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A tale of two hospital systems: Preparing new graduates for clinical practice

Niemi, Judith MSN, RN; McErlane, Kimberly MSN, RN, CNS; Vasseur, M. Megan MSN, RN, CMSRN; Bohl, Susan MSN, RN, CNRN

doi: 10.1097/01.NURSE.0000453003.94900.48

At the time this article was written, Judith Niemi was an education specialist at St. Elizabeth Healthcare in Edgewood, Ky. She now works at Indiana Wesleyan University in Marion, Ind. Susan Bohl is a director of Cardiovascular Specialty Services at St. Elizabeth Healthcare in Edgewood, Ky. At St. Elizabeth Healthcare in Florence, Ky., M. Megan Vasseur is an education specialist. At Northern Kentucky University in Highland Heights, Ky., Kimberly McErlane is an assistant professor.

The authors have disclosed that they have no financial relationships related to this article.

HOSPITAL MERGERS are becoming more common because of multiple advantages, including improved quality of patient care, better patient outcomes, and cost savings.1 According to Levin Associates, a nationally recognized consulting firm, “In 2010, $12.6 billion was committed to hospital mergers and acquisitions, an 86% increase from the $1.8 billion committed in 2009.”2

In the Midwest, two separate hospital systems merged into one system providing healthcare services to a four-county area. During this merger, many institutional changes were implemented, including changes in educational programs for staff. Staff development educators were challenged to expand an existing Nurse Transition Program (NTP) at one facility to serve an additional two facilities. This article describes how the NTP was successfully expanded for new graduate nurses in the additional facilities.

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Easing entry into practice

As a means to better prepare new graduate nurses for practice and to increase retention, many institutions have developed new graduate transition programs and residency programs.3-5 Entry into practice has been identified as a period of adjustment and transition for new graduate nurses. The retention of new graduate nurses can be problematic—50% of new graduate nurses leave within the first year of employment.3 However, retention rates for new graduate nurses increase when these nurses are enrolled in NTPs.3,6

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A force to be reckoned with

One institution involved in the merger already had a well-established NTP. This original NTP curriculum consisted of 6 days of classroom orientation, two NTP clinical days before the new graduate nurse began unit orientation with a preceptor, and four additional NTP classes during the first 6 months of employment. New graduate nurses were also scheduled for extra organization classes (such as the National Institutes of Health's stroke scale, ECGs, and Therapeutic Crisis Intervention) based on individual clinical unit requirements. In addition, education specialists provided support and follow-up on the clinical unit during the graduates' first year of employment.

To expand this NTP, the first step was to create a task force with a mission to assess, plan, and evaluate the existing NTP. The task force's objectives and strategies were aligned with the organization's values. (See the Nursing2014 iPad app for supplemental content.)

Early in the process, the task force researched evaluative models and selected the Kirkpatrick Measurement Model to guide the process.7 The Kirkpatrick Model identifies four evaluative levels:

  • Level I: participants' reaction to the class
  • Level II: knowledge learned
  • Level III: behavior change and application of the knowledge into professional practice
  • Level IV: benefit to the organization.

Using the Kirkpatrick Model, the task force agreed that the goal in the NTP expansion was to assist and support new graduate nurses at level III.

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The new curriculum

Before the NTP was expanded, the curriculum was reviewed and changes were made to improve it based on feedback obtained from key stakeholders. The new NTP curriculum incorporated more hands-on, interactive learning such as skills stations and simulation. It included close interaction between new graduate nurses and educators. Education specialists were assigned to each medical-surgical and telemetry unit to provide education, support, and follow-up for new graduate nurses.

After attending an initial 6-day classroom orientation, new graduate nurses had a 2-day clinical experience caring for one to two patients. The focus of the NTP clinical days included physical assessment, documentation, and medication safety.

Upon completion of the 2-day clinical practicum, new graduate nurses were individually evaluated for readiness to begin unit orientation with an assigned preceptor. Once released to the unit's preceptor, each new graduate nurse attended four NTP classes to continue to build his or her knowledge and skills. The NTP educator maintained contact and scheduled periodic meetings with each new graduate nurse during the first year of employment.

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Continued expansion

The initial evaluation was crucial because it provided data that were presented to administration supporting expansion of the NTP. Interviews were conducted with many of the NTP key stakeholders, including educators, nurse managers, preceptors, and new graduate nurses, to collect data related to program effectiveness.

The educators determined the main benefit of the NTP was that it helps new graduate nurses gain competence and confidence with entry into practice. The clinical focus provides a stronger foundation for new graduate nurses in equipment training, patient safety, and critical thinking.

Evaluations from both graduate nurses and preceptors have validated the success of the program. Graduate nurses were more prepared to begin orientation on the units with their preceptors and they felt the educators remained supportive throughout their first year of practice.

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NTP surveys

Nurse managers and preceptors were also surveyed about the success of the expanded NTP. Nurse managers were questioned about three aspects of the program:

  • communication regarding class schedule for new graduate nurses, which meant providing advanced notice of class schedules to managers so classes could be incorporated into the unit schedule and provided to graduates when they started orientation
  • new graduate nurses' knowledge about safe medication administration
  • new graduate nurses' knowledge about documentation practices.

The results ranged between 1.6 and 1.7 on a 2-point scale. Nurse managers reported satisfaction with the NTP and noted significant improvement in the performance of new graduate nurses after they completed the program.

Ninety percent of preceptors surveyed responded that new graduate nurses were better prepared to care for two patients after spending 2 clinical days with the NTP educator. This allowed new graduates time to focus on caring for two patients while being supervised by an education specialist and provided a smoother transition to their unit preceptor. The unit preceptor would then slowly help the graduate progress to caring for a full patient assignment over the clinical orientation period, with the nurse-to-patient ratio specific to the individual unit's level of care. This time varied based on unit of hire, previous experience, and individualized needs.

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What do the new grads say?

A survey of new graduate nurses who'd attended the NTP was conducted. A Likert style survey (1-4, 4 being strongly agree) was administered upon program entry (75 new graduate nurses), at 3 months (60), and 6 months (29). The number of nurse graduates at each time period reflects survey response rate—completion of the survey was voluntary. All new graduates completing the surveys reported positive support from the educators. Survey results further indicated that the NTP had a significant positive impact on new graduate nurses' comfort/confidence levels, work relationships, performance of skills/procedures, and ability to make a smoother transition to clinical work environments. In addition, NTP's year-long mentoring program provided new graduate nurses with ongoing support, education, guidance, and assistance in transitioning to hospital clinical practice.

New graduate nurses completed an evaluation of clinical days with their educator on knowledge learned (3.74 on a scale of 1 to 4) and benefits of clinical days (3.91) at the end of the second day. New graduate nurses evaluated the nurse transition classes and found them to be beneficial (3.74).

After all the evaluations were completed, it was evident that the NTP provided opportunities to apply nursing knowledge into the professional practice setting. Self-evaluation surveys at 6 months demonstrated behavior change and application of the knowledge into the professional practice setting. Data also showed new graduate nurse retention rates increased since the establishment of the NTP. (See NTP boosts graduate retention rates.)



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Ongoing evaluation

Educators used the results of the formative evaluations completed by new graduate nurses to implement improvements in the program. Examples of improvements include updated educational delivery methods (such as using more interactive technology-based platforms), simulation scenarios integrated into NTP classes, and confidential support group sessions under the guidance of Employee Assistance Program (EAP) counselors. Support group sessions were scheduled on the first and third Wednesday of each month and were held off campus. The voluntary confidential attendance provided new graduate nurses with an avenue to voice fears and concerns and to provide time for peer support. The EAP counselor led the group and provided anonymous feedback to the educators on new graduates' concerns. Based on feedback from the support group, educators scheduled open office hours once a month at three of the main healthcare system locations to give new graduate nurses more opportunities to meet one-on-one with an educator to discuss clinical issues and concerns.

NTP educators continued to enhance the program by including experienced nurses with no inpatient hospital experience in the 2 clinical days spent with NTP educator on the unit of hire. The organization considered a nurse to be experienced if he or she had more than 1 year of practice. If an experienced nurse had no acute care experience, he or she was automatically added to the NTP. An example would be an experienced nurse hired into the organization from a physician's office, nursing home, or rehabilitation facility.

The Basic Knowledge Assessment Tool (BKAT) was given to all participants.8 All new graduate nurses, nurses with no acute care experience, and experienced nurses with scores below the national BKAT pass rate were included in the NTP classes. The most recent improvement made was to offer unit-based simulations in which all staff could participate.

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Life goes on after a merger

With the oversight of staff development educators, nursing orientation programs for new graduate nurses will continue to evolve to meet demands of the current healthcare environment.9 According to the Institute of Medicine, a future implication includes a recommendation for hospitals to provide nurse residency programs to all new graduate nurses transitioning into practice.10

Merging organizational systems is challenging, even overwhelming at times. Identifying and building on positive aspects within each organization can enhance merger success.

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