CLINICAL
NEW GRADUATES IN THE EMERGENCY
DEPARTMENT: COULD YOU, WOULD
YOU, SHOULD YOU?
Authors: Susan Winslow, MSN, RN, NEA-BC, Marcus Almarode, BSN, RN, Sarah Cottingham, MSN, CNL,
Kim Lowry, RN, and Kristin Walker, BSN, RN, CCRN, Charlottesville, VA
Earn Up to 8.5 CE Hours. See page 598.
S
ince its founding as an independent community hos-
pital more than 100 years ago, Martha Jefferson
Hospital has constantly evolved to meet the diverse
health care needs of patients who entrust us with their care.
The emergency department at Martha Jefferson Hospital is
a 20-bed, 5-fast tract, 3-bay triage center in a community
hospital setting where care is provided for a variety of
patient populations. The interdisciplinary team focuses on
providing exceptional emergency medical care to patients
of all ages and providing nursing care for all specialty areas.
The theoretical framework that guides the professional
development of nurses at Martha Jefferson Hospital is
based on Benner’s “Novice to Expert” model.1 Our orien-
tation and initial competency programs validate and move
new hires from “novice” to “advanced beginners.” Our
Department of Nursing Education and Shared Governance
Education and Professional Development Council function
to move staff to “experienced,” “proficient,” and “expert”
levels through continuing education, certification, and a
clinical ladder advancement program.
Like many hospitals, our organization continues to be
challenged with recruiting sufficient numbers of experi-
Susan Winslow is Director of Nursing Education and Community Services,
Martha Jefferson Hospital, Charlottesville, VA.
Marcus Almarode, Member, Chapter 370, is Clinical Educator, Martha Jeffer-
son Hospital, Charlottesville, VA.
Sarah Cottingham is Clinical Nurse Leader Student, University of Virginia
School of Nursing, Charlottesville, VA.
Kim Lowry, Member, Chapter 370, is Nurse Manager, Martha Jefferson Hos-
pital, Charlottesville, VA.
Kristin Walker is Clinical Educator, Martha Jefferson Hospital, Charlottes-
ville, VA.
For correspondence, write: Susan Winslow, Martha Jefferson Hospital,
459 Locust Ave, Charlottesville, VA 22902; E-mail: susan.winslow@mjh.org.
J Emerg Nurs 2009;35:521-4.
Available online 20 March 2009.
0099-1767/$36.00
Copyright © 2009 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
doi: 10.1016/j.jen.2008.12.016
November 2009 35:6
enced emergency nurses. Demand for this specialty area
has historically exceeded qualified supplies and is magnified
with the current nursing shortage, an aging workforce, and
new graduate retention challenges. It is anticipated that by
2020, the United States will need about 1 million more
nurses than the predicted supply.2
Previous Strategies
With the national nursing shortage and nursing retirement
movement influencing the availability of specialty care
nurses, recruiting experienced emergency nurses continues
to be a struggle. Our organization has implemented a vari-
ety of programs to support nurse staffing in the emergency
department, including increasing monetary recruitment
bonuses, using hospital central float nurses, cross-training
nurses from other critical care areas, utilizing national
recruitment agencies and travel nurses, and approval of
overtime with incentive pay for current staff who elect to
work extra shifts. The drawback to utilizing these tempor-
ary solutions continued to be burnout of current staff, lack
of ownership in organizational programs, and increased
staffing costs. We also utilized strategies to “grow our
own” by organizational and scholarship support of employ-
ees enrolled in Paramedic to Registered Nurse (RN) pro-
grams and other traditional RN nursing programs.
Despite these efforts, we continued to experience a shortage
of qualified RNs to staff our emergency department.
Overview
In response to the shortage of experienced emergency
nurses to fill vacancies, we decided to pilot a highly struc-
tured, extended orientation program for new graduates in
the emergency department. The ED New Graduate Nurse
Internship Program prepares inexperienced RNs for the
challenging and fast-paced specialty of emergency nursing;
it allows for a successful transition of this cohort into prac-
tice and meets organizational retention goals.
The program is specifically built to enhance critical
thinking and professional practice skills in the new gradu-
JOURNAL OF EMERGENCY NURSING 521

ates. Emphasis is placed on evidence-based practice, scope,
competence, assessment skills, and teamwork. The program
features a comprehensive orientation, clinical coaching, and
mentoring by clinical experts in emergency nursing. The
transition for a new graduate nurse can be challenging,
but the ED New Graduate Nurse Internship program pro-
vides the skill development and environmental support to
face these challenges and have novice new graduates develop
into professional advanced beginner emergency nurses.
Candidate selection is critical to the success of the ED
New Graduate Nurse Internship Program. ENA3 cites the
following personal characteristics of ideal emergency nurses:
• Ability to shift gears and accelerate pace as needed
• Good observational, assessment, and prioritization skills
• Multi-tasking skills
• Good interpersonal and customer service skills
• Stamina
• Good personal coping skills
• Assertive patient advocate
• Ability to maintain calm amidst chaos
• Good sense of humor
• Ability to think fast on one’s feet
Candidates are screened using behavioral interviewing to
ensure they have the aforementioned attributes. Candidates
with experience as paramedics, EMTs, EMS volunteers,
ED student extern program participants, and those with
ED student senior honors or synthesis clinicals are preferen-
tially recruited. Candidates without any of these qualifica-
tions participate in a pre-hire, non-paid, 4-hour minimum
ED shadowing experience. All participants are required to
sign a letter of intent validating a 2-year commitment to
the organization from the beginning date of the program.
Unsuccessful performance issues invalidate this commitment.
The program formally began in July 2007 after an
exhaustive review of similar initiatives from other organiza-
tions’ extern programs was conducted,4,5 a proposal was
outlined, and approved operational support was obtained.
Candidates needed to be prepared to make a full-time com-
mitment to the internship program for the duration of the
6 months.
Program Structure
Our ED New Graduate Nurse Internship Program had
7 components: general orientation, clinical rotations, clini-
cal support, didactic learning, core learning enhancements,
and graduation. All participants underwent general hospital
orientation and general nursing orientation, including all
components of the unit-based orientation program and core
skill competencies. All participants rotated through a variety of
522
CLINICAL/Winslow et al
TABLE 1
Collective ratings of program participants on perso-
nal characteristics identified as important for emer-
gency nurses
Average rating
Trait at hirea
Ability to shift gears and accelerate pace 4.3
as needed
Good observational, assessment, and 3.3
prioritization skills
Multi-tasking skills 4
Good interpersonal and customer 4
service skills
Stamina 4
Good personal coping skills 4.3
Assertive patient advocate 3.6
Ability to maintain calm amidst chaos 4.3
Good sense of humor 4.6
Ability to think fast on one’s feet 4
a
Using a 5-point scale with 5 being excellent and 1 being poor.
clinical areas and also participated in an EMS “Ride-a-long”
program. The experiences focused on beginning assessment,
prioritization, resource management, and skill acquisition.
Throughout the 6-month program, didactic content as
well as clinical training were provided by RN preceptors and
staff dedicated specifically to the program. During a normal
work week, the new graduates would work three 12-hour
shifts in the emergency department with their preceptor
in a group clinical instructor model and spend 4 hours
per week in the classroom studying the ENA-accredited text
and companion interactive modules.6 Their didactic ses-
sions were facilitated by a Clinician IV expert ED staff nurse
certified in emergency nursing, who enhanced the text
material with critical thinking and anecdotal discussions.
Didactic content and clinical experiences were paired
when possible. When the participants studied cardiovascu-
lar assessment and the care of patients with cardiovascular
emergencies, their clinical preceptor prioritized to accept
patients who presented with cardiovascular complaints.
Clinical training included technical and assessment skills,
anticipation of interventions, hospital-specific nursing pol-
icy and procedures, and critical thinking and prioritization
guidance. Supplemental didactic training was provided.
By the fourth month of the program, the participants
began assuming responsibility for their patients. In the
pilot program, by this time they were functioning quite
independently but their preceptor continued to serve as a
JOURNAL OF EMERGENCY NURSING 35:6 November 2009
 CLINICAL/Winslow et al

TABLE 2
Assessment of behavioral and skill goals of the internship programa
Skill or behavioral attributes Pre-program Mid-program (3 mo) Final (6 mo)
Beginning assessment 3 3.8 4.2
Prioritization of patient needs 2.6 3.2 3.5
Overall nursing procedural skills 3 3.5 4.2
Evidence-based nursing practice 3.3 3.3 3.8
Understanding of the RN scope of practice 2.6 4.3 4.3
General knowledge of emergency nursing 2.3 3.5 3.8
Intravenous skills 2.3 3.3 4.2
Phlebotomy skills 3 4.3 4.5
Focused Emergency Nursing Assessment skills 2.3 3 4.2
Critical thinking skills 3.6 3.2 3.5
Teamwork 4 4.3 4.7
Medication administration Not assessed 4 5
Medical equipment Not assessed 4 4.7
Computer documentation Not assessed 3.8 4.7
Total score 2.9/5 3.5 4.5

a
Using a 5-point scale with 5 being excellent and 1 being poor.

resource as needed. By the end of the 6-month program, Recruitment

the new graduates were equipped with the skills and con-
The program concept was well received by potential
fidence to demonstrate safe, independent nursing practice.
employees, as evidenced by verbal feedback to the nurse
The unit-based clinical educator and nurse manager
recruiter at various recruitment events. It was viewed as a
oversaw the process through weekly debriefings with the
positive “tool” and showed the depth and sophistication
new graduates. The last 2 months of the program were
of orientation options into specialty care areas for poten-
focused predominately on 1:1 clinical experiences with an
tial staff. All candidates for the program were screened
assigned preceptor on the shift on which the new graduate
using ENA behavioral characteristics.3 In the original pilot,
would be working after the program’s completion. At the
placement in the program was offered to 5 candidates, and 3
completion of the program, a special celebration was held
of these offers were accepted. The 2 candidates who declined
to celebrate the program’s success and to recognize the par-
cited salary and geographic relocation as their reasons
ticipants’ accomplishments.
for refusal.
The program participants were asked to assess them-
Results and Outcomes selves on personal characteristics identified as important
for emergency nurses. Their collective ratings, using a
Expanded nurse orientation programs for new graduates
5-point scale with 5 being excellent and 1 being poor, are
transcend standard orientation programs in duration, focus,
listed in Table 1.
and complexity.4 Recent evidence supports the effectiveness
of these programs in reducing new graduate turnover rates.
Our program tracked success through measurement of: Program

1. Participant satisfaction before the program began, in the
middle of the program, and at the conclusion of the program
2. Skill and knowledge self-assessment before and after the
program, using the ENA orientation skills matrix checklist7
3. New graduate retention rates at 1 year
4. Perceived competency at 1 year (6 months after program
completion) using qualitative interviews
Behavioral and skill goals of the internship program were
assessed at the initiation of the program, mid program,
and at the program’s conclusion using a 5-point scale, with
5 being excellent and 1 being poor. Expected and desired
skills and behavioral development occurred (Table 2).
All of the participants successfully completed all 7 com-
ponents of the program—General Human Resources and

November 2009 35:6 JOURNAL OF EMERGENCY NURSING 523


General Nursing Orientation, Clinical Rotations, Clinical
Support, Didactic Learning, Core Learning Enhancements,
Study/Clinical Days, and a “Graduation” event—within
the allotted time frame. One year later, 100% retention
of these nurses has been achieved.
Qualitative Findings
The new graduates believe that the internship program ade-
quately prepared them to provide safe, high-quality patient
care. Aspects of the program that particularly enhanced
their knowledge and skills include the clinical preceptor-
ship, didactic learning, Advanced Cardiac Life Support
review, and the shadowing sessions (particularly in the car-
diac catheterization laboratory and on the ICUs). All par-
ticipants stated that the 6-month length of the program is
appropriate. In general, the new graduates report being
satisfied with their jobs. Each new graduate feels supported
by her peers, professionally and personally. See Appendix
for supporting comments.
Resources
The Association of Nurse Executives and Nursing Execu-
tive Center cite costs of $64,000 to recruit and orient a spe-
cialty care nurse.4 The resources required to recruit, orient,
and train the 3 new ED graduates included a primary ED
preceptor, extended length of the orientation program
(6 months versus standard 3 months), and full-time equiva-
lents to cover positions “held” by the new graduates and
facilitator for the didactic modules. The total cost for the
actual program was approximately $90,000, 50% less than
the benchmark cost of $192,000 to recruit 3 staff RNs.
Future Implications/Limitations
The program by all accounts has been highly successful.
Minor modifications have been made based on feedback
from the participants, preceptors, and ED and Nursing
Education leadership. The new graduates have measurable
core knowledge and skills that are higher than that of new
graduates on other units because of the comprehensive pro-
gram components. Since the pilot, this program has suc-
cessfully been repeated. It is unknown if the program
would be as successful in a larger organization, specialty
care emergency department, or in academic health care set-
tings, but the possibility exists.
REFERENCES
1. Benner PE. From Novice to Expert: Excellence and Power in
Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley,
Nursing Division; 1984.
524
CLINICAL/Winslow et al
2. Bureau of Labor Statistics, U.S. Department of Labor. Occupa-
tional Outlook Handbook, 2006-2007 Edition, Registered
Nurses. http://www.bls.gov/oco/ocos083.htm. Accessed September
12, 2008.
3. Emergency Nurses Association. You want to be a nurse. http://
www.ena.org/student/BeANurse.asp. Accessed January 31, 2007.
4. Nursing Advisory Board. Transition new graduates to hospi-
tal practice: profiles of nurse residency program exemplars.
http://www.advisory.com/members/default.asp. Accessed January
26, 2007.
5. Emergency Department Nurse Residency Program. http://
wwwsvh.stvincents.com.au/index.php?option=com_content& task=-
view&id=332&itemid=356. Accessed January 31, 2007.
6. Jordan KS. Emergency Nursing Core Curriculum. 5th ed. Phila-
delphia: Saunders; 2000.
7. MC Strategies [computer program]. ENA orientation skills
matrix. Atlanta, GA: Elsevier; 2008.
Appendix
Themes and recommendations.
THEME 1: REALITY SHOCK
“Even when it’s fully staffed and it’s at its best, it’s a
stressful thing to go through, and you do one shift and
you’re kinda like, phew.”
THEME 2: SENSE OF ACCOMPLISHMENT
“I’m at the point now where I can take 4 maybe 5 pa-
tients and help my fellow nurses, and that really is a
sense of accomplishment.”
THEME 3: HIGH EXPECTATIONS
“I think I’m hard on myself and I’ve always been hard
on myself and that doesn’t help. I’m not incompetent,
but what’s the word? I’m not confident, not confident
in myself, and that doesn’t help.”
THEME 4: FEAR
“The first time I did a STEMI by myself, I seriously
thought I was going to have to be in the Cath Lab next.”
THEME 5: AUTONOMY AND OWNERSHIP
“But, you know I honestly think it’s actually really good
to be a new nurse b/c …we’re scared to do stuff, we’re
very safe and I’m very protective of this little, of this little
license. I’ve gotta protect it, even if I’m tired and I’ve just
gotta remember to step back and do the most important
things first.”
THEME 6: THE RIGHT FIT
“I love being a nurse. I could not work on any other floor
besides the ER.”
JOURNAL OF EMERGENCY NURSING 35:6 November 2009