Nurses conquer opposition to ICU non-professionals
Hospital uses competency-based training on staff
According to estimates, about 10% or more of an RN’s typical duties in an ICU involve performing chores that are deemed extraneous to direct patient care. Well-trained, well-paid critical care nurses typically devote an aggregate of one full hour of a 10-hour day involved in bathing, feeding, and turning patients or helping them to get out of bed, according to most nurses.
Although important, no one would argue that these tasks could not be performed as easily by a nurse’s aide or someone else. That’s what officials at the University of Michigan Health System (UMHS) in Ann Arbor concluded in a successful nurse support training program that began several years ago and is still in use today.
The nurse productivity issue at UMHS didn’t spring from a perceived shortage of ICU nurses. The 872-bed hospital was under pressure to find places in its operations to trim costs, recalls Michael Williams, RN, MSN, CCRN, formerly a clinical nurse specialist in the thoracic ICU and currently an assistant professor of nursing at Eastern Michigan University in Ann Arbor.
The idea administrators formed was to hire a corps of non-nursing workers, train them to be nursing technicians, and assign them to the unit to bolster the regular nursing staff’s effectiveness by assuming responsibilities for routine patient-care duties that were eating up valuable nursing time and dollars. "This wasn’t an option but a mandate," Williams recalls.
Nurses resisted additions to staff
The idea seemed well received in other departments. In the ICUs, the plan involved hiring a number of assistive personnel to reflect about 10% of the regular nursing staff on any given shift. (The actual number varied due to different staffing requirements in each ICU and on various shifts.)
But strangely, the nursing staff at the medical center’s 20-bed thoracic and coronary care ICU didn’t take to the idea even though it meant hiring only one or two individuals and they were likely to do less work under the plan. "Overcoming initial resistance wasn’t easy," Williams adds.
General skepticism, turf guarding, and difficulty with accepting change may have collectively played a role in the nurses’ reactions, says Janet Watts, RN, MSA, nurse manager of both ICUs.
Faced with an irreversible mandate, how unit managers and nurse educators solved the problem and rolled out an effective training program for assistive personnel offers a practical lesson in organizational change for managers facing similar challenges.
Initially, the attitude of nurses to the plan threatened its success, Williams recalls. The notion of hiring untrained non-professionals to work with patients seemed ill-advised largely because many of the ICU nurses had not been exposed to primary care, where the presence of non-professional assistive personnel is quite common, Watts says.
Fortunately, the practice was familiar to Watts and Cindy Donaldson, RN, CCRN, the nurse educator who helped launch the effort in the ICU.
The simple solution was to get the nurses to buy into the program at each phase by giving them a crucial role to play in it, Williams says. Here’s the way the program rolled out and the role nurses played. Nurses were:
• given the opportunity to help design the educational curriculum. (The unit staff chose the term education over training.) During meetings, the nurse educators consulted with the nursing staff on the specific duties that would be assigned to the technicians and how they would be trained during the course of their education.
• empowered to determine the specific tasks they wanted to delegate. These tasks included the ones cited above but also included doing routine venipunctures and arterial line blood draws (under supervision). The department submitted the list to the hospital’s personnel department, which suggested the nursing ICU technician title as a job classification.
Managers used the list along with the American Nurses Association guidelines, "Questions and Answers for RNs Working with Unlicensed Assistive Personnel" to develop a list of competencies for the technicians working in the units.
• authorized to retain responsibility for competency checking in collaboration with a nurse educator. The competency training presented considerable challenges, says Watts. Hired applicants came from a variety of backgrounds. They included clerks, paramedics, and persons with no health care background at all.
One of the challenges involving candidates with previous health care experience included teaching them what do on the job, but also what not to do, Watts recalls. Nurses had to manage individuals who were bringing more to the job than necessary, and the problem resulted in some turnover among candidates.
• sought out for feedback about individual performance throughout the course of training. The nurses represented the best source of feedback but for more than one reason. In developing performance standards, nurse educators drew up a skills checklist, which incorporated standards from the hospital’s own registered nurses skills checklist. The units also developed a critical behavior for competencies list to assess achievement.
The unit also developed multiple-skills checklists, that the nurses had to complete, to verify a broad range of technician competencies.
"Not surprisingly, using designated RN preceptors for each ICU technician proved very effective," according to a later report about the education program.1
• included in determining when each technician is ready for advancement to a higher level of responsibility through individual endorsements and proven performance ability. Although staff nurses still teach some content, the nurse educators oversee most of the technicians’ attainments through lectures, bedside practice, demonstrations, and assigned readings. In addition, seasoned technicians have taken over much of the daily bedside instruction from nurses. But staff nurses are still queried about their opinions and play a key role in continuous evaluation of the program, says Watts.
Yet, despite such achievements, the program isn’t failsafe. And it is definitely not the final solution to a nursing shortage, adds Watts.
For one, employee turnover is relatively high due to the relative low pay the technicians receive in general and compared to other hospital professionals. The starting wage rate for the ICU nursing technician is $8.98 an hour, Watts says.
But the effort shows promise nonetheless, Watts adds. "Originally, we didn’t have a choice in doing this, but it’s worked out pretty well," she concludes.
Reference
1. Williams ML, Donaldson C, Watts J. Educate ICU assistive personnel. Nurs Manage 1998; 29:32B-32H.
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