Transition To Practice

This document outlines the of Newfoundland and Labrador College of Nurses’ position that structured transition to practice programs or processes foster the safe integration and retention of newly licensed nurses into nursing or psychiatric nursing practice in the interest of safe, competent, compassionate, and ethical client care. Transition extends beyond orientation. Orientation is a period of clinical support to familiarize staff with a new work environment, related expectations, and policies. Transition to practice programs or processes, in addition to orientation, assist newly licensed nurses to transition into professional practice.

Transition Shock

Transitions¹ occur at various stages along the continuum of ones’ professional career, for example, becoming newly licensed as a nurse, or moving to a new practice area within nursing or psychiatric nursing. Professional role transition such as moving from student to newly licensed nurse involves making changes from what one knows to what one doesn’t know, or with which one is not completely familiar. Newly licensed nurses experience unique challenges as they make this transition. The first three to six months are the most stressful for newly licensed nurses who view the novice period as both exciting and stressful, and who express a very high motivation to provide quality client care, with safety paramount in their nursing practice.

Research demonstrates that during the first year of practice, newly licensed nurses experience a complex but relatively predictable array of emotional, intellectual, physical, sociocultural, and developmental issues that, in turn, feed a progressive and sequential pattern of personal and professional evolution. The experience of newly licensed nurses has been described to include a transition shock at the initial stage of role adaptation. Transition shock, involving the apparent contrast between the relationships, roles, responsibilities, knowledge, and performance expectations in the academic setting versus the practice setting, reinforces the need to provide bridging between undergraduate educational curricula and escalating workplace expectations; the goal of which is to support successful integration of new nursing professionals into the highly dynamic context of professional practice. The unique challenges experienced by newly licensed nurses require managers and policy makers within the health system to both understand the stressors and to support the transition of newly licensed Nurses.

Transition and Collaboration

The collaborative efforts of education, regulation, employers, and both the newly licensed nurse and experienced nurses, position the newly licensed nurse for successful transition to a safe, competent, compassionate, and ethical practice. Newly licensed nurses, having met the competencies required for entry-level practice, graduate from an approved school of nursing or psychiatric nursing, successfully complete an approved regulatory exam, and meet all other licensure requirements. As health care team members, they accept responsibility, demonstrate accountability, recognize their limitations, ask questions, exercise professional judgment, and determine when consultation is required. Newly licensed nurses realize the importance of identifying what they know and don’t know. They display initiative, a beginning confidence, and self-awareness in taking responsibility for their decisions in the care they provide.

Regulator

The College, as the regulator, contributes to newly licensed nurse transition by articulating the requirements and expectations of the professional; for example, identifying the Code of Professional Conduct or Standards of practice, the scope of practice, entry-level competencies, ethical codes, and other self-regulatory requirements.

Employers

The practice setting proves a crucial link in providing newly licensed nurses with planned, preceptored practice experiences in environments conducive to learning. The advocacy role that nurses in leadership positions play in relation to funding and innovative programming support newly licensed nurses as they transition to practice. Furthermore, nurse leaders at all levels of the organization need to be attuned to the transition needs of new graduates in the promotion of quality outcome for patients.

Experienced Nurses

Role acquisition occurs in part by observing other nurses in practice and within the social network of their workplace. Time is required to establish professional relationships, learn practice norms and consolidate nursing or psychiatric nursing practice knowledge and judgment. As confidence develops in their new role, newly licensed nurses assume higher levels of responsibility and manage increasingly complex clinical situations. Their proficiency and efficiency with respect to workload management and technical skills will improve with support and experience. Experienced nurses advocate for and contribute to quality professional practice environments which support satisfied and empowered nurses, quality client care, and efficient and effective health care systems. Experienced nurses also support their transitioning colleagues by sharing their nursing knowledge and expertise.

Formal Transition to Practice Program or Process

A supportive transition to practice program or process can set the tone for confident, safe, and gratifying nursing or psychiatric nursing practice. Studies have demonstrated that newly licensed nurses require adequate support as they make the transition from the school environment to the work environment. Newly licensed nurses are reported to engage in concrete thinking, focusing on technology thereby potentially missing the bigger picture. Newly licensed nurses take longer to put the pieces together and would benefit from consultation with an experienced nurse. There are deterrents to newly licensed nurses reaching out to their more experienced colleagues, in that they are concerned with a sense of being a burden on already-taxed practitioners, feeling their self-confidence is threatened, and a concern over acceptance by colleagues should the new nurse be seen as unknowledgeable or inexperienced. A reluctance to seek assistance may present client safety concerns as newly licensed nurses assisting other newly licensed nurses may create situations in which errors in judgment will not be corrected in the absence of consultation with a more experienced nurse.

Preceptorship and Mentorship

The initial support provided to newly licensed nurses typically occurs during the orientation period and primarily through a preceptored² experience. Preceptors should receive a level of formal training prior to working with a newly licensed nurse. Benefits of preceptorship include enhanced preceptor satisfaction, preceptor retention, improvement in new graduate critical thinking, quality care, and newly licensed nurse satisfaction and retention. They further assert that formal support should be available to the newly licensed nurse at least through the difficult six to nine-month post-hire period. Opportunities for connection with peers should be provided, and organizations should strive to ensure clinical units with healthy work environments. Newly licensed nurses practicing in environments described as very healthy work environments reported higher professional work satisfaction, less environmental reality shock, expectations more in line with role conceptions, and having retention rates higher than other work environments.

In addition to preceptorship, mentoring has proven to be a successful way of facilitating the professional growth and development of newly licensed nurses. Mentoring is more than orientation or preceptorship and involves a reciprocal and collaborative learning relationship between two individuals with mutual goals and shared accountabilities for the success of the relationship. Mentorship has been defined as a mutually beneficial and usually long-term professional relationship in which one person is an experienced and knowledgeable leader (mentor) who supports the maturation of a less-experienced person (mentee). Mentoring provides a supportive environment and positively influences professional outcomes.

Benefits

It has been reported that structured transition programs and processes resulted in a cost-benefit due to improved newly licensed nurse retention and turnover, with some organizations quantifying their savings, while others reported data that demonstrated the average budget for managing their annual transition program is less than the cost to advertise for and recruit two nurses.

The 2011-2013 transition to practice study, a multi-site, randomized controlled study conducted by the National Council of State Boards of Nursing (NCSBN) confirmed that transition to practice is most effective when it encompasses clinical reasoning; patient and family centered care; communication and teamwork; evidence-based practice; quality improvement; and informatics. They assert that a formal program of study allows time for newly licensed nurses to apply their learning, obtain feedback, and share their reflections with others—increasing their competence. Newly licensed nurses in a structured transition program reported fewer errors, fewer negative safety practices³ and higher overall self and preceptor reported competence ratings.

Conclusion

It is College’s position that a structured and supportive transition that extends beyond orientation fosters the safe integration and retention of newly licensed nurses into a professional practice and is in the interest of safe, competent, compassionate and ethical client care. Studies show that strong, evidence-based transition programs improve outcomes for newly licensed nurses in their first year of practice. Within transition processes, there are roles for education, regulation, practice, the transitioning nurse, and the experienced nurses who support and participate in their transition. Nurses should seek out and utilize evidence based resources and best practices to inform the decisions they make about their own transition to practice, and when planning or developing orientation and transition programs or processes for others.