Excellence in Nursing Preceptorship-to-Hire, part 1 : Nursing Management

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Department: Team Concepts

Excellence in Nursing Preceptorship-to-Hire, part 1

Letourneau, Rayna PhD, RN; Robinson, Leah DNP, RN, NPD-BC; Cruz, Vivien MS, RN, PCCN-K, CNL; Pryor, Stacy MSN, RN; Williams, Kaylyn MSN, RN-BC, AHN-BC; Bonamer, Jennifer PhD, RN, AHN-BC, NPD-BC

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Nursing Management (Springhouse) 54(1):p 7-12, January 2023. | DOI: 10.1097/01.NUMA.0000905028.54159.cc
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Abstract

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Transition from academia to practice is an exhilarating and anxious time for newly licensed RNs (NLRNs).1 Many healthcare organizations offer Nurse Residency Programs (NRPs) for NLRNs to support their transition from academia into professional practice. Research demonstrates that NRPs are an effective strategy to give NLRNs structured training to build clinical and professional competencies, adapt to complex healthcare environments, and respond to challenges in nursing practice.2 Likewise, hospital-based, extracurricular programs for prelicensure nursing students can socialize students to the hospital setting and establish a pipeline to the organization's workforce.3 The Excellence in Nursing Preceptorship-to-Hire (P2H) framework is a program designed to recruit and retain qualified prelicensure nursing students to the organization's nursing workforce by providing support and socialization in a way that more seamlessly facilitates the interorganizational transition from academia to professional practice.

Background and significance

Studies show that the national supply of RNs may not be enough to keep up with future demands. Zhang and colleagues predict that the national RN shortage will continue to grow through 2030, with the largest shortages in the southern and western parts of the country.4 A statement from the Tri-Council for Nursing members calls for strategies to recruit and retain nurses in a manner to “overcome workforce issues that discourage long-term commitment to nursing.”5 Turnover rates among nurses in the hospital setting have increased by 8.4% and stand at 27.1%.6 Literature has identified that effective orientation and the use of NRPs can support the educational needs as well as address retention concerns. However, despite the widespread implementation of NRPs, the nursing workforce continues to struggle with high turnover rates. Alarmingly, the turnover rate of NLRNs is even greater. Specifically, 27.7% of NLRNs leave their job within the first year of practice, 19.2% leave within 2 years, and 27.6% leave between 2 and 5 years.6

High patient acuity and nurse turnover rates combine to present challenges to NLRNs' experience in their first year of practice.1 According to Duchscher's transition shock theoretical framework, NLRN's experience transition shock during their first year of professional practice.7 The COVID-19 pandemic has compounded nursing workforce issues, including restrictions on the availability of in-hospital clinical experiences.8 NLRNs need socialization to the profession, so they have a sense of belonging and support.9 In a Press Ganey survey on nurse intent to stay, NLRNs identified targeted strategies to promote job satisfaction and retention such as support, respect, appreciation, empowerment, and feeling safe in practice.10

An innovative partnership

In the summer of 2021, a symbiotic and innovative academic-practice partnership was formed between a college of nursing at a large, public university and an 800+bed Magnet®-accredited community hospital in the west central region of Florida. Both organizations share the goal to promote a healthy, highly educated, and competent local nursing workforce that will deliver the highest quality of safe nursing care. To accomplish our mutual goal, we collaboratively developed the Excellence in Nursing P2H program. This created a pipeline of baccalaureate-prepared nurses into the hospital's professional practice environment.

The purpose of the program is to:

  • 1) Facilitate the nursing students' transition from academia to professional practice;
  • 2) Fill vacancies within the organization's workforce with highly qualified bachelor's of science in nursing (BSN)-prepared RNs; and
  • 3) Reduce NLRNs' turnover rate.

Preceptorship

Preceptorship has been used as an educational approach to gain confidence, increase competence, and socialize nursing students.11 Preceptorship uses experienced staff clinicians to help nursing students learn about the clinical environment through mentored patient care assignments. It also helps bridge theory and clinical practice.12 The Excellence in Nursing P2H program uses the preceptorship model to impact future nurses' clinical learning, professional enculturation, and transition to practice. The organization's positive learning environment and the trusting relationship that develops during preceptorship entices nursing students to seek employment opportunities within the safety of the preceptorship environment.

Mutual respect and interest kinship happen between the preceptor and the nursing student. During this time, nursing students receive appropriate guidance in clinical assessments and the performance of tasks. The preceptors adjust teaching strategies to meet the student's level of performance and understanding. There's an opportunity for preceptors to ask questions to help build the rationale for the care provided. The time a nursing student spends in the clinical setting sets the stage for developing their knowledge and skills.13 Preceptors also facilitate the introduction to members of the health team, making students feel a sense of inclusion in the unit and providing the opportunity to communicate and collaborate with healthcare team members. Students begin to understand the role of the professional nurse as a team member in patient care. The clinical and professional experiences provided in a preceptorship practicum are an antecedent to building confidence and self-esteem.13

Program development

Dedicated personnel at the hospital and college of nursing were identified to design, implement, and evaluate the program throughout the pilot phases. The program was designed to support nursing students' educational needs as well as the needs of the college of nursing and the hospital. The overall program director was seated in the university; a counterpart hospital-based program lead was designated to coordinate program activities within the hospital.

The P2H program begins in the nursing students' final year of their prelicensure baccalaureate program, and ends with hire into the hospital as a NLRN. Although the program remains iterative, the following narrative provides a description of initial activities. The program has four sequential components: Program Recruitment, Program Application, Practicum Implementation, and Transition to Practice.

Program recruitment

Prelicensure nursing students were recruited for participation in the Excellence in Nursing P2H program during the semester prior to being eligible for enrollment. School-based recruitment methods included the academic-based program director presenting information at the end of students' class time; announcements sent through the learning management system students used for their classes; flyers and posters; and posts to the college of nursing's social media accounts.

Concurrently, the hospital-based coordinator and unit managers initiated recruitment discussions to identify potential practice placement settings. Interested units were included in the marketing materials as placement opportunities for Excellence in Nursing P2H participants. Many of the offered units were in desirable specialty areas often sought by students. The number of students that each cohort of the P2H program accommodated depended on the number of anticipated position vacancies that would be available when the student graduates and the number of available preceptors. Preceptors selected for the P2H program were RNs who demonstrated competency and safe practice, had completed the organization's preceptor training, and were available and willing to precept a student. On average, there have been about 10-20 spots available to each cohort for P2H student placements.

Program application

Enrollment in the Excellence in Nursing P2H program was a competitive process. Students completed an application packet that consisted of the following:

  • a cover letter expressing the intent to work at the hospital postgraduation,
  • a résumé,
  • an electronic recording of interview questions, and
  • a performance reference from a nursing faculty member.

Students were mentored through the application process by P2H program faculty at the university. During the program application process, the need to effectively match nursing students with their preferred practice setting was identified. The process was updated to allow nursing students to rank their top three choices for preferred hospital unit placement. Completed application packets were sent to unit-level nurse managers at the hospital. The nurse managers evaluated the application packets, paying close attention to the student's expressions of interest in staying at the organization and within the community; requests to work with a specific population; and behavioral characteristics consistent with the unit's dynamics, culture, and patient population.

Acceptance letters were sent to the selected students via email, providing information on their assigned placement area, shift, and nurse preceptor. Since the initiation of the program, all P2H participants have received either their first- or second-choice preferences.

Practicum implementation

The Excellence in Nursing P2H program enhances an existing experiential learning course (preceptorship) established in the college of nursing's prelicensure curriculum. The course provides students with a practicum experience by pairing a student with an RN preceptor in a clinical setting and gives the student the opportunity to synthesize theory and practice for professional nursing. There are no additional clinical hours or activities assigned to the students participating in the Excellence in Nursing P2H program. However, students in the program receive additional support and mentorship during the time they're enrolled in their preceptorship course. The university's P2H faculty meet with students regularly throughout the practicum to debrief their clinical experiences and provide guidance related to their career development.

The P2H preceptorship practicum begins with general hospital and nursing orientation, including the hospital's electronic documentation system. Students were also given their preceptor's schedule ahead of time. This allowed students to coordinate their clinical schedule with their preceptor and their nursing classes. Students were asked to record the number of hours spent in preceptorship. The number of precepted hours in the Excellence in Nursing P2H program was based on the number of credits in the preceptorship clinical course as established by the college of nursing.

During the Excellence in Nursing P2H practicum, informal meetings were scheduled between the hospital coordinator and the nursing students to discuss clinical experiences and unit fit. In addition, the hospital coordinator met regularly with the unit leadership team to obtain perspectives on the student's fit with the unit and organization.

Transition to practice

The Excellence in Nursing P2H transitional phase occurred during the students' last week in the practicum and continued until they started in the hospital's NRP. No later than the end of the practicum, a meeting with the unit manager and student was scheduled to discuss the possibility of future employment as a unit-based NLRN. Most managers had discussed and extended a contingent RN position offer of employment to the nursing student during the practicum (contingent because it requires successful completion of NCLEX-RN and employee health screening process).

In addition, the hospital resurrected the role of a graduate nurse (GN), which is recognized by the state's Board of Nursing. The GN role is a paid position that allows the unlicensed newly graduated nurse to work under direct supervision of an RN per the state statute. P2H students exclusively were given the opportunity for this position on the unit where they completed their preceptorship. Once the GN successfully passed the NCLEX-RN, they began the new role of RN in the hospital's accredited residency program.

Lessons learned

It was identified during the pilot phase that hospital-based representatives could recruit more students to the program using effective marketing strategies, such as hospital participation in career fairs at the college of nursing, where they could network, encourage interest, and distribute marketing tools and handouts to potential program participants. Additionally, it was acknowledged during the program pilot that professors should introduce nursing students to the Excellence in Nursing P2H program earlier in the nursing curriculum; for example, during the foundations and fundamentals levels. Waiting to introduce the program until the final year of the curriculum may reduce the number of participants because of a knowledge deficit about the program objectives.

Implications for nursing practice

The Excellence in Nursing P2H program has important implications for nursing practice, particularly related to improved clinical exposure, promotion of professional enculturation, and prevention of transition shock. An inability to address highly acute situations in clinical work environments has led to increased NLRN turnover rates within the first year of employment.14 In line with this, inadequate support and work preparation may affect NLRNs' patient-care delivery and job satisfaction. The Excellence in Nursing P2H program is a strategy that facilitates NLRNs' knowledge and skills development while providing support and guidance as the participant transitions from nursing student to NLRN. When nursing students receive positive experiences in their academic and practicum learning experiences, they have a better understanding and satisfaction with their role as a professional nurse.13 Effective preceptorship of new nurses is an intervention that can decrease turnover and increase retention.15 A program evaluation is currently in process that will evaluate the impact of the P2H on nurse, unit, and organizational outcomes.

In addition to P2H program benefits to the organization and students, there are noted benefits for the preceptors. While preceptors are matched with a student, they have frequent communication with the Residency Coordinators to discuss the student's experiences and progress and identify needs for additional support. This allows the preceptor to play an active role in developing the P2H participant from student to NLRN and determine if the participant is a good fit for the unit. Moreover, the P2H program allows preceptors to grow professionally and develop leadership skills.

Implications for nursing education

The journey and continued development of the Excellence in Nursing P2H program has several implications for nursing education. Prelicensure nursing students need strong educational structures in the academic setting as well as the practice setting to successfully transition into their professional role.

Literature has identified a gap between nursing theory and nursing practice.16 Nursing theory relates to the knowledge acquisition obtained in the classroom whereas nursing practice relates to the experiences obtained in the clinical settings. Both educational models are essential in the successful transition from nursing student to professional nurse. Clinical rotations, preceptorships, and other practicum experiences can assist in closing these educational gaps.16 With the onset of the COVID-19 pandemic, hospitals faced challenges such as personal protective equipment shortages and elevated patient census. To limit the risk of exposure and prevent further spread of the virus, hospitals limited or completely removed the opportunity for nursing students to complete clinical hours in the acute care setting.17 This resulted in nursing students leaving academia with little hands-on patient experience.

As newly licensed nurses enter the workforce, especially those who entered the workforce during the COVID-19 pandemic, many were taken aback by the fast-paced environment, skill acquisition required, and the acuity of the patient population.18 Although many of these challenges are expected, there are notable differences between the NLRNs who received adequate clinical opportunities and those who didn't.18 In addition, it's well documented that NLRNs must have a supportive and stable environment to assist in the successful transition into their role as a professional nurse.19 The need for preceptor support, guidance, practice of skills, and teaching remains important during the COVID-19 pandemic.20

Academic-practice partnerships could enhance and support the educational transition of NLRNs.18 The Excellence in Nursing P2H program allowed nursing students to apply knowledge, engage staff, and experience patient care in a way that couldn't be replicated in the classroom or in a simulated setting. Nursing students could communicate with patients, ask preceptors the “why” questions, and collaborate with interdisciplinary teams. Nursing education needs to include clinical hours and adequate preceptorship time to better prepare future nurses for the dynamic and complex nature of patient care in the hospital setting.

Nursing education models need to include all modalities of learning and incorporate a variety of educational settings. Simulations can imitate the practice environment; however, they can't replace the experience.18 The acute care practice settings are dynamic and complex. Recreating these environments in a controlled simulation lab is an unrealistic expectation. Removing clinical experiences from the nursing educational model could have serious and devastating consequences. As the pandemic continues to play a role in healthcare dynamics, nursing academia and hospitals need innovative mechanisms that foster long-lasting relationships to support the educational needs of nursing students and NLRNs. The development of academic-practice partnerships and innovative programs such as the Excellence in Nursing P2H program further supports our call to nursing. By better preparing our NLRNs, we can provide them with secure jobs, improve organizational retention and staffing needs, and keep nurses in the profession for their lifetime.

Editor's note: Look for Part 2 of this article, presenting the outcomes of the program evaluation, in a future issue.

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