- Email: [email protected]
Developing and evaluating an emergency nursing orientation pathway
Research Developing and evaluatingan emergencynursingorientation pathway Authors: Pamela Kidd, RN, PhD, CEN, and Patricia Sturt, RN, MSN, CEN, Lexington, Kentucky
Objective Orientee e v a l u a t i o n forms f r e q u e n t l y focus o n t a s k s a n d t e c h n i c a l skills r a t h e r t h a n d e c i s i o n - m a k i n g skills. A n o r i e n t a t i o n p a t h w a y w a s developed to e v a l u a t e orientee clinical d e c i s i o n - m a k i n g skills. The p a t h w a y c a n assist in identifying orientees w h o require additional e d u c a t i o n a l resources or i n t e r v e n t i o n s . Early i n t e r v e n t i o n s m a y d e c r e a s e t h e l e n g t h of orientation, i n c r e a s e a n e m p l o y e e ' s l e n g t h of stay in t h e institution, a n d c o n t r i b u t e to cost savings. Methods The p a t h w a y w a s d e v e l o p e d w i t h employee exit i n t e r v i e w data, p r e c e p t o r interviews, identification of critical indicators, a n d the o r i e n t a t i o n literature. The p a t h w a y consists of six categories. Indicators w i t h i n each category w e r e identified a n d r a n k e d according to four levels of proficiency (level 1 for t h e least proficient a n d level 4 for t h e m o s t proficient). A c o n v e n i e n c e sample of s e v e n ED orientee a n d p r e c e p t o r pairs a g r e e d to participate in the pilot u s e of t h e p a t h w a y . A n e x p e c t e d timeline of progress h a d b e e n d e v e l o p e d by a group of 20 preceptors d u r i n g a preceptor workshop. A n a v e r a g e proficiency level (score) w a s o b t a i n e d for each category for 12 w e e k s w i t h t h e weekly scores p l o t t e d o n t h e p a t h w a y . This level w a s c o m p a r e d w i t h t h e e x p e c t e d proficiency level in each category for each week. Demographic information w a s o b t a i n e d from the orientee a n d preceptor pairs to d e t e r m i n e w h e t h e r certain characteristics facilitate p a t h w a y progression. Data w e r e a n a l y z e d w i t h f r e q u e n c y distributions, a n d m e a s u r e s of central t e n d e n c y a n d variance. S p e a r m a n ' s rank correlations w e r e u s e d to e x a m i n e t h e proficiency level in each category for each w e e k in relation to d e m o g r a p h i c characteristics of the p r e c e p t o r a n d orientee.
Dr. Kidd is an associate professor, Collegeof 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
Results Orientees p r o g r e s s e d faster t h a n e x p e c t e d in all categories. It took 8 w e e k s for a n orientee to a t t a i n the h i g h e s t proficiency level in all categories. The f a s t e s t progress w a s m a d e in t h e category "Accurately E v a l u a t e s P a t i e n t R e s p o n s e s . " Slowest progress w a s m a d e in the category "Safety in Blood a n d Drug A d m i n i s t r a t i o n . " Preceptors a n d orientees r a t e d t h e p a t h w a y as very useful. Discussion F u r t h e r s t u d i e s w i t h the orientation p a t h w a y m a y help to d e t e r m i n e t h e ideal time frame for orientation, characteristics of orientees w h o progress as e x p e c t e d or faster, a n d e d u c a t i o n a l s t r a t e g i e s to facilitate orientee p r o g r e s s i o n a n d clinical decision making. (J EMERG NURS 1995;21:521-30.)
n t h e w i n t e r of 1992, the N u r s i n g R e s e a r c h a n d Staff D e v e l o p m e n t (NRSD) D e p a r t m e n t of University Hospital, a 400-bed facility i n Lexington, Kentucky, e v a l u a t e d t h e critical care o r i e n t a t i o n program. At University Hospital, the e m e r g e n c y d e p a r t m e n t is c o n s i d e r e d a critical care unit. This s t u d y w a s p r o m p t e d b y preceptor c o m p l a i n t s t h a t e x i s t i n g orie n t e e e v a l u a t i o n forms focused on task c o m p l e t i o n a n d did not " c a p t u r e " t h e complexity of clinical decis i o n - m a k i n g skills e s s e n t i a l to s u c c e s s f u l p e r f o r m a n c e in critical care units. This s t u d y also w a s p r o m p t e d by the r e c e n t i m p l e m e n t a t i o n w i t h i n the hospital of the u s e of critical p a t h w a y s for the p u r p o s e of case m a n a g e m e n t . A greater e m p h a s i s w a s b e i n g placed on cost s a v i n g s per d e p a r t m e n t a n d the NRSD departm e n t w a s exploring s t r a t e g i e s for p r o m o t i n g cost savi n g s in orientation of n u r s i n g personnel. In addition, n e w g r a d u a t e s w e r e b e i n g hired for the first t i m e in the e m e r g e n c y d e p a r t m e n t , a n d the staff believed that the e x i s t i n g o r i e n t a t i o n p r o g r a m m i g h t b e i n a d e q u a t e in m e e t i n g the n e e d s of n e w graduates. T h e NRSD D e p a r t m e n t d e c i d e d to develop a critical p a t h w a y for critical care orientation. The u s e of a critical p a t h w a y e n h a n c e s e v a l u a t i o n of orientee de-
I
December 1995 S 2 |
JOURNAL OF E M E R G E N C Y NURSING/Kidd a n d Sturt
c i s i o n - m a k i n g skills for t h e p u r p o s e of i d e n t i f y i n g orientees who require additional educational interventions early in their orientation. Early intervention may 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 the institution and contribute to cost savings. This article describes the early development and evaluat 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 .
Projectbackground A t a s k f o r c e c o n s i s t i n g of N R S D p e r s o n n e l , a n u r s e recruiter, critical care managers, and three nursing faculty members with collaborative appointments at University Hospital was formed to discuss orientation 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 e x 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 left t h e f a c i l i t y 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 t o s e a r c h for p a t t e r n s r e l a t i n g t o n u r s e s ' p e r c e p t i o n s of j o b e x pectations and the work environment. Simultaneously, informal interviews were conducted with preceptors 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 e a r l y 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 there were problems in job performance. The existing orientee evaluation form required the preceptor to make judgments regarding the orientee's competence i n 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 j o b p e r f o r mance were frequently related to the nurse's ability to s o l v e 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 p e r f o r mance. The task force planned two separate preceptor workshops designed to share clinical teaching
Table 1 R a t i n g of c r i t i c a l i n d i c a t o r s P l e a s e c i r c 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 its 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 a s a n i n d i c a t o r . D o 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 .
Critical indicator
1. Fail cardiac, respiratory, a n d neurologic critical
Rank
Not a meaningful indicator 1
Needs major revision to b e a meaningful indicator 2
Meaningful but needs minor revision to b e a n indicator 3
Very meaningful indicator 4
1
2
3
4
1
2
3
4
1
2
3
4
1 1
2 2
3 3
4 4
1
2
3
4
1
2
3
4
1 1
2 2
3 3
4 4
1 1
2 2
3 3
4 4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
care tests
2. Relience on preceptor for basic nursing skills 3. Reliance on preceptor for critical care nursing skills 4. Poor a t t e n d a n c e 5. High p r e c e p t e e s t r e s s level * 6. Poor transition from t a s k s to whole picture * 7. Orientee-preceptor comm u n i c a t i e n problem 8. Compromised orientation 9. Orientee h a s a b a d attirude * 10. Inability to prioritize "11. Poor recall of previous learning * 12. C a n n o t convey rationale for actions "13. Inability to tie in assessmerit d a t a w i t h other data * 14. Inability to perform t a s k s without assistance "15. Does not recognize norrnal values "16. Requires multiple demonstrations
*Indicate i t e m s w i t h 90% or greater a g r e e m e n t as a very meaningful indicator.
522
Volume 21, Number 6
Kidd and Sturt/JOURNALOF E M E R G E N C Y NURSING
strategies and to discuss creation of a learning environment. Identification
of critical indicators
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 t e m ) Items with ->90% agreement as a very meaningful indicator (N-- 9) were retained. Development
of the critical pathway
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 Perform a n c e of Procedures, (4) Establishes Care Priorities (requires managing multiple demands simultaneously), (5) Clinical Decision Making (developing an appropriate plan of care), and (6) Accurately Evaluates Patient Responses (examining patient outcomes, recognizing the need for adapting the plan of care). Benner'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 psychomotor 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 Proficiency levels 1. R e v i e w s p r i n c i p l e s 9 Seeks descriptive information 9 Reviews descriptive information 9 Observes others 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 information, a s k s q u e s t i o n s 2. D e s c r i b e s skill c o m p o n e n t s 9 F o c u s e s o n i n f o r m a t i o n n e e d e d for self-performance 9 S t u d i e s i n f o r m a t i o n in d e p t h 9 Discusses performance step-by-step, describes 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 e r f o r m 3. P e r f o r m s w i t h a s s i s t a n c e 9 Identifies patient needs 9 Plans p e r f o r m a n c e a c c o r d i n g to p o l i c y 9 P e r f o r m s w i t h v a r y i n g e f f i c i e n c y levels, n e e d s assistance troubleshooting 9 Evaluates own performance and patient's short-term outcomes 9 Needs help identifying problems 4. P e r f o r m s i n d e p e n d e n t l y 9 I d e n t i f i e s p a t i e n t n e e d s o n c a s e specific b a s i s 9 Modifies p e r f o r m a n c e b a s e d o n p a t i e n t n e e d s 9 P e r f o r m s s m o o t h l y , a n t i c i p a t i o n of p r o b l e m s is routine 9 Evaluates own performance without help 9 E v a l u a t e s p a t i e n t ' s l o n g - a n d s h o r t - t e r m outcomes
December 1995 523
JOURNAL OF E M E R G E N C Y NURSING/Kidd a n d Sturt
by the panel of expert preceptors in the s e c o n d workshop). a Identification of areas in w h i c h orientees require greater resources to m e e t e x p e c t e d proficiency levels.
9 Identification of profiles or characteristics of successful orientees. Successful orientees were defined as those individuals who progress along the pathw a y in the m a n n e r d e s c r i b e d by the panel of expert preceptors.
Table 3 S a m p l e categories w i t h indicators Week Date:
1
2
3
Category 5: Accurately Evaluates Patient R e s p o n s e s 1. R e c o g n i z e s a b n o r me/findings 2. V a l i d a t e s p r e s e n c e of a b n o r m a l findi n g s (i.e., c h e c k s e q u i p m e n t , ass e s s e s patient) 3. A c t s a p p r o p r i a t e l y for a b n o r m a l findi n g s (i.e., a d m i n i s t e r s t r e a t m e n t , cont a c t s physician) 4. M o n i t o r s p a t i e n t for r e s p o n s e to t r e a t ment 5. D o c u m e n t s res p o n s e appropriately 6. C o m m u n i c a t e s res p o n s e verbally to p h y s i c i a n or o t h e r staff Average:
3
3
2
3
3
3
3
3
2
3
2
3
2.5
3
Category 6: Clinical Decision Making 1. Identifies a b n o r m a l data and pertinent negative findings 2. Links f i n d i n g s i n a meaningful pattern 3. C o n s i d e r s p o s s i b l e c a u s e s of a b n o r m a l d a t a / n e g a t i v e findings 4. Selects p r o b a b l e c a u s e of a b n o r m a l d a t a / n e g a t i v e findi n g s a n d t e s t s for its p r e s e n c e 5. A d a p t s n u r s i n g care to fit p r o b a b l e c a u s e of p a t i e n t ' s response 6. A n t i c i p a t e s pat i e n t ' s f u t u r e res p o n s e s to t r e a t ment Average:
524
Volume 21, Number 8
2
2
2
2
2
2
1
2
2
2
2
2
1.8
2
4
5
6
7
8
9
10
Kidd and Sturt/JOURNALOF EMERGENCY NURSING
9 Determination of the benefits of an orientation pathway in monitoring orientee performance. The project team sought to systematically evaluate 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 evaluate preceptors' learning styles during the workshops. Orientees' learning styles were assessed before the start of orientation with the same instrument. Preceptor-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 p a t h w a y (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 emerg e n c y 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 averaging 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 (scatterplots, quartile ranges), measures of central tend e n c y (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 derived from the preceptors (Table 5). The fastest progress was made in the category "Accurately Evaluates 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 Making" (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. Orientees 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
December 1995 525
OURNAL O F E M E R G E N C Y
NURSING/Kidd a n d Stu~
Table 4A Preceptor data sheet Code # T h a n k y o u for sharing this information. T h e information will be u s e d to help us design critical care orientation programs. Please circle the correct response. I. I have b e e n working in the e m e r g e n c y 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 b e e n working in the e m e r g e n c y 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 e m e r g e n c y department at UKIV[C: I, This is m y first time 2. 2 to 5 times 3, Greater than 5 times 4. I have precepted n e w graduates in the e m e r g e n c y department: 1. Y e s
2. N o 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~ D i p l o m a 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. D i p l o m a 7. I h a v e c o m p l e t e d t h e f o l l o w i n g 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 b y 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 b y t h e U n i v e r s i t y of K e n t u c k y C o l l e g e 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 U n i v e r s i t y of K e n t u c k y 4. N o 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 f o l l o w i n g a g e r a n g e : 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. O v e r 50 y e a r s 9. I h a v e t h e f o l l o w i n g c e r t i f i c a t i o n s a n d v e r i f i c a t i o n s ( P l e a s e circle all t h a t apply): 1. ACLS 2. T N C C 3. C C R N / C E N 4. ENPC 5. P A L S
6. O t h e r s : P l e a s e s p e c i f y 10. I a m a t t h e f o l l o w i n g r a n k of t h e UKMC Clinical N u r s i n g L a d d e r : 1. A D N I 2. A D N II 3. A D N 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 i n f o r m a t i o n !
UKIMC, U n i v e r s i t y of K e n t u c k y M e d i c a l C e n t e r ; ACLS, A d v a n c e d C a r d i a c Life Support; TNCC, T r a u m a N u r s i n g Core C o u r s e CCRN/CEN, critical c a r e r e g i s t e r e d n u r s e ; certified e m e r g e n c y n u r s e ; ENPC, E m e r g e n c y N u r s e P e d i a t r i c C o u r s e ; PALS, P e d i a t r i c A d v a n c e d Life S u p p o r t .
526
V o l u m e 21, N u m b e r 6
Kictd a n d Sturt/JOURNAL OF E M E R G E N C Y NURSING
35, indicating strong a g r e e m e n t about the usefulness of the pathway.
should be collected to assess
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 p a r ticipated in the internship before the pathway
Discussion Because the orientees in this study participated in a 6-week e m e r g e n c y nursing internship program and they progressed faster than anticipated, more data
used completed
was
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
protocol. The pathway provides one tangible method 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 Orientee data sheet
Code # T h a n k y o u for s h a r i n g t h i s information. The information will b e u s e d to help u s d e s i g n Critical Care orientation prog r a m s . Please circle t h e correct r e s p o n s e . 1. I h a v e previous critical care experience in t h e following positions (Circle all t h a t apply): 1. N u r s i n g a s s i s t a n t 2. N u r s e a p p r e n t i c e 3. LPN 4. RN 5. Other (please specify) 2. I h a v e h a d p r e v i o u s n u r s i n g experience o u t s i d e of critical care in t h e following positions (Circle all t h a t apply): 1. N u r s i n g a s s i s t a n t 2. N u r s e a p p r e n t i c e 3. LPN 4. RN 3. I h a v e b e e n a n RN for: 1, L e s s t h a n 1 y e a r 2. 2 to 5 y e a r s 3. 6 to 10 y e a r s 4. Over 10 y e a r s 5. I a m a n R N A 4. T h e h i g h e s t d e g r e e I h a v e in n u r s i n g is: 1. A s s o c i a t e 2. Diploma 3. B a c c a l a u r e a t e 4. M a s t e r ' s 5. T h e critical care c o m p o n e n t of m y basic n u r s i n g e d u c a t i o n p r o g r a m c o n s i s t e d of: 1. O b s e r v a t i o n a l e x p e r i e n c e only 2. C l a s s r o o m a n d clinical e x p e r i e n c e 3. S e p a r a t e n u r s i n g c o u r s e 4. No critical care e x p o s u r e 6. I h a v e a c c e p t e d a critical care position at UKMC in: 1. SICU 2. MICU 3. CTICU 4. CCU 5. N e u r o s c i e n c e ICU 6. B u r n u n i t 7. E m e r g e n c y d e p a r t m e n t 8. General s u r g e r y ICU 7. T h e main r e a s o n I s e l e c t e d a critical care position is: 1. Smaller nurse~patient ratio 2. P a t i e n t complexity 3. I already k n e w s o m e o n e in t h e unit 4. E x c i t e m e n t 5. Prestige a s s o c i a t e d w i t h t h e role 6. Served a s a s t u d e n t n u r s e apprentice 7. Other (please specify) T h a n k you for s h a r i n g this information!
LPN, L i c e n s e d practical nurse; RN, r e g i s t e r e d nurse; RNA, R e g i s t e r e d N u r s e Applicant; UKMC, University of K e n t u c k y Medical Center; SICU, surgical i n t e n s i v e care unit; MICU, medical i n t e n s i v e care unit; CTICU, cardiothoracic i n t e n s i v e care unit; CCU, coro n a r y care unit.
D e c e m b e r 1995
527
OURNAL OF E M E R G E N C Y
NURSING/Kidd and Sturt
Table 5 Expected versus actual orientee progress
Name Preceptors: Fill in proficiency level Orientation week WK 1 Expected Safety in Level 1 Drug/Blood Administration Actual Level 2
WK 2 Level 1
WK 3 Level 2
WK 4 Level 2
WK 5 Level 3
WK 6 Level 3
Level 3
Level 3
Level 3
Level 3
Level 3
Expected Technical Skills/Safe Performance of Procedures Actual
Level 1
Level 1
Level 1
Level 2
Level 2
Level 2
Level 3
Level 3
Level 3
Level 3
Level 3
Level 4
Expected Safe Equipment Usage Actual
Level 1
Level 2
Level 2
Level 2
Level 3
Level 3
Level 3
Level 3
Level 3
Level 3
Level 3
Level 4
Expected Accurately Evaluates Patient Responses Actual
Level 1
Level 1
Level 2
Level 2
Level 2
Level 2
Level 3
Level 3
Level 3
Level 4
Level 4
Level 4
Level 1
Level 1
Level 1
Level 2
Level 2
Level 2
Level 3
Level 3
Level 3
Level 3
Level 4
Level 4
Level 1
Level 1
Level 2
Level 2
Level 2
Level 3
Level 3
Level 3
Level 3
Level 3
Level 3
Level 4
Expected Clinical Decision Making Actual Expected Establishes Care Priorities Actual
t h o s e n o t p a r t i c i p a t i n g in t h e i n t e r n s h i p c a n n o w b e c o m p a r e d w i t h t h e 8 w e e k s n e e d e d for t h o s e in this study. Prior ED e x p e r i e n c e for b o t h t h e a s s i g n e d prec e p t o r a n d t h e o r i e n t e e w a s a s s o c i a t e d w i t h faster p r o g r e s s i o n t h r o u g h t h e p r o f i c i e n c y levels. A l t h o u g h further t e s t i n g of t h e p a t h w a y is n e e d e d , m a n a g e r s m a y w i s h to hire n e w g r a d u a t e s w i t h prior ED nursi n g a s s i s t a n t e x p e r i e n c e w h e n n e w g r a d u a t e s are h i r e d for t h e e m e r g e n c y d e p a r t m e n t . T h e s e findings s u p p o r t t h e n e e d to r e t a i n e x p e r i e n c e d ED n u r s e s to s e r v e as p r e c e p t o r s . B e c a u s e n u r s e s w i t h critical care c o n t e n t in their b a s i c n u r s i n g p r o g r a m p e r f o r m e d at h i g h e r profic i e n c y levels in t h e CDM c a t e g o r y earlier t h a n their cohorts, p e r h a p s m a n a g e r s should a s s e s s t h e b a s i c n u r s i n g e d u c a t i o n p r o g r a m of any n e w g r a d u a t e before h i r i n g for t h e i n c o r p o r a t i o n of critical care c o n t e n t a n d clinical e x p e r i e n c e . M o r e s t u d i e s are n e e d e d w i t h larger s a m p l e sizes to confirm this conclusion. B e c a u s e no o r i e n t e e m a s t e r e d t h e h i g h e s t profic i e n c y level in any c a t e g o r y before 4 w e e k s b u t all orie n t e e s a t t a i n e d t h e h i g h e s t p r o f i c i e n c y levels by 8 w e e k s , t h e ideal o r i e n t a t i o n p e r i o d m a y b e 8 w e e k s . In our e x p e r i e n c e t h e l e n g t h of o r ie n t a t io n for orien ~ t e e s o t h er t h a n n e w g r a d u a t e s varies w i t h t h e a m o u n t of ED e x p e r i e n c e . S i n c e t h e initial evaluation th e pathw a y h as b e e n u s e d w i t h 13 r e g i s t e r e d n u r s e s w h o
528
Volume 21, Number 6
w e r e n o t n e w graduates. On t h e basis of t h e s e data, t h e a v e r a g e l e n g t h of orientation is 5 w e e k s for r e g i s t e r e d n u r s e s w i t h ED e x p e r i e n c e an d 7 w e e k s for r e g i s t e r e d nurses w i t h o u t previous ED experience. As m o r e s t u d i e s are c o n d u c t e d w i t h larger s a m p l e sizes u s i n g t h e p a t h w a y , t h e traditional 12-week length of orientation m a y be r e d u c e d w i t h o u t c o m p r o m i s i n g t h e outcomes.
I n d i v i d u al s w i t h a v a r i e t y of l e a r n i n g styles m a y thrive in t h e e m e r g e n c y d e p a r t m e n t . Th e m o s t imp o r t a n t factor m a y b e t h e p r e c e p t o r ' s a w a r e n e s s of t h e o r i e n t e e ' s l e a r n i n g style so t h a t t h e p r e c e p t o r c a n adjust t e a c h i n g m e t h o d s to t h e o r i e n t e e ' s n e e d s . Alt h o u g h l e a r n i n g style w a s n o t correlated w i t h orient e e s ' p r o g r e s s in our initial e v a l u a t i o n of t h e p a t h w a y , a s s e s s m e n t of learning style is still warranted. S o m e p r e c e p t o r s n o t e d t h a t o r i e n t e e s m a y b e at a c e r t a i n p r o f i c i e n c y level w h e n w o r k i n g w i t h pat i e n t s w i t h u r g e n t a n d n o n u r g e n t p r o b l e m s b u t function at a lower p r o f i c i e n c y level in e m e r g e n t situations, particularly in t h e c a t e g o r i e s of CDM an d e s t a b l i s h m e n t of care priorities. This f e e d b a c k w a s o b t a i n e d d u r i n g t h e w e e k l y m e e t i n g s of t h e p r e c e p t o r , orientee, a n d staff d e v e l o p m e n t specialist. F u t u r e res e a r c h is 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 s e p a r a t e s c o r i n g should be p e r f o r m e d b a s e d on p a t i e n t subgroup and progress scores derived through a w e i g h t e d formula.
Kidd a n d Sturt/JOURNAL OF E M E R G E N C Y NURSING
Table 5 Continued Unit
WK 7 Level 3
WK 8 Level 3
WK 9 Level 4
WK 10 Level 4
WK 11 Level 4
WK 12 Level 4
Level 3
Level 4
Level 4
Level 4
Level 4
Level 4
Level 3
Level 3
Level 3
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 3
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 3
Level 3
Level 3
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 3
Level 3
Level 3
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 3
Level 3
Level 3
Level 4
Level 4
Level 4
Level 4
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 Strongly agree
4
3
2
Agree
Neutral
Disagree
50
33
16
15
33
--
66
33
--
33
66
--
--
16
16
83
--
33
66
--
(%)
1. T h e o r i e n t a t i o n p a t h w a y e v a l u a t i o n f o r m w a s helpful in m e a s u r i n g o r i e n t e e ' s p r o g r e s s . 2. T h e o r i e n t a t i o n p a t h w a y h e l p e d m e to a s s e s s in w h a t a r e a s t h e o r i e n t e e n e e d e d t h e g r e a t e s t assistance. 3. T h e o r i e n t a t i o n p a t h w a y w a s e a s y to u n d e r stand. 4. T h e o r i e n t a t i o n p a t h w a y m e a s u r e d t h e a r e a s i m p o r t a n t in critical care n u r s i n g . 5. The o r i e n t a t i o n p a t h w a y w a s too time c o n s u m ing. 6. T h e o r i e n t a t i o n p a t h w a y w o u l d help to identify o r i e n t e e s u n a b l e to f u n c t i o n a s a r e g i s t e r e d n u r s e in t h e unit. 7. The o r i e n t a t i o n p a t h w a y w o u l d help m e to obt&in r e s o u r c e s to facilitate t h e o r i e n t e e s ' progress.
Revised pathway Based on user comments
(%)
(%)
(%)
-
dependently
ficiency level 3 (performs with assistance) was subdi-
requested
vided into performs with assistance
categories,
(level 3) a n d p e r -
became
(%)
i
33
forms with minimal assistance on the evaluation form, pro-
-
1 Strongly disagree
50
(level 4). P e r f o r m s i n -
p r o f i c i e n c y l e v e l 5. P r e c e p t o r s
that the SDBA category be divided into two "Safety
in
Drug
Administration"
D e c e m b e r 1995
and
529
JOURNAL OF EMERGENCY NURSING/Kidd and Sturt
" S a f e t y in Blood A d m i n i s t r a t i o n . " O r i e n t e e s prog r e s s e d faster in d r u g a d m i n i s t r a t i o n a s a result of their clinical e x p e r i e n c e s . Our future r e s e a r c h w i t h t h e p a t h w a y involves d e t e r m i n i n g t h e e x t e n t to w h i c h d e v i a t i o n from t h e p r o j e c t e d p a t h i n d i c a t e s a n o r i e n t e e p r o b l e m in ass u m i n g role r e s p o n s i b i l i t i e s . T h e s a m e p r e c e p t o r s w h o a s s i s t e d in t h e d e v e l o p m e n t of t h e p a t h w a y h a v e d e r i v e d a list of i n t e r v e n t i o n s for e a c h c a t e g o r y . A s a n i n t e r v e n t i o n is p e r f o r m e d to r e t u r n o r i e n t e e s to t h e p r o j e c t e d p a t h , w e are c a l c u l a t i n g t h e t i m e n e e d e d for t h e m to r e t u r n to t h e p a t h to d e t e r m i n e w h e t h e r t h i s i n t e r v a l is faster t h a n t h a t e x p e c t e d if a n i n t e r v e n t i o n h a d n o t b e e n p e r f o r m e d . T h e s e d a t a will help identify o r i e n t e e s w h o m a y n o t b e a b l e to a s s i m i l a t e t h e ED n u r s i n g role early in t h e o r i e n t a t i o n p r o c e s s so t h a t c a r e e r c o u n s e l i n g c a n b e p r o v i d e d . T h e information will also help u s justify e d u c a t i o n a l i n t e r v e n t i o n s from a cost perspective.
Surm'na~ A n o r i e n t a t i o n p a t h w a y w a s d e v e l o p e d u s i n g principles of c a s e m a n a g e m e n t b y p r e c e p t o r s w h o i d e n t i fied critical i n d i c a t o r s of role p e r f o r m a n c e in t h e e m e r g e n c y d e p a r t m e n t . T h e s e i n d i c a t o r s w e r e organ i z e d into c a t e g o r i e s b a s e d on B e n n e r ' s t h e o r y of clinical k n o w l e d g e d e v e l o p m e n t . Four p r o f i c i e n c y levels w e r e d e v e l o p e d for e a c h category. A s e c o n d
p a n e l of e x p e r t p r e c e p t o r s d e c i d e d w h e r e t h e transit i o n s in four p r o f i c i e n c y levels o c c u r r e d d u r i n g a 12w e e k o r i e n t a t i o n period. T h e p r o g r e s s in o r i e n t a t i o n of s e v e n n e w g r a d u a t e s w a s c o m p a r e d w i t h t h e expected transitions identified by the expert preceptors. All o r i e n t e e s p r o g r e s s e d faster in e a c h c a t e g o r y t h a n e x p e c t e d b y t h e p r e c e p t o r s . More s t u d i e s w i t h t h e 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 t h e l e n g t h of o r i e n t a t i o n m a y b e r e d u c e d w i t h o u t compromising outcomes. We thank Linda Holtzclaw, RN, MSN, for her support in implementing 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 A n error appeared in the August article, "Rapid Sequence Induction in the Emergency Department" (J EMERG NURS 1995;21:305-9). T h e mistake appears on page 308 in Table 4 under the fifthbullet, in the " C o m m e n t s " related to the muscle relaxant pancuroninm. The words "increased carbon monoxide" should read "increased cardiac output."
530
Volume 21, Number 6
Objective Orientee e v a l u a t i o n forms f r e q u e n t l y focus o n t a s k s a n d t e c h n i c a l skills r a t h e r t h a n d e c i s i o n - m a k i n g skills. A n o r i e n t a t i o n p a t h w a y w a s developed to e v a l u a t e orientee clinical d e c i s i o n - m a k i n g skills. The p a t h w a y c a n assist in identifying orientees w h o require additional e d u c a t i o n a l resources or i n t e r v e n t i o n s . Early i n t e r v e n t i o n s m a y d e c r e a s e t h e l e n g t h of orientation, i n c r e a s e a n e m p l o y e e ' s l e n g t h of stay in t h e institution, a n d c o n t r i b u t e to cost savings. Methods The p a t h w a y w a s d e v e l o p e d w i t h employee exit i n t e r v i e w data, p r e c e p t o r interviews, identification of critical indicators, a n d the o r i e n t a t i o n literature. The p a t h w a y consists of six categories. Indicators w i t h i n each category w e r e identified a n d r a n k e d according to four levels of proficiency (level 1 for t h e least proficient a n d level 4 for t h e m o s t proficient). A c o n v e n i e n c e sample of s e v e n ED orientee a n d p r e c e p t o r pairs a g r e e d to participate in the pilot u s e of t h e p a t h w a y . A n e x p e c t e d timeline of progress h a d b e e n d e v e l o p e d by a group of 20 preceptors d u r i n g a preceptor workshop. A n a v e r a g e proficiency level (score) w a s o b t a i n e d for each category for 12 w e e k s w i t h t h e weekly scores p l o t t e d o n t h e p a t h w a y . This level w a s c o m p a r e d w i t h t h e e x p e c t e d proficiency level in each category for each week. Demographic information w a s o b t a i n e d from the orientee a n d preceptor pairs to d e t e r m i n e w h e t h e r certain characteristics facilitate p a t h w a y progression. Data w e r e a n a l y z e d w i t h f r e q u e n c y distributions, a n d m e a s u r e s of central t e n d e n c y a n d variance. S p e a r m a n ' s rank correlations w e r e u s e d to e x a m i n e t h e proficiency level in each category for each w e e k in relation to d e m o g r a p h i c characteristics of the p r e c e p t o r a n d orientee.
Dr. Kidd is an associate professor, Collegeof 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
Results Orientees p r o g r e s s e d faster t h a n e x p e c t e d in all categories. It took 8 w e e k s for a n orientee to a t t a i n the h i g h e s t proficiency level in all categories. The f a s t e s t progress w a s m a d e in t h e category "Accurately E v a l u a t e s P a t i e n t R e s p o n s e s . " Slowest progress w a s m a d e in the category "Safety in Blood a n d Drug A d m i n i s t r a t i o n . " Preceptors a n d orientees r a t e d t h e p a t h w a y as very useful. Discussion F u r t h e r s t u d i e s w i t h the orientation p a t h w a y m a y help to d e t e r m i n e t h e ideal time frame for orientation, characteristics of orientees w h o progress as e x p e c t e d or faster, a n d e d u c a t i o n a l s t r a t e g i e s to facilitate orientee p r o g r e s s i o n a n d clinical decision making. (J EMERG NURS 1995;21:521-30.)
n t h e w i n t e r of 1992, the N u r s i n g R e s e a r c h a n d Staff D e v e l o p m e n t (NRSD) D e p a r t m e n t of University Hospital, a 400-bed facility i n Lexington, Kentucky, e v a l u a t e d t h e critical care o r i e n t a t i o n program. At University Hospital, the e m e r g e n c y d e p a r t m e n t is c o n s i d e r e d a critical care unit. This s t u d y w a s p r o m p t e d b y preceptor c o m p l a i n t s t h a t e x i s t i n g orie n t e e e v a l u a t i o n forms focused on task c o m p l e t i o n a n d did not " c a p t u r e " t h e complexity of clinical decis i o n - m a k i n g skills e s s e n t i a l to s u c c e s s f u l p e r f o r m a n c e in critical care units. This s t u d y also w a s p r o m p t e d by the r e c e n t i m p l e m e n t a t i o n w i t h i n the hospital of the u s e of critical p a t h w a y s for the p u r p o s e of case m a n a g e m e n t . A greater e m p h a s i s w a s b e i n g placed on cost s a v i n g s per d e p a r t m e n t a n d the NRSD departm e n t w a s exploring s t r a t e g i e s for p r o m o t i n g cost savi n g s in orientation of n u r s i n g personnel. In addition, n e w g r a d u a t e s w e r e b e i n g hired for the first t i m e in the e m e r g e n c y d e p a r t m e n t , a n d the staff believed that the e x i s t i n g o r i e n t a t i o n p r o g r a m m i g h t b e i n a d e q u a t e in m e e t i n g the n e e d s of n e w graduates. T h e NRSD D e p a r t m e n t d e c i d e d to develop a critical p a t h w a y for critical care orientation. The u s e of a critical p a t h w a y e n h a n c e s e v a l u a t i o n of orientee de-
I
December 1995 S 2 |
JOURNAL OF E M E R G E N C Y NURSING/Kidd a n d Sturt
c i s i o n - m a k i n g skills for t h e p u r p o s e of i d e n t i f y i n g orientees who require additional educational interventions early in their orientation. Early intervention may 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 the institution and contribute to cost savings. This article describes the early development and evaluat 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 .
Projectbackground A t a s k f o r c e c o n s i s t i n g of N R S D p e r s o n n e l , a n u r s e recruiter, critical care managers, and three nursing faculty members with collaborative appointments at University Hospital was formed to discuss orientation 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 e x 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 left t h e f a c i l i t y 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 t o s e a r c h for p a t t e r n s r e l a t i n g t o n u r s e s ' p e r c e p t i o n s of j o b e x pectations and the work environment. Simultaneously, informal interviews were conducted with preceptors 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 e a r l y 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 there were problems in job performance. The existing orientee evaluation form required the preceptor to make judgments regarding the orientee's competence i n 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 j o b p e r f o r mance were frequently related to the nurse's ability to s o l v e 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 p e r f o r mance. The task force planned two separate preceptor workshops designed to share clinical teaching
Table 1 R a t i n g of c r i t i c a l i n d i c a t o r s P l e a s e c i r c 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 its 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 a s a n i n d i c a t o r . D o 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 .
Critical indicator
1. Fail cardiac, respiratory, a n d neurologic critical
Rank
Not a meaningful indicator 1
Needs major revision to b e a meaningful indicator 2
Meaningful but needs minor revision to b e a n indicator 3
Very meaningful indicator 4
1
2
3
4
1
2
3
4
1
2
3
4
1 1
2 2
3 3
4 4
1
2
3
4
1
2
3
4
1 1
2 2
3 3
4 4
1 1
2 2
3 3
4 4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
care tests
2. Relience on preceptor for basic nursing skills 3. Reliance on preceptor for critical care nursing skills 4. Poor a t t e n d a n c e 5. High p r e c e p t e e s t r e s s level * 6. Poor transition from t a s k s to whole picture * 7. Orientee-preceptor comm u n i c a t i e n problem 8. Compromised orientation 9. Orientee h a s a b a d attirude * 10. Inability to prioritize "11. Poor recall of previous learning * 12. C a n n o t convey rationale for actions "13. Inability to tie in assessmerit d a t a w i t h other data * 14. Inability to perform t a s k s without assistance "15. Does not recognize norrnal values "16. Requires multiple demonstrations
*Indicate i t e m s w i t h 90% or greater a g r e e m e n t as a very meaningful indicator.
522
Volume 21, Number 6
Kidd and Sturt/JOURNALOF E M E R G E N C Y NURSING
strategies and to discuss creation of a learning environment. Identification
of critical indicators
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 t e m ) Items with ->90% agreement as a very meaningful indicator (N-- 9) were retained. Development
of the critical pathway
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 Perform a n c e of Procedures, (4) Establishes Care Priorities (requires managing multiple demands simultaneously), (5) Clinical Decision Making (developing an appropriate plan of care), and (6) Accurately Evaluates Patient Responses (examining patient outcomes, recognizing the need for adapting the plan of care). Benner'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 psychomotor 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 Proficiency levels 1. R e v i e w s p r i n c i p l e s 9 Seeks descriptive information 9 Reviews descriptive information 9 Observes others 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 information, a s k s q u e s t i o n s 2. D e s c r i b e s skill c o m p o n e n t s 9 F o c u s e s o n i n f o r m a t i o n n e e d e d for self-performance 9 S t u d i e s i n f o r m a t i o n in d e p t h 9 Discusses performance step-by-step, describes 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 e r f o r m 3. P e r f o r m s w i t h a s s i s t a n c e 9 Identifies patient needs 9 Plans p e r f o r m a n c e a c c o r d i n g to p o l i c y 9 P e r f o r m s w i t h v a r y i n g e f f i c i e n c y levels, n e e d s assistance troubleshooting 9 Evaluates own performance and patient's short-term outcomes 9 Needs help identifying problems 4. P e r f o r m s i n d e p e n d e n t l y 9 I d e n t i f i e s p a t i e n t n e e d s o n c a s e specific b a s i s 9 Modifies p e r f o r m a n c e b a s e d o n p a t i e n t n e e d s 9 P e r f o r m s s m o o t h l y , a n t i c i p a t i o n of p r o b l e m s is routine 9 Evaluates own performance without help 9 E v a l u a t e s p a t i e n t ' s l o n g - a n d s h o r t - t e r m outcomes
December 1995 523
JOURNAL OF E M E R G E N C Y NURSING/Kidd a n d Sturt
by the panel of expert preceptors in the s e c o n d workshop). a Identification of areas in w h i c h orientees require greater resources to m e e t e x p e c t e d proficiency levels.
9 Identification of profiles or characteristics of successful orientees. Successful orientees were defined as those individuals who progress along the pathw a y in the m a n n e r d e s c r i b e d by the panel of expert preceptors.
Table 3 S a m p l e categories w i t h indicators Week Date:
1
2
3
Category 5: Accurately Evaluates Patient R e s p o n s e s 1. R e c o g n i z e s a b n o r me/findings 2. V a l i d a t e s p r e s e n c e of a b n o r m a l findi n g s (i.e., c h e c k s e q u i p m e n t , ass e s s e s patient) 3. A c t s a p p r o p r i a t e l y for a b n o r m a l findi n g s (i.e., a d m i n i s t e r s t r e a t m e n t , cont a c t s physician) 4. M o n i t o r s p a t i e n t for r e s p o n s e to t r e a t ment 5. D o c u m e n t s res p o n s e appropriately 6. C o m m u n i c a t e s res p o n s e verbally to p h y s i c i a n or o t h e r staff Average:
3
3
2
3
3
3
3
3
2
3
2
3
2.5
3
Category 6: Clinical Decision Making 1. Identifies a b n o r m a l data and pertinent negative findings 2. Links f i n d i n g s i n a meaningful pattern 3. C o n s i d e r s p o s s i b l e c a u s e s of a b n o r m a l d a t a / n e g a t i v e findings 4. Selects p r o b a b l e c a u s e of a b n o r m a l d a t a / n e g a t i v e findi n g s a n d t e s t s for its p r e s e n c e 5. A d a p t s n u r s i n g care to fit p r o b a b l e c a u s e of p a t i e n t ' s response 6. A n t i c i p a t e s pat i e n t ' s f u t u r e res p o n s e s to t r e a t ment Average:
524
Volume 21, Number 8
2
2
2
2
2
2
1
2
2
2
2
2
1.8
2
4
5
6
7
8
9
10
Kidd and Sturt/JOURNALOF EMERGENCY NURSING
9 Determination of the benefits of an orientation pathway in monitoring orientee performance. The project team sought to systematically evaluate 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 evaluate preceptors' learning styles during the workshops. Orientees' learning styles were assessed before the start of orientation with the same instrument. Preceptor-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 p a t h w a y (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 emerg e n c y 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 averaging 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 (scatterplots, quartile ranges), measures of central tend e n c y (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 derived from the preceptors (Table 5). The fastest progress was made in the category "Accurately Evaluates 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 Making" (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. Orientees 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
December 1995 525
OURNAL O F E M E R G E N C Y
NURSING/Kidd a n d Stu~
Table 4A Preceptor data sheet Code # T h a n k y o u for sharing this information. T h e information will be u s e d to help us design critical care orientation programs. Please circle the correct response. I. I have b e e n working in the e m e r g e n c y 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 b e e n working in the e m e r g e n c y 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 e m e r g e n c y department at UKIV[C: I, This is m y first time 2. 2 to 5 times 3, Greater than 5 times 4. I have precepted n e w graduates in the e m e r g e n c y department: 1. Y e s
2. N o 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~ D i p l o m a 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. D i p l o m a 7. I h a v e c o m p l e t e d t h e f o l l o w i n g 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 b y 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 b y t h e U n i v e r s i t y of K e n t u c k y C o l l e g e 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 U n i v e r s i t y of K e n t u c k y 4. N o 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 f o l l o w i n g a g e r a n g e : 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. O v e r 50 y e a r s 9. I h a v e t h e f o l l o w i n g c e r t i f i c a t i o n s a n d v e r i f i c a t i o n s ( P l e a s e circle all t h a t apply): 1. ACLS 2. T N C C 3. C C R N / C E N 4. ENPC 5. P A L S
6. O t h e r s : P l e a s e s p e c i f y 10. I a m a t t h e f o l l o w i n g r a n k of t h e UKMC Clinical N u r s i n g L a d d e r : 1. A D N I 2. A D N II 3. A D N 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 i n f o r m a t i o n !
UKIMC, U n i v e r s i t y of K e n t u c k y M e d i c a l C e n t e r ; ACLS, A d v a n c e d C a r d i a c Life Support; TNCC, T r a u m a N u r s i n g Core C o u r s e CCRN/CEN, critical c a r e r e g i s t e r e d n u r s e ; certified e m e r g e n c y n u r s e ; ENPC, E m e r g e n c y N u r s e P e d i a t r i c C o u r s e ; PALS, P e d i a t r i c A d v a n c e d Life S u p p o r t .
526
V o l u m e 21, N u m b e r 6
Kictd a n d Sturt/JOURNAL OF E M E R G E N C Y NURSING
35, indicating strong a g r e e m e n t about the usefulness of the pathway.
should be collected to assess
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 p a r ticipated in the internship before the pathway
Discussion Because the orientees in this study participated in a 6-week e m e r g e n c y nursing internship program and they progressed faster than anticipated, more data
used completed
was
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
protocol. The pathway provides one tangible method 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 Orientee data sheet
Code # T h a n k y o u for s h a r i n g t h i s information. The information will b e u s e d to help u s d e s i g n Critical Care orientation prog r a m s . Please circle t h e correct r e s p o n s e . 1. I h a v e previous critical care experience in t h e following positions (Circle all t h a t apply): 1. N u r s i n g a s s i s t a n t 2. N u r s e a p p r e n t i c e 3. LPN 4. RN 5. Other (please specify) 2. I h a v e h a d p r e v i o u s n u r s i n g experience o u t s i d e of critical care in t h e following positions (Circle all t h a t apply): 1. N u r s i n g a s s i s t a n t 2. N u r s e a p p r e n t i c e 3. LPN 4. RN 3. I h a v e b e e n a n RN for: 1, L e s s t h a n 1 y e a r 2. 2 to 5 y e a r s 3. 6 to 10 y e a r s 4. Over 10 y e a r s 5. I a m a n R N A 4. T h e h i g h e s t d e g r e e I h a v e in n u r s i n g is: 1. A s s o c i a t e 2. Diploma 3. B a c c a l a u r e a t e 4. M a s t e r ' s 5. T h e critical care c o m p o n e n t of m y basic n u r s i n g e d u c a t i o n p r o g r a m c o n s i s t e d of: 1. O b s e r v a t i o n a l e x p e r i e n c e only 2. C l a s s r o o m a n d clinical e x p e r i e n c e 3. S e p a r a t e n u r s i n g c o u r s e 4. No critical care e x p o s u r e 6. I h a v e a c c e p t e d a critical care position at UKMC in: 1. SICU 2. MICU 3. CTICU 4. CCU 5. N e u r o s c i e n c e ICU 6. B u r n u n i t 7. E m e r g e n c y d e p a r t m e n t 8. General s u r g e r y ICU 7. T h e main r e a s o n I s e l e c t e d a critical care position is: 1. Smaller nurse~patient ratio 2. P a t i e n t complexity 3. I already k n e w s o m e o n e in t h e unit 4. E x c i t e m e n t 5. Prestige a s s o c i a t e d w i t h t h e role 6. Served a s a s t u d e n t n u r s e apprentice 7. Other (please specify) T h a n k you for s h a r i n g this information!
LPN, L i c e n s e d practical nurse; RN, r e g i s t e r e d nurse; RNA, R e g i s t e r e d N u r s e Applicant; UKMC, University of K e n t u c k y Medical Center; SICU, surgical i n t e n s i v e care unit; MICU, medical i n t e n s i v e care unit; CTICU, cardiothoracic i n t e n s i v e care unit; CCU, coro n a r y care unit.
D e c e m b e r 1995
527
OURNAL OF E M E R G E N C Y
NURSING/Kidd and Sturt
Table 5 Expected versus actual orientee progress
Name Preceptors: Fill in proficiency level Orientation week WK 1 Expected Safety in Level 1 Drug/Blood Administration Actual Level 2
WK 2 Level 1
WK 3 Level 2
WK 4 Level 2
WK 5 Level 3
WK 6 Level 3
Level 3
Level 3
Level 3
Level 3
Level 3
Expected Technical Skills/Safe Performance of Procedures Actual
Level 1
Level 1
Level 1
Level 2
Level 2
Level 2
Level 3
Level 3
Level 3
Level 3
Level 3
Level 4
Expected Safe Equipment Usage Actual
Level 1
Level 2
Level 2
Level 2
Level 3
Level 3
Level 3
Level 3
Level 3
Level 3
Level 3
Level 4
Expected Accurately Evaluates Patient Responses Actual
Level 1
Level 1
Level 2
Level 2
Level 2
Level 2
Level 3
Level 3
Level 3
Level 4
Level 4
Level 4
Level 1
Level 1
Level 1
Level 2
Level 2
Level 2
Level 3
Level 3
Level 3
Level 3
Level 4
Level 4
Level 1
Level 1
Level 2
Level 2
Level 2
Level 3
Level 3
Level 3
Level 3
Level 3
Level 3
Level 4
Expected Clinical Decision Making Actual Expected Establishes Care Priorities Actual
t h o s e n o t p a r t i c i p a t i n g in t h e i n t e r n s h i p c a n n o w b e c o m p a r e d w i t h t h e 8 w e e k s n e e d e d for t h o s e in this study. Prior ED e x p e r i e n c e for b o t h t h e a s s i g n e d prec e p t o r a n d t h e o r i e n t e e w a s a s s o c i a t e d w i t h faster p r o g r e s s i o n t h r o u g h t h e p r o f i c i e n c y levels. A l t h o u g h further t e s t i n g of t h e p a t h w a y is n e e d e d , m a n a g e r s m a y w i s h to hire n e w g r a d u a t e s w i t h prior ED nursi n g a s s i s t a n t e x p e r i e n c e w h e n n e w g r a d u a t e s are h i r e d for t h e e m e r g e n c y d e p a r t m e n t . T h e s e findings s u p p o r t t h e n e e d to r e t a i n e x p e r i e n c e d ED n u r s e s to s e r v e as p r e c e p t o r s . B e c a u s e n u r s e s w i t h critical care c o n t e n t in their b a s i c n u r s i n g p r o g r a m p e r f o r m e d at h i g h e r profic i e n c y levels in t h e CDM c a t e g o r y earlier t h a n their cohorts, p e r h a p s m a n a g e r s should a s s e s s t h e b a s i c n u r s i n g e d u c a t i o n p r o g r a m of any n e w g r a d u a t e before h i r i n g for t h e i n c o r p o r a t i o n of critical care c o n t e n t a n d clinical e x p e r i e n c e . M o r e s t u d i e s are n e e d e d w i t h larger s a m p l e sizes to confirm this conclusion. B e c a u s e no o r i e n t e e m a s t e r e d t h e h i g h e s t profic i e n c y level in any c a t e g o r y before 4 w e e k s b u t all orie n t e e s a t t a i n e d t h e h i g h e s t p r o f i c i e n c y levels by 8 w e e k s , t h e ideal o r i e n t a t i o n p e r i o d m a y b e 8 w e e k s . In our e x p e r i e n c e t h e l e n g t h of o r ie n t a t io n for orien ~ t e e s o t h er t h a n n e w g r a d u a t e s varies w i t h t h e a m o u n t of ED e x p e r i e n c e . S i n c e t h e initial evaluation th e pathw a y h as b e e n u s e d w i t h 13 r e g i s t e r e d n u r s e s w h o
528
Volume 21, Number 6
w e r e n o t n e w graduates. On t h e basis of t h e s e data, t h e a v e r a g e l e n g t h of orientation is 5 w e e k s for r e g i s t e r e d n u r s e s w i t h ED e x p e r i e n c e an d 7 w e e k s for r e g i s t e r e d nurses w i t h o u t previous ED experience. As m o r e s t u d i e s are c o n d u c t e d w i t h larger s a m p l e sizes u s i n g t h e p a t h w a y , t h e traditional 12-week length of orientation m a y be r e d u c e d w i t h o u t c o m p r o m i s i n g t h e outcomes.
I n d i v i d u al s w i t h a v a r i e t y of l e a r n i n g styles m a y thrive in t h e e m e r g e n c y d e p a r t m e n t . Th e m o s t imp o r t a n t factor m a y b e t h e p r e c e p t o r ' s a w a r e n e s s of t h e o r i e n t e e ' s l e a r n i n g style so t h a t t h e p r e c e p t o r c a n adjust t e a c h i n g m e t h o d s to t h e o r i e n t e e ' s n e e d s . Alt h o u g h l e a r n i n g style w a s n o t correlated w i t h orient e e s ' p r o g r e s s in our initial e v a l u a t i o n of t h e p a t h w a y , a s s e s s m e n t of learning style is still warranted. S o m e p r e c e p t o r s n o t e d t h a t o r i e n t e e s m a y b e at a c e r t a i n p r o f i c i e n c y level w h e n w o r k i n g w i t h pat i e n t s w i t h u r g e n t a n d n o n u r g e n t p r o b l e m s b u t function at a lower p r o f i c i e n c y level in e m e r g e n t situations, particularly in t h e c a t e g o r i e s of CDM an d e s t a b l i s h m e n t of care priorities. This f e e d b a c k w a s o b t a i n e d d u r i n g t h e w e e k l y m e e t i n g s of t h e p r e c e p t o r , orientee, a n d staff d e v e l o p m e n t specialist. F u t u r e res e a r c h is 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 s e p a r a t e s c o r i n g should be p e r f o r m e d b a s e d on p a t i e n t subgroup and progress scores derived through a w e i g h t e d formula.
Kidd a n d Sturt/JOURNAL OF E M E R G E N C Y NURSING
Table 5 Continued Unit
WK 7 Level 3
WK 8 Level 3
WK 9 Level 4
WK 10 Level 4
WK 11 Level 4
WK 12 Level 4
Level 3
Level 4
Level 4
Level 4
Level 4
Level 4
Level 3
Level 3
Level 3
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 3
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 3
Level 3
Level 3
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 3
Level 3
Level 3
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 4
Level 3
Level 3
Level 3
Level 4
Level 4
Level 4
Level 4
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 Strongly agree
4
3
2
Agree
Neutral
Disagree
50
33
16
15
33
--
66
33
--
33
66
--
--
16
16
83
--
33
66
--
(%)
1. T h e o r i e n t a t i o n p a t h w a y e v a l u a t i o n f o r m w a s helpful in m e a s u r i n g o r i e n t e e ' s p r o g r e s s . 2. T h e o r i e n t a t i o n p a t h w a y h e l p e d m e to a s s e s s in w h a t a r e a s t h e o r i e n t e e n e e d e d t h e g r e a t e s t assistance. 3. T h e o r i e n t a t i o n p a t h w a y w a s e a s y to u n d e r stand. 4. T h e o r i e n t a t i o n p a t h w a y m e a s u r e d t h e a r e a s i m p o r t a n t in critical care n u r s i n g . 5. The o r i e n t a t i o n p a t h w a y w a s too time c o n s u m ing. 6. T h e o r i e n t a t i o n p a t h w a y w o u l d help to identify o r i e n t e e s u n a b l e to f u n c t i o n a s a r e g i s t e r e d n u r s e in t h e unit. 7. The o r i e n t a t i o n p a t h w a y w o u l d help m e to obt&in r e s o u r c e s to facilitate t h e o r i e n t e e s ' progress.
Revised pathway Based on user comments
(%)
(%)
(%)
-
dependently
ficiency level 3 (performs with assistance) was subdi-
requested
vided into performs with assistance
categories,
(level 3) a n d p e r -
became
(%)
i
33
forms with minimal assistance on the evaluation form, pro-
-
1 Strongly disagree
50
(level 4). P e r f o r m s i n -
p r o f i c i e n c y l e v e l 5. P r e c e p t o r s
that the SDBA category be divided into two "Safety
in
Drug
Administration"
D e c e m b e r 1995
and
529
JOURNAL OF EMERGENCY NURSING/Kidd and Sturt
" S a f e t y in Blood A d m i n i s t r a t i o n . " O r i e n t e e s prog r e s s e d faster in d r u g a d m i n i s t r a t i o n a s a result of their clinical e x p e r i e n c e s . Our future r e s e a r c h w i t h t h e p a t h w a y involves d e t e r m i n i n g t h e e x t e n t to w h i c h d e v i a t i o n from t h e p r o j e c t e d p a t h i n d i c a t e s a n o r i e n t e e p r o b l e m in ass u m i n g role r e s p o n s i b i l i t i e s . T h e s a m e p r e c e p t o r s w h o a s s i s t e d in t h e d e v e l o p m e n t of t h e p a t h w a y h a v e d e r i v e d a list of i n t e r v e n t i o n s for e a c h c a t e g o r y . A s a n i n t e r v e n t i o n is p e r f o r m e d to r e t u r n o r i e n t e e s to t h e p r o j e c t e d p a t h , w e are c a l c u l a t i n g t h e t i m e n e e d e d for t h e m to r e t u r n to t h e p a t h to d e t e r m i n e w h e t h e r t h i s i n t e r v a l is faster t h a n t h a t e x p e c t e d if a n i n t e r v e n t i o n h a d n o t b e e n p e r f o r m e d . T h e s e d a t a will help identify o r i e n t e e s w h o m a y n o t b e a b l e to a s s i m i l a t e t h e ED n u r s i n g role early in t h e o r i e n t a t i o n p r o c e s s so t h a t c a r e e r c o u n s e l i n g c a n b e p r o v i d e d . T h e information will also help u s justify e d u c a t i o n a l i n t e r v e n t i o n s from a cost perspective.
Surm'na~ A n o r i e n t a t i o n p a t h w a y w a s d e v e l o p e d u s i n g principles of c a s e m a n a g e m e n t b y p r e c e p t o r s w h o i d e n t i fied critical i n d i c a t o r s of role p e r f o r m a n c e in t h e e m e r g e n c y d e p a r t m e n t . T h e s e i n d i c a t o r s w e r e organ i z e d into c a t e g o r i e s b a s e d on B e n n e r ' s t h e o r y of clinical k n o w l e d g e d e v e l o p m e n t . Four p r o f i c i e n c y levels w e r e d e v e l o p e d for e a c h category. A s e c o n d
p a n e l of e x p e r t p r e c e p t o r s d e c i d e d w h e r e t h e transit i o n s in four p r o f i c i e n c y levels o c c u r r e d d u r i n g a 12w e e k o r i e n t a t i o n period. T h e p r o g r e s s in o r i e n t a t i o n of s e v e n n e w g r a d u a t e s w a s c o m p a r e d w i t h t h e expected transitions identified by the expert preceptors. All o r i e n t e e s p r o g r e s s e d faster in e a c h c a t e g o r y t h a n e x p e c t e d b y t h e p r e c e p t o r s . More s t u d i e s w i t h t h e 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 t h e l e n g t h of o r i e n t a t i o n m a y b e r e d u c e d w i t h o u t compromising outcomes. We thank Linda Holtzclaw, RN, MSN, for her support in implementing 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 A n error appeared in the August article, "Rapid Sequence Induction in the Emergency Department" (J EMERG NURS 1995;21:305-9). T h e mistake appears on page 308 in Table 4 under the fifthbullet, in the " C o m m e n t s " related to the muscle relaxant pancuroninm. The words "increased carbon monoxide" should read "increased cardiac output."
530
Volume 21, Number 6