How do you maintain positive clinical outcomes with new staff?
As the nursing shortage lingers on like an unwelcome visitor, some outpatient surgery programs are struggling to keep their surgery schedules running at the same level. In fact, in a recent reader survey conducted by Same-Day Surgery, 10% of respondents said the nursing shortage had had a significant impact on quality of care.
The shortage also has impacted cancellation of elective surgeries. In a recent study conducted for the Chicago-based American Hospital Association (AHA), 10% of respondents reported that the nursing shortage has caused such cancellations.1 Programs increasingly are turning to contract nurses to fulfill their staffing needs. The AHA reports that 56% of hospitals are using agency or traveling nurses to fill vacancies.2
In the midst of this crisis, staffing effectiveness standards from the Joint Commission on Accreditation of Healthcare Organizations took effect for hospitals only July 1. The new standards help hospitals assess the number, competency, and skill mix of their staff by linking staffing effectiveness to clinical outcomes.
The standards rely on clinical and human resource screening indicators. Organizations collect and analyze data on multiple screening indicators that are sensitive to staffing effectiveness. The standards require organizations to choose at least four screening indicators. Two must be clinical/service-related, and two must be human resource-related. One of the human resource indicators that facilities may choose is "on-call or per-diem use."
"It’s a tool to assess staffing effectiveness," says Lucille Skuteris, RN, MS, associate director of the Standards Interpretation Group at the Joint Commission. "We’re not saying, just because there’s a high number of on call or per diem, that it’s causing negative clinical outcomes." The Joint Commission frequently receives questions regarding whether contract nurses still have to receive evaluations and whether managers must ensure their competence. The answer is yes to both questions, says Skuteris, who says these requirements can be found in Human Resource Standard 2 (HR 2).
To ensure positive clinical outcomes and good experiences with contract nurses, consider these suggestions:
• Verify their experience.
At Strong Memorial Hospital in Rochester, NY, Deborah G. Spratt, RN, MPA, CNOR, CNAA, nurse manager, talks to contract nurses who apply to determine their length and depth of experience. "Sometimes it’s hard to see from their paperwork," Spratt says.
As Strong Memorial has opened more operating rooms and more shift coverage on nights and weekends, the hospital added four contract nurse positions and four contract OR techs to the staff of approximately 140. Spratt looks for nurses who have a CNOR certification and four years of experience. She emphasizes that she doesn’t have time to train contract employees, "especially not for the money they make," she says. "They should be able to hit the ground running."
North Suburban Medical Center in Thornton, CO, is filling one of five nurse positions in the ambulatory center with a contract nurse, and two nurses out of 12 in the main OR are contract nurses. "It’s very difficult to find experienced OR nurses," says Lynn Parton, RN, BSN, CNOR, RNFA, director of surgical services.
To ensure the contract nurses are qualified, Parton conducts a thorough telephone interview. She asks applicants about how they would handle a difficult surgeon or peer, because that shows her how the applicant handles conflict. She also asks applicants to identify their favorite specialty. "That gives me a clue of what they’re really good at," Parton says.
She also obtains references from previous employers. "If I see a profile with evaluations that have exceptional marks, I feel much more confident hiring that person as a traveler’ than evaluations that are just standard," she says. "I look for exceptional people." In addition, because her center performs a large amount of orthopedic surgery, Parton looks for experience in that specialty. "I wouldn’t take one that didn’t list orthopedics as a high skill level," she says.
Parton uses a Performance-Based Delivery System (PBDS) to evaluate her applicants. (See manufacturer information under "resources" at then end of this article.) The PBDS uses methods and tools including videotaped patient scenarios, written scenarios, and audiotaped conversations. The system evaluates a nurse’s critical thinking and interpersonal skills. The answers are rated by nurses who compare the answers against model answers from nursing clinical experts.
"There are different situations that an experienced OR nurse would pick up on immediately, such as wrong instrumentation," Parton says. "It gives me a pretty close idea of what they know about surgery." If applicants fail the test, they are not given contracts. "It weeds out folks who are marginal," she says. If the applicant has limited experience, he or she is given an action plan to follow that includes education.
• Use contract nurses on off-shifts.
Spratt uses contract nurses on the off-shifts, such as 3-11 p.m., for a variety of reasons. Off-shifts are difficult to fill, she points out. "They were, for us, a godsend," she says of the contract nurses. She wants many of her full-time employees on the day shift to orient new staff. Also, because contract nurses are paid such high salaries, putting them on off-shifts works as an "equalizer" and minimizes disgruntled staff, Spratt says. This scheduling frees her to reward her regular staff with Monday through Friday day shifts. To avoid any problems on the off-shifts, Spratt ensures that she had top-notch supervisors there with whom contract nurses will feel comfortable.
• Learn from your contract nurses.
With some flexibility and open-mindedness, you may learn some new things from your contract staff, she says. "They bring in a fresh perspective," says Spratt, who points out that her contract nurses have made some positive suggestions in areas such as instrument pan review. "Sometimes, they have different ways of doing things," which can be good for the department, she says. If the contract nurse doesn’t work out, realize you typically can cancel contracts at any point, Spratt emphasizes.
Spratt says she has had a few contract nurses who weren’t satisfactory and was able to terminate them immediately after documenting the problems. "There was one person to whom we said, You’re not coming back tomorrow, and you’re going home today,’" she says. "That person didn’t meet our work ethic and our needs."
References
1. First Consulting Group study for the American Hospital Association, January 2002.
2. Joint Commission on Accreditation of Healthcare Organizations. Nursing Shortage Poses Serious Health Care Risk: Joint Commission Expert Panel Offers Solutions to National Health Care Crisis. Accessed at www.jcaho.org/News+Room/Press+Kits/Nursing+Shortage+Press+Kit.htm.
Resources
For more information on contract nursing, contact:
• Lynn Parton, RN, BSN, CNOR, RNFA, Director of Surgical Services, North Suburban Medical Center, 9191 Grant St., Thornton, CO 80229-4341. Telephone: (303) 450-4465. Fax: (303) 450-4558. E-mail: [email protected].
• Standards Interpretation Group, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Place, Oakbrook Terrace, IL 60181. Telephone: (630) 792-5900. Web: www.jcaho.org.
• Deborah G. Spratt, RN, MPA, CNOR, CNAA, Nurse Manager, Strong Memorial Hospital, 601 Elmwood Ave., Rochester, NY 14642. Telephone: (585) 275-9618. E-mail: Deborah [email protected].
The Performance Based Delivery System (PBDS) costs a minimum of $50,000 for the product and consulting services. For more information, contact: Performance Management Services, 13522 Newport Ave., Suite 200, Tustin, CA 92780. Telephone: (714) 731-3414. Fax: (714) 731-4620. E-mail: [email protected]. Web: www.pmsi-pbds.com.
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