Specializing in Diversity

Specializing in Diversity

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.

“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.

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.”

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.

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.”

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.

Critical Careers

Ronnie Ursin, BSN, RN, BS, figured there would be a lot to learn when he moved from his nursing job on a medical/surgical floor to a cardiac intensive care unit–and he was right. “It was like night and day,” he says. “It had been described to me as going through nursing school all over again, and that’s exactly what it was like.”

On the med/surg unit, Ursin took care of half a dozen patients at once, who for the most part could walk and talk and be left alone for periods of time. In the ICU, he cared for only one, maybe two, patients during each shift, but these patients were the most vulnerable of any in the hospital. Hooked up to multiple high-tech machines, they required vigilant monitoring and assessment, and their complex conditions could change in a blink of an eye.

Critical care nursing is one of the most intense specialties nursing has to offer. But for nurses who thrive in the practice, it also is one of the most rewarding.

“You can see these patients who are very sick and three days later you’re able to see them get better and send them off the unit,” says Ursin, a board member of the National Black Nurses Association. “You know you played a part [in their recovery]. That’s the most rewarding thing of all.”

After gaining experience in cardiac intensive care, Ursin became director of the Acute Medical Unit at Washington Hospital Center in Washington, D.C. He says his critical care experience helped broaden and deepen his medical knowledge, which has assisted him in his current position.

A great benefit of working in critical care is autonomy, Ursin adds. “Because the critical care nurse is at the patient’s bedside more than the doctors, the doctors really value the nurse’s opinion. There are some things we catch that the doctor doesn’t catch.”

The Human Touch in a High-Tech Setting

The concept of critical care is relatively new. Hospitals developed the first intensive care units in the 1950s to care for very sick patients, such as polio victims. Patient survival rates rose and more ICUs were added, with the first cardiac care units developed in the 1960s.

Today critical care nurses care for the most seriously ill and severely injured patients in a variety of settings: on emergency transport teams, in intensive care units, pediatric ICUs, neonatal ICUs, cardiac care units, cardiac catheter labs, telemetry units, progressive care units, emergency departments and recovery rooms. Smaller hospitals typically have a general intensive care unit for any patient in critical condition and perhaps a cardiac care unit. Large university medical centers often have 20 or more specialized critical care units.

In addition, today’s critical care nurses increasingly work in home health care, managed care organizations, outpatient surgery centers and clinics, according to the American Association of Critical-Care Nurses (AACN), headquartered in Aliso Viejo, California.

Martha Baker, PhD, RN, director of the BSN program at Southwest Baptist University in Bolivar, Mo., worked in critical care for more than three decades as a staff nurse, charge nurse and educator, as well as in staff development. She says she found the specialty exciting and she particularly enjoyed the opportunity to learn about new medical technology. Friends described her as an “adrenaline junkie,” but the most rewarding part of her critical care experience, she says, was providing the human touch in a high-tech environment.

In fact, Baker cautions, one thing critical care nurses have to guard against is getting too caught up in the mechanics. “Amid the multiple machines, you have to remember there is a person in the bed. You’re not taking care of the monitor, the ventilator and the balloon pump. You’re taking care of a human being.”

Cultural Critical Care

From the time in high school when he worked as a volunteer in an emergency room, Ramon Lavandero, MSN, RN, MA, FAAN, has been drawn to critical care. Lavandero has worked as a staff nurse, directed critical care at a university medical center and taught critical care nursing. In his work at hospitals, he enjoyed the team camaraderie as well as the intellectual stimulation of caring for patients with complex conditions.

“When a person is dealing with a life-threatening illness, every aspect of that individual is potentially affected,” he explains. “There are interactions of the different body systems and between the body and mind, and also with the family and social systems. You can’t be thinking in narrow boxes.”

Lavandero, who is now director of development and strategic alliances for AACN, says he found deep meaning in his work with patients and their loved ones. “I found the families were really fellow caregivers.”

“You’re there to keep the patient comfortable, but you also need to be there for the family,” Baker agrees.

This is one of the reasons why understanding and respecting cultural differences is so important in critical care, and why culturally knowledgeable minority nurses are so urgently needed in this specialty. Critical care nurses are advocates for their patients, respecting their rights, values and beliefs and intervening whenever the patients’ best interests are in question. They act as liaisons between the patient, family and other nurses and doctors, often bridging communication gaps that can develop under such stressful conditions. When end-of-life decisions must be made, critical care nurses are right there on the front lines.

Baker, who is president-elect of the National Alaska Native American Indian Nurses Association, often served as a resource for other hospital staff members who wanted to learn about traditional Indian customs to better serve their patients. At the request of families, she helped arrange smudging ceremonies and traditional drumming and singing for patients who were in intensive care. “It takes some creativity, but you can make those accommodations on the unit if you work at it,” she says.

With a diverse nursing staff, “everyone brings something different to nurture one another and support one another,” says Regina Cullen, senior nurse recruiter at Brigham and Women’s Hospital in Boston, which provides intensive in-house critical care training programs for both new and experienced nurses. The hospital has a minority mentorship fellowship for students in their junior year, and in many cases hires those nurses once they graduate.

Diversity goes beyond ethnicity, however, says Lavandero, a native of Puerto Rico. Diversity of religious beliefs, gender, geographical and educational background is important, too, to produce a staff with a variety of cultural perspectives. A patient’s needs may be overlooked if the perspective is too narrow, he warns.

Making the Move to Critical Care

Opportunities abound for minority nurses interested in working in critical care, a specialty that has been hit especially hard by the nursing shortage. Many experienced nurses are nearing retirement age at a time when hospitals are expanding their critical care units. According to a 2004 survey by the American Association of Critical-Care Nurses, 27% of the nation’s critical care units reported increases in the number of budgeted positions. Progressive care areas have a larger number of unfilled positions than intensive care units. The AACN survey found that it took an average of 62 days to fill a nursing position in intensive care versus 90 days in progressive care.

Baker tells her students to get at least six months of experience on a regular hospital floor before going into critical care. Nurses entering critical care must not only adjust to the intense pace, but they also have to master all the high-tech medical equipment, which can be overwhelming for brand new graduates.

“You have to be alert and on task because small changes [in a patient’s condition] make a big difference,” says Baker. “It’s very difficult to do that right out of school because you’re also learning to be a nurse.”

Brigham and Women’s Hospital, a teaching hospital for Harvard Medical School, focuses on growing its own critical care nursing staff from within by helping intermediate care nurses interested in critical care move into working in ICUs. Cullen says this makes for a highly successful transition because the nurses are already familiar with the hospital. They can focus all their attention on the critical care program without having to worry about adjusting to a new work environment as well.

The hospital also hires ten new graduates a year for critical care, but they must first spend six months working in intermediate care before moving into an intensive care unit. To be eligible, the nurses must also have completed a senior practicum in an ICU and worked as a student nurse or patient care assistant at the hospital. Initially the hospital tried hiring these nurses directly into critical care after four months of orientation. But, Cullen says, “We found they needed the basic nursing foundation first.”

Do You Have What It Takes?

What does it take to work in critical care? First of all, critical care nurses should have solid clinical skills. “When you listen to the heart or chest, you have to know what you’re hearing and be able to detect small changes,” Baker says. “You have to be able to be organized, prioritize decision making and be detail-oriented so you can monitor everything.”

An ability to think and act quickly is essential. “Things happen so fast, you constantly have to be on top of all the signs,” says Ursin. “You can’t just say, ‘okay, I’ll deal with that in five minutes.’”

Today’s critical care patients are sicker than ever before, and many would not have survived a generation ago. New treatments and technology are being developed every year, making patient care even more complex. Critical care nurses must stay on top of the latest information and constantly update their skills to keep pace.

Critical care is not for everyone, Baker says, and nurses must consider carefully whether the specialty is right for them. “For me, nobody is less of a nurse because they don’t like critical care,” she emphasizes. “Everybody’s gift in nursing is not the same, and that’s the beauty of nursing.”

For instance, nurses who get the greatest rewards from getting to know their patients personally are probably not best suited for critical care units, where patients are too ill to engage with others and are heavily medicated, which blurs their recall of the events in ICU and the nurses who cared for them. Patients often spend only short periods in the ICU before moving to units with less-intensive care.

But if this fast-paced, challenging career with its own unique rewards does sound exciting to you, the demand is there and the need for more culturally diverse nurses in the specialty is creating unprecedented opportunities. To learn more about what a career in critical care is like, Lavandero suggests talking to other critical care nurses and spending some time in an intensive care unit. Check with the educator for that unit, and seek out nurses with a variety of experience levels in critical care to get a good feel for the specialty, he advises.

For More Information

American Association of Critical-Care Nurses

Established in 1969, the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world, with more than 400,000 members. The association publishes a monthly newsletter, a scientific research journal, a clinical magazine for practicing nurses, a quarterly series for advanced practice nurses and an annual Career Guide. The association’s annual National Teaching Institute and Critical Care Exposition attracts more than 6,000 participants and exhibitors, providing nurses with a wealth of education and career information. AACN also offers scholarships to AACN members who are RNs completing a baccalaureate or graduate degree program in nursing. The association’s Web site features information about certification, clinical practice, education, public policy, research and more.

AACN Certification Corporation

The AACN Certification Corporation provides credentialing for nurses who maintain standards of excellence in acute and critical care nursing. The corporation administers the CCRN, CCNS (for clinical nurse specialists) and PCCN (progressive care) specialty credentials and the CMC (cardiac medicine) and CSC (cardiac surgery) subspecialty credentials. Its Web site provides information about each of these credentials, online exam registration and renewal, and information about exam review courses.