Newly approved legislation helps to address the 'dire shortage of healthcare workers in our state,' governor says.

Working certified nurse aides (CNAs) in Hawai'i who want to make the leap to become a licensed practical nurse (LPN) are getting a boost with legislation that Gov. Josh Green, MD, signed into legislation.

In addressing that statewide shortage of healthcare workers, Green signed legislation that appropriates $130,000 for instructional costs for the Certified Nurse Aide-to-Practical Nurse Bridge Program at University of Hawaiʻi Maui College, and $200,000 to provide student aid to participants in the CNA-to-LPN Program at the school.

The appropriation includes funds for tuition, fees, supplies, and related costs, according to a press release from the governor's office.

The program is designed particularly for working CNAs and other healthcare professionals who want to become LPNs, to enhance the quality and provision of healthcare services on Maui.

"This funding contributes to a robust education system in providing health workforce education and training, to enhance the quality of healthcare in our community and address the dire shortage of healthcare workers in our state," Green said.

The program partners with Hale Makua, ʻOhana Pacific Health, and Kaiser Permanente Hawaiʻi and provides eligible Maui and Oʻahu healthcare professionals with the opportunity to become LPNs while they are working.

"This is a proud day for UH Maui, as we will be able to contribute greatly to helping our state's healthcare system staff up, while at the same time, affording certified nurse aides an opportunity to advance their careers through the bridge program," said Lui Hokoana, chancellor of UH Maui College.

Green also signed additional legislation authorizing up to $20 million in bonds to build a new hospital—West Maui Hospital and Medical Center—in the county of Maui, including any necessary infrastructure.

"These two bills came out of the community and were actually driven by the community," said state Sen. Gil Keith-Agaran. "[The CNA-to-LPN bill] was probably one of the easiest bills to move through the legislature this year … because the expansion will also provide more healthcare positions on Kaua'i and O'ahu. This is helpful for healthcare throughout the state."

The new Collaborative Care Model is rooted in positioning team members to practice at top of their licensure.

Editor’s note: This article appears in the July-September 2023 edition of HealthLeaders magazine.

When UnityPoint Health began exploring new inpatient care delivery models, D’Andre Carpenter, DNP, RN, chief nursing officer, wanted to go beyond the concept of team-based care to position nurses and other clinicians to practice at the top of their license.

The result was UnityPoint Health's Collaborative Care Model (CCM), rolled out earlier this year, which is meeting the needs of the health system’s workforce, as well as its patients.

Early indicators point to a marked decrease in call light usage, increased team member satisfaction, and an increase in patient communication with nurses, Carpenter says.

Carpenter spoke with HealthLeaders about the new care delivery model and its positive impact on patient safety, patient experience, and staff satisfaction.

This transcript has been lightly edited for brevity and clarity.

D'Andre Carpenter, Chief Nursing Officer, UnityPoint Health / Photo courtesy of UnityPoint Health

HealthLeaders: What circumstances made it necessary to create this new, collaborative care model?

D’Andre Carpenter: We are not uncommon to many other systems across the country that are looking at alternative care delivery models to deliver care more efficiently and more cost effectively, and how to leverage team members, from a labor perspective, to deliver care in a different way.

We went down a path of exploring and examining our own processes to see if there were an alternative model that we could come up with that would help improve the overall quality and safe care that we provide to our patients that can also make our ability to staff to the clinical needs more efficient—increasing staff and patient satisfaction—while also finding a more cost-effective way to leverage labor across our enterprise.

These were some of the initial guiding principles that went into our exploration work and some of the themes that we fit into our model as we as we started to mature it.

HL: What team members does each CCM care team consist of and how does it work?

Carpenter: You hear a lot in industry right now about team-based care, because many of the alternative models that folks are thinking about involve some aspect of team-care delivery. When we started thinking about this, we challenged ourselves to look above and beyond that. That concept, in and of itself from a clinician standpoint, can often be looked at as negatively and we wanted to push beyond it, which was to get to, “How do we position our team members to practice at top of licensure?”

We love seeing that in nursing, but we looked at that and tried to understand what that really meant and how to focus on the care delivery needs of our patients and how to align the best functional scope of the individual interdisciplinary team members to deliver that care.

It created for us an opportunity to create some flexibility in the model to get to that because not every care delivery need is like the other and not every unit is like the other. There are lots of considerations there. So, foundationally, we introduced two roles that are unique to our current, traditional model, the first of which is what we refer to as the attending RN, and this is the leader of the collaborative care group. This is the team member that is leveraging holistic leadership skills, and the ability to delegate among multiple team members to align the best scope of the individual team members to the care needs of the patient.

The other one is taking the traditional concept of our charge nurse and elevating that to the next level and creating this clinical lead RN who has the ability to have some oversight over multiple collaborative care groups, generally over multiple areas. It’s a bridge between what you would normally refer to as a house administrative supervisor and the unit charge nurse and so those roles in addition to a licensed role or flex roles can include an LPN or an RN.

There's a flex role that we've built into the model that is used, depending on the patient care needs that day. So, some areas that have higher acuity needs will often opt in the flex role. And then we've factored in a supportive role for the nursing team that is generally filled by a patient care technician or another individual with similar scope.

The underpinning of this is the enhancement of our virtual nurse program. The virtual nursing team is aligned to each collaborative care group and there's a sub-function of the scope at the registered nurse level that is augmented to the virtual nurse.

HL: What are some of the specific benefits to nurses that this model provides?

Carpenter: The ability to practice at top of license. The ability particularly for a lot of our new-to-practice RNs or new-to-practice nurses to have the expertise and the resource from more-tenured team members to create an environment where they are able to learn independently and within a group is something that we are also building into the model.

We are onboarding the majority of our nurses and most clinical areas are new to practice, and it creates a compression gap in terms of the knowledge base when you're trying to rapidly get these folks in and get them productive. So, this is a model that they can continue to learn and develop their practice, while also being able to deliver care as a clinician.

With some surveys that we've seen, it's improving staff satisfaction in terms of how they see themselves in clinical practice, whether that's creating a safer environment because of the complement of team members that are there, or the ability to work in a learning environment. Those are some of the things that we're starting to see as outputs.

HL: What data are you seeing so far from the CCM?

Carpenter: During the first 100 days of using the CCM in select units at several hospitals, UnityPoint Health has seen a positive impact on patient safety, patient experience, and staff satisfaction.

Some of those include:

• A reduction of 1,500 call lights in one unit at our largest hospital during the first month.
• Staff vacancy rates decreased in one unit by nearly 10% while using the same number of contract staff.
• More than a 10% increase in patient communication with nurses using the model at two of our hospitals.
• More than half of the staff nurses surveyed from one unit participating in the model felt that it has improved teamwork.

We are rolling out the Collaborative Care Model to other units within our hospitals over the next several months.

HL: How does this care model benefit patients?

Carpenter: This is the outcome data that is really exciting. For an overall patient experience, we've measured the HCAHPS and one of the primary drivers and questions around that is related to communication with nurses. We’ve seen a 16% increase over the collaborative care units as it relates to the model. We've also seen, from a safety perspective, a decrease in call light usage, as I mentioned. We know that the more attentive we are to our patients, the less times they have to call out for us, which also helps improve fall rates and other things that we typically see that are downstream impacts.

In the patient experience question around care providers working together, our data suggests a 17% favorable increase, which is something that we're working to continue to track with this first phase-one unit. So, there's a lot of patient experience components that we're starting to see as a benefit to the model.

What I love hearing are the testimonials that our team members are sharing with us from our patients around never feeling like they were unattended to, and always feeling like there was someone there who could meet their needs and answer their questions.

HL: What are some of the testimonials you're hearing from nurses?

Carpenter: The feeling of being supported. More specifically for our experienced nurses who are more often working in the attending and the lead role, they're feeling value that's associated with their expertise in their practice, because they are being identified and seen in the space as a leader.

HL: When nurse leaders are considering changes like this, how should they effectively adopt a new care model into their organization and achieve buy-in?

Carpenter: The No. 1 thing that I led into my conversations with our leaders is this whole phenomenon of tradition and “the way we do things.” I often use a quote: “I love nursing and I am proud to be a nurse because of the rich tradition and the history that the profession brings to our patients, but tradition more often is something that can sometimes keep us back a little bit.”

So, we went into this with the spirit that we're still going to promote best practice in nursing but we're also going to break a little bit of tradition, because we know we need to do things differently. We wanted to create something from a model perspective that was standardized, aligned, and structured enough that we could continuously benefit from the improvements that we built into the model, both quantitative and qualitative, but also be nimble and flexible enough for our team members to make autonomous decisions about how they were thinking about the care delivery needs of the patients, and still be efficient.

I would say to leaders that you want to create a model that's going to get you to a high level of efficiency by standardizing and aligning to process, but at the same time, create components within the model that are flexible enough for your team members to be able to autonomously think on the fly and make some of those key decisions that they need in order to ensure that you're flexing the model to your needs, but still gaining the efficiency from it.

A pediatric charge nurse struggled to cope with critical patient events. What resulted is a more effective debriefing process.

A charge nurse at a pediatric hospital who struggled to cope with several traumatic resuscitations within a short time frame helped create a tailored debriefing process that resulted in increased levels of compassion.

The bereavement/wellness committee in the pediatric intensive care unit (PICU) at Lurie Children’s Hospital of Chicago, of which the nurse was a co-chair, changed its debriefing process from one in which critical patient events were clinically reviewed days, or even weeks afterward, to one that gave those involved an opportunity to reflect on the event, recognize each other’s efforts, and, in the case of a death, honor the patient’s life, before the end of the current shift. 

One year after the Rapid Review of Resuscitation (R3) debriefing process was developed, staff compassion fatigue scores improved significantly, while levels of burnout and secondary traumatic stress were the same as before implementation, according to the article, Debriefing After Critical Events Is Feasible and Associated With Increased Compassion Satisfaction in the Pediatric Intensive Care Unit, published in the June issue of Critical Care Nurse (CCN).

“Many debriefing processes focus on communication and teamwork but neglect the emotional impact of critical patient events,” says co-author Courtney Nerovich, BSN, RN, a nurse in the PICU and a member of the committee. “We specifically added elements to reflect, to honor the patient’s life and recognize the team’s efforts.”

“These additions may have enhanced clinician, patient, and team connections while supporting mindfulness and reflection,” Nerovich says.

Changing the process

Before the R3 implementation, the standard practice at the 40-bed, high-acuity, high-volume PICU was to hold an event debriefing several days to weeks after a traumatic event. The process was inconsistent and often had poor attendance.

Additionally, staff members were leaving work with significant distress after critical events, the article notes.

“The team’s objective was to create a sustainable debriefing process that allowed time for reflection and encouraged team communication after critical patient events,” according to the article.

The team conducted a literature review along with several individual staff interviews, in which staff members identified talking with colleagues as a primary method for coping and expressed a desire for a more consistent mechanism to process critical patient events.

The team then created a single-page debriefing guide with scripted language and open-ended questions. The guide included three essential process components that aligned with staff needs:

• A review of the patient event and team dynamics.
• Acknowledgement of the event’s emotional impact on staff.
• For events in which the patient died, a moment of reverence to honor the patient’s life.

The team sought feedback, which led to minor adjustments to the initial debriefing process, including development of a guide specific to the planned withdrawal of life-sustaining therapies, which was called R3-D.

The R3 process was designed to be completed voluntarily before the end of the shift with the expectation that after a critical patient event, an R3 champion would contact the primary medical team and determine a time to conduct a debriefing during the current shift, if possible.

Once the debriefing was scheduled, the champion would notify all staff members who were directly or peripherally involved in the event, with the goal of including as many of them as possible. During the debriefing, the champion read the guide and recorded the team’s responses, the article says.

“In the 12 months after implementation of the new process, the debriefings were integrated into the PICU culture and became expected and valued by staff,” the article reads. “It has since been implemented on other inpatient care units and has received overwhelmingly positive feedback.”

Galen College of Nursing has multiplied its campuses nearly fourfold since HCA's acquisition 3 years ago. 

When HCA Healthcare acquired a majority stake in Galen College of Nursing, one of the nation’s largest private nursing schools, in early 2020, the nursing school consisted of a handful of campuses.

Since the HCA acquisition, Galen has expanded to 19 campuses nationwide, plus an online program, with an enrollment of some 12,000 students. The newest campus, announced in April, will open in the latter part of 2023 in Salt Lake City, Utah.

Partnerships between hospitals or health systems and schools of nursing are becoming more common as healthcare leaders search for creative ways to bolster the number of nursing students, and thus, their nursing pipeline.

Sammie Mosier, DHA, MBA, BSN, NE-BC, CMSRN, HCA’s senior vice president and chief nurse executive, spoke with HealthLeaders about the health system’s supercharged approach to educating future nurses amid a national nursing shortage.

Sammie Mosier, SVP and CNE, HCA Healthcare / Photo courtesy of HCA Healthcare

This transcript has been lightly edited for clarity and brevity.

HealthLeaders: What have been benefits of HCA’s acquisition of Galen College of Nursing?

Sammie Mosier: Not all healthcare providers can offer degree programs like we can with our nursing school. One of the obvious opportunities is to ensure that we have a Galen College of Nursing in our markets, and that does a couple of things.

It introduces a supply of nurses and so it's an opportunity for us to recruit those nursing students early. Also, we have a nurse extern program that allows our nursing students to come into the hospitals and participate in that program. It gives them hands-on experience and exposure to healthcare, which has been something we've been challenged with over the last couple of years with some of our students. They have gotten out of school, and they passed their NCLEX but they didn't necessarily get a lot of hands-on training in their programs, so this is mitigating that barrier.

We have more than 5,500 nurse externs in our hospitals and that is allowing them to get hands-on opportunities with our patients, but then it also gives them exposure to different care areas so that they’re a little more familiar with the hospital environment and they also can determine which specialty they want to go in when they graduate. So, they're interviewing us just like we're interviewing them.

HL: How has Galen grown, and in what ways, since it became part of HCA?

Mosier: We’ve more than doubled in footprint. We're currently at 17 schools [Editors’ note: Two more campuses have opened since this conversation]. When we purchased Galen, it had four campuses and, I believe, was getting ready to open a fifth, so we’ve definitely helped expand that, and that's been based on market needs.

The school has about 12,000 students enrolled. We look at that and determine how many more schools of nursing we need. We do have some expansions planned over the next three years based on the enrollments that we're seeing, so Galen definitely has not been short on gaining students in every one of our markets. They actually have exceeded enrollment expectations, which emphasizes that it's not that people are not interested in nursing; it’s that there's a barrier for them getting into nursing school, so Galen is opening that up.

NCLEX testers since 2019 in the U.S. have numbered about 149,000 to 150,000 testers each year, and as we expand Galen, that's going to put more students with the ability to test, so we'll change the national statistics as we grow this program.

HL: You referenced barriers, and one barrier is that nursing schools don’t have enough instructors. How is how is Galen doing in filling those seats?

Mosier: This is where we have a really good partnership with Galen. They have a good culture with a positive and supportive environment, so they're able to attract talent. They have created a pathway that takes nurses who are passionate about education, and they teach them how to teach. They have unique training, where they take new faculty members and do extensive individual orientation with them that lasts about 12 months. Then they have additional programs and separate tracks so that those nurses who are becoming faculty continue to move from a novice to expert just like our nurses do.

We also have benefit where together we created a program for their master's program. They have a master's in education, and they have a master's in leadership. With the master's in education, they can build their instructor gaps with that, and the master's in leadership is where my pipeline comes into play as far as directors and ACNOs and CNOs for the future. So, there’s a good partnership there.

Galen also has invested heavily in resources to establish a common curriculum and assessment, so those 17 campuses don't look different. They're able to leverage the size and scale of Galen, to be able to help support their educators.

HL: How has the pipeline benefited HCA regarding filling staffing gaps? What percentage of Galen graduates go on to work in HCA facilities?

Mosier: We’re starting to get that data now because a lot of the programs that we opened are just starting to graduate students, so we'll have better statistics in the future to report on that. We're starting to see that, and that nurse extern pipeline is helping us think about the potential conversion rate there, too.

Obviously, our goal is to get them to convert to full-time nurses. I tell everyone that it's not a short-term strategy; it’s a long-term strategy when it comes to the Galen. Within the next year, we'll really start seeing the benefit of that in the markets that opened earlier and then that will continue to build.