This project was developed utilizing the seven steps of EBP (Melynyk, et al., 2015). The majority of new graduate nurses (NGNs) at this facility are associate-prepared nurses (80%).  It was identified that many of the NGNs are not staying at the facility after completing their BSN. Many move on to larger hospitals that require a BSN to be hired. This resulted in several issues for the hospital including increased cost for the training of new nurses, lack of experienced nurses to mentor newer nurses, and the increased need to use travel nurses as staff for the facility. Prior to the transition to practice program the orientation consisted of a 3-week classroom with skills practice and then 9-12 weeks of precepted orientation on the assigned unit. The goals of this transition-to-practice (TTP) program are to improve the satisfaction of NGNs and increase the retention at 1- and 2-years post-hire of NGNs.

This rural community hospital is in Southwestern New York. There are 186 beds and outpatient centers servicing 5 counties in NY and PA. The clinical education department is responsible for the orientation of the NGNs during the first 3 weeks of onboarding to the facility. NGNs were struggling to assimilate to practice and to practice independently.

The clinical education department worked with the hospital administration to develop and launch the first NGN residency at the hospital in the summer of 2023 with the onboarding of 2 NGN groups in May and June 2023. The program was developed to continue for one-year post-hire, with the introduction of monthly NGN residency classes. The administration approved an 8-hour class day for NGNs to come off the unit monthly for classes. The curriculum consists of presentations from clinical educators, faculty from a local university, and managers and administrators from the facility. The curriculum was based on the evidence found in the literature, including self-care, mentorship, and extended orientation time The residents also develop evidence-based practice projects based on identified problems from the practice, or the need for policy development, and are mentored through the seven steps of EBP (Melnyk et al., 2015). These projects help to give the NGNs confidence in their ability to participate in practice change utilizing EBP. In a Delphi study by Klimek Yingling, et. al. (2021) the researchers identified that barriers to implementing EBP in practice included resources and support. While an EBP project is not mandatory for TTP programs, this was an added benefit to this program.

Before initiating the project in the spirit of inquiry, the literature was reviewed for best practices in the TTP of NGNs. Key words included, new graduate nurses, nurse residency, transition to practice, nurse retention, and program evaluation. Articles reviewed were limited by year, 2014 – present, and by peer-reviewed journals.

American Nurses Credentialing Center (ANCC) Practice Transition Accreditation Program (PTAP) (2024) criteria were used in the design and development of this program, and the goal of accreditation has been set by the hospital administration. Mulkey and Casey (2021) identified that facilities that promote a healthy work environment, mentorship, support, and build a sense of belonging for NGN, increase retention rates. NGNs sometimes have unrealistic and unachievable work expectations and the transition to practice needs to be viewed holistically, including cultural, intellectual, developmental, and physical. (Boychuk-Duchscher, et.al. 2021).

Feeg, et.al (2022) completed a secondary analysis of the National Student Nurses Association 2021 survey that found some positive and negative aspects of the NGNs’ experiences. First a positive aspect: almost all NGNs were hired upon graduation despite difficulties with their education process due to the COVID-19 pandemic. However, due to dramatic shifts in education related to the pandemic half of the participants felt unprepared and lacked mentorship or preceptorship. Travel nursing was identified as the most frequent future goal for NGNs. Finally, the authors recognized that the TTP are expensive and if they are not following one of the two accrediting bodies, ANCC and CCNE, recommended best practices are they worth the cost to a facility?

Some challenges have been identified by Toothaker, et.al (2022) in their qualitative study.  The themes that emerged were lack of practical knowledge, imposter syndrome, safety culture, internalized fear, and seeking the sage. This study supported the need for quality nurse residency programs during the TTP, a minimum of 6 months of experience for improved confidence, and the belief that the TTP for NGNs can be uncertain and overwhelming.

Measurement of program goals and outcomes is important for accreditation of the program and for continued improvement. Standard 6 of the Nursing Professional Development Scope and Standards for Practice addresses program evaluation. Programs should have defined goals with measurable outcomes, and the data needs to be shared with all stakeholders and the academic programs from where the NGNs graduate (Casey, 2022). Participants completed evaluations throughout the program. This hospital chose the Casey-Fink New Graduate Nurse Experience Survey (CFGNES) to evaluate the program (Casey, 2021). The survey was administered during orientation, 6 months, and 1 year. Other process evaluations are completed also, including preceptor evaluation, class evaluations monthly, and EBP knowledge assessment pre/post project. Competency is measured using a core book which is completed by the NGN, preceptor, manager, and clinical education. Finally, retention of the NGNs will be assessed at 1- and 2-year post-hire.

The retention of the new graduates at the one-year mark is 100%, up from 60% the previous year. The CFGNES results for the first year comparing aggregate data at the start of the program, 6 months and one year did not demonstrate statistical significance, due to the small number of participants, there was clinical significance. However, for the measures of satisfaction, and confidence the results demonstrate the effect of ‘Reality Shock’ on new graduate nurses.  The important thing to note is that the residency program helped the NGNs through the downward turn at 6-month to a resolved confidence and satisfaction by the one-year mark.

An annual program meeting was conducted in May 2024 to discuss feedback from the stakeholders, managers, NGNs, and administration. Some additions are coming for the next group of NGNs.  After a GAP analysis of the program using the ANCC accreditation standards (2024), the program is weak in mentorship, and continued evaluation of the NGNs by the clinical educators. We also identified the need for better education of the preceptors and better communication with the management team.  The clinical educators will now be involved in all NGN evaluation meetings with management, preceptors, and each NGN. There is now an additional preceptor training specific to NGNs and the use of a married preceptor model of orientation. Lastly, the addition of a monthly lunch with the managers during the residency classes, to discuss project ideas, progression, and concerns of the NGNs. n

References:

Boychuk-Duchscher, J. E., Corneau, K., & Lamont, M. (2021). Transition to practice: Future considerations for new graduate nurses. Nursing Leadership, 34(4), 44-56.

Casey, K., & Cosme, S. (2022). Measuring nurse residency program outcomes: Selecting the right tool. The Journal of Continuing Education in Nursing, 53(9), 389-392. doi: 10.3928/00220124-20220805-02

Casey, K., & Fink, R. M. (2021). Revisions to the Casey-Fink graduate nurse experience survey reflect current healthcare trends. JONA, 51(5) 233-234. doi: 10.1097/NNA.0000000000001004

Feeg, V.D., Mancino, D., Vasques-Clarfield, B., Garrison, C.M., Mahler, E., & Vance, C. (2022). A national perspective on new graduate transition to practice: Secondary analysis of the National Student Nurses’ association 2021 new graduate survey. Nursing
Economics, 40(4), 167-185.

Harper, M. G., & Maloney, P. (Eds.). (2022). Nursing professional development: Scope and standards of practice (4th ed.). Association for Nursing Professional Development.

Melnyk, B. M., Buck, J., & Gallagher-Ford, L. (2015). Transforming quality improvement into evidence-based quality improvement: A key solution to improve healthcare outcomes. Worldviews on
Evidence-based Nursing, 12(5), 251-252. doi.org/10.1111/wvn/12112

Mulkey, D. & Casey, K. (2021). Factors that influence the retention of graduate nurses at a safety net teaching hospital. Journal for Nurses in Professional Development, 39(2), 70-79 DOI:10.1097/NND.0000000000000804

Toothaker, R., Rommelfaener, M.A., Flexner, R.S. & Hromadik, L.K. (2022). The challenges of transition to practice expressed through the lived experience of new-to-practice nurses. Patient Safety, 4(4), 11-17. DOI:10.33940/culture/2022.12.1

Walsh, A.L. (2018). Nurse residency programs and the benefits for new graduate nurses. Pediatric Nursing, 44(6), 275-279.

Yingling Klimek, J.A., DelPrato, D. M., Worrall, P. S., Levin, R. F., Record, V. L., and Elliot, D. (2021).
Evidence-based nursing practice in New York State: A Delphi study. Journal of the American Nurses Association-New York, winter 2021, https://ananewyork.nursingnetwork.com