Excellence in Nursing Preceptorship-to-Hire, part 2
Year: 2023
Type: article
Abstract: Nursing students' transition from academia to professional practice is often stressful and can cause significant turnover. In fact, 25% of newly licensed RNs (NLRNs) leave their job within the first year.1,2 Research has found that expectations, socialization, confidence, and support influence this transition.3-6 Transition-to-practice programs are designed to facilitate the transition process and decrease turnover rates of NLRNs.7-9 Furthermore, successful transition-to-practice programs can increase patient safety and build NLRNs' confidence and competence.10 With the increasing complexities of today's healthcare environment, additional support is needed to improve that transition through a preceptorship-to-hire program.11,12 In the summer of 2021, an academic-practice partnership was established to promote a healthy, highly educated, and competent local nursing workforce. This partnership led to the development of the Excellence in Nursing Preceptorship-to-Hire (P2H) program.11 The aims of the P2H program are to facilitate nursing students' transition from academia to professional practice, fill vacancies in the practice partner's workforce with highly qualified bachelor's of science in nursing (BSN)-prepared RNs, and reduce NLRNs' turnover rate. Part 1 of this article (Excellence in Nursing: Preceptorship-to-Hire, January 2023) discusses the background and implementation of the P2H program.13 The purpose of this article is to discuss outcomes related to the P2H program. Program description The P2H program was designed to recruit qualified prelicensure nursing students in their final semester of a baccalaureate program, specifically during their preceptorship clinical course, and work to retain them as they transition into professional practice. It's important to note that the P2H program started during the height of the COVID-19 pandemic in the US, and the high hospital census and number of patients with COVID-19 admitted to the hospital impacted the students' precepted time and experiences.14,15 Students in the first two cohorts were required to complete their precepted time in the second half of the final semester of their prelicensure nursing program. This strategy aimed to reduce the length of time spent away from the acute care environment between graduation and employment. This was an unidentified obstacle to program initiation. However, as the program continued, it was determined that the concentration of the clinical hours conducted at the end of the semester improved the seamless transition into professional practice. As part of this program, executive level leadership supported formation of an academic-practice partnership between a college of nursing at a large, public university and a 900-bed Magnet®-accredited community hospital in the west central region of Florida to close the gap between nursing academia and the organizational practice environment. This partnership aimed to provide support and socialization to seamlessly facilitate the interorganizational transition as the nursing student becomes an NLRN. A comprehensive group was formed between the university (BSN program faculty) and the hospital (program coordinators and clinical unit managers), and they garnered the support of clinical managers throughout the hospital, which was vital to the program's execution, implementation, and success. This group was also responsible for integrated efforts during the four phases of the P2H program: 1) Recruitment: Included efforts at the university to recruit students to participate in the program, as well as hospital-based discussions to identify practice placement settings and preceptors for the students. 2) Application: Students applied for the program; applications were evaluated; students' unit placements, preceptors, and shifts were determined; and decision letters were emailed to students. 3) Implementation: Students participated in orientation, a clinical experience with assigned RN preceptors, regular check-in meetings with university faculty, and informal check-in meetings with the hospital coordinator. The hospital coordinator also met regularly with the unit leadership team. The meetings enabled the students to share their experiences and helped the student and hospital leadership determine if the student was the right match for that unit. 4) Transition to practice: Students and unit managers met to discuss the student's potential employment as an NLRN. Some students were offered a contingent NLRN position based on successful completion of the NCLEX-RN and employee health screening. Students could work in a paid graduate nurse (GN) position until these criteria were met. Evaluation The impact of the P2H program was determined through turnover rates and stakeholder feedback. Feedback was received in a variety of ways, including regular evaluation meetings and informal interviews with the nursing students throughout the program. In addition, managers were given opportunities to report their satisfaction via a survey as well as in-person interviews. Preceptors provided their input to the managers during the precepted time. When the students transitioned into their NLRN role, they were evaluated by the hospital's nurse residency program coordinators through weekly progress meeting reports, the number of orientation shifts needed to establish competence, and a weekly evaluation tool that describes the level of competence and supervision required. Additionally, the residency program coordinators evaluated 1-year retention rates of the NLRNs. The 1-year mark started when they were hired to the hospital as an NLRN. Other elements of the program evaluation involved a review of the P2H student acceptances into an NLRN role upon program completion. This included: the number of P2H students who decided to stay at the organization, the number who chose to leave the organization and why, and those who chose to stay at the organization but apply to a different unit from their P2H placement. Although these analyses weren't included in the program's original outcome measures, it was important to review this information to validate the program's integrity and rationality. Because the manager's participation and support are vital in maintaining this program, it was essential to evaluate the manager's satisfaction level with the program. The P2H committee at the hospital and the university developed the P2H Leadership Feedback Survey, which was provided to the managers post-preceptorship. The electronic survey was sent via email and was based on a Likert-type scale ranging from 1 (very dissatisfied/strongly disagree) to 5 (very satisfied/strongly agree). The managers' responses were anonymous. It was sent only to managers who had a P2H student on their unit in cohorts 1 to 5. Some managers had multiple experiences with P2H students. Outcomes Since the P2H program was implemented in May 2021, there have been 5 nursing cohorts with 14 applicants. All applicants exceeded program admission criteria, and all were selected to participate in the program in either their first- or second-choice specialty areas. Two applicants declined the offer, leaving a total of 12 students who enrolled and completed the P2H program. Of the 12 who completed the P2H program, 9 started in an NLRN role at the hospital. It's important to note that students who began their preceptorship experience in May 2021 graduated from their prelicensure nursing program approximately 3 months later, then passed NCLEX-RN before being hired to the hospital. There is a span of 4 to 6 months between starting the P2H program and hire as an NLRN at the hospital. At the time this article was written, the three nursing students who were hired to the hospital in cohort #1 and cohort #2 had completed a full year at the organization, resulting in a 100% 1-year retention rate of NLRNs who participated in the P2H program. The remaining cohorts have not yet reached their 1-year mark and therefore were not included in the retention at 12 months in Table 1. Table 1: - P2H pilot process measures and outcomes Program phase Variable n∗ % (n/N) Application Students who applied to P2H program 14 n/a Implementation Students who started in the P2H program 12 85.7 (12/14) P2H participants who didn't successfully complete practicum on originally placed unit 12 8.3 (1/12) P2H participants who successfully completed practicum within the organization 12 100 (12/12) Transition Offered NLRN position at organization 11 91.7 (11/12) Offered NLRN position where the preceptorship was conducted 10 83.3 (10/12) Student accepted and started an NLRN position at organization 9 75 (9/12) Successfully completed clinical orientation as an NLRN 6 100 (6/6) Retention at 3 months 6 100 (6/6) Retention at 6 months 6 100 (6/6) Retention at 12 months 3 100 (3/3) ∗Note: “N” is variable based on timing of program completion. Average cohort size was three participants (range, two to four). Table 1 describes preliminary data from the first five cohorts that took place from February 2021 to August 2022. Recruitment phase. Cohort #1 was a pilot with two practice settings. Cohorts #2 through #5 had an average of 15 specialty settings to choose from, including the women and children's division, emergency care centers, and the cardiac, medical-surgical, critical care, and acute rehabilitation units. Managers throughout the hospital expressed substantial interest in participating in this program. Application phase. Of the 14 students who applied to the program, all were accepted in either their first- or second-choice units; 2 students declined participation for personal reasons. Implementation phase. The implementation phase included the 12 nursing students who started the P2H program and completed the precepted hours. During a check-in meeting, it was determined that one student wasn't a good match for their preferred specialty area. The hospital program coordinator and the academic faculty member met with the student to discuss the concerns, and the student shared that the specialty environment wasn't what they had expected. The program coordinator in conjunction with the academic faculty member coordinated the student's transition to another unit in the hospital. The student later accepted an NLRN role with the organization in a different specialty area from their preceptorship. Transition-to-practice phase. The transition-to-practice phase included the number of students who chose to accept an NLRN role at the hospital through their first year of nursing: of the 12 students who completed the P2H program, 11 were offered NLRN roles at the organization. One wasn't offered the role because the unit staff and unit manager determined that the student would have a difficult time being successful in the fast-paced clinical environment of that specialty area. The student was encouraged to look into other internal opportunities but chose not to pursue an NLRN role at the hospital. Out of the 11 who were offered an NLRN role, 9 accepted the position. The two students who didn't accept the NLRN position took positions at other hospitals. They reported during their preceptorship that the commute from their homes to the hospital for a night-shift position would be challenging. Of the nine students who accepted an NLRN role, eight were on the same unit as their preceptorship. As mentioned previously, one student took a position in a different area of the hospital from where they completed their preceptorship. Ultimately, the P2H program yielded a retention rate of 75% (9/12). Throughout the transition phase, the nurse residency program coordinators evaluated the NLRN clinical orientation and noted that those who participated in the P2H program required less clinical orientation and developed clinical competence earlier than those who didn't participate in the P2H program. On average, P2H NLRNs completed orientation 3.6 shifts (or 43.2 hours) earlier, requiring 10.3% less orientation time than their peers. Manager survey Of the nine managers who received the survey, seven responded for a 77.8% response rate. Figures 1 and 2 are based on the weighted averages of the Likert-type scale. There were 14 questions in the survey that specifically used the Likert-type scale, and the goal was to have a weighted average score of 4 or higher in each of the 14 domains; 13 of 14 domains reached the goal. The domain regarding “the hiring process of the P2H student into the RN role” didn't reach the goal and had an average weighted score of 3.75. Two domains had a weighted average score of 5; those included the “performance of the P2H student on my unit as a newly licensed nurse” and “the P2H program allowed me to determine if the student was a right fit for my unit.”Figure 1:: Results from the manager satisfaction survey (n = 7)Figure 2:: Results from the manager satisfaction survey (n = 7)Anecdotal outcomes Themes emerged related to the P2H students' transition, such as a reported confidence in their decision to start their nursing career in their specialty area. They shared excitement in their clinical experiences and felt supported by staff on the units. These experiences decreased the nervousness typically associated with starting a new career in a new hospital with unfamiliar staff. One student reported: “I feel the P2H program offered a glimpse into my specific unit's culture, which helped to reaffirm my decision to join this organization. Additionally, the P2H program supplemented my introduction to the unit.” Additionally, the clinical managers provided anecdotal feedback in the leadership survey. Specifically, one manager mentioned that “selecting the right candidate was key.” Another manager who chose not to hire a P2H student reported: “I did not hire [name], and [she] did not ask to work on the unit. The preceptor said she was nice and had decent knowledge, but her personality and ability to focus sometimes was distracting and felt [she] would struggle with the fast pace of the acute care environment.” Discussion The outcomes of the P2H program supported the program's threefold purpose: to facilitate the nursing students' transition from academia to professional practice; to fill vacancies within the hospital's workforce with qualified BSN-prepared RNs; and to reduce the NLRN turnover rate. The P2H program enabled nursing students to experience their desired practice area and the hospital culture before committing to an NLRN role in that setting. In the post-preceptorship interviews with the nursing students, they described the P2H program's value in allowing them to better understand specific patient populations, connect with the unit staff, establish a relationship with the unit manager, and evaluate the unit's working environment. They also shared the benefits of having used or observed complex and specialized skills specific to a patient population. The nursing students reported a sense of belonging with staff. Although each student was paired with a preceptor, other nurses on the unit often shared their knowledge and skills with the P2H student. The students felt supported by the unit staff and were enculturated into the unit team. It was through these experiences that the nursing students found validation in their decisions to start their nursing careers on these units and at this organization. It was also evident that the students transitioned well into their NLRN role. As evaluated during the weekly progress meeting and with the weekly evaluations, these nurses reported higher confidence in their role and quickly acquired skills specific to their specialty areas compared with NLRNs who didn't participate in the P2H program. The structured approach to the P2H program allowed the clinical managers and staff to have an active role in the hiring decision. With specialty areas come specialty skills. Staff and managers could provide students with the knowledge and application of those skills and then evaluate the student. Staff provided managers with feedback expressing support for or concern about hiring the student. Managers reported satisfaction with the P2H students and voiced their desire to continue to participate in the P2H program. This program supported the organizational outcomes of filling vacancies with highly qualified BSN-prepared nurses. The nine BSN-prepared P2H students who accepted an NLRN role at the hospital are still employed at the organization. Additional program outcomes supported the organization's retention and turnover rates. Currently there's zero turnover at the 1-year mark. Overall, the orientation for these individuals went smoothly, and they were identified as competent clinicians earlier than expected for their practice areas, which was evident from the decreased overall length of their clinical orientation. It supported the organization's need to fill nursing vacancies and provide adequate staffing that backed the unit matrices. The success of this program doesn't rely on the number of students who start as an NLRN on the precepted unit or on their acceptance of an NLRN role at the organization. Instead, the success of the program focuses on the student's and manager's determination of fit. The student's first choice of placement isn't always the right match. This is noted in the revised practice location for one of the P2H participants, and the organizational success with zero turnover at 1 year. Because of the COVID-19 pandemic, limited exposure to the acute care practice setting during nursing school created a larger academic-practice gap. Without the exposure to this environment, many nursing students didn't know what to expect. In addition, managers and staff had the opportunity to directly observe these potential hires in practice before making an offer of employment. As a result, this program allowed both the students and the managers an opportunity to evaluate their fit. Unsuccessful matches are still a win. Those who chose to take an NLRN position on a different unit or outside of the organization made the right decision for their professional and personal needs. In the post-preceptorship interview, the student who accepted an NLRN position in a new practice setting at the same organization said: “I feel that the preceptorship-to-hire program helped me make the right decision in determining my environment of practice. Without it, I may have been hired to a unit that wasn't my right fit.” Without the P2H experience, they may have taken a position at the hospital not realizing the physical and mental toll of the acute care environment or that a long commute wasn't sustainable long-term, thus resulting in increased turnover rates and decreased 1-year retention rates. The nursing workforce is currently facing high volumes of vacancy rates because of several factors, such as retirement, burnout, and inadequate work-life balances. The experiences in this P2H program allowed participants to make professional and personal decisions before making a costly commitment to the unit or organization. Limitations The program had several limitations. It started during the height of the pandemic in Florida, which affected the nursing students' clinical experiences. The overall sample of this pilot is small with a total of 12 students who completed the program. The program also required a significant amount of work and collaboration between the university faculty and the hospital's program coordinators, which increased the workload of the staff involved, making it difficult to have frequent check-ins with the students. Finally, the university and the hospital where the program was conducted were 60 miles apart. This created challenges for the students who were traveling back and forth for preceptorship and classes. It also may have contributed to the small sample size. After completing the preceptorship, three P2H students accepted a GN role offered to aid in the continuum of clinical skills and experiences while the participants were studying for the NCLEX-RN. However, there were delays in state authorization to test emails and test scheduling that prevented the students from participating. Therefore, data couldn't be collected to evaluate the transition from P2H nursing student to GN to NLRN. The testing delays also affected the hiring process of the P2H student to NLRN, thus resulting in lower satisfaction scores by the clinical managers in this area (see Figure 1). Implications for nursing management The new generation of nurses may be among the most vulnerable populations in our nursing workforce. A healthy and competent nurse requires adequate education and training. The P2H program is an integral part of diminishing the gap and maintaining a sustainable and healthy nursing workforce. A P2H program can be implemented in any setting in which an academic institution and practice-based facility work collaboratively and hold mutual goals to support the NLRN. The development and implementation of a P2H program has the potential to provide significant support and sustainability to the infrastructure of the nursing workforce. As the complexity and demands increase in the healthcare setting, creative interventions such as the P2H program can be a sustainable solution to the challenges in today's healthcare students The nursing to support the new generation of nurses the workforce The P2H program provided an opportunity to students' transition to the practice setting, improve vacancies in the nursing and improve the organizational turnover rates. The program benefits the students, the and the nursing workforce. The program students to new and unit managers evaluate the student's fit for the position and working environment, and for to the unit and the organization any or In a healthcare in which academic clinical experiences can be to vital to support nursing students with interventions to the academic-practice
Source: Nursing Management
Authors: Leah Robinson, Rayna Letourneau, Vivien Cruz, Stacy Pryor, Kaylyn Williams, Jennifer Bonamer
Institutions: University of South Florida, Sarasota Memorial Hospital
Language: English
Subfield: Research and Theory
Field: Nursing
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4388753613