创新人员配置模式解决护理人员短缺问题

保罗·安德森:欢迎来到ECRI的智能医疗安全，ECRI是医疗保健领域最值得信赖的声音，致力于推进有效的循证护理。我是主持人保罗·安德森。十多年来，我一直在ECRI监督我们的患者安全、风险和质量会员计划。成千上万的医疗保健领导者依靠我们作为一个独立的、值得信赖的权威机构来提高全球所有医疗保健机构的安全性、质量和成本效益。你可以在www上了解更多关于我们改善结果的独特能力。ecri。org。今天，我们再来看看医疗人员短缺的问题。过去，医疗保健行业一直面临着劳动力短缺的问题，甚至在COVID-19大流行使情况变得更糟之前，美国护士协会和美国劳工统计局就预测，到2022年底，将有50多万注册护士退休。我们今天的嘉宾是克莱尔·赞格勒，宾夕法尼亚州匹兹堡阿勒格尼健康网络的首席护士执行官，以及艾琳·托德，杰斐逊医院北五区的护士经理，也是阿勒格尼健康网络的一部分。 Claire, I'd like to start with you. And when we think about healthcare workforce shortages and specifically nursing shortages, I know that you've been leading development of a staffing model that we've called blended staffing. So can you describe a little bit about what that is?< / p >

克莱尔Zangerle:当然，谢谢你，保罗。谢谢你们今天邀请我和艾琳。我们很高兴能谈谈我们正在做的一些创新的事情在我护理生涯中最具挑战性的时期，也就是在人员配备方面的挑战。所以，正如你所说，即使在大流行之前，我们也面临着人员短缺的问题，但与我们现在拥有的相比，这根本不算什么。在流感大流行之前，我和大约250名护士在水下工作。今天，我在水下1200米左右。我很乐意回到250美元的日子。因此，拿出创造性的解决方案一直是我们高度关注的焦点。韦博体育app官网注册我们提出的其中一个解决方案，实际上韦博体育app官网注册我们甚至在大流行之前就开始了，因为这对我们来说是一个机会，就是让lpn回到急性护理中。回到80年代，90年代，2000年代，我们说，“lpn，谢谢你们的服务。 Go ahead and go to the LTACHs, go to rehabs, go to post- acute care because you know what? We've got it from here with the RNs at the bedside." A lot of it had to do with Magnet designation and Magnet saying you had to have BSNs at the bedside. And yes, there is evidence, and we believe in that evidence that having BSNs at the bedside is absolutely better for quality, safety and efficiency. However, in light of the shortages of nurses, we look to a blended model. And now, some of us may remember this as team nursing and there's not much of a difference. We just rebranded it into blended nursing because we feel blended is a better description of the team. And for us, blended nursing is utilization of a registered nurse as a team leader, an LPN as a member of the team, and a nursing assistant slash patient care technician, as a member of the team as well. So, that team takes on a cohort of patients and support each other as they're supporting those patients at the bedside in their unit. There's really not a big difference between team nursing and blended nursing. But I can tell you, with the different generations of nurses that we have, if I said team nursing to one group of nurses, they'd be like," Yeah, we've done that for years." Blended nursing is new to a different generation of nurses, but essentially, they're the same thing. And it's all about the teamwork. I think that's the essential piece of this entire model.< / p >

保罗·安德森:实际上，我想先退一步，就一会儿。我想知道您是否可以为不知道BSN，注册护士和LPN之间有什么区别的观众简单地定义一下?< / p >

克莱尔Zangerle:因此，学士预备护士是受过更多教育，更正规教育的护士。他们有四年制学位。有执照的实习护士接受了更多的技术培训，这是一种认证和执照。没有与之相关的副学士学位或学士学位。我想LPN，你可以说是介于护士助理和注册护士的技能之间。每个州，LPN都有执业范围在全国范围内，执业范围是非常不同的。我们专注于此，因为我们的足迹在宾夕法尼亚州，宾夕法尼亚州西部，以及我们北边一点点的地方。甚至在纽约西部，我们也关注这些地区的实践范围，这样我们就知道LPN在他们的实践范围内能做什么不能做什么。所以，它们是非常不同的学科，但它们肯定是相互补充的。我们关注lpn的另一个原因是我们没有得到足够的护理援助。 We had to relieve the workload of the registered nurse, and by introducing that LPN back into acute care, that also helped relieve some of the pressure on the nurse to get every single thing done, and allow our nurses, our registered nurses, to practice at the top of their license.< / p >

保罗·安德森:你猜到了我的几个问题。我想问的是lpn的范围是否真的在州一级设置。所以，你提到了这一点，我一直在想的一个短语，你说得越多，就是在他们的执照上练习的概念。所以，我想我的问题是当你有一个由注册护士，注册护士和护士助理组成的团队一起工作时，除了由国家实践条例定义的范围之外，显然这些就是他们，我们必须与他们合作。是否还有其他不可协商的因素来分割团队，你说，“好吧，不管发生什么，这是我需要注册护士做的事情。”是出于安全考虑还是其他原因?< / p >

克莱尔Zangerle:我可以从概念的角度告诉你，艾琳可以从生活经验的角度告诉你。所以，从概念的角度来看，注册护士，我们必须教很多注册护士授权的技巧。他们放弃了什么来允许LPN做呢?在他们的执业范围内，他们能信任LPN做什么?因此，从概念上讲，委派技巧、实践范围、团队合作以及如何作为一个团队一起工作都是非常重要的。但就生活经验而言，我要向艾琳推荐，因为她是真正做了大部分工作的人。我只是有想法的人，她才是执行的人。< / p >

艾琳·托德:所以，引入lpn，我们面临的第一个障碍是它们能做什么?这是很多人都不熟悉的东西。就像我们，从管理的角度来看，鼓励我们的员工团队合作一样，我必须向网络中拥有lpn的其他管理人员寻求资源，以弄清楚我的新员工可以做些什么?所以，我和我们的急诊室合作，另一家当地医院有一些lpn，开始了解实践范围，他们在哪里利用他们，并找出我们如何将实践范围应用到我们的单位中。所以，这绝对是我们的第一个障碍，就像，我们有了这些全新的双手，我们以前没有过。他们肯定能比护理员做得更多，但在住院时，或者当病人入院时，他们能做些什么?有些事他们能做，有些事他们不能做。什么是血液管理?他们可以共同签署血液制品吗?因为这是我们做很多事情都要反复检查的。 Where does that fall? And so those are things on the fly that our staff was wanting to delegate and wanting to work as a team, but we had to establish and really learn what they could do for us.< / p >

克莱尔Zangerle:我可以告诉你，一个真正的不可谈判的，艾琳知道这一点，因为她的生活，是沟通。你必须与你的每一个团队成员沟通，因为他们像管弦乐队一样一起工作。如果他们不能交流，如果他们的乐器不能一起演奏，那么病人就不能得到他们需要的。每个团队成员都会感到非常沮丧。所以，如果你要求一个不可谈判的，那就是它。< / p >

艾琳·托德:100%。< / p >

保罗·安德森:艾琳，你提到了一个最初的挑战，就是弄清楚这些lpn在加入团队后能做些什么?你还遇到了哪些障碍，是你预料到的，还是你一路走来遇到的惊喜?< / p >

艾琳·托德:当然,是的。护理界的变化，可能在其他任何地方，都不是一个好话题。没有人喜欢改变。所以，当我参加人员会议时，我说，“嘿，我们要推出这个新的混合项目。我太兴奋了，”她的眼睛转了转，这很难。所以，你必须在背后支持它。我真的在寻找我的关键球员，我有一些员工……无论发生什么，他们都会支持我。真正好的是，我有一个护士刚刚完成了她的学士学位，刚刚完成了混合护理的研究，她非常兴奋，因为它就在学校里，她知道这一点。她说，“我刚知道这个。 This is so awesome." So, really having those cheerleaders helped. You really struggle with the ones that are like," Ah, we've done this before. We tried something like this." And so, really being positive and continuing to... Sometimes it's baby steps, it's starting with a really, really, really small changes. And that's where we found, we rolled out this big thing, and this is what we're going to do. We're dividing into teams and you're going to tackle these patients and you're going to handle these patients. And it was too much too fast. And so, we backpedaled a little and we really started with, okay, the first thing we're going to do is you as a team are going to establish when you're going to lunch, because that's evidence- based practice. When you get a break and you physically can walk off the floor, you come back refreshed and you deliver better patient care. And that's nursing. Everything we do is based off of evidence- based practice. Nursing is a practice, it's not black and white. So, we have to look to always in the research and that's something that's proven all the time that when you get that break, it makes a difference. We started there and I would notice because that's something that we track, is they have the opportunity to delegate or explain that they didn't get a lunch for their shift. I watched those start to dwindle down within my timekeeping that," Hey, everyone's going to lunch. This is nice." And then the staff started to catch on like," Hey, I went to lunch every day this week." So very, very small things. And that's really what started to unwind, is they had to buy in to what we were selling essentially.< / p >

克莱尔Zangerle:我很抱歉打断保罗，但我想说的是，除了艾琳解释的，她解释得很好，我们还有另一个障碍，甚至是克服这些障碍的一些方法，就是补偿。lpn在急症护理之外赚了很多钱我们没有与时薪竞争我们仍然没有100%做到这一点。我们的很多私人执业医师都说:“你知道吗?我可以在LTACH工作，每小时多挣几美元，但我想做急症护理。”我们的大多数急症后护理合作伙伴都是营利性机构。有时候LPN是当班最高水平的临床医生。所以，他们当然会支付给他们。所以，我们在组织上的一个障碍，是审查lpn的补偿模式。另一个障碍是lpn的怀疑他们实际上相信我们会邀请他们回到急症护理并让他们成为团队的一部分。因为这么多年来，那扇门一直关闭着。 And once the word got out, that started to happen. And actually, we've even used our agency partners to help us identify LPNs who might want to come back into acute care, and not every region in the country has access to LPNs. Western Pennsylvania is blessed with a lot of LPN schools, so we are able to source those. This summer, we have 144 LPNs coming in to do clinical rotations in our hospitals. So, if we don't hire them, we are going to push them to our narrow network post- acute care partners to staff those, so that we can have a lower length of stay because our barrier to our length to stay is our post- acute partners not having staff. And if LPNs can help with that, then that's great.< / p >

保罗·安德森:是的。我的意思是，整个系统的连通性，才是真正的健康系统。< / p >

克莱尔Zangerle:肯定的。< / p >

保罗·安德森:这很有道理，是的。你提到了艾琳，注意到人们突然之间，真的一直都能吃午饭了。这听起来是一个非常好的胜利，也与患者的治疗结果有关。你还取得了哪些其他的胜利?尤其是那些你没有预料到的?< / p >

艾琳·托德:所以我真的没有预料到，克莱尔谈到了这一点，有助理人员，护理助理，护理技术人员真的听不见病人和工作人员一起工作。< / p >

保罗·安德森:当你实施这个过程时，你是否发现医院的某些区域或单位比其他地方更适合混合方法?< / p >

艾琳·托德:实际上，在担任这个管理职位之前，我做了三年半的医院运营经理。所以，本质上，这是一个四处走动的主管，确保每个人的事情都井然有序。我称自己为专业的消防队员。所以，你处理这些事情，但它总是回到经理那里。所以，我真的有机会看到所有单位的不同之处，以及它们是如何工作的。真的，我喜欢这种混合护理的地方我发现，它不是一刀切的，它必须以这种方式工作，一旦你接受了它，你就会真正弄清楚它是如何为你的单位工作的。所以我真的，真的认为这在任何地方都是有益的。真正要做的是理解它看起来是不一样的。北五区不会像重症监护室那样发挥作用，就是不一样。但如果你拿着那些钥匙… making sure people are getting breaks, making sure we're talking, making sure we're checking in with each other, it really will work anywhere.< / p >

保罗·安德森:克莱尔，早些时候你谈到了LPN人员的作用和影响，以及与磁体指定有关。我想知道您是否可以对此进行一点扩展，这个角色是什么?什么是影响?当你在发展这个过程中随着lpn数量的增加你有什么顾虑吗这将如何影响磁体的指定?< / p >

克莱尔Zangerle:是的。所以，我不太担心引入lpn会对我们的磁力指定产生影响，不管我们是已经被指定的医院，我们在旅途中，或者我们正在考虑走上这条路，只是因为这一点，因为不管我们在床边帮助护士的纪律如何，我们用来满足磁力标准的证据仍然会得到满足。使用任何可以帮助护士在他们的执照上执业的学科，这对我们也有帮助。它不会从我们带给磁体过程的价值中拿走任何东西。我知道这是很多人非常关心的问题，但如果你深入到实际问题，你就会有人帮助你做你的工作，这样你就可以在你的执照上练习，这一直是磁铁指定的一个元素。< / p >

保罗·安德森:在过去一年多的时间里，我们在ECRI和ISMP患者安全组织中关注了很多事情之一，就是当我们专注于减少护理中的不平等和差异时，其中一个不断出现的主题是确保我们有一支代表我们服务的社区的劳动力队伍，代表我们社区中所有相同的不同群体。我想知道把lpn带回急症护理队伍中，是否有助于使队伍更加多样化，更准确地反映你所服务的社区?< / p >

克莱尔Zangerle:是的,当然。我们所看到的是，护理学校的费用有时对任何人来说都是令人望而却步的。当然我们看到在我们的被边缘化的人群,在我们的社区,想上大学的人不会有这样的机会,但这是一个路径,它是一个入门级和LPN项目是负担得起的和它们与奖学金资助,你可以获得联邦政府的贷款,各种各样的东西,就像你可以护理,但就我们讨论的人群,不同的人口,他们吸引了获得学位或获得许可,开始工作，这是必要的。是的，这对我们来说也是一个附带的好处，让AHN的员工群体多样化，因为说实话，在全国范围内，医疗保健领域的多样性还不够。医生，护士，任何医疗领域都没有足够的多样性。必须有这种多样性，因为我们都从证据中知道，如果有人照顾你，长得像你，理解你的个人信仰，结果会更好。这一点非常重要。这也是我们对这个项目附带利益的希望。< / p >

保罗·安德森:在整个谈话过程中，我们谈到了证据的重要性，以及证据是否证明了工作人员的重要性，就像他们所服务的病人群体一样，是否证明了午休的重要性，回来后精神焕发，能够真正专注于手头的工作。我想知道，当你转向这种人员配置模式时，你是否看到了任何证据，表明它确实产生了你想要的影响?无论是安全结果，还是员工满意度，或者任何你可能会说，“是的，好吧。我们知道这是我们想做的事情。”< / p >

艾琳·托德:是的，所以实际上我们和Press Ganey合作，作为我们对病人的调查的一部分，看看他们在医院的经历。在我们部门，我看到一个增长的领域是，有一个问题问员工是否一起工作。这是我们在过去六个月里真正增加的东西。你可以看到。这是很棒的数据，它真的，真的适用于混合护理。上面写着"你的员工一起工作吗"这是不言自明的。所以，这绝对表明，嘿，人们注意到我们在互相帮助当我们一起工作的时候，或者一个护士换了一个上来，他们仍然作为一个团队一起工作，病人也看到了这一点。所以，从病人的角度来看，我们看到了。从员工的角度来看，我们有一点…… we call it a kudos board on our unit. And it's just that the nurses will leave shout outs to their team for helping them. And it's an idea I totally stole from somebody at a meeting that I said," I love that. That sounds great." And I put it up on our unit thinking," I don't know how this is going to do," and it just totally took off. And it's covered with thank yous," Thanks for helping with my assessment. Thanks for staying late with me. Thanks for doing my wound documentation." And it really shows that the staff is loving each other working together and it's just great to see.< / p >

保罗·安德森:我在想，如果你想到那个荣誉板，你有没有……我的第一个问题是，给我举个例子，看看人们把什么东西挂在上面，但我猜，你有没有听过那些被感谢过的人的反馈，他们肯定地说，“是的，看到我的名字挂在上面，我的同事感谢我，这实际上比你想象的更有意义。”< / p >

艾琳·托德:是的,当然。它来自于那些你绝对想不到会说:“嘿，那真的让我感觉很好。”我有时会往上面扔东西。上周是护士周。我在上面放了一个小宣传，说:“我甚至不想说谢谢，因为这不足以解释他们为我和彼此所做的一切。”我最近在十二月底接手了这个单位。所以，我之前是副经理，然后我突然出现，我说，“好吧，我们正在做这些事情，伙计们。很抱歉告诉你。但它来了。”让他们掌握它，它改变了我，能够真正拥有一个团队。 I'm really thankful to watch them work together like this and welcome me alongside of them.< / p >

保罗·安德森:在我们结束之前，我想说的最后一件事是AHN的回归实践模式。所以，我想知道你是否可以描述一下这是什么，也许也可以给出一些你是如何看到它发挥作用的例子?< / p >

克莱尔Zangerle:确定。我们早在2017年就开始了这项工作，因为我们意识到，我们知道有护士，有护士在那里保留着他们的执照，但他们没有执业。由于种种原因，他们没有练习。我们在医院工作，时间安排不是很灵活。大概是12小时一班，10小时一班，8小时一班，或者什么都没有。每个人都有自己的生活。他们可能需要抚养他们的孩子，他们可能想让他们的孩子上公共汽车，然后在他们回家的时候陪伴他们。他们可能有父母，他们要赶着去赴约，来回奔波，诸如此类的事情，他们不能每周工作3点12分，或者诸如此类的事情。我们需要了解这些护士的真实情况，而不是把她们放进我们的小模子里。因此，我们创建了这个名为“回归实践”的项目，并与一家名为iRelaunch的公司合作。 Initially, iRelaunch is a re- entry to work program for those exact types of people in other industries, in STEM, in banking and things like that, who have gone away from their career and wanted to come back into a career. And so we said," Let's do this for nursing." I'd done that at a previous organization where I was before. And I thought," I want to try this in Pittsburgh. I'm sure we can do it." And sure enough, we launched it. And we did a really soft launch because unlike where I was before in a different state, we had access to data that told us on their state nursing... The state board of nursing said," This is the group of nurses who are not working because on their license application, they check not working, but still licensed. And here's your pool of people." We didn't have that pool of people for Pennsylvania, but we just advertised about it. We talked about it. Our recruiters talked about it, word of mouth. The first year, we got about 60 nurses to come in to do that. Now, if you've been away from practice for five minutes, you need to get refreshed because every five minutes things change. So, we partnered with the University of Delaware because they had a very robust refresher course that people interested could do online. Self- paced, online and it assessed where they were. If they've been out five years, if they've been out 25 years, and we did have nurses that ranged from being out for a couple years, up to 25 years, want to come back. So, they'd take that refresher course and we'd pay for it. Upon completing that refresher course, we would pair them up with a preceptor on a unit of their choice, and they could go to that unit of their choice and work with that preceptor, and they got paid their hourly rate, which is a little bit less than our staff nurses because they didn't get benefits, or PTO, or anything like that at the beginning of the program. We've revisited that a little bit just because of the staffing shortages and because it's the right thing to do. So, they would partner and shadow with them. And then when they were ready to be independent, they were independent. And they had the flexibility of working a minimum of two hours up to a maximum of 12 hours in a shift. And there is not one time, 24/ 7, that we don't need a pair of hands. And if somebody wants to come in for two hours, we've got something for them to do. Mind you, this is a logistic nightmare for the nurse managers, but when they need those staff, they do it. I can tell you it, I think going forward, we're going to make this a harder push because I know that since the pandemic, people have left and do want to come back. So, Erin's got a lived experience where she's got return to practice nurses. And she probably has some of these experiences where it's worked and there's pros and cons of it, but we're leaning into the pros.< / p >

艾琳·托德:是啊，我们最近迎来了第一个重返实习护士岗位的人而他已经四年没有实习了。所以他参加了考试，通过了所有考试，开始工作，但后来家庭生活……在一家家族企业工作。所以，类似的故事，外面的东西把你拉开。所以，他回来了，这真的很好，因为他们开始，就像克莱尔说的，这几乎又像一个临床。所以，他每周在这里呆8个小时，我想大概是10周，然后做测试。做得很好，然后回到病房，像其他护士一样适应环境。我们所发现的是我们所期待的，因为他是一个回归者，准备好出发，真正简单的方向。这对我们来说是一个学习曲线，他必须从头开始，这很好。我们已经习惯了。 It was just not something that we were thinking. But what he really liked about the unit was, shameless plug for the blended nurse, saying how welcoming and how well of a team we were. So, it was really good to see that. And from the beginning, him being able to come in here and not feeling like he was alone, or like a fish out of water, because we had this assumption that he would be able to do things. We really gave him all the support that he needed, but would let him fly when he was ready to.< / p >

保罗·安德森:所以，我总是喜欢通过询问一个组织可以采取的一两个步骤来结束这些对话。所以，如果我在医疗系统工作，我听到了你所说的，我准备好迈出这一步，但我知道我可能不会在下一个工资期建立一个全新的人员配置模式。我从哪里开始朝着正确的方向前进?< / p >

克莱尔Zangerle:听不清。< / p >

艾琳·托德:从午休开始。从午休开始。这听起来很傻，但这很重要，而且……很容易买到。而是"听着，这周我唯一想让你做的事就是去吃午饭"这很容易推销。“好吧，我们可以解决这个问题。”为了让你去吃午饭，不是我的主管护士安排六个不同的人吃午饭，因为这是过去的工作方式，“你这个时候去。这个时候你得走了。”因为它不是那样工作的。 Things change, patients get worse, or something unexpected happens. So just encourage," Okay, you three are working together today. Figure out how you're all going to go to lunch today." And it is very, very small, but it's something that they'll see and they'll like, and then they'll want to know more." Okay, what is this all about exactly, because now I'm fed and I'm happy. Now I want to listen."< / p >

克莱尔Zangerle:所以，我的建议是让你的护士领导和你的员工参与他们认为的解决方案是什么。因为你可能认为是一个解决方案，我不知道，护士长，或者其他什么，这可能不是那个单位的正确解决方案。作为护士长，没有放之四海而皆准的办法，要根据自己的情况进行调整。只要你有共同的目标，你如何从你的单位到达那里。护士长是他们单位的首席执行官。如何达成共同目标就是如何达成共同目标并使之互动。不要用自顶向下的方法，用自底向上的方法，侧边接近。然后我想你会成功的。< / p >

保罗·安德森:克莱尔，艾琳，非常感谢你们今天能来。< / p >

克莱尔Zangerle:谢谢你！< / p >

艾琳·托德:谢谢。< / p >

保罗·安德森:您可以从ECRI网站www.ecri了解更多关于ECRI和ISNP和PSO的信息。ecri。Org，在那里你可以找到我们的2022年十大患者安全问题报告，其中人员短缺是排名第一的问题。你可以在www上了解更多关于阿勒格尼健康网络的信息。安。org。请务必在Spotify、iTunes、b谷歌Play或任何您获得播客的地方订阅我们的最新剧集。我们欢迎您的反馈。请访问我们的ecri。或发邮件给我们ecri- podcasts @ ecri。 org.< / p >