Orientation to Emergency Nursing: Perceptions of New Graduate Nurses

ORIENTATION TO EMERGENCY NURSING:PERCEPTIONS OF NEW GRADUATE NURSES

Authors: Barbara Patterson, PhD, RN, Elizabeth W. Bayley, PhD, RN, Krista Burnell, BSN, RN, andJan Rhoads, MSN, RN, CEN, Chester, Upland, and Reading, PA

Introduction: Emergency nursing is one of the mostchallenging and understaffed areas of professional nursing.Currently, little is known about how new graduate nursesperceive their experiences as novice emergency nurses. Thepurpose of this study was to gain an understanding of how newgraduate nurses who are oriented to emergency nursing as theirfirst professional area of nursing employment perceive theorientation program and emergency nursing at the beginning andend of a 6-month program.

Method: This descriptive study incorporated qualitative andquantitative methods consisting of interviews and a survey.Study participants included 15 women and 3 men. Their mean agewas 32 years. All were employed full time in their first position asa graduate nurse. They were asked their perceptions of theprogram at 3 and 6 months.

Results: Participants shared their perceptions of why they had beenattracted to the program, characteristics of the emergency departmentand emergency nursing, being in a new job and role, reflections ontheir performance, the classroom and clinical components of theprogram, and their recommendations for future orientation programs.Results of the quantitative survey on participants’ perceptions of theirfirst job as a registered nurse indicated that they found the work of theorientation program to be stressful.

Discussion: Understanding the experience of new graduatenurses to the emergency setting provides crucial information fororientation program design. Incorporating active teaching andsocialization strategies early in the program may facilitate thetransition from novice to beginning competent emergency nurse.

Key words: Orientation program; Emergency nursing; Graduatenurse; Evaluation research

The depth and breadth of knowledge and skill re-quired to work in an emergency department, aswell as the rapid pace of the clinical setting, often

overwhelm novice nurses.1 Unrealistic expectations, highanxiety levels, and decreased self-esteem commonly causeinexperienced nurses to question the wisdom of their ca-reer choice. The multifaceted and dynamic environmentof emergency care may be positive factors when attractinggraduate nurses (GNs) to an ED setting. Nevertheless,the complexity of care, high patient acuity, expectationsof experienced staff, limited clinical supervision, and fre-quent stressful experiences all have been reported to in-fluence nurse turnover.2,3 When GNs are recruited forED positions, costly orientation programs and high attri-tion rates can decrease department productivity for monthsat a time.

Prior studies1,4-6 have yielded no data about new GNs’perceptions of their ED orientation program or about theexperience of being new to emergency nursing. As therecipient of a Pennsylvania state grant for incumbentworker training, Crozer Keystone Health System (CKHS)was well positioned to fill this nursing practice and edu-cation knowledge gap. New GNs were enrolled in a6-month comprehensive orientation and education pro-gram, known as the Emergency Department FellowshipProgram (EDFP), to prepare them to function as staff

Barbara Patterson is Professor, Widener University School of Nursing,Chester, PA.

Elizabeth W. Bayley,Member, Delaware County Chapter, is Professor Emerita,Widener University School of Nursing, Chester, PA, and Director, NursingResearch, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.

Krista Burnell is Nurse Manager, Crozer Chester Medical Center, Upland, PA.

Jan Rhoads, Member, Berks Chapter, is Clinical Educator, The Reading Hos-pital and Medical Center, Reading, PA.

This study was partially supported by an Incumbent Worker Training Pro-gram grant to Crozer Keystone Health System by the Commonwealth ofPennsylvania Department of Labor and Industry.

Elizabeth W. Bayley, PhD, RN, received a consultation fee from CrozerKeystone Health System for her work in developing the evaluation studyon which this manuscript is based. Jan Rhoads, MSN, RN, CEN, and KristaBurnell, BSN, RN, were employees of Crozer Keystone Health System dur-ing the implementation and evaluation of the orientation program describedin the article.

For correspondence, write: Barbara Patterson, PhD, RN, Widener Univer-sity, One University Place, Chester, PA 19013; E-mail: [email protected].

J Emerg Nurs 2010;36:203-11.

Available online 31 August 2009.

0099-1767/$36.00

Copyright © 2010 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.

doi: 10.1016/j.jen.2009.07.006

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nurses in one of 4 health system emergency departments.We investigated how these GNs, in their first professionalnursing roles, perceived both their orientation program andemergency nursing in general.

This study addressed the question: What are graduatenurses’ perceptions of their orientation program and emer-gency nursing during both the early months of trainingand at the end of a 6-month comprehensive, structuredorientation program?

Description of the ED Fellowship Program

CKHS employees enrolled in a generic nursing programwere invited to apply for the EDFP a few months priorto graduation. Criteria for application included: a cumula-tive grade point average of 3.0 or higher; positive recom-mendations from a nurse manager and 2 nursing facultymembers; an interview with a CKHS clinical educator,nurse manager, and emergency staff nurse; a 200-wordessay describing the applicant’s reasons for choosing emer-gency nursing; evidence of nursing leadership activities inschool; and previous related health care work experience.

Twenty candidates were selected for the fellowshipprogram, and each signed a 2-year contract to work in aCKHS emergency department. Two participants in theEDFP came to the program with a history of previousnursing employment and therefore were excluded fromdata collection. All fellows were given 2 emergency nursingtextbooks, a critical care textbook, an electrocardiogramworkbook, and a personal digital assistant (PDA) loadedwith pharmacologic, diagnostic, signs and symptoms, nurs-ing procedures, emergency, and critical care software. Eachfellow also was enrolled in the American Association ofCritical Care Nurses Essentials of Critical Care Orientation(ECCO) course, a computer-assisted instructional program.

This 2006 class was the first EDFP offered. An ED nursemanager worked with the EDFP program coordinator and theED clinical instructor to plan and develop the fellowship ex-perience. The program coordinator and clinical instructorboth were dedicated to the EDFP for the 6-month courseduration. The instructor functioned primarily as a classroomteacher, assisting the coordinator with didactic componentsand supervising fellows in the largest of the 4 emergency de-partments. Clinical instructors at 2 of the facilities providedsupervision and served as primary resources for clinical prac-tica in their own departments. All ED staff members werebriefed on the program and its goals. Volunteers were soli-cited to serve as preceptors. Preceptors were selected basedon their willingness to work with new nurses, and prefer-ence was given to those who had completed the hospital’spreceptor course. Preceptors were kept abreast of fellowship

goals and their preceptee’s progress. Halfway through theprogram, the largest of the 4 health system EDs movedto a new facility. The disruption caused by the move pre-cluded assigning individual staff nurse preceptors to theGNs in this particular department.

A few ED clinical days were scheduled at the begin-ning of the program, but the majority of clinical time wasreserved for the last 3 months. Fellows spent 5 days in eachof the following areas: a medical surgical unit, an ICU, anda telemetry floor. Fellows were assigned 2 days in the laborand delivery, pediatric, and trauma units, and 1 day in boththe burn center and the psychiatric crisis unit. The remain-ing clinical days were dedicated to the emergency depart-ment of the fellow’s assigned hospital.

Physicians, nurse educators, and guest experts con-ducted classes organized by body system or diagnosis. Othercontent included the structure of emergency care, emer-gency medical services systems, legal issues, professional im-age concerns, palliative care, quality improvement, domesticand workplace violence, forensics, professional ethics, stan-dards and practice models, leadership, and evidence-basedcare. Emergency nursing skills were incorporated into theprogram with demonstrations and hands-on workshops.Most classes were offered at the largest of the 4 health sys-tem hospitals. All sessions were conducted during daytimehours for the first 3 months of the program. Successful com-pletion of the EDFP was determined by passing grades onmultiple written tests, completion of a competency check-list, satisfactory levels of clinical performance (as documentedby the clinical instructor), and an acceptable attendance andcourse participation record.

SAMPLE CHARACTERISTICS

The 15 women and 3 men in this study were employed fulltime for rotating shifts in their first professional nursingposition. They worked mostly 8-hour days during the pro-gram, with occasional 10-and 12-hour shifts. All partici-pants expected to work in the emergency department at aCKHS hospital upon program graduation. Fellows’ agesranged from 23 to 47 years (M = 32.28; SD = 7.56),and each had worked as an unlicensed GN for 1 to4 months prior to enrolling in the EDFP. Fifteen indi-viduals had 2 months to 25 years (M(years) = 5.15; SD =6.72) of prior full-time work experience in health care,with a median of 3 years. Twelve participants had workedpart time in health care for durations ranging from 6 monthsto 10 years (M(years) = 2.73; SD = 2.49). Seven partici-pants were employed as ED technicians prior to nursingschool graduation. Only 7 fellows had baccalaureate de-grees in nursing; the remainder were prepared at an associ-ate degree level.

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204 JOURNAL OF EMERGENCY NURSING VOLUME 36 • ISSUE 3 May 2010

Design and Methods

This descriptive study used both qualitative and quanti-tative methods consisting of semi-structured interviewsand a participant survey. After approval by the hospi-tal’s institutional review board, the program coordinatorscheduled fellows to meet individually with a qualitativenurse researcher. Participants who provided voluntarywritten consent were asked to complete a brief demo-graphic form.

Early in the third month of the EDFP, and again atthe end of the program, each fellow took part in a private1-hour interview. A single investigator conducted all of theinterviews using a semi-structured interview guide. The fel-lows were asked to describe their experience in the programat 3 months and again at 6 months. A comparison of theseperceptions was conducted across fellows. Additional inter-view questions focused on participants’ concerns as a newgraduate, perceptions of being an emergency nurse, strengthsand limitations of the EDFP, and recommendations forfuture programs. Interviews were audio taped and tran-scribed. No labels linked participants to their demographicdata. The EDFP program coordinator and clinical instruc-tor were not present during study enrollment or data col-lection and had no data access until analysis was complete.This process was done to facilitate frank responses andto ensure that fellows were not pressured to participatein the study.

Qualitative data analysis, using NVivo 7, was ongo-ing with data collection. The steps for content analysis7

of interview data included: reading and re-reading thetranscripts; extracting significant statements and pertinentphrases; and organizing statements into clusters. Withinand cross-case analyses were performed to compare re-sponses between the first and second interviews.8 Vali-dation of findings abstracted from the data occurredthrough constant comparison with the transcript anddiscussion among the research investigators. Additionally,participants were contacted by email and asked to vali-date the findings. An audit trail was established to ensuredata integrity.

During the final week of the program, a researcheradministered a 49-item survey adapted from Bowles andCandela’s Survey of Nurses’ Perception of First Job Experi-ence.9 This tool has been shown to be valid and reliable.9

Fourteen participants completed the tool in a classroomsetting; 4 returned the survey by mail. Additional itemswere constructed to evaluate specific elements of the EDFP.The 49-item tool included a combination of forced-choice,open-ended, and Likert-type rating scales. Descriptive sta-tistics (including means and standard deviations or frequen-

cies and percents of agreement) were calculated for thevarious responses.

Results

At each interview, participants shared their perceptions of:why they had been attracted to the EDFP; their emergencydepartment and emergency nursing; being in a new joband role; their professional performance; the EDFP; desir-able attributes for potential fellows; and recommendationsfor future orientation programs. At the second interview,participants reflected on whether their perceptions hadchanged since the initial interview and offered any newthoughts regarding participation in the EDFP. The follow-ing categories organize participants’ responses.

ATTRACTION TO THE ED FELLOWSHIP PROGRAM

Most participants said the educational value of the pro-gram attracted them to the EDFP, describing it as “a greatlearning opportunity” and “a foundation to succeed in thefuture.” Several noted that they liked working under pres-sure, being busy, and being challenged. Some spoke ofthe advantages of early career specialization. Other fellowsexpressed a preference for episodic care and enjoyed theopportunity to stabilize patients and then move them onin the health care system. Having responsibility for holis-tic patient care and making a direct impact on patient out-come also were cited as reasons for selecting emergencynursing. At the second interview, the fellows continuedto see the program as a great opportunity; none regrettedthe time and effort spent in the EDFP.

PERCEPTIONS REGARDING THE EMERGENCYDEPARTMENT AND EMERGENCY NURSING

Fellows saw the emergency department as “fast paced” and“busy,” encompassing a wide variety of patients and typesof care. They noted emergency nursing was “constantlychanging,” “challenging,” and “[kept] me on my toes.”Some found it “intimidating” or “scary,” “intriguing,” and“exciting,” never “knowing what’s coming in.” One fellowlikened emergency nursing to “putting a puzzle together”but needing to be “quickly on point.” Participants recog-nized that the emergency department was very differentfrom most inpatient clinical units and that emergency nurseshave their own ways of doing things. Several participantsmentioned they already enjoyed emergency nursing or even“loved it!” Between the 2 interviews, perceptions of the emer-gency department and emergency nursing changed very little.As these fellows gained more clinical expertise in the secondhalf of the program, many agreed they were “getting greatexperience” and “learning something new every day.” One

Patterson et al/RESEARCH


spoke of the “eye-opening diversity” of emergency care con-sumers, and another said that a positive patient response toher care was “a good high.”

BEING IN A NEW JOB

As employees new to a professional nursing role, a fewfellows expressed concerns over their terms of hire. Theywere anxious about which of the system’s 4 hospitals theymight ultimately work in and mentioned not understand-ing employee benefits and other “new job stuff.” At thefirst interview, one participant noted that it “doesn’t feellike a job, yet.” At the second interview, several fellowswere concerned about work schedules and their specifichospital assignments.

REFLECTIONS ON SELF

Most fellows “[felt] like a nurse” 3 months into the EDFP.Several spoke of their fast-growing knowledge, confidence,and comfort in the registered nurse (RN) role. Some fel-lows described feeling nervous about providing patientcare and doing the right thing. Fellows had a great senseof responsibility toward their patients, wanting to givetheir best care to each one. Participants frequently double-checked their work or accessed their instructor, concernedabout “not knowing what I don’t know” and wondering“Can I do it?” Some fellows reported that their brains wereoverloaded with new knowledge and worried about retain-ing so much information. Several participants were con-cerned about being accepted by experienced staff membersand wondered what support would be available to them fol-lowing the fellowship.

By the end of the program, at least half of the par-ticipants readily acknowledged that they “felt like an emer-gency nurse.” A few expressed concerns about “not havinga preceptor to catch me” once the EDFP ended, but moststated they were ready to function in the department. Somefellows allowed that they were still nervous about how theymight perform in the face of a true emergency. However,the fellows generally acknowledged feeling “comfortable,”“prepared,” and “ready to do things on my own.” Participantsagreed they had the tools to get needed information and knewwhat to expect. Several even described feeling “confident.”

FELLOWS’ PERCEPTIONS OF THE EDFP

Many participants found class days long, intense, and“draining.” This perception was still apparent at the endof the program as the fellows recalled the many class hoursassigned in the initial 3 months. Participants noted a lotof repetition in class content, especially about shock andcardiac care. While most fellows seemed annoyed by thisrepetition, several fellows valued it, hoping it would rein-

force important concepts. At the second interview, someparticipants suggested that it would have been valuable tospend time late in the program reinforcing important con-tent such as cardiac rhythms, frequently used drugs, andthe care of patients with critical diagnoses including myo-cardial infarction, stroke, and obstructed airway.

The program instructors generally were hailed as “great,”caring, flexible, approachable people who wanted the fellowsto succeed. At both the first and second interviews, severalparticipants expressed that the ratio of fellows to instructorswas high. Sometimes they had to wait for an instructor tofinish with another fellow before getting help with a newprocedure or clinical question. Most participants agreed thathaving the same preceptor for every clinical shift would be/was valuable. At the end of the EDFP, fellows were able toevaluate the use of staff nurse preceptors. Participants weresplit in their opinions about the value of preceptor conti-nuity. Having a consistent preceptor allowed the experiencednurse to gain an understanding of the fellow’s competenciesand plan for additional experiences. Having multiple precep-tors gave fellows a chance to see how different nurses orga-nized their work, approached patients, and provided care.Two fellows noted, “preceptors [could] make or break the[EDFP] experience.”

Most of the fellows valued the learning tools they re-ceived, particularly the PDA software. They also appre-ciated the workbook materials and case studies. Whilesome admitted they did not read the textbooks during thecourse of study, most considered the books good referencesand referred to them after work to learn more about specificdiagnoses or clinical procedures. Homework assignmentswere helpful, although some fellows found them too time-consuming, “like being in school again.” Having to spendan hour or more on homework, most nights, conflicted withfamily responsibilities and produced mental fatigue after afull day of orientation. Some participants stated the EDFPseemed like a continuation of school with repetition ofconcepts already learned. At the second interview, severalfellows reflected that, because they had recently completednursing school with a practicum on a medical-surgicalunit, repeating that particular experience was not a bene-ficial part of orientation. However, rotations to other pa-tient care areas, particularly the ICU, were valuable.

Some fellows indicated that the program’s critical caredidactic content exceeded what they would likely use asemergency nurses or was too advanced for novices. Theysuggested critical care information would be more perti-nent if it were offered later in the program, once partici-pants had sufficient ED exposure and a context for care.Participants wanted additional time in the simulation labo-ratory for practicing skills. Although the ECCO modules



were reportedly useful, most fellows remarked that the ex-pectation to independently access the course on their owntime, after a long class or clinical day, was burdensome.

Wanting more “hands-on practice” to reinforce class-room learning, many fellows also expressed a desire forincreased clinical time in the emergency department earlyin the program, to provide a context for information ac-quired in class. Participants maintained the opinion thatfellows who had been scheduled for a greater number ofED shifts prior to or at the beginning of the program hadan advantage and were “ahead of the others.”

The fellows often described the EDFP as “great. . . agood program and opportunity,” and said they felt “luckyto have it” or “lucky to have gotten in.” Participants foundthe emergency department to be “stressful,” “chaotic,” and“overwhelming at times.” However, by the end of the pro-gram, most stated that both the emergency departmentand emergency nursing were pretty much what they hadexpected them to be. Several fellows noted that the programwas harder than anticipated; they had underestimated theinvestment of personal time necessary for independentstudy. Most agreed that 6 months were adequate for thistype of dynamic learning experience and that their time inthe program had passed quickly.

DESIRABLE ATTRIBUTES OF ED FELLOWS

Asked to identify desirable characteristics for future EDorientation program participants, fellows cited “excitedto learn and study” and “willing to try new things.” Otherimportant traits included being competent, easy-going,outgoing, patient, energetic, and flexible. Additionally, theability to think critically, handle stress, manage time, talkwith people, and put them at ease were identified as im-portant attributes.

OTHER PERCEPTIONS

Reflecting on the group’s dynamics, most fellows expressedgratitude that they “had each other,” “our own team,” and“were part of a group going through the same thing.” Fel-lows drew support from each other. They wanted a chanceto meet together throughout the program, not just duringthe initial period of intense classes. Although demographi-cally diverse, participants believed they got along well witheach other.

Some participants remarked that experienced nurseson inpatient units had questioned whether GNs shouldbegin their careers in the emergency department. Fellowsperceived negative attitudes toward the EDFP from thesenurses or described feelings of being “watched.” Partici-pants also were anxious about experienced emergencynurses’ expectations of them and concerned about how the

fellows would be received in the emergency department. Acouple of participants related they had been told they were“not real nurses.” Most, however, stated that the expe-rienced emergency nurses were helpful and some were par-ticularly supportive. A few fellows sensed that unionizednurses seemed afraid the orientees would “take their jobs”or questioned how, without seniority, fellows got ED posi-tions. Emergency staff nurses’ expectations and responseswere very important to these GNs, directly affecting theirperceptions of themselves as nurses.

ED FELLOWS’ RECOMMENDATIONS FOR FUTUREFELLOWSHIP PROGRAMS

The ED fellows shared many ideas at their first interview,which were reiterated at the end of the program, about howa future EDFP might be constructed. Participants univer-sally agreed it would be helpful to have more ED exposureearlier in the program in which they could “shadow” anemergency nurse. Participants mentioned needing to havea better understanding of the flow of ED care and moreinformation about important guidelines, routines, anddocumentation systems in order to put class content intocontext. Fellows wanted fewer 8-hour class days, fewer se-quential class days, and class and clinical content that weremore integrated in order to apply concepts quickly andpractice new skills soon after learning them. Early on,some participants feared they would lose proficiencies ac-quired in nursing school because they had little opportu-nity to practice and reinforce skills while in class. Thisconcern waned by the time of the second interview.

At both interviews, the fellows almost universally rec-ommended condensing class content and spreading it over6 months, rather than having most of the didactic materialin the first 3 months. They recommended more opportu-nities for clinical practice, skills workshops, simulationlearning, and other interactive educational strategies. Addi-tional time dedicated to acquisition of specific skills, (eg,intravenous catheter insertion) also was mentioned as desir-able. Other suggestions included increasing opportunitiesfor in-class discussion, spending more time reviewing andconnecting laboratory data and clinical experiences withdidactic learning, and reorganizing lecture content to re-duce repetition and class time. Fellows cited the need to keeplearning focused on information that would be of most usein the emergency department, only including critical carecontent directly relevant to emergency care. Some partici-pants suggested placing critical care information at theend of the program, after they had more ED experienceand were feeling less overwhelmed. Holding periodic “re-fresher” sessions throughout or at the end of the programalso was proposed.



Several fellows indicated that they needed emotionalsupport and time to discuss and reflect on their clinicalexperiences (“debriefing”). One fellow reported, “You seesome weird stuff.” Periodically reconvening the entire fel-lows group would provide an opportunity to share expe-riences, discuss patient cases, express the emotions thatclinical experiences evoked, and strengthen the social andsupportive relationships the fellows had established duringthe early phase of the program.

Many of the fellows took their National Council Licen-sure Exam for Registered Nurses (NCLEX) examinationafter beginning the EDFP. Taking this examination was amajor concern for participants. Studying for the NCLEX,while simultaneously participating in an intense orientationprogram, caused them to miss some EDFP content. Therewas not enough time for both. The priority of the fellowswas to pass the NCLEX examination; without passing, theirED job and EDFP participation would be in jeopardy. Al-though some fellows identified EDFP content as helpfulto their NCLEX review, in general, the group advocatedhaving GNs pass the NCLEX before beginning orientation.

In future programs, the fellows recommended morefrequent and accurate communication among hospital hu-man resources personnel, administrators, EDFP instructors,ED managers, ED staff members, and preceptors. Partici-pants perceived that preceptors and ED RNs needed moreinformation about what the fellows were learning, clinicalperformance expectations, and specific educational situa-tions needed to facilitate preceptees’ growth. Participantsunderlined the importance of clearly explaining the EDFPschedule, objectives, sequence of topics, and individual ex-pectations at the beginning of the program. Participantssuggested that there be planned opportunities for fellowsand ED staff members to socialize in order to introducefellows to experienced staff members.

FINDINGS FROM THE SURVEY ON PERCEPTIONSOF FELLOWS’ FIRST JOB AS AN RN

Participants were asked if they strongly disagreed, dis-agreed, slightly disagreed, slightly agreed, agreed, or stronglyagreed with each survey item (Table 1). Responses revealedthat participants found the EDFP workload stressful. A fewreported having to stay at the hospital beyond their shiftto finish work or indicated that working conditions made itdifficult to provide safe patient care. Half of the participantsconsidered staffing levels inadequate. Nevertheless, most fel-lows stated they were not expected to function independentlybefore they were ready and reported having enough time tospend with patients. None of the participants worked over-time shifts during the program. One fourth responded thattheir work in the emergency department involved too many

non-patient activities. Most fellows found that the ED staffwas helpful, functioned together as a team, and engagedsocially outside of the workplace. The majority of participantsdid not consider the workplace atmosphere negative. Fellowsagreed they had input into their evaluations and that evalua-tions accurately reflected their job performance.

All participants agreed that the orientation programadequately prepared them for their new positions. Onlyone respondent disagreed that continuing education wasencouraged after EDFP completion; most agreed that theirnew position offered opportunities for advancement. Ac-cording to 75% of participants, involvement in unit andfacility affairs was encouraged, administrators listened tostaff member concerns, and their ED manager was sup-portive. All fellows agreed that charge nurses held a re-spected position in their respective departments. One thirdof participants agreed their salary was insufficient; nearly allwere satisfied with employee benefits. Three quarters of thefellows disagreed that others questioned their clinical deci-sions, and the majority found that physicians valued theirinput.Most participants agreed the health care team collabo-rated on cases and that staff nurse input resulted in positivechanges in the workplace. When fellows rated the help-fulness of EDFP components, 78% or more agreed eachcomponent was helpful, with the exception of the ECCOcomputer program, which only 50% considered helpful.

Discussion

The 18 new nurses who participated in a comprehensive,intensive 6-month orientation program to prepare them forpractice in the ED setting viewed the program as successfuland themselves as competent novice emergency nurses.This program supported Loiseau, Kitchen, and Edgar’sassertion that “a viable solution to the ED nursing shortageis to hire newly graduated nurses and provide them witha thorough, well-planned orientation program that fullyintegrates them into the hospital work environment”(p. 522).5 However, participants in the EDFP stronglyexpressed that future programs should not start until GNshad passed the NCLEX. Participants were overwhelmedpreparing for licensure while simultaneously learning anew specialty involving intense classes and clinical work.

The fellows indicated that some didactic content, par-ticularly critical care classes, would have been more helpfulif placed later in the course, after they had a better sense ofhow the information would be used in the ED setting. Itseemed important to participants to first have a context forthe things they were expected to learn. In the interviews,participants frequently expressed a need for greater expo-sure to the ED environment and flow of care early in the



TABLE 1Perceptions of fellows’ first job as a registered nurse (N = 18)

Factor

% Rating each category

SD D SLD SLA A SA

Factor 1. Patient care/work role concernsThe work was stressful 11.1 – 11.1 38.9 38.9Had to stay beyond shift to finish work 27.8 38.9 11.1 16.7 – 5.6Working conditions made it difficult to provide safe patient care 33.3 44.4 11.1 5.6 – 5.6The level of staffing was not adequate – 33.3 16.7 38.9 5.6 5.6Did not have time to spend with patients – 27.8 27.8 33.3 11.1 -Was expected to function independently too soon 33.3 27.8 16.7 16.7 – 5.6Voluntarily worked overtime shifts during the program 50.0 43.8 6.3 – – –

Job included too many non-patient activitiesa 23.5 41.2 5.9 17.6 5.9 5.9Factor 2. Support from other staff members and the nursing care teamThe work atmosphere was negative 22.2 44.4 5.6 16.7 5.6 5.6Staff members worked together as a team 5.6 5.6 5.6 16.7 27.8 38.9Unit staff members were helpful to fellows – – 11.1 22.2 27.8 38.9The staff engaged socially outside worka 5.9 29.4 5.9 17.6 41.2 –

Factor 3. Supervision and evaluation of fellows’ workEvaluations were reflective of fellows’ work 11.1 5.6 11.1 11.1 61.1 –

Fellows did not have input into their evaluations. 22.2 33.3 22.2 11.1 5.6 5.6Charge nurses were respected – – 11.1 33.3 33.3 22.2

Factor 4. Support for AdvancementThe unit orientation prepared me for the position – – – 22.2 55.6 22.2There were opportunities for advancementa 6.3 12.5 25.0 25.0 31.3 –

Continuing education was encouraged – – 5.6 27.8 55.6 11.1Factor 5. Administrative support for carrying out fellows’ workInvolvement in unit/facility affairs was encouraged – 5.6 16.7 27.8 33.3 16.7Supplies needed for patient care were not on the unit 16.7 44.4 11.1 22.2 – 5.6Equipment needed for patient care was readily available 11.1 – 16.7 22.2 44.4 5.6There were reliable services available for patient transport – 22.2 5.6 22.2 44.4 5.6Salary was not sufficient 5.6 50.0 11.1 16.7 11.1 5.6The nurse manager was supportive as fellows learned the RN rolea 5.9 5.9 – 41.2 35.2 11.8Hospital administrators listened to the concerns of the staff members – 5.6 22.2 33.3 33.3 5.6The benefits package was satisfactory 5.6 – 5.6 11.1 66.7 11.1

Factor 6. Collaboration and having a voice in decisionsFellows’ input was valued by physicians – 11.1 11.1 27.8 38.9 11.1Orientee’s clinical decisions were questioned by others – 50.0 22.2 11.1 11.1 5.6Health care team members collaborated on cases – – 11.1 38.9 38.9 11.1Staff nurse input resulted in positive changes in the workplacea 5.9 5.9 29.4 17.6 35.3 5.9

A, Agree; D, disagree; SA, strongly agree; SD, Strongly disagree; SLA, slightly agree; SLD, slightly disagree.aOne or two respondents did not reply to this item; therefore, percentages are based on the number who responded and not N = 18.



program, in order to better relate didactic information totheir clinical assignments. These comments support opinionsexpressed by several nurse educators5-10 who have advocatedthat the first few months of an orientation program should bespent in the home unit; rotation to other departments cancome later. The fellows clearly saw themselves as “hands-on” learners who desired more psychomotor skills practice.

Comparing EDFP survey responses to those of 352 grad-uate nurses in Bowles and Candela’s original survey,9 thefellows were much less likely to agree that they had to staybeyond their shift to finish work, that working conditionsmade it difficult to provide safe patient care, that staffing wasinadequate, or that they were expected to function while feel-ing unqualified. Furthermore, participants in the present studyreported their work atmosphere as more positive. The fellowsalso perceived much greater input into their evaluations, indi-cated that charge nurses were respected, and were in greateragreement that physicians valued their input, the health careteam collaborated on cases, and continuing education was en-couraged. All of these positive responses support the value ofa structured, comprehensive orientation program. Regardingretention, Bowles and Candela reported that 30% of theirsample left their initial job in the first year and 57% within2 years.9 In the EDFP there was only a 6% 1-year attritionrate; 22% of fellows left the job by the end of the second year.

The fast pace, multiple medical diagnoses, and culturaldiversity of ED patients challenged the fellows. They iden-tified a need for frequent communication among courseinstructors, clinical preceptors, and themselves in order to

meet individual learning needs and maximize progressiveachievement of program goals. This finding supports theobservations of other researchers who have noted that com-munication is key to a successful orientation.11

The fellows in this study ended the program feelingpositive about their decision to become emergency nursesand to invest 6 months in intense learning so soon aftercompleting school. Furthermore, they highly valued thesupport of nurse educators and the health system, whichprovided them with many educational tools and invited themto participate in a very dynamic learning opportunity. Thefellows appreciated staff members and instructors who tooktime to bolster their confidence and share nursing care ap-proaches. These findings are consistent with Valdez’s con-clusion that social support is critical to graduate nurses in theemergency setting early in the GN’s socialization process.12

The new ED orientees began to see themselves as emer-gency nurses by the end of the EDFP, although they recog-nized there was a lot more to learn to achieve proficiency.Participants expressed a desire to spend more time in theemergency setting early in their orientation. The fellows ap-preciated the role of more experienced staff nurses, precep-tors, and their ED instructor, especially as nearby supportsin critical situations.

Implications for Emergency Nursing

ED nurse managers, educators, staff nurses, and precep-tors can learn much from the revelations of the GNs who

TABLE 2Recommendations for ED orientation programs for graduate nurses

Strengths of program Areas for revision and improvement

Health care system support to provide opportunitiesfor graduate nurses

Require passing the NCLEX examination prior to the startof the program

6-month program length Improve communication among all involved partiesComprehensive screening process for newgraduate program applicants

Class scheduling: schedule classes over the length of the programinstead of holding the majority of didactic sessions at the beginning

Dedication and support of the program coordinator,clinical instructor, and preceptors

Class content: increased the focus on emergency nursing contentwith less emphasis on critical care nursing content (eg, pulmonaryartery catheters)

Strength and diversity of the fellows and thedevelopment of supportive relationships

Provide early exposure to the emergency department by increasingthe number of ED clinical hours at the beginning of the program

Materials: emergency nursing textbooks and personaldigital assistants loaded with nursing software

Increase the use of simulation activities and interactivelearning strategies

Class content repetition for reinforcement ofdifficult concepts

Increase opportunities for debriefing and discussing experiences

NCLEX, National Council Licensure Exam for Registered Nurses.



participated in this study. Successful NCLEX completionshould be a prerequisite for enrollment in a comprehensivenursing specialty orientation program. Recognition that newgraduates have only recently completed a professional nurs-ing program suggests the need for active learning strategies,such as simulation laboratories,13 to facilitate acquisitionof psychomotor skills and understanding of complex clini-cal scenarios.

Optimally, didactic instruction should be interwovenwith clinical experiences throughout the orientation pro-gram. It is important to new graduates to understand pa-tient flow and processes in the department for which theywere hired prior to opportunities to gain specific skills inother hospital areas. Incorporating regular debriefing ses-sions allows orientees to communicate their learning needs.Planned time for communication among clinical instruc-tors, preceptors, nurse managers, and orientees enhances thelearning experience and provides opportunities to revise goalsand evaluate progress. Additionally, educators need to incor-porate social support into orientation programs from thestart. Table 2 provides a summary of EDFP strengths andsuggestions for revision and improvement.

Limitations

This study was conducted in a single health system, witha sample size of 18 nurses, in one geographic area, limit-ing the generalizability of these findings. Moreover, thestudy is limited by the self-response format of the inter-views and survey.

Conclusions

Two years following EDFP completion, 14 of the 18 fel-lows remained employed in their respective emergency de-partments. Understanding the experience of new graduatesin the emergency setting provides crucial information fororientation program design. Incorporating active teaching-

learning and socialization strategies early in an orientationprogram may facilitate the transition from novice nurseto beginning competent nurse level. This study adds tothe emerging body of knowledge about best practices forthe orientation of GNs to a specialty setting, specifically theemergency department.

REFERENCES1. Bechtel D, Butler CL, Kurz P. Development and implementation of an

ED residency program for graduate nurses. J Emerg Nurs. 2006;32:213.

2. Lavoie-Tremblay M, Viens C, Forcier M, et al. How to facilitate theorientation of new nurses into the workplace. J Nurses Staff Develop.2002;8:80-5.

3. Carroll TL. Stressful life events among new nurses: implications forretaining new graduates. Nurs Admin Q. 2005;29:292-6.

4. Ross H, Clifford K. Research as a catalyst for change: the transition fromstudent to registered nurse. J Clin Nurs. 2002;1:545-53.

5. Loiseau N, Kitchen K, Edgar L. A comprehensive ED orientation fornew graduates in the emergency department: the 4-year experience ofone Canadian teaching hospital. J Emerg Nurs. 2003;29:522-7.

6. Keim DA, Scholten T. A new graduate assimilation and orientation pro-gram geared for success. J Emerg Nurs. 2004;31:9.

7. Krippendorff K. Content Analysis: An Introduction to Data Analysis. Thou-sand Oaks, CA: Sage; 2004.

8. Miles M, Huberman A. Qualitative Data Analysis. 2nd ed. NewburyPark, CA: Sage Publications; 1994.

9. Bowles C, Candela L. First job experiences of recent RN graduates: improv-ing the work environment. J Nurs Admin. 2005;35:130-7.

10. Wolf L. An ED orientation/fellowship: an experiment in process-orientedtraining and learning to think like an emergency nurse. J Emerg Nurs.2005;31:298-301.

11. Chestnutt BM, Everhart B. Meeting the needs of graduate nurses in cri-tical care orientation. Crit Care Nurs. 2007;27:36-51.

12. Valdez AM. Transitioning from novice to competent: what can we learnfrom the literature about graduate nurses in the emergency setting? JEmerg Nurs. 2008;34:435-40.

13. Zekonis D, Gantt LT. New graduate orientation in the emergencydepartment: use of a simulation scenario for teaching and learning.J Emerg Nurs. 2007;33:283-5.



Orientation to Emergency Nursing: Perceptions of New Graduate Nurses

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