Crtical Care Plus: Finding ICU Nurses: What’s Working?
Critical care directors share their secrets for success
Patti Crimmins-Reda, RN, says the significant difficulty ICUs have recruiting enough nursing staff is due to the increasing acuity of patient illnesses and to the number of uninsured patients who use emergency services as primary care.
"ICU patients today are far more ill than they were 10 years ago," she says. "We’ve had to be creative about getting and keeping enough nursing staff to take care of them."
Crimmins-Reda is director of critical care, emergency services, and cardiology at Barnes-Jewish Hospital in St. Louis, a 1387 bed academic hospital affiliated with Washington University’s School of Medicine. Barnes-Jewish is consistently listed on the U.S. News & World Report "Honor Roll" of top hospitals, ranking 7th in the nation in 2001.
To deal with the current shortage of ICU-qualified nursing staff, Crimmins-Reda says her facility’s ICU significantly improved its orientation and unit-based training programs, taking in nurses with less experience and giving them more intensive training.
She notes that 10 years ago it was virtually impossible to get a job in an ICU without 3-5 years experience as a staff nurse. A couple of years ago, Barnes-Jewish developed 3- to 6-month ICU nursing internships that provide intensive training taught by physician staff and nurse specialists, a move the facility repeated for its emergency medical department during the past year.
Intensively Trained ICU Nurses Feel More Comfortable
Crimmins-Reda says this allows new nurses to begin ICU work more quickly. "They also feel safer and more comfortable because they’re getting an intensive, knowledge-based experience," she says. "We’re able to provide new nurses with the knowledge and confidence they need to manage acutely ill patients."
ICU nurses at Barnes-Jewish don’t get paid more than their colleagues who work in other areas of the facility.
The need for better-trained ICU nurses is a result of changes in treatment trends. Crimmins-Reda observes that many patients who 10 years ago would have received their care in an ICU are now being managed in a less acute environment. A GI bleed, for example, may be treated in a step-down unit instead of in intensive care. "What we’re seeing in intensive care today are more total system failures," she says. "Much of that is due to long-term management of chronic illnesses such as diabetes."
Crimmins-Reda says her ICU strives for a 2 patients-to-1 RN ratio. Barnes-Jewish is currently considering implementing patient care dyads comprised of a registered nurse and a skilled, unlicensed patient care assistant who work with the physician staff. Such a move, she says, would provide the licensed caregivers with another pair of hands, thus increasing time efficiency.
"In the areas we’re able to have that now, it works well," Crimmins-Reda says. "I think it influences our outcomes area very positively."
Financial, Scheduling Incentives Brings Success
Another successful staffing strategy—based on salary and scheduling changes—is being used by Children’s Memorial Hospital in Chicago.
Paul Ocon, RN, MPA, administrator of critical care with Children’s Memorial Hospital in Chicago, says Children’s Memorial has much lower vacancy rates and turnover than ICUs nationwide. "I’ve heard vacancy rates ranging from the high teens to low twenties," Ocon says. "We’re under 10%." He attributes retention success to first increasing salaries, then improving scheduling flexibility.
Salary increases stemmed from comparing Children’s Hospital to 14 other facilities in the Metropolitan Chicago Health Care Consortium. "We wanted to be sure we were paying our team competitively," Ocon says. "We found we were lagging behind the marketplace. We now make sure we offer base salaries that are midpoint to the city range."
ICU nurses at Children’s Memorial have the option of earning a financial bonus by working weekend shifts for 12 consecutive weeks. The goal, Ocon says, is to enable the rest of the staff to work only every third weekend rather than every other weekend.
Unless they go on medical leave, nurses opting for the weekend bonus need to work 2 out of the 3 weekend days plus 2 other days of the week for the entire period or they forfeit the bonus, which is not prorated. At the end of the 12-week period, they receive bonus pay, after which they may choose to sign on for another 12-week period or return to their regular schedules.
Ocon says Children’s Memorial also offers a seasonal ICU financial bonus. "We know that winter months are high-census for pediatrics ICUs, so we’ve put a dollar incentive in place there, too," he says.
Ocon notes that his facility recently became the first children’s hospital in the country to be awarded magnet status by the American Nursing Credentialing Center, the research and academic arm of the American Nursing Association. Under a program called "Destination Nursing," the Healthcare Advisory Board recently recognized the hospital as 1 of 5 nationwide with successful nursing strategies.
Float Pool, Agency Pay Increase Staffing Efficiencies
To make staffing more efficient, Children’s Memorial increased its internal float pool, which Ocon refers to as a resource team. These nurses receive slightly higher pay than their counterparts on the floor because they float among various floors, getting daily assignments to the units needing the most help. Ocon says this has reduced the amount of time other staff members must spend floating.
A limited but popular staffing solution used only for certain units and for a restricted period of time involves paying agency rates to nurses for shifts above their commitment.
"The thought was that most of our nurses work extra anyway, for agencies filling shifts in other hospitals, Ocon says. "It didn’t make sense for them to work elsewhere if we were using agency nurses here."
Ocon stresses that any bonus plan Children’s Memorial offers is for a fixed amount and is periodically reviewed to determine its success rate in meeting ICU staffing goals. "We always try to manage the expectations of the team so that we don’t keep something in place we will later have to take away," Ocon says. "We strive to be the employer of choice."
For more information contact Patti Crimmins-Reda at (314) 286-0301, and Paul Ocon at (773) 880-3947.
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