Nursing

Should new graduates be hired into specialty areas? If so, can they be successful? Independent of personal opinion, the nursing shortage is dictating the answer to the first question, offering no choice to specialty departments but to hire new graduates and take on the responsibility to make them successful.

Three years ago, our emergency department began developing a new graduate program geared to the characteristic of the generational learner, combining theory, clinical competency, and evaluation methodology. The result is competent nurses, low vacancies, and retention, while maintaining a fiscally responsible orientation budget.

In the beginning, we looked at the factual elements: A new graduate will take 18 to 24 months to become competent in the entire ED¹. Overwhelming the new graduate with information too quickly leads to a lack of competence and confidence. The new graduate requires support during the entire learning process. Nursing is taught, practiced, and modeled over an extended period of time. Failure to provide an ongoing, supportive program will lead to costly turnover.^1,2,3

Three theories—Patricia Benner's Novice to Expert Theory, Edwin A. Locke's Goal Directed Theory, and the principle of segmented learning—are the foundation of a competency-based orientation program. Benner's theory states the new graduate enters the work force as an advanced beginner with the expectation of orientation to teach competent care. Advanced beginners are excited and eager to learn, but are easily overwhelmed with multiple tasks, interruptions, and increased departmental stimulation. They are not attuned to subtle patient changes and elements outside what the textbook tells them to anticipate. Advanced beginners do not understand there is a wealth of information that they do not know.⁴ The fellowship program needs to recognize the elements of advanced beginners, capitalize on their abilities such as task management, and move them into a competent phase in which learners realize the long-term learning potential, the fluidness of illness, and the ability to know when rules do not apply.

Locke's theory states that learners need to be successful in increments. Educators and learners must collaborate to set simple goals that can be met quickly. Locke supports frequent evaluation of goals in order to take "baby steps" toward attaining the big picture, and enhancing a feeling of confidence and success for the learner.⁵

The ED, like most specialty areas, can be segmented into different areas of specialized learning. In keeping with the Locke and Benner theories, the ED orientation is divided into five segments of learning, each with clinical competency, goals, and a systematic evaluation dictating success and readiness to move to the next level.

These segments are:

• 1. Formal orientation—main ED;
• 2. Front-end assessment;
• 3. Resuscitation–trauma/code roles;
• 4. Phase I precepting; and
• 5. Triage.

Learners begin each segment as advanced beginners. The segmented process allows learners to focus on one element at a time, which prevents them from feeling overwhelmed.

FORMAL ORIENTATION Formal orientation is divided into two phases encompassing 14 weeks. During the formal orientation period, the learners experience clinical orientation time, ED didactic learning, and a hospital internship program. The time frame may be shortened or extended, based on the learners' abilities to meet goals of the phase and show signs of competency.

Phase I focuses on socialization, rules, and clinical skills, such as starting IVs and assessment. Learners must master the "how-to" of tasks—how to start an IV, how to complete a physical assessment of the pediatric patient, and how to know who is who in the department. Phase I preceptors have one to two years' experience in the competent phase of their learning. These preceptors remember what it was like to be new in a specialty area, how scared they were, and what others did to help them feel supported and accepted. The relationship with the Phase I preceptors provides the support and socialization that the new graduates require.

Weekly meetings with the orientation coordinator (educator), preceptor, and learner begin in Phase I of formal orientation. Each meeting involves setting goals, evaluating the past week's goals, role-playing through difficult situations, and planning for the following week. The orientation coordinator evaluates the learners to ensure they are getting the concrete skills required in this phase and the key competency of physical assessment. Meeting results are documented in the learners' orientation packets to monitor ongoing progress. Learners not meeting competency are identified in weekly meetings. Success plans are implemented, or transition out of the department can follow.

Learners who are deemed competent in Phase I move to Phase II of formal orientation, which focuses on the care of patient populations, including pathophysiology, anticipation of care, prioritizing, and beginning critical-thinking skills. Preceptors assist the learners to think through problems and come up with solutions, and motivate them to anticipate care, communicate effectively, and advocate for patients. By the end of Phase II, the learners are prepared to independently manage patient assignments in the main ED. Evaluation through the phase reviews documentation, types of patients assigned, resource utilization, and percentage of independent care the learners are able to provide each week.

The end of Phase II opens a period of vulnerability with new graduates. Suddenly, no one is there to oversee care, leaving learners with the perception they are "alone." This perceived lack of support could cause the new graduate to quit a position, with a loss to the unit of between $10,000 and $15,000 in salary alone. To alleviate fears, it is crucial that the preceptors become mentors. One strategy is to align the schedules of the learners and their preceptors for the first month after formal orientation. This provides the new grads with a person of comfort, to whom they can address questions and voice concerns. The mentor knows the new graduate well, and can identify—better than other staff—if he or she is overwhelmed by verbal and nonverbal communication. The relationship with the orientation coordinator moves to a biweekly meeting with just the coordinator and the learner to evaluate progress and concerns.

After successful completion of formal orientation, new graduates focus on care of patients in the main ED. Timeline is approximately three to six months, to give them time to feel comfortable and master care of ED patients prior to learning new skills.

FRONT-END ASSESSMENT After triage, a nurse in the front-end assessment area will assess patients deemed safe for the waiting room. The nurse obtains a more in-depth history and completes the assessment, and potentially upgrades or downgrades the patient. Nurse-initiated protocols are initiated when patients meet inclusion criteria. This area requires nurses to have good assessment skills, knowledge of existing unit pathways and care of the patient in the ED, and the confidence to make decisions. New graduates tend to be ready to learn front-end assessment approximately three to six months after the completion of formal orientation.

Orientation to front-end assessment includes a meeting between the learner and educator to complete a didactic orientation focusing on pathway implementation, the escalation of sick patients, and resources available. Learners are clinically precepted by educators to the assessment role in two four-hour blocks of time (peak ED volume times). Competency completion includes focused physical assessment; pathway initiation, including administering antipyretics; topical anesthesia; first-aid care; extremity X-ray; and use of resources.

At this point, the learner is able to function independently in the main ED and the front-end assessment area. The learner will continue to work in these two areas for another six months, developing skills and practicing care.

RESUSCITATION ROLES New graduates are invited to attend Phase III orientation resuscitation roles at approximately one year, with completion of pediatric advanced life support. Each will pick up a pre-orientation packet that includes articles for discussion; code medication review and test; a template for letters of peer recommendation, stating readiness to care for critical children; and a template for the new graduate to write an exemplar showcasing the care the nurse has provided to a sick child and how decisions were made to implement care and critical thinking. Each learner must complete the pre-orientation packet one week prior to the orientation in order to attend the class.

The orientation is a two-day interactive course focusing on resuscitation equipment, medications, and skills. Learners are involved in mock scenarios, during which they function in different roles in the code. At the end of the two days, each learner is given the assignment of identifying a piece of high-risk/low-volume equipment to master and review with 20 other nurses in the department.

Evaluation of Phase III includes getting a copy of the competency check-off for each of the four code roles. Learners are responsible for working with the charge nurse to facilitate precepted experiences when opportunities arise. The onus is on the learners to determine when they are competent to perform each role individually. At that time, each learner will ask the preceptor to sign the competency. Time to completion of this phase varies due to resuscitation opportunities, staffing to free additional staff members to have a role in the resuscitation, and the eagerness of the learners to seek out the opportunities.

PRECEPTING Phase IV utilizes new graduates as preceptors for another set of new graduates. They now are Formal Orientation Phase I initial preceptors. This advances the learners' knowledge by teaching others skills, flow, and ED functions. Learners regularly comment on how much they learn while teaching others and having others ask questions. Competency in this phase is evaluated by the new graduate and educator during weekly evaluations of the Phase I nurse.

TRIAGE A triage nurse must be able to quickly sort patients into "sick and in need of care now" or "safe for the waiting room." The role requires the ability to anticipate patient needs, determining in minutes if a child needs immediate care or could deteriorate quickly. To ensure success in this role, the nurse needs ED experiences and must be able to tell patient care stories from the ED. A new graduate requires a minimum of 18 months to acquire these stories.

The nurse is invited to attend triage orientation. Invitations are sent based on charge nurse recommendation. Learners are given articles to read on the triage process. They must successfully complete the Emergency Nursing Pediatric Course and complete a test based on existing ED pathways for high-volume pediatric ED patient populations. Completion of the packet is the ticket into triage interactive didactic class. The course includes several case scenarios and prioritization of patients. Learners like to focus on events and patients they have seen in the ED, which allows for good discussion and problem solving. Following class completion, the nurse is assigned two or three shifts of four hours each with an experienced triage nurse during peak ED visit times. The goal of the precepted experience encompasses completing triage assignment with explanation of decision.

Evaluation includes completing the triage competency and 20 triage documentation examples for the educator, who evaluates the components of documentation and the reliability of the decision in relation to the triage acuity assignment.

MENTORING Of course, the process has not been perfect. Experienced staff needs continual reminders of the new graduates' abilities. Learning is a process, and completion of formal orientation does not make a nurse experienced. It takes time and exposure to recognize sickness, move efficiently, think critically through the flow of the department, and so on.

Millennium-generation learners want to know everything immediately and feel "expert" level should be attained quickly. Educators must provide frequent support throughout the two years, reminding learners of the milestones they have reached, and the knowledge and abilities they have acquired.

Existing staff has had to learn the art of feedback. In the past, the educator was the source of information to new staff. With segmented learning, weekly goal setting, and evaluation—in addition to the needs of the millennium generation—the staff has been expected to provide real-time feedback throughout the two-year fellowship. Teaching positive affirmation came easily to most, but many struggled with crucial conversations. Through individual role-playing and preparation, many existing staff nurses have improved. We still struggle with the occasional "Go tell the educator."

We have hired 26 new graduates in 2½ years. Of those, 22 continue to work in the ED. Four nurses have left the ED: Two were asked to leave during the formal orientation for not meeting key elements of competency, one left to travel, and one transferred to the pediatric intensive care unit.

The success of our new graduate program has caused some growing pains. About 40% of our staff has less than two years' experience. Most are within a phase of orientation. The department must continue to support the senior staff with the struggles and strains of being preceptors and mentors. To overcome this dilemma, we are developing a formal mentorship program. The role of the team leader is the identified solution, currently in pilot phase. The team leader is assigned to the entire team, not to individual patients. Expectations include moving flow and identification of staff within the orientation program (formal orientation through two years), anticipating the need for assistance, being available for questions and help, and seeking opportunities for learning.

It is important to remember and remind staff that this is a two-year program, and it takes budgeted time, money, and patience. The program requires an identified orientation coordinator who can focus solely on the new graduates through all the phases of learning, keep up with feedback and goal setting, and be available for both learners and preceptors when problems and issues arise.

Investing wisely in new graduates yields competent and confident ED nurses. This program can be customized to fit any specialty area in which new graduates are a source of contention.

REFERENCES

1. Beecroft, P. C., Dorey, F., & Wenten, M. (2008). Turnover intention in new graduate nurses: a multivariate analysis. Journal of Advanced Nursing, 62(1), 41-52.

2. Salt, J., Cummings, G. G., & Profetto-McGrath, J. (2008). Increasing retention of new graduate nurses: a systematic review of interventions by healthcare organizations. Journal of Nursing Administration, 38(6), 287-96.

3. Scott, E. S., Engelke, M. K., & Swanson, M. (2008). New graduate nurse transitioning: necessary or nice? Applied Nursing Research, 21(2), 75-83.

4. Benner, P. (1984). From Novice to Expert: Excellence and power in clinical nursing practice. (pp. 13-34). Menlo Park, CA: Addison-Wesley.

5. Locke, E. A. (1991). Goal theory vs. control theory: Contrasting approaches to understanding work motivation. Motivation and Emotion, 15, 9-28.

JENNIFER KINGSNORTH-HINRICHS, RN, MSN, CCRN, is the clinical manager in the emergency department at Children's National Medical Center in Washington, DC.