Preparation of a New Intensive Care Unit Nurse: Is There a Best Practice?
This issue's theme is focused on the different methods hospitals may use to prepare an intensive care unit (ICU) nurse. At one time new graduates were not admitted directly into the forbidden territory of intensive care. The privilege of ICU nursing was reserved for the time-tested medical-surgical nurse. The nursing shortage and increase in ICU beds has forced us over time to rethink that old standard and include new graduates into the fold. Now new graduates in intensive care are more the norm than the exception as nurses are retiring faster than they can be replaced. No matter what experience the new ICU nurse has (none, medical-surgical, telemetry, or step-down), we all agree that a training program is required for safe entry. Dempsey and McKissick explain how nursing students may be prepared through summer student and extern programs for a smoother entry into the ICU. Tanna Thomason's preliminary survey on current practices in ICU training tells us (assuming that this sample is representative of the population) that formal training is standard throughout the United States. But what is the right way to do it? Her survey also illuminates the hunch we had that there is a wide variety of methods for executing a training program.
At one time most hospitals had individual preparatory programs. In-house training programs are very time consuming for the people who teach them. Even if guest speakers are cajoled into helping out, the coordinator spends countless hours coordinating the process, and the guest speakers may add an element of uncertainty to the predictability of the material being covered. At what point is the cost of this type of program prohibitive? If you train 4 nurses per quarter, is it worth it? 10? 15? Do you hold the training program until you have enough people, or do you need these nurses bad enough you will put on a program for 5 nurses now!! The beauty of an internal program is that it is completely customizable-you make it whatever you desire and you are not dependent on technology or others to put it together. Scot Nolan and Janet Murphy's description of an in-house training program that commits the nurse from entry into practice to CCRN attainment is a clearly articulated blueprint for those institutions with adequate resources to replicate.
Consortium programs have developed in collegial cohesive environments. They still require hours in coordination, but can reduce the time spent dramatically in both oversight and instructor hours per institution. They especially benefit small hospitals that do not have the resources to develop and execute a program for a small number of nurses. The San Diego chapter of the American Association of Critical Care Nurses is one prime example of a training consortium. Their award winning program has been in place for many years and educated 30 to 50 nurses per quarter from a variety of hospitals within San Diego. The benefit of this type of program is that experts in a given content area have the opportunity to standardize the education for a whole community. If one hospital does not have a "renal" expert for instance, they can rely on the consortium instructor to help fill that gap. The downside is keeping a qualified pool of instructors and coordinating across political currents in a highly competitive market. Institutions that belong to a larger health system are ideal candidates for the consortium approach. If a system has 5 hospitals within a reasonable radius, producing one didactic program would be a cost-effective alternative to individual in-house programs. Patricia Graham, founder of the SDAACN consortium program, writes us a telling description of the evolution over time and the threats imposed to live-instructor-led programs now that computer training is available for purchase.
The computer age has introduced computerized training programs as well. On the surface these programs seems to answer the "How am I going to get an instructor to teach this content over and over and over again?" dilemma. The computer programs do standardize essential elemental learning and allow you to start up new staff at any time. They decrease interinstructor variability in presentation. The downside to computer training programs are, however, computer access for training in a quiet environment, computer skills of older nurses (remembering that the average age of the nurse is approximately 46 years), and the lack of interaction with a live instructor when questions arise. Hospitals that choose to purchase a prepackaged program quickly find out that it cannot replace educators or advanced practice nurses necessary to provide learner feedback and case studies of real-life experiences. Kristine Peterson and Krystal van Buren share their experience with the ECCO program produced by the American Association of Critical Care Nurses (Aliso Viejo, Calif). You can see from their description that when calculating the cost of the program, hours still need to be added to the budget to tailor the program past the basic knowledge provided.
The ultimate in instructional technology shows its splendor in the simulation laboratory. Here learning with a dummy who talks, breathes, pumps blood, and vomits adds to the aura of a real-life experience without the risk of harming a living breathing human. Mary Beth Parr explains what it was like to bring up a simulation laboratory from the ground floor as part of the ICU critical care elective for San Diego State University. These simulation laboratories are expensive and have a steep learning curve for instructors, but are making quite an impression with learners. As one nurse explained to me after learning in a simulation laboratory, "My heart rate started climbing as his dropped. I felt as if I really were in a code. My hands were trembling, heart racing, and I didn't want him to die." The future is ripe for consortium-type simulation training centers, and technology-laden critical care is fertile ground for the planting. Debra Brady and colleagues take the programs by Graham, Peterson, and Parr one step further by blending them to yield a cost-effective consortium approach maintaining live instruction through simulation experiences (instead of lectures) and computer-based training.
After reading through all of the manuscripts, it is clear to me that there is no established best practice yet. Each person we spoke with felt that his or her method was best. If we are truly going to honor adult learning styles as professionals, we may need to accept this and provide a variety of learning methods. Computer programs may be the best for some, with hours budgeted for case review and answering questions. Instructor-led programs may be better for others. Indeed one young nurse called me just last week to "shop around" for an ICU position. Her list of questions started with a query on the method of ICU instruction used for the formal training program. "How do you do your training? Is it on a computer or with a teacher? How long is it? How many days of classroom are given?" (Table 1). We may find that hospitals will attract the type of learner (and nurse) who matches their program. Is this a good thing or a bad thing? Only time will tell. A textbook as an adjunct to learning seems to be an agreed-upon essential element of any program. The cost needs to be added into the figures. Simulation laboratories, when affordable, provide depth to any training program with a qualified instructor at the helm. A consortium approach may allow many hospitals to participate in a quality program that may not otherwise be affordable if the administrators have the vision to see past the politics of joining forces with competitors. A checklist of options to consider when planning a preparatory program is offered (Table 2). Future research is necessary to study outcomes such as time to completion, knowledge acquisition, turnover rate, competency, and nursing satisfaction in relationship to the style and length of training programs. Until then, "What is best practice for intensive care preparatory programs?" is a question left unanswered.
Judy E. Davidson, MS, RN, CCRN, FCCM
Issue Editor, Clinical Nurse Specialist, Scripps Mercy Hospital, San Diego, Calif. e-mail: [email protected]