Preceptor Capstones: Are they Beneficial in ADN Programs to Help Transition New Graduates? Chapter I

Running head: PRECEPTOR CAPSTONES 1 Preceptor Capstones: Are they Beneficial in ADN Programs to Help Transition New Graduates? Mary Margaret Evans Bradley University A Directed Scholarly Project Submitted to the Department of Nursing In the Graduate School of Bradley University in Partial fulfillment of the Requirements for the Degree of Doctor of Nursing Practice. Peoria, IL 2018 PRECEPTOR CAPSTONES 2 Abstract The purpose of the present study was to determine the extent to which the community college’s capstone course was congruent with the general content of the NRPs at two local hospitals and to further determine the extent to which new nursing graduates perceive the importance of the capstone program in preparing them for nursing practice. The project design incorporated both qualitative and quantitative elements. The qualitative design element used summative content analysis to examine and compare the two local hospital NRPs and the community college capstone course content. The quantitative design element consisted of a survey of recent community college nursing graduates who have completed the community college capstone course and were in enrolled in the NRP of a local hospital to determine their perception of the importance of the capstone program content in preparing them for nursing practice. The results of this study indicated four primary findings: The results of this study indicated four primary findings: 1. The commonalities among the community college capstone course content and hospital #2 NRP content suggest that these programs are complimentary and supportive. 2. NRP content from hospital #2, and the community college capstone course were congruent with content items identified as important for capstone courses in the literature review. 3. The results of the study indicate four primary important capstone course content areas: patient care, critical thinking/problem solving, teamwork and the professional role and readiness to practice in that order. PRECEPTOR CAPSTONES 3 4. The identified importance of the overwhelming majority of capstone content items did not vary significantly with previous nursing experience, which supports the use of a single curricula. The results from this project provided significant information to the community college with respect to capstone course curriculum. For the two local hospitals, the results of this project indicate strengths and weaknesses related to their current nurse residency programs compared to the NCSBN model, as well as areas of importance related to content identified by students who are now new graduates in their institutions PRECEPTOR CAPSTONES 4 Table of Contents Chapter I: Introduction 6 a. Background and Significance 6 b. Problem Statement 8 c. Project Aims 8 d. Clinical Question 8 e. Congruence with Organizational Strategic Plan 8 f. Review of Literature 9 g. Conceptual or Theoretical Framework 16 Chapter II: Methodology 17 a. Needs Assessment 17 b. Project Design 18 c. Population 18 d. Tools 18 e. Project Plan 19 f. Data Analysis 19 g. Institutional Review Board and/or Ethical Issues 19 Chapter III: Organizational Assessment and Cost Effectiveness Analysis 20 a. Organizational Assessment 20 b. Cost Factors 20 Chapter IV: Results 21 a. Quantitative Analysis of Implementation Process 21 b. Qualitative Analysis of Implementation Process 21 PRECEPTOR CAPSTONES 5 c. Quantitative Analysis of Project Outcome Data 22 d. Qualitative Analysis of Project Outcome Data 26 Chapter V: Discussion 30 a. Findings 30 b. Limitations or Deviations from Project Plan 31 c. Implications 31 Chapter VI: Conclusion 31 a. Value of the Project 31 b. DNP Essentials 32 c. Plan for Dissemination 33 d. Attainment of Personal and Professional Goals 33 References 35 Appendices 38 PRECEPTOR CAPSTONES 6 Preceptor Capstones: Are they Beneficial in ADN Programs to Help Transition New Graduates? Chapter I Working in a rural setting, many local hospitals desperately seek to employ nurses to meet the demands of the community. In a community college, it is important to produce new nursing graduates who can fill employer needs and serve the community they live in. Bridging the gap from graduation to employment is a key aspect in making sure that new nurse graduates are prepared to enter the workforce, as well as be successful in their first year of nursing. Revising curriculum to meet the changing needs of healthcare includes meeting the needs of the students. Producing high quality nursing graduates who are able to be a successful part of the nursing workforce is part of the mission of the community college, and the reason to explore the transition from nursing student to successful nursing professional. The project incorporated both qualitative and quantitative elements. The qualitative element used summative content analysis to examine and compare curricular content of the twolocal hospital’s Nurse Residency Programs (NRPs) and the community college capstone course. The quantitative element consisted of a survey of recent community college nursing graduates who have completed the community college capstone course and are enrolled in the NRP of a local hospital to determine their perception of the importance of the capstone program in preparing them for practice. In an ideal world, what is taught in academe is taught in industry and also perceived favorably by the student. The project contributions were designed to support seamless transition from academia to the workforce. Background and Significance Nursing faces many challenges today with one of the most prevalent issues being a significant nursing shortage. To characterize an aging workforce, “Approximately 75% of PRECEPTOR CAPSTONES 7 registered nurses (RNs) in the United States are ages 50-64, with 55% of nurses currently employed planning to retire by 2020” (Cochran, 2017, p. 53). Burnout and retention are also significant issues that lead to a decrease in available bedside nurses. In particular, “during the first year of practice, 30% to 61% of new graduates change their place of employment” (Bratt, 2009, p. 417) and to make matters worse, “many new nurses leave the nursing profession within 2 years of graduating from nursing school” (Bratt, 2009, p. 417). Adding to these issues is the need for more complex care with sicker patients and shorter hospital stays, all requiring nurses to have the ability to care for critically complex patients. Unfortunately, healthcare organizations do not feel that new graduate nurses are prepared to deal with these complex patients; “employers believed only 41% of baccalaureate graduates were definitely prepared to care for patients” (Welding, 2011, p. 37). To address these issues, many hospitals and organizations have developed NRPs. A NRP is a program that traditionally incorporates a 12 month one on one mentor program with didactic components that address topics such as communication, skills, leadership, management, stress and critical thinking. As a way to support the industry NRPs, one community college in northern Illinois most recently created a new Capstone Transition into Practice course. There are two goals of this capstone course: 1) to prepare students for the NCLEX exam, and 2) to provide students with a learning experience that enables the student to apply the knowledge, skills and attitudes necessary to implement advanced nursing theory and skills and to transition effectively into the workplace. By incorporating these two goals into the new capstone course, the community college’s nursing program is designed to address the nursing shortage and provide quality nursing graduates that are ready to enter the workforce with confidence. PRECEPTOR CAPSTONES 8 Problem Statement It was presently unknown the extent to which the curricula of the community college’s capstone course and the NRPs of two local hospitals content are congruent and support new graduate nurses’ needs. It was additionally unknown how recent nursing graduates evaluate the importance of the content in the capstone course in preparing them for nursing practice. Given the nursing shortage, aging workforce, burnout and retention issues, these programs needed to be evaluated in terms of their curricular congruence and perceived importance by recent nursing graduates. Project Aims Given the identified nursing shortage and retention problems, the purpose of the present study was to determine the extent to which the community college’s capstone course was congruent with the general content of the NRPs at two local hospitals and to further determine the extent to which new nursing graduates perceive the importance of the capstone program in preparing them for nursing practice. Clinical Question 1) How do new nursing graduates who have completed the community college capstone course and are enrolled in the NRP of a local hospital perceive the importance of the capstone program in preparing them for nursing practice? 2) To what extent are the curricula of the community college’s capstone course and the nurse residency programs of two local hospitals congruent? Congruence with Organizational Strategic Plan The community college’s mission states, “the nursing program, through quality education, desires to transform the lives of our students and the communities they serve. It is PRECEPTOR CAPSTONES 9 vital that our graduates continue to develop the knowledge, skills and attitudes needed to adapt quickly within the ever-changing health care environment in our community in an ethical and collaborative manner” (ADN Handbook, 2018-2019, p. 4). To this end, the aim of this researcher was to eventually partner with two local healthcare organizations to align the NRPs and the community college’s capstone course content to ensure that congruence of content and collaboration of important content are present. The overall goal was to expand the knowledge, skills, attitudes and employment retention of new nursing graduates. Review of Literature Utilizing Bradley University’s library and the community college’s library, a search was conducted using CINAHL and ERIC EBSCO host. Keywords used included “Nursing Residency Program” and “Transition into Practice” with no-limiting terms used in the search. The search was limited to include English as the primary language and articles published between 2009 and 2018. One hundred fifty-five articles were initially returned, and further narrowed down to ten that were considered relevant to the purpose of this study. The articles ranged from qualitative research, quantitative research, systematic reviews, peer reviews and some informational pieces. After completing the literature review, common themes that emerged were such that: 1) nursing retention is a problem, 2) nursing residency programs are successful, 3) common content utilized in NRP’s were identified. These themes are explored further in the sections as follows: Nursing Retention is a Problem. Nursing retention and turnover is an ongoing problem for new nursing graduates. Nurses aren’t adequately prepared for the complex patient care of the real world in that “Employers perceived new graduate nurses to be inadequately prepared for practice” (Latourneau & Fater, 2015, p. 96). Some of the challenges that face new graduates include “being unprepared to perform basic skills and lacking the ability to connect their PRECEPTOR CAPSTONES 10 classroom experiences to real-life clinical practice” (Welding, 2011, p. 37). Bratt (2009) went further to state that “Many new graduates feel unprepared for the demands of practice and struggle with mastery of clinical skills, time management, development of clinical judgement and the need to manage a heavier patient care load” (p. 417). These issues form the core of nurse turnover. According to Cochran (2017), acute care nursing experiences “general turnover rates of 13% and new graduate nurse turnover 18- 50%” (p. 53). When looking at new graduates specifically, “they are also more likely to resign than experienced new hires” (Welding, 2011, p. 37). Furthermore, many new graduates are subjected to reality-shock and traumatic experiences during their first year of work. “New graduates are faced with significant challenges associated with transitioning from the role of student nurse to that of newly licensed” (Bratt, 2009, p. 416). These challenges lead them to change jobs in that, “during the first year of practice, 30% to 61% of new graduates change their place of employment” (Bratt, 2009, p. 417). Of greater concern is exit from the profession all together in that, “many new nurses leave the nursing profession within 2 years of graduating from nursing school” (Bratt, 2009, p. 417). This impacts the nurse, the patient, and the healthcare organization in many ways, but most significantly is the financial impact. As a result, “When they leave within a year, the hospital loses its’ investment in their orientation” (Welding, 2011, p. 37). Nursing turnover and retention issues lead to higher costs for healthcare organizations. It is estimated that “the cost to recruit and train one new nurse at $62,100-$67,000” (Cochran, 2017, p. 53). Additionally, Bratt (2009) estimated that “a nurse with less than 1year experience who leaves costs the organization almost $50,000” and “turnover costs can be as high as $145,000” (p. 417). Welding (2011) additionally estimated a “turnover cost per nurse of PRECEPTOR CAPSTONES 11 $22,420-$77,200.” (p.37). These costs can only be estimated and may be grossly underestimated when you consider all costs related to hiring a new nurse. Organizations face financial drains related to the cost of advertising, recruitment, and temporary replacements. These costs are underestimated because they do not capture the tremendous consumption of resources required to orient and educate novice nurses or the potential negative influence of turnover on staff moral and patient satisfaction. (Bratt, 2009, p. 417) Nursing retention and turnover has a clear financial impact on healthcare organizations and the industry in general. Nursing residency programs are successful. NRPs are successful in combating nursing turnover. “The burgeoning emergence of NRPs has been stimulated in part by the report published by the Institute of Medicine (2010) that recommended implementation of residency programs after pre-licensure education” (Bratt, 2013, p. 102). NRPs’ goals are to support the new graduate nurse through their first year, increase competence, critical thinking and safety, and decrease turnover costs to healthcare organizations. As such, “The intention of nurse residency programs is to help new graduates transition to professional nursing practice” (Latourneau & Fater, 2015, p. 96). The outcomes are clear; “Nurse residents showed 41% improvement upon completion of the 1-year NRP” (Welding, 2011, p. 37). Welding (2011) also concluded that “Besides decreased turnover, this report documented increased confidence, competence, and mastery among nurse residents” (p. 38). Blevins (2016) suggested that NRPs have shown a “significant improvement among nurses in the use of technology while providing care, communications with healthcare providers and patients, the ability to work independently and accountability for actions” (p. 367). In addition, Blevins stated that research supports the notion PRECEPTOR CAPSTONES 12 that nurses who participate in a NRP are able to cope with typical stressors encountered during the first year because they had a support system in place. NRPs also help to build a culture of support in nursing as well as build confidence and competence in the new graduate. In addition to the NRP’s impact on the lives of nurses, researchers have reported they also help decrease turnover rates and provide cost savings related to the implementation of NRPs. Cochran (2017) reported “Turnover of new nurses decreased from 36.8% before NRP implementation to 6.4% after the residency program began, with contract labor costs dropping from $19,099 to $5,490 per average inpatient daily census…” (p. 53). There are savings with NRPs even compared to normal orientation practices in that “Net savings of using the NRP rather than a traditional orientation was $10-$50 per patient day over 2 years” (Cochran, 2017, p. 54). Consequently, as turnover rates decrease, retention improves. “Retention rates before implementation were 35%-61%. After implementation, retention rates improved to 94-97%” (Cochran, 2017, p. 54). By supporting new nurses through their first year of being a nurse, there is significant evidence that NRPs combat problems regarding retention and turnover. In summary, “Evidence regarding the outcomes of residency programs is compelling and reveals that NRPs are associated with higher rates of new nurse retention, decreased nurse vacancy, cost savings” (Bratt, 2013, p. 102). Common content utilized in NRP’s. Implementing a nurse residency program allows a healthcare organization to make positive changes to retention and turnover rates while supporting the new nurse. Stating that a nurse residency program is simply in place is not enough to implement change in that it is the content of these programs that makes a real difference. NRP programs are on average 12 to 18 months in length, with most being 12 months. Exceptions included one program that was as short as 3 months, while another program had an PRECEPTOR CAPSTONES 13 additional 12-month program (total 24 months) that was voluntary for nurses to participate in (Latourneau & Fater, 2015). As a model of program structure, “A residency program is built with a robust structure, a variety of educational opportunities based on evidence and support strategies that create multiple learning opportunities” (Levine, 2017, p. 267). Based on the review of literature, common components identified included a mentor program, preceptors, face to face educational sessions, evidence-based practice and many overlapping topics. Key content topics identified in general included leadership, violence, professional practice, conflict, teamwork and collaboration and communication. Many of these topics were covered in greater depth to include setting goals, personality and leadership styles. One program grouped their program on a “building” basis to include: Building Capacity in Self, Building Capacity of Team, Building Capacity as a Practitioner, Building Capacity Within the Organization, Building Capacity Within the Profession. This program also included a review of medical-surgical content that compromised months 3-10 of their program and was under the Building Capacity as a Practitioner category (Bratt, 2009). A summary of NRP content gleaned from the literature review can be found in Table 1. A total of nine content areas for NRPs were identified from the literature to include content items of professionalism, clinical skills/medical topics, communication, teamwork and collaboration, leadership, culture, evidence based practice, safety & quality, violence. Specific content areas varied by state with Florida and Wisconsin identified as being the most heavily represented in seven and six content areas respectively. Both Wisconsin and Florida programs were additionally identified as having partnerships between academe and service areas. Professionalism, communication, and clinical skills could be found in almost all of the reviewed programs. PRECEPTOR CAPSTONES 14 Unique to some programs were the content areas of violence, culture, and evidence-based practice. Table 1 Comparison of Common Content utilized in NRPs from Literature Review Regardless of content, many of the programs shared the same belief that “These new nurses need to walk away from these sessions with knowledge of evidence-based care, best practice, and ‘pearls of wisdom’ imparted by more experienced nurses” (Bratt, 2009, p. 423). Common Content Utilized in Local NRPs. Table 2 represents a summary and comparison of NRP content areas for the two local hospitals, which are employers of graduates of the community college nursing program. Hospital #1 is currently revising their NRP to a program more specific to their hospital. Until the revision is completed, hospital #1 is utilizing the University of Iowa’s online NRP curriculum. Hospital #2 utilizes the National Council of PRECEPTOR CAPSTONES 15 State Boards of Nursing (NCSBN) Transition to Practice (TPP) modules for their NRP. Both programs utilize common concept of communication but vary in other regards. Table 2 Comparison of NRP Content Utilized in Hospital #1 and Hospital #2 Hospital #1 Hospital #2 - NCSBN Transition to Practice • Transition from Student to Professional Nurse • Communication • Responsibilities of the Professional Nurse • Decision-Making at the Point of Care ("Curriculum overview," 2018) • Patient Centered Care • Communication and Teamwork • Evidence Based Practice • Quality Improvement • Informatics (“Transition to practice”) Content Utilized in the Community College’s Capstone Course. Table 3 represents a summary of the community college capstone course content as drawn from the course outline and course syllabus. The content for the present capstone course was initially constructed internally without the benefit of rigorous external NRP content literature review or nursing graduate input. Table 3 Content Utilized in the Community College Capstone Course Capstone Course Content • Delegation • Communication • Teamwork & Collaboration • Clinical Judgement • Medical-Surgical Topics • Professionalism • Evidence-Based Practice PRECEPTOR CAPSTONES 16 Capstone Course Content • Prioritization • Hazard & Violence • Quality Improvement • Data Analysis • Quality Care (Transition into practice course outline) At first glance, there appears to be a number of commonalities of content identified in the literature review of NRPs, the two local hospitals’ NRPs, and the community college’s capstone course content. Further in-depth analysis of this commonality was performed using summative content analysis as previously discussed in paper methodology. Summative content analysis of hospital #1 and community college capstone course content will be anchored to hospital #2 which utilizes the National Council of State Board of Nursing (NCSBN) Transition to Practice program. Conceptual or Theoretical Framework Benner’s “From Novice to Expert” framework proposes that nurses develop skills and understanding over time through educational experiences. Benner’s theory implies that nurses acquire nursing knowledge not only through learning the skill but just as importantly by learning the theory behind the skill as well. Nurses gain experience and grow as nurses by learning from the experiences they participate in as nurses. NRPs help build the continuing education and experience for the new nurse graduate and help them in the transition from novice to expert. Utilizing Benner’s theory in the capstone course and as part of this project, emphasis is placed on the importance of the development and understanding of the new nurse graduate. (Benner, 1984) PRECEPTOR CAPSTONES 17 According to Benner, nurses progress through five stages of professional development: novice, advanced beginner, competent, proficient and expert. The five levels show progression through critical thinking and skill acquisition. The novice nurse moves to the advanced beginner by showing independence in skills and thinking abstractly (Benner, 1984). Benner’s theory guides the community college’s curriculum to advance the principles of partnership, critical thinking, collaboration, communication and evidence-based practice toward continuous process improvement of the graduate’s knowledge and for the safe delivery of patient centered care. The capstone course provides a strong foundation for students to build from to take with them as new nurse graduates. The ability to think critically is imperative to their success as a nurse. (ADN Handbook, 2018-2019). Chapter II Needs Assessment “Operating from a common belief that it is the mutual responsibility of academe and service to collaborate to create programs that will ensure a quality nursing work force for the future” (Bratt, 2009, p. 418), the need for this project was based on the ongoing need to coordinate academic and workforce transition in general, and in particular the community college capstone course content and local healthcare provider NRPs content. Project Design The project design incorporated both qualitative and quantitative elements. The qualitative design element used summative content analysis to examine and compare the two local hospital NRPs and the community college capstone course content. Summative content analysis can be defined as “A summative content analysis involves counting and comparisons, usually of keywords or content, followed by the interpretation of the underlying context” (Hsieh PRECEPTOR CAPSTONES 18 & Shannon, 2005 p.1). As such, a summative analysis of content emerging common factors was completed. The quantitative design element consisted of a survey of recent community college nursing graduates who have completed the community college capstone course and were in enrolled in the NRP of a local hospital to determine their perception of the importance of the capstone program in preparing them for nursing practice. Population The population for this project was the most recent nursing graduates (academic year of 2017-2018) of a local community college who participated in the capstone course and are enrolled in two local hospitals’ NRPs (n=44). Tools An expanded Casey-Fink Readiness for Practice Survey was utilized to survey participants (see Appendix A). Permission to expand and use the survey was obtained from the authors (see Appendix B). The original survey was constructed in 2008 with “survey items and demographics summarized using descriptive statistics and tests of associations. Alpha was set at 0.05” (Casey & Fink, 2008, p. 649). This survey was expanded to exclude demographic questions and other questions not relative to the present project or capstone course content. The question scale utilized for the additional questions was a scaled important/unimportant assessment drawn from capstone course content. Face validity is provided on the basis that this survey has been used by a number of other researchers, including Aggar, Bloomfield, Thomas and Gordon (2017). Convergent content validity is provided by the observation that the proposed expanded survey includes all content items common to the present capstone course curriculum. There have been no specific reliability studies performed or identified relative to the Casey-Fink Readiness for Practice Survey. The survey also included content and items common PRECEPTOR CAPSTONES 19 to the literature review, NRP content, and the local hospital NRP content as a matter of divergent validity. The respondents were asked to indicate on a 4-point Likert scale the extent to which the capstone program content is considered important or unimportant in preparing them for nursing practice. Project Plan The Casey-Fink Readiness for Practice Survey was administered in an email and on Survey Monkey on June 25, 2018 with a cut-off date of July 2, 2018. The survey was administered using Survey Monkey and sent via e-mails provided voluntarily by graduating students of academic year 2017-2018 of the community college’s nursing program. As per prior table summary analysis of the NRP content gleaned from the literature review, a summative content analysis using simple counts and comparisons of content was used and represented in a color-coded table as a summary of the community college’s capstone program curricula and the two local hospitals NRP curricula benchmarked on hospital #2 and the NCSBN program. An additional interpretation of the underlying common content was performed in terms of subset similarities as a matter of greater in-depth comparison. Data Analysis A simple distribution of responses was calculated to include response mean and standard deviation per item as a measure of response variance. In addition, a t-test analysis of significant differences in responses between those students with and without prior nursing experience was performed using an alpha level of .05 for null hypothesis rejection. Institutional Review Board and/or Ethical Issues Institutional Review Board approval for this project was obtained from the Bradley University’s Committee on the Use of Human Subjects in Research (CUHSR) (see Appendix C). PRECEPTOR CAPSTONES 20 No respondent identifiable data was collected. Participants were made aware of the project when they voluntarily provided their e-mail to the community college’s Dean of Health Professions. A cover letter was included that explained the purpose and extent of the study (see Appendix D). Completion of the survey indicated informed consent. Chapter III Organizational Assessment For this project, organizational cooperation and collaboration was forthcoming. Current e-mail addresses for nursing graduates used in the sample were obtained from the community college with permission from the administration. Organizational cooperation was further achieved by contact with representatives from the two local hospitals who provided information about how they currently utilize a NRP and the curriculum used for their NRP. Hospital #1 currently utilizes the University of Iowa’s Nurse Residency Program online curriculum. Hospital #1 has been dissatisfied with the curriculum, and they are currently exploring developing their own curriculum to implement when their contract is completed. Hospital #2 utilizes the Transition to Practice program and was one of the participating hospitals in the NCSBN study on the Transition to Practice program. Cost Factors No budgetary needs existed for the research in that no expenses were incurred with the project. The potential cost savings to healthcare organizations are significant however, as indicated in the literature review. PRECEPTOR CAPSTONES 21 Chapter IV Quantitative Analysis of Implementation Process The expanded Casey-Fink survey was reproduced into a SurveyMonkey questionnaire and administered online via e-mail on Monday, June 25, 2018. The survey was sent to 44 students who successful passed the community college capstone course. The survey closed on Monday, July 2, 2018 after 8 days. There were 20 total responses, with 19 of the 20 surveys completed with no missing data. As such, 19 were identified as being usable for a response rate of 43%. Modification was made to the inception date the survey was administered, and no interventions were required during questionnaire administration. Questionnaires were completed and submitted on reasonable and consistent basis over time. Which may be reflective of the four reminder e-mails sent, the last being sent on July 1st. At the close of the survey, the raw data and responses were exported to Excel and basic data analysis was performed. Qualitative Analysis of Implementation Process Hospital #1 and hospital #2 each provided an outline of their nurse residency programs, with each program being one year in length. Hospital #1 was in transition to change from the University of Iowa’s Nurse Residency Program online curriculum to their own nurse residency program, and as such, provided a limited and non-detailed program curriculum in outline form. Hospital #2 utilizes the NCSBN Transition into Practice modules for their nurse residency program. This program content was much more comprehensive in nature and used as the benchmark for content analysis. The unequal program content and detail created a challenge in terms of a balanced analysis. A more complete comparison was possible between the community college capstone course content and hospital #2 nurse residency program content. PRECEPTOR CAPSTONES 22 Quantitative Analysis of Project Outcome Data Table 4 presents the demographic profile of the survey respondents. As such, 84% of respondents were female with the average age of all respondents being 33 years. Respondents and sample characteristics were therefore considered a reasonable representation of community college nursing students. Table 4 Demographic Profile n (%) Average Age of Respondents Female 16 (84) 33 years Male 3(16) Table 5 presents the rank order distribution of capstone content importance means. Table 5 Rank Order Distribution of Capstone Content Importance Means Question M* SD Prioritizing patient care needs 3.74 0.523 Recognizing changes in patient condition 3.74 0.523 Having opportunities to practice skills and procedures more than once 3.74 0.523 Providing Quality Care 3.74 0.523 Taking action to solve problems 3.63 0.571 Identifying actual or potential safety risks and hazards to my patients 3.63 0.571 Problem solving/Clinical 3.58 0.587 Collaborating with interdisciplinary team members 3.58 0.587 Readiness to assume an RN role 3.53 0.681 Asking for help 3.53 0.681 Using current evidence-based practice to make clinical decisions 3.53 0.598 Analyzing patient data 3.53 0.681 Preparing for the professional role 3.53 0.821 Reviewing Medical-Surgical patient care for various diseases 3.47 0.826 Simulation to help me feel prepared for clinical practice 3.42 0.761 PRECEPTOR CAPSTONES 23 Quality Improvement in work processes 3.42 0.827 Ethical issues in my patient care responsibilities 3.37 0.826 Responding to workplace violence 3.37 0.826 Communicating with patients from diverse populations 3.32 0.821 Documenting care in the electronic medical record 3.26 1.040 Communicating with physicians 3.05 0.813 Delegating tasks to the nursing assistant 2.89 0.918 Note. *n=19 The means of the capstone content importance responses ranged from a high of 3.74 to a low of 2.89, with some natural clustering noted. It is also noted that all but one of the content item means were measured to be important at least at the 3+ level indicating general perceived importance for almost all content items. Said another way, no content item means were identified as unimportant or very unimportant. Using a general rule of thumb data break point of 3.5 on a 4-point scale of importance, four identifiable clusters of high importance were observed. The first high scoring cluster consisted of four content areas: providing quality patient care, prioritizing patient care needs, recognizing changes in patient condition and having opportunities to practice skills and procedures more than once. This cluster had the highest mean of 3.74 and had the lowest variance of 0.523. These first cluster content items could be interpreted to center around patient care. The second highest scoring cluster had the largest between group mean separation of 0.11 of all the content areas. The second cluster consisted of two content items: taking action to solve problems and identifying actual or potential safety risks and hazards to my patients. It had the second highest mean of 3.63 with the second lowest variance of 0.571. The second cluster content items could be interpreted to center around critical thinking related to problem solving. The third highest scoring cluster consisted of two content areas: problem solving/clinical and collaborating with interdisciplinary team members. It had the third highest mean of 3.58 with the third lowest variance of 0.587. The third cluster content items PRECEPTOR CAPSTONES 24 could be interpreted to center around problem solving and teamwork. The fourth highest scoring cluster consisted of five content areas: readiness to assume an RN role, asking for help, using current evidence-based practice to make clinical decisions, analyzing patient data, and preparing for the professional role. It had a mean of 3.53 with a variance that ranged from 0.598-0.821. These fourth cluster content items could be interpreted to center around the professional role of a nurse and readiness to practice. As such, the results of the study indicate four primary important content areas to include patient care, critical thinking, problem solving, teamwork and the professional role and readiness to practice in that order. Therefore, it is this researcher’s conclusion that capstone courses should include and emphasize the four content areas. Table 6 presents the t-test analysis of content item importance responses between those students with and without prior nursing experience. As such, an independent samples t-test was conducted to compare levels and capstone course content importance in previous nursing employment and no previous employment conditions. The mean of each content item relative to students with nursing experience was compared to those with no previous nursing experience. Table 6 Comparison of Means for Participants With and Without Previous Nursing Experience Question With Previous Nursing Experience M n = 8 Without Previous Nursing Experience M n =11 Sig Communicating with physicians 3.13 3.00 0.914 Communicating with patients from diverse populations 3.13 3.45 0.231 Delegating tasks to the nursing assistant 3.00 2.91 0.632 Documenting care in the electronic medical record 3.38 3.36 0.736 Prioritizing patient care needs 3.63 3.82 0.231 Readiness to assume an RN role 3.50 3.55 0.605 Problem solving/Clinical 3.50 3.64 0.365 Ethical issues in my patient care responsibilities 3.25 3.45 0.391 Recognizing changes in patient condition 3.50 3.91 0.032* Having opportunities to practice skills and procedures more than once 3.63 3.82 0.231 PRECEPTOR CAPSTONES 25 Asking for help 3.50 3.55 0.605 Using current evidence-based practice to make clinical decisions 3.38 3.64 0.176 Collaborating with interdisciplinary team members 3.50 3.64 0.365 Simulation to help me feel prepared for clinical practice 3.38 3.45 0.563 Taking action to solve problems 3.50 3.73 0.209 Identifying actual or potential safety risks and hazards to my patients 3.50 3.73 0.209 Providing Quality Care 3.50 3.91 0.032* Reviewing Medical-Surgical patient care for various diseases 3.50 3.73 0.832 Analyzing patient data 3.38 3.64 0.237 Quality Improvement in work processes 3.38 3.45 0.595 Responding to workplace violence 3.38 3.36 0.750 Preparing for the professional role 3.50 3.55 0.669 Note. *p < .05. Independent-samples t-tests were conducted to compare the means for responses given by participants with and without previous nursing experience. The overwhelming majority of content importance ratings did not vary significantly by previous nursing experience. This indicates that regardless of nursing experience, students in the community college capstone course viewed the content items as similarly important. As such, capstone course content need not vary because of previous nursing experience. Only two of the 22 content areas were identified as being significantly different at the 0.05 level. One of these was recognizing changes in patient conditions. There was a significant difference in the scores for those with nursing experience (M=3.5, SD =0.523) and those without nursing experience (M=3.91, SD=0.523) conditions; t(17)=2.292, p=0.032. This result indicates that nursing experience has an effect on rating the importance of including capstone content regarding recognizing changes in patient conditions. Specifically, experienced nurses are more comfortable with recognizing changes in patient conditions and therefore do not rate it as being important capstone course content. The second significant difference was rating the importance of providing quality care. There was a significant difference in the scores for those with nursing experience (M=3.5, SD =0.523) and those without nursing experience (M=3.91, SD=0.523) conditions; t(17)=2.292, PRECEPTOR CAPSTONES 26 p=0.032. This result indicates that nursing experience has an effect on providing quality care. Specifically, nurses with experience may feel that it is an expectation that nurses provide quality care and therefore do not rate it as being important capstone course content. Qualitative Analysis of Project Outcome Data Table 7 presents the primary content of the two local hospital nurse residency programs (NRPs) and the community college capstone course. Table 7 Summative Content Analysis of Local Hospital NRP’s and Community College Capstone Course Hospital #1 Hospital #2 (NCSBN Model) Community College Capstone Course Patient Centered Care EMR/Documentation/Chart Audit Time Management Stress Management/SBAR Patient Centered Care (NCSBN Model) • Multi-Dimensional Care • Advocacy • Decision Making related to Patient Care • Prioritizing • Evaluating Patient Care • Professional Boundaries Patient Centered Care Quality Care • Clear communication • Quality Improvement Processes related to Patient care Clinical Judgement • Patient Needs • Community Needs • Clinical Judgement • Detect Patient Variances Prioritization • Plan care on acuity of patients Medical-Surgical Topics • Invasive Monitoring • Traction Devices Communication and Teamwork Work Place Violence/Horizontal Violence Leadership Professionalism/Social Media/Organizations Communication and Teamwork • Socializing Organization • Personal Effectiveness with Communication • Clearly Communicate and Collaborate • Delegation • Scope of Practice (RN/LPN) • Team Functioning • Professional Development Communication and Teamwork Delegation • Decision Making related to Patient Care • Facilitate Tasks Teamwork & Collaboration • Strategies for Improving Team Function Communication • Clear communication Evidence Based Practice Journal Article Review/Evidence Based Practice Evidence Based Practice • Evidence Based Practice • Search Databases • Critiquing • Evaluate Practice Changes • Evidence Based Implementation Models • Utilizing and Implementing Evidence Based Strategies/Practices Evidence Based Practice Evidence-Based Practice • Utilize databases to support clinical decisions • Evidence based practice to guide care • Evidence based practice and patient teaching Professionalism • Professional Standards • Nurse Practice Act • Roles of Nurses • Leadership Skills PRECEPTOR CAPSTONES 27 Hospital #1 Hospital #2 (NCSBN Model) Community College Capstone Course Quality Improvement Quality Improvement • Use data to identify gaps in care • Identify methods of opportunity • Identify barriers • Utilize Evidence Based Practice • Develop Implementation Plan Quality Improvement Quality Improvement • Structure and process of care related patient outcomes • Quality Improvement and Patient outcomes • Safety Designs Hazard & Violence • Potential hazards Informatics Casey Fink Survey Personalities/Color Test Informatics • Identify electronic/print resources for point of care • Information needed at point of care • Access information • Tools/Technologies to improve point of care • Challenges with technology • HIPAA • Compliance Informatics Data Analysis • Quality Improvement Processes • Root Cause • Data Trends • Workflow Targeted Changes Summative content analysis of hospital #1 and community college capstone course content was benchmarked with hospital #2, which utilizes the National Council of State Board of Nursing (NCSBN) Transition to Practice program. While not identified in the literature review as a gold standard, the NCSBN surveys nursing graduates every two years to consistently understand expectations of the first-year nurse, and as such is the most current. At first glance, hospital #1 content does not align well with the content from Hospital #2 and the community college capstone course. However, the community college capstone course content aligns well with the Hospital #2 content. Hospital #1 includes content relevant to topics for a new nursing graduate. However, when compared to hospital #2, hospital #1 is lacking in content and appears to be missing important content items such as patient centered care and clinical judgement, and decision making. After comparing hospital #1 and hospital #2 content items, the NRP at hospital #1 leaves much to be desired and is not congruent with current recommended content found in the literature. The community college capstone course content aligns more directly with content from the hospital #2 NRP. Natural alignment of similar content items can be seen in Table 7. The PRECEPTOR CAPSTONES 28 commonalities among the community college capstone course content and the hospital #2 NRP content suggest that the programs are complimentary and supportive. Capstone course content areas not included in hospital #2 NRP content include hazards and violence. No content was identified as missing from the capstone course content when compared to hospital #2 NRP content. Performing a summative content analysis of the hospital #2 NRP, the community college capstone course, and content areas identified in the literature as important for capstone courses (as summarized in Table 1) produced the following results (see Table 8). Table 8 Summative Content Analysis of Literature Review, Hospital #2 NRP Program and Community College Capstone Course Literature Review Hospital #2 NRP Community College Capstone Course Patient Centered Care Clinical Skills/Medical Topics Culture Patient Centered Care • Multi-Dimensional Care • Advocacy • Decision Making related to Patient Care • Prioritizing • Evaluating Patient Care • Professional Boundaries Patient Centered Care Quality Care • Clear communication • Quality Improvement Processes related to Patient care Clinical Judgement • Patient Needs • Community Needs • Clinical Judgement • Detect Patient Variances Prioritization • Plan care on acuity of patients Medical-Surgical Topics • Invasive Monitoring • Traction Devices Communication and Teamwork Communication Teamwork & Collaboration Leadership Communication and Teamwork • Socializing Organization • Personal Effectiveness with Communication • Clearly Communicate and Collaborate • Delegation • Scope of Practice (RN/LPN) • Team Functioning • Professional Development Communication and Teamwork Delegation • Decision Making related to Patient Care • Facilitate Tasks Teamwork & Collaboration • Strategies for Improving Team Function Communication • Clear communication PRECEPTOR CAPSTONES 29 Literature Review Hospital #2 NRP Community College Capstone Course Evidence Based Practice Professionalism Evidence Based Practice Evidence Based Practice • Evidence Based Practice • Search Databases • Critiquing • Evaluate Practice Changes • Evidence Based Implementation Models • Utilizing and Implementing Evidence Based Strategies/Practices Evidence Based Practice Evidence-Based Practice • Utilize databases to support clinical decisions • Evidence based practice to guide care • Evidence based practice and patient teaching Professionalism • Professional Standards • Nurse Practice Act • Roles of Nurses • Leadership Skills Quality Improvement Safety & Quality Quality Improvement • Use data to identify gaps in care • Identify methods of opportunity • Identify barriers • Utilize Evidence Based Practice • Develop Implementation Plan Quality Improvement Quality Improvement • Structure and process of care related patient outcomes • Quality Improvement and Patient outcomes Informatics Informatics • Identify electronic/print resources for point of care • Information needed at point of care • Access information • Tools/Technologies to improve point of care • Challenges with technology • HIPAA • Compliance Informatics Data Analysis • Quality Improvement Processes • Root Cause • Data Trends • Workflow Targeted Changes Misc Violence Misc • Safety Designs Hazard & Violence • Potential hazards The prior identified content analysis congruence between hospital #2 and the community college capstone course were also compared against the nine literature review areas. Natural alignment can be seen in Table 8. The last content topic of informatics from hospital #2 wasn’t congruent with literature review content. Of the nine content items from Table 1, violence was not identified as congruent with hospital #2 NRP content. The commonalities between the literature review content and the hospital #2 NRP content and the community college capstone course content suggest that the three sources are complementary and supportive. Therefore, NRP content from hospital #2, and the community college capstone course are congruent with content items identified as important for capstone courses found in the literature review. PRECEPTOR CAPSTONES 30 Chapter V Findings The results of this study indicated four primary findings: 1. The commonalities among the community college capstone course content and hospital #2 NRP content suggest that these programs are complimentary and supportive. 2. NRP content from hospital #2, and the community college capstone course were congruent with content items identified as important for capstone courses in the literature review. 3. The results of the study indicate four primary important capstone course content areas: patient care, critical thinking/problem solving, teamwork and the professional role and readiness to practice in that order. 4. The identified importance of the overwhelming majority of capstone content items did not vary significantly with previous nursing experience, which supports the use of a single curricula. Limitations or Deviations from Project Plan No deviations from the project plan occurred. A limitation in analysis was that hospital #1 provided only a basic NRP outline, which limited the ability to conduct an in-depth content analysis with hospital #2 program and the community college capstone course. Another limitation is related to the timing of the data collection. The nursing graduates completed the NCLEX in late May and early June. With the survey being administered at the end of June, many of the graduates had just begun working, so their perspective of perceived importance of capstone content may have been limited by this limited nursing experience. This study’s results PRECEPTOR CAPSTONES 31 pertain to a population from rural northern Illinois, which may or may not be applicable to the entire state or the nation as a whole. Implications The results of this study can be used to revise the community college capstone course curriculum by incorporating and emphasizing content items identified as most important by the nursing graduates. The implications for hospital #1 are significant. As presented and reviewed, the hospital #1 NRP curriculum falls well outside that of hospital #2 as well as content identified as important in the literature review. Implications for future research include capstone course content evaluation after new graduates have completed the NRP at their place of employment. This could provide a more comprehensive evaluation of the capstone course content. A statewide evaluation of important capstone content items with nursing programs that have a capstone course in their final semester could provide a large sample size and greater statewide representation. On the basis of the literature review, it appears in general that the states of Wisconsin and Florida lead the nation in NRP content areas and were additionally identified as having partnerships between academe and service providers. This implies that the state of Wisconsin and Florida may have a future leadership role in program development on a national basis. Chapter VI Value of the Project The results from this project provided significant information to the community college with respect to its capstone course curriculum. Reviewing capstone course content through the feedback of student perception of course content importance helps to validate the content of the course and identify any curriculum revisions that might need to occur. For the two local PRECEPTOR CAPSTONES 32 hospitals, the results of this project indicate strengths and weaknesses related to their current nurse residency programs compared to the NCSBN model, as well as areas of importance related to content identified by students who are now new graduates in their institutions. It allows them to understand what those new graduates perceive to be important content items and can help guide the curriculum of the nurse residence program specific to the new graduates they are hiring. DNP Essentials This project meets several aspects of the DNP Essentials and has provided great professional and personal growth. In Essential I, the project aligns with “develop and evaluate new practice approaches based on nursing theories and theories from other disciplines”. This project recognized different learning and nursing education theories related to nursing curriculum and new graduate success. In Essential III, the project aligns with “use analytic methods to critically appraise existing literature and other evidence to determine and implement the best evidence for practice”. This project evaluated local nurse residency program content compared to the local community college capstone course content and their natural alignment with nurse residency program content identified as important in the literature. Another outcome from Essential III aligned with this project, “use information technology and research methods appropriately, and disseminate findings from evidence-based practice and research to improve healthcare outcomes”. Specifically, this project involved utilizing a research database search engine to conduct a literature review, as well as analyzing the findings of the literature review to determine the importance and value of the project related to nursing education. From Essential VI the project aligns with, “employ effective communication and collaborative skills in the development and implementation of practice models, peer review, practice guidelines, health PRECEPTOR CAPSTONES 33 policy, standards of care, and/or other scholarly products”. This project involved communication and collaboration with the two local hospitals to understand what their NRP needs were and, how they were utilized in the program content. Finally, from Essential VIII, this project aligns with “guide, mentor, and support other nurses to achieve excellence in nursing practice, along with use of conceptual and analytical skills in evaluating the links among practice, organizational, population, fiscal, and policy issues”. Specifically, this project will guide the content of the community college capstone course curriculum to help educate future nursing students. Plan for Dissemination The results from this study will be shared with the community college administration, and hospital #1 and hospital #2 nursing administrations in August. Further discussion in the form of a presentation of this study may result after the college and hospital administrations review the study. After the project is presented to college administration and hospital administrations submission for publication will be forthcoming in an appropriate journal. Attainment of Personal and Professional Goals Through this project, I have been able to determine the importance of a course that I developed and taught as part of a new nursing curriculum. Being able to have a more in-depth questionnaire-based evaluation of what students perceive as important to their education can help guide my professional practice as an educator. Through the literature review, a clear goal for the community college capstone course became apparent, transition students from academe to the workforce. It was the goal of the course all along but there wasn’t significant data or information that provided insight on how or if it was being achieved. This project has provided the research, data and support to help the capstone course evolve into a true transition from student to new nurse graduate. This project has allowed me to see a course development from start to finish PRECEPTOR CAPSTONES 34 with, much like the nursing process assessment, diagnosis, planning, implementing and evaluation. PRECEPTOR CAPSTONES 35 References Aggar, C., Bloomfield, J., Thomas, T. H., & Gordon, C. J. (2017). Australia's first transition to professional practice in primary care program for graduate registered nurses: a pilot study. BMC Nursing, 1-11. http://dx.doi.org/10.1186/s12912-017-0207-5 Benner, P. (1984). From Novice to Expert; Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley. Blevins, S. (2016). Nurse residency programs: Supporting nurse graduates. MEDSURG Nursing, 25(5), 367-368. Bratt, M. M. (2009). Retaining the next generation of nurses: The Wisconsin nurse residency program provides a continuum of support. The Journal of Continuing Education in Nursing, 40(9), 416-425. Bratt, M. M. (2013, November 3, 2013). Nurse residency program: Best practices for optimizing organizational success. Journal for Nurses in Professional Development, 29(), 102-110. http://dx.doi.org/10.1097/NND.0b013e318292649f Casey, K., & Fink, R. (2008). Casey-Fink Readiness for Practice Survey [Survey]. Published instrument. Retrieved from https://www.uchealth.org/professionals/professionaldevelopment/casey-fink-surveys/casey-fink-readiness-practice-survey/ Casey, K., Fink, R., Jaynes, C., Campbell, L., Cook, P., & Wilson, V. (2011). Readiness for practice: The senior practicum Experience. Retrieved from https://www.uchealth.org/wpcontent/uploads/2016/10/PROF-Casey-Fink-Journal-Nursing-Ed-Readiness-Article.pdf Cochran, C. (2017). Effectiveness and best practice of nurse residency programs: A literature review. MEDSURG Nursing, 26(1), 53-57, 63. PRECEPTOR CAPSTONES 36 Dyess, S., & Sherman, R. (2009). The first year of practice: New graduate nurses' transition and learning needs. The Journal of Continuing Education in Nursing, 40(9), 403-410. http://dx.doi.org/10.3298/00220124-20090824-03 Hsieh, H., & Shannon, S. (2005, November 1, 2005). Three approaches to qualitative content analysis. Qualitative Health Research. http://journals.sagepub.com/doi/abs/10.1177/1049732305276687?journalCode=qhra Latourneau, R., & Fater, K. (2015). Nurse residency programs: An integrative review of the literature. Nursing Education Perspectives, 36(2), 96-101. http://dx.doi.org/10.5480/13- 229 Levine, J. (2017). Transition to practice - part 1: Implementing the AAACN ambulatory care nurse residency program: The importance of a structural framework. Nursing Economic$, 35(5), 267-271. More, L. (2017). Transition into practice - part 2: Implementing an ambulatory care registered nurse residency program: Competency - it's not just a task. Nursing Economic$, 35(6), 317-322. Nurse residency program curriculum overview. (2018). Retrieved April 28, 2018, from https://uiowa.edu/ionrp/curriculum-overview Outline of NCSBN's transition to practice modules. In Outline of NCSBN's transition to practice modules. Retrieved from www.ncsbn.org Sauk valley community college: Associate degree nursing student handbook. (2018-2019). Dixon, IL: Sauk Valley Community College. Sauk valley community college: Transition into practice course outline. (2018-2019). Dixon, IL: Sauk Valley Community College. PRECEPTOR CAPSTONES 37 Welding, N. M. (2011). Creating a nursing residency: Decrease turnover and increase clinical competence. MEDSURG Nursing, 20(1), 37-40. PRECEPTOR CAPSTONES 38 Appendix A Expanded Casey-Fink Readiness for Practice Survey Thank you in advance for your willingness to participate in this survey. All responses are anonymous and held in confidence and used as input into the nursing capstone course and nurse residency program content. Please fill in the blank or circle the best response that represents your individual profile. 1. Age ______ years 2. Gender a. Female b. Male 3. What previous health care work experience have you had: a. Nursing Assistant b. Medical Assistant c. Volunteer d. Unit Secretary e. EMT f. EMT – Paramedic g. LPN h. Other: (Please specify)___________________ 4. Was your capstone clinical practicum experience at your current place of employment? a. Yes b. No 5. How many NCLEX-RN questions/week did you review while in your capstone course? #_____________Questions List THREE skills/procedures you are most uncomfortable performing independently at this time? Select from the list below. 1.____________________________ 2.____________________________ 3.____________________________ 4. __________ I am independent in all skills listed below List of Skills Assessment skills Bladder catheter insertion/irrigation Blood draw/venipuncture Blood glucose monitoring device Central line care (dressing change, blood draws, discontinuing) Charting/documentation Chest tube care PRECEPTOR CAPSTONES 39 EKG/Telemetry monitoring and interpretation Giving verbal report Intravenous (IV) medication administration Intravenous (IV) starts IV pumps/PCA pump operation Medication administration NG tube/Dobhoff care Pulse oximetry Responding to an emergency/CODE/changing patient condition Trach care/suction Wound care/dressing change/wound vac Please answer each of the following questions by placing a mark inside the box/circle: What is your current level of confidence in managing a patient care assignment on an adult Medical/Surgical unit: Not Confident Confident 1 2 3 4 5 Caring for 2 patients Caring for 3 patients Caring for 4 patients TABLE 1 STRONGLY DISAGREE DISAGREE AGREE STRONGLY AGREE I feel confident communicating with physicians. I am comfortable communicating with patients from diverse populations. I am comfortable delegating tasks to the nursing assistant. I have difficulty documenting care in the electronic medical record. I have difficulty prioritizing patient care needs. My clinical instructor provided feedback about my readiness to assume an RN role. I am confident in my ability to problem solve. I feel overwhelmed by ethical issues in my patient care responsibilities. I have difficulty recognizing a significant change in my patient’s condition. I have had opportunities to practice skills and procedures more than once. I am comfortable asking for help. PRECEPTOR CAPSTONES 40 I use current evidence to make clinical decisions. I am comfortable communicating and coordinating care with interdisciplinary team members. Simulations have helped me feel prepared for clinical practice. Writing reflective journals/logs provided insights into my own clinical decision-making skills. I feel comfortable knowing what to do for a dying patient. I am comfortable taking action to solve problems. I feel confident identifying actual or potential safety risks to my patients. I am satisfied with choosing nursing as a career. I feel ready for the professional nursing role. How important were the following capstone program items in preparing you for nursing practice? Very Unimportant Unimportant Important Very Important Communicating with physicians Communicating with patients from diverse populations Delegating tasks to the nursing assistant Documenting care in the electronic medical record Prioritizing patient care needs Readiness to assume an RN role Problem solving/Clinical Ethical issues in my patient care responsibilities Recognizing changes in patient condition Having opportunities to practice skills and procedures more than once PRECEPTOR CAPSTONES 41 Asking for help Using current evidence-based practice to make clinical decisions Collaborating with interdisciplinary team members Simulation to help me feel prepared for clinical practice Taking action to solve problems Identifying actual or potential safety risks and hazards to my patients Providing Quality Care Reviewing Medical-Surgical patient care for various diseases Analyzing patient data Quality Improvement in work processes Responding to workplace violence Preparing for the professional role What content could be added to help you feel more prepared to enter the nursing profession? ______________________________________________________________________________ ______________________________________________________________________________ Thank you for completing this survey! PRECEPTOR CAPSTONES 42 Appendix B PRECEPTOR CAPSTONES 43 Appendix C Dear Investigators: Your proposed study (CUHSR 44e-18) Project proposal: Preceptor capstones: Are they beneficial in ADN programs to help transition new graduates? has been reviewed and was found to be exempt from full review under Category 2. Your vita and ethics certificates are on file. Be aware that future changes to the protocols must first be approved by the Committee on the Use of Human Subjects in Research (CUHSR) prior to implementation and that substantial changes may result in the need for further review. While no untoward effects are anticipated, should they arise, please report any untoward effects to CUHSR promptly (within 3 days). As this study was reviewed as exempt, no further reporting is required unless you change the protocol or personnel involved. This email will serve as notice that your study has been reviewed unless a more formal letter is needed. Please let me know, and I will provide the letter. Ross L. Fink, Ph.D. Chairperson, CUHSR PRECEPTOR CAPSTONES 44 Appendix D Cover Letter for Survey April 30, 2018 Dear Nursing Graduate, I am a graduate student at Bradley University. I am conducting a study to determine the importance of the community college’s capstone program that you completed related to preparing you for nursing practice. This is the topic of my scholarly project, which is one of the components required to complete my Doctorate of Nursing in Leadership. Given the identified nursing shortage and retention problems that many hospitals face, the purpose of the study is to determine the extent to which the community college’s capstone course prepared you for professional nursing practice. Please take approximately 15 minutes to complete the attached survey. All responses are confidential and anonymous. Informed consent in this study is implied if the questionnaire is completed and submitted. Anonymity will be maintained. You can choose not to participate in this study by not answering or submitting the questionnaire, but I encourage you to participate in this study to help address the educational needs of new graduate nurses. Thank you in advance for your time and participation. Sincerely, Mary Margaret Evans, MSN, RN PRECEPTOR CAPSTONES 45

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