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Big increases in patient numbers in recent months left University Hospitals scrambling to add nurses to the front lines of patient care.

New hires must go through orientation – from six to 12 weeks, depending on the unit and experience of the nurse so that has meant overtime and extra shifts for existing staff, as they wait for more nurses to come through the pipeline.

Hospitals in Cedar Rapids haven’t seen patient growth to the extent University Hospitals has, though St. Luke’s is seeing about 15 to 30 more patients a day in recent months and overall hiring is up slightly compared to last year, officials there said.

Midland Memorial Hospital in Midland, TX, recently changed its process for tracking not only online training but demonstrated proficiencies among its nurses. The change has resulted in a real-time information tracking program that has helped not only with tracking training, but documenting growth of its employees for its ANCC Magnet Recognition Program ® (MRP) journey.

Jenny Delk-Fikes, BSN, RN-BC, clinical excellence manager with Midland Memorial, explains that previously, e-learning was tracked online, while checklists for demonstrated proficiencies were tracked in paper format—leading managers to have to look in multiple locations, in multiple formats, just to figure out what their staff knew and how well they knew it.

This has been much improved with an all-electronic system.

"The first thing we did was get a system that met our needs," says Delk-Fikes.

They needed a centralized component that gave the hospital real-time access to knowledge skills and critical thinking skills of the nursing staff.

"We need to know when something is new and when it has changed. We need to be able to communicate those changes in real-time," says Delk-Fikes.

The previous system had a delay, because the learning management system, while it was a good program, did not have all the necessary components in one place.

"We needed an integrated competency system that could support the practice model," she says.

With the new system, managers could look at their staff as a whole to determine who the right person is for the right patient. Previously, managers would literally have to look in three locations to assess staff competency.

Midland Memorial went with a system called Decision Critical, a 360-degree learning and evaluation system.

This new system actually allows them to track input from the staff as well, at times tracking downward trends early.

"Our staff knows performance is low before our data even shows it," says Delk-Fikes. "We want them to be able to communicate that with us."

The facility also wanted a system that could demonstrate skills in practice—are the lessons being taught then put into practice?

Finally, they needed a system that could capture professional development inside and outside the organization.

"We have a lot of people who are very active in their professional organizations," says Delk-Fikes. "They're attending conferences, doing training certification classes, things that are not deliverable through a computer system that you want to track. We want to know if you are an ED-trained nurse working on the oncology floor, because if a head trauma is transferred to our unit, you're the best provider to work with that patient. It's all in the individual portfolios."

The first delivers the knowledge component of nurse education.  

"Here's the content, now take the test," says Delk-Fikes. This is the basic component of demonstrating that information has been given and taught, but does not yet demonstrate competency in the field.

Communicating comfort level

Next up: a check list going over everything in a given area of practice that is important for nurses to know to drive up performance, adhere to standards of care, and provide safer and more beneficial healthcare.

"This is essentially your peer evaluation," she says. "We need you to work on X proficiency, but you did Y efficiently. The individual can communicate what they feel they need to work on in the self-assessment component, and there is also an annual needs assessment."

This one-two punch of assessment is key to success of the program. A nurse can identify their own strengths and weaknesses and ask for additional training or help in the latter.

"They might tell you, I'm good at IVs, at foley catheters, and at restraints., but this list includes tracheostomy care, and I haven't taken care of a tracheostomy patient in three years, so I'm going to say I'm average," says Delk-Fikes. "I have the knowledge but not the skill."

The program pulls in everything the nurse has accomplished, needs to work on, and has not done yet, she says.

This level of communication also helps design methods for training. If the nurse needs help learning or re-learning tracheostomy care, why not send them down to the cardio-pulmonary unit to shadow a more experienced nurse to pick up those skills? When managers are going through nurses' files, they aren't bouncing from source to source—the educators and managers can see each nurse's self assessment, their annual assessment, and all of this can be used to plan upcoming education events.

It also means that educators can identify how great a need certain training requires. How many nurses identify themselves as not proficient in a given task? How many have been identified by their peers as needing additional training?

"If one nurse says she's not comfortable with tracheostomy care but the majority of her peers are, I'm going to loop her through cardio-pulmonary to increase her knowledge," says Delk-Fikes. "But if the whole unit says it's a problem, rather than looping them I'm going to bring the education to them on that floor."

Midland Memorial has shared governance with a multidisciplinary team they turn to for when they encounter practice issues. For example, if they were to discover they are not hitting their benchmarks for Foley catheters based on CMS guidelines, they bring this issue to the council to update how this information is going to be rolled out to staff.

"In our old system, I worked with every council, key departments  like quality management, infection control, human resources, and said, we are doing 32 annual training modules," says Delk-Fikes.

These were just testing knowledge. That's a significant amount of time, she says.

"Our employees were spending four to nine hours completing each of these," says Delk-Fikes.

They needed to find a more efficient way of handling training. Non-clinical roles now have 22 training modules required, and clinical still have 32 on hire, but 24 annually.

"When we reevaluated we looked at more effective learning," says Delk-Fikes. "We moved things off the checklist or added depending on need."

Regulatory requirements

They also pulled in the requirements for NIAHO (National Integrated Accreditation for Healthcare Organization) standards in order to align their required training with the standards (the organization is DNV accredited). But they also looked beyond their own standards for best practices.

"We still look at The Joint Commission because they also have wonderful practices. We put everything we were doing under the appropriate categories," says Delk-Fikes. "If a regulatory agency says okay, you need to provide training on, for example, confidentiality and ethics, we need to know how to demonstrate that."

To show all the components they engage in annually is great, but how does it align with the standards? You need to be able to demonstrate that.

Nursing excellence documentation

Midland Memorial is seeking ANCC Magnet Recognition Program® (MRP) status. They need to be able to track and trend their nursing education to show progress. With the new system, they are able to drill down, whether it's an organizational problem they want to fix, or a performance issue they want to improve.

"If our scores are stagnating at 88 or 89% and we want to do better, we can do that," says Delk-Fikes.

The way a critical care unit nurse is trained is completely different from a pediatric nurse. Under the new system the organization can document the progression of each nurse in accordance to their unit's requirements.

"One of the things about this system that we're using is that, for MRP's requirements in the area of innovation and technology and nurse organization-wise performance, this actually is your Source of Evidence," says Delk-Fikes. "If you want to show nurses are growing professionally, you can pull it from this program."

Previously, it was a challenge to simply show how many certified nurses were on staff at a given time. Now, a nurse manager just has to look at a given nurse's portfolio to see whether they have been CPR recertified, for example. Is the nurse a certified medical interpreter? That is in the portfolio as well.

Nursing levels

Midland Memorial Hospital uses "levels" to describe each nurse's skills and training: beginner, novice, and expert.

At orientation they are given the on hire checklist. Evaluations are done six months to a year out, allowing time to acclimate and grow into the culture of the facility. By the end of the first year, nurses begin their competency-based assessment.

After reaching the expert level, nurses start getting into individualized growth plans. They enter preceptor roles, take on mentoring tasks, and help train skilled nurses in areas where there is a knowledge gap.

But before reaching that level, there is quite a climb—and that climb is ever changing. Expert level nurses cannot stagnate—there are always new things to learn. If, for example, 10 new requirements arise for experta, they must become proficient in all of those requirements before being considered an expert/level 3 nurse again.

In fact, most of the time, nurses are considered advanced beginners. Nurses are paired in training with the appropriate trainer—a beginner is not handed over to an expert to shadow at first, but instead are paired up with a novice/level 2 nurse who can bring them up to their level of training first.

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This article was adapted from one that originally appeared in the November 2010 issue of HCPro's Advisor to the ANCC Magnet Recognition Program®, an HCPro, Inc. publication.