VOL: 98, ISSUE: 03, PAGE NO: 42
Rebecca O’Sullivan, CertEd, RGN, ENB 100, is staff development sister in ICU, Guy’s and St Thomas’ Hospital NHS Trust, London
It has long been known that intensive care nurses need extra training to cope with the demands of their jobs (Benner, 1982; Atkinson, 1990). Other research shows that nurses starting work in a totally new area need support (Benner, 1982; Alspace, 1990; Atkinson,1990).
Many commentators have written about the effects of novice nurses being inadequately prepared (Benner, 1982; Alspace, 1990; Atkinson, 1990) and Andrews and Wallace (1999) recognise that support is required to ensure nurses are able to work safely and competently.
At national level, PREP should help to ensure that nurse education is sensitive, dynamic and relevant to practice (UKCC, 1997).
However, in intensive care there is a gap in training provision. The ENB’s general intensive care nursing course (ENB 100) suits those already experienced in intensive care nursing but, until recently, there was no provision for nurses entering the ICU straight from the wards.
In 1990, intensive care at Guy’s Hospital in London underwent an enormous change due to the amalgamation of two separate units, the appointment of a new consultant and the arrival of new equipment and new medical techniques.
The workload of nursing staff altered and intensified, and there was an increased emphasis on research-based care. All these factors meant that new staff were not as well supported as before. Nurses were feeling the pressure of working in an evolving environment and of facing new roles without the required knowledge.
The senior nurse decided that a possible solution was to offer a structured course of in-house teaching that provided theoretical knowledge coupled with training in the skills required to care for critically ill patients. However, developing such a course entailed a great deal of work. At the time, the amount of literature available to support such a course was limited, although since then more has been published (Calpin-Davies, 1996; Hansten and Washburn, 1997).
Launching the course
After discussions and much hard work the course finally began in 1991. The aim was to provide theoretical knowledge and clinical support to nurses who were new to the ICU.
Staff were put into groups of four to six and given training in how to carry out self-directed learning.
The bulk of the course was based on learning about outcomes and competencies. This approach ensured that essential learning was completed by nurses before they obtained advanced skills (Alspace, 1990).
Nurses learned practical skills, such as respiratory assessment and hand ventilation (bagging), electrocardiogram interpretation, blood gas analysis, nutritional assessment and renal replacement therapy.
Emphasis was placed on teaching the theory before demonstrating the clinical procedure. The course also used a variety of teaching methods and experiential learning was encouraged - this involved the use of clinical scenarios.
Nurses were assessed on learning outcomes, such as clinical supervision of direct patient care, and they had to complete a written assessment at the beginning and end of the course, which took the form of a knowledge-based review. Atkinson (1990) shows the importance of such evaluations in course development. Nurses on the course were supernumerary for the first three weeks.
As recommended by PREP (UKCC, 1997), each learner also had a preceptor. They were allocated before the nurses started the course. Nurses also received additional clinical support from the teaching team when they were actually working in the ICU.
Originally, the course was designed to last six months and, despite some alteration following evaluations, it still lasts six months.
Two years later, in 1993, the course was accredited by South Bank University and awarded 30 credits at level 2. The accreditation demonstrated that the teaching team had developed a course that was clinically and academically successful.
The course was assessed using eight written critical incidents that were marked jointly by the university and the unit-based teaching team. Subsequently, the number of written critical incidents was reduced to six in recognition of over-assessment.
The accreditation also allowed nurses to progress to Accreditation of Prior Learning, applicable to the ENB 100 course at King’s College London.
In 1995, an Accreditation of Prior Learning claim was agreed with the Nightingale Institute in London (which is now called the Florence Nightingale School of Nursing and Midwifery and is based at King’s College). By completing written assignments course participants were able to claim 15 credits at level 2 and were given exemption from a written assignment during the ENB 100 intensive care nursing course taught at the institute.
A further refinement of the course brought another decrease in the number of assessed pieces of work required. The written critical incidents were then based on specific aspects of the course relating to patient care which used research-based evidence to evaluate the care given and also to make recommendations for future practice (see Box 1). Eventually, the assessed work was reduced to three written pieces and one piece of work presented as a seminar.
In 1998, because of the trust’s educational contract with King’s College London and the need for revalidation at South Bank University, the course was transferred to King’s College London.
One measure of the course’s success is that it has lasted for more than nine years, albeit changing and adapting to meet the needs of staff, patients and the unit.
From a clinical perspective, the course has provided the unit with 12 nurses a year, locally trained to a skill and knowledge level that has meant that they are able to nurse patients in a critical care environment. Knowing that they had the support of colleagues, the stress and dissatisfaction levels among new ICU nurses gradually fell and the majority took advantage of further opportunities in the unit.
All members of the multidisciplinary team, patients and their relatives felt the nurses had benefited from the course. The unit was able to staff beds that otherwise would have been closed.
Hard evidence of its success as a recruitment and retention tool can be seen from the retention statistics (see Table 1). Of the 138 students who took the course between November 1994 (when it was accredited) and February 2000, 73 (53%) stayed and completed the ENB 100, 28 (20%) stayed but did not do the ENB course and 26 (19%) left immediately after the course. This gave an overall retention figure of 73%. Fifty-four per cent were still working on the unit 12 months after induction and 28% were still there after two years.
When interpreting the retention rates certain factors have to be considered:
- Some people left at the end of the course having found that ICU was not for them;
- The ENB 100 was run only once a year in September and staff left because other ICUs could offer courses at different times;
- Nurses also left because they wanted to travel before developing their careers.
Intensive care nurses need special training if they are to care for a wide range of patients. They need a range of clinical skills and a well-developed knowledge-base that enables them to draw on research, education and training.
The need for professional education can be considered as an essential part of maintaining competence and, although it consumes resources, it should also be viewed as an investment (Calpin-Davies, 1996).
The induction to intensive care course provides specialised training to nurses new to intensive care. The competencies are designed to produce safe and competent nurses and are measured against a standard. The staff development team uses research to support its teaching and also provides clinical support by working with the nurses throughout the course.
However, the cost of providing trainers and paying the wages of nurses brought in to replace those attending the course is high. Therefore, an evaluation of the effectiveness of the training was essential. Nurses who had attended the course were asked to submit written evaluations.
Crucially, the figures showed that the average retention rate among those taking the course at six months was 69% and 54% at 12 months.
Critical to Success (Audit Commission, 1999) and Comprehensive Critical Care (Department of Health, 1999) make recommendations about the recruitment, training and retention of staff along with core skills training for ward staff. The induction to intensive care course has always been oversubscribed and the retention data show that it has certainly been a success in terms of staff recruitment.
Those nurses leaving the ICU setting can transfer their skills to any clinical environment. This course would benefit any nurse new to the critical care environment.
Having been involved in the development and evaluation of the course in the previous five years, I am enthusiastic about what has been achieved but am also aware of the amount of hard work involved.
Anyone contemplating setting up a course like this needs to ensure that they have the full support of clinical and senior staff. It is difficult to ensure a balance of theory and practice, and constant evaluation and audit means that change is inevitable.
After the course was moved to King’s College London, it continued to run as an important part of the transition from ward nursing to critical care nursing and it is now accredited at levels 2 and 3.
Over the years the course has been adapted in response to evaluations and the needs of the unit and patients. The provision of an introductory course that has a strong academic foundation and is clinically based and supervised has ensured that nurses have become competent at managing critically ill patients. As a result, high standards of patient care have been maintained in the ICU at all times.