The demand for critical care nurses continues to outpace the supply due to an aging population, increasing number of critical care beds, downsizing of healthcare staff and declining enrollment in nursing schools.
But the employment of nurses in a critical care setting is a catch-22, of sorts. Working on a critical care unit requires specialized training but one can't get experience without a job or a job without experience.
The solution? Developing internship programs to attract new graduate nurses who have an interest in critical care and experienced nurses who want to transfer to a critical care area. Hospitals in San Diego have collaborated with the San Diego Chapter of the American Association of Critical Care Nurses (AACN) to provide a community-wide, consortium-based Critical Care Nursing Internship Program (CCIP).
UC San Diego Medical Center (Hillcrest) uses the CCIP model of formal classroom training and then exposes interns to a wide variety of patients and a clinical forum of experienced nurses. Individuals who have not yet been hired into a position may attend the CCIP in hopes of increasing the chance of being hired.
The hospital's critical care unit (CCU) is a combined unit with medical and neurologic intensive care components. The patient caseload on the 13-bed unit includes complex pulmonary medicine patients with multi-system disease and complex stroke and neuro critical care patients.
Finding the Right Applicants
"The CCU nurse is a highly technical role," explained Nancy Barker, RN, clinical nurse at UC San Diego Medical Center (UCSD). "We need capable, informed clinicians who can adapt to the continual changes on the unit."
The CCU is different than it was 30 years ago and as a result, the role of a CCU nurse is more specialized than ever. "Because of increased knowledge and technological advancements, patients are surviving diseases they were dying from a few years ago. Increased acuity and advanced technology have made nursing orientation to critical care much more challenging than in previous years," Patty Graham, RN, MS, CCRN, CNS, UCSD.
"For this to be the right fit, we need individuals who are strong critical thinkers, articulate and motivated to be working on the CCU," Graham shared. "This needs to be their passion."
UCSD requires a California licensed RN with CPR and ACLS certifications and a GPA of 3.0 or greater. Other criteria considered in an applicant may include involvement in self-directed activities, volunteering in the community, a critical care externship and rich life experiences. "There has been a lot of success with hiring new graduate nurses, especially those who have gained real-life experiences," Graham said.
The CCU typically retains a 1:1 or 1:2 nurse-to-patient ratio but sometimes, a patient requires 2 nurses. "It may be because that patient has multiple comorbidities to complicate the main diagnosis. Critical care nursing requires a high level of analysis, immense organizational ability and tremendous empathy," Graham said.
Physicians, nurses, respiratory therapists, pharmacists, social workers, and most importantly, the patient and family members, participate in rounds on the CCU. "The multidisciplinary, patient and family centered care approach is important at a teaching hospital," Graham shared. "Our students need to learn the importance of partnership with the patient and family as well as the importance of collaboration among the medical team dealing with the complexities of patient care."
The orientation program lasts a minimum of 12 weeks with both clinical and didactic components. New graduates have an additional 12-week mentorship with an expert nurse and attend ongoing training classes.
Critical Success: Richard Howard, RN, Megan Kelly, RN, and Nancy Barker, RN, on the CCU at UC San Diego Medical Center. photo by Rebecca Mayer Knutsen.
Some of the topics addressed in the program include addressing issues with healthy work environments, patient and family centered care, stroke, pulmonary and gastrointestinal/genitourinary patients, mechanical ventilation management, safe handling and administration of IV medications and monitoring rhythms on the telemetry monitors.
The students round with Graham so they may ask questions and gather knowledge through first-hand observation of patients in the CCU.
"We want our students to succeed and we give them the tools to do so," Graham said.
Richard Howard, RN, completed the new critical care nursing internship in 2009 and is now a full-time employee on the CCU. "The classroom portion was more detailed and focused specifically on the CCU than anything we covered in school," he recalled.
"The intense training on the ICU took my schooling to another level and provided me with the knowledge I need to succeed," Howard explained. "The support on the unit is unparalleled. My mentor was beyond helpful but others always volunteered to help me whenever I needed it."
Howard led a hand-off initiative on the unit, for example, to ensure that attention to detail is followed from one nurse to another. "This important initiative particularly helps during shift changes," Barker said.
Megan Kelly, RN, worked with 2 preceptors to build skills and expertise during her time in the new grad program. Kelly chose to extend the preceptor program by 2 weeks to ensure that she was 100% comfortable and prepared before striking out on her own. "I benefited from the flexibility of the program, wide variety of patient exposure and forum of experienced nurses available to answer questions," Kelly said.
Learn From the Best
Through a culture of collaboration, mentorship and support, the unit has placed a priority on acquiring, training and retaining skilled, personable and devoted nurses.
The program features a formal mentor program designed to create and promote a positive and healthy work environment for nurses by supporting, teaching and encouraging professional and personal growth. The mentor program matches mentors and mentees, provides support and encouragement of mentoring pairs and facilitates the mentoring relationship. The mentors share experience and knowledge with nurses new to the CCU and help establish goals and objectives.
Preceptors are chosen based on experience but also on interpersonal skills and teaching ability. "We try to match the preceptor and preceptee based on similar personality traits and common interests," Graham said. "It's important to have a preceptor who is able to adjust his teaching style to meet the needs and learning style of a particular student."
Bedside mentorship is perhaps the most important part of the program, Graham told ADVANCE. "In addition to knowledge of physiology and the technical nature of the job, our nurses need to learn the crucial role that communication plays in all aspects of care," she stated. "Communication is the cornerstone of patient safety and is often best learned through clinical mentorship."
Barker is one of the unit's resource nurses. She teaches classes, conducts evaluations, provides bedside care, serves as the wound resource person and performs administrative duties. As a certified wound care specialist, Barker participates in the hospital's wound committee, teaches preventive measures and documents wounds with photos. New graduates are educated on skin care approaches and treatments so they are comfortable at the bedside.
The new graduates are assigned to a specific preceptor during the whole process-as they rotate from the day to the night shift. But all nurses on the unit are available to answer a question or assist with a problem, when needed.
The preceptors are required to attend classes so they are formally trained and prepared for the role. The preceptors gain credits for their participation in the program via a preceptor incentive program that can be used in the bookstore or gift shop.
Nursing education does not end with the internship program. "Mentorship occurs at all levels of nursing from the novice to the expert and it is not a one-way street," Graham said. "The novice nurse and the experienced nurse bring a lot to the table, each growing because of experiences with the other."
"We expect our nurses to be leaders: organized, professional and on top of current topics and literature," Graham said.
Staff members at UC San Diego attend professional conferences and study journals to ensure that all clinical practice is supported by evidence. It's not uncommon to change protocols because of new information that has been discovered.
The program encourages new grads to become involved on the unit and evoke change. For example, one of the students discovered a gap in HIV education in for the community and developed a website to provide information and resources. "When we become more involved, it trickles down to patient care," Barker observed.
The CCU nurses are involved throughout the whole hospital. "You see our nurses heading committees and teaching basic and advanced resuscitation classes," Barker said.
The nurses at UCSD are involved in a variety of pursuits, according to Graham. One of the nurses held bake sales over the holidays to raise funds to feed the elderly. Others volunteer to immunize people at local schools, check blood pressure at races in the community or participate in international medical missions. In addition, CCU nurses also respond throughout the hospital in their role as Code Blue and Rapid Response Nurses.
The hospital's Chaplin helps the patients and families-as well as the nurses-with coping techniques. "We don't just nurse the patient, we nurse the family," Barker explained. "Health statuses change so quickly in this environment that we need to be there for the families."
Balance is important in the daily life of a critical care nurse. "This area of healthcare pushes people to their limit," Barker said. "The critical health of a loved one can be hard on the family but can also be very challenging for the bedside nurse."
Life/work balance is encouraged at the hospital. Nurses' schedules are adjusted to accommodate the needs of the nurses as well as the needs of the unit. "It's the best of both worlds because patients get the best care and nurses are able to attend important life events," Barker stated.
UCSD has learned that if nurses are fulfilled at work-and outside-the level of patient care is at its best.
"A collaborative multidisciplinary team allows the CCU to appear calm even though there is always a lot going on," Graham said. "I feel fortunate to work with such a tremendous team."
Rebecca Mayer Knutsen is on staff at ADVANCE. Contact: firstname.lastname@example.org.