1 Immersing New Emergency Room Nurses Heather Harris College of Nursing, Michigan State University NUR997: Doctor of Nursing Practice Project Paper Dr. Jackie Iseler April 9, 2023 2 Table of Contents Abstract/Executive Summary……………………………………………………………..4-5 Introduction………………………………………………………………………………..6 Background/Significance………………………………………………………….6-9 Problem Statement………………………………………………………………...9-10 Organizational Assessment “Gap Analysis” of Project Site………………………9 Theoretical Framework……………………………………………………………13 Review of the Literature (related to evidence-based practice to address the problem)…...10-13 Methods……………………………………………………………………………………13-18 Project Site and Population………………………………………………………..15 Ethical Considerations/Protection of Human Subjects…………………………....15-16 Setting Facilitators and Barriers…………………………………………………..16-17 The Intervention and Data Collection Procedure………………………………....17-18 Timeline…………………………………………………………………………..18 Analysis & Sustainability Plan…………………………………………………………..20-21 Discussion/Implications for Nursing…………………………………………………….21-22 Cost-Benefit Analysis/Budget…………………………………………………………...19-20 Conclusion……………………………………………………………………………….22 3 References……………………………………………………………………………….23-26 Appendix………………………………………………………………………………..27-50 Appendix A (Synthesis table)…………………………………………………..27-34 Appendix B (Prisma diagram)………………………………………………….35 Appendix C (Fishbone diagram)………………………..………………………36 Appendix D (Nursing Evidence-Based Practice, Quality Application)………...37 Appendix E (The Casey-Fink Graduate Nurse Experience Survey)……………38-46 Appendix F (Informal Survey Questions)………………………………………47 Appendix G (GN Immersion Program Outline)………………………………..48-49 Appendix H (Gantt Chart)……………………………………………………...50 4 Abstract Purpose/Objectives: A 92-bed Emergency Center is hiring Graduate Nurses (GNs) at a much higher rate than historically. The GNs have attended and finished nursing school during the COVID-19 pandemic and have expressed concern with not feeling prepared and able to care for the specialized population of emergency center patients. Experiential learning during the pandemic was limited for the new nurses and decreased their perceived competence with patients in general. Description of Project: This project included creating and implementing a 10-week Graduate Nurse Immersion orientation program to bridge the learning gap from academia to nursing practice after graduation. The 10-week program, based on the Emergency Nurses Association GN Residency outline, is broken down into a once a week 8-hour class for new nurses to learn specialized content to care for emergency center patients with various complaints and needs. Outcomes: The newly graduated nurses will improve their job satisfaction and competence within the specialized Emergency Center setting. The Casey-Fink Graduate Nurse Experience Survey results will reflect improved satisfaction. Nursing retention rates within the Emergency Center will improve at the 1-year, 2-year, and 5-year periods. Conclusion: The results are yet to be determined with the first group currently attending the GN Immersion program and surveys will be collected in June of 2023 to determine job satisfaction. Preliminary verbal feedback is satisfaction within the program to supplement the experiential in- unit orientation process. Discussion: This project has the potential to decrease nurse turnover in the Emergency Center and improve overall satisfaction and perceived competence within the work environment. The 5 hospital system CNO is interested in implementing this GN Immersion program into all ECs (Emergency Centers) within the system. The improved nursing retention can decrease the hospital’s cost for replacing nurses, estimated between $50,000 to $80,000, including the nursing salary and all incidental costs for learning (precepting and educator costs). Keywords: Graduate nurse, Novice nurse, Emergency room, Emergency department, Emergency Center, Orientation, Training 6 Immersing New Emergency Room Nurses The Emergency Center (EC) is a fast-paced and exciting acute care setting for nursing, making nurses and nursing students dream of working within such an area (Roncallo et al., 2020). This environment initially attracts nurses who like frequent change and variability of their working environment. However, with this dynamic work environment comes drawbacks. In general, things happen very quickly in the EC, but this means it requires nurses who can process and react quickly (Campbell, 2020). The emergent aspect of care can easily be overwhelming for some, and the EC can accentuate this (Roncallo et al., 2020). Attrition of nurses for the department remains a concern and there are a lot of factors that will help develop well-trained nurses in this setting to keep them within the unit (Kaiafas, 2021). Background Immersion into a graduate nurse (GN) position in the EC is not always ideal or easy, and historically to be hired into an EC, a minimum of one year of nursing experience in an acute care setting, or experience within the unit as nursing support staff was required. At a level two trauma center in a suburban area, a 92-bed EC is hiring more GNs than it previously has in the past. In fact, many of the nurses being hired at this time have minimal experience if any (GNs), recently graduating with an associate degree in nursing (ADN) or a bachelors in the science of nursing (BSN). This brings challenges and the need to address success and retention of the GNs, in hopes of improving the current nurse retention rate, along with improving the performance and competence of those nurses. Nursing retention within an emergency department is not unique to this EC. It is another problem identified globally, attributed to stress and burnout, especially with the current 7 coronavirus disease 2019 (COVID-19) pandemic and nurse staffing crisis (Phillips et al., 2022). The targeted health system has been tracking nursing retention for many years for the whole facility and further delineates into the separate units. These retention rates are broken down by unit, to make it easier to track the EC’s retention and address trends noticed within those statistics. Currently, the nursing retention for the level two trauma center is calculated to be at less than 70% per year for the last two years, much higher turnover than historically seen. Significance Nursing retention is most certainly a concern and focus of the leadership within the EC of the suburban level two trauma facility. Retention has been impacted by the COVID-19 pandemic from the beginning in March 2020. Normal retention decreased with nurses leaving to travel or being furloughed due to decreased EC patient volumes. Additionally, nurses within the EC sought nursing positions away from the bedside to decrease risk of infection by COVID-19. Stress related to nursing care during the pandemic pushed still others away from practice in the EC environment (Lavoie-Tremblay et al., 2022) A recent trend noted within the designated level two trauma center, is more National Council Licensure Examination for Registered Nurses (NCLEX) failures for GNs than previously seen. Out of 24 GNs in one very recent orientation cohort, five of the new GNs did not pass their NCLEX exam on the first try. Two of those five did not pass on their second attempt, requiring a third attempt before passing. Two of the orientees did not remain within orientation because of their failure and contribute to the attrition rate. According to the nursing educator within the unit and corroborated by unit leadership, the normal number of failures in large cohorts (about 20-25 nurses) is usually about two to three GNs have not passed on the first try. The most recent amount of five is about double the anticipated normal failure rate. 8 The COVID-19 pandemic has created additional challenges for nursing students to attain experiential learning within clinical rotations, as many universities converted to online or alternative virtual learning opportunities instead of the traditional acute care clinical settings. Most nursing schools began this change in March 2020 and continued through to winter of 2021, while others have continued beyond that period, creating more challenges for those students transitioning into new GNs (Garcia-Martin et al., 2021). The connection of real-life experience and learning for nursing students is imperative for applying didactic learning into expertise, for safe and effective patient care (Leighton et al., 2022). This lack of exposure can lead to less situational learning opportunities and practice of nursing students with patients and within the healthcare environment, leading to difficulty transitioning into the nursing role (Benner et al., 2010). Cost of training is a controversial topic when determining training priorities for new nurses because there is not an indefinite amount of time available to train new nurses for any and all nursing care within the emergency setting. It also leads to the discussion of the need for new nurses to replace trained nurses that have left. The determined average cost of nursing orientation for new hires into the level two trauma facility is about $18,000, strictly for the cost of the nurses’ salaries during that period. Additional costs include the cost of preceptor pay, education costs of the unit, hospital, and systems’ educators’ salaries and time. According to an independent nursing recruitment agency, the cost of training a new nurse is estimated at $58,000 (NSI Nursing Solutions, 2022). This can translate into a loss for a hospital system of as much as $4.8 million dollars per year ($270,880 per percentage rate point) based on an average turnover rate of around 18% (Plescia, 2021). 9 The COVID-19 pandemic has created a perceived volatility within nursing as nurses are seen leaving the nursing field for other careers or other positions, including travel nursing for higher pay or completely away from the bedside to decrease the perceived stress (LaVoie- Tremblay et al., 2022). Travel nursing has increased within the designated EC, from staff leaving to travel and the need to hire travel nurses to fill positions. Retention of experienced and competent nurses is imperative to safe quality patient care and required for training of the novice nurses (LaVoie-Tremblay et al., 2022). Bonding of nurses with co-workers during the orientation process has long been seen for retaining staff and decreasing turnover. Friends like to work together and may stay at a facility longer if remaining with those friends (Udod et al., 2021). Before the pandemic, there were multiple opportunities for the novice nurses to group together for learning and experiences, but due to COVID-19, this has decreased the time and opportunities for GNs to create those bonds and stay in the department at the bedside. Root Cause Analysis A fishbone diagram helped to identify the contributing factors to the high rate of nursing attrition within the EC department. They included COVID-19, the nursing orientation process, the people within the department, the whole learning process within the department, the unit immersion, and the unit support for professional growth (Appendix C). Problem Statement The attrition rate of nurses at a mid-western, designated level two trauma center, is at 30% and higher than before the COVID-19 pandemic rate of 17%. The financial and human resources needed for recruitment and onboarding/orienting is substantial. The clinical question 10 is: what evidence-based strategies can be employed to slow the rate of attrition among new emergency room nurses? Search Strategy Multiple searches were conducted to ensure that the breadth of evaluation was adequate for the topics. Two literature searches were conducted within the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database and the PubMed database to formulate a comprehensive plan. The literature searches revolved around novice nurses, education, emergency departments, and nursing competency. The inclusion criteria were English language, academic journals published in the last five years. First Search The first CINAHL database search utilized the phrases: “emergency department OR emergency room”, “nursing”, and “education OR school OR learning OR teaching OR classroom OR education system.” This search yielded 766 articles, of which seven were selected as relevant to the problem being identified. The inclusion criteria were English language, academic journals published in the last five years. The PubMed search for the same keywords yielded 3,792 articles initially but after review, only three articles were selected as relevant. Second Search The second CINAHL database search utilized the phrases: “novice nurse OR newly graduated nurse OR junior nurse OR new nurse”, “emergency department OR emergency room”, and “orientation OR onboarding.” This search yielded 25 articles, of which two were applicable, but were repeats from the previous search. The same inclusion criteria were used as the previous 11 search. The PubMed search yielded 5 articles, all of which were either duplicate or removed due to inappropriateness such as population or factors identified. Final Search Results The two separate searches were completed within CINAHL and PubMed for 4,583 articles from both databases. After review and deletion, twelve articles were deemed relevant to the topic (See Appendix B Prisma Diagram). The level of evidence and quality of the studies were also investigated. See Appendix A Literature Table for details. Synthesis of Findings The literature selected for this project identified many factors that impact nursing satisfaction, retention, and competency in practice. Breaking down all the individual parts can allow for identification and planning for an improvement. The main themes identified include engagement of nursing staff, more interprofessional or collaborative approaches to education, and a more robust education program to support the nursing staff (Appendix A). Engagement of Nursing Staff Engagement of nursing staff can engrain them within the department, forming bonds and lasting job satisfaction with direct input and participation (Udod et al., 2021; Phillips et al., 2022). The thought begins with making the nurses feel more involved and tied to their department, to improve their thoughts about their own work environment. Additionally, direct input into factors involving their work environment can engage the nursing staff and promote a better work environment to increase job satisfaction. Simply put, embracing a positive work environment will allow nurses pride and satisfaction of their own making within their role (Phillips et al., 2022). The increased satisfaction improves and increases the retention of staff 12 that are happy with where they work and the ability to continue to grow and develop within the role, based on a firm learning foundation. A decrease in leadership support is directly tied to a decrease in nurse retention and the potential for a higher nursing turnover rate (Udod et al., 2021; Phillips et al., 2022). Interprofessional and Collaborative Approaches The interprofessional and collaborative approach to novice nursing education will create a better team with improved communications and improved patient outcomes (Roncallo et al., 2020; Kaifas & Bennett, 2021). Healthcare teams are naturally interprofessional and interprofessional training solidifies the teamwork atmosphere. Mock codes and simulation can benefit the development of the team competence through practice and interprofessional education. Teamwork in healthcare teams is proven to have a direct impact on clinical outcomes and can be improved through interprofessional training of the entire healthcare team (AHRQ, 2012). Creation of a better engagement with interprofessional interactions will improve patient outcomes and improve the entire healthcare team performance (Roncallo et al., 2020, Kaifas & Bennett, 2021; & AHRQ, 2012). Education The last theme is increasing the education training in the acute care setting. This should include more simulation and learning opportunities, collaborative and interprofessional, for novice nurses will improve retention and competence of those nurses, to improve patient outcomes (Boyer et al., 2022; Calder et al., 2022; Campbell, 2020; Casse, 2019; Kaifas & Bennett, 2021). The theme of education improving outcomes can be explained by improved knowledge through improved training to move nurses from novice to expert (Benner et al., 13 2010). The improvement of practice can increase job satisfaction and improve retention (Boyer et al., 2017). The better a nurse feels about their own practice, the more likely they are to stay within that working environment for longer periods of time. The integration of education and engagement through a collaborative process of novice nurses and educators can be used to improve novice nursing performance and progress from novice to expert level through controlled and organized training and experience (Benner et al., 2010). If the novice nurses can identify areas of weakness or knowledge deficit to the educators, through needs assessment, it lays the groundwork to improve that education and make it more meaningful. When considering this in relation to the designated emergency center, a few of the changeable factors of the EC’s nursing retention opportunity were noted to be within the orientation and the learning processes. Theoretical Framework Benner’s Novice to Expert model lays an appropriate groundwork for working on identifying and improving nurse progression from a novice nurse to an expert role through learning and experience (Benner et al., 2010). The development of an expert nurse can improve the quality of patient care and improve the nurses’ performance. Method The Donabedian model for structure, process, and outcome within the framework of examining healthcare services can be used to evaluate a GN immersion program's effectiveness. Currently, the healthcare institution utilizes a vetted survey, the Casey-Fink Graduate Nurse Experience survey, to evaluate a GN’s orientation experience to track their learning, support, and satisfaction with the entire orientation process (Appendix E) (Fink, Tsai, & Fink, 2021). This 14 survey is found to have an adequate reliability of 0.86 using Cronbach’s  (Fink, Tsai, & Fink, 2021). In addition to determining an improvement in nursing orientation satisfaction, nursing retention rates in the unit will be compared from pre-GN Immersion program to post-GN Immersion program implementation. Structure The goal of retaining nurses and improving their clinical practice is paramount to the process improvement project. This project will implement a ten-week GN Immersion education program for novice nurses, adapted from the Emergency Nurses’ Association (ENA) “Graduate Nurse Residency” program (ENA, 2022). The ENA’s ten-week program outline is provided on their website and is broken down by systems and topics per week. This program can be adapted to align with the educational needs of novice nurses within didactic and experiential learning content. The goal of the program is to improve nursing knowledge for specialized practice within the EC setting. The premise of such a program is to create uniform and organized learning opportunities, to make sure all GNs receive the same information and opportunities for learning, to ensure that all GNs have the opportunity to progress from novice to expert (Benner et al., 2010). The GN immersion program will be tailored after the ENA’s 10-week program. Process The Clinical Nurse Specialist (CNS) and the Nursing Professional Development Specialist (NPDS) for the department will collaborate to create the content for the GN Immersion based on the ENA’s topic outline. The content will contain specifics to the unit and health system, following protocols and evidence-based practice. Each week’s class will be a 15 combination of simulation, didactic learning, combined with hands-on learning stations to promote experiential learning opportunities. Outcomes The expected outcomes of this project are improved novice nurse performance and satisfaction in their jobs, as evidenced by an improvement in the Casey-Fink GN Experience survey results. The intent is to improve nursing retention through the improvement of this orientation process. A SMART goal was created: The EC GNs will improve their job satisfaction from the pre-implementation survey and the EC Registered Nurse (RN) retention rate will improve by 5% within the first two years after GN Immersion program implementation. Project Site and Population A mid-western, level two trauma center, emergency center with 92 beds will engage the new nurses within this GN Immersion program, as they join the department. The target population for this project will be all orientees starting employment as nurses with less than one- year experience, and/or GNs within the department, as of January 2023. Ethical Considerations/Protection of Human Subjects Michigan State University Internal Review Boards (IRB) “non-human research” approval was obtained prior to initiating this Doctor of Nursing Practice (DNP) project. The hospital site’s IRB “non-human research” approval was also obtained (See Appendix D). Anonymous, voluntary completion of the GN experience survey from nurses that completed orientation from January 2022 until December 2022, prior to implementation, will be collected and compared to the nurses who complete the GN immersion program. No personal information will be collected 16 during this survey. Retention rates of the department nurses will be used to evaluate one-year after the program implementation, available through the departmental leadership team. Setting Facilitators and Barriers The facilitators within the department are the Director of Nursing Education and Research for the facility, the EC CNS, the EC Nursing Professional Development Specialist (NPDS) who acts as the primary unit educator, and the nursing leadership. The department’s leadership team of four managers is new within the last two years and is engaged enough to encourage such a project as the GN Immersion but will require active participation by those unit leaders. Regularly scheduled meetings can be taxing to the leadership team, but if divided between the four leaders, the demand will be lessened on everyone. Division of the support will also allow for more opportunities of novice nurses to bond and be supported by different leadership members (Udod et al., 2021). The potential barriers identified include the weekly rotating classes due to potential vacations of the unit educators, the breadth of need for mentors related to those willing and able to fill the mentor role, and the coordination of interprofessional simulation activities. The primary ways to overcome the barriers include an ability to move content from one week to another, as well as incorporating one ‘vacation’ week between full cycles. Additional barriers and challenges are mentors. Mentors will have to be nominated and accepted into the role, with outlined expectations and responsibilities. Those mentors will receive a coaching class by the CNS and NPDS to promote effective performance within the mentor role. Lastly, the CNS and NPDS will work with the educators of all the other healthcare disciplines present within the EC to coordinate interprofessional simulations and opportunities to create 17 interprofessional learning. The current number of experienced preceptors within the department is small and the need for supplemental learning opportunities and support of the GNs is required to promote adequate learning opportunities for them. Graduate Nurse Immersion Leadership Team Lead: CNS in unit Evaluator: Clinical Nurse Manager (CNM) of the unit Team: CNS, NPDS in unit, CNM, Director of Nursing Education and Research (NER), Director of Emergency Center, and two staff nurses. The GN Immersion and Data Collection Procedure The GN Immersion will follow a cycling 10-week class schedule. Each week will have an 8-hour classroom day (every Wednesday) and will occur during the first 10 weeks of orientation for all GNs. The class topics are outlined in Appendix G. This program will combine classroom lectures with simulations and hands-on practice sessions to fulfill the learning needs of diverse types of learners. The classroom lectures will be provided by either the unit educators or selected content experts from within the hospital (i.e., security, departmental leadership, program directors, etc.) All new GNs in the department will attend and be responsible for content make-up in the event of illness or absence. An additional non-vetted survey will also be given (Appendix F), distributed by email to all nurses that have completed orientation between January and December 2022. The same survey will be given to the orientee group starting in April 2023 with the new GN Immersion program and will be solicited from all orientees until January of 2024. A comparison of the 18 satisfaction results from the control group versus the intervention group will be presented to the unit leadership team and the Director of NER. The questions were formulated by the CNS and unit educator after thoughtful discussion and literature review, and the questions were reviewed by unit leadership to maintain appropriateness and breadth of content. The survey will be distributed electronically via Microsoft Forms to allow for quick, easy, and anonymous results. Per the request of the healthcare facility, the Casey-Fink Graduate Nurse Experience survey results will also be obtained from the healthcare system’s collection person, to be compared from before implementation to after implementation. As stated earlier, this survey is seen to have an internal consistency reliability score of 0.86 on the Cronbach alpha scale. The survey review of new nurses after the implementation of the GN Immersion program will occur starting in June of 2023, when the department’s GNs are generally asked to complete the survey, six months after hire. Both survey results will then be presented to the departmental administration team for review and discussion. Nursing retention rates will be compared from within the one year prior to the GN Immersion program implementation. One-year, two-year, and five-year retention rates will be reviewed at their respective timeframes to investigate changes and potential improvements in the rates. The retention rate data is provided by the health care system and can be broken down by unit to give an accurate representation of the actual nursing retention. Timeline The timeline for this project will evolve over a year’s time from September 2022 until January 2024, for data collection and implementation, followed by data abstractions. See Gantt chart, (Appendix H). 19 Stakeholder Assessment Stakeholders for this project include the entire unit leadership team, hospital administration, GNs, and patients. The stakeholders will be engaged through monthly meetings to review the program’s progress as well as review feedback from GNs along with patient satisfaction scores utilized by the department. Resources The resources available and needed for the program include the curriculum development for the weekly classes. This content is based on the ENA’s GN residency program, but tailored to the mid-western, level two trauma center’s specific uses. The staff required are the two unit educators, along with support from interdisciplinary teams to assist in teaching topics for the GNs. The class will be held for 8 hours every week in a hospital classroom. Cost-Benefit Analysis The Emergency Nurses’ Association (ENA) has a ready to use “New Emergency Nurse Residency Program” for purchase and use (ENA, 2022). This program costs over $56,000.00 for a yearly contract to access. Utilizing a similar set-up to the ENA’s program, the nurse educators avoid this yearly cost, while retaining the topic needs and program rewards. The GN Immersion project is being created to follow the example of the ENA’s new GN residency program (ENA, 2022). The program will follow the overall outline of the program but is formulated to follow the identified needs and desires of the stakeholders to follow the departmental requirements. The estimated average cost for training new nurse hires stated at the designated hospital is $18,000. This amount is strictly the cost of the new nurse’s salary during orientation, not including the costs of preceptors, development of training, and the nursing educators’ salaries. 20 Adding the additional resource costs would significantly increase the cost estimate. External sources give much more cost, averaging over $51,000 per nurse for all resources and costs involved with on-boarding (Plescia, 2021). Repeated orientation costs without retention are undesirable to the facility, in addition to the cost of a comprehensive orientation program developed for the emergency room's specialty nursing. The nursing educators will create a program from the template and save the hospital the cost of the orientation program. Additionally, if the nursing retention increases after the program implementation, this decreases the payroll budget of new nurses through decreased turnover and decreased demand of onboarding. Analysis and Sustainability Survey results, along with the retention rates will be evaluated during the first year after implementation and will be reviewed monthly by the Clinical Nurse Specialist and unit leadership team, to ensure continued effectiveness of the GN Immersion program and to promote program improvement as needed. The improvement will be partially based on feedback from the GNs attending. Currently, only verbal responses are available as feedback, which has been highly positive. The Casey-Fink GN survey data collection will begin in June 2023 to analyze the effectiveness of the program and begin the monthly review of results to compare to pre- program data. The informal survey questions (Appendix F) will be available for the new GNs as they finish their orientation process and can be compared to the results received prior to January 2023. The program's sustainability depends on the success of the desired outcomes of improved nursing satisfaction and increased retention rates. With each monthly review, the program effectiveness will be determined and the decision to continue the program will be decided by the 21 entire project team and the stakeholders. Improvement of the program can be led by participant feedback, along with lessons learned and changes in best-practice. Discussion and Implications for Nursing Nationally, the COVID-19 pandemic has impacted nursing students’ learning and confidence in practice (Ulmen, et al., 2022). To improve competence in nursing practice, additional resources and learning opportunities added to the traditional nursing orientation process can improve GN performance and job satisfaction. Building a program based on the ENA’s newly released GN orientation program outline can allow for a better orientation experience and improve competence in emergency nursing care provided to patients. Additional data components will be abstracted from the Casey-Fink Graduate Nurse Survey to determine perceived competency and job satisfaction throughout the next few months until the end of the year. The nursing retention rates will be monitored for the next few years and feedback from the staff in the GN Immersion program will be used to change and improve the program content. The results of this project will directly impact new nurse training and determine if the project is successful. Additionally, other emergency centers can implement similar programs if it is deemed successful and generalizable. A meeting is currently scheduled with the health system Chief Nursing Officer to see if the GN Immersion program can be implemented in other emergency centers within the designated health system. A limitation of the study is that it does not have a control group receiving the old orientation program. The GN Immersion program envelopes everyone in orientation starting in January 2023. Thus, there is no way to compare current groups, only the ability to compare previous results to new results. Another limitation is that the participants in the program all have 22 different preceptors and different daily experiences during clinical learning hours with their preceptors. This can be a confounding variable. Additional studies can be made to see if the GN Immersion program has generalizability to implement in other settings. The GN orientation group will likely be less than 50 GNs within the first year, so the data will be a limited number. This could be a benefit of future studies for larger groups and more data review. The content presented within the actual GN Immersion program can be revised based on the emergency center setting content desires and needs, along with the feedback of the GNs and their learning desires. Conclusion A successful transition from student nurse to practicing nurse can be difficult and overwhelming. Adding in impact that COVID had on nursing schools and clinicals also contributed to these concerns and challenges. Implementing a more robust orientation program to overcome the challenges and allow for competent nursing care in a specialized setting is needed for satisfactory practice and positive patient outcomes. 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Nursing Education Perspectives, 43(5), 292-296. https://doi.org/10.1097.NEP.0000000000001015 27 Appendix A Literature Table Citation Design/Level of Sample Intervention Measurement: Findings Strengths Evidence/Purpose Variables and Limitations Instruments Implications Boyer, S.A., Quasi- 162 surveys Specialty Survey tool, Not statistically Strengths: Valdez-Delgado, experimental; (58 provided residency quantitative significant, but evidence-based K.K., Huss, J.L., intervention study; data) program to data change seen program used Barker, A.J., Level 3 support and within the Mann-Salinas, develop nurses intervention Limitations: E.A., (2017). during transition units small sample Impact of a nurse period group, turnover residency program in units', on transition to leadership staff, specialty practice. high unit census, Journal for Nurses limited preceptor in Professional training, Development, individual biases 33(5), 220-227. of surveyed staff Implications: clinical performance improvement in specific areas after intervention Calder, S., Quasi- 4 regional Collaboration of Needs More Strengths: easily Tomczyk, B., experimental emergency 4 regional ERs assessment, confidence replicated, Cussen, M.E., Intervention; Level rooms with to create an regional within nursing standardized Hansen, G.J., 3 10-15 nurses emergency strategic staff and program through Hansen, T.J., per ER nurse education planning, reduction of 28 Jensen, J., Mossin, and training curriculum resources all facilities P., program for new creation, train- required implemented Andersen, B., ER nurses the-trainer through train- Rasmussen, C.O., courses, the-trainer Limitations: & Schliemann, P. education format utilized as a one- (2022). A implementation, day competency- framework for post-program based education standardizing evaluation framework now emergency nursing education and Implications: training across a Collaboration regional health among the care system: regional ERs, Programming, investment in planning, and training and development via education to international provide high- collaboration. quality nursing Journal of care Emergency Nursing, 48(1), 104-116. Campbell, D. Pre-test/post-test 20 graduate ACLS ACLS written ACLS Strengths: easy (2020). An design; Level 4 nurses simulation- test taken outcomes implementation initiative using based learning before and after (intervention and not a lot of simulation to aid experience the SBLE, implementation) financial burden in retention of outcome improved after advanced cardiac measures of SBLE Limitations: life support “time to shock” implementation; small sample at a knowledge and were measured ACLS test single hospital skills in an in seconds scores site emergency decreased from department nurse 29 residency program. pre-test to post- Implications: Dimensions of test repetition of Critical Care learning Nursing, 39(1), improves 33-38. retention and knowledge grasp Casse, K. (2019). Intervention 11 nurses Revised Qualitative Higher retention Strengths: ED opportunities Design; Level 4 emergency surveys; nurse and greater job Outcome was for new graduates: nurse residency retention rates satisfaction positive Implementing an program emergency nurse Limitations: very Residency small sample size program. Nursing at 1 facility, only Management, revamp of 50(4), 36-41. already implemented program, limited information on revamp details Implications: benefits of ER nurse residency within retention and satisfaction Garcia-Martin, M., Qualitative design 16 nurses Semi-structured Interview Fears and Strengths: Roman, P., study; Level 5 interviews of format tool concerns Looked at the Rodriguez- ER nurses regarding impact of Arrastia, M., Diaz- nursing and experienced Cortes, M., COVID-19, nurses on novice Soriano-Martin, organizational nurses P.J., concerns for the 30 & Ropero-Padilla, facilities Limitations: very C. (2021). Novice surveyed, and small nurse’s decreased convenience transitioning to support of sample size, emergency nurse novice nurses semi-structured during Covid-19 interviews can pandemic: A decrease qualitative study. reliability Journal of Nursing Management, Implications: 29(2), 258- 267. shadowing and EB technology will help provide novice nurses with support and confidence within their patient care practice Kaiafas, K.N. & Intervention 2 military Skills Cost and The staff Strengths: Bennett, R.C. Study; Level 3 hospitals competency savings; staff required less showed cost (2021). Cost training mandatory prompting to savings in savings of frequently training completely staffing frequent, concise instead of yearly compliance yearly training skills competency and the nurse Limitations: training in the educators small sample emergency provided group at 2 department. frequent military Journal of training during hospitals, no Emergency busy times follow-up data Nursing, 47(1), for tracking of 181-185. the benefits of 31 knowledge attained, skills, and attitudes after the training Implications: frequent training with SCT eases the burden on nurse educators and is more cost effective LaVoie-Tremblay, Cross-sectional 1705 nurses Anonymous Validated A high Strengths: good M., Gelinas, C., survey; Level 2 online survey of questionnaire proportion of sample size Aube, T., perceptions and 29.5% stated Tchouaket, E., attitudes intentions to Limitations: only Tremblay, D., leave setting focused on a Gagnon, M., Cote, and nursing specific time J. (2022). profession when the survey Influence for was sent out and caring for Covid- completed 19 patients on nurse’s turnover, Implications: work satisfaction, nurses are facing and quality of care. stress and fatigue Journal of Nursing due to working Management, conditions and 30(1), 33-43. the pandemic patients Leighton K., Systematic review; 109 articles Systematic Study of Clinical Strengths: large Kardong-Edgren, Level 1 reviewed review and outcomes of education is a search S., McNelis, A., & prelicensure required portion 32 Sullo, E. (2022). meta-analyses clinical of prelicensure Limitations: no Learning outcomes criteria education education recommendations attributed to given based on prelicensure systematic clinical education review in nursing: A systemic review of Implications: qualitative further research research. Nurse on the Educator, 47(1), prelicensure 26-30. clinical education is required Phillips, K., Integrative 16 articles Systematic Review of Work schedule, Strengths: Knowlton, M., & literature review; review resilience and shift schedule, focused on ED Riseden, J. (2022). Level 1 burnout workplace over the past 5 Emergency violence, and years department emotional nursing burnout exhaustion all Limitations: and resilience. factored into variables of size Advanced resilience and of institutes and Emergency burnout locations; Nursing Journal, consideration; nursing 44(1), 54-62. resilience can perceptions of be increased burnout and through training resilience are and education to subjective; a decrease cross-sectional burnout study only looks at one time Implications: interventions that target burnout 33 and resilience to support the staff require further research and development Roncallo, H.R., Interventional 1 large Implementation Needs High level of Strengths: it was Ray, J.M., Kulacz, Study; Level 3 Level 1 of 4 assessment; satisfaction with a very R.C., Yang, T.J., trauma interprofessional outcome debriefing; interactive-based Chmura, C., facility simulations measurement positive impact project Evans, L.V., & emergency through DASH on clinical skill Wong, A.H. department; instrument development Limitations: an (2020). An 24 and comfort, evolving interprofessional orientation improvement in program makes it simulation-based sessions communication difficult to track orientation and teamwork progress and program for intervention transitioning sustainability novice nurses to critical care roles Implications: in the emergency more department: Pilot opportunities for implementation collaboration can and evaluation. build the team’s Joint Commission performance Journal on Quality & Patient Safety, 46(11), 640-649. Theobald, K.A., Exemplar study, Purposive 3 workshops for Focus group Respectful Strengths: Coyer, F.M., Level 4 sampling of postgraduate interviews, relationships examined the Henderson, A.J., 38 nurses follow-up between post- relationship Fox, R., Thomson, stakeholders consultations graduate between pre- B.F., & McCarthy, settings and licensure and A.L. academic 34 (2021). settings are post-licensure Developing a required to education postgraduate attain a professional mutually Limitations: lack education beneficial of framework for education generalizability emergency program of the study nursing: A co- design approach. Implications: BMC Nursing, continued 20(1), 1-10. collaboration between pre- licensure and post-licensure settings will directly impact nurses and nursing students Udod, S., Qualitative, 2 tertiary Survey, focus Synergy tool Use of patients’ Strengths: MacPhee, M., descriptive care groups, needs Engagement of Wagner, J.I., analysis; Level 3 emergency interviews assessment will staff using Berry, L., Perchie, rooms highlight different tools G., & Conway, A. nursing care (2021). Nursing issues to Limitations: perspectives in the improve convenience emergency workload sample in one department: The management city; subjective synergy tool in and the nurses’ interpretation of workload engagement in interviews and management and the department open-ended work engagement. answers Journal of Nursing 35 Management, Implications: 29(6), 1763-1770. reviewing the results of a patient’s needs assessment can reflect ER nurses’ workload issues and concerns 36 Appendix B- PRISMA flow diagram 37 Appendix C-Fishbone Diagram 38 Appendix D 39 Appendix E- Casey Fink Graduate Nurse Experience Survey (Revised) 40 41 42 43 44 45 46 47 48 Appendix F-Survey Questions (Likert scale: Excellent, Good, Neutral, Poor, Very Poor) 1. Overall, how satisfied were you with your EC (Emergency Center) GN orientation? 2. Did you pass the NCLEX on your first attempt? Second attempt? 3. How supported did you feel during your orientation process overall? 4. How supported did you feel by unit leadership during orientation? 5. How supported did you feel by your preceptor during orientation? 6. How supported did you feel by corporate orientation? 7. How supported did you feel by your unit educator(s) during orientation? 8. How did you feel your orientation process prepared you to work independently? 9. How likely are you to stay more than 1 year in your current role? 10. How likely are you to stay more than 2 years in the EC? 11. How likely are you to stay more than 5 years in the EC? 12. What do you wish could have been included or more developed within orientation? (Text box for answers) 49 Appendix G-GN Immersion Program Outline Objective: Develop a comprehensive Graduate Nurse immersion program to provide exemplary training and support for new graduate nurses within the Emergency Center. The aim will be to ensure safe and competent patient care along with improving the new nurses’ satisfaction within the new role. Requirements: 1. 10-week rotating classes in specific order of contents 2. 2-year commitment for GN residents for employment Proposed organization of 10-week immersion content (based on ENA residency program schedule): · Week 1: Overview and Cardiology · Week 2: Shock and Sepsis · Week 3: Respiratory Emergencies · Week 4: Neurological Emergencies · Week 5: Metabolic and Behavioral Emergencies · Week 6: Trauma 1 · Week 7: Trauma 2/Pediatrics · Week 8: GI and GU · Week 9: Special Populations: OB and Pediatric Emergencies · Week 10: Older Adults and Putting It All Together Breakdown of each Weeks’ content: Week 1: Welcome, scheduling, customer service, lab, press ganey, documentation, purple team, patient room set-up; ACLS information (dysrhythmias, pump or electrical problem, meds), CHF, Acute MI (STEMI or NSTEMI), PFO’s, DVT’s/PE’s/stroke, chest pain Week 2: 4 types of shock and treatment; sepsis treatment protocol (3-hour and 6-hour bundles), Gift of Life; central lines, art lines, mediports, PICC lines; pharmacy Week 3: asthma, COPD, BiPAP, RSI (rapid sequence intubation), aspiration, pneumonia, influenza/RSV/Covid, ABG’s, PE, pneumothorax Week 4: Stroke, TIA, dizziness/vertigo, MS, meningitis, cerebral palsy, dementia/delirium (VDT), migraines, seizures; legal blood draws, sedation 50 Week 5: PSW (petition/certification, sitters, placement), CIWA protocol, security, diabetes, DKA, HHNK, malignant hyperthermia, fluid and electrolytes (dehydration, hyponatremia treatment), adrenal issues Week 6: Trauma overview, Simulation w/patient expiration, GOL; Hazmat Week 7: Trauma cont’d, Pediatric emergencies Week 8: SBO, crohn’s, ulcerative colitis, IBS, GI bleed, N/V/D, c-diff; urinary retention, kidney stones, vag bleeding, CBI, CAUTI, transgender patients Week 9: Tocomonitor, fetal monitoring, methotrexate, products of conception, human trafficking, ENT/ocular Week 10: geriatrics/age related changes (assessment and triage, polypharmacy); discharge instructions 51 Appendix H-Gantt Chart