1Volume 31, No. 2 • November/December 2009

The National Council of State Boardsof Nursing (NCSBN) is embarkingon an initiative that will change the

face of nursing. We have been develop-ing an evidence-based regulatory modelfor transitioning new nurses to practice(see Figure 1). Several factors haveinspired this inquiry, such as recentInstitute of Medicine reports of medicalerrors and the need to transform healthcare education, the increased complexityof care for sicker patients with multipleconditions, a continued need for systemsthinking, and the exponential growth oftechnologic advances.

There have been national calls for astandardized transition program for newnursing graduates, including from theJoint Commission (2002), the draft of theCarnegie study of nursing education rec-ommendations (P. Benner, personal com-munication, April 2009), a synthesis ofnational reports (Hofler, 2008), and froman excellent article by Orsolini-Hain andMalone (2007) exploring the “perfectstorm” that is brewing in nursing.

Several transition programs aroundthe country have been very successful,and worldwide transition programs are

being designed (NCSBN, 2009). Indeed,the Commission on Collegiate NursingEducation (2009) has developed anaccreditation process for residency pro-grams. Yet, transition experiences arevariable across the country, dependingon the setting and the level of nurse edu-cation (NCSBN, 2006).

It is well accepted that standardizedtransition programs reduce turnover inthat first year of practice (NCSBN, 2009).A review of discipline data in the IllinoisBoard of Nursing indicates that tempo-rary nurse replacements have more disci-pline reports than regular staff nurses(Behrens, 2000). This is understandableas evidence shows that unfamiliaritywith patients is linked to errors or nearmisses (NCSBN, 2009). Further, emergingevidence supports that well-developedtransition programs decrease practiceerrors and improve patient outcomes(Elfering, Semmer, & Grebner, 2006;NCSBN, 2007). Yet the most heart-wrenching evidence is seen in this quotefrom a newly licensed nurse (Foundationfor Nursing Excellence, 2009):

I am frightened for my patients andfor my own license as I will soon beturned loose with only a resource personand expected to take a full load after only5 days of orientation in my new assignedunit. (p. 48)

This situation is not the fault of edu-cation falling short, nor is it the fault ofpractice expecting students to “hit theground running.” In nursing, we are miss-ing a piece that many other health careprofessions have; that is, we do not havea standardized program to transitionnew nurses to practice. Therefore, for thesafety and quality care of our patients, itis time for nurses to take action. NCSBNis developing a regulatory model that

will assist regulators in their mission ofpublic protection. However, NCSBN isnot doing this alone. We are collaborat-ing with education and practice becauseit is only through collaboration and con-sensus with our nursing colleagues thatthis model will be successfully imple-mented. To this end, NCSBN has held col-laborative meetings and conference callswith more than 35 stakeholders, and wehave invited a representative from theAmerican Organization of NurseExecutives to participate in all meetingsof our Transition to Practice Committeesince practice will be critically affected bythis initiative.

NCSBN’s Transition to Practice regu-latory model has been designed to berobust, meaning that it will include allhealth care settings that hire newlylicensed nurses and all educational levelsof nurses, including practical nurse, asso-ciate degree, diploma, baccalaureate,and other entry-level graduates. It hasalso been designed to be flexible so thatmany of the current standardized transi-tion programs will meet the require-ments of this model.

The new graduate must first takeand pass the NCLEX®, obtain employ-ment, and then enter the transition pro-gram. The preceptors in this model willbe trained and will either work one-on-one with newly licensed nurses or inteams. There is recent evidence thatteam preceptorships are successful

A Transition to Practice Regulatory Model:Changing the Nursing Paradigm

Nancy Spector, PhD, RN

Volume 31, No. 2 • November/December 2009

Nancy Spector, PhD, RN, is the Director ofRegulatory Innovations, National Council of StateBoards of Nursing (NCSBN). She is responsible forassisting member boards with education issues, aswell for developing innovative regulatory solu-tions. Please feel free to contact Dr. Spector atnspector@ncsbn.org if you have any questions.

2 Volume 31, No. 2 • November/December 2009

(Beecroft, Hernandez, & Reid, 2008).Preceptors will work with the new gradu-ates throughout the six-month transitionprogram, and this will be followed by sixmonths of continued institutional sup-port. The model is strongly dependenton a well-developed preceptor-nurserelationship, and this is supported in theresearch. Novice nurses will learn theimportance of learning from a seasoned,dedicated preceptor and therefore in thefuture, more nurses will offer to serve aspreceptors to new nurses. It is hoped thatthere will be a culture change in nursingso that becoming preceptors and men-tors for new nurses will be an expectedpart of professional nursing.

Orientation – being instructed onthe policies and procedures of the work-place, as well as role expectations – isrequired before entering the transitionprogram. Therefore, orientation, accord-ing to this model, is separate from theconcept of transition to practice, which isa formal program designed to supportnew graduates during their progressioninto practice.

The five transition modules, support-ed by the evidence (NCSBN, 2008,2009), for this model are based on theInstitute of Medicine (Greiner & Knebel,2003) competencies and the Quality andSafety Education for Nurses (2009) initia-tive:

• Patient-Centered Care• Communication and Teamwork• Evidence-Based Practice

• Quality Improvement• Informatics

Safety and clinical reasoning will beintegrated throughout the experientiallearning of these modules. We envisionthat these modules will be designed tointegrate experiential and active learningand will not incorporate relearning ofcontent that the new nurses havealready learned in their nursing pro-grams. The new nurse will successfullyaccomplish these modules during the six-month preceptorship. The modules willeither be offered by the employer, in acollaborative program with other institu-tions, or NCSBN is developing interactive,online modules using cutting-edge tech-nology to meet this requirement. Further,NCSBN is planning to offer electronicsocial networking to connect new nursesto preceptors in those settings or regionsof the country where preceptors are inshort supply. Therefore, all nurses, nomatter where they are employed, willhave the opportunity to meet therequirements of this regulatory model.

While the time period for the precep-torship will be six months, the preceptor,having been trained, will be able to eval-uate how much support the new gradu-ate needs during the preceptorship.Some novice nurses will need more sup-port than others. Moreover, feedbackand reflection were strongly supported inthe literature and therefore are essentialparts of this model and must be integrat-ed throughout the entire transition pro-

gram. This should be built into the pre-ceptor-nurse relationship, but also shouldbe maintained after the six-month transi-tion period is complete.

It is the vision of this model that newnurses will be required to provide theirBoard of Nursing with evidence of com-pleting all the requirements of this stan-dardized transition program in order tomaintain their license after their first yearin practice. In many states, new drivershave similar requirements for maintain-ing their license after their first year ofdriving. Of course, this is just a model forthe Boards of Nursing, and each jurisdic-tion will decide whether or not to imple-ment this model. Jurisdictions also mightadapt the model to the particular needsof their states or territories.

Because this is such a big step fornursing, we intend to pilot this model.Plans for the pilot include developing abusiness plan, as well as designing theonline modules for those workplacesthat don’t have the resources or opportu-nities for partnering with other organiza-tions to deliver the program. We will con-vene national advisory panels of expertsto assist us in establishing outcomemeasures and for implementing themodel. Further, we are looking for fund-ing possibilities to assist practice withdeveloping a transition program thatwould meet the requirements of ourstandardized transition program. Federalmonies support medicine, pharmacy,and pastoral care residency programs, sothere might be a possibility that nursingcould also receive funding. Our toolkithas more information, including a time-line, and can be accessed online(https://www.ncsbn.org/363.htm). DN

ReferencesBeecroft, P., Hernandez, A.M., & Reid, D. (2008).

Team preceptorships: A new approach for pre-cepting new nurses. Journal for Nurses in StaffDevelopment, 24(4), 143-148.

Behrens, M.J. (2000, September 10). Dangerouscare: Nursing mistakes kill, injur thousands; Cost-cutting exacts toll on patients, hospital staff.Chicago Tribune.

Commission on Collegiate Nursing Education.(2009). Post-baccalaureate nurse residency pro-gram accreditation. Retrieved from http://www.aacn.nche.edu/Accreditation/nrp.htm

Elfering, A., Semmer, N.K., & Grebner, S. (2006).Work stress and patient safety: Observation ofwork stressors as predictors of characteristics ofsafety-related events reported by young nurses.Ergonomic, 49(5-6), 457-469.

Foundation for Nursing Excellence. (2009).Evidence-based transition to nursing practice ini-tiative in North Carolina: Executive summary ofPhase I findings. Retrieved from http://www.ffne.org/images/File/Transition/Report%20%20of%20Phase%20I%20Survey%20Findings%20%20January%202009.pdf

Figure 1. Transition to Practice Model

Volume 31, No. 2 • November/December 2009 3

Dermatology NursingUnveils Free

Full-Text Article ArchiveTo celebrate 20

years of publicationand dedicated serv-ice to the nursingcommunity, Derm-atology Nursing isbuilding a freeonline archive ofjournal articles forviewing and down-

load. Education is the journal’s top prior-ity, so the publisher is pleased to makethis high-quality, peer-reviewed contentavailable to the health care community,researchers, educators, and patients.Articles from 2009, 2008, 2007, 2006,and 2005 are now available. The archivewill continue to grow, so visit the “Issues”section of the journal’s Web site often forupdates.

Follow the knowledge. To view thefree articles, visit www.dermatologynursing.net and click on “Issues.” Asdeans, please share this information andlink with your students. They are sure tofind this free educational vehicle to bequite helpful in their studies. DN

Flu Season—Teachable Moments

Letter to the Editor

Greiner, A.C., & Knebel, E. (Eds.). (2003). Healthprofessions education: A bridge to quality.Washington, DC: The National Academies Press.

Hofler, L.D. (2008). Nursing education and transi-tion to the work environment: A synthesis ofnational reports. Journal of Nursing Education,47(1), 5-12.

Joint Commission, The. (2002). Health care at thecrossroads: Strategies for addressing the evolvingnursing crisis [White Paper]. Retrieved fromhttp://www.jointcommission.org/NR/rdonlyres/5C138711-ED76-4D6F-909F-B06E0309F36D/0/health_care_at_the_crossroads.pdf

National Council of State Boards of Nursing(NCSBN). (2006). Report of findings from thepractice and professional survey – Transition topractice: Newly licensed RN and LPN/VN activi-ties. Retrieved from https://www.ncsbn.org/Vol_22_web.pdf

National Council of State Boards of Nursing(NCSBN). (2007, February). Transition of newnurses to practice: A regulatory perspective. InSpector, N. (Chair), Transition National Forum.Symposium conducted at the meeting of NCSBN,Chicago.

National Council of State Boards of Nursing(NCSBN). (2008). NCSBN transition to practicereport. Retrieved from https://www.ncsbn.org/388.htm

National Council of State Boards of Nursing(NCSBN). (2009). Transition evidence grid.Retrieved from https://www.ncsbn.org/Final_08_Transition_grid.pdf

Orsolini-Hain, L., & Malone, R.W. (2007). Examiningthe impending gap in clinical expertise. Policy,Politics & Nursing Practice, 8(3), 158-169.

Quality and Safety Education for Nurses. (2009).Quality and safety competencies. Retrieved fromhttp://www.qsen.org/

The flu season and H1N1 flu epidemic offer nursing faculty a great opportunity toengage nursing students in the process of public education and service. NSNA schoolchapters with Community Health and Disaster Preparedness Committees are excellentvenues for these activities.

The 2009-2010 Community Health theme, Get Fit, Stay Fit: Wellness, Fitness, andPrevention, works well with preventing influenza. A campus activity such as an infor-mation table in the student center, or a community activity such as an informationtable in a local bank, elementary school, senior center, or community hospital, offersgreat venues for students to interact with the public. Demonstrations on proper handwashing, use of hand sanitizer, and correct use of a face mask along with informationabout where to get influenza vaccination can be provided. Faculty should superviseand review the public health information literature to be distributed. Government Websites (see list below) offer excellent user-ready public health influenza prevention andtreatment information. A faculty member should also be present during the activity tohelp answer questions and offer the students guidance. We never know what “teach-able moments” may arise.

These activities also fit well with the 2009-2010 NSNA Disaster Committee theme,Disaster Planning: A Student Nurses’ Role. What better way to prevent an influenza disas-ter than by teaching how to prevent the illness!

There may also be opportunities for nursing students to be involved (even asobservers) in influenza and H1N1 vaccination. Check with the health department inyour community to explore this possibility.

Faculty who teach clinical, community health, and leadership courses may consid-er offering students who participate in community health projects academic recogni-tion for their learning. This can be in the form of extra points, clinical hours, independ-ent study, or perhaps one of the activities needed to fulfill course requirements. If aca-demic recognition is given, be sure to submit a request for an NSNA LeadershipUniversity Certificate (see www.nsnaleadershipu.org for details). And don’t forget tosubmit the project for an NSNA Award (go to www.nsna.org and click on Publicationsfor the Awards and Honors Booklet).

Timely, topical activities can enhance student interest and boost participation.Recognize and capitalize on the teachable moments that this public health crisis offers. DN

ResourcesOne-stop access to U.S. Government H1N1, avian, and pandemic flu information: http://www.flu.gov/Centers for Disease Control and Prevention influenza homepage and podcasts: http://www.cdc.gov/flu/American Lung Association flu clinic locator: http://flucliniclocator.org/

Your article about the entry level positions for new graduates (September/October2009) is the California story and one that we’ve been working on for the last severalmonths. Everything you have in the article validates everything we have found inCalifornia and reads as if you wrote the California story.

We are attempting real-time solutions, and are developing community-based tran-sition programs (internships) housed in educational institutions with health care com-munity partners providing clinical experiences and precepting/clinical coaching. Wealready have a funding commitment for kicking off the concept in the San FranciscoBay Area and recently applied for a DOL grant for statewide implementation of thisconcept. For details about this program and other information about how theCalifornia Institute for Nursing & Health Care is addressing this issue, visithttp://www.cinhc.org/

Our organization serves as California’s nursing workforce center. Your article helpsre-enforce the severity of the issue. DN

Deloras Jones, RN, MSExecutive DirectorCalifornia Institute for Nursing & Health CareBerkeley, CAdeloras@cinhc.org

4 Volume 31, No. 2 • November/December 2009

© Anthony J. Jannetti, Inc., 2009

EditorCarol A. Fetters Andersen, MSN, RN

President, NSNAKenya Haney

Executive DirectorDiane Mancino, EdD, RN, CAE

Art DirectorJack Bryant

Managing EditorKatie R. Brownlow, BELS

Graphic ArtistMelody Edwards

PublisherAnthony J. Jannetti

Advisory Board 2009-2010G. Rumay Alexander, EdD, RNMichael L. Evans, PhD, RN, NEA-BC, FACHEFlorence L. Huey, MS, FNPMary P. Tarbox, EdD, RNRebecca M. Wheeler, MA, RN

DEAN’S Notes is indexed in Cumulative Index toNursing & Allied Health Literature.

DEAN’S Notes published five times a year (September/October,November/December, January/February, March/April, and May/June) byAnthony J. Jannetti Inc., East Holly Avenue, Box 56, Pitman, New Jersey08071-0056. Telephone 856.256.2300. FAX 856.589.7463. All rightsreserved. No part of this publication may be reproduced without theexpress written permission of the publisher. Address changes shouldinclude mailing label and be forwarded to the publisher.

Volume 31, No. 2 • November/December 2009

The themes selected for publication in Dean’s Notes in spring 2010(January/February, March/April, and May/June issues) will be announcedin the Dean’s Notes Call for Manuscripts at the MidYear Career PlanningConference in Phoenix, AZ, from October 29-November 1, 2009. If youwould like to receive notification of the themes, the submission deadlineschedule, and a copy of the Call for Manuscripts, please contact CarolFetters Andersen, MSN, RN, Editor of Dean’s Notes (carol@nsna.org).

Manuscript Style Sheet/Copy GuidelinesVisit www.nsna.org/whats_new.asp for more information.

How nursing faculty and nursing programs can receive a print copy ofDean’s Notes:

For $50 per year, faculty can join as an NSNA Individual SustainingMember and enjoy many benefits, including a personal print copy ofDean’s Notes, published five times during the academic year by Anthony

J. Jannetti, Inc., featuring information of interest to nursing education faculty andDeans/Chairs/Directors. (Note: $5 from dues of each individual NSNA sustaining mem-bership goes to the state student nurses’ association.)

Schools of Nursing can benefit too from joining NSNA as a Sustaining School ofNursing Member for annual dues of $250. Schools will receive one copy of Dean’s Notesand faculty will have electronic access to the journal. DN

Call for Dean’s Notes Manuscripts to beLaunched at the 2009

MidYear Conference in Phoenix, AZ