For most people, an emergency room visit or a extended stay in a hospital’s intensive care unit is a trying, perhaps even frightening experience. So imagine going through the same ordeal while looking up into the faces of health care providers who look nothing like you, don’t speak your language and know nothing about your culture.

That’s what a growing number of hospital patients encounter these days as the nation’s population becomes increasingly diverse and the shortage of emergency department and critical care nurses–especially minority nurses–continues.

A January 2002 report by the American Organization of Nurse Executives states that the average nurse vacancy rate in critical care fields is 14.6% compared with 10.2% overall, and nurse executives surveyed said staffing shortages are contributing to emergency department overcrowding. According to the American Association of Critical-Care Nurses, the number of requests for temporary and traveling critical care nurses to fill staffing gaps has skyrocketed in every part of the U.S., with an especially pronounced demand in the areas of adult critical care units, pediatric and neonatal ICUs and emergency departments.

Given the severe underrepresentation of minority nurses in the nation’s overall RN workforce, it’s easy to understand why the nursing staffs in emergency departments and critical care units don’t reflect the racial and ethnic diversity of the patients they serve. The National Association of Hispanic Nurses estimates that Hispanics make up only 2% of RNs in the United States, even though they account for 12.5% of the nation’s population. African Americans, meanwhile, account for 12.1% of the population but only 4.9% of RNs. On the other hand, Caucasians make up 69.1% of the population, yet they account for an overwhelming 86.6% of the RN workforce.

Training RNs to become emergency department and critical care specialists is the goal behind an innovative collaboration between HCA (Hospital Corporation of America) Affiliated East Florida Hospitals and Broward Community College (BCC) in Miami. The program, which is open to HCA nurses only, is funded by a $4 million Specialty Nurse Training Grant awarded under the President’s High Growth Job Training Initiative and implemented by the U.S. Department of Labor’s Employment and Training Administration. The award is divided between the Florida and Texas divisions of HCA.

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“We are focusing on these two specialties because we saw the most vacancies in these areas,” explains Broward Community College’s Alicia Hinton, BSN, RN, MBA, emergency department project manager for the grant.

One reason for those vacancies, says Kathy King, ARNP, MSN, CCRN, the college’s director for the specialty grant, is that because more patients are now able to be treated without hospitalization, the patients who do end up in the hospital are sicker than they were in the past and therefore require more care. At the same time, the nursing population is getting older and is less inclined, as a whole, to work in these specialties.

“We are seeing nursing shortages really impacting those areas of the ICU and the [ED] the most,” King says. “The literature suggests that cardiovascular ICUs are also having a large percentage of shortages. [These jobs are] very physically demanding, so [RNs are] trying to transfer into a less acute area of nursing.”

“Unbelievable” Diversity

The BCC/HCA Specialty Nurse Training Program, which began training students in January 2005, isn’t designed specifically to increase the number of minority nurses in critical care and emergency nursing. But because the training is offered in the culturally diverse Miami area, a large percentage of the program’s students and graduates are nurses of color.


“The cultural diversity in this program has been unbelievable,” says Charlene Ingwell, MSN, RN, project manager for HCA.

Of the 130 nurses who have either completed or are currently enrolled in the program, 37 are African American, 37 are Hispanic, 28 are Caucasian, 15 are Asian and 13 are classified as “other.”

“I think every cohort has had at least one male student,” adds King. “In this last group we had three, and it averages between one to three per class, so we’ve probably had close to 20 male students.” To be exact, the breakdown by gender is 108 females and 22 males.

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The project’s goal was to enroll at least 80 RNs into the training program over the two-year grant period. Of the 130 nurses who have participated in the program, 79 chose training as a critical care specialist while 51 chose emergency department training, which builds on the critical care component. Graduates from the program receive college credit from BCC, in the form of an Advanced Technical Certificate that can transfer to other colleges and universities.

Pedro Valdes, Jr., RN-CEN, was in the second cohort of nurses who completed the specialty training. He chose to become an emergency department specialist and now works as an ED nurse at HCA’s Kendall Regional Medical Center.

“We were a very eclectic group, ” says Valdes, who has been a nurse for three years. “We had someone from everywhere.”

Having such diverse classmates not only made him feel comfortable, he says, it also provided unique learning opportunities as students shared their experiences treating patients from different cultures. That sort of knowledge is beneficial in a hospital like Kendall Regional, where the patient population is becoming increasingly diverse, Valdes adds.

Disparities between the quality of health care received by Americans of color compared to the majority Caucasian population are well documented. The National Healthcare Disparities Report, published annually by the Agency for Healthcare Research and Quality (AHRQ), reported in 2003 that “racial, ethnic and socioeconomic disparities are national problems that affect health care at all points in the process, at all sites of care and for all medical conditions.” The Institute of Medicine, the Sullivan Commission on Diversity in the Healthcare Workforce and other groups recommend increasing the number of culturally diverse minority nurses in order to help eliminate these inequities. And health care providers like HCA have taken notice.

“To bridge the gap between caring and cultural competency, many health care organizations are looking to hire minorities who represent their patient population,” says Hinton. “They have found that this has been effective in reducing patient complaints, and I would venture to say it reduces the potential for lawsuits, because many lawsuits start out as misunderstandings or miscommunications.”

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Learning While Earning

HCA nurses who are selected to enroll in the specialty training program–which is open to both current employees and newly hired RN grads–first complete a two-week basic arrhythmia course (or pass a challenge exam) before moving on to a two-week clinical on a telemetry unit. Experienced nurses then move on to the four-week critical care course, while graduate nurses continue to gain experience by working on a telemetry unit for three to four months before starting the critical care program.

Students who are not planning to advance to emergency department training go through clinicals on a critical care unit for six to eight weeks. Those who do desire the ED specialty complete a two-week critical care rotation, followed by a two-week emergency department course and six to eight weeks of clinicals in the ED. After three months, all students return for a three-day, 12-lead EKG course.

The training includes a mix of didactic courses, skills lab and a clinical internship. Courses are taught at Broward Community College and simulcast to HCA’s JFK Medical Center. Students must attend class daily, with both online learning and face-to-face classroom activities. This intensive learning environment is designed to accelerate the time typically needed for nurses to become familiar, comfortable and confident with their new specialized skills.

Nurses who work in any of the 13 HCA Affiliated East Florida Hospitals are eligible to apply for the Specialty Nurse Training Program. During the training period, participants are considered both employees and enrolled students of Broward Community College, remaining on HCA’s payroll while earning college credits.

One of the most beneficial aspects of the program is the one-on-one pairing of students with preceptors experienced in emergency department or critical care nursing. Students make rounds with their preceptors, who are given a normal patient load so they can spend the time needed to train their preceptees. The student and preceptor develop a trusting relationship, King says, and as the student’s skills increase, assignments become more complex and the student’s independence grows.

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In addition, placing nurses together who are seeking training in separate specialties helps bridge the gap between emergency department and critical care nurses, Hinton says.

“There has been a long history of a little disconnect between critical care nurses and ED nurses,” she explains. “We feel we are planting a seed of empathy, if you will, amongst the two areas, so ultimately the patients will get the greatest care possible. I believe the way our program is set up helps foster and enhance that collegial relationship that is so important in facilitating a good patient outcome.”

Keeping It Going

Ultimately, one of the key benefits of having such an ethnically diverse group of students in the BCC/HCA Specialty Nurse Training Program is the education of more nurse specialists who can help increase the overall cultural competency among the nursing staff at their respective HCA hospitals.

“Culturally competent nurses can contribute to positive patient outcomes,” Hinton emphasizes. “Patients feel more comfortable if they feel their culture is being accepted, and they also communicate more to that nurse.”

Culturally competent nurses are often able to detect various illnesses based on their comfort level with patients, Hinton says, and that makes it easier for them to ask the right questions and guide the patient toward the proper treatment.

The training program addresses the need for cultural competency by requiring students to interview someone from a culture other than their own and to develop a 15-minute slide presentation on communication style, space preference and social organization. The students are required to incorporate into the presentation three things that can be implemented to promote cultural harmony.

Students are encouraged to pay attention, Hinton says, by the inclusion of questions on the final exam that are drawn from the presentations. King, who has sat in on some of the slide shows, says she has found them enlightening: “As a faculty member, I have learned numerous points about care and management of not only different cultures but different religions.”

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HCA employees who enroll in the training program must commit to remaining with the company for at least two years. HCA is gauging response to the program, King says, by surveying nurses and nurse managers. So far, comments have been overwhelmingly positive, and the retention rate among the program’s graduates is 88%, which King says is above the national average. Nurses who have left have generally been those who were forced to move because a spouse was being relocated, while a few have decided that emergency department or critical care nursing is not for them.

“If a nurse is not [psychologically] prepared to be in those [highly intense critical care areas]–and even if he/she is prepared–[the stress] can take its toll,” says Hinton, adding that burnout contributes to the shortage in critical care and emergency department nursing.

Prior to implementation of the program, HCA hospitals trained nurses to work in these two crucial specialty areas on their own. There was concern that training was inconsistent in these specialties where consistency, skill and knowledge are indispensable. Now, Ingwell says, nurses receive the theory behind what they’re being taught combined with the hands-on clinical component. “The program is absolutely amazing because they get the training, the knowledge and the resources they need to really shine in these two specialties,” she explains.

With the grant scheduled to expire in May 2007, the project managers are looking toward future sustainability for this successful initiative. “The idea is that [once the grant ends] HCA will step up and say, ‘How can we continue with this program without the presence of the grant,’” says Ingwell.

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