Hospitals brace for the coming critical care nursing shortage

Salaries and benefits to increase for ICU nurses

Hospital intensive care units may experience a shortage of critical care nurses in the coming months. For ICU directors and managers, this means retention programs should be positioned for implementation. For administrators, the shortage means an increase in salaries and benefits for critical care nurses.

"Sure signs of a nursing shortage are popping up everywhere - from recruitment ads and job fairs that look specifically for critical care nurses to hospitals creating policies regarding new graduate training for critical care," says Kathleen Dracup, RN, DNSc, professor of nursing at the University of California at Los Angeles.

Justine Medina, RN, MS, CCRN, clinical practice specialist for the American Association of Critical Care Nurses (AACN) in Aliso Viejo, CA, says, "The nursing shortage we are experiencing now is definitely a regional one. It is also a complex problem because when a hospital needs critical care nurses, it must recruit, train, and retain them. The problem lies in that there are too few critical care nurses to recruit, and it's hard to retain them because incentives are being diminished."

While some states are on the brink of a nursing shortage, others may experience no shortage at all; however, hospitals must begin to react to reports of a shortage, or they may be caught off guard with unsafe staff-to-patient ratios.

"If trends in data show that a shortage may be looming, it is the hospital's choice to be proactive and implement strategies immediately to prevent a shortage of ICU nurses," Dracup says.

The shortage is due in part to the health care downsizing of the 1990s, she says. When critical care nurses were downsized, they went into other professions such as consulting, advance practice roles, or even academics. Now that a potential shortage is at the doorstep, many hospitals find that these highly skilled clinicians, educators, coaches, and leaders are not available. Hospitals are faced with creating a new generation of leaders in the ICU and providing these future critical care nurses with the support, education, and resources needed to maintain quality care.

Solutions to consider

The strategies that worked to recruit critical care nurses during the nursing shortage in the late 1980s will work again, such as flexibility in shift scheduling, opportunities for child care, and showcasing the role of nursing in the hospital, Dracup says. "Nurses want to feel valued and part of the professional team."

Dracup and Medina offer several solutions to the nursing shortage for hospitals to consider.

1. Put in place recruitment strategies that focus on credit for work performed, clinical ladders, recognition of special achievements, and pay differentials for certifications such as CCRN.

2. Hire consultants to develop a top-rate orientation program with critical care courses and preceptorship programs, which can prepare nurses to enter the ICU quickly and competently. Seek consultants with a background in critical care and education.

3. Consider contracting with large hospitals that have a critical care nursing orientation and preceptorship program to benefit from a more extensive educational program.

4. Increase communication on both sides of the table: Nurses should consider the challenges facing administrators, and administrators need to understand that nurses want to maintain quality of care. Experts recommend that hospitals coordinate roundtable discussions or information sharing to keep channels open.

5. Continue to use education to reinforce and empower nurses, which shows them the hospital values their expertise.

6. Re-establish an education department or assign resources to education programs to develop in-house critical care staff.

7. Encourage nurses to seek their own education to differentiate themselves.

8. Pool staffing resources among community hospitals to create a collaborative effort to train critical care nurses.

"All hospitals and nurses want the same thing: to put the best clinician at the bedside," Medina says. "It is important to combine resources to provide programs that work toward this common goal."

She emphasizes that a cooperative spirit of training and education is happening in smaller communities and could be the wave of the future. "A community of hospitals that work from a collective float pool of critical care nurses creates a mechanism for exchanges of information, technology, and competencies," she says. "Cross-training provides the skilled clinician experience in several ICUs so that shortages are kept to a minimum."

Hospital leaders must develop orientation programs with a critical care focus to meet the rising demand for experienced and competent nurses to cover ICU shifts. An orientation program can be developed by a centralized staff development department or a clinical nurse specialist brought in as a consultant. Hospitals have to rely on internal expertise to develop orientation programs that fit their needs if cost is an issue.

The AACN offers a sample curriculum for critical care nurses that outlines the core educational requirements for an orientation program in an effort to standardize the core competencies that critical care nurses should have in addition to experience in ICUs. A critical care orientation program has a long learning curve, Medina says. "Organi-zations can expect to reap the benefit of the orientation programs six months into it," she says.

Kathy Guentner, RN, MSN, unit director of the medical ICU at the University of Pittsburgh Medical Center, says her organization just completed the first round of a critical care orientation program, which took several months to complete. (See related story, p. 51.)

"We knew it was going to take time to get all the nurses we hired through the extensive orientation program we offer," she says. "And we are quite pleased with the caliber of people that we recruited. It is the excellence of the orientation program that I think has made the difference in keeping these nurses interested in critical care."

Developing the orientation program takes time, experts say, but a smooth process can be achieved through implementing several tips provided by Guentner:

· Respond to shortages in an aggressive and proactive manner by recruiting nurses at the first signs of changes in the census.

· Monitor increases in patient census for several months before beginning a recruitment program.

· Act quickly if data show a potential shortage, and hire people immediately.

· Implement orientation programs in critical care early so skilled nurses are available when the census rises.

· Have available resources and expertise ready to begin recruitment, retention, and preceptorship programs.

· Be proactive in developing the hospital's own staff to become ICU nurses.

· Consider training student nurses in the fundamentals of critical care and encourage them to enter critical care nursing.

· Hold a social open house at which nurses can speak with ICU directors to get a sense of the expectations of the department.

· Offer potential hires a tour of the unit.

· Make the organization user-friendly by streamlining the application and interview process.

· Schedule interviews with several directors in one day, instead of having candidates return several times for different interviews.

· Hold interviews in a designated room on the unit, if possible, rather than in a centralized area so nurses can see the unit if they ask.

· Include unit staff in the interview process so they can take part in decision making.

· Have critical care nursing staff and physicians take an active role in training new staff.

The current critical care nursing shortage may not be present in many regions of the country, but experts agree that hospitals will experience shortages in a matter of time. ICU managers and hospital administrators must ready themselves to respond to this shortage with innovative methods to retain nurses and avoid another shortage.

"This certainly is not the last shortage we will experience in critical care," Medina says. "But an organization must look at its resources now to help retain current nurses and work to recruit new ones, as well as provide mechanisms to identify the core needs of nurses."