Developing and evaluating an emergency nursing orientation pathway

Research Developing and evaluating an emergency nursing orientation pathway Authors: Pamela Kidd, RN, PhD, CEN, and Patricia Sturt, RN, MSN, CEN, Lexington, Kentucky

Object ive Orientee evaluat ion forms f requent ly focus on tasks and technical skills ra ther t han decis ion-making skills. An or ientat ion pa thway was developed to evalua te or ientee clinical decis ion-making skills. The p a t h w a y can assist in ident i fying or ientees who require addit ional educat ional resources or in tervent ions . Early in te rvent ions may decrease the l eng th of orientation, increase an employee ' s l ength of s tay in the inst i tut ion, and contr ibute to cost savings.

Methods The p a t h w a y was developed wi th employee exit in te rv iew data, preceptor interviews, identif ication of critical indicators, and the or ientat ion li terature. The p a t h w a y consists of six categories. Indicators wi th in each category were identif ied and ranked according to four levels of proficiency (level 1 for the least proficient and level 4 for the most proficient). A convenience sample of seven ED orientee and preceptor pairs agreed to part icipate in the pilot use of the pa thway. An expected t imeline of progress had b e e n developed by a group of 20 preceptors dur ing a preceptor workshop. An average proficiency level (score) was ob ta ined for each category for 12 weeks wi th the weekly scores plot ted on the pa thway. This level was compared wi th the expected proficiency level in each category for each week. Demographic information was ob ta ined from the or ientee and preceptor pairs to de te rmine whe the r certain characterist ics facilitate p a t h w a y progression. Data were analyzed wi th f requency distr ibutions, and measures of central t e n d e n c y and variance. Spearman ' s rank correlations were used to examine the proficiency level in each category for each week in relat ion to demographic characterist ics of the preceptor and orientee.

Dr. Kidd is an associate professor, College of Nursing, University of Kentucky, Lexington, Kentucky. Ms. Sturt is a staff development specialist, Emergency Department, University Hospital, Lexington, Kentucky. Reprints not available from authors. Copyright �9 1995 by the Emergency Nurses Association. 0099-1767/95 $5.00 + 0 18/1/67680

Resul t s Orientees progressed faster than expected in all categories. It took 8 weeks for an or ientee to a t ta in the h ighes t proficiency level in all categories. The fas tes t progress was made in the category "Accurately Evaluates Pat ient Responses ." Slowest progress was made in the category "Safety in Blood and Drug Adminis t ra t ion." Preceptors and orientees ra ted the pa t hw a y as very useful.

D i s c u s s i o n Further s tudies wi th the orientat ion pa t hw a y may help to de te rmine the ideal t ime frame for orientation, characterist ics of or ientees who progress as expected or faster, and educat ional s t ra tegies to facilitate or ientee progress ion and clinical decision making. (J EMERG NURS 1995;21:521-30.)

I n the winter of 1992, the Nurs ing Research and Staff Development (NRSD) Depar tmen t of Univer-

sity Hospital, a 400-bed facility in Lexington, Ken- tucky, evaluated the critical care or ientat ion program. At Universi ty Hospital, the emergency depa r tmen t is cons idered a critical care unit . This s tudy was p rompted by preceptor complaints tha t exis t ing orien tee evaluat ion forms focused on task complet ion and did not "cap ture" the complexity of clinical deci- s ion -mak ing skills essent ia l to successful performance in critical care units . This s tudy also was prompted by the recen t imp lemen ta t ion wi th in the hospital of the use of critical pa thways for the purpose of case man- agement . A greater emphas i s was be i ng placed on cost sav ings per d e p a r t m e n t and the NRSD depart- m e n t was exploring s t ra tegies for p romot ing cost savings in or ientat ion of nu r s i ng personnel . In addition, n e w gradua tes were b e i n g hired for the first t ime in the e me r ge nc y depar tment , and the staff bel ieved that the exis t ing or ientat ion program migh t be inadequa te in m e e t i n g the ne e ds of n e w graduates .

The NRSD Depa r tmen t dec ided to develop a critical pa thway for critical care orientation. The use of a critical pa thway e n h a n c e s evaluat ion of orientee de-

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c i s i o n - m a k i n g ski l ls for t h e p u r p o s e of i d e n t i f y i n g ori-

e n t e e s w h o r e q u i r e a d d i t i o n a l e d u c a t i o n a l i n t e r v e n -

t i o n s ea r ly in t h e i r o r i e n t a t i o n . Ea r ly i n t e r v e n t i o n m a y

u l t i m a t e l y i n c r e a s e e m p l o y e e s ' l e n g t h of s t a y w i t h i n

t h e i n s t i t u t i o n a n d c o n t r i b u t e to c o s t s a v i n g s . T h i s

a r t i c l e d e s c r i b e s t h e ea r ly d e v e l o p m e n t a n d e v a l u a -

t i o n of a c r i t i c a l p a t h w a y for c r i t i c a l c a r e o r i e n t a t i o n .

Project background A t a s k fo rce c o n s i s t i n g of NRSD p e r s o n n e l , a n u r s e

r e c r u i t e r , c r i t i c a l c a r e m a n a g e r s , a n d t h r e e n u r s i n g

f a c u l t y m e m b e r s w i t h c o l l a b o r a t i v e a p p o i n t m e n t s a t

U n i v e r s i t y H o s p i t a l w a s f o r m e d to d i s c u s s o r i e n t a t i o n

i s s u e s . T h e g r o u p s t u d i e d d a t a f r o m ex i t i n t e r v i e w s of

E D / I C U n u r s e s w h o lef t t h e fac i l i ty w i t h i n 2 y e a r s of

e m p l o y m e n t . T h e p u r p o s e of t h i s s t u d y w a s to s e a r c h

for p a t t e r n s r e l a t i n g to n u r s e s ' p e r c e p t i o n s of job ex-

p e c t a t i o n s a n d t h e w o r k e n v i r o n m e n t . S i m u l t a n e o u s l y ,

i n f o r m a l i n t e r v i e w s w e r e c o n d u c t e d w i t h p r e c e p t o r s

for s o m e of t h e s e d e p a r t i n g n u r s e s . C o n t e n t a n a l y s i s

of t h e s e d a t a r e v e a l e d t h a t b o t h n u r s e a n d p r e c e p t o r

r e c o g n i z e d ear ly i n e m p l o y m e n t or o r i e n t a t i o n t h a t

t h e r e w e r e p r o b l e m s i n j ob p e r f o r m a n c e . T h e e x i s t i n g

o r i e n t e e e v a l u a t i o n f o r m r e q u i r e d t h e p r e c e p t o r to

m a k e j u d g m e n t s r e g a r d i n g t h e o r i e n t e e ' s c o m p e t e n c e

in p e r f o r m i n g skills. H o w e v e r , p r o b l e m s i n job pe r fo r -

m a n c e w e r e f r e q u e n t l y r e l a t e d to t h e n u r s e ' s ab i l i t y to

so lve p r o b l e m s a n d n o t i n p s y c h o m o t o r skill pe r fo r -

m a n c e . T h e t a s k fo rce p l a n n e d t w o s e p a r a t e p r e c e p -

to r w o r k s h o p s d e s i g n e d to s h a r e c l in ica l t e a c h i n g

Table 1 R a t i n g of cr i t i ca l i n d i c a t o r s P l e a s e c i rc l e t h e n u m b e r f r o m 1 to 4 for e a c h i n d i c a t o r t h a t b e s t r e f l e c t s i ts u s e f u l n e s s . R a n k o r d e r of e a c h i n d i c a t o r w i t h #1 b e i n g h i g h e s t p r i o r i t y as a n ind ica tor . Do n o t g i v e t h e s a m e n u m b e r to t w o i n d i c a t o r s .

N e e d s m a j o r M e a n i n g f u l b u t r e v i s i o n n e e d s m i n o r

N o t a to b e a r e v i s i o n V e r y m e a n i n g f u l m e a n i n g f u l to b e a n m e a n i n g f u l

i n d i c a t o r i n d i c a t o r i n d i c a t o r i n d i c a t o r Cr i t i ca l i n d i c a t o r R a n k 1 2 3 4

1. Fail cardiac, respiratory, 1 2 3 4 and neurologic critical care tests

2. Relience on preceptor for 1 2 3 4 basic nurs ing skills

3. Reliance on preceptor for 1 2 3 4 critical care nurs ing skills

4. Poor a t t endance 1 2 3 4 5. High p recep tee s t ress 1 2 3 4

level * 6. Poor t rans i t ion from tasks 1 2 3 4

to whole picture * 7. Orientee-preceptor com- 1 2 3 4

munica t ien problem 8. Compromised or ientat ion 1 2 3 4 9. Orientee has a b a d atti- 1 2 3 4

rude * 10. Inability to prioritize 1 2 3 4 "11. Poor recall of previous 1 2 3 4

learning * 12. Cannot convey rat ionale 1 2 3 4

for act ions "13. Inability to tie in assess- 1 2 3 4

merit da ta w i th other da ta

* 14. Inability to perform tasks 1 2 3 4 wi thou t ass i s tance

"15. Does not recognize nor- 1 2 3 4 rnal values

"16. Requires multiple demon- 1 2 3 4 s t ra t ions

*Indicate i tems wi th 90% or grea ter ag reemen t as a very meaningful indicator.

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strategies and to discuss creation of a learning envi- ronment.

I d e n t i f i c a t i o n o f c r i t i c a l i n d i c a t o r s

During the first preceptor workshop the preceptors were asked to list critical indicators that reflected an orientee "in trouble." To initiate discussion, the workshop faculty used a handout with critical indicators identified in the content analysis of the interview data and by the task force based on experience working with orientees and a literature review.

For each of the 16 critical indicators identified (Table 1), 30 preceptors rated the indicator on a 4-point Likert scale ranging from not a meaningful indicator (1) to very meaningful indicator (4). A content validity index was calculated for each i tem) Items with ->90% agreement as a very meaningful indicator (N-- 9) were retained.

D e v e l o p m e n t o f t h e c r i t i c a l p a t h w a y

We reviewed the literature a second time to study the consistency between the preceptor-identified indicators a n d those in the literature related to critical thinking and clinical decision making. The next step was to identify skill categories considered essential to critical care nursing practice. Categories were selected on the basis of Benner's findings, 2 as well as the themes identified in the content analysis of the interview data. The following categories were used: (1) Safety in Blood and Drug dministration, (2) Safe Equipment Usage, (3) Technical Skills/Safe Perfor- mance of Procedures, (4) Establishes Care Priorities (requires managing multiple demands simultaneous- ly), (5) Clinical Decision Making (developing an appropriate plan of care), and (6) Accurately Evaluates Patient Responses (examining patient outcomes, rec- ognizing the need for adapting the plan of care). Ben- ner 's model was selected because of its emphasis on the acquisition of clinical knowledge and the belief that this knowledge involves cognitive as well as psy- chomotor skills. Four proficiency levels were developed for each category (Table 2). 3 Indicators within each category were identified with data obtamed in the first preceptor workshop (Table 3). These indicators were ranked according to the four levels of proficiency with level I being the least proficient. The critical indicators served as recognizable cues for preceptors.

During a second workshop, 20 preceptors were asked to plot a typical orientee's progress in each category during a 12-week period (length of ED orientation). The purpose of plotting progress was twofold: (1) to make explicit preceptor expectations of the orientee based on their own experience as serving as a preceptor; and (2) to identify an expected timeline of

progress. Nurse managers recommended these preceptors attend the workshop because they had served as preceptors numerous times and were considered clinical experts by their department. This panel of experts decided when the transitions among the four proficiency levels usually occurred in each category. The most frequently selected transition point (week of orientation) between each proficiency level was selected as the norm to which orientees would be compared.

Testing the pathway The next step was to test the projected pathway for its degree of fit with actual orientee performance in an orientation group of seven new graduates. A study was conducted to determine the following: �9 The appropriate length (defined as how much time

was required to achieve level 4 proficiency in each category) of ED orientation to assume a staff nurse role.

�9 Comparison of the average length of time required to reach the highest proficiency level in each category with the expected length of time (as identified

Table 2 P r o f i c i e n c y l e v e l s

1. R e v i e w s pr inc ip les �9 S e e k s descr ipt ive i n f o r m a t i o n �9 R e v i e w s descr ip t ive in format ion �9 O b s e r v e s o th ers �9 E v a l u a t e s o w n u n d e r s t a n d i n g of t h e informa-

tion, a s k s q u e s t i o n s

2. Descr ibes skil l c o m p o n e n t s �9 F o c u s e s o n in format ion n e e d e d for self-perfor-

m a n c e �9 S tudies in format ion in d e p t h �9 D i s c u s s e s p e r f o r m a n c e s tep-by-s tep , descr ibes

o r g a n i z a t i o n of r e s o u r c e s �9 E v a l u a t e s r e a d i n e s s to p er fo rm

3. Performs w i t h a s s i s t a n c e �9 Ident i f ies p a t i e n t n e e d s �9 Plans p e r f o r m a n c e a c c o r d i n g to pol icy �9 Performs w i t h v a ry in g e f f ic iency levels , n e e d s

a s s i s t a n c e t r o u b l e s h o o t i n g �9 E v a l u a t e s o w n p e r f o r m a n c e and pat ient ' s

shor t - t erm o u t c o m e s �9 N e e d s he lp ident i fy ing p r o b l e m s

4. Performs i n d e p e n d e n t l y �9 Ident i f ies p a t i e n t n e e d s o n case specif ic bas i s �9 Modif ies p e r f o r m a n c e b a s e d on p a t i en t n e e d s �9 Performs smooth ly , ant i c ipa t ion of p r o b l e m s is

rout ine �9 E v a l u a t e s o w n p e r f o r m a n c e w i t h o u t he lp �9 E v a l u a t e s pat ient ' s long- a n d short - t erm out-

comes

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by the panel of expert preceptors in the second workshop).

a Identification of areas in which orientees require greater resources to mee t expec ted proficiency levels.

�9 Identification of profiles or characteris t ics of successful orientees. Successful orientees were defined as those individuals who progress along the pathway in the manner descr ibed by the panel of expert preceptors.

Table 3 Sample categories w i t h indicators

Week

Date: 1 2 3 4 5 6 7 8 9 10

Category 5: Accurately Evaluates Patient Responses 1. Recognizes abnor- 3 3

m e / f i n d i n g s 2. Val idates p r e s e n c e 2 3

of abno rma l findings (i.e., checks equ ipmen t , as- s e s s e s pat ient)

3. Acts appropr ia te ly 3 3 for abno rma l findings (i.e., adminis- t e r s t r ea tmen t , con- t ac t s physician)

4. Moni tors pa t i en t for 3 3 r e s p o n s e to t reat- m e n t

5. D o c u m e n t s re- 2 3 s p o n s e appropri- ately

6. C o m m u n i c a t e s re- 2 3 s p o n s e verbally to phys ic ian or o ther s taff

Average: 2.5 3

Category 6: Clinical Decis ion Making 1. Identif ies abno rm a l 2 2

da ta and pe r t i nen t nega t ive f indings

2. Links f i nd ings in a 2 2

mean ingfu l p a t t e r n 3. Cons iders poss ib le 2 2

c a u s e s of abno r m a l da t a /nega t i ve findings

4. Selects p robab le 1 2 cause of abno rma l da t a /nega t i ve findings and t e s t s for its p r e sence

5. A d a p t s nu r s ing 2 2 care to fit p robab le cause of pa t i en t ' s r e s p o n s e

6. Ant ic ipa tes pa- 2 2 t i en t ' s fu ture re- s p o n s e s to t reat- m e n t

Average: 1.8 2

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�9 Determination of the benefits of an orientation pathway in monitoring orientee performance.

The project team sought to systematically evalu- ate the usefulness and feasibility of the pathway. An evaluation framework was selected to ensure that information necessary to conduct the evaluation was collected. 4 This framework includes predisposing and reinforcing factors that may influence success of a project. Predisposing factors in this study included orientee and preceptor characteristics and learning styles. The Learning Style Inventory was used to eval- uate preceptors' learning styles during the workshops. Orientees' learning styles were assessed before the start of orientation with the same instrument. Precep- tor-orientee assignments (seven pairs) were made based on congruency of style whenever possible. A data sheet was developed to collect demographic information. Reinforcing factors were also considered. Reinforcing factors positively support project completion. Reinforcing factors included preceptor and orientee satisfaction with the pathway as a measurement tool. An evaluation form was developed and completed by each preceptor and orientee using the pathway (Table 4).

Sample A convenience sample of seven ED orientee-preceptor pairs agreed to participate in the pilot phase of the pathway. All of the orientees had participated in a 6-week emergency nursing internship program (required of all new graduates employed in the emergency department) consisting of didactic material and clinical experiences in critical care units other than the emergency department.

Procedure A longitudinal descriptive correlational design was used to identify characteristics associated with a change in a study variable. In our situation, we were interested in multiple characteristics of both preceptor and orientee that may be associated with orientee success. A meeting was held with one of the investigators (NRSD personnel), the preceptor, and assigned orientee to explain the purpose and use of the pathway, to complete the demographic form, and to obtain informed consent.

The preceptor completed the pathway weekly by assigning a proficiency level in each category by av- eraging orientee abilities across competencies within the category (see Table 3 for sample scoring). This proficiency level was inserted to represent the orientee 's abilities for each week in each category. In weekly meetings with one of the investigators, the orientee's progress was discussed by preceptor and

orientee. Completion of scoring required 15 minutes each week.

Analysis Data were analyzed by frequency distributions (scat- terplots, quartile ranges), measures of central ten- dency (mode, median), and measures of variation (standard deviation). Spearman's rank correlations were used to examine the proficiency level in each category for each week with demographic characteristics of the preceptor and the orientee (e.g., years of ED experience for the preceptor, prior ED experience as a nursing assistant for the orientee). The average proficiency level was calculated in each category for each week and compared with the expected proficiency level in each category for each week identified by the preceptors who participated in the earlier workshop.

Results Orientee progress It took only 8 weeks for an orientee to attain the highest proficiency level in all categories, compared with the 12-week period traditionally used for ED orientation at our facility and the expected length of time de- rived from the preceptors (Table 5). The fastest progress was made in the category "Accurately Eval- uates Patient Responses" (AEPR) (4 weeks), compared with the slowest progress in the category, "Safety in Blood and Drug Administration" (SBDA), which required 8 weeks. It took an average of 6 weeks to reach level 4 proficiency in "Clinical Decision Mak- ing" (CDM). Orientees progressed faster than expected in all categories.

Orientees with previous ED experience as a nursing assistant progressed faster in the category, "Technical Skills/Safe Performance of Procedures" (TS) (R = 0.50; p -- 0.05), than their counterparts. Ori- entees whose preceptors had ED experience progressed faster in all categories, but only the correlation with the AEPR category was statistically significant (R = 0.50; p--0.05). Orientees who had critical care content in their basic nursing education program progressed the fastest in the CDM category (R = 0.50; p = 0.05). Although correlations were significant and moderately positive, the results must be interpreted cautiously because of the small sample size. Learning style and pathway progression was not correlated.

Preceptor and orientee evaluation o f the pathway Preceptors and orientees rated the pathway for its usefulness (Table 6). Possible scores ranged from 7 to 35, with 35 indicating strong agreement that the pathway was useful. Actual scores ranged from 28 to

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Table 4A P r e c e p t o r d a t a s h e e t

Code #

Thank you for sharing this information. The information will be used to help us design critical care orientation pro-

grams. Please circle the correct response.

I. I have been working in the emergency department for:

1. Less than 1 year

2. 1 to 2 years 3. 3 to 5 years

4. 6 to 10 years

5. Greater than 10 years

2. I have been working in the emergency department at UKIVfC for:

1. Less than 1 year

2. I to 2 years

3. 3 to 5 years

4. 6 to 10 years

5. Greater than 10 years

3. I have served as a preceptor in the emergency department at UKIV[C:

I, This is my first time

2. 2 to 5 times

3, Greater than 5 times

4. I have precepted new graduates in the emergency department:

1. Yes

2. No 5. T h e h i g h e s t e d u c a t i o n p r o g r a m I h a v e c o m p l e t e d is:

1. A s s o c i a t e d e g r e e 2~ Dip loma p r o g r a m 3. B a c c a l a u r e a t e d e g r e e 4. M a s t e r ' s d e g r e e

6. T h e h i g h e s t e d u c a t i o n p r o g r a m I h a v e c o m p l e t e d in n u r s i n g is: 1. A s s o c i a t e d e g r e e 2. B a c c a l a u r e a t e d e g r e e 3. M a s t e r ' s d e g r e e 4. Dip loma

7. I h a v e c o m p l e t e d t h e fo l lowing p r e c e p t o r w o r k s h o p p r o g r a m s (Circle all t h a t apply): 1. P r o g r a m p r o v i d e d by UKMC Staff D e v e l o p m e n t 2. P r o g r a m p r o v i d e d by t h e Un i ve r s i t y of K e n t u c k y Col lege of N u r s i n g 3. P r o g r a m p r o v i d e d o u t s i d e of Un i ve r s i t y of K e n t u c k y 4. No p r e c e p t o r w o r k s h o p p r o g r a m

8. I a m in t h e fo l lowing a g e r ange : 1. 20-25 y e a r s 2. 26-30 y e a r s 3. 31-35 y e a r s 4. 36-40 y e a r s 5. 41-45 y e a r s 6. 46-50 y e a r s 7. Ove r 50 y e a r s

9. I h a v e t h e fo l lowing cer t i f ica t ions a n d ver i f ica t ions (P lease circle all t h a t apply): 1. ACLS 2. TNCC 3. CCRN/CEN 4. ENPC 5. PALS

6. O the r s : P l e a s e spec i fy 10. I a m a t t h e fo l lowing r a n k of t h e UKMC Clinical N u r s i n g Ladder :

1. ADN I 2. ADN II 3. ADN HI 4. BSN I 5. BSN II 6. BSN III 7. MSN I

T h a n k y o u for s h a r i n g t h i s in format ion!

UKIMC, Unive r s i t y of K e n t u c k y Medica l Cen te r ; ACLS, A d v a n c e d Card iac Life Suppor t ; TNCC, T r a u m a N u r s i n g Core C o u r s e CCRN/CEN, crit ical ca re r e g i s t e r e d nu r se ; cer t i f ied e m e r g e n c y nu r se ; ENPC, E m e r g e n c y N u r s e Pedia t r ic Course ; PALS, Pedia t r ic A d v a n c e d Life Suppor t .

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35, indicating strong agreement about the usefulness of the pathway.

Discussion Because the orientees in this s tudy participated in a 6-week emergency nursing internship program and they progressed faster than anticipated, more data

s h o u l d b e c o l l e c t e d to a s s e s s t h e f e a s i b i l i t y of d e -

c r e a s i n g t h e l e n g t h of o r i e n t a t i o n . O r i e n t e e s w h o pa r -

t i c i p a t e d in t h e i n t e r n s h i p b e f o r e t h e p a t h w a y w a s

u s e d c o m p l e t e d a 1 2 - w e e k o r i e n t a t i o n a c c o r d i n g to

p ro toco l . T h e p a t h w a y p r o v i d e s o n e t a n g i b l e m e t h o d

of m e a s u r i n g t h e w o r t h of t h e e m e r g e n c y n u r s i n g in-

t e r n s h i p p r o g r a m b e c a u s e t h e l e n g t h of o r i e n t a t i o n for

Table 413 O r i e n t e e da ta s h e e t

Code # Thank you for shar ing this information. The information will be u s e d to help us des ign Critical Care orientat ion pro-

g rams . Please circle the correct response. 1. I have previous critical care experience in the following posi t ions (Circle all t ha t apply):

1. Nurs ing a s s i s t an t 2. Nurse apprent ice 3. LPN 4. RN 5. Other (please specify)

2. I have had previous nu r s ing experience outs ide of critical care in the following posi t ions (Circle all t ha t apply):

1. Nurs ing a s s i s t a n t 2. Nurse apprent ice 3. LPN 4. RN

3. I have b een an RN for: 1, Less t h a n 1 year 2. 2 to 5 years 3. 6 to 10 years 4. Over 10 years 5. I a m a n R N A

4. The h ighes t degree I have in nurs ing is: 1. Associa te 2. Diploma 3. Baccalaureate 4. Mas te r ' s

5. The critical care componen t of my basic nurs ing educat ion p rogram cons is ted of: 1. Observat ional exper ience only 2. Classroom and clinical exper ience 3. Separate nu r s ing course 4. No critical care exposure

6. I have accepted a critical care position at UKMC in: 1. SICU 2. MICU 3. CTICU 4. CCU 5. Neuroscience ICU 6. Burn uni t 7. Emergency d e p a r t m e n t 8. General su rge ry ICU

7. The main reason I se lec ted a critical care posit ion is: 1. Smaller nurse~patient ratio 2. Pat ient complexity 3. I a lready k n e w someone in the unit 4. Exci tement 5. Prest ige assoc ia ted wi th the role 6. Served as a s t u d e n t nu r se apprent ice 7. Other (please specify)

Thank you for shar ing this information!

LPN, Licensed practical nurse; RN, regis tered nurse; RNA, Regis tered Nurse Applicant; UKMC, University of Kentucky Medical Center; SICU, surgical in tens ive care unit; MICU, medical in tensive care unit; CTICU, cardiothoracic in tens ive care unit; CCU, cor- onary care unit.

December 1995 5 2 7

OURNAL OF E M E R G E N C Y NURSING/Kidd and Sturt

Table 5 E x p e c t e d v e r s u s ac tua l o r i e n t e e p r o g r e s s

Name

Preceptors: Fill in proficiency level Orientation week WK 1 WK 2 Expected Safety in Level 1 Level 1

Drug/Blood Ad- ministration

Actual Level 2 Level 3

Expected Technical Level 1 Level 1 Skills/Safe Performance of Procedures


Expected Safe Level 1 Level 2 Equipment Usage


Expected Accurately Level 1 Level 1 Evaluates Patient Responses


Expected Clinical Level 1 Level 1 Decision Making


Expected Establishes Level 1 Level 1 Care Priorities


WK 3 WK 4 WK 5 WK 6 Level 2 Level 2 Level 3 Level 3

Level 3 Level 3 Level 3 Level 3











those not par t ic ipa t ing in the in ternship can now be

c o m p a r e d wi th the 8 w e e k s n e e d e d for those in this

study.

Prior ED expe r i ence for both the a s s igned pre-

cep tor and the or ien tee w a s assoc ia ted wi th faster

p rogress ion th rough the prof ic iency levels. A l though

further t e s t i ng of the p a t h w a y is needed , m a n a g e r s

may wish to hire n e w g radua te s wi th prior ED nurs-

ing ass i s tan t expe r i ence w h e n n e w gradua tes are

h i red for the e m e r g e n c y depar tment . These f indings

suppor t the n e e d to re ta in expe r i enced ED nurses to

serve as preceptors .

Because nurses wi th crit ical care con ten t in their

bas ic nur s ing p rogram performed at h igher profi-

c i ency levels in the CDM category earlier than their

cohorts, pe rhaps m a n a g e r s should assess the bas ic

nurs ing educa t ion p rogram of any n e w gradua te be-

fore hi r ing for the incorporat ion of cri t ical care con ten t

and clinical exper ience . More s tudies are n e e d e d wi th

larger sample sizes to confirm this conclusion.

Because no or ien tee mas t e r ed the h ighes t profi-

c i ency level in any ca tegory before 4 weeks but all ori-

e n t e e s a t t a ined the h i g h e s t prof ic iency levels by 8

weeks , the ideal or ienta t ion per iod m a y be 8 weeks .

In our e x p e r i e n c e the l eng th of or ientat ion for orien ~

t ees other than n e w g radua te s varies wi th the a m o u n t

of ED exper ience. Since the initial evaluat ion the path-

way has b e e n used wi th 13 regis tered nurses who

were not new graduates. On the basis of these data, the

average length of orientat ion is 5 weeks for regis tered

nurses wi th ED exper ience and 7 weeks for regis tered

nurses wi thout previous ED experience. As more

s tudies are conduc ted wi th larger sample sizes us ing

the pathway, the traditional 12-week length of orienta-

t ion may be reduced wi thout compromis ing the out-

comes.

Individuals wi th a var ie ty of learning styles may

thrive in the e m e r g e n c y depar tment . The mos t im-

por tant factor may be the p recep to r ' s awareness of the

o r i en tee ' s learning style so tha t the preceptor can ad-

just t e a c h i n g m e thods to the or ien tee ' s needs . Al-

t hough learning style was not correlated wi th orien-

tees ' p rogress in our initial evaluat ion of the pa thway,

a s s e s s m e n t of learning style is still warranted.

Some preceptors no ted tha t or ientees may be at

a cer ta in prof ic iency level w h e n working wi th pa-

t ients wi th u rgen t and nonurgen t problems but func-

t ion at a lower prof ic iency level in e m e r g e n t si tua-

tions, particularly in the ca tegor ies of CDM and

e s t ab l i shmen t of care priorities. This feedback was

obta ined dur ing the weekly m e e t i n g s of the preceptor ,

or ientee, and staff d e v e l o p m e n t specialist . Future re-

search is war ran ted to d e t e r m i n e w he the r separa te

scor ing should be per formed based on pa t ien t sub-

group and progress scores de r ived through a w e i g h t e d

formula.

5 2 8 Volume 21, Number 6

Kidd a n d Sturt/JOURNAL OF E M E R G E N C Y NURSING

Table 5 Continued

Unit

WK 7 WK 8 WK 9 WK 10 WK 11 WK 12 Level 3 Level 3 Level 4 Level 4 Level 4 Level 4

Level 3 Level 4 Level 4 Level 4 Level 4 Level 4











Table 6 Results of critical p a t h w a y evaluation form

5 4 3 2 1 Strongly Strongly

agree Agree Neutral Disagree disagree (%) (%) (%) (%) (%)

1. The or ienta t ion p a t h w a y evaluat ion form w a s 50 33 16 helpful in m e a s u r i n g o r i en tee ' s p rogress .

2. The or ienta t ion p a t h w a y he lped me to a s s e s s in 15 33 - - w h a t a reas the or ientee n e e d e d the g r ea t e s t as- s i s tance .

3. The or ienta t ion p a t h w a y w a s ea sy to under- 66 33 - - s tand .

4. The or ienta t ion p a t h w a y m e a s u r e d the a reas 33 66 - - impor t an t in critical care nurs ing .

5. The or ienta t ion p a t h w a y w a s too t ime consum- - - 16 ing.

6. The or ienta t ion p a t h w a y wou ld help to identify 16 83 - - o r ien tees unab le to f u n c t i o n as a r eg i s t e red n u r s e in the unit.

7. The or ienta t ion p a t h w a y w o u l d help m e to ob- 33 66 - - t&in r e sou rces to facilitate the or ien tees ' p rogress .

- - i

33 50

R e v i s e d p a t h w a y

B a s e d o n u s e r c o m m e n t s o n t h e e v a l u a t i o n fo rm, p r o -

f i c i e n c y leve l 3 ( p e r f o r m s w i t h a s s i s t a n c e ) w a s s u b d i -

v i d e d i n t o p e r f o r m s w i t h a s s i s t a n c e ( level 3) a n d p e r -

f o r m s w i t h m i n i m a l a s s i s t a n c e ( level 4). P e r f o r m s in -

d e p e n d e n t l y b e c a m e p r o f i c i e n c y l eve l 5. P r e c e p t o r s

r e q u e s t e d t h a t t h e S D B A c a t e g o r y b e d i v i d e d i n t o t w o

c a t e g o r i e s , " S a f e t y i n D r u g A d m i n i s t r a t i o n " a n d

December 1995 5 2 9

JOURNAL OF EMERGENCY NURSING/Kidd and Sturt

"Safe ty in Blood Admin i s t r a t i on . " Or ien tees pro- g r e s s e d faster in d rug admin i s t r a t i on as a resul t of thei r c l inical expe r i ences .

Our future r e s e a r c h w i th t he p a t h w a y involves d e t e r m i n i n g the e x t e n t to w h i c h dev ia t ion from the p ro j ec t ed p a t h i n d i c a t e s an o r i en tee p rob lem in as- s u m i n g role respons ib i l i t i es . The s a m e p r ecep to r s who a s s i s t e d in the d e v e l o p m e n t of the p a t h w a y have de r i ved a list of i n t e rven t ions for e a c h ca tegory . As an in t e rven t ion is pe r fo rmed to re turn o r i en tees to the p ro j ec t ed pa th , w e are ca lcu la t ing the t ime n e e d e d for t h e m to re turn to t he p a t h to d e t e r m i n e w h e t h e r th is in terva l is fas ter t h a n t ha t e x p e c t e d if an in te rven t ion h a d no t b e e n per formed. T h e s e d a t a will help ident i fy o r i en tees w h o m a y not b e able to ass imi la te t he ED nu r s i ng role early in t he or ien ta t ion p roces s so tha t ca ree r counse l ing can be provided . The informat ion will also help us just ify e d u c a t i o n a l in t e rven t ions from a cos t pe r spec t ive .

Surm'na~ A n or ien ta t ion p a t h w a y w a s d e v e l o p e d u s i n g pr inci - p les of c a se m a n a g e m e n t by p r ecep to r s who iden t i - f ied cr i t ical i nd ica to r s of role pe r fo rmance in the e m e r g e n c y d e p a r t m e n t . T h e s e ind ica tors were orga- n i zed into ca t ego r i e s b a s e d on Benner ' s theory of c l inical k n o w l e d g e deve lopmen t . Four p rof ic iency levels were d e v e l o p e d for e a c h ca tegory . A s e c o n d

pane l of expe r t p r e c e p to r s d e c i d e d w h e r e t he t ransi- t ions in four p rof ic iency levels occu r red dur ing a 12- w e e k or ien ta t ion period. The p rogress in or ien ta t ion of s even n e w g r a d u a t e s w a s c o m p a r e d wi th the ex- p e c t e d t rans i t ions iden t i f i ed by the expe r t p recep tors . All o r i en t ees p r o g r e s s e d faster in e a c h ca t ego ry t han e x p e c t e d by the p recep to r s . More s tud ie s w i th the p a t h w a y are w a r r a n t e d to d e t e r m i n e w h e t h e r the l eng th of or ien ta t ion m a y be r e d u c e d wi thou t com- p r o m i s i n g ou tcomes .

We thank Linda Holtzclaw, RN, MSN, for her support in im- plementing the pathway in the emergency department. We also thank Linda Holtzclaw, Deborah Hall, Karen Hall, Karen Johnson, Kathy Wagner, Suzanne Springate, and Carol Dickey as task force members.

References

1. Lynn M. Determination and quantification of content validity. Nurs Res 1986;35:382-5. 2. Benner P. Excellence and power in clinical decision making. Menlo Park, California: Addison-Wesley, 1984. 3. Cash N, Staul L. Four proficiency levels for critical care skills certification. Crit Care Nurse 1992;12:40-2. 4. Green L, Lewis F. Measurement and evaluation in health care research. Palo Alto, California: Mayfield Publishing, 1986. 5. Kolb DA. Learning style inventory. Boston: McBer and Company, 1985.

CORRECTION

An error appeared in the August article, "Rapid Sequence Induction in the Emergency Department" (J EMERG NURS 1995;21:305-9). The mistake appears on page 308 in Table 4 under the fifth bullet, in the "Comments" related to the muscle relaxant pancuroninm. The words "increased carbon monoxide" should read "increased cardiac output."

530 Volume 21, Number 6

Developing and evaluating an emergency nursing orientation pathway

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