This transition program builds confidence and reduces turnover.
- Without proper preparation, new graduate nurses can become overwhelmed by their transition to practice.
- A workforce strategy aimed at creating workplace environments that allow new nurses to build confidence can improve their professional practice.
- The NSPIRE program at this organization not only helps to build nurse confidence, it also seeks to improve RN recruitment and reduce turnover.
New graduate nurses inadequately prepared for their work environment may experience transition shock. According to Graf and colleagues, this can lead to increased errors with a negative impact on patient care. Hampton and colleagues added that without transition to practice programs, new nurses may lack confidence and struggle with competencies, which can increase turnover and exacerbate the nursing shortage.
A critical review of transition models conducted by Graf and colleagues noted that since the change to university-based education, nursing students receive less clinical instruction and exposure to hospital procedures and processes. To address this concern, healthcare organizations have begun working to improve the transition to practice for new graduates. They implemented preceptor programs and new nurse residencies to enhance the transition to practice, and they worked to make orientations more comprehensive for novice nurses.
However, according to Djukic and colleagues, the COVID-19 pandemic interrupted these efforts. Less clinical time and subsequent delayed efforts by healthcare organizations to improve the clinical transition to practice exacerbated new graduate nurses’ lack of workplace readiness.
NSPIRE
As organizations emerged from the pandemic and began addressing the consequential nursing shortage, Hackensack Meridian Health (HMH) began strategizing how to enhance the transition to practice for new graduate nurses. Recognizing the gap between graduation and the start of new nurse residency education, two HMH nurse leaders developed NSPIRE (NurseS Practicing in a Readiness Environment), a new graduate nurse transition-to-practice program. NSPIRE aims to create workplace environments in which recently graduated nurses preparing to take the NCLEX licensing exam can build confidence and improve their professional practice.
NSPIRE also seeks to improve RN recruitment, increase the candidate pipeline, reduce new nurse turnover, and increase new nurse satisfaction. By hiring new graduate nurses through NSPIRE before they take the NCLEX, the organization provides them with additional exposure and experience in the hospital practice environment in preparation for the exam.
About the program
We piloted NSPIRE at two HMH acute care hospitals—a 175-bed community hospital and a 353-bed academic medical center. Before implementation, the vice president of nursing education, professional practice, and leadership development created the job description and compensation package for NSPIRE nurses. They receive compensation at an hourly rate higher than a patient care technician (PCT) but lower than a new RN. Their hours are applied to a network cost center with budgeted vacant positions. After passing the NCLEX, the NSPIRE nurses transfer to their full-time position as a nurse resident and receive the new RN salary rate. Currently, NSPIRE remains budget neutral.
Eligibility. For consideration into the NSPIRE program, new graduate nurses must have a GPA of 3.0 and two letters of recommendation. We promote the program throughout the HMH network as well as affiliated local nursing schools. Many candidates report that they learn about NSPIRE from previous participants.
Interested new graduates first apply to any open RN position at one of the participating sites. After an interview with a nurse leader and screening by the NSPIRE program manager, selected new graduates receive an offer of employment. The hospital then reserves that position for them pending licensure. Currently, the program can accommodate hiring 15 new graduate nurses at one time. This remains a rolling hiring process as participants transfer into their RN roles.
Interprofessional immersion
Nurses in the NSPIRE program participate in immersions in the following departments:
- Cardiology
- Care management/multidisciplinary rounds/placement
- Central monitoring
- Critical care/cardiac cath lab
- Emergency department
- Environmental services/facilities
- Food and nutrition
- Hospice/palliative care
- Infection prevention
- Lab
- Legal risk
- Patient experience
- Perioperative/special procedures
- Pharmacy
- Quality outcome
- Radiology
- Respiratory
- Transport and security
The new graduate nurses also meet with or shadow the following individuals:
Overview and orientation. The NSPIRE program (which lasts from 8 to 10 weeks) begins with a 1-day orientation, facilitated by the program manager, which includes an overview, a review of the organizational chart, and discussions of the principles of high reliability and topics relevant to new nurses (for example, delegation, role acclimation, nightshift tips, and the network’s nursing shared governance Magnet® model). The program helps to jump start participants’ orientation, which includes an 8-hour electronic health record computer training, skills day, any mandatory clinical education classes for their position, and required e-learning modules. Ultimately, the program decreases classroom orientation by 9.5 days, which affords additional time for unit orientation with preceptors after passing the NCLEX.
The program also introduces NSPIRE nurses to overall hospital operations and the healthcare system. The nurse residency program manager meets with the NSPIRE nurses to provide an overview of the nurse residency program, which they will begin after passing the NCLEX. Participants also have an opportunity to meet an integrative health coach, after which they can arrange for personal sessions if they wish.
Immersion. A key component of the NSPIRE program is the immersive experience in hospital-wide operational and clinical departments. For each participating nurse, the program manager creates an individualized orientation and coordinates the immersions, which include shadowing various teams, such as infection prevention, risk management, sepsis, patient experience, and wound care. Nurses also can request experiences that interest them. On average, they receive 240 hours of immersion time.
The program manager also invites the nurses to individual weekly sessions to evaluate their needs and discuss their immersion experiences. As the program continues to grow, group sessions have helped foster peer discussions about experiences and prompted sharing NCLEX preparation tips.
These immersion experiences provide an opportunity for new graduate nurses to understand the importance of collaboration with other hospital departments and the interprofessional teamwork necessary to deliver high-quality care. The immersions foster discussion on department functions and their impact on patient outcomes and interprofessional team relationships. Ultimately, the nurses synthesize this information and apply it to their future practice.
Because the participants aren’t yet licensed, they have no hands-on clinical interactions with patients; they only observe. Each department has a designated immersion leader, who receives orientation to the NSPIRE program before launching it at their sites. (See Interprofessional immersions)
NCLEX. The NSPIRE nurses work 6 to 8 hours per day, 3 to 4 days per week, Monday through Friday; they don’t work weekends or holidays. This schedule allows time to study for the NCLEX. Immediately prior to their exam date, nurses receive additional time off to study and for self-care.
After passing the NCLEX and license verification, the NSPIRE nurses transition into the new nurse residency program, where they complete their unit orientation and remaining competencies. If an NSPIRE nurse fails the NCLEX, they’re offered a PCT position within the health network, but they’re no longer eligible for the NSPIRE program. They’re encouraged to reapply to the new nurse residency program if they pass their boards at the second attempt.
Program outcomes
Since 2022, 57 nurses have completed the NSPIRE program and we’ve retained 89% of them to date. Most of the NSPIRE participants (82% female and 18% male) graduated with their BSN (67%); 33% received an ADN. They work on all types of units at the 10 HMH hospitals. (See Participant reflections.)
Participant reflections
During the program, NSPIRE nurses complete one to two reflections a week about an immersion that impacted them the most. Examples include the following:
I was surprised to see that the director of infection prevention is also a nurse and that a nurse can take on these roles. It really sparked my passion in infection prevention and epidemiology and public health to know that roles in nursing are also active in this department.”
I was surprised to actually sit in on three committee meetings and experience first-hand what happens during council meetings. This experience has definitely encouraged me to become proactive in my nursing career to become a member of these committees. It is extremely empowering to see policies actively being changed and discussed in real time and to witness how all members are encouraged to express their thoughts and concerns.”
Although we learned about sepsis in school, it was very surprising to me how vast the effects of this condition can be and by affecting multiple organs in the body a patient can quickly decompensate. It is important for clinicians to be relentless in reviewing labs that are indicative of a potential complication.”
In 2023, we began conducting pre- and post-immersion surveys with NSPIRE nurses to gauge their level of confidence in department knowledge. All participants demonstrate increased levels of confidence. (See Immersion outcomes.)
At the end of the program, the participants also complete a program evaluation. Responses, collected since the program launch, indicate that 93% of participants agree that the program allowed them to experience immersions important to a new RN. The immersions enhanced the nurses’ understanding of other departments and highlighted the importance of teamwork in improving patient outcomes. (See Program evaluations.)
Program evaluations
When asked if the NSPIRE program allowed them to experience immersions important to a new RN, 93.10% strongly agreed; 100% said they would recommend the program to others. Qualitative data from the program evaluations included the following responses:
I enjoyed meeting all of the different departments and truly making those connections that I would not have otherwise on such a personal level. I truly had zero idea what other areas of the hospital did on a normal basis, but after these immersions, I feel like I have such a good understanding and I will feel confident reaching out to these individuals if need be.”
Each immersion built upon the previous. It was well thought out and the experience helped to further my understanding of the collaborative efforts that are required to provide quality patient/family-centered care to improve outcomes.”
The ability to see how the different teams come together for the greater good of our patients. I honestly think everyone should go through this, or a version of this, program as the added perspective I’ve gained is unmeasurable.”
The program evaluations also indicated areas of opportunity, including better directions to the immersion departments and ensuring everyone understands the immersion objectives. The program manager now provides more concise directions for participants, who also have access to either hardcopy hospital maps or a QR code to download a digital version.
To enhance and ensure department frontline team members understand the NSPIRE program’s objectives, the program manager created a frequently asked questions sheet for distribution at each immersion location. At the completion of the program, nurses participate in a debriefing with the location’s immersion leaders. Participants share feedback about their successes and opportunities for future NSPIRE nurses.
Building confidence
The NSPIRE program demonstrates the value of immersion experiences that provide new nurses with the opportunity to process information and perform reflective recall as they transition to practice.
In 2023, we ended the pilot and expanded the program to six HMH acute care hospitals, followed by two more in 2024. The program now functions in all of the system’s ten acute care hospitals.
An increasing number of applicants points to program success. NSPIRE has grown from six applicants in 2022 to 84 in 2023 and 145 in 2024. By acclimating new nurses to the operational functions of the organization, NSPIRE eases the transition to practice for new nurses, enhances their competency, and reduces attrition. Ultimately, the program builds new nurse confidence.
Mildred Patrick is the director of network clinical education at Hackensack Meridian Health Network in Edison, New Jersey. Donna Ciufo is the vice-president of nursing education professional practice and leadership development at Hackensack Meridian Health Network in Neptune, New Jersey.
References
Church CD, White M, Cosme S. Helping students identify a healthy transition-to-practice work environment. Nurse Educ. 2019;45(4):174-6. doi:10.1097/NNE.0000000000000751
Djukic M, Padhye N, Ke Z, et al. Associations between the COVID-19 pandemic and new nurses’ transition to practice outcomes: A multi-site, longitudinal study. J Nurs Regul. 2023;14(1):42-9. doi:10.1016/S2155-8256(23)00067-4
Graf AC, Jacob E, Twigg D, Nattabi B. Contemporary nursing graduates’ transition to practice: A critical review of transition models. J Clin Nurs. 2020;29(15-16):3097-3107. doi:10.1111./jocn.15234
Hallaran AJ, Edge DS, Almost J, Tregunno D. New nurses’ perceptions on transition to practice: A thematic analysis. Can J Nurs Res. 2023;55(1):126-36. doi:10.1177/08445621221074872
Hampton KB, Smeltzer SC, Ross JG. The transition from nursing student to practicing nurse: An integrative review of transition to practice programs. Nurse Educ Pract. 2021;52:103031. doi:10.1016/j.nepr.2021.103031
Shaw C. A different mindset for a different culture: Sustaining the next-generation workforce. Nurs Adm Q. 2024;48(2):107-15. doi:10.1097/NAQ.0000000000000638
Key words: new graduates, transition to practice, Pre-NCLEX
