Two Successful models for Preparing Competent Critical Care Nurses

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Critical Care Education

Two Successful Models for Preparing Competent Critical Care Nurses The Parkland Health and Hospital System Critical Care and Trauma Nurse Internship and Critical Care Residency Terry L. Jones, PhD(c), RN, Barbara Clark Mims, MSN, RN, and Laura E. Luecke, BSN, RN, CCRN

Nursing care in the highly technical and complex critical care environment requires knowledge, skill, and judgment exceeding that typically acquired in undergraduate nursing programs. The proliferation of intensive care units in the 1970s and 1980s created a demand for critical care nurses that surpassed the supply of nurses experienced in this specialty. Out of neccessity, many institutions subsequently began to open their intensive care unit doors to new graduates and other intensive care unit (ICU)-naive nurses. More recently, the decentralization of health care away from acute care hospitals and the growth of managed care have created employment opportunities that compete with those in intensive care units. 4 With the increasing age and falling employment activity among registered nurses (RNs), this has

From the Parkland Health and Hospital System, Dallas, Texas

resulted in a smaller pool of experienced applicants seeking employment in critical care. 3 Thus, the demand for experienced critical care nurses continues to exceed the supply in many areas, and the need for educational programs to prepare nurses in this specialty seems unlikely to disappear. Varying approaches to the preparation of nurses for the critical care environment, ranging from unstructured clinical preceptorships to structured and lengthy educational programs, have emerged over the years. The terms "nurse internship" or "nurse residency" frequently are used to identify these hospitalbased programs. These terms have neither a standardized definition nor a standardized curriculum. Consequently, much heterogeneity exists among nurse internships and nurse residencies with respect to structure, content, and resource requirements. To date, there has been no large-scale evaluation of the effectiveness of these programs, and the relative contributions of various structural

CR ITICAL CARE NURSING C LI NICS OF NORTH AMERICA I Volume 13 I Number 1 I March 2001

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characteristics to program outcomes have not been established. Absent the availability of such information in the literature, nurse educators and nurse administrators seeking to implement these programs often resort to anecdotal reports of successful strategies from their colleagues in institutions already offering them for guidance. Parkland Health and Hospital System (PHHS) is a large urban county hospital that serves the indigent population of Dallas county. PHHS also serves as the primary teaching and research facility for the University of Texas Southwestern Medical Center of Dallas. The facility is licensed for 997 beds and supports approximately 1450 fulltime equivalent (FTE) RN positions. Approximately 240 of these FTEs are designated for the seven units that provide care for the adult critically ill population. These areas include emergency services, trauma services, coronary care, medical-respiratory intensive care, burn intensive care, surgical-trauma intensive care, and neurosurgical intensive care. PHHS has a long and successful history of providing educational programs to prepare ICU-naive nurses (including new graduates) for practice in critical care areas. Two such programs are provided currently at PHHS, the Critical Care and Trauma Nurse Internship and the Critical Care Residency. The following discussion of these two models is intended to serve as an anecdotal reference for our colleagues struggling to meet the demand for educating competent critical care nurses.

Critical Care and Trauma Nurse Internship The Critical Care and Trauma Nurse Internship at PHHS is a specialty program conducted once a year for a select group of new baccalaureate nursing graduates. Although it originated in 1974 in response to the need to promote basic competency in nurses beginning practice in the newly developed specialty of critical care, the program has evolved into a highly structured, comprehensive academic program with a strong clinical component. Goals of the program: Assist new graduates in making the transition from a baccalaureate program to the

complex environment of a critical care unit. Provide advanced theory and clinical practice in nursing management of the adult patient in the critical care setting. Recruit outstanding new graduates from throughout the United States to work at Parkland Health and Hospital System. Contribute to retention of critical care nurses at Parkland by enhancing job satisfaction through promoting a high level of competence and effectiveness in nursing practice. Develop nurse leaders and educators for clinical practice at Parkland. The conception of the program preceded the publication of Benner's 2 work on the stages of clinical proficiency, but many of the strategies incorporated in this program certainly would be consistent with her framework. Although development of basic clinical competence is integral to the program, its length and structure provide the opportunity for participants to develop a broad, in-depth cognitive knowledge base. Supervised clinical experience in specialized critical care areas enables participants to develop quickly into skilled clinicians, who ultimately contribute significantly to the quality of care in this large, metropolitan teaching hospital. General Structure

The internship is 28 weeks. It begins with 2 full weeks of class, followed by supervised clinical rotations through five adult ICUs and the Emergency Department (Table 1). Nurse interns are classified as full-time employees and work 80 hours per 2-week pay period. Various shifts are included, with accessing the optimal learning experience the major consideration in planning the intern's schedule. The interns are not counted in the staffing pattern for the duration of the program. Patient assignments are made according to the participant learning objectives (Appendix 1). Class is held an average of one 8-hour day per week. Recruitment and Admission Processes

Recruitment posters are sent to every National League for Nursing accredited baccalaureate nursing program once each year.

TWO SUCCESSFUL MODELS FOR PREPARING COMPETENT CRITICAL CARE NURSES

Table 1 CRITICAL CARE AND TRAUMA NURSE INTERNSHIP CLINICAL ROTATION PLAN

Unit

Burn Intensive Care Unit Coronary Care Unit* Emergency Department Medical Intensive Care Unit Neurosurgical Intensive Care Unit Surgical-Trauma Intensive Care Unit Electives Unit orientation Total

Length of Rotation (wk)

2 4 4

5 2 5 1

2

25

'Patients who require cardiac surgery are referred to another institution on campus and are not routinely cared for at PHHS.

Other than usual job fairs, advertisements, and the overall program used by the Department of Nurse Recruitment, no additional recruitment efforts are implemented specifically for the nurse internship. Admission to the internship is competitive, with many more applicants than positions each year. To be eligible for the internship, applicants must have graduated from an accredited baccalaureate degree nursing program within 1 year before the beginning of the internship. An overall grade point average of 3.2 on a 4.0 scale is required, and each applicant must participate in a personal interview with the internship coordinators. Each applicant submits a written application, including several essays and an official transcript. Applications are evaluated, with consideration given to content and quality of essays, grade point average, short-and longterm career goals, work experience, community/volunteer work, awards and honors, and extracurricular activities. Although it varies from year to year, an average of 135 applications are received for the program. From this pool, approximately 60 applicants are selected to interview for the 15 positions budgeted anually. Candidates travel to Dallas at their own expense for the interview. During the interview, the applicant meets with the two internship coordinators simultaneously. A structured rating scale is used to evaluate each applicant in the areas of appropriate appearance, demeanor, verbal

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communication, nonverbal body language, concept of the role of the critical care nurse, compatibility of the applicant's expectations with the internship goals and curriculum, and the applicant's plans for how she or he can contribute to Parkland. After the interview, a tour of the hospital is given by a nurse intern currently enrolled in the program. In addition to providing the applicant with an awareness of the Parkland critical care environment, the tour also is an opportunity to ask questions about the internship of someone who is actually participating in the program. Because the decision to accept a position in the Nurse Internship is a substantial commitment and requires the individual to sign a contract, every effort is made to inform the applicant as accurately as possible of what the nurse internship experience entails. The tour also has proven to be a powerful way of recruiting those applicants who are not offered positions in the internship. Many will seek other positions at PHHS after seeing the hospital and talking with a nurse intern. Because many of these applicants are not from the immediate geographic area, it is likely that some who accept positions at Parkland outside of the internship would not have explored other career opportunities here if not drawn to the hospital by the educational opportunity offered by the internship. Many nurses have commented that one of the reasons they chose to work at Parkland is the institution's commitment to education and professional growth, as evidenced by the administrative support for the internship. The interviews generally take place in March and April. The applicants are ranked, and written employment offers are mailed to the top 15 in April. Acceptance in the program is contingent on passing the state board examination (NCLEX). If any of the top 15 applicants decline the offer or fail to pass the NCLEX, an applicant from the alternate list is selected and offered a position. Curriculum Design

The internship curriculum is designed using a core systems approach. During the first 2 weeks, the technical skills fundamental to critical care practice are emphasized. Once clinical rotations begin, the core systems

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begin with a comprehensive review of anatomy and physiology, with considerable depth in the physiology of each system. Subsequent lectures address the diseases and injuries that are commonly responsible for the admission of the adult patient to the critical care unit in a large, urban, teaching hospital. Lecture content includes pathophysiology, diagnostic procedures, assessment techniques, medical and surgical management, and nursing care. Also included are presentations on psychosocial, spiritual, and ethical aspects of critical care. There are a total of 32 8-hour class days that include lectures, group discussions, demonstrations, and interactive sessions such as case studies. Practice sessions in arrhythmia recognition, 12-lead ECG interpretation, troubleshooting ventilators, calculating intravenous infusion dosages, interpreting arterial blood gases, and similar activities also are included (see Appendix 2 for the Class Day Topic List). Faculty and Supervision

The Nurse Internship is a separate cost center from the Department of Nursing Education and has no additional responsibilities other than program management. The faculty consists of one part-time Administrative Coordinator, one full-time Program Coordinator, and two full-time instructor positions. Secretarial support is shared with the Department of Nursing Education. The number of nurse interns averages 15 each year. The primary role of the nurse internship instructor is to maximize the learning opportunities of the nurse interns in the clinical area. The instructor maintains a visible presence at the bedside and is involved in hands-on clinical teaching. Instructors are not in each unit at all times, but they carry beepers and move between areas as needed. The instructors also quiz the nurse interns and assist them in assimilating information learned in the classroom and with practical application of cognitive knowledge. Although their primary responsibility is teaching, the instructor's role in supervising the nurse interns is essential to ensure that the quality of patient care is not compromised by having neophyte critical care nurses at the bedside in this complex, fastpaced environment. The internship faculty

are also responsible for the management of all personnel issues that arise among the nurse interns. One of the key features to the considerable success of the Parkland internship is that the instructors are fully dedicated to this role, without being pulled away by committee responsibilities, orientation duties, CPR recertification, and other important but time-consuming responsibilities frequently assumed by nurses in teaching positions. Interface Between Nurse Intern and Staff Nurse

The nurse interns are always assigned with another nurse during clinical rotations. The two share responsibility for the patients. The nurse intern assumes an active role in providing patient care, and in a short time after beginning the program, the intern provides most, if not all, of the care for one critically ill patient. This includes administration of all medications and documentation. Later, nurse interns provide care for two patients at a time in selected units. The staff nurse answers questions, assists and supports the nurse intern as needed, oversees the total care of the patient, and maintains ongoing assessment of the patient and the data on the flowsheet. The staff nurse is encouraged but not required to quiz the nurse intern about the patient, his lab values, pathophysiology, hemodynamic parameters, and the like, as time allows. The staff nurses contribute significantly to the overall learning experience of the nurse interns. Course Requirements

The Nurse Internship consistently has been approved by the American Association of Critical Care Nurses for continuing educations units, and participants also can receive 6 hours of graduate credit toward the Master of Science in Nursing at the University of Texas at Arlington. Those who wish to obtain the graduate credit must apply and gain admission to the Graduate School and pay the required tuition and fees. However, no additional activities are required of those who obtain the graduate credit. Six hours of credit is awarded for successful completion of the Nurse Internship course requirements.

TWO SUCCESSFUL MODELS FOR PREPARING COMPETENT CRITICAL CARE NURSES

Participation in the Nurse Internship involves a significant amount of independent reading and self-study, as it is a graduate level course with substantial course requirements. In addition to working full-time taking care of some of the sickest patients in the hospital, the nurse interns are rotating to a different unit every 2 weeks, working with different nurses almost daily, and working a variety of shifts. They also are studying for tests, reading articles to prepare for class and to supplement their clinical experiences, and participating in a journal club. They also must make a formal presentation on a selected critical care topic to a group of staff nurses, which requires reading a minimum of 30 to 50 articles as part of the preparation. Certification in Advanced Cardiac Life Support (ACLS) and Trauma Nurse Core Course (TNCC) is also included in the internship. Evaluation Methods

For the nurse intern to continue in the program and graduate, she or he must demonstrate satisfactory performance in both academic work and clinical practice. A technical skills test is given before the start of clinical rotations. This requires the nurse intern to demonstrate competence in performing basic technical skills, all of which have been taught during the first 2 weeks of class. Written tests of cognitive knowledge are given approximately every 2 weeks, and comprehensive final examinations are given at the end of each semester. Written clinical performance evaluations are done by the instructors at the end of each rotation, which averages 2 weeks. A technical skills checklist must be completed to verify skill in performing various technical procedures. Transition from Nurse Intern to Staff Nurse

Toward the conclusion of the Nurse Internship, the nurse interns apply for positions in one or more of the specific units. Interviews are conducted by the unit managers. Once all nurse intern interviews have been conducted, each manager lists the nurse interns in order of their preference for hiring. The nurse interns rank the units according to their choice for permanent employment. The

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nurse internship coordinators match the two lists, with the nurse interns' preferences taking priority. The nurse interns work in their units of employment during the final 2 weeks of the internship. Salary and Benefits

The nurse interns receive a salary approximately 14.5% less than that of other newly graduated registered nurses. They receive all the standard benefits of any other full-time employee, excluding shift and weekend differential. The rationale for excluding the differentials is because the shift assignments are made to maximize learning opportunities rather than to meet staffing needs. Employment Contract

The nurse interns are required to sign a contract agreeing to work full-time in critical care at Parkland for a minimum of 2 years after completion of the internship. During the first 90 days of the internship, the nurse intern can resign with no penalty. After that time, a specified sum is required to be paid as partial compensation to the hospital. The exact sum required depends on the date that the individual resigns, with the maximum being $6000. The Chief Financial Officer (CFO) at PHHS is charged with enforcing the contract. If a nurse intern leaves PHHS before the contract expires, she or he is notified in writing by the Department of Accounting as to the money owed. Instructions are given regarding whom to contact to set up a payment schedule. The contract does not guarantee that a position will be offered to the intern on graduation from the program. There has never been an instance, however, in which a nurse intern graduate has not been hired into a staff nurse position in a critical care area on graduation from the program. Budgetary Considerations

The major expense of this program is the salaries of the faculty and the nurse interns, and it is considerable. Although no formal cost/benefit analysis has been done, the recruitment and retention impact are perceived to be significant. In addition, the nurse

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interns and the instructors provide a valuable supplement to the regular critical care nursing staff. The supply expense is relatively low and consists mainly of books, journals, printing, and medical supplies used in teaching technical skills. Keys to Success

The term "nurse internship" has been used to describe a considerable variety of educational programs in hospitals throughout the United States. The PHHS program is certainly one of the longest lived, if not the longest lived, internship in existence. The following factors have been identified as "keys to success" of this unique program. The Nurse Internship is separate from the nursing staff in any one particular critical care area. The nurse interns are selected, hired, and eventually evaluated by the internship faculty. The nurse interns are not counted in the staffing totals in the critical care areas. The internship has a permanent, full-time faculty consisting of nurses with both sound theoretic knowledge and clinical expertise. The role of the Nurse Internship Instructor is defined clearly and responsibilities are focused almost totally in the internship. Clinical teaching is paramount in this job description. The curriculum is highly structured, and classes are held on a regular basis. The complexity and variety of patients in the critical care areas of this large metropolitan teaching hospital provide ideal learning opportunities for those desiring to specialize in critical care. The course requirements are articulated clearly, and evaluation methods are specified.

Critical Care Residency In the late 1980s, the pool of experienced critical care nurses recruited to PHHS was not sufficient to meet the growing demand. The graduates of the Nurse Internship helped fill some of the vacancies, but the need to prepare additional nurses to meet this demand remained. Given the structure and length of

the Nurse Internship, it was not conceivable to offer the program more frequently, and increasing enrollment would increase the supply of critical care nurses only once per year. Further, because the Nurse Internship was designed specifically for new graduates, experienced med-surg nurses interested in critical care could not be included. As a result, the concept of a Critical Care Residency Program was conceived. The Critical Care Residency is a specialty program provided four times a year to prepare nurses lacking experience in critical care to fill staff nurse positions in these areas at PHHS. The Residency shares many features with the Internship, but the two programs have significant differences. The development of basic clinical competence in critical care is integral to both programs; however, the Residency is more narrowly focused in both cognitive knowledge base and clinical exposure. In the Internship, all aspects of both program and participant management are performed directly by the faculty, whereas the Residency is a collaborative effort between the Department of Nursing Education and the Nurse Managers of the individual critical care units. Consequently, for purposes of this discussion, the basic Residency format has been divided into management-related and education-related components. Management-Related Components

The clinical managers in the respective critical care units are responsible for hiring the nurse residents. When staff nurse positions become available, the critical care unit managers request that a position be posted in Nurse Recruitment and advertised as indicated. Applicants are interviewed by unit management, and, if a nurse without critical care experience is hired, she or he is registered for the Residency with Nursing Education. Because each critical care area interviews and hires its own staff, specific admission criteria can vary among the units. Both new graduates (regardless of basic nursing preparation) and nurses with experience in non-critical care areas are eligible for the Residency at the discretion of the unit managers. The interview process is variable, with some units involving unit staff and others not.

TWO SUCCESSFUL MODELS FOR PREPARING COMPETENT CRITICAL CARE NURSES

Unlike the Nurse Internship, however, there is no written component beyond the general hospital employment application, and academic transcripts are not requested. Like the nurse interns, the nurse residents are classified as full-ti!me employees and work 80 hours per 2-week pay period. Their salary, however, is never less than the minimum for staff RNs. Nurse residents can be assigned to any shift depending on the availability of preceptors and are not counted in staffing for the duration of the program. Unlike the nurse interns, however, their clinical experience is limited to the individual unit in which they were hired. Each nurse resident's salary is paid by the clinical cost center to which she or he is employed, and management issues are handled by the clinical unit managers. Education-Related Cc1mponents

The Critical Care Residency program is 14 weeks long and includes both classroom instruction and a supervised clinical preceptorship. The didactic content is presented in 19 8-hour class days interspersed throughout the 14 weeks. Each week of class is separated by an average of 2.5 weeks of clinical time. The course begins with content on anatomy, physiology, and assessment of each body system; ECG monitoring; and technical skills common to the critical care environment. Subsequent content includes pathophysiologic states commonly encountered in the critical care environment and the medical, pharmacologic, and nursing management strategies involved in their diagnosis and treatment. The psychosocial and ethical aspects of care also are addressed, along with techniques for stress management and professional development. The patient populations encountered in each critical care area are inherently different with respect to primary pathophysiologic disease states and interventional needs. Consequently, the clinical experiences of the nurse residents and the knowledge and skill essential for safe, competent practice varies according to the patient population. The didactic content received by individual nurse residents therefore is limited to that considered essential for safe and competent practice in their respective units. Some content

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is considered essential for all of the critical care areas. Examples of core content include anatomy, physiology, and assessment of each body system, ECG monitoring, shock, sepsis, arterial pressure monitoring, fluids and electrolytes, acid-base balance, arterial blood gas (ABG) interpretation, and mechanical ventilation (Table 2). All the nurse residents jointly attend class days providing core content. On class days in which unit-specific content is provided, however, only select nurse residents are required to attend (Table 3). For example, on the trauma class day, the nurse residents hired by the emergency department and the surgical trauma ICU would be required to attend, but those hired by the medical respiratory ICU would be scheduled in the clinical area. Nurse residents are tested only on that didactic content required for their unit. This approach allows the residents to concentrate on becoming proficient in the knowledge and skill used in the care of the patients most frequently encountered in their chosen unit. In this sense, the nurse residents are not exposed to the same breadth of knowledge as the nurse interns, and their clinical experience is not as diverse and comprehensive. Several teaching strategies are used in presenting the didactic content. In addition to traditional lecture and discussion, various small-group interactive review sessions and clinical labs are incorporated into most class days. This allows for the accommodation of multiple learning styles and provides opportunities for the practical application of knowledge, which is so important for adult learners. 5 In addition, it facilitates the learning process by providing a mechanism to reinforce content previously covered and allows for feedback regarding the participants' level of understanding and performance .1 Nurse Educators and Preceptors

The staff of Nursing Education is responsible for management of the educational portion of the residency program, including curriculum development, evaluation of learning, competency assessment, and program scheduling. In the Department of Nursing Education, eight full-time nurse educators are designated for the adult critical care areas.

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Table 2 CRITICAL CARE RESIDENCY CORE CONTENT Cardiac anatomy and physiology Cardiac assessment Pulmonary anatomy and physiology Pulmonary assessment Neurologic anatomy and physiology Neurologic assessment Gastrointestinal anatomy and physiology Gastrointestinal assessment Renal anatomy and physiology Renal assessment Arterial blood gas interpretation Airway management Diagnosis of acute myocardial infarction/unstable angina/chest pain Management of AMI/USA/chest pain Antimicrobial therapy Arterial puncture Blood transfusions Cardiac arrest management Chest drainage Congestive heart failure/pulmonary edema

Collectively these educators are responsible for planning, implementing, and evaluating orientation and continuing education activities for the critical care nursing staff. The residency falls under the category of orientation activities. The relative contribution of each educator to these activities varies according to work assignments. Five of these educators are assigned to the individual ICUs and emergency department, two of them are assigned to coordinate housewide continuing education and resuscitation programs, and one is assigned to coordinate the Critical Care Residency Program. The residency coordinator is primarily responsible for the day-to-day management of the didactic component of the program. She oversees the development of the curriculum, writes course objectives, generates the course schedule, contacts and confirms speakers, constructs and grades tests, and serves as a primary speaker. The five clinical educators are responsible for managing the clinical component of the residency program. They work with the unit managers to assign preceptors, generate the clinical schedule, provide clinical bedside instruction, and collaborate with preceptors in the evaluation of clinical competency and performance. These educators also provide input for curriculum decisions and serve as primary speakers in the program. The primary responsibilities of the two program

Central venous infusions Central venous pressure monitoring Disseminated intravascular coagulation ECG monitoring (3-day course) Ethics Fluid and electrolytes Gastrointestinal bleed Hepatic failure Mechanical ventilation Pain management Pneumonia Psychosocial aspects of critical care Pulmonary embolism Renal fai lure Rhabdomyolosis Sepsis Shock Stress management Tissue donation

educators fall under the category of continuing education, but they contribute to the residency program by serving as primary speakers, grading tests, and assisting with clinical bedside instruction as needed. Unlike the internship instructors, the nurse educators have many responsibilities in addition to those related to the residency program, and they cannot be in the clinical area to supervise the nurse residents every day. Consequently, the residents are paired with a staff nurse in their unit. This individual serves as a clinical preceptor during the program. The preceptors are responsible for selecting appropriate patient assignments for the nurse residents and serve as the nurse of record for the assignment. Like the nurse interns, the nurse residents assume an active role in providing patient care from the beginning of the program. The preceptors provide clinical instruction, supervision, and intervention such that the resident gains the knowledge and skill needed and patient care is not compromised. As the resident's clinical knowledge and skills progress, the preceptor selects more challenging assignments. The preceptor is also responsible for evaluating the resident's level of competency on those skills included in the skills checklist and providing a written evaluation of their overall clinical performance . As the primary clinical teachers and evaluators, the preceptors play a pivotal role in

TWO SUCCESSFUL MODELS FOR PREPARING COMPETENT CRITICAL CARE NURSES

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Table3: CRITICAL CARE RESIDENCY AREA SPECIFIC CONTENT Content

CCU

MICU

BICU

SICU

NICU

Arterial lines Advanced mechanical ventilation Dialysis ICU documentation Multisystem organ dysfunction Nutritional support PA pressure monitoring Shock and hemodynamics Weaning from mechanical ventilation Acute stroke Hypertensive crisis Drug overdose Pancreatitis Ventriculostomy and camino bolt ARDS AIDS management Asthma Exacerbation of COPD Diabetic ketoacidosis and hyperglycemic hyperosmolar non-ketotic syndrome Coronary artery disease Trauma (all systems) SVo 2 monitoring lntracranial pressure management Advanced CV assessment Advanced dysrhythmias Cardiac pharmacology Cardiomyopathy Complications of acute Ml Pacemakers Percutaneous transluminal coronary angioplasty/cardiac catheter postprocedure management Diabetes insipidus Surgical abdomen Surgical wound care Care of thoracic surgery patients Care of vascu lar surgery patients Burn care Pediatric burn care Abdominal pain Alcohol abuse Altered mental status Environmental emergency ER documentation OB/Gyn emergencies Pulmonary emergencies Sickle cell crisis Status epilepticus Initial stabilization of the burn patient

x x x

x x x

x x

x x

x

x

x x x x

x x

x x x

x x x

x

x x x x

x x

x x

x x x x

x x x x x

x

x

x

x

x

x

x

x

x

x

x

x

x

x x x

x

x

x

x

x

ER

x x

x x x

x

x

x x x

x x x

x

x

x

x

x

x x x

x

x

x

x x

x x

x x

x x

x

x x

x x x x x x

x

the residency program. PHHS has selection criteria for official preceptors, who are required to attend an 8-hour educational program designed to introduce them to the preceptor role and responsibilities. To qualify as an official preceptor, a nurse must

x x x x x x x x

x x x x

have at least 1 year of nursing experience, 6 months of which must be in the current unit of employment. The educational program consists of principles of adult learning, stages of clinical proficiency, learning theory, clinical teaching strategies, conflict

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management, skills validation, and clinical performance evaluation. The program includes both traditional didactic presentations and an interactive component. Participants view videotaped preceptor-orientee scenarios and are asked to evaluate the interactions based on what was learned from the didactic presentations. Despite such educational efforts and selection criteria, the quality and level of experience of staff nurses used as preceptors is highly variable. As a result, learning experiences are not consistent across all participants in the residency program. The nurse educators make every effort to interface with the preceptors and their assigned residents on a regular basis and troubleshoot issues that arise. Every attempt is made to keep the total number of preceptors per resident to a minimum, but it is not always possible for a resident to remain with a single preceptor throughout the program. Evaluation Methods and Course Requirements

The nurse residents are required to take and pass five written exams. A score of 80% or more is considered passing. Three of these exams are take-home tests involving openended, essay-type questions based on case scenarios and some matching and full-in-theblank items. The focus is on application of knowledge, and many items require interpretation of assessment and diagnostic data to identify the most appropriate course of action. The other two exams are objective tests completed during class time. One test is given as a midterm and the other as a final exam. The midterm and final are both cumulative. In addition to the written exams, the nurse residents must demonstrate competent performance of the essential skills on the technical skills checklists for their preceptor or nurse educator. The residency is not affiliated with a graduate school, and no formal presentations or papers are required of the nurse residents. Certification in ACLS or TNCC is not included in this program. The nurse residents receive written clinical performance evaluations completed by the preceptors and nurse educators approximately every 2 to 3 weeks

during the program. Successful completion of the program requires passing all written tests, completing the technical skills checklist, and achieving a satisfactory rating on the final written clinical performance evaluation. Nurse residents who do not receive a passing score on any of the exams are allowed to take the exam a second time. If a passing score is not achieved on the second attempt, the educators and managers meet to determine whether the nurse resident will be permitted to remain in the program. Resource Requirements and Employment Contract

As in the nurse internship, the salaries of the nurse residents represent a major component of the expenses for the residency. This expense is shouldered by the respective clinical cost centers. The other major expense involves educator time. As mentioned previously, one FTE in Nursing Education is designated to coordinate the program. In addition, approximately 15% to 30% of the clinical educators' time is devoted to residency-related activities annually, depending on the number of nurse residents hired. Given the expense of this program to the institution, an employment contract has been implemented to ensure some degree of return on this investment. The employment contract signed by the nurse residents is similar to that signed by the nurse intern and is enforced by the CFO. The contract requires the nurse resident to work full time at PHHS for a minimum of 18 months after completing the program or pay the sum of $2500. If a nurse resident does not successfully complete the program, she or he is offered an opportunity to seek employment in any of the non-critical care areas of the hospital and is relieved of the contract obligations. Success of the Program

Since its premiere in January 1989, the Critical Care Residency has been attended by over 550 ICU-naive nurses, 89% of whom successfully completed the program. Approximately 40% of these participants were new graduates, and 60% were other ICU-naive nurses. There have been no significant differences in program pass rate between new graduates

TWO SUCCESSFUL MODELS FOR PREPARING COMPETENT CRITICAL CARE NURSES

and other participants. The didactic component of the program has been opened to non-PHHS employees for a reasonable tuition fee, and many hospitals in the community use our program to prepare ICU-naive nurses to fill their critical care positions. In fact, approximately 7% of the course participants have been from other local institutions. With this model's success in preparing nurses in the critical care specialty, it has been applied in other nursing specialties. Currently, residencies for neonatal intensive care nursing, perioperative nursing, and perinatal nursing are offered at PHHS. At one time there was a separate residency for the emergency department. Much of the content was the same as that in the Critical Care Residency, however, and the two programs have been combined to prevent duplication of effort by the nurse educators. Over 1000 nurses have participated in nurse residency programs at PHHS in the last 10 years.

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Shared Resources Although these two programs are distinct, there is a great deal of collegeality and collaboration among the faculty. Many of the nurse educators serve as primary speakers in the Nurse Internship, and the Internship faculty serve as primary speakers for the Residency. The nurse educators occasionally fill in as clinical instructors for the nurse interns, and the Internship faculty assist with many other programs provided by Nursing Education. In addition, classroom space, clerical support, audiovisual equipment, and simulators for the monitoring labs also are shared. The nurse residents and nurse interns do not attend class together, however. The faculty of both programs work together to ensure consistency of information to participants and adherence to standards of care and institutional policy.

SUMMARY Part of the mission statement of Parkland Health and Hospital System involves participating in educational programs dedicated to the art and science of caring for the sick and injured, the promotion of wellness, and the delivery of health services. The concept of the Nurse Internship and Nurse Residency fits well in the framework of this hospital. The continued support of these programs from the PHHS administration is visible evidence of the institution's commitment to excellence. Together these programs provide a continual supply of competent critical care practitioners to meet the never-ending demand in this large county facility as well as opportunities for new graduates to begin the exciting and rewarding journey into critical care nursing.

REFERENCES 1. Bandura A: Social Foundations of Thought and Ac-

tion: A Social Cognitive Theory. Englwood Cliffs, NJ, Prentice-Hall, 1986 2. Benner P: From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Reading, MA, Addison-Wesley, 1984 3. Buerhaus PI: ls another RN shortage looming? Nurs Outlook 46(3):103-108, 1998

4. Houston CJ, Fox S: The changing health care market: Implications for nursing education in the coming decade. Nurs Outlook 46(3):109-114, 1998 5. Knowles MS: The Adult Leamer: A Neglected Species. Houston, Gulf Publishing, 1984 6. Penn BK: Leaming styles in staff development. In Abruezzese RS Ced): Nursing Staff Development: Strategies for Success. St. Louis, Mosby, 1996

Address reprint requests to Terry L. Jones , PhD(c), MS, RN Nursing Education Parkland Health and Hospital System 5201 Harry Hines Boulevard Dallas, TX 75235

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Appendix 1 Critical Care and Trauma Nurse Internship Participant Learning Objectives A. Essential Clinical Performance Objectives

1. Accurately assess a critically ill patient. a. Perform a baseline assessment at the beginning of the shift and every 4 hours. b. Perform a neuro check. c. Identify abnormal breath sounds. d . Identify abnormal heart sounds. 2. Accurately interpret lab values, including the following: a. Arterial blood gases b. CBC c. Electrolytes d. Cardiac enzymes e. Clotting profiles f. Liver function tests g. Metabolic parameters (albumin, bilirubin, BUN, creatinine, glucose, lactate, total protein) 3. Interpret cardiac rhythm strips with accuracy. 4. Identify patterns of ischemia, injury, and infarction on a 12-lead ECG. 5. Manage a patient-ventilator system correctly, including: a. Identification of mode b. Perform a ventilator check c. Verify appropriate alarm settings d. Troubleshoot alarm violations 6. Assess patient's comfort level and provide analgesia and sedation as needed. 7. Provide emotional support and comfort measures to patients and family members. 8. Obtain and interpret pulmonary artery pressure readings correctly. 9. Use hemodynamic parameters (pulmonary artery pressure readings, cardiac output values, Svo2 ) to make decisions regarding care, including: a. Fluid administration b. Management of cardiovascular infusions c. Administration of diuretics d. Appropriate notification of the physician

10. Administer intravenous infusions of the following inotropic and vasoactive drugs safely and correctly. a. Dobutamine b. Dopamine c. Epinephrine d. Esmolol e. Labetol f. Milranone g. Neosynephrine h. Nicardipine i. Nitroglycerin j. Nitroprusside k. Norepinephrine Management should include: a. Calculation of dosage being delivered by a continuous infusion already in progress. b. Calculation of infusion rate needed to initiate an ordered dose by continuous infusion. c. Identification of appropriate monitoring parameters for each infusion in each specific patient situation. 11. Administer all ordered medications correctly. 12. Explain rationale for administering each medication in each specific patient situation. 13. Administer IV fluids and blood products safely and correctly. 14. Collaborate w ith colleagues and demonstrate a spirit of unity during clinical practice. 15. Document appropriately, completing flowsheet and medication administration record thoroughly, accurately, and according to policy. B. Fundamentals of Critical Care 1. Obtain CPR certification. 2. Demonstrate proper ventilation of a mannequin using bag-valve-mask. 3. Participate in CPR by performing the following: a. Ventilate patient with bag-valvemask connected to endotracheal tube

TWO SUCCESSFUL MODELS FOR PREPARING COMPETENT CRITICAL CARE NURSES

b. Perform external cardiac compressions c. Defibrillate d. Administer medications per ACLS guidelines e. Manage arrest cart during CPR f. Document on the arrest record 4. Prepare for and assist the physician during the following procedures: a. Arterial line insertion b. Central venous catheter insertion c. Chest tube insertion d. Endoscopy e. Endotracheal intubation f. Lumbar puncture g. Peritoneal lavage h. Swan-Ganz catheter insertion i. Ventriculostomy 5. Use established procedures for isolation of patients with life-threatening infections. 6. Practice universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other blood-borne pathogens as recommended by the Centers for Disease Control and Prevention. 7. Adhere to established safety precautions relating to a . Fire b. Use of oxygen c. Electrical hazards d. Needles e. Restraints f. Radiation 8. Complete a minimum of 80% of the Technical Skills Checklist. 9. Demonstrate proper use of the needleless system and incorporate use in practice whenever possible. C. Core Systems 1. Neurologic System a. Demonstrate knowledge of the major structural anatomy of the central and peripheral nervous systems through written testing. b. Apply principles of neurophysiology in caring for patients with injury to the central nervous system. c. Assess, plan, implement, and evaluate care of patients with the following disorders: (1) Acute spinal cord injury

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(2) Arteriovenous malformation (3) Brain attack (4) Cerebral aneurysm (5) Closed head injury (6) Drug overdose (7) Intracranial hematoma (8) Meningitis (9) Penetrating head injury (10) Seizures (11) Skull fracture d. Provide appropriate nursing interventions for patients undergoing the following diagnostic procedures: (1) Computed transaxial tomography (CT scan) (2) Cerebral angiography (3) Electroencephalogram (EEG) (4) Lumbar puncture (5) Magnetic resonance imaging (MRI)

2. Cardiovascular System a. Demonstrate knowledge of the major structural anatomy of the cardiovascular system through written testing. b. Apply principles of cardiac physiology in caring for critically ill patients. c. Assess, plan, implement, and evaluate care of patients with the following disorders: (1) Angina pectoris (2) Acute myocardial infarction (3) Cardiomyopathy (4) Congestive heart failure (5) Heart and great vessel injuries (6) Hypertensive crisis (7) Peripheral vascular surgery (8) Sepsis (9) Shock d. Identify the following arrhythmias and discuss the physiologic consequences and treatment of each. (1) Sinus node (a) Sinus arrhythmia (b) Sinus tachycardia (c) Sinus bradycardia (d) Sinus arrest (e) Sinus exit block (f) Sick sinus syndrome (2) Atrium (a) Premature atrial contraction (b) Supraventricular tachycardia (c) Atrial flutter

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e.

f.

g. h.

(d) Atrial fibrillation (e) Multifocal atrial tachycardia CD Wandering atrial pacemaker (3) AV junction (a) Junctional rhythm (b) Junctional tachycardia (c) Premature junctional contraction (d) First degree AV block (e) Second degree AV block type I (Wenckebach) CD Second degree AV block type II (Mobitz II) (g) Third degree heart block (4) AV dissociation (5) Ventricle (a) Idioventricular rhythm (b) Accelerated idioventricular rhythm (c) Premature ventricular contraction (d) Ventricular tachycardia (e) Ventricular fibrillation (f) Asystole (6) Pacemaker rhythms (a) Atrial (b) AV sequential (c) Ventricular (7) Pulseless Electrical Activity (8) Narrow complex tachycardia (9) Wide complex tachycardia Given a 12-lead ECG, identify the following: (1) Rate (2) Rhythm (3) Axis (4) Patterns of ischemia, injury, infarction (5) Bundle branch block Discuss the clinical implications, actions, normal dosage, side effects , and nursing implications for commonly administered cardiac drugs. Assist the physician during elective cardioversion. Provide appropriate nursing interventions for patients undergoing the following diagnostic procedures: (1) Cardiac catheterization (2) Myocardial scan (3) Electrophysiology study ( 4) Echocardiogram

i. When caring for patients undergoing the following therapeutic interventions, provide teaching and appropriate nursing interventions: (1) Thrombolytic therapy (2) PTCA (percutaneous transluminal coronary angioplasty) 3. Pulmonary System a. Demonstrate knowledge of the major structural anatomy of the pulmonary system through written testing. b. Apply principles of pulmonary physiology in caring for critically ill patients. c. Assess, plan, implement, and evaluate care of the patient with the following conditions: (1) Acute respiratory distress syndrome (2) Acute severe asthma (3) Chest trauma ( 4) Chronic obstructive pulmonary disease (5) Inhalation injury (6) Pneumonia (7) Pneumothorax (8) Pulmonary edema (9) Pulmonary embolism d. Discuss the clinical significance of the following pulmonary function studies: (1) Tidal volume (2) Forced expiratory volume in 1 second (3) Vital capacity (4) Maximal inspiratory pressure (5) Rapid shallow breathing index e. Given a set of arterial blood gas values, describe the patient's state of acid- base balance and state of oxygenation. f. Plan care to minimize pulmonary complications in a patient with multiple trauma. 4. Gastrointestinal System a. Demonstrate knowledge of the major structural anatomy of the gastrointestinal system through written testing. b. Apply principles of physiology related to the gastrointestinal system when caring for critically ill patients.

TWO SUCCESSFUL MODELS FOR PREPARING COMPETENT CRITICAL CARE NURSES

c. Assess, plan, implement, and evaluate nursing care of patients with the following disorders: (1) Bowel obstruction (2) Gastrointestinal bleeding (3) Hepatic failure ( 4) Pancreatitis (5) Peritonitis (6) Portal hypertension (7) Trauma to GI structures (blunt and penetrating) d. Identify appropriate nursing interventions for patients undergoing the following diagnostic procedures: (1) Barium enema (2) Cholangiogram (3) Endoscopy/sclerotherapy/band ligation (4) Proctoscopy (5) Small bowel series (6) Upper GI series 5. Renal and Urologic System a. Demonstrate knowledge of the major structural anatomy of the renal and urologic system through written testing. b. Apply principles of renal physiology in caring for critically ill patients. c. Assess, plan, implement, and evaluate nursing care of patients with the following disorders: (1) Acute renal failure (2) Chronic renal failure (3) Rhabdomyolysis ( 4) Renal insufficiency (5) Trauma to the kidneys, ureters, bladder, or urethra d. Recognize fluid and electrolyte imbalances and discuss etiology, clinical signs and symptoms, and treatment. e. Discuss the principles of hemodialysis and devise a plan of care for the patient undergoing acute hemodialysis in the ICU setting. f. Administer medications safely and effectively to the patient with renal insufficiency and patients undergoing hemodialysis. g. Assess the following types of circulatory access for patency and prevent complications of each:

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(1) Arteriovenous fistula

(2) Single-lumen temporary access (3) Double-lumen temporary access h. Manage a patient undergoing continuous arteriovenous hemofiltration (CAVH) or continuous arteriovenous hemofiltration dialysis (CAVHD) 6. Musculoskeletal System a. Assess, plan, implement, and evaluate nursing care of patients with the following disorders: (1) Cervical vertebra (2) Face (3) Femur (4) Pelvis b. Describe common complications related to major fractures and devise a plan of care to minimize their occurrence. c. Demonstrate proper technique in managing the patient with skeletal traction. D. Subsystems 1. Endocrine System a. Demonstrate knowledge of the major structural anatomy of the endocrine system through written testing. b. Apply principles of physiology related to the endocrine system when caring for critically ill patients. c. Assess, plan, implement, and evaluate nursing care of patients with the following conditions: (1) Diabetes insipidus (2) Diabetes mellitus (3) Diabetic ketoacidosis (4) Hyperosmolar coma (5) Syndrome of inappropriate secretion of ADH 2. Hematologic System a. Assess, plan, implement, and evaluate nursing care of patients with the following conditions: (1) Disseminated intravascular coagulation (2) Acquired immune deficiency syndrome b. Interpret common hematologic system laboratory tests and incorporate findings into plan of care.

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E. Specialities 1. Postanesthesia Nursing a. Describe the normal dosage, major physiologic effects, and potential complications of the following classes of medications: (1) Narcotics (2) Neuromuscular blocking agents b. Assess postoperative patients for stability of core system function and absence of anesthesia effects. 2. Emergency Nursing a. Discuss the principles of triage and apply in common emergency conditions. b. List questions that are helpful in assessing potential injuries based on mechanism of injury. c. Establish priorities in assessing and caring for patients with multiple trauma. d . Use theoretic knowledge base to provide emergency nursing care to patients with the following: (1) Medicine (a) Acute asthma (b) Acute myocardial infarction (c) Cardiac arrest (d) Cardiac arrhythmia (e) Congestive heart failure CD Diabetic ketoacidosis (g) Drug overdose (h) Inhalation injury (i) Pulmonary edema (j) Respiratory failure (k) Seizure disorder (2) Surgery/Trauma (a) Acute abdomen without trauma (b) Blunt trauma: abdomen/ chest (c) Burns: thermal/electrical (d) Fractures: pelvis/femur/vertebra/face (e) Head trauma CD Hypovolemic shock (g) Penetrating wounds: abdomen/chest (h) Pneumothorax and hemothorax (i) Traumatic amputation

e. Discuss the standard policies and procedures pertaining to (1) Preservation of trace evidence (2) Collection of toxicology specimens (3) Disposition of valuables and clothing (4) Postmortem preparation (5) Public information release (6) Screening visitors and observers (7) Use of restraints (8) Weapons or harmful substances 3. Burn Nursing a. Discuss the pathophysiology and medical-surgical management of the following types of thermal trauma: (1) Flame, flash, and scald burns (2) Electrical burns (3) Chemical burns b . Calculate fluid resuscitation requirements for the burn patient. c. Use theoretic knowledge base to provide care to patients with the types of burns listed above. d. Perform assessments of major systems during both the initial and acute phases of burn treatment. 4. Psychosocial Aspects of Critical Care Nursing a. Discuss the following psychosocial concepts that affect the critically ill patient and family. (1) Changes in body image (2) Sense of powerlessness (3) Fear/anxiety/ stress (4) Sensory deprivation and overload (5) Depression (6) Loneliness/ isolation (7) Guilt (8) Anger b. Develop a plan to minimize the effects of the above. c. Describe various measures staff members can use to cope with stress experienced while caring for the critically ill patient. d . Describe the psychosocial impact of the critical care environment on patients, family, and staff.

Note: Additional objectives are specified for each lecture listed on the class schedule.

TWO SUCCESSFUL MODELS FOR PREPARING COMPETENT CRITICAL CARE NURSES

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Appendix 2 Critical Care and Trauma Nurse Internship Course Content Topic List

Anatomy of the heart

Antibiotic therapy

Venipuncture

Sedation and neuromuscular blockade Pathophysiology of shock Classification of shock X-ray interpretation Heart sounds Angina Diagnosis of acute MI

Peripheral IV insertion Needleless system Introduction to ECG Arrhythmia practice Arterial pressure monitoring Anatomy of the pulmonary system Artificial airways Drawing blood from arterial line Pressure tubing Radial artery puncture Suctioning Oxygen delivery devices Central lines PA pressure monitoring

Complications of acute MI Management of myocardial infarction CHF/Pulmonary edema Baseline assessment in the ED Cardiomyopathy Cardiovascular assessment Pacemakers Cardiac drugs

Infusion pumps

Wound care

Fluid line preparation Syringe pumps Endotracheal tube care Sinus arrhythmias Electrolyte replacement Ventricular arrhythmias Obtaining blood cultures

Introduction to 12-lead ECG Axis determination Ischemia, injury, infarction Bundle branch blocks Sepsis MODS DKA and HHNS

IV push drugs (lab)

Nutritional therapy

Bedside lab testing

Spiritual aspects of critical care Pulmonary embolism

Interpretation of laboratory values Management of CV infusions ACLS drugs Management of NG/enteral feeding tubes Defibrillation Nurse's role in cardiac arrest Baseline assessment

Acute, severe asthma Pneumonia COPD exacerbation Bronchodilators and other respiratory drugs ABGs and ventilator settings Neuroanatomy and physiology

Positioning and splint application Renal anatomy and physiology Acute renal failure Clinical manifestations of ARP Rhabdomyolosis Renal replacement therapy Physiology of the GI system GI bleed Hepatic failure Pancreatitis Bowel obstruction Acute abdominal disease Myocardial revascularization Valve replacement Complications of CV surgery Vascular disease/vascular surgery Calcium, phosphorus, magnesium Noncardiac thoracic surgery DIC

Sudden cardiac death Hypertensive crisis Cardiac drugs Drug overdose Chest pain, syncope, SOB, altered mental status Myasthenia gravis, GuillainBarre, polyneuropathy Seizures Meningitis Alcohol abuse Ventilator-induced lung injury Innovative strategies in ARDS Care of the trauma patient in the ICU Acid- base emergencies Electrolyte emergencies

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Cardiac monitoring Pulmonary physiology Ventilator modes Assessing and managing the patient-ventilator system Troubleshooting ventilator alarms Arterial blood gas interpretation Oxygen transport and use Atrial arrhythmias Chest drainage Skin care Auscultation of breath sounds ARDS Drug-resistant infections in the ICU

Cerebral dynamics Neurologic assessment ICP monitoring and physiology Vascular abnormalities of the CNS Acute stroke

Ethics in critical care Legal aspects of critical care Geriatric patients in critical care Sodium and water imbalance

Case studies in head trauma

Preservation of trace evidence Gunshot and stab wounds HIV Hepatitis

Neurologic drugs SIADH/DI Pathophysiology of burn inju1y Nursing care of the burn patient Psychosocial aspects of burn nursing Inhalation and electrical injuries Care of the organ donor

Fluid balance assessment

Nursing care postanesthesia Abdominal pain Intraaortic balloon pump