A Model for Stabilizing the Team
Diane Thorgrimson, MHSA
Director, Patient Services Administrative
Children’s National Medical Center
Washington, DC
Sharon Shoyer, RN, MSN
Director, Nursing Administration and Operations
Chicago’s National Medical Center
Washington, DC
Registered nurse (RN) staffing in a pediatric intensive care unit (PICU) involves many daily and long-term challenges. The subspecialties of pediatric and neonatal intensive care nursing mandate specific skill sets and competencies that only can be achieved through strong internal collaboration among nursing leadership and operations, nursing education and physicians. At Children’s National Medical Center (CNMC) in Washington, DC, RN staffing issues in the critical care units are further complicated by the facility’s urban setting, the national and international RN shortage, and the constant pressure to provide more rapid patient turnaround times. An additional factor complicating nurse staffing at the hospital is the need to instantly “flex up” nurse staffing during high peaks in patient census and the need to instantly “flex down” nurse staffing when patient volumes plummet. These peaks and rapid patient turnover are not appropriately represented in the hospital’s midnight census.
In the late 1990s and early 2000s, CNMC was hit hard by the nursing shortage. Despite the implementation of many RN recruitment and retention initiatives and strategies, the institution had a difficult time maintaining small gains. By 2002, CNMC’s RN vacancy rate reached 33%, and the turnover rate was holding at 23%. In 2002, CNMC restructured the RN compensation and benefit programs to provide programs and services targeted at improving the quality of work life. For instance, staff nurses are now offered flexible scheduling, self scheduling, shared decision-making, access to chaplain and other counseling services, and multiple other programs focused on professional growth, development and retention. The new compensation structure and quality of work life programs were considered a success. During a nine-month period, the vacancy rate decreased to 5%, and the turnover rate declined to 17%. Today, the RN vacancy rate is 6%, and the RN turnover rate reported at the end of December 2004 was 7.6%. The CNMC RN vacancy rate continues to remain well below the 2003-2004 national average, which ranged from 10.2% to 13%. The 2003 – 2004 national average turnover rate ranged from 15% to 17%.1
As the achievement of recruitment and retention goals progressed, orientation and ongoing development of the critical care nurse were integral to the overall success of critical care nursing services at CNMC. Leaders from nursing operations and nursing education collaborated to develop orientation programs for critical care nurses designed to provide the new or experienced nurse comprehensive information related to the care of the critically ill patient. The developed curriculum includes selected aspects of pathophysiology related to each organ system and utilizes the nursing process as well as Benner’s principles of adult learning.2 Course objectives and clinical goals of the orientation program are achieved through the use of lecture, discussion, audiovisuals, and group activities. The clinical focus is on the expansion of theoretical knowledge, the use of the nursing process, and the use of learning opportunities to achieve competence in order to provide quality care both to the pediatric patient and to the family experiencing clinical alterations in health. The CNMC RN critical care orientation program utilizes a strong preceptor role. Participants attend class one day per week and then follow their assigned preceptor for the remaining work days. The preceptor concept allows for a more tailored approached designed to address the individual needs of the participant.
Methods of instruction include:
• Physician and nurse lectures, skill labs, game play, Socratic method case review, weekly oral and written quizzes, clinical rotation, and specialty experiences
• The use of audiovisual tools
• Attendance at pertinent Grand Rounds
• Weekly clinical review and interview the critical care clinical instructor
Orientation time frames alter based on individual trainee needs. The new graduate orientation program is at least six months long. A trainee RN with critical care experience will typically participate in a two to three-month orientation program. The successes of the critical care RN recruitment and training programs also have allowed critical care RN staff to support other areas of the hospital in RN training and development. They assist with peri-operative services and emergency medicine and trauma services. Furthermore, the staffing successes in the critical care units have allowed critical care nurses to participate in the Institute for Healthcare Improvement’s (IHI) IMPACT Action Network, a program that serves to advance multi professional collaboration. Through CNMC’s IMPACT initiative, communication at the nurse and physician levels was targeted for improvement. Physicians and nurses implemented a concept of daily goals for patient care. This initiative empowered nurses with decision-making authority on a daily basis and provided them with feedback.
Despite the overall RN recruitment and orientation successes, critical care nursing services at CNMC are still required to meet the fluctuating and often unpredictable census scenarios resulting from planned and unplanned high and low patient volumes. To this end, CNMC regularly contracts with traveler and per diem nurses to minimize staffing variances and to provide safe patient care. Working with a more stable set of contract nurses has proven beneficial to the institution in terms of the quality of patient care as well as nursing orientation and education.
To manage critical care nurse staffing proactively, CNMC’s nursing leadership continues an ongoing focus on RN recruitment and retention. Monthly monitoring activities at the unit level include RN vacancy and turnover reviews, quality measures, customer satisfaction scores, costs-per-patient day analyses, use of contractual RNs and para-professional vacancy rates, and staffing variances. These activities have allowed nursing leadership to better understand unit operations and needs and to investigate and pursue new issues and actions on an ad hoc basis in real time. In addition, nursing leaderships’ increased collaboration with critical care physician leadership has allowed both parties to understand better the needs of the critical care patient and provider. For instance, nurses and physicians work together to impact positively patient and family education and physicians actively support nursing education as well as development needs and opportunities. The redesigning of hospital systems and support personnel roles is reviewed collaboratively among physicians and nurses, and the need for emotional support is respected and encouraged by all parties.