MICU RESIDENCY: DEVELOPMENT OF A UNIT BASED REGISTERED NURSE
PROGRAM
Joan M. Mallum
B.S.N., California State University, 1977
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SCIENCE
in
NURSING
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2010
MICU RESIDENCY: DEVELOPMENT OF A UNIT BASED REGISTERED NURSE
PROGRAM
A Project
by
Joan M. Mallum
Approved by:
__________________________________, Committee Chair
Bonnie Raingruber, PhD, RN
____________________________
Date
ii
Student: Joan M. Mallum
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the Project.
_________________________________
Kelly Tobar, PhD, RN, Graduate Coordinator
Date _____________
Department of Nursing
iii
Abstract
of
MICU RESIDENCY: DEVELOPMENT OF A UNIT BASED REGISTERED NURSE
PROGRAM
by
Joan M. Mallum
Statement of Problem
New graduate nurses and new hires with limited critical care experience in a hospital
need additional education. In the Medical Intensive Care Unit (MICU) at the University
of California Davis Medical Center there was no model to provide relevant ongoing
learning opportunities to meet the individual needs of the staff. The focus of this project
was to develop a residency program to meet the educational needs of new staff that
included graduate nurses, experienced non-critical care nurses and experienced critical
care nurses.
Sources of Data
The source of data was a Likert Scale survey distributed to the nursing staff in the MICU
before and after implementation of the unit based residency program. Turnover statistics
were provided by the patient care services department.
Conclusions Reached
A unit based residency program may increase staff satisfaction and comfort levels related
to clinical judgment. Statistical significance was not achieved on the majority of items on
iv
the questionnaire. Turnover rate did decrease however this may be for reasons unrelated
to the residency program.
_______________________, Committee Chair
Bonnie Raingruber PhD, RN
_______________________
Date
v
ACKNOWLEDGMENTS
This author would like to acknowledge the Center for Nursing Research at the University
of California, Davis and the Eula Wiley Award program.
vi
TABLE OF CONTENTS
Page
Acknowledgments.....................................................................................................................vi
List of Tables ........................................................................................................................... ix
Chapter
1. INTRODUCTION ............................................................................................................. 1
Purpose.......................................................................................................................... 1
Key Terms..................................................................................................................... 1
Introduction of Problem ............................................................................................... 1
Significance of Problem................................................................................................ 2
Benefits of Project ........................................................................................................ 3
2. LITERATURE REVIEW ................................................................................................... 4
Review of Research ..................................................................................................... 4
3. OVERVIEW OF PROJECT ............................................................................................. 17
Description .................................................................................................................. 17
Development of Materials........................................................................................... 19
Learning Strategies ..................................................................................................... 20
Implementation ........................................................................................................... 21
Setting ......................................................................................................................... 23
Evaluation Method ...................................................................................................... 24
4. CONCLUSIONS AND RECOMMENDATIONS ............................................................ 31
Evaluation Summary................................................................................................... 31
Limitations .................................................................................................................. 32
Implications for Nursing ............................................................................................ 33
Appendix A Residency Questionnaire ................................................................................... 35
Appendix B Preferred Learning Methods .............................................................................. 36
Appendix C Likert Questionnaire ......................................................................................... 37
Appendix D Educational Goals ............................................................................................. 38
Appendix E Audio and CD-ROM Video Resources ........................................................... 39
Appendix F Power Point Competencies ............................................................................... 40
Appendix G Case Studies ...................................................................................................... 41
vii
Appendix H Sample Case Study ............................................................................................ 42
Appendix I Web Based Resources ........................................................................................ 44
References…………………………………………………………………………………….45
viii
LIST OF TABLES
Page
1.
Table 1 Mean, Standard Deviation and Standard Error………………………....25
2.
Table 2 T-test results / logistic regression analysis……………………………...28
ix
1
Chapter 1
INTRODUCTION
Purpose
The purpose of this project was to develop a Residency Program for all registered
nurses (RN’s) in the Medical Intensive Care Unit (MICU).
Key Terms
Residency Program: The definition of Residency Program is a structured
educational program to increase the skill level of all registered nurses’ employed at the
University of California Davis Medical Center (UCDMC) in the MICU.
Introduction of Problem
New graduate nurses and new hires with limited critical care experience in a
hospital need additional education. Needed education consists of learning new
equipment, policies, procedures and competencies. In the MICU at UCDMC there was no
model to provide relevant ongoing learning opportunities to meet the individual needs of
all staff.
Initially this problem was brought to the attention of the clinical nurse educators
(CNIII’s) by the night shift who verbalized concern about their lack of knowledge and
comfort with critical decision-making. These nurses had successfully completed
orientation yet they did not feel competent in the clinical setting. The need for extended
support of graduate nurses during their first year has been reported as new graduates do
not posses a high level of skill, comfort or confidence (Casey, Fink, Krugman, & Propst,
2004). As the materials for the residency program were being developed it became
2
apparent that most nurses in the MICU were feeling some gaps in their knowledge base
and would like to participate in a comprehensive education program.
Significance of Problem
It is a challenge to provide high quality care in the complex environment of the
intensive care unit. Adverse events that harm the patient or near misses are somewhat
common. The lack of knowledge or skill of the clinician often contributes to adverse
events. An analysis of 2074 incidents from 23 adult and pediatric ICU’s identified
education, knowledge, skills and competence as frequent contributing factors implicated
with harming patients (Pronovost, Thompson, & Holzmueller, 2006).
Nurse residency programs have been developed to recruit and retain nurses to
reduce the cost of nursing turnover. The cost of nursing turnover is difficult to estimate as
many factors are taken into account such as hiring, recruitment, and orientation costs.
Indirect costs may include decreased productivity of new nurses as well as their
preceptor. The literature has estimated these costs to exceed $60,000 for every RN
position that turns over (Jones, 2004).
Several studies indicate the monetary impact of nursing turnover is significant
however it is difficult to measure the effect of turnover on the quality of care. One study
correlated employee turnover with risk-adjusted mortality and severity adjusted length of
stay. Hospitals with less than 12% turnover rate had the lowest scores in both areas.
Hospitals with turnover rates greater than 22% demonstrated an adjusted length of stay
1.2 days greater than those with the lowest rates (Veterans Health Administration [VHA],
2002).
3
Benefits of Project
The focus of this project was to develop a residency program to meet the needs of
new staff that included graduate nurses, experienced non-critical care nurses, and
experienced critical care nurses as well as preexisting staff. A comprehensive educational
plan was developed to address differences in learning styles as well as nurses with
different levels of expertise. Critical thinking, competency validation, relevant learning
opportunities and evidence-based practice were emphasized. This program was offered to
all staff and was not time limited.
The potential benefits of offering this program included improved patient safety,
integration of evidence-based research into practice, enhanced nurse satisfaction and a
decrease in staff turnover. It was hoped that economic benefit to the hospital would be
realized if there was a decreased turnover rate. The residency program provided increased
educational opportunities for all staff. The MICU program model was to advocate for a
continuous process of advancing clinical practice and knowledge for all intensive care
nurses.
4
Chapter 2
LITERATURE REVIEW
Review of Research
The literature review focused on nurse residency programs in the acute care
setting. The purpose of this review was to examine studies that demonstrated educational
interventions that improved competency and autonomy of the participants. Given that
residency programs vary in design, methods and length of time it was a challenge to
identify relevant literature. There is not one definition of a nurse residency program in the
literature and there has been minimal research conducted on program outcomes.
The literature search was performed using electronic data bases. These included
PubMed, CINAHL, and the Cochrane Library from 2000 to 2009. Search terms included
RN residency, nurse orientation, preceptors, mentor, critical thinking and competency.
Educational programs in the adult acute care setting with a preceptor or mentor
component were reviewed. Articles selected for review had to evaluate a component of
competency. Competency could have been measured by an ability to prioritize, exhibit
critical thinking skills, demonstrate increased confidence in decision making, or display
an ability to manage a patient care assignment or emergency situations. Qualitative
analyses and small investigations (N<10) were excluded. A total of six studies met the
above criteria. Most of these studies also measured retention or turnover rates.
Morris (Morris, et al., 2009) conducted a quasi-experimental study to examine the
effect of a residency program model of critical care orientation. This study presented a
comprehensive residency program that employed multiple learning modalities as well as
5
three distinct pathways to accommodate differences in learning needs. This study
measured program satisfaction and preparedness to manage patient care assignment,
preferred teaching strategies, turnover and retention rates.
This study was conducted at Northwestern Memorial Hospital which is an 800
bed teaching facility. A total of 197 nurses participated in the study. This included 43
experienced critical care nurses, 44 experienced non-critical care nurses, and 110
graduate nurses. These nurses were recruited over a period of 34 months. Subject
selection consisted of all newly hired RNs’. Their previous model of orientation consisted
of classroom education and clinical time with a preceptor. The length of orientation was
eight to twelve weeks depending on the nurses needs (Morris, et al., 2009).
Their new model of orientation was designed with three distinct pathways for the
critical care nurse, the experienced nurse and the graduate nurse. Depending on a nurses’
needs a variety of learning modalities were made available. These included Web-based
learning, case studies, high fidelity simulation, and clinical experience with a preceptor
(Morris, et al., 2009).
Preparedness to manage patient care assignments and satisfaction was evaluated
using a survey distributed to the manager, staff educator and the preceptor. Managers
rated experienced critical care nurses as being able to manage patient care assignments at
80%, experienced non-critical care nurses at 53% and graduate nurses at 70%. The reason
that managers found a graduate nurse more prepared than experienced nurses was not
addressed. Staff educators rated preparedness of experienced critical care nurses at 90%,
experienced non-critical care nurses at 73% and graduate nurses at 65%. Preceptors rated
6
experienced critical care nurses at 86%, non-critical care nurses at 75% and graduate
nurses at 54%. Overall satisfaction with the unit residency program was rated 77% by
managers, 88% by educators and 74% by preceptors. Graduate nurses rated human
simulation and pocket guides as the most useful teaching strategies with scores of 4.85
each on a 5-point scale (Morris, et al., 2009).
The rate of annual turnover in the ICU (Intensive Care Unit) prior to
implementation of the new program was 8.77%. One year after implementation of the
program the rate was 6.29%. The retention rate in the ICU prior to program
implementation was 91.2%. Measuring the retention rate at the end of the first year of
the program demonstrated an increase to 93.7%. This data was reported by the human
resources department (Morris, et al., 2009).
Limitations of this study included the fact that the tool used to measure the
perceptions of the preparedness of the nurse to care for their assignment was not a
reliable tool, but rather a questionnaire. A panel of experts reviewed the questions to
maximize content validity however reliability testing was not performed. It is unclear
how the managers or clinical educators interacted with the residents to evaluate their
ability in the clinical setting. If the nurses themselves were surveyed this was not
reported. The number of surveys completed was not provided. It is not specified at what
point these surveys were taken in the project. Other limitations include the variability of
the length of orientation. Orientations spanned from eight to twelve weeks. Turnover rate
did decrease and the ICU turnover rate was reported below the general hospital rate.
7
The University Health Systems Consortium (UHC) was increasing the number of
baccalaureate graduate nurses hired into their facilities. This group partnered with the
American Association of College of Nursing (AACN) to establish a national PostBaccalaureate Graduate Nurse Residency Program (Krugman, et al., 2006). The purpose
of this research was to evaluate their program at six different sites.
Krugman (Krugman, et al., 2006) conducted a descriptive comparative study of
residency program outcomes across multiple sites using specific instruments to describe
demographics including turnover, and to evaluate outcomes. To be admitted to the
graduate nurse residency program the nurse was required to be a graduate of a BSN
program in the last six months and have a nursing license or permit pending licensure. A
willingness to work full time and complete a one year commitment to the program was
requested.
The residency program was structured into two phases. Phase one consisted of
six months of hospital orientation with a preceptor who had completed training using the
national residency curriculum. Training concentrated on the resident’s primary area. For
example an ICU resident would complete a critical care course and monthly resident
seminars. Interactive case studies provided the framework for group discussions at the
monthly seminars. Phase two continued with the monthly seminars for a period of six
months (Krugman, et al., 2006).
Residents were grouped according to date of hire to foster relationships and build
trust during the year. The clinical exemplars were considered a key component of the
program to allow the residents an opportunity to partake in reflective inquiry. Complex
8
case studies were used to promote clinical judgment. The resident facilitator assisted
residents during these discussions to foster critical thinking and introduce evidence-based
practice (Krugman, et al., 2006).
A resident program coordinator was responsible for communicating with
residents and the clinical units. They were responsible for data collection and evaluating
program outcomes. A resident facilitator was a clinical expert who promoted residents
learning and development through phase two of the program (Krugman, et al., 2006).
Multiple instruments were used to compare outcomes of resident’s across sites.
Data was collected when the resident was hired, at six months and at twelve months upon
program completion. The following instruments were used: McCloskey, Mueller
Satisfaction Scale, Gerber Control Over Practice Scale, Casey-Fink Graduate Nurse
Experience Survey, UHC Demographic Database and Investigator Developed Residency
Evaluation Form (Krugman, et al., 2006).
Gerber’s Control Over Nursing Practice has a Cronbach’s alpha of 96. One item
of the 21 item survey was reported on which was: “I feel control over decisions related to
my patients care.” Residents rated themselves high at the beginning of their orientation
and then dipped down at six months. By the end of the program satisfaction had risen.
There were large variations between five sites and one site. The low site scored a mean of
4.8 and the remaining sites scored between 5.5 and 5.9. The scoring was a seven point
Likert scale of 1 (agree) to seven (disagree) (Krugman, et al., 2006).
The Casey-Fink Survey has proven to be valid and reliable in tracking changes in
a residents experience over time with a Cronback alpha of .89. Stress was high at baseline
9
and decreased over time which is a positive and an expected outcome of a residency
program. Data also indicated the residents perceived their organization and prioritization
skills had improved over time (Krugman, et al., 2006).
The outcomes of this study suggest the transition into practice is not complete
until at least nine to twelve months after hire for graduate nurses. This was reflected in
the resident’s response to stress and self-perception of organization and priority setting.
This program supports graduate nurses for a period of one year (Krugman, et al., 2006).
Limitations of the study are the inability to control the content and
implementation of the residency program at the different sites. Although there were
general guidelines and curriculum each hospital developed their own learning materials
to meet their situation. The data was provided by five different sites but the number of
participants who responded was not reported. Not all the scales from the standardized
instruments were reported. The authors reported the turnover rate of the residents was
8%. This was unclear whether this was an averaged rate of all institutions and how it
compared with their baseline.
Blanzola (Blanzola, Linderman, & King, 2004) described a new graduate nurse
internship program at a United States Navy hospital implemented to increase clinical
competence, confidence and comfort. An additional goal of this program was to facilitate
a smooth transition to the leadership role expected of a Navy Nurse Corps officer. Their
traditional orientation lasted for six weeks during which time the nurse was relocated to a
new geographic location and expected to complete the general hospital orientation
regarding computer training, fire safety, and infection control policies. How the
10
internship developed clinical skills was not detailed although it was reported many
graduate nurses were reporting with minimal nursing experiences and frequently without
licensure.
The nursing internship program (NIP) was implemented to provide learning
experiences in diverse areas as military nurses face a variety of working conditions. This
twenty four week program emphasized priority setting and clinical decision making.
Several learning activities were employed including video and audio tapes, interactive
role playing, lectures and group seminars. A clinical experience was provided to meet
individual learning needs with an assigned clinical preceptor. A clinical nurse specialist
was available for consultation (Blanzola, et al., 2004).
A total of eight new graduate nurses went through the first NIP. This experimental
group was compared to a control group of ten new graduate nurses who had gone through
orientation six months prior to starting the NIP. The instrument used in this quasiexperimental study was an evaluation of clinical competencies and organizational
attributes. The items were chosen based on what the nurse officer would be rated on
during his or her annual evaluation. Cronbach’s alpha for the tool was reported to be .84
and determined from nurse interns at some stage during the first program year. Clinical
nurse leaders, peers and the graduate nurse completed the tool. The tool was completed at
the end of a thirty day rotation of the control group and again in six months. The pilot
group was evaluated at the end of the NIP and again in six months (Blanzola, et al., 2004)
11
The results showed significantly higher scores for the pilot group on core
competencies rated both by the nurse graduate and by peer evaluation when compared to
the control group at six months. Scores obtained after each group was assigned to their
unit assignment for six months were compared to the pilot group. The pilot group had
significantly higher scores. Limitations of this study were the small sample size. Content
validity of the tool was not tested. The results of this study may be attributed to an
extended orientation. The control group received six weeks as opposed to the pilot group
who received six months. The retention or turnover rate was not applicable to a military
setting since turnover is not possible in that setting (Blanzola, et al., 2004).
The Journal for Nurses in Staff Development published a study in 2001 by Owens
and colleagues. This graduate RN internship program was developed by the Inova Health
System (IHS) with the goal of finding one program to meet the needs of five different
hospitals in their system. The task of curriculum development was difficult as the five
hospitals had a wide variety of acuity and specialties ranging from a level one trauma
center to long term care facilities. It was agreed that the focus would be on practical
knowledge and skills as well as information about the hospital’s systems. A variety of
educational methods were used to connect with the various learning styles of new
graduates. Lectures were augmented with group discussions, role play, demonstrations,
case studies, self-directed learning modules, simulation, and videos. Learning styles were
discussed and the orientees were encouraged to share their learning style with their
preceptor to enhance their learning experience in the clinical area. Peer support was
provided by scheduling all graduate nurses together to discuss work place problems with
12
peers and an experienced leader. Performance ratings from preceptors and managers
determined if the graduate nurse was functioning at an acceptable level.
A performance evaluation tool was developed to assist with program assessment.
Content validity and reliability was not established. The tool was provided to the graduate
nurse, primary preceptor and patient care director after three months. A total of 75
graduate nurses completed the program however only 19 graduate nurses returned the
tool, 23 preceptors and 15 patient care directors. Differences among the three groups was
not demonstrated using a one-way ANOVA of the following items: assessments, critical
thinking, clinical decision-making skills, documentation, basic nursing procedures,
recognizing patient status change, effective communication, time management,
appropriate delegation and stress management. Patient care directors scored the graduate
nurses significantly lower in one behavior “asks questions of healthcare team to increase
practice knowledge” (Owens, et al., 2001).
Limitations of this study included the small sample size and use of an unproven
tool. The survey response rate was low at 25%. Although all graduate nurses came
together for parts of the program they were practicing in five different settings. The
reported data seemed conflicting. The author stated there were no significant differences
among the groups scoring the graduate nurses yet in the same paragraph the statement
was made patient care directors consistently scored the new graduate RN lower in all
areas except time management skills. Their retention rate was 74% of the graduate nurses
remaining in their original unit. The authors did not compare this outcome with their past
retention rates (Owens, et al., 2001).
13
Beecroft (Beecroft, Kunzman, & Krozek, 2001) conducted a quasi-experimental
study to evaluate their internship program at Childrens Hospital of Los Angeles (CHLA).
The program consisted of 716 hours with a preceptor, a mentor to facilitate transition to
the professional nurse role and 225 hours of classroom time including skills laboratory
training. Debriefing and self-care sessions were provided as well as clinical experiences
in other areas of the hospital involving their patient population.
Subject selection consisted of 50 graduate nurses hired during the first year of the
internship program. Initially 68 new graduates were hired but 18 left the program. This
group was compared to 45 graduate nurses hired within the previous 24 months.
However, only 28 graduate nurses hired during this time period returned the evaluation
questionnaires. This single information point coincided with the beginning of the
internship program. The Schutzenhofer Professional Nursing Autonomy Scale was used
to measure autonomy. This tool was validated by a panel of nursing experts. Reliability
was tested with a correlation coefficient of .79. There was no statistical significance
between the two groups. A skill Competency Self-Confidence Survey was used to
measure confidence in providing safe patient care. This survey allowed interns to rate
themselves at the beginning, middle and end of internship. Results of this survey
demonstrated continuous increases in confidence. Intern scores at 12 months compared to
the control group did not show a difference. This finding may suggest the internship
program promoted skills competency of the graduate nurse as the RN experience of the
control group was much greater when surveyed. The tool used to measure professional
autonomy did not show a statistical difference between the control group and the nurse
14
interns. The turnover rate at 12 months in the control group was reported to be 36% as
compared to the intern group was 14% (Beecroft, et al., 2001).
Limitations of this study included differences in the demographics of the control
group versus the pilot group. It was reported 79% of the control group had 1.5 years or
more RN experience when data was collected as opposed to the pilot group who had on
average 8 months experience at 12 months of employment. The tool to measure
competency had not been validated or undergone reliability testing.
Marcum and West (2004) evaluated a program for graduate nurses consisting of
13 weeks of unit based training subsequent to 2.5 weeks of hospital orientation. Twenty
graduate nurses were hired however two did not complete the program due to their
performance. Graduate nurses were pared with a preceptor. Additional support was
provided in the form of case studies, lecture, articles, computer assisted instruction and
hospital based experiences to view procedures. Clinical experience was scheduled with
different specialists as needed by the graduate nurse. For example, a nurse who would be
assigned to a respiratory unit could work with a respiratory therapist to gain additional
understanding of ventilator management and breathe sound assessment. This training
took place on an 18 bed medical unit set up specifically to train the graduate nurses.
The Performance Based Development System was used to measure critical
thinking and interpersonal skills. This was administered on the fourth day of hospital
orientation and repeated during week eight of the nurses’ clinical orientation. Statistically
significant differences were realized between the first and second assessment indicating
critical thinking and interpersonal relationships had increased (Marcum & West, 2004).
15
A second tool to determine peer evaluation of critical thinking skills and judgment
was the Professional Judgment Rating Form. This was administered to the graduate
nurse, preceptor and one RN staff from the unit. This tool was completed 1-year post
program. The tool classified critical thinking skills as being very strong, positive,
marginal/ambiguous, negative or very poor. The data reported 83.3% of the graduates
demonstrated very strong critical thinking skills with the remaining 16.6% scored as
having positive skills. Turnover rates decreased significantly from the prior year by 17%
(Marcum & West, 2004).
Limitations of the study involved the Professional Judgment Rating Form as
content validity and reliability was not specified. The results from this form were
reported as one number yet three different groups were surveyed. If the graduate nurse
response was included this would not truly be a peer evaluation of skill assessment but a
self-evaluation. The number of these surveys returned was not reported. Two groups of
graduate nurses were going through orientation at the same time on the medical unit
designated as the graduate nurse training unit. This unit was too small to accommodate
appropriate patient assignments for all the graduates. To resolve this problem the first
group of graduate nurses started progression to their home units three weeks early.
Therefore all graduate nurses did not have the same experience.
The studies reviewed were rated using the John Hopkins Nursing Evidence Based
Practice process to evaluate their strength and quality of evidence (Newhouse, Dearholt,
Poe, Pugh, & White, 2007). Overall, studies represented level II evidence to support the
strength of research. The evidence was obtained from quasi-experimental or descriptive
16
studies. The quality of the studies was good with reasonably consistent results. Studies
had sufficient sample size with a sample size of 10 to 197. Fairly definitive conclusions
were reached with reasonable consistent recommendations based on a comprehensive
literature review.
All studies that compared retention or turnover rate before and after
implementation of their programs demonstrated an improvement. The use of preceptor or
mentor based programs improved satisfaction. The effect of orientation or residency
programs on competency or patient outcomes was not well measured. The identification
of specific elements of a residency program to be most critical to a nurse’s success was
not addressed. In the literature the methodologies and small sample sizes proved
inadequate to allow generalized conclusions in this area.
17
Chapter 3
OVERVIEW OF PROJECT
Description
This project was designed to provide appropriate learning opportunities to meet
the specific needs of the individual residents. Learning opportunities were tailored to an
individual’s preferred method of learning and the content was varied to accommodate all
levels of experience. Using Benners’s “novice to expert” model provided the framework
for the program. Benner’s five levels are: novice, advanced beginner, competent,
proficient, and expert. Teaching and learning activities were designed to advance a nurse
through the five levels of proficiency (Benner, 1984).
Review of the literature identified several different learning activities employed to
promote critical thinking. Knowledge and concepts were reinforced with concrete
experience to develop clinical judgment. Provision of a variety of learning methods may
enhance critical thinking skills.
With these principles in mind the author developed multiple educational
offerings to be incorporated in the program. Unit specific case studies were developed to
facilitate discussion of possible interventions. High-fidelity simulation was tailored to
mimic situations found in the MICU. Interactive web-based programs were purchased or
web sites identified that could be used. Audio CD’s were provided for use at work, home
or in the car. An on-site resource library was created to promote evidence based practice.
Unit competencies were placed on a memory stick to provide pictures of what was being
presented as opposed to exclusively narrative information.
18
In the past our orientation would end in eight to twelve weeks. Although this may
be sufficient for a new nurse to practice they will lack the judgment and experience to
make crucial decisions. In order to support all nurses regardless of their level of expertise
the commitment was made to implement an ongoing program for all staff. This also
facilitated integration of evidence-based practice at the bedside.
The learning needs of the staff were varied based on their experience and
knowledge. With this in mind learning needs and preferred method of learning were
assessed to personalize the educational offerings. Using an excel data base a tracking
sheet was developed to record individual needs and preferred learning methods.
The requirement for change in the orientation and educational offerings was
identified by the nursing staff. Management was supportive of implementing a new
model of education to improve staff satisfaction, integrate evidenced based research into
practice, and decrease turnover. In order to fund the initial time spent developing and
organizing the program the Eula Wiley Award was applied for and granted. This
provided $10,000 for salary and development of educational materials. The Nurse
Manager was supportive of this project and provided additional paid time. This program
has become the method used by the clinical educators to orient and educate the nursing
staff in the MICU.
In order to collect demographics of the nurses and questionnaires regarding their
educational experience a study was proposed and approved by the Institutional Review
Board (IRB) of the University of California Davis Medical Center. Informed consent was
waived as this study involved minimal risk and consent was implied by completion of the
19
survey. The surveys were confidential without identifying information. A cover letter was
provided explaining the purpose of the questionnaire, how to contact researchers
regarding questions, and how to contact the IRB regarding subject’s rights while taking
part in the study. Nurses could decline to participate or stop their participation at any
time.
Development of Materials
The first phase of this project consisted of gathering the educational materials.
This consisted of the following types of learning tools: CD-ROM’s, Audio CD’s, study
guides, MICU case studies, an evidence based library, and web based self-directed
learning modules. The Pulmonary Artery Catheter Education Project (PACEP) was used
to explain hemodynamics and pulmonary artery catheters. This free web based program
covered physiological concepts, vasoactive drugs, waveform analysis, and the technical
aspects of hemodynamic monitoring. Five copies of American Association of Critical
Care (AACN) nurses study guide for Critical Care Registered Nurse (CCRN)
certification were purchased and made available for the nurses to check out.
A clinical resource library was established. In order to integrate proven standards
into practice research articles and protocols for best practice were collected. This
included information on adult respiratory distress (ARDS NET Protocol) and Surviving
Sepsis Campaign. Other research articles provided information on best practices to
decrease nosocomial infections or other topics relevant to a medical intensive care unit.
High-fidelity simulation education was scheduled once a month in the Center of
Virtual Education. Scenarios were written to mimic common diagnosis and emergency
20
situations found in our MICU. These included airway and cardiovascular emergencies.
Staff input was solicited for future topics. Critical Care competencies were converted into
Power Point presentations and placed on a flash drive for use at bedside computers. Staff
was given the option of choosing between the traditional hard copy study guide and the
Power Point method of learning. Competencies involving complex procedures were
verified when demonstrated to a unit educator.
Staff participation was encouraged during the development of learning resources.
Input was solicited regarding topics and all suggestions regarding content were
incorporated into the program. Nurses were provided time to develop case studies on the
patient populations specific to the MICU. Participation in the conversion of competencies
to Power Point presentations was encouraged. Only two staff nurses participated in these
activities. Lack of participation could have been due to nurses being too busy, low
motivation, or not knowing how to create a Power Point presentation. The development
of cases studies and Power Point presentations were completed primarily by the unit
educators. These activities served as a learning tool for those who did participate.
Learning Strategies
In order to tailor the program to the individual nurse an assessment of learning
needs and identification of the nurses preferred learning methods was conducted with the
unit educator. This information allowed the nurse educators to focus on the specific needs
of a nurse. Learning interventions were chosen for the nurse’s preferred method of
learning. For example, if a nurse reported she learned best by concrete experiences she
could be scheduled for human simulation.
21
All learning strategies were blended with clinical experiences. Patient
assignments were chosen according to the content being studied. Reflection with the
nurse educator allowed further learning as well as validation of competence regarding a
particular topic. Required hospital and critical care competencies have a test or return
demonstration of skills. Verification is signed off by the unit educator and recorded in the
MICU competency binder as well as the hospital’s clinical education department.
Comprehension of pathophysiology and nursing management of specific diagnosis by
mentees was not standardized and could elicit varied interpretations among the unit
educators. Multidisciplinary rounds and discussion with the nurse educator encouraged
critical thinking skills, as did case studies.
Implementation
The program design was developed and introduced to the unit educators. A Power
Point presentation was provided to all preceptors outlining the goals and objectives of the
program as well as the learning materials. The expectation was for them to familiarize
themselves with the various learning materials and topics. Paid administrative time was
provided for this purpose. Monthly meetings with the nurse manager, administrative
nurses and unit educators were conducted to address concerns or answer questions.
Unit educators were also oriented to a database designed for tracking individual
learning needs and preferences. The database was populated with each individual’s
preferred learning method and topics. Preceptors were instructed how to record the
completion of each topic or competency. The unit educator would consult with the
individual as to whether or not they had achieved proficiency in the designated topic.
22
There were no reported discrepancies in the nurses’ view versus the unit educators’ view
of achieving proficiency.
Each unit educator was given responsibility for six to eight RN’s. This
responsibility included distributing appropriate learning material and arranging time to
complete the material away from the bedside. This also included seeking out a patient
assignment to correlate with learned material to solidify learning. Assigning each nurse to
a unit educator allowed the unit educator to track the progress and educational needs of
each assigned individual.
The Assistant Nurse Managers (ANII’s) had the role of facilitating relevant
clinical experiences to reinforce the concepts learned through experience at the bedside.
This was accomplished through patient care assignments that correlated with the current
topic of learning. The four ANII’s attended monthly meetings with the unit educators as
well as monthly meetings with the unit manager to discuss implementation and maintain
consistency. During change of shift report the ANII’s would discuss with a nurses’
preceptor patient assignments that could provide an appropriate experience. The ANII’s
would also provide time off the unit to complete learning materials or schedule release
time to attend the simulation training. Initially six night shift and two day shift nurses
were scheduled for monthly simulation training. Night shift was given preference due to
their lack of clinical experience.
Nurses were encouraged to develop specific goals during the education program
such as obtaining national certification or an advanced degree. Financial reimbursement
23
was provided by the University of California for degree courses and a stipend was paid to
nurses who achieved and maintained a national certification in their area of practice.
Introduction of the Residency Program to staff started with the same Power Point
presentation provided to the unit educators. A voluntary survey to identify their preferred
method of learning as well as their perceived knowledge deficits or areas they identified
as needing more experience was conducted. Results were reviewed and recorded in the
data base developed to track each person’s needs and completed competencies.
Setting
The University of California Davis Medical Center is a 612-bed teaching hospital.
The Medical Intensive Care Unit is one of seven specialty intensive care units consisting
of twelve beds. There are approximately fifty registered nurses’ on staff. A nurse
manager oversees the twenty-four hour operation of the unit. Four assistant nurse
managers direct daily unit operation. There are seven nurse educators divided between
the day and night shift whose responsibilities include orientation, staff development and
education.
The mean age of the RN’s participating in the residency program was 38.6 years
of age. A total of four men and twenty four females completed questionnaires. Three
subjects did not provide their age and two subjects did not provide their gender. The
mean time as an RN was 13.1 years. The mean years of ICU experience was 10 years.
However 31% of the staff had one year or less experience in the ICU setting. New nurses
were hired for night shift and progress to day shift based on seniority; therefore the night
shift had less critical care experience. Initially 30 RN’s took part in the residency
24
program. The clinical educators and management were encouraged to utilize the program
material but were excluded in the evaluation process.
Evaluation Method
A Likert Scale Questionnaire was distributed to staff before starting the program
and at six months after participation in the residency program. The assessment tool was
developed to measure the following: staff comfort levels for effective decision-making
skills related to clinical judgment, use of evidence based research into practice, and nurse
satisfaction. Other statements measured anxiety and confidence in the work environment.
The Statistical Packages for the Social Sciences (SPSS) Version 16.0 was used to
calculate the means and standard deviation, on each item of the Likert scale survey.
T-tests were used to determine if there were differences between the pretest and posttest
evaluations. The significance level was 0.05. The patient care services department
provided data on turnover rates. The following two tables will provide the statistical data
for each question.
Chapter four evaluates the project and describes the limitations. Implications for
nursing and questions for further nursing research are offered.
25
Table 1
Mean, Standard Deviation and Standard Error
_______________________________________________________________________
Question
N
M
SD
SE
_______________________________________________________________________
1. I felt I received adequate
Pretest 30
4.3667
.61495
.11227
orientation before I started caring
Posttest 30
4.4333
.72793
.13290
for patients independently.
Total 60
4.0000
.66892
.08636
2. I feel like my personal goals
Pretest 30
4.0000
.62146
.11346
are supported in this unit.
Posttest 30
4.3667
.55605
.10152
Total 60
4.3833
.58488
.07551
3. Many times I feel overwhelmed
Pretest 30
2.1333
1.00801
.18404
and unsure in my patient care.
Posttest 30
1.6333
.61495
.11227
Total 60
1.8833
.86537
.11172
4. I have had sufficient clinical
Pretest 30
4.1000
.95953
.17518
experiences to safely care for the
Posttest 30
4.4000
.56324
.10283
critically unstable ICU patient.
Total 60
4.2500
.79458
.10258
5. I can apply critical thinking
Pretest 30
4.3667
.61495
.11227
skills in my nursing practice.
Posttest 30
4.6000
.49827
.09097
Total 60
4.4833
.56723
.07323
6. I currently utilize evidence based
Pretest 30
3.9000
.84486
.15425
research in my daily practice.
Posttest 30
4.1333
.73030
.13333
Total 60
4.0167
.79173
.10221
26
Table 1 (continued)
Mean, Standard Deviation and Standard Error
________________________________________________________________________
Question
N
M
SD
SE
________________________________________________________________________
7. I am encouraged to take
Pretest 30
4.3000
.74971
.13688
professional responsibility for
Posttest 30
4.5000
.68229
.12457
advancing my nursing practice.
Total 60
4.4000
.71781
.09267
8. Learning methods included in
Pretest 30
3.8333
.74664
.13632
unit education were tailored to my
Posttest 30
4.2333
.81720
.14920
knowledge and skill level.
Total 60
4.0333
.80183
.10352
9. I experience physical signs and
Pretest 30
2.1333
1.04166
.19018
symptoms of anxiety when
Posttest 30
1.9333
1.01483
.18528
Total 60
2.0333
1.02456
.13227
10. I am satisfied with my current
Pretest 30
3.8000
.96132
.17551
work environment.
Posttest 30
4.0667
.73968
.13505
Total 60
3.9333
.86095
.11115
11. I feel anxious when coming to
Pretest 30
2.0333
1.03335
.18866
work in the ICU.
Posttest 30
1.8333
1.01992
.18621
Total 60
1.9333
1.02290
.13206
12. I am confident in my priority
Pretest 30
4.1333
.73030
.13333
setting and time management in
Posttest 30
4.3667
.61495
.11227
the ICU.
Total 60
.67961
.0877
4.2500
27
Table 1 (continued)
Mean, Standard Deviation and Standard Error
________________________________________________________________________
Question
N
M
SD
SE
________________________________________________________________________
13. I feel that I am respected
Pretest 30
3.9667
.76489
.13965
on this unit.
Posttest 30
4.0000
.78784
.14384
Total 60
3.9833
.77002
.09941
14. I am able to collaborate with the
Pretest 30
4.2333
.62606
.11430
health care team on this unit.
Posttest 30
4.4000
.67466
.12318
Total 60
4.3167
.65073
.08401
28
Table 2
T-test results / logistic regression analysis
________________________________________________________________________
Question
df
F
p
________________________________________________________________________
1. I felt I received adequate
Between groups
1
orientation before I started caring
Within groups
58
for patients independently.
Total
59
2. I feel like my personal goals
Between groups
1
are supported in this unit.
Within groups
58
Total
59
3. Many times I feel overwhelmed
Between groups
1
and unsure in my patient care.
Within groups
58
Total
59
4. I have had sufficient clinical
Between groups
1
experiences to safely care for the
Within groups
58
critically unstable ICU patient.
Total
59
5. I can apply critical thinking
Between groups
skills in my nursing practice.
Within groups
58
Total
59
1
6. I currently utilize evidence based
Between groups
1
research in my daily practice.
Within groups
58
Total
59
.147
.703
.048
.827
5.379
.024*
2.181
.145
2.607
.112
1.310
.257
29
Table 2 (continued)
T-test results / logistic regression analysis
________________________________________________________________________
Question
df
F
p
________________________________________________________________________
7. I am encouraged to take
Between groups
1
professional responsibility for
Within groups
58
advancing my nursing practice.
Total
59
8. Learning methods included in
Between groups
unit education were tailored to my
Within groups
58
knowledge and skill level.
Total
59
9. I experience physical signs and
Between groups
symptoms of anxiety when
Within groups
58
coming to work.
Total
59
10. I am satisfied with my current
Between groups
1
work environment.
Within groups
58
Total
59
1
1
11. I feel anxious when coming to
Between groups
1
work in the ICU.
Within groups
58
Total
59
12. I am confident in my priority
Between groups
1
setting and time management in
Within groups
58
the ICU.
Total
59
1.168
.284
3.917
.053
.597
.454
1.450
.233
.569
.454
1.792
.186
30
Table 2 (continued)
T-test results / logistic regression analysis
________________________________________________________________________
Question
df
F
p
________________________________________________________________________
13. I feel that I am respected
Between groups
1
on this unit.
Within groups
58
Total
59
14. I am able to collaborate with the
Between groups
1
health care team on this unit.
Within groups
58
.028
.869
.984
.325
Total
59
________________________________________________________________________
*p <.05
31
Chapter 4
CONCLUSIONS AND RECOMMENDATIONS
Evaluation Summary
The Likert Questionnaire results demonstrated a trend toward increased staff
satisfaction and comfort levels related to clinical judgment. Fifteen nurses verbalized an
improved level of confidence in their priority setting and increased comfort in the clinical
setting although statistical significance was not achieved on the majority of items on the
questionnaire. One question did achieve statistical significance. “Many times I feel
overwhelmed and unsure in my patient care” had a p value of .024. It may be the sample
size was too small to achieve statistical significance on other questions.
The turnover rate did decrease to 6.1% the past nine months however this may be
for reasons unrelated to the residency program. Turnover rate the year preceding the
residency program was 15.49%. The year the residency program was implemented
turnover rate was 7.43% and the following year remained low at 7.85%. At this time the
high unemployment rate and poor economy may have influenced nurses to stay in their
current job.
Unit based clinical nurse educators are critical to implementation of this model.
CNIII’s had difficulty with the expectations of educators in the new model. The
employee database of learning needs and preferred learning method was difficult to use.
This was changed to allow one unit educator the job of updating the information and
providing each educator with a summary of their clients needs on a quarterly basis.
32
Staffing was an obstacle as frequently the unit educators were unable to afford
staff time away from the bedside to complete their learning. This was not an issue during
the formal orientation of new hires as they are not responsible for patient care. However
this time period is limited to twelve weeks in the clinical area. Staffing was an obstacle
for advancing the education of experienced nurses on the unit. The administration was
supportive in providing paid release time for simulation training and administrative time
for CNIII’s to relieve nurses from the bedside, however additional time would have been
helpful.
Program maintenance was critical. Although there was a procedure for checking
out resources there needed to be a dedicated person to track checked out materials and
maintain the resource library. Without this, program content was lost and not returned in
a timely manner. This person should also maintain the database, ensure program
materials are up to date and provide supervision of simulation training. Group educator
meetings are held quarterly to identify new topics for education or other issues with the
program.
Limitations
This study had several limitations. There was no control group in the design.
Program evaluation could have used a different instrument. A proven tool would have
been a better choice to evaluate the program as reliability and content validity testing was
not done on the questionnaire. This would also allow comparison of our results with
others who may choose to implement this type of program. Pre and post surveys were not
distinguished between experienced and graduate nurses. This significantly limited the
33
analysis. Had the surveys only been administered to those with less than one year
experience the outcomes may have been significant.
Hospital and critical care competencies had tests or specific return demonstrations
to maintain consistency of competency verification. There may have been a difference
among unit educators when determining competence of a nurse on a particular diagnosis
or nursing management of a patient.
Self reported data has many influencing variables such as organizational climate,
or how someone may feel at the time they complete the survey. Subjects may try to
disguise who they are when filling out answers or may try to please the investigator when
completing the questionnaire. The use of self reported data submitted to assistant nurse
managers on a small unit was a limitation.
Participation was voluntary. It is possible that nurses who chose to participate
differed from those who did not. A convenience sample of RN’s was used and that
limited the ability to generalize the findings.
Implications for Nursing
Support for education in the work environment is necessary to achieve and
maintain clinical competence. The Joint Commission on Accreditation of Healthcare
Organizations recommends support for the development of health professionals’
knowledge and skill necessary to care for patients in an increasing complex environment
(Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2001). A
unit based RN Residency Program as described in this project is one way to achieve this.
Adequate staffing is necessary to afford nurses the time to attend educational activities.
34
Unit-based educators allow bedside learning to occur and provide and immediate
feedback on clinical performance.
The residency program provided a template and direction for unit-based educators
and incorporated a variety of teaching methods to meet each learners needs. Additional
research is necessary to identify the best methods to increase critical thinking skills of
practicing RN’s and how to adapt curriculum to other intensive care units. Although the
competency and critical thinking may be a desired outcome of a residency program this
has not been well measured in the past. Questions for further research include the
following:
1. Is learning enhanced by use if a nurse’s preferred method of learning?
2. Does an ongoing residency program increase the use of evidence-based
practice at the bedside?
3. Does an ongoing residency program improve critical thinking skills?
4. Does an ongoing residency program improve competency?
It is this author’s hope that implementation of a comprehensive educational
program for all nurses will improve the safety and quality of care to all patients through
competent, proficient and expert nurses. Residency programs have demonstrated a
correlation with a decrease in turnover rate. In this atmosphere of budget cuts it is
important for the nursing profession to measure outcomes related to nursing education
programs especially in regards to competency and the delivery of safe patient care.
35
APPENDIX A
Residency Questionnaire
Age_____
M/F_____
Years/Months as RN_____
Years/Months in ICU______
Race/Ethnicity: Caucasian_____ African American_____ Hispanic_____
Asian_____Other (please specify) ______________
Please indicate below the number of hours spent in the following education activities.
Classroom education
<10
10-20
21-40
41-60
61-80
>80
Education with preceptor
<10
10-20
21-40
41-60
61-80
>80
Self-directed learning
<10
10-20
21-40
41-60
61-80
>80
Case study reviews
<10
10-20
21-40
41-60
61-80
>80
Simulation training
<10
10-20
21-40
41-60
61-80
>80
Articles/Reading
<10
10-20
21-40
41-60
61-80
>80
If you have completed your orientation period, how many hours did you complete?
<80 (2 weeks or less) ___ >80<160 (2 to 4 weeks) ___ >160<240 (5 to 6 weeks) ___
>240<320 (7 to 8 weeks) ___ >320 (more than 8 weeks) ___
What tools if any were utilized to assess your learning needs?
Skills checklist ____ Learning assessment ____ Verbal conversation with preceptor ____
None ____ Other (please specify) ____________
What type of clinical experiences do you feel you need to enhance your nursing practice?
What type of educational training would be helpful in advancing your practice as an ICU
RN?
36
APPENDIX B
Preferred Learning Methods
Return separately to your unit educator. (CNIII)
Name: _________________________________
Please indicate what learning methods best meet your needs, and rate them in order of
preference. (Number one as most preferable and ten the least preferable.)
Computer on-line education
Case Studies
Simulation training
Self-Directed learning modules
Articles/Reading
Testing
Classroom lectures
Demonstration/Return Demonstration
Preceptor guided training
Other __________________________________
37
APPENDIX C
Likert Questionnaire
Complete the following questions utilizing the scale provided.
Strongly
Disagree (1)
Disagree
Neutral
Agree
(2)
(3)
(4)
Strongly
Agree (5)
I felt I received adequate orientation before I started caring for patients independently.
I feel like my personal goals are supported in this unit.
Many times I feel overwhelmed and unsure in my patient care.
I have had sufficient clinical experiences to safely care the critical unstable ICU patient.
I can apply critical thinking skills in my nursing practice.
I currently utilize evidence-based research in my daily practice.
I am encouraged to take professional responsibility for advancing my nursing practice.
Learning methods included in unit education were tailored to my knowledge and skill
levels.
I experience physical signs and symptoms of anxiety when coming to work.
I am satisfied with my current work environment.
I feel anxious when coming to work in the ICU.
I am confident in my priority setting and time management in the ICU.
I feel that I am respected and able to collaborate with the health care team in this unit.
38
APPENDIX D
Educational Goals
Name: _____________________________
Date: _____________
Please circle the topics you would like to receive educational support.
Arterial Blood Gas Interpretation
High Frequency Oscillator
Acid/Base Balance
High Risk Pregnancy
Acute Coronary Syndromes
Multi-system Failure
Acute Myocardial Infarction
Organ Donation
Acute Pulmonary Embolism
Overdose/Toxicology
Acute Stroke
Propofol Toxicity
Adult Respiratory Distress Syndrome
Pulmonary Hypertension
Airway Pressure Release Ventilation
Richmond Agitation Sedation Scale
Cardiac (Pressure vs. Volume)
Rapid Infuser
Cardiovascular Drugs
Right Ventricular Failure
Continuous Cardiac Output
Status Asthmatics
Diabetic Ketoacidosis
Vasopressors in the ICU
Delirium Tremor
Ventilator Modes
EKG Interpretation
Weaning Protocols
Gastrointestinal Bleed
Other _____________________
Hemodynamics
Other _____________________
Hepatorenal Syndrome
Other _____________________
39
APPENDIX E
Audio and CD-ROM Video Resources
Audio CD’s
Central Venous Oxygen Saturation Monitoring in the Critically Ill
Current Recommendations for Pharmacologic of Heart Failure
Deciphering the New Cardiac Marker Alphabet
Metabolic Cardiology
Multisystem Series
Physiological Basis of Cardiovascular Drug Therapy
Right Heart Disconnects: Heart Rate and Vasopressor Administration
CD-ROM’s
Mastering Sepsis: Identification and Treatment
Pressure vs. Volume
Top Ten Factors that Help Ventilated Patients Wean
40
APPENDIX F
Power Point Competencies
ABG Sampling and Analysis
Mechanical Ventilation
Administration of IV Medications
Neurological Assessment
Administration of Cardiovascular Medications
Neuromuscular Blocking Agents
Arterial Pressure Monitoring
Nitric Oxide Therapy
Basic Arrhythmia Detection
Peripheral Nerve Stimulator
Bi-Pap
Richmond Agitation Sedation Score
Chest Tubes
Total Parenteral Nutrition
Code Blue
Respiratory Assessment
Confusion Assessment Method
Transcutaneous Pacemaker
Flolan
Transporting Critical Care Patients
Fluid Resuscitation
Ventilators and Endotrachael Tubes
Glycemic Protocol for the ICU
Ventilator Management Protocol
41
APPENDIX G
Case Studies
Acid-Base Disorders
Adult Respiratory Distress Syndrome (ARDS)
Brain Death and Organ Donation
Cerebral Vascular Accident
Diabetic Keto-Acidosis
Drug Toxicity/Drug Overdose
End of Life Care
Gastrointestinal Bleeding
Management of the Agitated Patient
Myocardial Infarction
Respiratory Failure
Sepsis
Vasopressor Agents
42
APPENDIX H
Sample Case Study
Gastrointestinal (GI) Bleed
Mrs. Roberts is a 56 year old female with a history of end-stage liver disease due to
alcohol-related cirrhosis. She comes to the unit from the Emergency Department
reporting two days of bloody emesis, dark maroon stools, nausea and dizziness upon
standing. Her heart rate is 115, blood pressure is 95/60, respiratory rate is 18, and oxygen
saturation is 95%.
1. Given what you know about Mrs. Robert’s history, you suspect her GI bleed is
due to:
a. Mallory-Weiss tear
b. Gastric ulcers
c. Esophageal varices
d. Diverticulitis
2. Mrs. Roberts is at risk for all of the following except:
a. Hypovolemic shock due to blood loss
b. Aspiration
c. Oral thrush
d. Increased ascites
3. What may not be an appropriate intervention for Mrs. Roberts?
a. Head of bed (HOB) up 30 degrees
b. Administer oxygen via nasal cannula
43
c. Insert nasal gastric tube for gastric lavage and/or medications
d. Establish two large bore intravenous catheters and /or prepare for central line
placement
e. Type and crossmatch four units of packed cells
f. Administer fresh frozen plasma to correct coagulopathies
4. Which medications would you expect Mrs. Roberts to have?
a. Octreotide drip at 50 micrograms an hour for 72 hours
b. Protonix by mouth (PO) 40 milligrams (mg) twice a day (BID)
c.
Protonix intravenous (IV) 40 mg BID
e.
Heparin subcutaneously 7500 units BID
f.
A and C
g.
A, C, and D
Unfortunately, Mrs. Roberts begins to vomit large amounts of bloody emesis. Her heart
rate increases to 140, blood pressure drops to 70/40, and oxygen saturation is 80%.
5. What are appropriate interventions at this time?
6. What procedure may Mrs. Roberts need to further decrease her risk of bleeding?
a. Exploratory laparotomy and hemi-colectomy
b. Esophageal resection and gastric pull-up
c. Transjuglar Intrahepatic Portosystemic Shunt (TIPS procedure)
44
APPENDIX I
Web Based Resources
Clinical Resource Center (CRC) This Intranet site is available on clinical computers or
from home with a password. http://ecrc.ucdmc.udavis.edu
Essentials of Critical Care Orientation (ECCO) will be provided on manager’s approval.
Pulmonary Artery Catheter Education Project (PACEP) http://www.pacep.org
45
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