Canada could face a shortage of up to 113,000 registered

Transcription

1 CLINICAL A Comprehensive ED Orientation for New Graduates in the Emergency Department: The 4-year Experience of One Canadian Teaching Hospital Authors: Diane Loiseau, N, BScN, CEN, Kathryn Kitchen, MSc(A)(cand), and Linda Edgar, N, PhD, Montreal, Quebec, Canada Diane Loiseau is Nurse Professional Development Educator, Emergency Department; Kathryn Kitchen is Research Assistant, Nursing Research Department; and Linda Edgar is Nursing Research Consultant, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada. For reprints, write: Linda Edgar, N, PhD, 2500, Pierre-Dupuy, Apt 411, Montreal, Quebec, Canada; linda.edgar@muhc.gill.ca. J Emerg Nurs 2003;29: Copyright 2003 by the Emergency Nurses Association /2003 $ doi: /j.jen Canada could face a shortage of up to 113,000 registered nurses by the year Furthermore, with the restructuring of health care in Canada, emergency departments have become busier, often functioning as the core of a health care system in trouble. 2-4 At this time, it can take 60 days to fill a nursing vacancy for an experienced nurse in an emergency department, in contrast to 20 days to recruit a new graduate for a general medicalsurgical unit. 5 Considering the current nursing shortage, it will be even more difficult to recruit nursing students. Retention is every bit as important as recruitment. The cost of nurse turnover is estimated to be 4 to 5 times higher than typically suspected by hospitals, primarily because of a failure to account for lost productivity by the new hires and the nurses who must assist them in their work and the high cost of hiring, orienting, and training nurses to achieve the skill level of competent, experienced nurses. 2 In some cases, this cost has resulted in short, inadequate orientations or the complete elimination of formal orientation programs! One study demonstrated that the turnover rate for poorly prepared and undersupported new nurses hired to work in a specialty unit was 92% within the first year. 6 A viable solution to the ED nursing shortage is to hire newly graduated nurses and provide them with a thorough, well-planned orientation program that fully integrates them into the hospital work environment. 6 The ED staff of the Royal Victoria Hospital site of the McGill University Health Center in Montreal, Quebec, Canada, led by the nurse manager and unit educator, developed a 4-month comprehensive orientation program to prepare new nurses to work in the emergency department. 522 JOURNAL OF EMERGENCY NURSING 29:6 December 2003

2 Selection criteria Our objectives were to help orientees develop self-efficacy and focus on continuous learning and to help the nurses function safely, efficiently, and competently. We sought nurses who would demonstrate high motivation and an interest in ED nursing; in addition, we wanted them to identify personal objectives for their clinical preceptorship, which has been identified as important elsewhere. 7 Because prior experience as students in the emergency department has been associated with faster progress in orientation, 8 and because nursing students with high marks have been noted to have a higher level of self-efficacy, we selected nurses who met those criteria and who demonstrated enthusiasm and professionalism that seemed to fit with the culture of our department. We selected preceptors based on the following desirable qualities: resilience and enthusiasm, 3 experience in emergency nursing, 9 demonstration of professionalism and knowledge, 3,7 interest in precepting, 7,9,10 and attendance at conferences on adult learning and orientation course content. 7,8,10 Classes or workshops for training preceptors included topics in communication, establishing learning objectives, adult learning principles, and techniques for providing feedback to orientees. The increased knowledge and skill of the preceptors has improved the learning environment for the orientees and has increased the preceptors job satisfaction. 11 Decreasing the preceptors patient assignments from 6 patients to 2 to 4 patients (depending on the ED staffing and the acuity of the patients) has increased the time available to them for teaching. 10 Preceptors receive a premium of $1.57 (Canadian) for each hour of preceptor time. Recruitment Historically, the normal route for nurses coming to work in our emergency department was first to spend at least 2 years working on a general medical or surgical floor. However, our challenge during the past few years has been to attract new graduates and prepare them to work in the emergency department within 4 months without overwhelming them. To this end, in 1999 we began to send flyers to all the nearby college and university nursing programs. Representatives from the emergency department visited the colleges on career days to speak to the students, and we held an open TABLE 1 Description of orientees No. of orientees (%) Started program 18 (100) Education Diploma (community college) 11 (61) University degree (BScN/other major) 6/1 (39%) Age (y) (39) (28) >25 6 (33) Language of education English 9 (50) French 9 (50) Moved to Montreal for the program 5 (28) Removed from program 3 (17) Completed program 15 (83) Still in emergency department 1 y after 15 (83) completing program house so that prospective employees could visit the department and receive information about the program. The response from the students and teachers was excellent; we received more than 40 inquiries. Decreasing the preceptors patient assignments from 6 patients to 2 to 4 patients (depending on the ED staffing and the acuity of the patients) has increased the time available to them for teaching. Orientation program development During their 4 months of orientation, orientees work in the acute area of the department where patients require more care than in the ambulatory care area. During the first 3 months, the orientees reinforce their knowledge, learn and practice new techniques, increase their organizational skills, develop their ability to prioritize, and become comfortable with the emergency nurse s role. They spend their fourth month working one-on-one with a preceptor. The goal is to have the new graduate carry a typical 4- to 6-patient assign- December :6 JOURNAL OF EMERGENCY NURSING 523

3 ment by the end of orientation. Thus far, our program has been used for 5 groups of orientees 18 nurses altogether. The nurses need further orientation before they can function independently in the resuscitation room, the Minor Care Area (an ambulatory care area where the nurse works alone with a physician, organizing 10 rooms), and triage. Students train with a preceptor for these specialty areas and attend 4 to 6 hours of classes. This training takes place after they have spent 6 months or more in the emergency department, according to the needs of the department and the availability of preceptors. Some of the graduates of the orientation program have requested an earlier orientation to the other areas, but we believe that the 6-month time frame is important to allow the graduates to solidify their emergency skills. One problem...was the lack of continuity of preceptors. Continually needing to update preceptors on an orientee s progress and learning needs sometimes wasted valuable time... [Now, each] group of 4 new graduates has 1 to 2 preceptors assigned for all 12 weeks to allow for better follow-up. When the program first started in 2000, the nurses spent the first 3 months on a medical unit providing patient care with a preceptor. The assistant head nurse (AHN) or the educator from the emergency department met with them at least weekly. The preceptors kept notes and evaluated the new graduates at the end of the 3 months, before they spent the fourth month in the emergency department. The ED educator or the ED AHN kept in contact with the AHN of the medical floor to deal with any problems. The new nurses had the ED educator s pager number and were encouraged to use it if necessary. One problem identified by some orientees and preceptors was the lack of continuity of preceptors. Continually needing to update preceptors on an orientee s progress and learning needs sometimes wasted valuable time. In February 2001, after we had completed 4 orientations, we modified the program. Now the nurses spend their first 12 weeks in the emergency department instead of on a medical unit. We provide a cardiology course, a Heartsaver CPR course, and lectures on physical assessment and other topics pertinent to the department. Each group of 4 new graduates has 1 to 2 preceptors assigned for all 12 weeks to allow for better follow-up. The nurse educator worked at home as well as on her work time to develop learning tools for the orientees. The preceptors were given periods of 2 hours at 4 different times to work with the educator and discuss the documents that she had developed. These included written objectives, a treasure hunt list of equipment, a weekly meeting form, a summary of techniques to be accomplished by the orientees, a list of commonly used ED medications, a summary list of the most common ED investigation (diagnostic) tests, and a sheet to list the new graduates overall and personal goals for the program. Toward the end of their 12 weeks, we require the orientees to select a topic related to emergency nursing and give a 15- to 30-minute presentation to the rest of the staff. After 12 weeks, we assign each new graduate to another nurse for a more concentrated, one-on-one orientation for the remaining 4 weeks of the program. The new graduates are partnered with a staff nurse to work together on an average patient assignment. Now the nurses spend their first 12 weeks in the emergency department instead of on a medical unit. We provide a cardiology course, a Heartsaver CPR course, and lectures on physical assessment and other topics pertinent to the department. Two nurses commented that they would have liked more classroom time. (The classroom time consisted of an hour at the end of the nurses shifts.) Too often teaching sessions had to be canceled because of the high activity in the department. We decided that the preceptors and new graduates should continue to work full time. However, instead of ten 8-hour shifts in a 2-week period, they would work eight 9-hour shifts and one 8-hour shift. The last hour of 524 JOURNAL OF EMERGENCY NURSING 29:6 December 2003

4 the 9-hour shift would be spent teaching or discussing the events of the day. Our unit is based on 8-hour shifts so the preceptors and new graduates were counted as staff for the first 8 hours (but staff on orientation with reduced patient assignments), and then were not counted as staff for this last hour. Another positive improvement suggested by a preceptor was the use of case studies. These studies of actual patient situations became part of the classroom hours. Occasionally, during a general nursing meeting in the emergency department, a case study would be presented to elicit feedback from all of the staff nurses. Outcomes of the orientation program/results of a questionnaire and survey During or after the completion of the program, we administer the Student Self-Efficacy Questionnaire to each orientee. This 52-item questionnaire has a 4-point scale and a demographics section that asks students to rate their self-efficacy on their performance of listed behaviors (eg, How confident are you that you can plan nursing interventions? ). The higher the score, the greater the selfefficacy. Reliability coefficients range from The total average score from The Self-Efficacy Questionnaire for the orientees from 1999 to 2002 was 3.07 or confident ; the orientees believed that they were generally able to fulfill their tasks. The high scores that were given to self-development, nursing strategies with clients, and professionalism indicate that orientees were confident in their ED nursing abilities and professional identity during the orientation program. They felt supported in the program and believed that they were allowed to learn and grow in their role. The Gallup Organization Employee Attitude Survey, a 12-item survey that uses a 5-point Likert scale, measures organization performance and manager effectiveness based on workplace factors that correlate positively with 4 outcomes: employee retention, customer satisfaction, productivity, and profitability. 13 Although this survey does not measure competence, higher scores have been found to be highly correlated with productivity, greater organization performance, and manager effectiveness. 6 The new graduates complete this survey near the end of their program. The results of the Gallup survey were comparable with those obtained by baccalaureate students after they were oriented to medical-surgical areas, and signify that the program met basic work-related needs. 12 Some items in the survey were ranked lower by our orientees; these items may not reflect the effects of the orientation program as much as the current, stressful nursing work environment in Canada, including a lack of equipment, that hinders their ability to achieve their professional best. Overall evaluation of the program We looked for nurses who were enthusiastic, willing to work hard, committed to work in the emergency department, and who seemed to have learning skills conducive to ED nursing (eg, critical thinking skills, ability to prioritize, and ability to remain calm and handle stressful situations). Four of the new graduates chosen had clinical rotations in the emergency department as part of their university course. The more mature the nurses were, the better they managed in the program and in the emergency department. For example, one new graduate was in the Armed Forces on a part-time basis and had leadership experience, and 2 others entered nursing after completing other degrees. Older age seemed to be related to success in the program, with or without previous nursing experience (Table 1). Fifteen of 18 new graduates have completed the program. We noted that 2 of 5 nurses who moved into Montreal from small towns found the program difficult. We believe there was a lack of support for them in this new big city environment. Three new graduates were withdrawn from the program because of their failure to have the basic knowledge needed for the program, failure to show initiative to learn independently, and/or failure to take responsibility for their own learning and severe discomfort with the ED stress level. The orientation team suggested that one of the latter orientees should return to a medical floor for more experience in a less stressful environment and possibly return to the emergency department later. (She was in one of the earlier orientation programs.) Her inability to cope with the ED stress may have been detected earlier if she had not spent the first 12 weeks on a medical unit and if she had only one preceptor instead of several. Another nurse left the December :6 JOURNAL OF EMERGENCY NURSING 525

5 unit after a year to obtain a position with fewer off-shifts than the emergency department could provide. When discussing the orientation program, the preceptors stated that they were well supported by the rest of their co-workers. However, at times when the unit was very busy they felt pressure from the nurse in charge to take more patients, especially at the start of the orientation program when their patient load was limited to 4 patients for the benefit of their orientees. Nevertheless, the preceptors reported an increase in their personal and professional growth as a direct result of their participation in the orientation program. Our orientees competence was measured by the preceptors and educator s evaluation of the orientees performance. The nursing and medical staff of the emergency department also were asked for their evaluations of how the orientees performed during stressful emergencies. The ED staff reported that they believed the new graduates were competent and safe to practice and that the staff felt confident in working with them. Summary Based on our experience, a structured orientation program can prepare new graduate nurses to function competently in an emergency department with a satisfactory sense of self-efficacy. A combination of classroom and clinical learning has reduced nurse vacancy rates and accelerated entry into the staffing of the emergency department. Thus far, the retention rates of the graduates of our program are above average for the hospital. We suggest that having colleagues at work, making good friends in the department, celebrating birthdays and holidays, and knowing that there is someone at work available to talk to about concerns or difficulties provides support for the orientees. We were able to identify a number of factors that are important to the success of our program. For example, our careful selection of preceptors with good communication skills who had experience both in general and ED nursing and a commitment to teaching facilitated the orientation process. We found that having the preceptors follow the same orientees over the length of the orientation provided continuity for the orientees. The new graduates benefited by being introduced to the emergency department at the start of their orientation with a gradual increase in their patient responsibilities. Weekly meetings lasting an hour were held in the ED conference room and involved the ED educator, preceptors, and orientees. These meetings helped to resolve issues early and to track the orientees progress. The preceptors and new graduates gave their weekly feedback forms to the educator. The forms were not anonymous, but they provided an outlet for comments, problems, and suggestions that the educator followed up on, and changes to the program were made on the basis of the feedback provided. The forms also provided a safe and productive opportunity for the participants to vent their feelings and review small issues. We have 4 nurses in our orientation program at one time and recommend that the number of students be limited to this number. The orientation requires a great deal of dedication and hard work not only by the preceptors and educators but also by the entire staff, who must acquaint themselves with and welcome new staff and provide support to them during the shifts. The retention rates of the graduates of our program are above average for the hospital. The new graduates found it difficult in the first few months after orientation as the relative security of orientation ended, but they saw themselves as contributing members of the ED team. They reported that the support from the staff continued to be high and readily available and that they would recommend the program to other new graduates. Future development In future programs, we will give the questionnaires previously described to measure self-efficacy and employee attitudes both before and after completion of the orientation program. As our orientation program continues to develop, we plan to include peers in the hiring and interviewing process to help ensure compatibility of the applicants with the unit work environment. As our hospital administration has viewed the results of the program, they have been convinced of its worth. A review of costs is planned for the future. The Nursing Execu- 526 JOURNAL OF EMERGENCY NURSING 29:6 December 2003

6 tive Center estimates that the total cost of such a program will be equal to or less than the cost of traditional specialty orientation programs (where nurses begin their training on a medical or surgical floor), because there will be a more rapid entry of new nurses into the staffing mix. 6 Acknowledgment We thank the following groups for assisting in this project: ED orderlies, unit coordinators, nurses, and doctors, and the staff of 10 medical. Special thanks to the preceptors who participated in the project. REFERENCES 1. Sibbald B. The future supply of registered nurses in Canada. Can Nurse 1998;94: Wong FWH. Learning group: facilitating the adaptation of new nurses to the specialty unit. J Cont Educ Nurs 2000;31: Rudzik J. Establishing and maintaining competency. J Intravenous Nurs 1999;22: Mathews JJ, Nunley C. Rejuvenating orientation to increase nurse satisfaction and retention. J Nurs Staff Develop 1992;8: McGill University Health Center Human Resource Department. Internal memo. Montreal: The Department; Nursing Executive Center. Reversing the flight of talent: practice portfolio. Washington: The Advisory Board; p Ephron J, Andrea J. Collaborative university/emergency student nurse preceptorship program. J Emerg Nurs 1989;15: Kidd P, Sturt P. Developing and evaluating an emergency nursing orientation pathway. J Emerg Nurs 1995;21: Alban A, Coburn M, May C. Addressing the emergency nursing staffing shortage: implementing an internship using a nursing school instructor model. J Emerg Nurs 1999;25: Meyer RM, Meyer MC. Utilization-focused evaluation: evaluating the effectiveness of a hospital nursing orientation program. J Nurs Staff Develop 2000;16: Stevenson B, Doorley J, Moddeman G, Benson-Landau M. The preceptor experience. J Nurs Staff Develop 1995;8: Goldenburg D, Iwasiw C, MacMaster E. Self-efficacy of senior baccalaureate nursing students and preceptors. Nurse Educ Today 1997;17: Buckingham M, Coffman C. First, break all the rules. New York: Simon & Shuster; p Reviewers Acknowledgment The Journal of Emergency Nursing gratefully acknowledges the time, effort, expertise, and advice donated by the following reviewers of this issue s content: Sue Barnason Donna Benedict Nancy Bonalumi Howard Bondell Karen Kernan Bryant Pat Clutter Laura Criddle Valerie Novotny Dinsdale Kathy Emde Faye Everson Susan Fitzgerald Elizabeth Glaser David Glorius Kevin High Heidi Jahnke Diane Lapsley Susan MacLean Peter Maningas Christine May Barbara Pierce Jim Richmann Kathleen Rourke Linda Scheetz Marilyn Simon Deb Smith Anne Wojner Polly Gerber Zimmermann December :6 JOURNAL OF EMERGENCY NURSING 527