This paper will discuss the wide range of duties found in staff development and nursing education departments, and the importance of funding these activities. Review of articles reporting on various aspects of responsibilities, and a personal interview gives an overview of the many activities found in outstanding departments. The need for responses to sentinel events, meeting JCAHO requirements, and influence of educational funding on magnet status applications is also discussed. The finding is that adequate funding for this essential department of well run health care organizations is very important, pays off in indirect ways, and is itself worth the investment.
Staff Development and Funding : Introduction
Nursing education is a vast and far reaching topic. Its importance is not just in the education and training of new students, but continues through the entire career of a nurse. This is acknowledged not only within the world of health care but also by state legislative bodies, as evidenced in part by the continuing education requirement of State Boards of Nursing in order to maintain licensure to continue practicing. The ever evolving and increasingly technological profession of nursing demands constant updating and adaptation to the new realities of health care. As evidence arises from new research which challenges current practice, the need to adapt to and adopt changes must be disseminated. Health care organizations have put into place staff development departments, sometimes called nursing education despite not being limited to nursing, to provide for the educational needs of staff.
The issue of funding for nursing education, especially in staff development is a two horned one. While no one doubts the need for education and staff development, proving its cost worthiness is difficult. The benefits are indirect, contributing on the nursing side to job satisfaction and feelings of competency, to hospital wide effects, such as avoidance or addressing sentinel events, meeting Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, and in recruitment and retention of skilled nurses. Yet, when budget crises arise, education is one of the first areas to be cut (Long, 2004; Sarmiento, Spence-Laschinger, & Iwasiw, 2004). Brown, Belfield and Field (2002) searched for but found very few studies that actually report cost effectiveness of continuing professional education in health care organizations, and most could not truly be compared in a meaningful way.
To demonstrate the importance of funding for staff development, there must be a less direct approach. By showing the broad scope of duties and expectations on staff development as regards to nursing, and the benefits such as recruitment and retention, the monetary benefits may be inferred. This paper will explore examples of studies that show staff development and education departments are crucial to a well run hospital or health care organization, as well as in seeking magnet status, and the direct or indirect cost benefits they provide.
In one of the few studies that gives specific savings in dollar amounts as a result of staff education, Coopersmith et al. (2002) reported an estimated saving of 185,000 up to 2.8 million dollars through the use of a self study course designed to teach better central catheter line care in order to reduce infection rates. This approximately one hour course resulted in a 28% decrease on nosocomial infections in one facility, and a 67 % decrease in primary bloodstream infections in another. While this improvement may have been influenced by increased awareness on the part of staff, since they were part of ongoing evaluations, the end result was better care through education, and with significant monetary savings. Savings were calculated by estimated cost of treating infections, increased time in the intensive care unit, extended hospital stays, etc.
The importance of orientation of newly graduated nurses cannot be overemphasized. Karen Drenkard, the chief nursing executive and vice president of Inova Health System, is quoted by Stein and Deese (2004) as saying they are not "adequately prepared or ready to do the work" (p.276). There has been a significant drop in hands on clinical experience in BSN programs, and new graduates themselves feel neither skilled nor competent for up to a year.
Hall's (2004) research into stress and coping factors for nurses gives insight into how important a role staff development can be in assisting nurses cope with the unique problems faced in today's health care milieu. When nurses feel they are doing well, they report satisfaction with their accomplishments, feel challenged and enjoy learning new skills. However, when sources of stress become overwhelming, feelings of anger, difficulty sleeping, self doubt and a wish to avoid their jobs rise significantly. Four themes of stress were identified; ranging from patient care, self expectations, excessive workloads, and lack of available assistance from colleagues, usually due to inexperience, but also including excessive workloads. Nurses most often dealt with stress by talking it out with colleagues, formally or informally, needing time to debrief.
A related source of stress is reported by nurses when entering a new area of practice, whether they are experienced or new to nursing, according to Butt et al. (2006). In today's health care settings, job change may be frequent and/or involuntary. This results in nurses encountering situations where they (again) become novices rather than experts. Desire for education about "disease conditions, medications, models of care, interdisciplinary practice and medical treatment" (Butt et al., 2002, p.70) was expressed by more than half of the nurses put into new jobs, yet they felt their orientations only moderately prepared them.
Retention is a real consequence of having good staff development. Jones (2004) points out that investing in employees with orientation and socializing of new employees, to on the job training and paying tuition contributes to human capital. Nurses are less likely to leave when they feel valued, which decreases the organizational cost of employee turnover. Administrators "should be willing to invest in employee retention" (Jones, 2004, p.567). McCormick and Slater's (2006) research is into the role itself of the clinical education facilitator, whose purpose is seen as coordinating education and training across the site. The importance of having a staff development educator is clearly shown to help a hospital's retention of staff.
Sarmiento, Spence-Laschinger and Iwasiw (2004) looked at the issues of empowerment and burnout among nurse educators, and found burnout rates are high when they feel powerless. These authors defined power (in part) as the ability to control resources to reach goals, which in turn results in greater job satisfaction, as well as better student outcomes. Yet, most educators have high levels of responsibility along with low levels of decision-making power and feel overwhelmed with "too many tasks in too little time" (Sarmiento et al., 2004, p.135).
Meretoja, Leino-Kilpi, and Kaira (2004) thought it important to compare how nurses rated themselves as competent in different work settings, partly in order to guide staff development interventions. Nurses generally rate themselves as competent, their weakest areas being in assessing patient education effectiveness, on using research findings, and the ability to develop better patient care and education.
Karen Stumpff, the Clinical Education Department Manager for St. Vincent Hospital (personal interview, June 9, 2006) reported that funding for education is "always cut first". Violano, Corjulo, Bozzo, and Diers (2005) report cost control efforts have cut out many unit based nurse educators, which throws the burden of education back to the staff development department. In this study, educational curriculum based on patient needs (not nursing) resulted in improved quality of care. The hospital based education service mined data from charts to identify needs by frequency of diagnoses seen and treated, rather than nurses' perceived needs.
Fernandes et al. (2002) tried an education program in an Emergency Department (ED), designed to decrease violence. Although the long term results of actually decreasing violence were not promising, nurses did have a perception of a safer environment, which may improve morale. Because of feeling unsafe, staff tended to hide identity, lose work time and leave the ED, showing the need for education and interventions to promote safety and assist in appropriate responses to escalating violence.
JCAHO requires that sentinel events be addressed through investigation with recommendations for preventing future reoccurrences as well as following up to be certain the interventions were effective (Joint Commission on Accreditation of Healthcare Organizations [JCAHO], n.d.) Staff development is involved in this process, according to Stumpff.
In applying for a site visit to be considered for magnet status, Steinbinder (2005) recommends that certain areas be included in the written application, based on her ten years of work as an appraiser. One area is that of finance, identifying monies budgeted for recruitment, retention, tuition programs, and funds available for education, national certifications, conferences and workshops; demonstration that learning is highly valued. Empowerment, autonomy and control are also highly valued, as reported by Aiken, Havens, and Sloane (2000); organizations that provide "high levels of access to information, support, and resources" (Armstrong & Laschinger, 2006, p.129) also show these characteristics.
Staff development and continuing education are shown to cover a very broad expanse of responsibilities. The importance of empowered and well functioning departments cannot be overstated, in supporting the nurses on the front lines of care.
The very real cost savings in terms of infection control have been shown. While all nurses have learned the basics of hygiene in school, the importance of specialized training in critical areas has been amply demonstrated. Education to meet the needs of specialized areas depends on those needs being identified, not only by staff members, but by mining charts to demonstrate areas of high concentrations of diagnoses, complications and patient needs. Staff development nurses are in a unique position to do this. Staff members tend to remember and identify cases that are unusual, or stand out in their memories in identifying needs, yet chart reviews show the needs of the more frequent or chronic issues to be dealt with. Since staff development nurses are looking on from the outside as it were, the less notable cases are more readily found. Taking into account both nursing and patient needs leads to the courses being developed that are targeted and useful.
Newly graduated nurses are coming into hospitals with an utter lack of necessary skills to function as full staff members. Their orientation calls for preceptors and extended time on the unit in order to learn enough new skills to provide adequate and safe care. Before they can be assigned as preceptors, experienced nurses must be taught how to precept, assess skills and encourage their charges. A course of orientation, with competencies and feedback must be developed and provided. Nurses who are moving into new departments or areas of practice, but already have at least basic skills, or even expertise need a much shorter orientation. However, they do feel the need for education and courses related to their new area, which increases self confidence and thereby job satisfaction. Even nurses who are remaining in their own sphere of expertise but are simply in a new job location expressed the need for orientation to the unit; this fortunately is a fairly short term need. Having an excellent orientation will do much toward developing confidence and decreasing stress for new grads, and make it more likely that graduates will stay at a hospital and remain in nursing. Developing and keeping such a program up to date is definitely in the purview of staff development; as well as orientation designed to meet needs at various levels.
The stress experienced by nurses in today's health care world is very real, and leads to burnout, anger, physical symptoms and nurses leaving the field. One source of stress is the inability to complete a task because of systems barriers (difficulty in obtaining supplies, getting tests done, etc.), resulting in the nurse feeling that she has delivered less than optimal care (Hall, 2004). Not knowing what to do for unfamiliar diagnoses or changing situations is another source of stress. New staff, whether graduates or older staff simply unfamiliar with an area, are not as able to assist; having to teach someone how to help slows one down, rather than being provided with assistance, it increases workload. The new staff are also stressed by knowing they are not ready to adequately care for patients in these situations. To relieve stress surrounding specific events, nurses tend to talk to each other. People outside health care rarely empathize completely with what bothers nurses, so that talking with each other is the only outlet. While this helps, at times it simply adds to the stress of the listener. Staff educators can help nurses cope with all these things: from teaching nurses how to overcome systems barriers that inhibit patient care, the use of algorithms to boost confidence in one's own ability to adequately meet new and changing situations, teaching managers and mentors of new staff about the needs of new staff and how to help them cope, and lastly in organizing debriefing sessions as needed. Staff development must be responsible for providing adequate and appropriate education for nurses in order to maintain a competent and confident workforce.
While most nurses feel they are competent in their own specialties, areas they self identified as felling least competent in are in finding and using research, and the ability to develop new and better means of patient care and education (Meritoja, Leino-Kilpi, & Kaira, 2004). Staff development nurses are well placed to do research, and provide this data to nurses, through courses and in response to specific requests, resulting in up-to-date patient care.
Investing in employees, through staff education, continuing education courses, and providing (or sending personnel to outside) courses for national certifications, works to the benefit of the organization in several ways. Having a strong education department is a good recruitment tool, as well as a factor in attaining magnet status. Retention also increases when nurses feel valued, and invested in. These costs are offset by lower turnover, not having to recruit and orient new staff as frequently, and increased competency among the existing staff. Not only does increased competency lead to increased confidence, it provides better patient care and outcomes. Empowerment of the educators themselves also leads to better retention and decreased stress in their own departments; putting control of the monies and resources used in investing in employees to the employees themselves shows a high level of trust and cooperation.
Another important area staff development addresses is that of sentinel events. These events are a very serious, defined as "an unexpected occurrence involving death or serious physical injury, or the risk thereof....they signal the need for immediate investigation and response" (JCAHO, n.d.). Once identified, staff development is responsible for the research and response, according to Stumpff, to address the prevention of a future such event. This also meets the requirements to "conduct a ... root cause analysis ... reduce risk, and monitor the effectiveness of those improvements" (JCAHO, n.d.). Staff development thus plays an important part of maintaining JCAHO accreditation, which qualifies a hospital (in part), for Medicaid/Medicare and other federal funds.
Staff development departments also play an important role in achieving magnet status. Hospitals and health care organizations that want to be seen as setting the standards for modern health care must demonstrate a high level commitment to staff development and education. Departments with high levels of empowerment and control of their resources are far more able to function well, and this is a factor looked for by appraisers in reviewing applications for accreditation for magnet status.
Staff development nurses and departments are responsible for a wide array of duties, beginning with orientation of new staff: from newly graduated nurses, to those returning to nursing or changing areas of practice, to experienced nurses changing location but not areas of expertise. The educational needs of each group are different, and should be addressed differently. In addition, these departments are taking over more of the duties that once belonged to individual unit educators, as more positions are cut. Recognizing and meeting individual unit or specialty needs must be done, researching the areas of interest, and presenting courses adequate to the needs. Getting continuing education credits for classes requires time and paperwork, yet to not award nurses for their limited time available for classes would be demoralizing, especially if they then had to find credits outside the organization in addition to required classes within. Either presenting or providing for nurses to achieve national accreditations in their specialties is also important, for when nurses feel competent in an area, their confidence and job satisfaction rises. Keeping a workforce happy and willing to stay is especially important in today's health care world of nursing shortages and competition for scarce resources. Investing in staff development pays off in many ways.
Staff development is a key factor in meeting both JCAHO and magnet status requirements. This helps provide for income to the organization, through meeting requirements and through attracting patients, by having a good reputation for excellence in patient care.
In short, cutting funding for such an essential part of a health care organization's team is shortsighted and self defeating. Providing adequate funding provides for education pay offs in many indirect ways, but definitely proves itself worth the investment.
In order to have strong staff development and nursing educators, first the training must be available for those entering this field. Nurses who transfer into the department "because there was no one else to do it" face a difficult and stressful time of learning and adjustment, simply because the scope of the job is so vast. Having an advanced practice, master's prepared nurse in the lead position would seem to be the most desirable, yet salaries rarely reward such preparation.
Learning how to mine data from charts, develop courses, seek accreditation for continuing education credits from the state BON, locate and prepare instructors, are only a few of the actual duties of the nurse educator in a staff development position. Having courses in how to do all these things needs to be available to these nurses. On-line courses would allow for access by those in remote areas, and fit into already overwhelming duties. Weekend seminars on specific aspects, such as developing continuing education courses with all the correct paperwork, teaching techniques and recruitment of instructors need to be available as well. Attendance also allows for networking among different organizations' departments, and the possibility of exchanging courses; what one department has to offer may be extended to another facility in return for their specialized courses. This would save in money and man power, having to develop fewer courses yet having access to more.
Grant writing is another skill nurse educators may wish to acquire, since organizational funding is tight, obtaining outside funding would be beneficial. Involving more than one facility would increase the likelihood of receiving a grant, as part of a greater good to the communities involved.
Educating the educators is an open field, whether or not the courses lead to a higher degree academically. The need for these courses and their usefulness is clear.
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JBudd, RN BSN