Digital Repository Masters Projects Spring 2023 Comprehensive Orientation for Newly Hired Trauma Program Managers Jennifer Goodman Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Goodman, J.. 2023. Comprehensive orientation for newly hired trauma program managers. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. 1 WSU REPOSITORY MSN/DNP Comprehensive Orientation for Newly Hired Trauma Program Managers Project Title by Jennifer Goodman Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT April 1, 2023 Date Jennifer Goodman, BSN, RN, MSN Student April 1,2023 Student Name, Credentials Date (electronic signature) April 4, 2023 MSN Project Faculty (electronic signature) Date 5/5/2023 Melissa NeVille Norton (electronic signature) DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. Date 2 Comprehensive Orientation for Newly Hired Trauma Program Managers Jennifer Goodman, BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing 3 Abstract Trauma programs across the United States improve injured patients' care and patient outcomes while improving hospital patient care. Hiring trauma program managers (TPMs) without a formal, comprehensive orientation increases stress and decreases job satisfaction. The increased pressure and reduced job satisfaction often play a role in the TPM deciding to leave the job. Developing a robust, effective trauma program with process improvement takes time; thus, the TPM must stay in the position for a significant period. Many newly hired TMPs also struggle with changing roles from competent, successful floor nurses to managing a complex hospital-wide trauma program. TPMs are not given formal training in management, leadership, or other essential skills like budgeting and communication, which are needed to be successful leaders. A complete, comprehensive orientation will increase job satisfaction and decrease TPM stress, allowing and supporting the creation of a robust and successful trauma program. Hospitals, communities, and patients will benefit from successful trauma programs as they improve patient care for the entire hospital and elevate the care of the community. Creating an orientation manual for the newly hired TPMs will result in the retention of the managers, improved trauma programs, and improved patient care and outcomes. Keywords: trauma program manager, trauma program, orientation, process improvement, injured patients, patient outcomes, management, leadership, community outreach 4 Comprehensive Orientation for Newly Hired Trauma Program Managers Trauma programs around the country decrease mortality in injured patients (Vernon et al., 2020). Successful programs are developed and implemented through a strict designation verified by the American College of Surgeons (ACS) or at a statewide level following the ACS guidelines (ACS, 2018). Robust trauma programs consist of many components, such as care for the injured patient consistently and systematically, injury prevention, community outreach, and hospital-wide involvement. In addition, each part of the program must work together to form a network of team members caring for the injured patient on the way to the hospital and when they arrive. The Trauma Program Manager (TPM) is responsible for the leadership of the hospital-wide trauma program. The TPM must be a person that can influence others and be engaged, passionate, and dedicated (Gosnell, 2021). The TPM must be willing to lead by example and set high standards for the rest of the hospital and the trauma team (Gosnell, 2021). The TPM reports to and works directly with the Trauma Program Medical Director (TMD). The TPM must also have a good working relationship with the Emergency Department (ED) Manager. There must be mutual goals and high levels of commitment from all involved in or to shape a strong trauma program (Gosnell, 2021). The hospital administration holds the TPM responsible for the program's quality, and the TPM reports to them at upper-level Trauma Executive Committee (TEC) Meetings (ATS, 2020; Gosnell & Silvinski, 2021). The TPM must regularly look for ways to improve the program using performance improvement (PI) based on trauma data and patient outcomes (ACS, 2022; Gosnell & Slivinski, 2021). Implementing process improvement (PI) in the program leads to a more robust and mature program. When the hospital sits for redesignation every three years, the TPM must show this improvement to succeed. For example, creating a mass transfusion protocol for trauma patients is a PI that will improve the effectiveness of patient care in a healthcare facility or system (ACS, 2022). PI can also improve things such as decreasing length of stay times, decreasing physician response times, or decreasing door-to-CT times (ACS 2022). The TPM must use 5 and interpret accurate trauma data to identify and trend injuries, then reach into the community to prevent individuals from further injuries through community education and injury prevention programs. Injury prevention should focus on injuries verified by data and seen in the local community, then provide solutions such as helmet use, fall prevention, Stop the Bleed classes, and car seat use (American Trauma Society, 2020). The TPM uses benchmarking to compare the program's performance against similar hospitals at the state and national levels (ATS, 2020). When correctly used, benchmarking can help determine which PI programs would be needed and effective (ATS,2022). Statement of Problem Quality training and educational programs positively affect managers' knowledge, skills, sense of competence, and overall job satisfaction (Keith et al., 2020; Ravaghi et al., 2021). Because nurse managers receive insufficient training, implementing the proposed project will address this gap by providing a comprehensive orientation that will increase the new manager's confidence, abilities, and likelihood of success. At a Level IV Trauma Center, the TPM leads the program independently. Capable and skilled nurses hired as Level IV TPMs are not given a comprehensive orientation to their new role. Lack of orientation and training results in frustration, decreased job satisfaction, and frequent turnover. In addition, since many nurse managers do not receive a formal orientation or mentorship, they often learn by making mistakes, causing increased stress and job dissatisfaction. (Keith et al., 2020; Keil, 2020; Saifman & Sherman, 2019). Effective leaders must lead a successful trauma program (Ramirez et al., 2021). Successful trauma programs achieve and maintain trauma designation or verification from the state or the ACS survey. In addition, successful programs see improvement in trauma data, organization support or buy-in from the organization, and improved patient outcomes supported by the trauma data (ACS, 2022; Gosnell & Slivinski, 2021). Unfortunately, many new TPMs feel inadequate transitioning from the role of competent and seasoned patient care nurses in the ED to managing a trauma program due to a lack of training 6 (Newcomb et al., 2020). With the high turnover rates of TPMs and the lack of experience in newly hired TPMs, it is often challenging to demonstrate success in the trauma program. PI implements changes that improve trauma patient outcomes. These changes and improvements take time and require a TPM that is invested in the program long-term and can oversee the program and influence the needed modifications (Coniglio et al., 2018). Ways Project Contributes to Intended Recipients Providing a comprehensive orientation program to newly hired TPMs may help them feel more supported and aware of their many responsibilities. Orientation is critical whether the TPM is employed to create a new trauma program in the hospital or sustain and improve an existing one. Under the direction of The ACS and the Bureau of Emergency Medical Services and Preparedness, the Utah Department of Health approves trauma programs. It provides guidelines and requirements that must be met for trauma designation in a Level IV facility to obtain and maintain the verification. The TPM ensures all of these guidelines and conditions are met. If the TPM creates a new program, the program must meet just under 300 specific requirements for a successful Level IV trauma designation (ACS, 2022). Providing an orientation will help the new TPM balance the many tasks and gain confidence in developing or growing a trauma program. Rationale for Importance of Project Implementing quality improvement in trauma programs, directed by TPMs, significantly decreases trauma patients' mortality and complication rates (Hashmi et al., 2021). The TPM must ensure that the entire trauma team is educated and follows the Advanced Trauma Life Support (ATLS), Trauma Nurse Core Course (TNCC ), and Emergency Nurse Core Pediatrics (ENPC) trauma guidelines. In addition, the TPM reviews patient charts to ensure adequate documentation and that the care meets trauma standards. In preparing for and leading trauma process improvement committee (TPIC) meetings, the TPM helps ensure the entire hospital is actively engaged in a trauma culture (ACS, 2022). Liaisons from each hospital department attend these meetings. In addition, Level IV trauma centers support Level I Trauma Centers by 7 providing the initial assessment and resuscitation before transfer to facilities that have more resources to care for severely injured patients (Choi et al., 2022). In addition, they must oversee other parts of the trauma program, including disaster preparedness, hospital committees, the trauma registry, and the transfer of patients to a higher level of care when additional resources are needed. Continuing education includes trauma grand rounds, Emergency Medical Services (EMS) lunch and learns, trauma education for the ED team, and case reviews. The TPM must also monitor any injured patients admitted to the hospital to ensure they have no adverse events during their hospital stay (ATS, 2020). Finally, the TPM works closely with (EMS) regarding pre-hospital care and patient transfers (ATS, 2020). Frequent, updated, and current training and educational programs positively affect hospital managers' knowledge, skills, and competencies. Conversely, not having a sound orientation program affects turnover (Keil, 2020); Keith et al., 2020; Ravaghi et al., 2021). According to anecdotal data from newly hired TPMs in the Salt Lake Valley, they feel overwhelmed, discouraged, unsure, and have to figure things out themselves. Others stated that they work extra hours off the clock, take the stress of their job home with them, and even have trouble sleeping. One nurse said they feel like they are losing their nursing skills, doubt themselves, and are always looking for another job. These comments suggest that a formal, comprehensive orientation is needed. Providing a thorough orientation will give direction and support to new TPMs hired. The connection between nurse managers' stress from workload, overall job stress, and decreased job satisfaction is genuine. Reduced job satisfaction causes nurse leaders to retire or leave their jobs (Cox, 2019; Jappinen et al., 2021; Labrague, 2020). Because a successful program does not happen overnight, the TPM must be dedicated and committed for several years (Gosnell & Slivinski, 2021). Literature Review and Framework A literature search was conducted to identify and explore current evidence regarding nurse manager orientation, stress levels, job satisfaction, and intent to leave their jobs. As a result, nurse managers need a comprehensive orientation to succeed in their roles. Research with various levels of evidence was reviewed 8 during the search. In addition, evidenced-based frameworks were identified, reviewed, and evaluated to assist in selecting a framework for this project. Framework A comprehensive orientation process for newly hired TPMs will help build successful trauma programs and improve patient outcomes. The newly revised 2022 Johns Hopkins Nursing Evidenced-Based Practice Model (JHNEBP) allows the discernment of best practices and helps to incorporate them into everyday practices (Dang et al., 2022). Administrative leaders at the Johns Hopkins hospital developed this model specifically for the department of nursing (Gawllinski& Rutledge, 2008). The JHNEBP model, according to Dang et al. (2022), will be used to clearly identify the practice question or problem, determine the best evidence to answer the question or solution to the problem, and, most importantly, assist in translating that new evidence into practice. In addition, the JHNEBP will help evaluate the current policies and procedures used to onboard new TPMs and use its step-by-step guidelines to decide how to create a new orientation program that is sound and evidence-based (Dang et al., 2022). JHNEBP is the framework that will be used to implement the new comprehensive orientation process for newly hired TPMs (Dang et al., 2022). The model will help guide the creation of the new orientation process by using a problem-solving approach to needed change (Dang et al., 2022). The JHNEBP has three main phases: developing an evidenced-based practice question; searching for and summarizing evidence; and translating the evidence into an action plan (Dang et al., 2022). The model uses a robust problemsolving approach to making clinical decisions and is user-friendly with a step-by-step fill-in-the-blank guide to help organizations through the change process in individual or group settings (Dang et al., 2022). During phase one, a practice question is developed through seven steps, including assembling a team, identifying stakeholders, choosing a team lead, clarifying the problem and verifying the need, refining the question, and scheduling future meetings. Phase two is an evidence search and includes steps 8-12. In phase two, the internal and external search for information occurs, and the results are appraised, summarized, and 9 synthesized. Finally, recommendations for the suggested change are made. Phase three is the translation and includes steps 13-20. In this phase, the team identifies specific recommendations, creates an action plan, secures resources needed to implement the plan, implements the plan, evaluates outcomes and determines improvements, reports the results to stakeholders, identifies next steps, then disseminates the findings (Dang et al., 2022). Strengths and Limitations The strengths of the JHNEBP include being nursing-centric or nurse-centered and a strong focus on enhancing team collaboration and care coordination. In addition to being nursing-focused, it is also patientcare-focused(Dang et al., 2022). The model can also easily translate to several areas of nursing, including clinical settings and administrative and educational nursing practice (Melnyk & Fineout-Overholt, 2019). The model uses current evidence as a base for decision-making (Gawlinski & Rutledge, 2008). The model helps the team decide whether moving forward with the change should be implemented or whether there are other options (Dang et al., 2022). For example, one step asks if there are alternatives for solving the problem, and another asks if it is feasible to make the proposed changes (Dang et al., 2022). Using this model will help in the project because it will ensure that a change is needed and the change will improve processes. In addition, demonstrating evidenced based practice to the trauma operations management team will likely result in their support of the change. The model's limitations are that engaging stakeholders to embrace implemented change can often be a barrier, and the JHNEBP does not address this. However, it does encourage using stakeholders to form the team (Melnyk & Fineout-Overholt, 2019). Nurses often realize barriers to implementing EBP from organizations, such as not having the authority to make changes (Alqahtani et al., 2022). Often administrators and leaders must be consulted and be involved in the process of planning and implementation of change. Leaders may not embrace or fully support the changes, or facilities may be inadequate to 10 implement EBP (Alqahtani et al., 2022). Once a change occurs, sustaining the difference can be challenging for the JHNEBP model (Melnyk& Fineout-Overholt, 2019). Analysis of Literature In developing orientation for newly hired trauma managers, it will be essential to use quality reviews to determine what is likely to be successful and which things have not been successful. Following the steps from the JHNEBP, a careful examination of the current literature was conducted to answer the proposed questions. The search aimed to identify research and other literature that could be used to substantiate the problem and plan a solution. In addition, current literature was searched to identify appropriate orientation techniques for new managers. Search Strategies A literature search was conducted to identify current evidence on the topic, using databases such as Google Scholar, CINAHL, MEDLINE, and the Weber State University's Stewart Library's OneSearch. Peerreviewed articles published from 2017 to 2022 related to the following search terms: trauma program managers, Level IV trauma, orientation, new managers, manager stress, manager retention, nurse manager job satisfaction, nurse manager turnover, American College of Surgeons trauma programs, rural trauma, nurse manager training, trauma coordinator, trauma program implementation, and trauma manager. Nurse Manager Retention, Job Satisfaction, and Stress Evidence suggests that the turnover of nurse managers is related to decreased job satisfaction, increased job stress, and increased burnout (Cox, 2019; Jäppinen et al., 2021; Labrague, 2020; Loveridge, 2017). For example, in a qualitative interpretative phenomenological study by Cox (2019), researchers interviewed nurse managers (N=20). The most common reasons for intent to leave employment were burnout, stress, and lack of leadership support (Cox, 2019). In addition, nurses are often promoted to manager positions without formal leadership training, increasing stress levels (Cox, 2019). 11 In a cross-sectional-descriptive non-experimental study, Jäppinen et al. (2021) researchers surveyed nurse managers (N=209). They found that 20% of nurse managers experienced high stress from workload, which is associated with increased anxiety and decreased job satisfaction. In addition, stress factors, such as inadequate preparation, satisfaction with training, personal satisfaction, professional satisfaction, feelings of empowerment, and intention to leave, had statistical significance (p<0.001) in causing significant stress. These stress factors make managers more likely to leave their jobs (Jäppinen et al., 2021). In another crosssectional-descriptive non-experimental study by Labrague (2020) (N = 240), nurse managers' job satisfaction and stress correlated with stronger turnover intentions. (p<.001), (Labrague, 2020). In a descriptive qualitative design (N=12), 92% of new nurse managers felt thrown into their new role without any orientation, struggled to transition from being a peer to being a leader, and became overwhelmed at the immensity of their unique position (Loveridge, 2017). In another cross-sectional survey, (N=86) nurse managers were found to have high levels of emotional exhaustion (22.4%), little sense of personal accomplishment (57.6%), and high levels of burnout (34.1%) (Membrive et al., 2022). Burnout is an emotional response to chronic stress, a common, serious problem among nurse managers (Membrive et al., 2022). Turnover is high among TPMs due to not understanding their role, having limited knowledge about PI and benchmarking, and feeling that they lack support or resources (Coniglio et al., 2018). In addition, frequent TPM turnover creates challenges for trauma centers because they struggle to implement quality benchmarking and improve trauma outcomes (Coniglio et al., 2018). Nurse Manager Orientation Many staff nurses fall into new management roles without training, mentoring, or formal orientation (Cox, 2019; Saifman & Sherman, 2019). When staff nurses take on manager roles, they are often shocked at what this new role entails (Saifman & Sherman, 2019). Sometimes with new manager roles, the new manager only gets a brief handoff from the previous manager and may be left unsure of expectations, lack 12 knowledge, and experience high-stress levels (Coogan et al., 2020). In a qualitative interpretative study by Saifman & Sherman, 2019, researchers interviewed new millennial nurse managers (N= 25). The results addressed themes that may prevent new nurse managers from leaving. Several of these themes directly pertain to the onboarding process of a new manager, including the quality of the orientation and mentor process, support and feedback from their director, learning to manage change, and learning to stay balanced by disconnecting from work (Saifman & Sherman, 2019). Researchers found that nurse managers do not feel competent in their roles until they have about five years of experience (Warchawsky, 2018). When new nurse managers leave their positions after a few years, they never achieve that competency. Nurse managers are not given enough preparation and support in their new roles (Ullrich et al., 2021). In a systematic, structured literature review, Ullrich et al. (2021) found a clear need for nurse manager development and training. By providing these, the new manager has a smoother role transition and will stay at the job longer (Ullrich et al. 2021). Keith et al. 2020 performed a literature review that states a direct correlation between a new manager's plans to stay in their role and the quality of their initial orientation (as cited in Hewko et al., 2015). One new nurse manager said, "I am a millennial, so I don't even know how to balance a checkbook, and now I am in charge of a $1.2 million budget" (Keith et al., 2020, p. 381). Newly hired TPMs must also manage the trauma budget and run a lucrative trauma program (ACS, 2022). A comprehensive manager orientation is critical in assisting novice managers in transitioning into their new roles, increasing job satisfaction, and increasing the likelihood they will stay in their new roles (Loveridge, 2017). Providing new managers with a systemized, organized, comprehensive orientation will support them in their new position (Coogan et al., 2020). Leadership development programs are proven to develop nurse leaders (Ramseur et al., 2018). Researchers surveyed nurse participants (N=41) in a structured leadership development program using a pre-post competency assessment. At the end of the program, the participants had an increased 13 perceived competency, and all 41 nurse participants had increased nursing leadership knowledge. These results support the importance of leadership development programs (Ramseur et al., 2018). Training and Educational Outcomes Quality training and educational programs positively affect managers' knowledge, skills, sense of competence, and overall job satisfaction (Keith et al., 2020; Ravaghi et al., 2021). Unfortunately, nurse managers frequently see insufficient training (Keth et al., 2020). Orientation programs should include sound educational principles, nursing theory, and adult learning principles (Kiel, 2020). Kiel, 2020 shows evidence that comprehensive orientation programs reduce nurse turnover. Orientation programs should be structured, focusing on learning needs and work-life balance, using various methods such as case studies, games, and group discussions (Keil, 2020). The manager orientation program should last about 13 weeks (Keil, 2020). Nurse managers that receive sufficient support and adequate training have increased job satisfaction and less turnover (Warchawsky, 2018). Kiel, 2020 presents a case report where several orientation programs were reviewed, including a Magnet hospital using the internship transition program, the Versant RN Residency Program at Los Angeles Children's Hospital, and the Vermont Nurse Intern Project (VNIP). Each orientation focused on clinical skills and learning needs, work-life balance, and acclimating to the new role using a structured approach and ensuring a smooth transition (Kiel, 2020). In a pilot study using a one-group, pre-/posttest design (N=9), new nurse managers attended a five-month orientation program. Post-program competencies focused on financial management, human resource management, performance management, foundational thinking skills, technology, strategic management, relationship management, and professional accountability (Coogan et al., 2020). After the orientation program, all participants improved in competency levels, with the most significant increase being self-determination (Coogan et al., 2020). When people feel more competent, they can complete their work (Coogan et al., 2020). 14 A systematic review by Ravaghi et al. 2021 found that more investment and planning are needed to develop knowledgeable and competent managers. Investing in managers regularly and with the most current information is an effective solution (Ravaghi et al., 2021). Flatekval et al. (2019) agree that continuous leadership training should be provided and suggest annual education needs assessments. A pilot study at a medical center in the northeastern US shows the need for leadership development (Fltaekval et al., 2019). The pilot study developed a curriculum with eight online modules addressing business management, effective leadership, and personal growth. The curriculum also had weekly education sessions called Lunch and Learns, covering conflict resolution or budgeting subjects. Finally, the curriculum included live instructor-led courses held for two full days, one week apart (Flatekval et al., 2019). There was a statistically significant (p<.001) relationship between leadership development and improved self-reported competency levels, with the participant's (N=8) self-reported competency levels being higher after taking part in the orientation program (Flatekval et al., 2019). Summary of Literature Findings and Application to the Project A gap in research results shows a need to study TPMs specifically because they are a very specialized type of manager, and there is little research on this population. Current literature on new manager orientation confirms that if a manager is unsatisfied, stressed, or burned out, they are more likely to leave their job. The literature also shows that many newly hired managers do not receive a formal orientation, which increases their stress. A comprehensive, focused, and structured orientation process positively affects a manager's skills, competence, and knowledge making it less likely that they will leave. Project Methodology The literature synthesis determined that a comprehensive, quality orientation is needed for newly hired TPMs (Coogan et al., 2020; Flatekval et al., 2019; Keith et al., 2020; Keil, 2020; Ravaghi et al., 2021; Saifman & Sherman, 2019; Ullrich et al., 2021). In addition, authors support that newly hired managers need a formal orientation (Cox, 2019; Saifman & Sherman, 2019). First, themes from the literature review were 15 extracted to create a comprehensive orientation guide for newly hired TPMs. Next, existing manager orientation methods were reviewed and evaluated. Finally, an outline for a comprehensive orientation guide was created using evidence-based, practical strategies for orienting new managers. Description and Development of Project Deliverables The foundation and structure of the TPM orientation manual are based on the literature review and evidence-based findings (Keith et al., 2020; Ravaghi et al., 2021). The deliverables identified to implement and sustain this project are a) the themes from the literature review, b) the daily, weekly, monthly, and yearly plan, c) a PowerPoint presentation introducing the orientation manual, d) an orientation manual to be uploaded to a shared drive, e) a timeline of the process, and f) a post-survey that will assess the effectiveness of the manual. Several levels of review of the manual before implementation will occur to ensure it is correct, usable, and complete. The six items created to create and implement this project are described in the following sections. Basic Foundational Structure of the TPM Orientation Guide Seven basic themes were exacted from the literature review. The first three themes include the timeline and type of orientation, transitioning to the new role, and the need for basic management training. Themes four and five include performance and evaluation training and emotional and coping skills. Theme six is the need for basic skills like budgeting, technology, strategic planning, and process improvement. Finally, theme seven addresses the ongoing quality of the orientation. These themes were organized into sections (see Appendix A). The sections were organized as topic headings in the orientation guide and will help drive the orientation process. Frequency of Duties The TPM must keep current on duties that should be completed by specific deadlines. Some of these things must be done daily, weekly, monthly, quarterly, or annually. The outline for the guide will break 16 down duties to be completed at these different intervals (see Appendix B). The frequency of responsibilities can easily be seen by reviewing the outline. PowerPoint Introduction to the Orientation Manual An uplifting and encouraging narrated PowerPoint will introduce the orientation manual to the new manager (see Appendix C). The PowerPoint briefly describes the TPM role and explains how to use and benefit from the orientation manual. The PowerPoint will be uploaded with the orientation manual to the shared drive so that each TPM can access it in the organization. TPM Orientation Guide Outline A QR code links the user to the orientation manual (see Appendix D). There are additional QR codes that link to the orientation manual section corresponding to what should do on the first week of hire, the second week, the third week, and so on. The orientation manual then moves to monthly requirements and continues each month for six months. Plan and Implementation Process The orientation manual will go through several levels of approval. First, a review will occur by a peer mentor from a sister hospital. After changes and clarifications are made from this review, it will be presented to a group of peers in similar roles. After this level of review, any suggested modifications or additions will be made. Next, a Level I TPM will review the manual as they support and educate lower-level trauma centers (ACS, 2022). Finally, it will be reviewed by the Trauma/ED Operational Lane Executive Directors. Once final approval is received and all additions and changes are completed, the manual will be implemented. When the guide is completed, it will be presented to the TPMs during a formal trauma meeting. This meeting has all the TPMs in the organization and sister organizations in attendance. The TPMs will have a final opportunity to give input on the guide. The guide will then be uploaded to the shared drive so that all TPMs in the organization can access it. Finally, the manual will be used to orient newly hired TPMs. Each 17 new manager will be given the QR codes to access the manual when initially visited by the Trauma/ED Operational Lanes Executive Directors. A timeline was created to guide the review process (see Appendix E) and avoid implementation delays. Interdisciplinary Teamwork Orienting TPMs will positively impact patient care and improve patient outcomes (Coniglio, 2018; Gosnell, 2021; Ramirez, 2021). Complex interdisciplinary teamwork, including all levels of management, will be used to collaborate in creating and reviewing the orientation guide. This collaboration will allow seasoned TPMs to share their expertise, knowledge, and skills to ensure the manual is complete and accurate. The Trauma/ED Operation Lane Executive Director. Before creating the manual, the director reviewed the orientation guide's basic outline. The director ensured that the focus was appropriate and that the concepts aligned with the corporation's beliefs and were feasible to implement within the organization. The Executive Director will also provide the final review and approve the completed manual. Sister Hospital Mentor TPM. Once the director approved the basic outline, the sister hospital TPM reviewed the guide. The sister hospital TPM gave insightful suggestions for other things to include, clarification, and recommendations. In addition, the sister hospital TPM gave positive feedback, stating that the orientation manual was very much needed and would be helpful. Level IV TPMs. Next, all other Level IV TPMs were asked to review the guide to share their expertise, knowledge, and skills. Their collaboration assisted in creating a comprehensive orientation manual. This orientation guide will improve patient outcomes as a well-trained TPM can create and run a trauma program more capably (Coniglio, 2018; Gosnell, 2021; Ramirez, 2021). One TPM said they wished they could be re-oriented using the new manual. Another stated that the creation of this manual was very 18 overdue and much needed. A third TPM noted that the manual would have been so helpful when they were hired and trying to understand their role. Level I Trauma Center TPM. The next level of review was the TPM of the Level I Trauma Center. ACS states Level I centers must support, train and assist the lower-level trauma centers (ACS, 2018). After this expertise approval and suggested revisions, the guide was again refined and updated. Future modifications and updates of the guide will include feedback from newly hired TPMs regarding the effectiveness and usefulness of the guide. Timeline The new manager orientation guide will be implemented over several months (see Appendix E). The manual was reviewed and written in an order that would support the new TPM in the best way possible, and care was taken to ensure that it was complete and correct. The Executive Director will review the manual's outline in the first few weeks of the project before the manual is started. In the first month, the Sister TPM will check the manual; in the second month, it will be sent to all TPMs in the organization to review. The Level I TPM will review the manual during the third month. After the final manual is assembled in the fourth month, it will be uploaded to the shared drive. A QR code will allow users to access the manual. The manual will be presented via a narrated PowerPoint at an online formal TPM meeting upon final approval. After implementation, after the fifth month, an evaluation tool will be sent out to the TPMs to evaluate the perceived impact and usefulness of the manual. Plan for Evaluation of Project When the manual is completed and implemented, an informal post-survey will be created and distributed to the Level IV TPMs. (See Appendix F). The post-survey will request feedback on the usefulness of the manual and will include questions on a scale from 1-5, with one being the lowest and five being the highest. In addition, the post-survey will have a few questions regarding the value and benefit of 19 the manual and whether the manual has the correct focus. Finally, there will be an area for any additional comments to be added. The effectiveness of the new manager orientation guide will also be evaluated by feedback from newly hired TPMs and their reported feelings and feedback about their orientation. This feedback will be compared to previous anecdotal experiences of newly hired TPMs without formal orientation. The recently oriented TPM's opinions and feedback will be strongly encouraged, and changes will be made to the manual accordingly. The manual must be kept updated as policies and procedures change. Therefore, updates will need to be done at least annually after collaborating with the TPMs, director, and Level I TPM to make sure all changes and updates are captured and implemented, keeping the manual up to date and current. Keeping the manual updated is the only way it will remain helpful. Ethical Considerations Ethical considerations must be contemplated in every aspect of nursing. The characteristics of nursing care are that nurses are caring, compassionate, trustworthy, and committed (Alilu et al., 2022). Nurses' decision-making, conduct in and out of work, and moral philosophy of dealing with ethical issues at work make up professional ethics (Alilu et al., 2022). Ethical leadership helps create ethical nurses, and ethical leadership helps embed ethics into healthcare (Schick-Makaroff & Storch, 2019). Ethical behaviors are crucial to healthcare and fundamental to high-quality patient care and better patient outcomes (Sakr et al., 2022). Nurses with high professional ethics have increased job and patient satisfaction and inspire ethical behavior among their peers (Alilu et al., 2022). Work ethics are broad and not specific to any job, so they also apply to TPMs (Sakr et al., 2022). Many nurse leaders wish they had more guidance on ethical leadership (Schick-Makaroff & Storch, 2019). Unfortunately, there is frequently increased pressure to do more with fewer financial and staff resources (Alilu et al., 2022), which is often seen with TPMs. This 20 increased pressure can lead to professional standards slipping (Alilu et al., 2022). Nursing can be stressful and have unclear, overwhelming role expectations, especially as a manager (Alilu et al., 2022). Leaders tend to have higher work ethics, leading to higher motivation (Sakr et al., 2022). Challenging, diverse jobs with autonomy, social interactions, and learning opportunities drive high work motivation, which all describe the TPM role (Sakr et al., 2022). All Level IV TPMs were given information and instructions about the manual and its purpose and asked to review the material and provide suggestions for improvement. A Level I TPM was also asked to review the manual. The review will not include TPMs outside the organization, ensuring that organization policies and procedures are protected. The instructions clarified that reviewing the manual was appreciated but optional and that reviews would remain anonymous and confidential. Any statements would stay anonymous, and personal or location identifiers would be removed before publication. They were also informed that the Trauma/ED Operational Lane Executive Director would review the manual's final edition. The completed manual will be available to all TPMs in the organization with no discrimination. The orientation guide will be a resource for all that desire to utilize it. If a hospital decides not to participate and use the guide, their choice will be protected and not made public. Discussion Newly hired TPMs often do not receive formal training or orientation for a stressful, complex job. However, they are expected to quickly acclimate to their duties and develop a successful hospital-wide trauma program (Gosnell, 2021; Newcomb, 2020; Ramirez, 2021). Seasoned ED nurses are typically hired for the role of the TPM. These nurses come with years of beside and clinical experience. However, the role of the TPM differs significantly from that of the accomplished bedside nurse. The TPM role requires effectively leading a team in providing excellent patient care, cultivating hospital-wide engagement in the 21 trauma program, and quickly creating meaningful relationships with community leaders and EMS agencies (Gosnell, 2021; Newcomb, 2020; Ramirez, 2021). Coogan (2020) suggests that with a comprehensive orientation, managers are likely to be successful, have increased job satisfaction, and stay in their roles. Unfortunately, effective trauma programs take years to develop, and the rapid turnover of TPM often does not allow for this to occur. Providing a complete and comprehensive orientation manual will allow the newly hired TPM to be trained in the unique requirements of this role and provide primary manager and leadership training that the seasoned bedside nurse often lacks. The strengths and weaknesses of this project, as well as additional research recommendations, will be discussed. Evidence-based Solutions for Dissemination After the orientation manual is completed and has undergone several levels of review to ensure accuracy and completeness, dissemination will occur in several ways. First, the manual will be presented at a formal TPM virtual meeting using PowerPoint to explain and introduce the manual to all the TPMs in the organization. Next, the manual and the PowerPoint will be uploaded to a shared drive for everyone to use. Finally, as new TPMs are hired, they will be visited by the Trauma/ED Executive Directors, and they will be shown the TPM manual and instructed to view the PowerPoint. This project will also be shared with Weber State University faculty and peers through an online virtual presentation, including the manual, the PowerPoint, and a detailed poster. Significance to Advance Nursing Practice This project can benefit all hospitals that have or plan to have a trauma program. For a trauma program to be successful, it must be managed by a capable, competent leader (Gosnell, 2021; Newcomb, 2020; Ramirez, 2021). When new managers are not given adequate orientation, they have decreased job satisfaction and quit (Coogan, 2020; Cox, 2019; Jäppinen, 2022; Keith, 2021). Providing a complete, 22 comprehensive orientation manual to new managers will increase job satisfaction, reduce turnover, and keep the manager in their role long enough to fully develop a trauma program (Penconek, 2021; Ramirez, 2021). Trauma programs improve the care of all hospital patients (Gosnell, 2021; Ramirez, 2021) and elevate the care of the entire community (ACS, 2018; ATS, 2020). This project will benefit all future patients, all hospital patients, and the community. Implications This project will orient TPMs to be able to create and successfully run a trauma program or improve an existing program. The orientation manual outlines all the responsibilities the TPM needs to master, along with essential leadership, management, communication, budgeting, and collaboration training. The manual will give the TPM the tools required to manage a trauma program, demonstrate process improvement, educate those involved in trauma, and develop relationships with community leaders to develop injury prevention programs and increase community outreach. Seasoned TPMs reviewed the completed manual to ensure it was comprehensive and complete. The manual was designed to help the newly hired TPM with a first-time trauma designation. It can also be used for a newly hired TPM to improve an existing program that will prepare for their next site visit from the state to show that standards are met to redesignate their trama program. Redesignation occurs every three years. TPMs will have increased job satisfaction if they are oriented well and have a written guide navigating them through complex duties and requirements (Coogan, 2020). The limitations of this project include the rapidly changing nature of hospitals, healthcare, trauma, and staff roles. Continual updates to the manual will be required as state guidelines, hospital policies, and organizational changes occur frequently; thus, a regular schedule of updates will need to be implemented. Another limitation may be that the manual will not be used to orient new TPMs because of its length. Some new TPMs may feel the suggested course activities are time-consuming and unnecessary. Still, others may 23 want to jump right in and start work, skipping vital training that has been proven to increase job satisfaction, decrease turnover, and improve trauma programs (Ramseur, 2018). To avoid this, the Executive Directors must embrace the project and strongly encourage new TPMs to use it as they assume their new roles. In addition, new TPMs will need to be encouraged to use the manual daily until the entire manual is reviewed and the concepts are integrated into the trauma program. Learning the complex role of the TPM is not feasible in a short time. The manual is written to be completed over several months, with some sections completed after a few years. As TPMs are thoroughly oriented and feel confident in their abilities, they are empowered to lead the hospital team and successfully create hospital-wide and community buy-in to the trauma program. A successful trauma program will improve the injured patient's care and improve patient outcomes (ATS, 2020). The manual is long and may take up to 6 months to complete, but it will be well worth the investment, as well-trained managers are more likely to remain in their positions for a more extended period, have less stress, and have greater job satisfaction (Ramseur, 2018). Recommendations After using the orientation manual to train newly hired TPMs, it is recommended to obtain feedback on how they felt the orientation prepared them for their role. Using the input received is crucial to make necessary updates and changes to ensure the manual is easy to understand, pertinent, and helpful. It is also recommended that the manual be updated at regularly scheduled intervals to ensure it stays current. Finally, the literature review found significant evidence on general healthcare managers, emergency department managers, and hospital department managers, but there was very little on the unique role of the TPM. More research needs to be done on the TPM specifically. The TPM role is particular, and additional research regarding the TPM, their specific orientation, job duties, and factors for success would benefit trauma programs and hospitals across the organization, the state, and the nation. 24 Conclusions Providing a comprehensive orientation for newly hired TPMs will increase job satisfaction and lead to retention in their new role. Trauma Programs led by well-trained managers will thrive and improve. Improvement in trauma programs will increase the quality of care for injured patients. Trauma programs enhance the quality of care for all patients in the hospital. Trauma Programs elevate the care of communities by providing injury prevention, community outreach, and collaboration with community leaders, EMS, and individuals that live in the communities. 25 References Alilu, L., Parizad, N., Habibzadeh, H., Cund, A., & Esmhoseini, G. (2022). Nurses' experience regarding professional ethics in Iran: A qualitative study. 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Journal of Trauma & Acute Care Surgery, 87(3), 666–671. https://www.doi.org/10.1097/ta.0000000000002383 Warshawsky, N. E. (2018). Promote nurse manager job satisfaction and retention. American Nurse Today, 13(8), 33–34. 29 Appendix A Basic Foundational Structure of the TPM Orientation Guide Creating a comprehensive orientation guide for Trauma Program Managers using current evidence-based research. The orientation guide will need to include the seven following themes. The themes will create the basic foundation and structure of the guide. Theme 1: Timeline and Type of Orientation Theme 2: New Role 13 to 20 weeks Structured Formal Systemized Organized Comprehensive Focus on Learning Needs Educational Principles Nursing Theory Adult Learning Theories Transitioning from Peer to Leader Onboarding Mentors Acclimating to a new role Theme 3: Management Theme 4: Performance/Evaluation Leadership Program Manager Role Human Resources Management Strategic Management Business Management Effective Leadership Organization Skills Theme 5: Emotional/Coping Performance Professional Accountability Support and Feedback from Director Support Resources Balance Disconnecting Managing Change Work-Life Balance Personal Growth Conflict Resolution Critical Conversations Theme 7: BLACK Quality Process Improvement Benchmarking Budget/Financial Management Technology Strategic Planning Communication Skills Team Building Most Current Information Continuous Training Annual Education Need Assessment Theme 6: Training Topics 30 Appendix B Frequency of Duties Daily: Review Trauma Charts Review ED Log Review Trauma Log Process Improvement Feedback to ED Staff Answer emails Answer phone calls Patient Follow up from transferring hospitals Ensure Tertiary Exams were completed Ensure NIDA was completed Review Trauma Admits for Hospital Events Weekly: Record Budget Expenses Record Divert Log Attend Grand Rounds Work closely with department managers making contact with at least one per week Present trauma Huddle to ED (or any form of education you like) Monthly: Organize agenda and hold TPIC Meetings Organize agenda and hold TEC Meetings Send out minutes of meetings Send out attendance of meetings Attend Trauma Meetings Trauma Data presentation to TPIC and TEC Calculate under and over triage Teach Stop the Bleed Community Outreach Record CEUs Attend EMS Meetings Attend ED Meetings Meet with TMD and ED Manager Communicate with Radiology CT Times Submit Trauma Charges Communicate with ICU/MedSurg NIDA Communicate Tertiary Exam Compliance Review Trauma Charges Yearly: Trauma Data Presentation Trauma Conferences Renew Subscriptions and memberships Demonstrate & Record improvement in the program Speak to budget with the finance director Speak to administration about the trauma program Plan a yearly calendar of events, including community outreach and injury prevention Quarterly: Record Trauma Audits EMS Station Visits Meet with Marketing to plan out the year Plan and carry out EMS Lunch & Learns Attend Regional Trauma Meetings Special Dates or As Needed: EMS Week Trauma Awareness Month Trauma Survivor Network Fall Prevention Week Stop the Bleed Day Prepare for the re-designation survey Fill out the re-designation survey application Present case reviews for EMS 31 Appendix C Introduction PowerPoint Presentation Trauma Program Manager Orientation Manual 1 Welcome to Trauma! 32 2 33 Trauma Program Manager or Trauma Program Coordinator What will I be doing? 3 Where Do I Start?? Read the Orange and Gray Books Meet Everyone! Roll yourself out! Go on Field Trips 4 34 Your New Leadership Role Manager Training Leadership Training Empowered to Lead! 5 Daily Workflow Review Each Trauma 6 Ensure Excellent Care Create Process Improvement 35 Process Improvement! Did they get the best care possible? Did things go wrong? Can I make improvements? Provide Feedback to the ED Team! 7 Document! Document! Document! Create a trail that can be followed to show process improvement! 8 36 Meetings Agendas 9 You are an influencer! 10 Meetings Minutes 37 Attending Trauma Meetings 11 Community Outreach & Injury Prevention 12 38 Trauma Designation Application 13 Trauma Designation Survey! 14 39 One Step at a Time Step 1 Don’t get overwhelmed Step 2 Take care of you 15 Improve the care of injured patients 16 Step 3 Use the manual Step 4 Ask for help 40 Appendix D QR Code to TPM Orientation Manual TPM Orientation Manual This is a comprehensive orientation manual for newly hired Trauma Program Managers Note: The QR Code will only work on-campus with access to the hospital intranet through the shared drives or if you can work from home using the VPN. TPM Orientation Manual: Accessing the manual will take you to several links you should follow to acclimate to your new role. Each week or month will contain many activities, videos, and documents you should review and become familiar with. All videos can be accessed through Udemy using the My Learning links in Workday. 41 Week 1 Week 2 Week 3 Week 4 Getting Started Month 2 Leadership Training Trauma Manuals Month 3 Process Improvement Chart Reviews Month 4 Designation Trauma Meetings Month 5 Community Outreach 42 Month 6 Putting it all together 43 Appendix E Timeline Project Implementation Timeline Week 1 Month 1 Month 2 Month 3 Month 4 Month 5 Meet with ED/Trauma Operational Lane Director for project approval and to review the first draft of the orientation manual outline Meet with Sister Hospital TPM Mentor and review the orientation manual outline Send Orientation Manual Outline to all Level IV TPMs for their review and input Send the Orientation manual outline to Level I Trauma Center TPM for review and input Upload Send out PowerPoint Orientation manual And Evaluation orientation Tool to Level manual to IV TPMs the shared drive Evaluate the perceived impact of the orientation manual Make adjustments as needed to the manual and continue updating the manual if going well. Ongoing Yearly meetings to evaluate the need for updated material Evaluate the efficacy of the manual and report findings to the trauma/ED operational lane director to consider implementing the orientation manual system-wide across all regions. 44 Appendix F Evaluation TPM Manual Evaluation Strongly Disagree Disagree (2) (1) The orientation manual is valuable to newly hired TPMs. The manual focuses on the correct topics to be learned to be an effective TPM. The orientation manual will be a useful tool for orienting newly hired TPMs. The manual is helpful in my current practice and a reminder of what I should do in my role. Comments: Neutral (3) Agree (4) Strongly Agree (5)