AS FRONTLINE CARE providers, nurse technicians (NTs) can contribute to quality care in acute care settings. In North Carolina, NTs are unlicensed assistive personnel (UAP) who are certified by the North Carolina Board of Nursing (NCBON) at two levels: NT-I and NT-II. UAPs at the higher skill level, NT-II, can perform 10 patient care tasks specified by the NCBON (see NCBON nurse aide tasks). Each state's board of nursing defines what UAP can do in that jurisdiction.
Cone Health System in Greensboro, N.C., offers an additional NT skill level between NT-I and NT-II.UAP designated as NT+3 are trained and permitted to perform 3 of the 10 NT-II skills in addition to routine NT-I duties. These are sterile technique, inserting indwelling urinary catheters, and assisting with monitoring and discontinuing I.V. fluid infusions administered through short peripheral venous catheters.
Educational programs are crucial to prepare NTs to care for older adults; for example, by assisting with fall prevention activities. The nurse technician academy (NTA) is a training program that was implemented at Cone Health System, a Magnet®-designated institution, to educate frontline staff on the why and how of caring for older adults.
This article describes the development and implementation of the NTA, which included general orientation and education designed to enhance quality of care for patients age 65 and older. The goal was to ensure that NTs provide evidence-based care under the supervision of an RN. The implementation of this quality improvement initiative was not based on untoward safety events regulated by agencies such as The Joint Commission. Instead, the primary goal was to ensure a standard education for all NTs onboarding within the institution.
A 2010 report from the National Academy of Medicine (formerly the Institute of Medicine) recommended that healthcare organizations provide support and educational resources for nurses and nursing personnel.1 With an average length of stay of 7.8 days, older adults comprise 37% of hospital discharges and 43% of hospital days in the US.2 Nurses Improving Care for Healthsystem Elders (NICHE) is a national, nurse-driven program to ensure hospitalized older adult patients receive quality care that promotes dignity, function, and autonomy.3,4 The goal of the NTA was to incorporate NICHE principles to prepare NTs for a growing population of retiring baby boomers and ensure high-quality care was provided to older adult patients and their families.
The 2010 report also noted that healthcare systems should create innovative solutions related to care delivery and focus education on the delivery of nursing services.1 Using both didactic teaching and simulation, a standardized NT training program ensures that new staff attain knowledge and skills during the onboarding process. By engaging frontline staff in the orientation phase, NTA programs provide an opportunity to incorporate care principles for older adults early on.
The NTA offers a blueprint for the design and implementation of other NT training programs. The executive leadership at Cone Health System endorsed the NTA and NICHE programs, and a multidisciplinary approach was used to coordinate and develop the academy using a shared governance model. The curriculum was developed by content experts who incorporated information from NICHE geriatric patient care associate (GPCA) modules into training presentations. Staff education specialists incorporated best practices for education, including the encouragement of learner participation, daily evaluations, simulation exercises with structured debriefing, and multiple opportunities to apply learning in the clinical environment. The development of an NT orientation pathway ensured standard processes were followed.
During planning, it became apparent that the existing orientation pathways were outdated and rarely used. The nursing departments had moved away from orientation programs and were developing department-specific training. The first step in standardizing the NTA program was to ask: “Which departments are currently using any form of pathway for the NTs?”
Hard and electronic copies were requested, many of which were several years old. The content was often outdated and no longer met best-practice criteria, nor did it meet the standards of a Magnet organization. A second request for feedback on the onboarding process led to pathways that had been adapted to reflect department needs.
Recognizing inconsistencies in orientation, NT scope, and education, the planners developed a new pathway that could be utilized by all nursing units and modified for department-specific competencies. Key categories consisted of learning objectives and competencies, learning activities, and methods of evaluation. Mandatory content included general hospital orientation, such as safety phone numbers and safety content (fire safety, call bell notifications, and so on). Information on organizational core values and the desired work culture was also included. The 4-week program included 7 days of hospital and department orientation.
Each NTA class had measurable objectives facilitated by a content expert. Teaching strategies, including return demonstration, case studies, simulated scenarios, and gaming, were used to enhance learning throughout the program. Additionally, each participant was provided information on standardized orientation pathways, job descriptions, and organizational clinical competencies.
Following completion of the NTA program, graduates were qualified as GPCAs and as NT+3s within the institution, allowing them to perform some advanced skills. While newly hired NT-IIs already had these skills, they also attended the NTA to ensure that they had received standard education provided for all onboarding NTs, were utilizing NICHE principles, and understood the organization's core values and desired work culture.
Pre- and posttests were used to assess knowledge acquisition, each consisting of 25 questions worth 4 points apiece. In the initial September 2015 class of 17 NTs, pretest scores ranged from 68 to 100 points, with two students earning perfect scores; posttest scores ranged from 86 to 100 points, with over half the class earning a perfect score. In subsequent classes, scores on the second test improved for all 95 students who have been through the program.
In the spring of 2016, after NTA graduates were placed in nursing departments throughout the organization, feedback surveys were administered. The NTs and their respective departmental leadership completed different surveys, each consisting of seven questions. The NTs rated their own abilities and preparedness, whereas the departmental leaders were asked to evaluate the NTs. The response rate for survey completion was 91% for NTA participants and 15% for departmental leaders, respectively.
Investigators conducting an integrative review of nursing orientation found that there are no standard measures to assess how orientation programs affect patient outcomes, and that retention rates are the most common measure reported.3 The NTA program has produced seven academies and 95 graduates, with an overall retention rate of 80%. Before the NTA, the 1-year retention rate of NTs ranged from 50% to 60%.
Seventeen students participated in the first class, with a 100% retention at 11 months and over 50% retention after 3 years. Six of the initial graduates have become RNs currently employed at the institution, and an additional 18 NTs are currently enrolled in nursing school.
Outcomes and limitations
NT training was standardized throughout the healthcare organization, meeting Cone Health System's goals. The NTA promotes employee retention and encourages NTs to pursue formal nursing education. Additionally, departmental leadership is very supportive of the academy, representing a major culture shift. Managers have reported a distinct difference in the interpersonal skills, collaboration, preparedness, and practices of NTA graduates compared with those hired before the program began. NTA graduates routinely serve as mentors and take on leadership roles. NTs hired before the implementation are strongly encouraged to enroll in the academy.
Because the program was not started to correct poor patient outcomes, no data were gathered to support improvement in this area. This is a major limitation of the project. An integrative review found that all orientation programs are designed to increase frontline quality care, but no measures are available to determine whether this has occurred.3
Developing skills and confidence
Training and orientation programs provide entry-level NTs with the resources to develop skills, competence, and confidence to assist the nursing staff with distinct patient populations. Professional nursing organizations and regulatory agencies must develop standardized measures to document the effectiveness of these programs. The NTA has led to improved retention rates and strengthened relations with local academic institutions, promoting continued education.
NCBON nurse aide tasks5,6
NT-Is can perform the following NCBON-approved tasks:
- personal care, such as mouth care
- body mechanics, such as range-of-motion exercises
- nutrition, such as preparing patients for meal time
- elimination, such as perineal/catheter care
- safety, such as proper use of side rails
- special procedures, such as vital signs and clean dressing changes.
NT-IIs have acquired all 10 of these NCBON-approved skills:
- oxygen therapy, such as monitoring flow rates
- breakup and removal of fecal impaction
- sterile dressing change (wound over 48 hours old)
- wound irrigation
- I.V. fluid assistive activities, such as site care and dressing changes
- nutrition activities, such as gastrostomy tube feedings
- oropharyngeal and nasopharyngeal suctioning
- tracheostomy care
- elimination activities, such as ostomy care
- urinary catheterization.