Temp work has spread to ICU - but is it safe?

Changing economic conditions have tightened the job market to the extent that hospitals hire more temporary workers than ever. While the practice of hiring nursing assistants and practical nurses from job registries has become widespread, few hospitals employ highly trained nurses as temps in intensive care units or in operation rooms.

There is a lingering fear that poorly trained or insufficiently instructed nurses may put a hospital at risk for medical negligence or malpractice suits.

The death of a patient at Brigham and Women's Hospital in Boston a few years ago is a case in point. According to news reports, a temporary ICU nurse allegedly administered an accidental overdose of potassium chloride to a patient there.

Temps are a success

Yet at Maricopa Medical Center in Phoenix, the practice of hiring temporary ICU nurses has been used for the last 10 years. And with great success, according to Tara Shepherd, RN, MS, the center's nursing systems support coordinator. Despite a staff of 4,000 permanent employees, the hospital relies heavily on temporary help. As Shepherd estimates, the greatest majority - about 60% - are employed in intensive care units, approximately 7% to 8% in surgery, 5% to 6% in obstetrics and gynecology, and the rest "wherever needed."

"We can only do this because we have a very rigorous screening process, and we only work with established registries that send us well-trained, well-tested nurses," says Shepherd.

Though some registries balk at the unpaid day of orientation required by Maricopa, Shepherd considers it one of the most important screening tools. "Following a nurse through a day of ICU practice, a preceptor nurse can pretty well identify problems due to poor training, inexperience, or carelessness," says Shepherd.

However, only less than 1% of prospective ICU temps are rejected at orientation. The majority who are rejected "flunk" the tests. One of the four registries supplying Maricopa with temporary ICU staff confirms Shepherd's statistics.

One nurse registry that has supplied Maricopa with well-trained and well-tested temp nurses for years explains that each registry adheres to a screening policy of comprehensive background investigations, drug testing, reference verification, and gauging their applicants' experience and competency with tests that are close to what the medical center requires.

It is customary that registries pay for nurse orientation. Even though some are not happy about this practice, one of the registry managers, who declines to be identified, considers it a good investment to ensure excellence and ongoing business with Maricopa.

Dual process of testing

While screening is done with all temporary caregivers hired through agencies to work at Maricopa, ICU nurses must undergo a dual process of testing: one to be hired by a registry and one to be contracted by the medical center. All applicants, Shepherd hastens to add, must have a minimum of one year ICU work experience.

Testing from Maricopa involves the study of an 80-plus-page information booklet, the successful passing of a two-part take-home test - pharmacology and critical care drug calculation - and a day of orientation with evaluation by a preceptor nurse.

The pharmacology test is made up of 25 multiple-choice questions; the critical care drug calculation test is made up of five. The latter is mandatory only for all adult critical care units. Applicants are required to make a passing score of at least 80%, and retakes may be considered. (See examples of tests, p. 53 and inserted in this issue.)

On the day of orientation, applicants must bring the completed tests, all current licenses and cards (nursing, CPR, and CLS), and proper identification. They wear scrubs or uniforms and are shown to the appropriate units and instructed in the hospital routine.

At the end of an eight- to 10-hour day of orientation, temps are evaluated on the basis of their comprehension of patient needs, physicians' instructions, drug identification, and observation and reporting practices.

Despite the good experiences Maricopa has had with hiring temporary nurses for IC units, hospitals contacted either rejected the practice or admitted to making only sporadic or emergency use of it. The Medical Center of the University of California in Los Angeles "absolutely never uses temporary nursing help in any ICU," says Gail Nishi, RN, manager of the nursing recruitment office.

Sandy Deerhold, RN, nursing coordinator at Johns Hopkins University Hospital in Baltimore, expresses an equally categorical view on the subject. "No temps are ever employed in ICU. Our ICUs are only staffed with permanently employed nurses."

Some hospitals avoid temp use

Although she has no policy regarding the use of temporary nurses, Dee Marks, senior associate of human resources at Emory University Hospital in Atlanta, has contracted seven temporary nurses in operation rooms on a trial basis. However, she knows of no plans that would include temp nurses for ICU duty and foresees none.

Similarly, nursing recruiter Angela Biechly, RN, who is in charge of hiring at the Northeast Alabama Regional Medical Center in Anniston, has never relied on temporary nurses for ICU duty. Biechly says, "In the four years I've been here, I've never even heard the idea discussed. But that may be because we're lucky to be so close to two universities that supply us with plenty of qualified staff."

Ellen Hamilton, RN, MSN, CAN, director of nursing at Nanticoke Memorial Hospital in Seaford, DE, admits to having used temporary nurses from registries on occasion. Though scrutinizing these temps closely and putting them through orientation with a preceptor nurse by their side satisfied concerns over competency and safety, Hamilton says the largest regional Delaware hospital made only "spotty use of that resource."

Carolyn Steed, RN, the clinical manager of the intensive care unit at Grady Health System in Atlanta, says, "We've relied occasionally on temporary help in ICU."

She adds that the hiring was done only after intensive testing and orientation. Much along the lines of the requirements at Maricopa in Phoenix, Grady demands a minimum passing score of 80% of its pharmacology and critical care drug calculation tests, satisfactory evaluation by a preceptor, and up-to-date proof of all cards and licenses. In spite of Grady's long checklist, Steed has hired few ICU temps.

'Parachuting into unfamiliar territory'

Based on 25 years of experience with catastrophic injuries and medical malpractice suits, attorney Don C. Keenan, JD, of The Keenan Law Firm in Atlanta, cannot accept the concept of hiring temporary nurses in ICUs under any conditions. To him, temps are "parachuting from the sky into unfamiliar territory."

"There is no more vital care a patient in the most vulnerable conditions has to rely on than in ICU," says Keenan. "That's the place where the staff has to have continuity of experience, familiarity with protocol, team work - in short, a track record."

Keenan believes that hospitals have the right to hire any type of qualified help they can get. However, patients have the right to know who takes care of them.

If a hospital puts temporary nurses in ICUs, Keenan thinks that it has the obligation to clearly identify them as such on their nametags, or issue them different colored nametags and explain that to patients at admission.

Tara Shepherd, the nursing systems coordinator at Maricopa, says, "I've never heard of any hospital identifying registry nurses by different nametags. In our own health system, there is no special separation of registry nurses because we make sure that all are competent."