Education, Training, and Use of Unlicensed Assistive Personnel in Critical Care

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Critical Care Education

Education, Training, and Use of Unlicensed Assistive Personnel in Critical Care Shirley A. Spencer, MS, RN

The dynamics of the health care delivery system have undergone major changes over the past decade. Economic rationing due to the growth of managed care, advanced technology at the bedside, competition for market shares as patients become more selective, federal and state cost containment efforts, increased patient acuity, and shortened hospital stays have created an increasingly complex environment. Health care administrators responded to the dynamic health care industry by modifying their patient care delivery system. Terms like reengineering, work redesign, restructuring, and reorganizing are used to describe the process. Because compensation constitutes a substantial percentage of hospital budgets, administrators looked here to cut cost. Administrators did not foresee that the complexity of the health care environment would create a need for more nurses. Administrators encountered obstacles that they did not predict. Many erroneously posited one or more of the following assumptions:

From the University of Chicago Hospitals, Chicago, Illinois

• Use of unl icensed assistive personnel (UAP) decreases the number of professional nurses (RN) needed. • Professional nurses know how to delegate to and supervise UAP • Professional nurses will know and understand how to delegate, make assignments, and supervise UAP once they attend the appropriate classes. • Class content covering team building ensures that the professional nurses and UAP will work well as a team. • UAP can be trained to perform duties with mini mal educational requirements. • Nurse educators need not spend much time educating and training UAP, because they already have the knowledge base and skills needed to perform effectively. • UAP receive comparable basic education and training in their field. • UAP have good work ethics.

Currently, the growing demand for professional nurses exceeds the supply despite restricted funding for health care. The National Association for Health Care Recruitment Survey reported a 6% vacancy rate among professional nurses. 6 Fifty-seven percent of hospitals nationwide reported that critical care positions are the most difficult to fill. 6 Administrators are challenged to look at alternate

CRITICAL CARE NURSING CLINICS OF NORTH AMERICA I Volume 13 I Number 1 I March 2001

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ways to deliver quality care and contain cost simultaneously. The integration of UAP in critical care is a conceivable alternative.

diatric intensive care units (PICU) include a 13-bed ICU and a 9-bed step down unit.

Literature Review Future Health Care Environment The pendulum will remain steady, and hospitals will continue to use UAP in response to the nursing shortage and cost containment concerns. 1• JO Hospitals will no longer fund the same number of professional nurses as they have in the past. 9 • 12 The public will continue to demand quality care at a conservative cost. The status of the professional nurses will be upgraded as a new breed of nurses emerges. Nurses will focus on developing their higher order thinking skills (e.g., critical thinking, solution finding, decision making, creative thinking) to administer high-quality care. Nurses will continue to delegate, supervise, and coordinate patient care activities and spend less time performing duties that others can perform effectively. 1• 9• JO

History of Unlicensed Assistive Personnel The UAP have appeared periodically in the acute health care setting during nursing shortages and when there was a need for cost containment. The use of UAP can be traced as far back as the 1950s. JO Their use in the 1960s was cyclic, because it depends on the supply of professional nurses. JO There was a decreased use of UAP in acute settings , and an increased use of professional nurses from the 1970s to the early 1980s. 1• JO, 12 The recruitment of UAP in the latter part of the 1980s was driven primarily by the nursing shortage. 1• 10 • 12 The recruitment of UAP in the 1990s was driven by cost containment efforts. 1• JO, 12 This article provides an overview of hiring practices, education, orientation and training activities, and a competency-based program that promotes integration of the UAP role in critical care with positive outcomes. The University of Chicago Hospitals' Patient Care Technician (PCT) Program serves as an intermediary to visualize the process of integrating the role of UAP in critical care. The adult intensive care units contain 50 beds. The pe-

Illinois State Nurse Practice Act

The Illinois State Nurse Practice Act establishes minimal standards that govern professional nurses in providing safe and effective care. The Act does not prohibit UAP from being employed in the acute care settings. The governor of the state of Illinois appointed an 11-member task force in July 1998 to determine if there was a need for regulation of UAP by the Department of Professional Regulation. The UAP Task Force members examined the roles, responsibilities, training, competency, and supervision of UAP. 8 The UAP Task Force members recommended the following: • Enforcement of current laws that prohibit individuals from practicing nursing without a license. • Define UAP as individuals to whom nursing tasks are delegated. Tasks are defined as work that does not require professional knowledge, judgment, or decision making. • UAP must have minimum qualifications and have completed a standardized and approved basic training program. • Rules for the administration of the Nursing and Advance Practice Act must include guidelines for the professional nurse on delegation, supervision, and assignment of nursing care. • Curricula for professional nursing programs must include content on supervision, delegation , assignment, and legal aspects regarding the nurses' use of assistive personnel. • Curricula for RN staff development and continuing education programs must include content on the Standards of Professional Practice, supervision, assignment, and legal aspects regarding the nurses' use of assistive personnel.

The UAP Task Force members currently are waiting for the governor to respond to their recommendations. 15 American Nurses Association (ANA) Position

The nursing profession dictates and defines how UAP operate. The American Nurses

EDUCATION, TRAINING, AND USE OF UAP

Association (ANA) defines UAP as "individuals who are trained to function in an assistive role to the registered professional nurse in the provision of patient/client care activities as delegated by and under the supervision of the registered professional nurse." 1 UAP include the following job titles: technicians, nursing assistants, orderlies, and attendants. The role of UAP is to augment, complement, or enhance nursing care. UAP are not used to replace the professional nurse. Nurses are held accountable to the public by the standards of practice. The Professional Standard of Practice is a legal agreement between nursing and society to administer competent care. The foundation of the Professional Standard of Practice is based on the Nursing Social Policy Statement, Standards of Clinical Practice, and Code for Nurses with Interpretive Statements. Delegating, assigning, and supervising patient care activities occur in the context of the professional nurses' responsibility to the public. 1 The role of the nurse is to assign, delegate, and supervise patient care activities. The ANA defines supervision as "the active process of directing, guiding and influencing the outcome of an individual performance of an activity or task." 1 The nurses and UAP share responsibility for performing the tasks accurately. Additionally, the RN is responsible for completing the tasks and is accountable for delegating and supervising the performance of the UAP. 1 American Association of Critical Care Nurses (AACN) Position

The position of the American Association of Critical Care Nurses (AACN) on UAP is consistent with the State Nurse Practice Acts and the views of the ANA. The AACN recommends that the framework for training and supervision of UAP and the supporting systems be in place before using UAP. The orientation for UAP typically lasts 6 to 8 weeks. The job descriptions should delineate role, responsibilities, and qualifications. A competency-based program for UAP should be established and continuous performance appraisals maintained. The orientation and training of UAP should be appropriate for performance expectations and role responsibilities. A continuous evaluation and monitoring system should be in place to

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appraise patient outcomes and the impact of UAP adherence to standard of care. 2 • 14

Liability Hospitals are susceptible to civil liability. The landmark decision of Darling v Charleston Community Memorial Hospital held that a hospital has an independent legal duty to its patients. A hospital has a duty to monitor and to review the qualifications and care rendered by its health care providers. 10 Standards set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and published in its hospital manual provide an example of how hospitals should define the customary standard of care for their particular institution. Hospitals should provide an adequate number of staff whose qualifications are comparable with defined regulation or certification. Competence of staff members should be assessed, maintained, demonstrated, and improved on an ongoing basis. 10 The staff must receive the appropriate orientation, training, and ongoing education. JO The policies and procedures concerning the delegation and supervision of UAP should be consistent with the State Nurse Practice Acts. Potential liability occurs when UAP operate outside the State Nurse Practice Acts and the task is outlined in the individual's job description, or when there is nonstandardized training. The nurse risks liability when (1) delegating to individuals lacking adequate education or experience to perform the nursing task; (2) delegating contrary to the State Nurse Practice Acts; (3) delegating poses substantial risk or harm to the patient; and (4) there is inadequate supervision of the UAP after delegating the tasks .1• 5• JO

Use of Unlicensed Assistive Personnel Ninety-seven percent of hospitals use UAP. 11 Their use allows nurses to shift focus from performing nonprofessional tasks to delegating, supervising, and coordinating care given by other team members. The hospital national norm for activity reveals that UAP spend more time providing direct care on personal activities than the professional nurse .3· 4 · 7 Personal activities are activities that

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60 50

-" l:lll

40


=

i:...

30 20 10 0 Direct Care

Indirect Care

Unit Related

Personal

are not related to patient care or unit management (e.g. , coffee breaks, personal phone calls, and mealtimes). The professional nurse spends more time providing indirect care and on unit-related activities than UAP. 3· 4 Figure 1 illustrates the patterns of activities for nurses and UAP. Nurses provide 35% direct care, 33% indirect care, 19% unit-related activities, and 13% personal activities. 7 The UAP provide 57% direct care, 11 % indirect care, 11% unit-related activities, and 21% personal activities.7

The University of Chicago Hospitals The mission of the University of Chicago Hospitals (UCH) is to provide superior health care in a compassionate manner, ever mindful of each patient's dignity and individuality .13 Professional nursing practice at the UCH is adapted from the Standards of Clinical Practice as dictated by the American Nurses Association (ANA). Patient Centered Care Model

The Patient Centered Care Model includes a care management system, support systems, and behavioral framework for providers. The care management system focuses on the patient and family. Care is coordinated, managed, and administered in a clear, caring, and consistent manner. This system is upheld on a platform of quality, efficient, safe, and costeffective care. The integrated and interdependent support systems are designed to meet the patient needs. The behavioral framework for providers is built on collab-

Figure 1 Patterns of hospital activities for staff nurses (open bar) and unlicensed assistive personnel (solid bar).

oration and sens1tiv1ty. The service pride values (i.e., respect, honesty, participation, unity, diversity, and excellence), the principles of patient centered care, performance standards, and consequence management provide the foundation for a collaborative and sensitive work force. 13 Patient care teams, led by the charge nurse, provide direct patient care in the critical care units. The care team members include the physician, professional nurse, case manager (when applicable), one or more patient care technicians (PCT), and patient service assistant (i.e., environmental worker) . Instructional resources are available to prepare nurses for their role and responsibilities in the delivery of patient centered care. Topics covered include Coping with Change, Valuing Differences, Teamwork, Improving System Performance, Delegation, Conflict Management, Situational Leadership, and Role Review. The nurse educators and adjunct faculty present didactic information over a 20-hour time frame. The Coping with Change Module is a skill-building interactive workshop designed to prepare nurses to respond to challenges that can arise as they are asked to adapt to new roles and responsibilities. The Valuing Differences Module examines how cultural similarities and differences can assist or hinder effective working relationships. The Teamwork Module introduces the stages of team development and provides skill-building exercises that emphasize the characteristics of high-performing teams. The Improving System Performance Module focuses on improving systems through goalsetting and problem-solving methods. The Delegation, Conflict Management, and Situational Leadership Modules are designed to

EDUCATION, TRAINING, AND USE OF UAP

Table 1 ORIENTATION CURRICULA FOR PROFESSIONAL NURSES

Course

No. of Hours

Coping with change

2

Valuing differences Teamwork Improving system performance Situational leadership Conflict management

4 2 4

Delegation Role review

2 2

2 2

Instructor Nurse educator, faculty adjunct Faculty adjunct Nurse educator Faculty adjunct Faculty adjunct Nurse educator, faculty adjunct Nurse educator Nurse educator

prepare nurses as patient: centered care team leaders. The nurse learns how to communicate performance expectations and manage performance through daily feedback and coaching. The process of determining what tasks can be delegated and specific interpersonal skills and techniques for handling conflict arising from difficult on-the-job situations are discussed. The Situational Leadership Module integrates the competencybased interviewing techniques. The Role Review Module provides an overview of roles and responsibilities of each team member. The case management processes of assessing, planning, coordinating, and monitoring patient care activities are discussed. 13 Table 1 summarizes the orientation curricula for nurses. Role of the Patient Care Technician

The integration of the role of the PCT in critical care occurred in 1995. The PCT is an allied health care professional or equivalent who is assigned by the RN to perform technical and nontechnical services in the treatment and care of patients and their families. They assist the nurse by providing basic care to patients. Care such as activities of daily living (ADL), dressing changes, nutrition and elimination activities, respiratory therapy, IV therapy, and data collection are performed in collaboration with the nurse. ADLs are activities that meet the patient's basic needs. The PCT applies elastic stockings, sequential compression devices, ace wraps, splints, and Stryker boots. They assist with prescribed activity level, range

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of motion (ROM), repositioning, and patient transfers. They observe and maintain a safe environment by applying and maintaining restraints, keeping siderails up and padded when indicated, and keeping call lights in reach. They assist with admissions, discharges, and transfers. The PCT changes simple dressings. They change A-line, peripheral IV, and surface wound dressings. They set up and assist with complex dressing changes. The nutrition and elimination responsibilities include assisting with feeding and filling out the menu. The PCT maintains tube feedings by adjusting the rate of tube feeding, adding blue coloring, and maintaining precautions for patients receiving tube feedings. They change feeding bags and tubing every 24 hours. They prime tubing for bladder irrigation. They empty and record nasogastric, Jackson Pratt, ostomy, and urine drainage. They obtain urine specimens and test urine. They change and empty ostomy appliances, and apply and change fecal incontinence bags. They flush nasogastric tubes (NGT) or Dobhoff tubes with water after the RN verifies placement. The respiratory therapy activities include incentive spirometry, assisting the patient with coughing and deep breathing exercises, maintaining oxygen therapy via the appropriate mask or nasal cannula, and administering 100% oxygen via ambu bag. PCTs perform chest physiotherapy (CPD procedures. They perform nasal and oral suctioning and suctioning via tracheostomy or endotracheal tube. They communicate amount and character of sputum. They administer hand-held nebulizer treatments to nonvented patients and assist in endotracheal tube tape changes and tracheotomy tie changes. They apply the pulse oximeter probes and observe and record values. The IV therapy responsibilities include priming IV lines and pressure lines. The PCT inserts and discontinues peripheral IV catheters. The PCT performs phlebotomy procedures, including drawing blood from the arterial line. Data collection responsibilities include recording vital signs, recording intake and output, recording body weight, and measuring and recording abdominal girth. The PCT documents blood gases and laboratory results. The PCT notifies the RN of behavior

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changes from baseline, skin integrity prob. lems, and equipment alarm status. The PCT calibrates and uses the blood glucose monitor, calibrates pressure lines, and levels transducers prior to running strips. The PCT obtains ECGs and hemodynamic waveform strips and attaches them to the flow sheet. The PCT applies and changes electrodes, disconnects patients from the monitor, attaches patients to transport monitors, and procures 12-lead ECGs. The PCT sets up and cleans for invasive procedures. The PCT inventories supplies and checks the crash cart and emergency equipment. Interview Process The UCH are committed to selecting candidates whose training, experiences, and interests best prepare them to succeed at the UCH. Pre-employment testing and personal interviews by the senior employment specialists and patient care managers are used to create a good match between the candidate and the job, to meet the needs of all involved. The PCTs hired for the ICU and other areas are certified phlebotomists, medical assistants , paramedics, emergency medical technicians, respiratory therapy technicians, or ECG technicians. Patient Care Technician Critical Care Program The PCT critical care program at UCH is a rigorous education and training program. The program is designed to educate and train PCTs in areas in which they have little to no experience (e.g., phlebotomy) , because they enter the program with varying degrees of experience and different levels of knowledge in their classification. The teaching format includes didactics, a skills learning laboratory, and preceptored clinical experience. The PCTs are informed during the interview that successful completion of the 8-week program is a job requirement. They attend Hospital and Patient Services Sector Orientations during the first week. The Hospital Orientation introduces the mission, purpose, values, and service standards, and the Patient Service Sector Orientation provides an overview of the Patient Centered Care Model.

In the second week, the PCTs attend the Patient Care Orientation. Topics include Patient and Family Needs, Patient Hygiene, Measuring Intake and Output, Infection Control Practices, Bed Making, Materials Management, Equipment Management, Nutrition, Mobilization, and Cardiopulmonary Resuscitation (CPR). The PCT must pass the Patient Care Exam and Basic Life Support (CPR) and meet the competency requirements to complete the Patient Care Orientation successfully. The Core Orientation for the PCTs lasts 4 weeks. Topics covered include respiratory therapy, venipuncture, and ECG monitoring. The respiratory therapy topics include pulmonary anatomy and physiology, assessment, suction and aspiration precautions, oxygen and inhalation therapy, nebulized bronchodilators, chest physiotherapy, and respiratory procedures. The venipunture topics include introduction to the laboratories, cardiovascular system, phlebotomy, IV cannulation, and venous and arterial lines. Introduction to basic ECG monitoring and taking a 12-lead ECG also are included. Additional topics include medical terminology, documentation, hand-held bar code printer device, Frontline/ Last Word (computer class), math calculations, and role review. The clinical rotations during Core Orientation allow the PCTs the opportunity to broaden their knowledge base and enhance their skills. The clinical rotations include transportation, phlebotomy, 12-lead ECG , and ICU. During the ICU rotation, the PCT is preceptored by an experienced PCT and oriented by the RN. The PCTs can perform venipuncture, respiratory therapy, and ECGs and assist with ADLs by the time they start their ICU orientation. The Critical Care Orientation and the ICU clinical rotation occur simultaneously during the last 2 weeks of the program. The PCTs receive 8 to 12 hours of didactics. Each PCT spends 24 to 60 hours being preceptored by an experienced PCT and 12 to 36 hours being oriented by the RN. Topics covered during class include Telemetry and Patient Monitoring, Care of the Critically Ill, Admission, Dressing Changes, and Assisting Physicians and Nurses at the Bedside . The Telemetry and Patient Monitoring Module provides an overview of equipment used.

EDUCATION, TRAINING, AND USE OF UAP

The Care of the Critically Ill Module gives an overview of the critically ill patient, death and dying, and how to transport patients out of the ICU. The Admission Module provides an overview of the admission process. The Dressing Changes Module includes an overview of dressing changes for burn patients. The Assisting the Physicians and Nurses at the Bedside Module describes procedures commonly performed at the bedside. The RN and the experienced PCT validate the skill checklists for the PCTs during the Critical Care Orientation (see Appendix). The PCTs are tested throughout the program. Seventy-five to eighty percent of the PCTs successfully complete the program. Successful completion is based on the following criteria:

• The PCT must meet the Patient Care Orientation requ irements and become certified in Basic Life Support (CPR). • The PCT must demonstrate competency on all performance criterion checklists (see Appendix). • The PCT must display evidence of adhering to the UCH behavioral standards. The behavioral assessment is based on respect, honesty, participation, unity, diversity, and excellence. • The PCT must score 75 or higher on the ECG test. • The PCT's final average must be 75 or higher. The final average is based on four quizzes and three exams.

The PCTs can take proficiency exams for any module. Passing any proficiency exam with a score of 75 or higher facilitates accelerated progression through the program. Only a few PCTs elect to take any of the proficiency exams offered. Some of the paramedics and comparable emergency medical technicians and ECG technicians elect to take the ECG test and omit the ECG didactic sessions. Clinical Monitoring and Evaluation

Four written quizzes and three exams assess the PCT's comprehension of the theoretic components of the program. The nurse educator, nurse, or designee evaluates the clinical performance of each PCT throughout

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the Critical Care Orientation. The evaluation tool assesses the PCT's ability to successfully complete the competency-based skill checklist according to the UCH policy and procedural guidelines or accepted practice. The nurse or designee demonstrates the skill. The PCT is deemed competent when the PCT performs the skill safely and complies with the guidelines. The nurse or designee shares his or her concerns with the patient care manager when problems occur. The problems most typically encountered relate to ineffective communication. The PCTs can be reluctant to ask for additional information or training to perform the skill safely and effectively. The nurse educator, patient care manager, and nurses jointly appraise the performance of the PCTs after 3 and 6 months and annually. Annual Competency-Based Program

The annual competency-based program is founded on a continuous learning cycle model. It is designed to provide employees learning opportunities and revalidation of role-specific competencies. The program includes revalidation of technical, critical thinking, interpersonal, and team skills. The competencies selected are based on the results from the Quality Improvement Program, employee feedback, sentinel events, and learning need assessments. The annual competency days are scheduled 12 times a year. The same content is included at each session for an entire year. The annual competency day includes morning and afternoon sessions. Everyone attends the same morning session, which provides updated information (e.g., fire and safety, infection control, team building, cultural diversity, use of restraints). The role-specific competency revalidation/ education occurs during the afternoon session. The competency revalidation for the PCTs includes ECG monitoring, respiratory therapy, venipuncture, and safety issues. Decentralization Versus Centralization

Before redesigning the patient care delivery system, the PCTs were centralized and operated in singular roles as ECG technicians, phlebotomists, or respiratory assistants. The

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three roles were combined and titled "PCT" after the implementation of the patient centered care delivery model. The purpose of combining the three roles emanated from cost containment and productivity concerns and the need to bring technical care closer to the bedside. Decentralizing the technicians and combining the three roles increased productivity and decreased the number of technicians needed to perform technical care. The PCTs became versatile, and the nurse no longer had to contact other departments for technical support. The leadership group recommended centralizing PCTs working in the adult ICU and patient care areas, allowing them to cover more areas, in response to the need to use available resources effectively. These PCTs centralized in September 1999, and now report to the Respiratory Department. The PCT supervisors formerly worked in the PCT role. The scope of PCT activities and responsibilities is reduced; they no longer perform basic patient care activities or assist the nurses. They now perform phlebotomy, simple respiratory therapy, and 12-lead ECG procedures and assist with emergency codes. They operate as sitters (similar to the private duty nurse's assistant) when the demand for technical support is low. Centralization enables the leadership group to scrutinize technical care quality improvement concerns on an organizational scale versus a unit base. The leadership group can identify system problems and examine the efficacy of simple respiratory therapy more efficiently. Supply management has improved now that supplies are in one location rather than multiple locations. Centralization is more conducive to equitable distribution of the PCTs when need arises (e.g., sick calls, increased patient acuity) compared to decentralization. Centralization aids in the maintenance of standards and consistent expectations because the PCTs are aligned with one department rather than multiple areas. There is a standardized corrective action plan. The supervisors are able to manage the PCTs effectively without the distractions that the patient care managers have because they manage only PCTs. There is unity among the PCTs, and they feel valued. The nurses and the PCTs are coping with the change. The PCTs are adjusting to

their revised role, and the nurses are back to performing basic care and requesting technical support. The PCTs who work in the pediatric ICU remain decentralized and their role unchanged. They report to the pediatric ICU management team. The nurses and the PCTs have a trusting relationship and work well as a team. The PCTs are valued. The nurses are comfortable assigning, delegating to, and supervising the PCTs. The nurses trust the PCTs to complete assignments safely and competently and to ask for assistance as needed. The PCTs assist the nurses and each other to enhance patient care activities. Financial Implications

The UCH spends much time and money educating, training, and orienting PCTs who, unfortunately, do not remain at the hospitals for any length of time. Attendance problems are the primary reason for termination, and role misconceptions were the main reason given by PCTs who resigned. Their idea of the PCT role does not coincide with the Patient Centered Care Model. Additionally, the PCTs who work in the adult ICU left because they did not feel valued. Sixty-three PCTs have been hired for the adult ICU since 1995 to fill 32 full-time equivalent (FTE) positions. Nine percent of the 63 PCTs remain today. Twenty-eight percent (13 of 46) remain in the PICU for the same time period. It takes approximately 6 to 9 months for the PCTs to become effective in their role. Modification of the hiring practices since 1997 helped to decrease the amount of money spent. Emphasis is no longer on recruiting paramedics and comparable emergency medical technicians because of their high turnover rate. Paramedics are dissatisfied with the restrictions that the role entails. For example, paramedics manage IV therapy in the field under the direction of a physician, whereas they cannot prepare IV bags or regulate the flow rate as PCTs in the hospital. Many phlebotomists and respiratory therapists are not comfortable performing bedside care. Minimal phlebotomy punctures are performed because the patients have central and arterial lines. Current emphasis is on hiring medical assistants and lower levels of emergency medical technicians.

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EDUCATION, TRAINING, AND USE OF UAP

Before the integration of the PCT role, the pediatric ICU had 52 FTE positions allocated for professional nurses. The number of RN positions decreased to 39 after the integration of the PCT role. The managers elected not to displace nurses; however, open positions were not filled. The nurse-to-patient ratio, which was 1 to 1 and 1 to 2 before integration of the PCT role, now is 1 to 3. Nineteen FTE positions were allocated for the PCTs. Effective use of the PCTs has decreased the need for more PCTs. Only 12 to 13 PCTs actually were needed. Before the integration of the PCT role, the adult ICU had 80 FTE positions allocated for professional nurses. The number decreased to 63 after the integration of the PCT role. The managers elected not to displace nurses. The nurse to patient ratio was 1 to 1 and 1 to 2 before the integration of the PCT role, and up to 1 to 3 afterwards. Thirty-two FTE positions were allocated for the PCTs. The managers were not able to fill the PCT positions. The adult ICU operated with 10 or fewer PCTs. The managers replaced the PCT positions with professional nurses. The integration of the role of the PCT in critical care had a slight effect on the hospitalwide RN turnover rate. The RN turnover rate before the integration of the PCT role was 14.6%. The current RN turnover rate is 15%. Four nurses (two from the pediatric ICU and two from the adult ICU) stated that they left critical care because they did not want to work with UAP. The UCH spends an estimated $6085.32 annually on the recruitment of PCTs. Additionally, it costs $7572.63 to procure and orient each PCT. Table 2 summarizes the cost of recruiting, procuring, and orienting the PCTs. Nursing Implications

The UCH developed a well thought out plan to integrate the role of the PCT in critical care areas. The PCT Critical Care Program supports the hospitals' mission statement and the Patient Centered Care Model in the provision of high-quality care. The policies and procedures governing the role of the professional nurse and the use of PCTs are consistent with the Illinois State Nurse Practice Act and the

Table 2 PCT RECRUITMENT, ASSESSMENT, AND ORIENTATION COST* Category

Cost($)

Assessment (pre-hire) Background check Basic health screening Orientation Hospital orientation Patient services sector orientation Care team orientation Core orientation Critical care orientation

470.25 3312 06 2518.79

Total cost per cand idate Annual recruitment cost

7572.63 6085.32

264.12 11.50 424.00 379.31 192.60

' Th is is a conservative cost estimate.

views of the ANA and the AACN. The supporting infrastructure is in place to support the PCT role. The leadership group encountered unforeseen obstacles. In general, the nurses and the PCTs do not work well as a team, possibly due to team fragmentation. The nurses require additional information on how to assign, delegate to, and supervise UAP effectively. The five units in the adult critical care area are located on five different floors. The PCTs are assigned to one to three teams. Each team is located on a different floor. The PCT team membership depends on the number of PCTs scheduled to work. The team leaders in the adult critical care area have difficulty coordinating and following up on assigned tasks because the PCT may be delayed on another unit or assigned additional tasks without the team leaders' knowledge. This establishes ineffective communication between the nurses and the PCTs, causing a chain reaction. The nurses have difficulty making assignments, delegating, and supervising effectively, and their expectations of the PCTs vary from unit to unit. Moreover, the PCTs may not be able to complete assignments because of the number of units that must be covered. The nurses do not trust many of the PCTs to complete their assignments safely and competently. They elect to complete the PCT assignments rather than check periodically to determine if the PCTs have completed their assignments or require assistance. A lack of mutual trust develops, and the PCTs feel overwhelmed

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and undervalued. The leadership group is currently reviewing ways to build effective teams and improve the nurses' ability to delegate and supervise effectively.

Recommendations Effective teams and the nurses' ability to assign, delegate to, and supervise UAP are key to the integration of UAP in critical care. Nurses need mentorship in these skills. Nurses who are willing to orient UAP should be selected. Nurses who assume the responsibility for UAP orientation but do not want to serve in the role prove detrimental. Using the same pool of nurses builds trust and camaraderie and establishes positive relationships. They should be available to orient UAP on all shifts and validate the initial performance criterion checklist. Their assignments should be modified to permit time to orient UAP effectively. The nurses who orient UAP should be actively involved in their hiring and selection.

Involving the staff nurses earlier in the program, instead of waiting until UAP complete Core Orientation and arrive on the assigned unit, should be considered. These nurses should meet regularly with the nursing leadership group to discuss what is working, and to report opportunities for improvement. Managerial support should be available to address problems that occur during delegation and supervised activities. The UAP performance should be appraised continuously. The nurse educator should schedule meetings with the nurses and UAP to discuss their education and training needs and to arrange the appropriate classes, reviews, and skill practice. The nurse educator should schedule meetings with the PCT supervisors to discuss their education and training needs. Education should be provided on a continuous basis. Research is needed to validate use of the new role and to determine the effect of UAP on patient outcomes (e.g., nosocomial infection, cost/productivity, nursing satisfaction, and improved technical support).

SUMMARY The integration of the role of UAP in critical care requires a long-term commitment to patient centered care by the professional nursing staff. Standardized education and training of professional nurses and UAP, support for nurses who orient UAP, support for the PCTs who precept, and a supporting infrastructure promote integration of UAP in critical care with positive outcomes. The education of UAP does not conclude with orientation. Education, training, and competency revalidation should be ongoing to broaden individuals' knowledge base and enhance skills. The monitoring and evaluation of programs with timely modifications will support or enhance effectiveness of the programs.

REFERENCES 1. American Nurses Association: Registered Profes-

sional Nurses and Unlicensed Assistive Personnel, ed 2. American Nurses Publishing, Washington, DC, 1994 2. American Association of Critical Care Nurses: AACN Critical Care: Unlicensed assistive personnel fact sheet 9503. AACN, Aliso Viejo, CA, 1999 3. Barter M, McLaughlin FE, Thomas SA: Use of unlicensed assistive personnel by hospitals. Nurs Econ 12(2):82-87, 1994 4. Bernreuter M, Cardona MS: Survey and critique of studies related to unlicensed assistive personnel

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from 1975 to 1997, part 2.] Nurs Adm 27(7/ 8):49-55, 1997 Bloutin AS, Brent NJ: Legal insights. Unlicensed assistive personnel: Legal considerations. ] Nurs Adm 25(11):7-8, 1995 Cone M, McGovern CC, Barnard K, et al: Satisfaction with a new model of professional practice in critical care. Crit Care Nurs Q 18(3):67-74, 1995 Flynn E, Heinzer MM, Radwanski M: A collaborative assessment of workload and patient care needs in four rehabilitation facilities. Rehabilitation Nursing 24(3): 103-107' 1999 Illinois Department of Professional Regulation: Nursing and Advanced Practice Nursing Acts and rules for the administration of Nursing and

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Advanced Practice Nursing Acts. Public Act 90-0742: 65/5-5, 65/5-10 Public Act 91-0630: 65/ 5-17, 1999 Kirby KK, Garfink CM: The university hospital nurse extender model Part I: An overview and conceptual framework: J Nurs Adm 21(1):25-30, 1991 Kreplick]: Unlicensed hospital assistive p ersonnel: Efficiency or liability? Journal of Health and Hospital Law 28(5):292-309, 1995 Russo ]MK, Lancaster DR: Evaluating unlicensed assistive personnel models: Asking the right questions, collecting the right data. ] Nurs Adm 25(9):51-57, 1995 Salmond SW: Models of care using unlicensed

assistive personnel. Part II: Perceived effectiveness. Orthop Nurs 14(6):47-58, 1995 13. The University of Chicago Hospitals: Innovations in patient care: Design documentation for patient centered care. Chicago, The University of Chicago Hospitals, Chicago, 1994 14. Turner SO: Competency-based skill building curriculum for unlicensed assistive personnel. AACN Critical Care Publication, 1996 15. Unlicensed Assistive Personnel Task Force: Illinois: Roles, responsibilities, training, competency and supervision of UAP. Illinois Department of Professional Regulation, Chicago, 1998

Address reprint requests to Shirley A. Sp encer, MS, RN 19001 Maple Avenue Country Club Hills, IL 60478-5736

Appendix 1 PCT CRITICAL CARE PERFORMANCE CHECKLIST

PCT Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Unit: _ _ __ _ __ _ _ __

Directions: The nurse or designee observes the PCT and puts initials in the Observer column if the PCT demonstrates the skill safely and according to policy and procedure or accepted practice. The date that the skill is performed is put in the Date Skill Performed column.

Activity

Observer

Date Skill Performed

Comment

Activities of Daily Living The PCT assists the RN in the following activities:

Perform activities associated with admission, transfer, room preparation, and discharge Perform a complete bed bath including hair washing and shaving Perform oral care (denture, brushing teeth, swab) Perform Foley care Perform perinea! care Apply sequential compression device (SCD) and TED hose Assist with Ace wraps and splints Apply Stryker boots Assist patient with prescribed activity level Perform range of motion (ROM) Assist physical therapist Turn and reposition patient within prescribed activity limitation Make occupied bed Make unoccupied bed Perform postmortem care Observe and maintain proper functioning of specialty bed App ly and maintain restraints Assist patient with elimination (bedpan, urinal, and commode) Stock drawers and supply room (Continued)

116

SPENCER

Activity

Observer

Date Skill Performed

Comment

Observe and maintain patient environment for safety hazards (siderails, call light within reach, padded siderails prn) Data Collection

Record oral, axillary, rectal, or electronic temperature Record respiratory rate Record standing , sitting, or supine blood pressure via cuff or arterial line Record intake and output hourly, shift, and 24 hours Zero and calibrate A-line Obtain ECG and pressure transduced strips and attach to flow sheet after reviewed by RN Obtain routine and stat 12-lead ECG* Measure and record abdominal girth Calibrate and use glucose monitor* Record arterial blood gases and report laboratory result Notify RN of behavior changes (e.g ., confusion , agitation) from baseline Record body weight using standing scale, bed scale, and sling Notify RN of skin integrity problems and use RN-directed preventative skin devices (e.g ., Duoderm) Measure and order TED hose Notify RN of alarm violation (monitor, ventilator, IV pump) Apply or change ECG electrodes Disconnect patient from monitor at direction ofRN Attach patient to monitor Assist RN with transfer of patient Check and order emergency supplies, including IV solution Order supplies Set up invasive procedures (sterile and clean) and clean up after invasive proced ures Document appropriately Check crash cart and emergency equipment Level transducer prior to running strips and after repositioning IV Therapy

Perform the following when not connected to the patient: 1. Prime pressure lines after heparin flush bag prepared and checked by RN 2. Prime IV 3. Prime blood tubing with saline and place at bedside 4. Prime bladder irrigation Sign and date IV lines after changed by RN Cap a peripheral IV to a heparin lock (only RN can flush) Prime TPN and lipid tubing Insert peripheral IV catheter* (Continued)

EDUCATI ON, TRAINI NG, AND USE OF UAP

Activity

Observer

Date Skill Performed

117

Comment

Respiratory Assist patient to perform incentive spirometry Assist patient with coughing and deep-breathing exercises Maintain proper oxygen therapy via mask or cannula* Assist with insertion of oral or nasal airway Administer 100% oxygen via Ambu bag Perform CPT manual ly or by using a percussor* Suction patient using regular suction or different catheters (Yankauer, in line, Red rubber, coude) Describe character of sputum Administer hand-held nebulizer treatments to nonventilated patient* Assist RN to change ET tube tape Assist RN to change trach ties Clean trach plate and change disposable cannula Apply and record pulse oximetry (Sp02)* Observe and record Spo 2 value Set up Pleurevac unit Record drainage from Pleurevac unit every hour and document level

Dressing Changes Change A-line and peripheral IV dressings Report redness , swelling, pain , and signs of infection to RN Change surface wound dressings, including removing old dressing and cleaning wound, but cannot apply any medications (RN must ob serve wound site at dressing change to assess and document wound characteristics) Assist with changing chest tube dressing per protocol Gather equipment and set up for packing wound

Labs Retrieve lab results from computer and record Complete lab requisitions Perform finger stick procedure* Collect and send urine for culture and sensitivity (C & S) , Gram stain , and electrolyte Collect and send respiratory specimen for C & S and Gram stain on nonintubated patient Perform venipuncture* Draw blood from A-line Draw b lood from central line* Draw blood for antibiotic level*

Nutrition and Elimination Assist with setting up and feeding patients Assist patient with menu Adjust rate of tube feeding after notifying RN

(Continued)

118

SPENCER

Activity

Observer

Maintain precautions for patients receiving tube feedings Change feeding bag and tubing every 24 hours Refill tube feeding as indicated by infection control procedural guidelines (4 hours of feeding) Add blue coloring to tube feeding as directed by RN Maintain tube drainage systems (Foley, Jackson- Pratt, jejunostomy, gastrostomy, ileostomy) Empty and record nasogastric , Jackson-Pratt, and ostomy drainage and urine output Change and empty ostomy appliance Apply and change fecal incontinence devices Flush nasogastric tube or Dobhoff with water after placement verified by RN * Skills with asterisk require documentation on a separate skil l checklist.

Date Skill Performed

Comment