Eager to use new graduates in the ED but aware that these nurses increase hospitals'' liability risks, St. Louis, Mo.-based Barnes Jewish Hospital is using a rigorous fellowship program to train new nurses to provide effective emergency care.

Jennifer Ann Williams, a Barnes-Jewish Hospital clinical nurse specialist, told the Watch that the hospital''s Trauma and Emergency Nursing Fellowship, which aims to bring new grads and other nurses without acute care experience to the ED, was the emergency department''s main source of new hires in 2002-2003. According to Williams, the "intense" four-month program, which combines classes and clinical work, means a new nurse doesn't "have to have five years of ED experience to be a really good ED nurse."

Since Barnes-Jewish Hospital started the program in June 2001, ED nurse turnover has declined from 20% to less than 10%; ED nurse-to-patient ratios have improved from 1:6 to 1:4-and are expected to improve further to 1:3, a long-term goal for the institution.

Giving new ED nurses a ''jump-start''
In early 2001, Williams realized Barnes-Jewish Hospital needed to leverage new graduates in the ED because "the ED needed nurses, but highly experienced ED nurses were not available." The hospital, which already had staffing vacancies, was finishing construction of a new ED that would require 40 additional RNs. Williams culled ideas from a number of sources-including the nurse fellowship program at Washington D.C.'s Washington Hospital Center and the Emergency Nurses Association''s "didactic modules"-then proposed four months of class and on-site lab work, including orientation to the hospital, and marketed the program to administrators as a "jump-start" on critical thinking and other care skills.

Using newspaper advertisements and a college recruiter, and eventually word of mouth, the program has attracted practicing nurses as well as new graduates from area schools, Colorado, and Texas; Williams fills each class of nine from a pool of about 30 applicants. In addition to the $9,800 normally spent on conventional orientation, Barnes-Jewish Hospital pays $16,200 per fellow to cover compensation for instructors and preceptors, costs that Williams believes the hospital recoups in the long run through improved retention and reduced vacancy rates. Fellows, who commit to working at Barnes-Jewish Hospital for two years in exchange for the training, receive salaries and benefits during the program but are not considered part of the staff.

Balancing class, clinical experience
The program begins with three weeks of classes-taught by Barnes Jewish staff including Williams, former fellowship RNs, nurse managers, and charge nurses-that review each body system and teach students how to treat patients who need immediate attention. Students then alternate between eight-hour class days and 12-hour clinical days in the ED, shadowing nurse preceptors who are trained and compensated for their service (Ollier, Patient Care Staffing Report, April 2004). While traditional orientation provides enough introduction for experienced nurses, the fellowship seeks to give ED novices a complete overview of ED processes and relevant care topics.

Williams said that traditional orientation is useful for experienced nurses because they simply need to learn the hospitals'' processes; new nurses, however, benefit from the fellowship''s "safety zone" while learning the skills they need for the ED. In creating and updating the curriculum, Williams observes fellows'' clinical work and regularly meets with staff and preceptors to ask them if fellows need more experience in any particular area, making changes accordingly. Williams also tracks fellows'' progress, recommending that they stay in the program only if they are solving problems quickly and aggressively seeking out "new experiences."

Positive performance
The fellowship program not only gives new graduates the opportunity to "start somewhere exciting," Williams said, but also allows nurses to "bypass" the years it normally takes them to get their feet wet on a typical med/surg floor, become "well-grounded" in an ICU, and finally move to the ED. Out of 52 enrollees across the past three years, 34 graduated and are on staff in the ED-a 65% graduation rate; thirty-five percent of fellows drop out from each semi-annual class, usually after discovering that they are not cut out for ED nursing, Williams said (Watch interview, 4/23/04; Ollier, Patient Care Staffing Report, April 2004).

Three-quarters of the fellowship graduates have "performed exceptionally well," Williams noted, especially in "problem-solving" skills, and none of the fellows have been involved in more medical errors or patient falls than experienced nurses. She acknowledged that the remaining 25% "have struggled" in the ED, taking too much time for each task; nurses in this group are required to participate in additional classes, extended orientation, and meetings on ED guidelines. Based on the fellowship''s success, the ICU has launched a similar initiative.

For more information
The Nursing Executive Center''s 2001 study, Elevating Frontline Performance, spotlights enhanced new graduate orientation. In addition, the NEC''s 2000 study, Reversing the Flight of Talent, discusses accelerated specialty orientation and new hire support programs.