Editor's note: This article is based on a series of informal discussions among colleagues concerning meeting the needs of evening and night shift staff.
Providing learning opportunities for evening and night shift staff requires innovation and commitment. People who work evenings and nights often complain they feel slighted when it comes to education. They are often asked to come in early or stay beyond their shifts so they can participate in educational offerings. They would prefer in-person programs during the hours they work.
Staff development specialists have their own concerns about providing in-person offerings during these shifts. Attendance is often poor, and thus some educators feel it is a waste of time to try to offer education during the evening and night shifts. How can staff development professionals reconcile such problems and still establish a presence on these shifts?
Consultation with colleagues has generated much discussion and some practical ideas for problem resolution. A physical presence on evenings and nights is important, but must be carefully planned. Few departments have the staffing resources to assign regular persons to these shifts. If you do, you need to show that it is cost-effective and has a positive effect on job performance and organizational functioning. Let's start by reviewing the distance learning methods established for all shifts.
Distance learning
Distance learning techniques, such as self-learning modules, computer-based learning, and podcasts, are good strategies for all staff members. However, these techniques require good communication between learner and staff development specialist. Since much of this communication occurs via phone, e-mail, or other distance mechanisms, we must be meticulous in how we address concerns and respond to issues that affect the learners.
The following are some tips for facilitating distance learning on evening and night shifts:
Make sure that all necessary equipment is in good working order and accessible during evenings and nights. There is nothing more frustrating than trying to participate in a distance learning experience and not being able to access equipment (e.g., DVD player, computer programs) or having to deal with broken equipment. This can be especially aggravating when the staff development department is closed.
Set up specific e-mail boxes for each shift. This may seem like an unnecessary step, but it will help you track questions, comments, and concerns by shift. All distance learning programs should indicate on the evaluation forms a mechanism for direct communication, such as by e-mail. Establish a time frame for your response, such as 48 hours. But remember, once you establish a time frame, you need to stick to it. Be sure someone is assigned to read/review e-mails and respond, and designate a backup responder to cover sick days, vacation days, etc.
If the distance learning experience requires a posttest or other written evaluation of knowledge acquisition, establish a time frame for letting learners know whether they passed. Make sure the time frame is clearly stated as part of the written evaluation and that you meet the deadlines you established.
If the distance learning activity requires a skill demonstration component, set up the skills lab so all shifts have the same opportunities to practice prior to testing.
Professional development
Be sure to include members of the evening and night shift in activities that promote professional growth and development. The training and education of preceptors on these shifts is critical. Some orientation, of course, is accomplished on day shift. However, nurses and other staff who work other shifts must participate in orientation directly with preceptors on evenings and/or nights, depending on the shift the orientee will work.
Mentoring opportunities must include members of evening and night shifts, both as mentor and mentee. Leadership development is one such mentoring opportunity. Too often, potential leaders are selected and groomed predominantly from the day shift. If your organization has mentor and/or leadership development programs, be sure to recruit staff from evenings and nights. They bring a different perspective to most topics of discussion. They see a predominance of visitors, cope with disgruntled family members, and deal with episodes of environmental problems (e.g., fire, safety issues) without the more extensive staff and resources available on day shift.
In addition, facilitate committee membership among evening and night staff. Thanks to technology, it is not necessary for staff to be physically present during committee meetings, which are routinely held during the day. Instant messaging, e-mails, and Web and teleconferencing are options for attendance. Risk management, quality improvement, and Joint Commission readiness are just a few examples of critical areas that require input from those who work during the evening and night hours.
Analysis of medication hours, for instance, cannot be adequately performed without input on how the process works during these time periods. Evening and night shift supervisors, in addition to staff members, must be included in the process. What better way to include them than to have interested staff members serve as committee members? This also helps these staff members feel that their input is important and their contributions to the organization are recognized and valued. Remember this when it comes time for recognition and award ceremonies; nominate members from these shifts, as without them, no organization could function.
Most staff development departments facilitate publication in professional journals and submission of abstracts for paper and/or poster presentations at conferences and conventions. However, representation from evening and night shift perspectives is historically lacking. The next time you encourage colleagues to publish or present, make sure that you seek out individuals who work evenings and nights.
In-person programming on evenings and nights
What about the physical presence of staff development specialists during evening and night shift hours? As already mentioned, few organizations have the luxury of assigning staff development specialists to specific shifts. A few of our colleagues from large health systems said they have part-time staff development specialists assigned to evenings and/or night shifts. However, these are the exception, and some of these positions are in danger of being eliminated due to budget constraints. So for the purpose of this article, let's address this issue from the perspective of having to rotate staff development specialists to evenings and nights.
The following are some recommendations:
Select a regular day of the month (e.g., the first and second Tuesday of the month) to cover evening and/or night shifts, and stick to it. Staff need to know that you will be present during your scheduled times.
Consult with evening/night shift supervisors (and staff members when possible) when planning your schedule. They are the best persons to suggest days, times, and desired learning experiences.
Select your learning activities carefully. When working these shifts, present need-to-know rather than nice-to-know information.
Choose learning experiences that have a skill demonstration component whenever possible. Sitting in a classroom at 2 a.m. is not conducive to learning, but participating in an active, hands-on learning experience will be.
Some of our colleagues have met with success when they set up a skills lab available for multiple hours throughout the evening and night. Examples of what to cover include new procedures, equipment, and competency demonstrations. Staff can drop in when they please. Naturally, if only one staff development specialist is present, he or she cannot teach and evaluate demonstrations. Didactic information can be available as self-learning modules, DVD, or posters. After completing the didactic portion, staff can proceed to the demonstration portion of the learning experience. Don't forget to set up an area for practice prior to the actual demonstration. Most learners will welcome the opportunity for practice.
Mock drills, such as mock Joint Commission survey tracers, are also good learning activities. Too often, such drills are limited to the day or early evening portions of shifts. But Joint Commission readiness means being ready 24/7.
Avoid learning activities that are sedentary. Again, sitting in a classroom or watching a DVD at 2 a.m. may be more conducive to sleep than to learning.
Maintain your enthusiasm. Be a positive advocate for ongoing learning.
Consider promoting research projects that focus on evening and night shift patient outcomes. Round-the-clock input is important when investigating patient outcomes.
Make sure you gather evidence-based staff development data specific to your activities during evening and night hours. Focus on attendance, knowledge acquisition, and application of knowledge in the work setting. Link your presence on these shifts to positive patient outcomes and improved job performance.
In summary, opportunities for continuing education and professional growth and development must be an around-the-clock process. Establish a system that facilitates staff development presence during the evening and night shift hours. Provide opportunities for mentoring and leadership development.
But most of all, establish an environment for learning from which evidence can be gathered that shows education has a positive effect on patient care, job performance, and organizational effectiveness.
A crackdown by U.S. drug agents on the dispensing of prescription drugs in nursing homes is coming under industry fire and congressional scrutiny, the Wall Street Journal reports. The Drug Enforcement Administration last year began probing allegations that nursing staff at some nursing homes were illegally dispensing powerful medications without doctor authorization. The issue is the subject of a Senate hearing set for Wednesday. Nursing-home and hospice- care trade groups say patients have been left to "languish in pain" while nursing homes and pharmacies try to find ways to comply with DEA regulations requiring physicians, in most cases, to write prescriptions, the Journal reports.
Nurses at Morton Hospital and Medical Center in Taunton, MA, say they are contemplating a strike after months of meetings and stalled contract negotiations with hospital management. The Massachusetts Nurses Association, which represents more than 400 nurses, physical therapists, and other staff at Morton, wants to end mandatory overtime shifts that require some employees to work more than 12 hours. The union is also fighting an effort to switch nurses' traditional pension plans to contribution-based funds, primarily 401(k) plans. David Schildmeier, a spokesman for the nurses group, said the hospital has threatened to change the plans by March 31, despite the ongoing contract talks.
Market-savvy healthcare organizations have implemented workforce development strategies to address the existing and projected labor shortages. This helps organizations determine where the strategic priorities lie.
The recent economic downturn will have lasting effects. The recession, which officially started in December 2007, has affected the job market.
Picture the current state of the nursing shortage as a tsunami. The first thing that happens in a tsunami is that the water on the beach rushes away from the shore. Nurses are filling current vacant positions en mass. Nurses who had planned to retire, work only part-time, or reduce their hours find they have had to change their plans. They are staying and taking on full-time, rather than part-time, positions (Buerhaus, 2009). "As RN spouses lost their jobs (70% of RNs are married) or worried that they might be laid off, many non-working RNs rejoined the workforce" (Buerhaus).
With RN vacancies being filled at an exceptional rate, organizations might have an urge to ease their recruitment and retention efforts. This is exactly the wrong strategy to take. As the economy begins to adjust, the tidal wave will hit. The impact of the tsunami wave depends on how quickly the economy recovers. If the economy recovers quickly, jobs will be rapidly added back to the market. Many nurses who had to come back to work or work more hours to supplement the family income will leave the job market (Buerhaus). Nurses who postponed retirement may stay in the market a little longer than anticipated to rebuild their retirement incomes, but they will also leave (Buerhaus).
What about the new graduates coming out of nursing school? In a down economic climate, employers are able to be more selective when posting positions. When employers were faced with a lack of experienced nurses applying for jobs in specialty areas (e.g., emergency room or neonatal ICUs), they had no choice but to take on new graduate nurses (Clavreul, 2009). If the economy recovers at a slower pace, nurses will not leave the workforce. This means that new graduates will continue to have difficulty finding jobs unless they are willing to be flexible and work in a more generalist role. Whether the economic recovery is fast or slow, it will have long-lasting effects on healthcare organizations.
Organizations cannot afford to simply react to the workforce shortage. Instead, they must take proactive steps to reduce the effects of the shortage on their organization and take an aggressive stance in terms of recruitment and retention strategies. The financial viability of an organization depends on it.
Case in point: The cost to fill an RN position due to turnover is between $82,000 and $88,000 (Jones, 2008). RN vacancy rates have an even greater financial effect on organizations. Costly approaches to filling the void include using agency/traveler temporary nurses, mandatory/voluntary overtime, closing patient units, and/or diverting patients to other facilities (Jones).
References
Buerhaus, P.I. (2009). "The shape of recovery: Economic implications for the nursing workforce." Nursing Economic$ 27(5): 338–336.
Clavreul, G.M. (2009). "Why nursing school grads have trouble finding jobs." WorkingNurse.com. Retrieved November 3, 2009, from www.workingnurse.com/articles/Why-Nursing-School-Grads-Have- Trouble-Finding-Jobs.
Jones, C.B. (2008). "Revisiting nurse turnover costs: Adjusting for inflation." Journal of Nursing Administration 38(1): 11–18.
Editor's note: This article is based on information found in the book Nursing Orientation Program Builder: Tools for a Successful New Hire Program. For more information, visit www.hcmarketplace.com.
Each year, Wendy Fletcher says, she and two partners see more than 5,000 patients at their practice in Morehead, KY. They are not doctors, but rather registered nurse practitioners who say they are able to increase access to healthcare and make it more affordable. "None of us are trying to play doctor," she said. The Kentucky Medical Association claims otherwise and is fighting proposed legislation that would lift some limits on the ability of about 3,700 nurse practitioners in Kentucky to prescribe medication and perform other, mostly routine tasks such as signing a child's immunization certificate or certifying the need for employee sick leave.
You probably address legal concepts when talking about documentation, medication administration, and delegation. But most orientation programs do not allot specific time to legal issues in general as there is constant pressure to conduct orientation more efficiently and in less time.
How can you introduce this additional information into an already crowded orientation schedule? One possibility is to develop a basic handout and include some scenarios for general discussion or self-study. Remember that you are not expected to offer a continuing education program on legal issues in nursing. This is beyond the scope of orientation. You are simply introducing some basic concepts and stimulating interest. Let's start with some basic legal concepts and a handout that will guide your discussions.
Laws and regulations
Each state has its own Nurse Practice Act, which contains information about the specific scope of practice and educational requirements. Each act also contains statements that prohibit nurses from performing tasks determined to be within the scope of medical practice.
You cannot review the entire Nurse Practice Act in orientation, but you should encourage nurses to obtain a copy of it from the State Board of Nursing and to become familiar with it. You should also include information about avoiding conflicts with employing organizations and volunteer organizations. Tell orientees that their employers cannot expand the scope of their practice to include actions that are prohibited by the state's Nurse Practice Act. All nurses have a legal obligation to practice within their Nurse Practice Act limits (Follin, 2004).
The first three items on the sample handout (p. 3) deal with your state's Nurse Practice Act and legal obligations pertaining to it. Exceeding those limits may result in disciplinary action by the State Board of Nursing or even loss of license. The next items deal with scope and standards of specialty practice and regulatory bodies. You don't need to go into great detail; simply mention those that are most applicable to your organization, such as The Joint Commission (particularly the National Patient Safety Goals) and American Nurses Association (ANA) Standards of Practice. Individualize the handout so it is applicable to your state and organization.
Delegation
It's a good idea to mention delegation responsibilities, especially to orientees who are newly licensed RNs. RNs may delegate to another RN, an LPN, and/or an unlicensed staff member, such as a nursing assistant. However, the RN may only delegate tasks to persons who are competent to perform them and who are able to perform them as part of their legal scope and standards of practice. The delegating RN is still ultimately responsible for his or her patient's care, even if some tasks are delegated to others (Follin, 2004).
The RN needs to know the competency, skills, and abilities of the persons to whom he or she is delegating tasks. He or she must evaluate these persons on an ongoing basis, continually evaluate patients, and report persons who are incompetent or who fail to perform tasks safely.
Elements of professional malpractice
Professional malpractice cases review the patient care provided to determine whether deviations from the appropriate standard of care took place. This is usually initiated with a review of the medical record. Standards of care are measured according to practice acts, professional scope and standards of care, and organizational policies and procedures.
To prove liability for malpractice, four elements must be shown (Morales, 2009):
Duty. There must be a duty that is owed to the patient as indicated by the nurse-patient relationship. This can be interpreted broadly. As a simple example, nurses have a duty to provide a safe environment for patients. Patients must be able to reach their call bell when they need to get out of bed to go to the bathroom. Part of the safe environment, and nurses' duty, is to make sure patients' call bells are within reach and they know how to access them.
Breach of duty. Breach of duty means nurses fail to fulfill their duty to the patient. Suppose nurses fail to adequately assess patients' environment. The nurses know a patient needs assistance to ambulate to the bathroom but fail to secure the call bell within the patient's reach. The patient can't reach the call bell and calls out for help. Unable to wait until someone hears him, the patient gets out of bed and falls. The duty to the patient was breached.
Injury. To prove liability, injury must occur as a result of the breach of duty. The patient who fell in an attempt to get to the bathroom breaks his hip as a result of the fall. He was injured due to a breach of duty. The injury must also result in monetary damage. In this example, the additional expense of hip surgery and extended hospitalization are part of the damages.
Causation. There must be a direct cause and effect between the patient's injury and the breach of duty. This is usually the most difficult element to prove at a malpractice trial. In the case of our example, it must be proved that had the call bell been within reach, the patient would not have been injured.
In addition to discussing the handout, develop case scenarios of your own that illustrate the four elements of negligence. You may also want to develop a mock court role-play scenario. Your legal department can be a big help when developing mock courts.
Legal tip: This article is intended as an introductory guide, not as legal advice. When developing legal tools, consult with your organization's legal and risk management department. Issues to address, in conjunction with your legal department, include advance directives, living wills, and hospital policy regarding employees witnessing patient wills.
References
Follin, S.A. (Ed.). (2004). Nurse's Legal Handbook (5th ed.). Philadelphia: Lippincott Williams & Wilkins.
Morales, K. (2009). "Elements of medical malpractice." Retrieved December 18, 2009, from www.nursetogether.com/tabid/102/itemid/1406/Elements-of-Medical-Malpractice.aspx.