In many acute care settings, unlicensed assistive personnel, including certified nursing assistants, nursing attendants, and patient care technicians (PCTs), play important roles in patient care. According to the U.S. Department of Labor's Bureau of Labor Statistics, more than 348,000 unlicensed assistive personnel were employed in the hospital setting in 2011, and their numbers are likely to increase as hospitals try to lower labor costs.1 Unlicensed assistive personnel are integral members of the multidisciplinary team, and patient care quality and safety depend, in part, on how well they perform their jobs. Because these staff members spend a great deal of time with patients, they can often alert nurses to important health status changes.
In 2008 NYU Langone Medical Center, a large teaching hospital in New York City, decided to implement a hospital-wide upgrade of nursing attendants to PCTs. The upgrade was piloted by our medical–surgical unit, where patient acuity had increased in the previous two years, and more attention was required from RNs to ensure patients' safe, timely, and efficient care. In addition to the duties previously performed by PCTs, which included the provision of basic care, such as giving bed baths, taking vital signs, and changing linens, after the upgrade they would also be expected to perform procedures that require more advanced skills, including drawing blood, monitoring blood glucose levels, and performing electrocardiograms. The hospital provided an education program to teach nursing assistants the newly required PCT skills and reinforce skills previously acquired. Most nursing assistants welcomed this change and many took the initiative to upgrade their skills ahead of the scheduled training.
The transition from nursing attendant to PCT brought attention to two facts: there was wide variation in knowledge and skill among the unlicensed staff; and errors, particularly in obtaining and documenting patient weight, fluid intake and output, and vital signs, were occurring as a result. Many nursing attendants had been on the job for five to 10 years and had received very little continuing education. Some expressed the need for more education to reinforce basic job skills.
Two of us (AS, then the nurse manager on the unit, and LAO, then assistant manager) recognized that it would be necessary to provide ongoing continuing education to ensure the delivery of safe, high-quality patient care, and we decided that the RNs on the unit would lead this effort. Providing continuing education would ensure that all the PCTs were knowledgeable and proficient in the skills needed for optimal performance in their new roles. This article describes the design and implementation of the continuing education program and its outcomes.
DESIGN AND IMPLEMENTATION
We performed a literature search on MEDLINE and Google Scholar for articles about continuing education for unlicensed assistive personnel in the hospital setting, using patient care technician, nursing attendants, unlicensed assistive personnel, and continuing education as search terms. No date limitations were used. While we found several articles on the relationship between unlicensed assistive personnel and RNs or RN delegation of care,2-5 we found only one article—published in 1995—that reported on continuing education of unlicensed assistive personnel in the hospital setting.6
Salmond conducted a multicenter survey of 53 nurse managers, 620 staff nurses, and 305 clinical nursing assistants and found that half of the nurses and 10% of nursing assistants “felt that there was inadequate ongoing training” to maintain clinical competency for unlicensed assistive personnel.6 A 1999 article by Barczak and Spunt described a competency-based program for the initial training of unlicensed assistive personnel but did not address continuing education.7
We met with the nurse educator to clarify the PCTs' scope of practice and the education the hospital was providing. We decided to survey the RNs and PCTs to find out their thoughts about continuing education needs and to engage them in the project from the outset. (In addition to asking questions about RNs' and PCTs' priorities in continuing education, we asked them to rate on a 4-point Likert scale a series of statements about teamwork, RN and peer support, and workplace communication. We conducted this part of the survey with the PCTs again approximately three months after the continuing education sessions were completed.) Surveys were distributed at unit meetings and made available on the unit. Staff members completed the surveys anonymously and left them in an envelope on the unit for collection.
Survey findings. Thirty-three percent of the 45 nurses on the unit and 78% of the 18 PCTs completed the initial survey. Both groups welcomed the idea of continuing education for PCTs and were enthusiastic about participating in the project. Both groups also identified similar topics for inclusion in the program, which focused on improving skills related to electrocardiography, telemetry, and pressure ulcer prevention, among others (see Staff-Identified Educational Needs). The survey results informed our selection of topics for the sessions, which would be presented monthly for six months.
Box. Staff-Identifie...Image Tools
Education sessions. We asked expert RNs to volunteer to develop and lead the sessions in their areas of expertise. Many of the nurses on our unit had participated in our hospital-wide nurse champion initiative that prepares bedside nurses to be experts on a specific topic; after this, they serve on units as resource nurses who can answer questions about that topic. All nurses who volunteered to lead education sessions (including one of us, TJ) had participated in this initiative.
Two of us (AS and LAO) provided the RNs conducting the education sessions with information on the education the PCTs had received during their orientation and specified that the sessions should combine best practice guidelines and existing hospital protocols and standards. We also worked with the nurse educator to provide support and guidance for the staff nurses.
Each RN wrote a teaching plan that included information relevant to the topic, such as basic physiology, rationales for procedures, and implications for current practice (see Example of a Teaching Plan). For example, it's important to obtain and accurately record the patient's weight, because body weight is often the basis for individualized treatments, including medication dosages; inaccurate weight measurement could result in overdosing or underdosing. One of us (LAO) reviewed each teaching plan with the nurse educator prior to the education sessions. In each session the PCTs had the opportunity to perform hands-on practice and received a one-page summary of the information covered in the session. At the end of each session, the PCTs completed a short written test of their knowledge and, when appropriate, a “return demonstration” (after the session on telemetry, for example, the PCTs were expected to demonstrate the correct placement of electrocardiogram leads on a manikin).
Box. Example of a Te...Image Tools
Scheduling. To facilitate maximum attendance, we scheduled education sessions on the day when the greatest number of PCTs were working—in our case, Wednesdays—and repeated them on the evening and night shifts. Because PCTs' eight-hour shifts started at 8 AM, 4 PM, and midnight, sessions were typically scheduled at 3 PM, 5 PM, and 2 AM. Flyers were posted on the unit at least one week in advance of the sessions. On the day of the sessions, session times were posted on the assignment board and one of the nursing leaders or the RN scheduled to lead each session reminded the PCTs at the start of the shift and one hour before each session began.
All PCTs who were scheduled to work the day of the education sessions were expected to attend. Whenever possible, we increased RN staffing to allow all PCTs to be off the floor without compromising patient care. Those who were unable to attend received a handout, and the RN who led the session reviewed the handout with them. Most of the time the RNs who led the sessions were scheduled to work that day, but occasionally we granted overtime to nursing staff to come in and teach on their day off.
The major scheduling challenge we encountered—how to provide education sessions for PCTs who worked on the night shift—was solved by giving teaching plans to the assistant nurse manager who worked nights, and she or another night-shift RN led the sessions. Another related problem was that fewer staff members work nights, making it difficult to pull PCTs off the unit for education sessions. We made a special effort to give handouts and one-on-one information reviews to night-shift PCTs who were unable to attend the sessions.
Overall, both nurses and PCTs supported and participated in the program. Once the education sessions started, we received frequent anecdotal feedback from members of both groups who said the program was working well. The nurses were enthusiastic about leading the sessions, enjoyed creating them, and felt the PCTs were receptive and found the classes beneficial. Many PCTs told us the sessions were valuable in improving their practice and increasing their knowledge and skill level. After the session on indwelling urinary catheter care, for example, several PCTs said they had been cleaning only the proximal part of the catheter where it entered the urethra and weren't aware that they should also be cleaning the full length of the catheter to the collection bag.
Nurses also commented on positive changes they saw in practice after the education sessions. For example, PCTs had routinely been using multiple barriers—incontinence briefs, waterproof pads, and drawsheets—between the patient and the mattress on pressure reduction beds, which are designed for use with a single barrier. After the session on skin care, a PCT caring for a patient on a pressure reduction bed reminded the nurse she was working with that they should use only one barrier and explained the rationale for the practice.
Three months after the program ended, we surveyed the PCTs to gather feedback on the program, using the same statements about teamwork, RN and peer support, and workplace communication used in the earlier survey. Rating statements on a 4-point Likert scale (with 1 representing “strongly disagree” and 4 representing “strongly agree”), the PCTs reported improved teamwork and the belief that the continuing education program had a positive impact on their day-to-day practice (see Table 1). They also reported feeling that the RNs respected them more.
According to a meta-analysis conducted in 2006 by Griscti and Jacono, there is little empirical evidence that continuing education has a positive impact on nursing practice or patient outcomes8; however, it's widely accepted that continuing education is essential for safe, high-quality patient care. Both the American Nurses Association and the Institute of Medicine have called on nurses to participate in lifelong learning.9, 10 It seems reasonable to extend this call to nursing staff who work in assistive positions, including PCTs and other unlicensed personnel; everyone engaged in patient care needs to keep their skills and knowledge up to date. But we found nothing in the literature to indicate that this is happening.
Traditionally, hospital educators plan and conduct continuing education programs. Our program differed in that the RNs on the unit designed and led the sessions. The unit-based approach created opportunities for the nursing staff, both RNs and PCTs, to communicate their needs, upgrade specific skills, and improve knowledge and understanding. The RNs exercised their leadership and creative skills in designing and delivering the education sessions. An added benefit was that their participation helped the RNs meet requirements for advancement on the hospital's clinical ladder system.
The unit-based approach also allowed us to keep the classes small, with five to six PCTs in each class. Each PCT's specific needs could be addressed and individualized attention could be given during return demonstrations. Because the PCTs didn't have to leave the unit to attend classes in a separate location, they found the sessions easier to attend.
In their 1997 study of RN satisfaction with the use of unlicensed assistive personnel in hospital acute care settings, Barter and colleagues concluded that all nursing staff should know what training the assistive staff members on their unit received, including continuing education.11 When RNs design and deliver the continuing education, they are aware of the training assistive personnel receive and are able to ensure that the right unit-specific training needed to provide competent care has been delivered. This is especially important because the RN is ultimately accountable for the care the PCT provides.
We continue to get informal positive feedback from the nursing staff at our hospital. Both RNs and PCTs want the program to continue and have asked that additional classes be scheduled. We plan to make RN-delivered continuing education for PCTs an ongoing program on our unit.
1. Bureau of Labor Statistics. Occupational employment statistics. Occupational employment and wages, May 2011. 31-1012 nursing aides, orderlies, and attendants
. U.S. Department of Labor 2011. http://www.bls.gov/oes/current/oes311012.htm#(1)
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8. Griscti O, Jacono J. Effectiveness of continuing education programmes in nursing: literature review J Adv Nurs. 2006;55(4):449–56
9. American Nurses Association. Code of ethics for nurses with interpretive statements. 2001 Washington, DC
10. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The future of nursing: leading change, advancing health. 2011 Washington, DC National Academies Press
11. Barter M, et al. Registered nurse role changes and satisfaction with unlicensed assistive personnel J Nurs Adm. 1997;27(1):29–38
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