The first-year transition from a nursing program to direct patient care is a challenging time for new nurses. Kovner and colleagues, in a study analyzing data from the RN Work Project, a 10-year longitudinal study of new RNs, estimate that 17.5% of new graduate RNs will leave their first nursing job within a year and 33.5% will leave within two years.1 In an effort to ease the integration of new graduate RNs into the workplace and give them the skills they'll need to contribute to the improvement of patient care and outcomes, the Institute of Medicine (IOM) in its 2011 report, The Future of Nursing: Leading Change, Advancing Health, recommended a transformation of nursing curricula and the expansion of the use of nurse residency programs.2 When new graduate RNs are adequately prepared to transition from nursing student to professional RN and supported at the start of their careers, they are more likely to develop bedside leadership roles and to have increased job satisfaction and a reduced first-year turnover rate.3, 4
The voice of a new grad. The purpose of this article is to describe my transition as a new graduate RN from nursing student to professional RN. It will examine how aspects of my nursing curriculum, as well as my participation in a nurse residency program at my hospital, better prepared me to respond effectively to a perceived problem in my unit's policy of making new graduate RNs with three months' experience on the unit available to float to comparable units. It will describe how it was possible to work within hospital and unit processes to influence a change in this floating policy. It will also describe how a former nursing professor acting as a writing mentor and I retrospectively developed the RN LEADER framework to identify the steps that were used to strategically influence this change, in the hope of providing a model for other nurses who also seek to bring about change.
A NURSING CURRICULUM INCORPORATING IOM RECOMMENDATIONS
In its analysis of ways the nursing profession could play a more integral role in influencing the shape of our complex and rapidly changing health care system, the IOM Future of Nursing report examined the current state of nursing education and recommended several curriculum changes to better prepare new nurses to act as leaders at the bedside and play an active role in improving patient care and outcomes.2
In line with several of these recommendations, in 2013 the Maine Partners in Nursing Education and Practice established the Maine Nurse Core Competencies, the first competency-based approach to nursing education and practice in the state of Maine.5
Applying evidence to real-world problems. At a private university in the Northeast, I participated in a baccalaureate nursing curriculum grounded in the Maine Nurse Core Competencies. The curriculum included three courses in evidence-based practice (EBP) and a course called Transitions to Practice. The primary focus of the first EBP course was to provide a foundational appreciation for scholarly inquiry and an introduction to research methods. The second EBP course fostered understanding the value of research, familiarity with available research designs, and the application of research in real-world health care settings. In the third EBP course, students identified real-world problems within a variety of health care settings and applied the best available evidence to develop interventions to address them.
Students were also charged with creating an implementation plan for the interventions they developed. We strategized about common challenges associated with change and how to circumvent these challenges to promote successful implementation of our evidence-based intervention. We were strongly encouraged to use evidence as the driving force in recommending solutions to problems in diverse health care settings.
Preparing for common issues in the transition to practice. In the final semester's Transitions to Practice course, course content was developed based on a review of the specific challenges new graduate RNs face during their first year in practice, with five thematic categories:
* communicating with providers
* communicating with leaders and preceptors
* bullying, and meeting the expectations of experienced nurses
Students in my class were divided into teams and asked to search out evidence in support of these common challenges and to develop a positive, evidence-based intervention to address them. Upon completion of the course, we presented our data and interventions in small-group discussions. Throughout the process, our ability to work effectively as a team was evaluated. A variety of guest speakers presented data and resources on common challenges such as bullying, self-care, and securing a position within a formal nurse residency program. Activities and resources from the National Council of State Boards of Nursing's Transition to Practice Modules were used during in-class activities.6 Throughout, our professor encouraged us to speak confidently and in a professional manner in class.
CASE STUDY: INFLUENCING CHANGE IN A NURSE RESIDENCY PROGRAM
In addition to changes to nursing curriculum, the IOM Future of Nursing report recommended that new graduate RNs should complete a nurse residency program at the start of their careers.2 When supported by higher administration, formal nurse residency programs can provide new graduate RNs with adequate time to learn content, apply skills, and participate in specialty training specific to their assigned unit.7
When I finished nursing school, I was accepted into a formal nurse residency program. This yearlong program gives baccalaureate-prepared RNs with less than six months of experience a full-time position in a variety of adult and pediatric medical-surgical and intensive care settings. Under the guidance and support of trained nursing staff and unit educators, new graduate RNs participate in didactic sessions, hands-on clinical training, and professional development workshops. Additionally, they are encouraged to participate in shared governance.
A unit's float policy for new RNs. The American Nurses Association (ANA) describes floating as a means for institutions to "meet their obligations to ensure that all patient care areas are adequately staffed."8 Within the first year of employment, many new graduate RNs are expected to float to comparable care units in short-staffed areas. Unit policy at my hospital required new graduate RNs to float, when necessary, after only three months of employment. With no formal orientation to floating, all the new graduate RNs in my nurse residency cohort were concerned that such float assignments could exceed our skills and experience.
The rationales provided for the unit's float assignment policy were that it had always been done that way; that all new graduate RNs had successfully passed the National Council Licensure Examination for Registered Nurses (NCLEX-RN), thereby demonstrating adequate preparation for safe entry into nursing practice; that the policy met the staffing needs of the hospital; and that it was an effective means of containing costs.
In response to the concerns of some nurse residency program members, I set out to pursue a significant policy change in the staffing practice of floating. I found myself able to apply the knowledge and skills I'd acquired in competency-based courses in EBP and transition to practice in an attempt to influence refinement of the float policy. In addition, since the nurse residency program was supported by higher administration in the hospital, it provided a positive environment in which to pursue this effort to bring about change at the unit level.
Retrospective reflection on the steps I took to bring about a change, informed by the knowledge and insight of my former professor and coauthor, resulted in development of the RN LEADER framework-an action-oriented framework empowering RNs to lead evidence-based change in direct care settings (see Figure 1).
| The RN LEADER Framework|
THE RN LEADER FRAMEWORK
Creating and maintaining a work environment that prepares and supports new graduate RNs as potential leaders of and advocates for evidence-based change is key to improving quality health care and ensuring patient safety. As transformation takes place in nursing education and practice, RNs will be more prepared with the essential knowledge, skills, and confidence to initiate change processes. The RN LEADER framework-designed to conform to the acronym L-E-A-D-E-R-can empower nurses to lead evidence-based change in direct care settings. The framework originates from subsequent analysis of my successful experience in pursuing a policy change. The application of the RN LEADER framework to the float policy case is concretely demonstrated, as follows:
Step 1: Lead with the evidence. Evidence is crucial for making meaningful policy and practice changes.9 I conducted a review of current literature on the turnover rate among new graduate RNs as well as on the staffing practice of floating. According to the IOM Future of Nursing report, inadequate orientation to nursing units is one of the primary causes of high turnover for new graduate RNs during their first year of employment.2 Participants in formal nurse residency programs that provide enhanced training for new graduate RNs have made substantially fewer self- and preceptor-reported patient safety errors.7 Reports of greater job satisfaction, less work-related stress, and a lower staff turnover rate have also been noted in formal nurse residency programs compared with "unstructured" programs that do not provide this enhanced training.
Are new nurses adequately prepared to float to certain units? The 2009 ANA position statement, Patient Safety: Rights of Registered Nurses When Considering a Patient Assignment, marshals both ethical arguments and a brief review of current existing evidence.8 It emphasizes the importance of safe staffing practices and of an awareness of the RN's level of expertise before deployment to floating duty, asserting the following: "Accepting such an assignment can place the nurse in jeopardy of caring for patients for which the nurse is not adequately prepared."
After collecting the supporting evidence, it is essential to speak the language of the institution and link the evidence to the institutional values and mission. To accomplish this, I condensed my findings into a clear, consistent, and evidence-based message: appropriate nurse staffing and adequate orientation to nursing units are critical in reducing the excessive turnover rate of new graduate RNs and improving patient safety.10, 11
Step 2: Engage colleagues at work. Engagement is the required spark that facilitates evidence-based change. I enthusiastically engaged new and experienced colleagues, including unit management, with a clear, consistent, and evidence-based message. Specific modes of engagement consisted of developing sincere rapport, maintaining positive relationships, offering tokens of appreciation for teamwork, and motivating colleagues to stay involved in shared governance. Listening to colleagues' perspectives also proved crucial, building engagement and enabling me to anticipate the pushback I might encounter from institutional leaders when I proposed the plan. As I listened for evidence of how floating affects the work environment, I collected anecdotes from colleagues and gave them an opportunity to offer suggestions for making policy change.
Step 3: Act to gain traction. The previous steps establish a foundation for evidence-based change. Step 3 is the implementation stage, requiring the RN leader to take purposeful action to advance the change. First and foremost, this means determining the proper institutional avenues through which to achieve the change.
In my case, I gained a seat at the table, so to speak, by regularly participating in staff meetings. At this particular institution, a unit board-comprising staff nurses democratically elected to leadership positions-conducts staff meetings. This format has provided a structured environment that supports innovation, seeks quality improvement, integrates EBP, and fosters staff participation in shared governance. Unit board leaders and staff RNs are allowed one vote each on a proposed policy or practice change.
I asked the unit board to review the current float policy and align it more closely with current evidence. The unit board allowed an exchange of ideas about staffing practices, particularly floating, and sought insights as well from the nurse educator, unit manager, and chief nursing officer. I continued to focus on the delivery of a clear, evidence-based message to all team members, emphasizing the retention of new graduate RNs and the preservation of patient safety.
Step 4: Determine the best solution. When advocating for a policy or practice change, it is imperative for the RN leader to determine the best solution. This means identifying a realistic, evidence-based, and readily available solution with an established time frame for implementation. Identifying a workable solution demonstrates commitment to positive, timely change and duty to colleagues.
I advocated for a twofold solution, grounded in the evidence:
1. Require a formal orientation to floating.
2. Deploy new graduate RNs to floating duty only upon successful completion of the yearlong formal nurse residency program. A time frame of one month was established for development of a plan to achieve the proposed refinement of the float policy.
Step 5: Evaluate the outcome. Evaluation of the outcome requires answering the following questions:
* Was the proposed solution adopted?
* How did the policy or practice change improve the work environment (what was its impact on job satisfaction, staff retention, and patient safety)?
A modified solution was adopted by unit board leaders and participating staff RNs. The new float policy offers new graduate RNs a formal orientation to floating and mandates that they be given floating duty only after six months of employment. Although my proposed solution was not adopted as presented, I recognized the adoption of a modified solution as a step forward. We had achieved a refinement of the float policy in service of the goal of retaining new graduate RNs and improving patient safety. Subsequent to implementation of the new policy, new graduate RNs anecdotally reported greater job satisfaction, reduced feelings of stress, and improved perceptions of patient safety.
Step 6: Revise the plan of action. Organizational and individual resistance is a common barrier to a proposed policy or practice change. If resistance is met, revise steps one through four (L-E-A-D). When seeking a policy change by following the RN LEADER framework, it may be necessary to improve the delivery of a clear, consistent, and evidence-based message or focus more on colleague engagement. In this case, my proposed solution was met with resistance from a select few. Opponents of the proposed policy change, primarily experienced staff, said, "We've always done it this way!"
Clearly, it was necessary to more fully engage with my more experienced colleagues. I focused on communicating a shared vision by emphasizing the retention of new graduate RNs. This, I argued, would ensure safe nurse-patient staffing ratios, with the goal of ultimately allowing for greater flexibility in staffing. This effort at engaging experienced nurses reduced their resistance and made possible the significant policy change in floating.
In those cases in which insurmountable resistance exists to a proposed EBP change, it's nevertheless important to remain confident, committed, and professional.
To safely meet increasingly complex patient needs, nurses must lead evidence-based change initiatives. Schools of nursing are charged with competency-based curricular revision and the development of evaluation methods that ensure that their programs can address the complexity of the U.S. health care system. As evidenced by the example presented here, when nursing students are better prepared to transition to a complex care environment and provided with a foundation in EBP, they are more equipped to lead. In keeping with the recommendations of the IOM Future of Nursing report, I earned a baccalaureate through a transformed nursing curriculum and was able to contribute to a policy change for new graduate RNs who were concerned about the safety implications of floating before they were ready. Empowering new graduate RNs is essential to transforming nursing education and practice and complements other strategies proposed by the IOM to adequately prepare new graduate RNs.
The RN LEADER framework fosters engagement in meaningful work and is potentially applicable to all RNs who work in direct care settings across all patient populations. When RNs have a voice within an institution, they can contribute to its goals-in turn, the greater institutional engagement of RNs is associated with increased job satisfaction, reduced turnover, and improved patient outcomes.12, 13 The RN LEADER framework is a model for RNs to facilitate workplace engagement, empowering nurses to lead when facing challenges related to patient safety, quality care, and job satisfaction.
The IOM recently published an update on the progress made toward achieving the Future of Nursing recommendations.14 While the progress has been significant, the committee that authored the report continues to advocate for transforming nursing education and practice to empower nurses as leaders in a rapidly changing health care system.
Implications for nursing practice and future research. We developed the RN LEADER framework in the hope that it would be included in nursing curricula and tried in nurse residency programs and professional development workshops. Nurse scientists could evaluate its effectiveness and application one year into nursing practice, particularly in direct care units. Outcome measures to evaluate the effectiveness of the framework might include application of the framework, the success of application, turnover rates, RN engagement in meaningful work, RN empowerment, patient satisfaction, and patient safety.
Additionally, the framework may be used by seasoned nurses who are motivated to inspire change but feel unprepared. Both new graduate and seasoned RNs play critical roles in leading evidence-based change in health care settings. Empowering RNs to lead evidence-based change, regardless of tenure, requires strong organizational support from administrative partners.
The RN LEADER framework illustrates that leading with evidence is essential to achieving policy and practice changes. Efforts to lead evidence-based change will benefit the nursing profession at a time when the U.S. health care system is increasingly reliant on frontline nurses and nursing professionals who are seeking to practice at the limits of their licensure. The RN LEADER framework empowers both new graduate and seasoned RNs alike to address the ongoing challenges of our health care system and support its improvement and transformation.