This organization-specific course enhanced competency and saved time and money.
The U.S. Bureau of Labor Statistics projects that 195,400 RNs will leave the nursing profession from 2021 to 2031. Addressing this predicted nursing shortage will require innovative approaches and the support of well-trained assistive healthcare personnel, including patient care assistants (PCAs). To ensure these unlicensed healthcare workers can meet the demands of the work required of them, they must receive appropriate training and ongoing education.
At The Christ Hospital Health Network (TCHHN) in Cincinnati, Ohio, feedback regarding training courses attended by new-hire PCAs during the onboarding process indicated that they weren’t receiving instruction appropriate to their work in an acute care hospital. To address this shortfall, the chief nursing officer set out to create an internal PCA course (with didactic, simulation, clinical experience, and testing components) to provide knowledge, skills, and competency customized to the organization.
TCHHN, which first received American Nurses Credentialing Center Magnet® recognition in 2010 and most recently in 2020, has over 2,000 frontline team members (including RNs, licensed practical nurses, and PCAs) who provide direct patient care. The previous onboarding process for PCAs included a state tested nursing assistant (STNA) program offered by a local career training facility. Many PCAs reported that the curriculum didn’t cover the skill and time management needs of an acute care facility; it focused on long-term care/skilled nursing facilities. As a result, unit educators had to supplement onboarding of new-to-healthcare PCAs with impromptu training, including taking vital signs, using hospital equipment, conducting blood sugar testing, collecting specimens, and performing ECGs.
In addition, the state of Ohio STNA certification requires annual continuing education specific to long-term care/skilled nursing facilities. PCAs credentialed under the STNA struggled to maintain their certification while employed in the acute care environment. The hospital received only a minimal return on investment by sending new team members to external STNA training.
Per the Ohio Administration Code, PCAs work under an RN, who delegates assignments and tasks. At TCHHN, PCAs play an integral role in providing safe patient care. Newly hired, new-to-healthcare PCAs attended 2 weeks of external career training, which required 16 hours of clinical rotation in a long-term care facility. After completing the training, they participated in 3 days of centralized hospital orientation. PCAs and unit-based educators reported that these new employees didn’t receive an adequate foundation for the care they’d be expected to provide in an acute-face facility.
The CNO asked human resources to present a business case for moving from STNA training to an internally developed PCA training course. The proposal highlighted key differences, including a shorter training period, more appropriate curriculum, and reduced costs. (See External vs internal training)
The CNO accepted the proposal, and implementation began in the third quarter of 2019. A PCA role content expert partnered with training and development experts in the organization’s network learning department to design and implement the internal PCA course in 2020. The director of the Center for Nursing Excellence oversaw curriculum development; the manager of clinical education directly supported the training course.
PCA course development began in late 2019 with plans to launch the new program in the winter of 2020. The course development team addressed several questions: What will be taught? Who will attend? How many days should the course take? How do we ensure students absorb the information? What do they require for success?
Time and structure
The team decided to focus on new-to-healthcare employees. Many of the new hires were in their first to third year of college and just beginning their healthcare journey; most were attending local nursing programs. To address the time constraints of college schedules, the team developed a program of 4 consecutive days, 8 hours each. Days 1 and 2 are didactic and hands-on training in the simulation lab; Day 3 consists of a morning skills review, clinical hands-on rotation with a preceptor on their home unit, and a debriefing. Day 4 is testing day (a 50-question written test and a hands-on skills test with the course instructor selecting three random skills for return demonstrations). Courses are offered once a month with the possibility to add classes as needed. The classes are capped at ten students to one instructor.
Skills and curriculum
Next, the team reviewed the PCA competency packet with the TCHHN educator forum. After exploring the RN-delegated tasks included in a PCAs daily routine, this house-wide council made recommendations regarding skills for course inclusion. These skills include checking vital signs and blood sugars, providing perineal/urinary catheter care, positioning patients, collecting specimens, transferring patients, and charting. The team also reviewed the PCA job description and included several additional elements, including safety, hygiene, comfort, nutrition, exercise, and elimination.
To ensure an evidence-based approach to the course, the team referred to resources such as Lippincott’s Textbook for Nursing Assistants and Nursing Reference Center Plus. Grouping skills created an efficient course flow, which was then broken down into four teaching modules, two each day. Each module includes objectives and hands-on return demonstrations that students are later tested on randomly. (See Course objectives)
The team collaborated with the in-hospital simulation center staff, which includes RNs who specialize in group teaching, working with high-fidelity simulators, and specific debriefing techniques. The team aimed to present an experience similar to actual patient care. Simulation manikins help to provide true-to-life practice; they can moan, groan, sweat, simulate high and low blood pressure, code, and switch from male to female. In addition, class supplies, stocked by the simulation team, are the same as those used on the units.
On Day 3, students move to using what they’ve learned on real patients. In a 6-hour clinical rotation on their home units, the students work with a PCA preceptor who stays by their side to offer mentoring and guidance, and to answer questions. After completing the clinical rotation, the students participate in a debriefing session with the course instructor.
Testing concludes the course on Day 4. To help reinforce what the students have learned and ease test anxiety, the day begins with a brief content review. Individually, students complete a written test and a hands-on skills test with the course instructor. The skills test is pass/fail; the written test passing grade is 80% and above. If students don’t pass the written test, they can participate in a remediation session focused on the questions they missed and then take a new test.(To read more about the final course design, See Final course design.)
Clinical leader buy-in
The team presented the course design to clinical leadership for their feedback and approval. They highlighted the differences between the previous training and the new course; the biggest positives were time and cost savings. The presentation received an overwhelmingly favorable response.
The managers asked about electronic health record (EHR) access by the students. As a result, a computer access/welcome session was added to the course to ensure a complete orientation. The welcome session gives students access to their work email, timecard, scheduling, and the EHR system.
They also received access to the e-learning platform, which has become an important piece of Day 4 as they learn about basic life support (BLS) and its skills, annual hospital safety training, and other regulatory topics. By the end of Day 4, the students will have completed the PCA course and become BLS certified through the American Heart Association.
The goals of the internal PCA course included enhanced competency development, decreased orientation time, and reduced costs. Historically, the organization paid about $1,674 per person to train through the outside facility and compensate the PCAs at their hourly rate. The internal course went live on February 18, 2020. By March 2023, 394 students had participated, with a cost savings of $659,556.
The internal course, which reduces training time by 1 week, allows for improved competency development by focusing on content specific to the skills and time management needs of an acute care facility. This has downstream impacts as unit educators no longer need to supplement PCA orientation.
The clinical rotation provides PCAs with an introduction to their home unit and an opportunity to test their newly acquired skills and return to the course with follow-up questions. Based on course feedback, this approach improves PCA confidence.
The pass rate for the course is 99.2%; 391 out of 394 students passed their skills and written competency tests on the first attempt. Those who didn’t pass received remediation and retesting. All passed the re-test.
The PCA retention rate 1 year after implementing the training program was 88% (91 of 103 students remained with the organization). In 2023, the team added a formal check-in focused on feedback and retention. The clinical training specialist meets individually with each course participant 3 to 6 months after course completion to check in on them and support retention efforts. Recent 2023 data indicate a retention rate of 77.5% (110 of 142 students remain with the organization). (See Positive feedback)
Meeting needs, developing confidence
Through Transformational Leadership (the hallmark of organizations that have received Magnet recognition) provided by the CNO, the PCA course team developed effective training that reduces costs and decreases orientation time. By customizing the training to meet the needs of PCAs working in acute care, the organization has helped to increase their skill levels, enhance their healthcare knowledge, and build their confidence for their professional journey.
The authors work in patient care services at The Christ Hospital Health Network in Cincinnati, Ohio. Carol Tierney is associate chief nursing officer. Lori Wood is a clinical training specialist II. Julie A. Holt is chief nursing officer and vice president. Jamie Heidrich is manager of clinical education services.
American Nurse Journal. 2023; 18(9). Doi: 10.51256/ANJ092362
Carter P. Lippincott Textbook for Nursing Assistants: A Humanistic Approach to Caregiving. 5th ed. Ambler, PA: Lippincott Williams & Wilkins; 2019.
The Joint Commission. Competency assessment vs orientation. April 18, 20222. jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/human-resources-hr/000002152
Ohio Legislature Service Commission. Ohio Administrative Code Rule 4723-12-01 Definitions. February 1, 2012. codes.ohio.gov/assets/laws/administrative-code/authenticated/4723/0/13/4723-13-01_20120201.pdf
U.S. Bureau of Labor Statistics. Occupational Outlook Handbook. Registered nurses. September 8, 2022. https://www.bls.gov/ooh/healthcare/registered-nurses.htm
Key words: transformational leadership, unlicensed role, training, nurse retention