Connecticut Sen. Edith Prague and the leader of the Connecticut League for Nursing on Tuesday criticized Gov. M. Jodi Rell's plan to suspend a nurse training program, saying the program not only creates jobs, but addresses a nursing shortage. Faced with a budget deficit, Rell has decided to suspend the state's adult education program for licensed practical nurses, which trains about 350 LPNs every 16 months. Prague said nurses are critically needed at hospitals and nursing homes, particularly as the population ages.
Imagine you could interact with multiple patients, diagnose and treat their illnesses, administer drugs, and even ensure that staff members are following infection control best practices 24 hours per day, seven days per week, all without getting out of your chair.
This is the basic premise of the eICU, an electronic subdivision of the ICU at Alegent Health in Omaha, NE. Mark Kestner, MD, senior vice president and chief medical officer at Alegent Health, likens it to an air traffic control tower. Nurses and physicians man an off-site location filled with two-way cameras linked to ICUs in three metropolitan hospitals and one rural hospital in the system.
Six nurses in the eICU routinely manage 15–20 patients each, in conjunction with on-site ICU staff members. A physician handles high-risk patients, and Alegent recently added a pharmacist to monitor antimicrobial activity.
The software built into the eICU not only feeds real-time data for roughly 100 patients, including vital signs, laboratory tests, cultures, and pharmacy data; it also sorts the information and sets off alerts if there are concerns with a patient. Nurses and physicians in the eICU can also alert bedside staff members if a patient needs emergency care.
"What it does is it frees up the bedside staff because they know that certain elements of information are being sorted and addressed and that they can then be more available for the immediate needs of the patients or the routine bedside needs of the patient," Kestner says.
Involving infection control
In its first two years, the eICU at Alegent has focused primarily on patient care, but Emily Hawkins, RN, BSN, director of IC at Alegent Health, says the centralized location of the eICU makes it a great opportunity to integrate infection prevention compliance, as well.
A pharmacist has already been incorporated into the eICU to monitor drug interaction, but Hawkins says there are also plans to use the eICU to build antimicrobial reviews, which will forward information to the lab and pharmacy. Going forward, an infectious disease physician will be present to intervene with antimicrobial counsel.
The eICU team is already incorporating ventilator and central line bundles into its everyday care.
"I think what this allows us to do is to standardize our compliance with ventilator bundles and with standards of care," Kestner says. "We already had a very low infection rate, but this allows us to have another set of eyes on the team asking very specific questions every day. The eICU team does have the checklists and they make sure the central line is taken out if it's not needed, the ventilator bundles are adhered to, the patient's head of the bed is up, and the patient is being extubated quickly if they don't need to be on the ventilator."
It also helps that the eICU suite is in the same office as the infection prevention program.
You're on candid camera
If this sounds a bit too Big Brother for you, you're not alone. ICU staff members were initially resistant to the idea of someone watching over their shoulder from a well-placed camera, Kestner says.
"If you think of these people doing their work and all of a sudden they have a two-way video camera in the room and they know at any point in time someone could turn the camera on and be looking over their shoulders, they found that to be very intrusive," Kestner says.
The clinical practice committee that oversees the eICU created a set of rules to alleviate the Big Brother feeling, including:
A bell rings to alert the on-site employee when the camera has been turned on
Twice per day, the on-site nurse and the eICU nurse conduct interdisciplinary care rounds with patients and their families, fostering a working relationship between the bedside and eICU staff members
These team rounds were particularly helpful to establish a working relationship between the eICU and bedside nurses and the patients.
"And so not only now do the nurses have a relationship with the eICU, but families and the patients know who is on the other end of the camera and establish a relationship with those care providers," Kestner says. "It took us sort of actively intervening and teaching people how to act as a team in order to establish that relationship and not feel like the presence of eICU is intrusive, the presence of eICU is really being a part of their team."
U.S. Department of Health and Human Services Secretary Kathleen Sebelius praised the system when she visited Alegent's Lakeside Hospital July 12 to experience this interaction first hand.
Ultimately, patients and families also feel more secure when they interact with the person on the other side of the camera and they don't feel like it's just a machine, Kestner says.
"We have patients that are transferred from some of our smaller facilities to our bigger facilities, and the eICU will talk to the family before the patient leaves the smaller facility and then talk to them when they arrive at the new facility, so it makes them feel like their care has been seamless," Kestner says. "Families like having that extra set of eyes and have a sense of comfort knowing that they are there."
Absorbing the cost
Of course, as with any elaborate technology, the eICU comes with a hefty price tag. Alegent was able to integrate its rural hospital because of a United States Department of Agriculture Rural Development grant, Kestner says.
Some argue that having that extra set of eyes will decrease infections and lengths of stay and shorten patient days throughout the unit, ultimately benefiting hospitals' financials. But Kestner says it's also worth it from a patient satisfaction and efficiency perspective.
"I think the way we are looking at it is length of stay for the whole hospitalization, shortening length of stay in the whole ICU, shortening length of stay on the ventilator," Kestner says. "We just have our baseline data, so I'm not sure we can say we have absolutely saved enough money to offset the initial expense, but it allows us going forward to remain efficient."
As to whether this is sustainable technology for the future, Kestner recognizes that the startup costs are too high for most hospitals. He suggests this kind of movement in the future would require government involvement.
"You can almost suggest that it's something similar to meaningful use," Kestner says. "Is there a meaningful justification for this type of technology, and does it improve outcomes and improve care and start to rationalize our workforce issues?"
This article was adapted from one that originally appeared in the October 2009 issue of Briefings on Infection Control, an HCPro publication.
Connecticut Gov. M. Jodi Rell has decided to suspend the state's adult education program for licensed practical nurses to help address the state's budget deficit. The program, offered at 10 state technical high schools, produces about 350 LPNs every 16 months who go on to work in the state's health provider settings. Officials from the Connecticut Office of Policy and Management told the Hartford Courant state labor market reports suggest that the supply of new nurses adequately fills Connecticut's need, noting that the production of new nurses has gone up significantly since 2000.
When the University of Colorado Hospital (UCH) moved to a new facility in July 2007, it saw an opportunity to improve nurse satisfaction by upgrading the computer process nurses used at the bedside. The Aurora-based hospital first received ANCC Magnet Recognition Program® (MRP) designation in 2002 and was resdesignated in 2006.
In the old facility, nurses in med-surg areas had their own carts assigned to them, which they had to roll from patient room to patient room as they made their rounds so they could use the computer on the cart as they administered medication and documented at the bedside.
The carts were a huge frustration for nurses, according to Kathy Smith, MS, PMC, RN, supervisor, nursing informatics—and former MRP project director—for UCH. The carts were difficult to roll on the carpet in the hallways when moving from one patient room to another, and if the cart encountered a bump, it often logged nurses off the computer, so they had to start again when they reached the patient room. The computers also had batteries—which made the carts heavy to maneuver, and needed to be recharged all the time—and nurses found the batteries were always dying at the wrong moment.
Smith relates that many times the batteries needed to be replaced, which increased workload for the IT staff. In addition, UCH realized that having one cart per nurse wouldn't work with the new bar code medication administration it system was implementing.
"We could see right away that was not going to work," says Smith. "It would require that every time a nurse wanted to administer a medication, she would have to go find her cart, unplug it, move it into the room, then plug it back in, then boot it up, then administer the meds."
Smith relates that this was a fantastic example of the CNO advocating for nursing's needs. The hospital had already budgeted and expended money on the new bar code medication administration system, and then the CNO went back to the executive level and said that the nurses needed to have a computer in every room in the hospital. Despite the significant budget, the hospital invested in its nurses.
UCH chose another cart system, rather than a wall-mounted computer, because nurses wanted flexibility with moving the cart around to different parts of the room. Also, UCH had already planned the rooms in the new building, which weren't designed for wall-mounted computers.
To choose the best system, the hospital staged a "cart fair," at which nurses could examine the different types of carts on the market and determine the ones that would best meet their needs. They eventually chose mobile computing carts from Rubbermaid Medical Solutions.
"The new carts now stay put in every patient room," says Smith. "They are plugged into the wall, so nurses don't have to worry about the battery ever being run down." But still having the computer on a cart allows nurses the freedom to move around the room as they like and use the computer where it makes most sense for them and the patients.
The carts have a computer screen, the CPU in box, a big work space, a drawer, and a light. The light enables nurses to see medications and so forth during the night shift without turning on the lights in the room and greatly disturbing patients.
The new computers were crucial to the successful adoption of the bar code medication administration system, Smith says. "I think we would have had a revolt if we hadn't done it," she adds. "They would have been very dissatisfied. And it would probably have been a failure for our bar code medication administration project."
Smith says the carts contribute to nurse satisfaction. "The nurses love them," she says. "They made a big poster with a big thank you card and gave it to the CNO. It said 'Cow-a-bunga! ["Cow" is an abbreviation for "computer on wheels."] We love the new computers in patient rooms!'"
This article also appears in the December 2009 issue of HCPro's Advisor to the ANCC Magnet Recognition Program®, an HCPro publication.
Offering a nurse residency program is an important strategy for planning for the future in nursing, but many hospitals are finding these programs costly, considering the current economic conditions affecting many healthcare organizations. Despite the financial and personnel resources it takes to support a nurse residency program, there are sound reasons to continue or begin such a program in your organization.
Nurse orientations cost an estimated $20,000–$50,000 per nurse (Blanzola et al., 2004). In addition to orientation costs, turnover costs include marketing and recruitment expenses, salaries for overtime and/or external staffing resources to cover clinical staffing needs, and the potential effect on customer satisfaction scores. Nursing turnover has been estimated to cost 75%–125% of the average annual salary of an organization's nurses (Pine et al., 2007).
Organizations must weigh the cost of a nurse residency program against the cost avoidance of nurse turnover. A successful nurse residency program can lead to positive outcomes for organizations, such as lower turnover and the development of competent clinical practitioners. Anticipated future returns include improvements in staff satisfaction, clinical productivity, outcomes of care, patient safety, and, as a result, customer satisfaction (Keller et al., 2006). A successful nurse residency program helps nurses develop advanced nursing skills that contribute to these outcomes.
Challenges for new graduate nurses
Although 90% of academic nurse leaders feel new nurse graduates are fully prepared to practice, only 10% of hospital nurse leaders share this opinion (Berkow, 2009). The challenges of transitioning from nursing school to clinical practice for new nurse graduates leads to first-year turnover rates of 35%–60% (Blanzola).
New nurse graduates face a huge challenge as they transition from student to competent practitioner. New nurses must adjust to the clinical demands and environment of a new work arena, which have increasingly complex patients and specialties that are becoming more technology-focused.
In addition, new nurse graduates often work demanding alternate or rotating shifts that they were unaccustomed to as students.
For these reasons, new nurse graduates are attracted to organizations offering nurse residency programs that facilitate their transition to professional practice. Many have identified an interest in and desire to begin work in specialty areas that require strong clinical knowledge.
Cultural considerations that may lead to a new nurse graduate selecting an organization's nurse residency program include professional growth opportunities, coworker and physician relationships, nursing autonomy, scheduling, and recognition of nurses.
Orientation structure
Orientation programs are generally structured to introduce new hires to the new work environment and their new unit's scope of services. Programs typically provide information regarding the organization and the unit. Programs also assess new hires' knowledge and skill base and connect them to peer resources who can role-model expectations for nurses on that unit, as well as facilitate a sense of belonging to the team. The orientation period gives nurse leaders time to evaluate clinical competency, efficiency, communication skills, productivity, and customer service focus. Orientation programs are usually designed to guide nurses' transition to a different work arena, not a different role.
New nurse graduates have a different transition challenge—one from student to the role of a nurse—and a nurse residency program needs to be more than an extended orientation. There are a wide range of goals, program lengths, and outcomes reported for nurse resident programs (Keller et al., 2006).
New nurse graduates can become competent practitioners more quickly with the guidance of a nurse residency program. Programs should offer didactic and leadership components in addition to the standard clinical components offered in an orientation program. Incorporating didactic and leadership components supports the nurse resident's development beyond clinical skills, enhancing clinical judgment and critical thinking skills.
Residency design
Nurse residency is not a new concept—programs were first documented in 1980s literature (Altier & Krsek, 2006), and most are based on Benner's theory of novice to expert. Benner felt competence was typified by nurses who had been on the job in the same or similar situations and were consciously aware of connecting their actions to a long-range plan (Benner, 1984). Benner noted that competence was generally reached only after years of gaining experience as a practicing nurse. A nurse residency can facilitate new nurse graduates to advance more quickly from novices to competent nurses, lessening time as advanced beginners. A nurse residency, focused on developmental concepts, attracts new nurse graduates, and the organization enjoys the benefits of competent nurses and the bonus of low turnover.
Our experience at Northwest Community Hospital reflects these ideals. The initial nurse residency program was founded in 1995 and, based on Benner's theory, was originally a 24-month program. We discovered in the early nurse resident groups that through the mentorship of the residency program, nurses reached competence more quickly, and the program was reset first to 18 months and then to 12 months. These nurses come out of the program as competent practitioners. There remains some turnover among our nurse residents, but there is also longevity: 30% of the first nurse residents were still employed at our organization after 10 years. We have a culture of longevity at Northwest Community Hospital, but our nursing work force, like nursing in general, is aging. We are fortunate that our turnover rate is currently below the national and Greater Chicago–area averages. Because of our low nursing turnover, we enjoy a low nursing vacancy rate. But ours is a forward-thinking organization, so we continue to offer and support our nurse residency program. It's the smart thing to do.
References Altier, M., and Krsek, C. (2006). “Effects of a one-year residency program on job satisfaction and retention of new graduate nurses.” Journal for Nurses in Staff Development 22(2): 70–77.
Benner, P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley.
Berkow, S., Virkstis, K., Stewart, J., and Conway, L. (2009). “Assessing new graduate nurse performance.” Nurse Educator 34(1): 17–22.
Pine, R., and Tart, K. (2007). “Return on investment: Benefits and challenges of a baccalaureate nurse residency program.” Nursing Economics 25(1): 13–18, 39.
Blanzola, C., Lindeman, R., and King, L. (2004). “Nurse internship pathway to clinical comfort, confidence, and competency.” Journal for Nurses in Staff Development 20(1): 27–37.
Keller, J., Meekins, K., and Summers, B. (2006). “Pearls and pitfalls of a new graduate academic residency program.” Journal of Nursing Administration 36(12): 589–598.
U.S. Department of Health and Human Services, Health Resources and Services Administration (2004). “What is behind HRSA's projected supply, demand, and shortage of registered nurses?”
Vicky Goeddeke, RN, MS, CEN, CPEN, is the ANCC Magnet Recognition Program® and nursing excellence manager at Northwest Community Hospital in Arlington Heights, IL.
Designation as a stroke center requires that all clinical and nonclinical hospital employees receive training on how to recognize a stroke and take appropriate actions. This was the challenge JFK Medical Center, a 500-bed acute care and rehab facility in Edison, NJ, undertook in 2007 when it pursued designation as a comprehensive stroke center by the New Jersey Health and Senior Services and a primary stroke center by The Joint Commission.
Why do nonclinical staff members need stroke education? A security officer, for example, might encounter a patient or family member exhibiting behaviors consistent with stroke. The officer must be able to recognize the signs and symptoms of stroke and how to promptly summon qualified patient care providers.<.P>
Direct patient care providers need more in-depth education, depending on their roles and the amount of care they provide to stroke patients.
Reaching far and wide
Educating an entire hospital is a daunting task. Donna Kozub, BSN, RN-BC, was assigned responsibility for educating non-licensed nursing department personnel, known as patient care technicians (PCT), in 2007. Kozub's target audience members were those who had the most contact with stroke patients. PCTs who had little or no direct contact with stroke patients (e.g., pediatric unit staff members) received basic education, but those who had more contact needed additional training, she explains. There were no specific mandates from accrediting bodies regarding the hours of education required, only that staff members must be educated. Length and content was to be determined by the educators.
Kozub began by searching the literature for education specific to non-licensed personnel. "I really relied heavily on the American Stroke Association's division of the American Heart Association's wonderful Web site. Part of it is designed for the community, which was a big help when writing at a level appropriate for our PCTs."
Kozub also relied on an interdisciplinary subcommittee of the Stroke Certification Team to help design the education. Members of the subcommittee included nurse managers, speech pathologists, and the neurovascular nurse clinician.
"We looked at it from not only a content perspective, but how to make the information meaningful for the PCTs so that they could apply it not only to their patients, but to their families and themselves as well," Kozub explains.
Nurse managers identified specific duties of PCTs so that education could be geared to helping them fulfill their responsibilities. The clinical director of speech pathology and audiology provided essential elements of curriculum related to communication with aphasic patients.
The senior speech pathologist gave input on topics related to dysphagia, and the neurovascular nurse clinician served as a clinical expert to evaluate completeness and accuracy of content.
Teaching strategies
All employees watched a one-hour stroke video. Kozub developed a three-hour stroke education program consisting of two one-and-a-half-hour modules for PCTs from the targeted patient units.
The first module was entitled "Care of the Stroke Patient," which Kozub offered frequently. "I tried to make it personal and fun," she says. "There were lively discussions about how stroke risk factors were affecting their own lives and the lives of their families."
The second module was entitled "Care of the Patient with Dysphagia" and was presented by the senior speech pathologist. During module two, learners could sample various diet consistencies and learned appropriate patient feeding techniques.
PowerPoint, lectures, discussions, handouts, and demonstrations were primary teaching strategies. Participants were evaluated with a written test after each module. Tests were graded at the end of each class and certificates presented to those who successfully completed the program.
"Most PCTs passed the written test without problems," says Kozub. "They were so proud, and I was proud of them."
Ongoing education
Although the classroom setting had many advantages, it also meant that program administrators had to offer modules frequently so everyone could attend, take time to grade tests, and keep manual records.
Since stroke education is required annually, changes had to be made to increase efficiency. In 2008, Kozub made the decision to move to a computer-based learning (CBL) strategy. "Although I love the energy of the classroom setting, it just wasn't practical to offer this type of education annually in the classroom," she says.
The advantages of CBL were easy access, around-the-clock training, and the ability to print test scores and confirmation of attendance. Disadvantages included the inability of participants to share experiences and practice hands-on feeding techniques and administrators not being able to perform demonstrations.
However, Kozub says the training worked just as well. Test scores with CBL were as good as when the content was presented in the classroom setting, and transfer of knowledge to the patient care setting remained high in both 2007 and 2008. Nurse managers expressed satisfaction with the CBL training since outcomes remained consistently high and scheduling was less of an issue.
Kozub hopes to develop an interactive education program that allows instant feedback when learners are asked to answer questions during the program. This technology could also allow learners to review specific slides and revisit challenging questions.
CBL training is now incorporated into orientation for PCTs hired for targeted units. The hospital also has used specific facets of the training to develop stroke competencies for PCTs. This initiative not only facilitated transfer of knowledge to the patient care setting, but enhanced the self-esteem and pride of the PCTs working with such a special patient population.
JFK Medical Center achieved stroke designation from The Joint Commission and the New Jersey Health and Senior Services. Education will continue to play a pivotal role in maintaining these designations.
This article was adapted from one that originally appeared in the November 2009 issue ofThe Staff Educator, an HCPro publication.