SCCM Pod-528: The Impact of Advanced Practice Provider Retention on Quality

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Retaining highly skilled advanced practice nurses and physician assistants in intensive care units is vital for maintaining excellent quality and safety in critical care. In the third episode of SCCM’s podcast series on quality and safety in critical care, Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, is joined by Roy H. Constantine, MPH, PA-C, PhD, FCCM, and Jose Chavez, DNP, CNS, RN, CCRN, FCCM, to discuss best practices for retention and how retention impacts patient outcomes in critical care settings.

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Transcript:

Dr. McLaughlin: Hello and welcome to the Society of Critical Care Medicine Podcast. I’m your host, Diane McLaughlin. Today we’re joined by Roy Constantine and Jose Chavez in the third episode of our multipart series discussing quality and safety in critical care.

Roy Constantine is the administrative director for advanced practice providers at Catholic Health St. Francis Hospital and Heart Center in New York, New York. He’s chair of the Society of Critical Care Medicine Quality and Safety Committee, past chair of the Council of Surgical and Perioperative Safety, and has held leadership positions with the American Association of Surgical Physician Assistants and the New York State Society of Physician Assistants. He has a 44-year history of practicing clinically as a PA with academic, administrative, and organizational roles.

Jose Chavez is a critical care clinical nurse specialist in the cardiac intensive care unit at Cedars-Sinai in Los Angeles, California, and is the current chair of the Society of Critical Care Medicine Nursing Section. Welcome to both of you. Before we start, do you have any disclosures to report?

Dr. Constantine: Hi, it’s Roy. I don’t have any disclosures.

Dr. Chavez: Hello, this is Jose Chavez. I disclose that I am a consultant for Acura Medical, but I have no conflict with this talk.

Dr. McLaughlin: All right, perfect. We’re jumping into a very important topic today, which is looking at the link to retaining advanced practice nurses and physician assistants or associates in critical care. Can you talk about why retaining highly skilled APNs and PAs is particularly crucial in the ICU?

Dr. Constantine: I can start. Simply put, the costs in dollars of replacing healthcare employees is just staggering. There are many references in journals that cite that the cost of replacing a healthcare executive or a highly skilled professional could be up to 213% of our salary. If the average starting salary, let’s say, starts at $120,000 and you start investing in that candidate, that could be over $250,000 to replace, so usually double or more as a replacement figure.

In addition to that, the amount of labor, and it’s time intensive in the orientation process as well. And you have to shift staffing models in order to onboard. It becomes a very big project. That’s the reason why it can become very crucial.

Dr. Chavez: I can add on to that. Exactly what Roy said, that financial aspect is a really big part. In addition to the consistency of practice, having highly skilled APNs and PAs in the ICU, especially for facilities that are teaching facilities, those APNs and PAs play a big part in making sure that the standard of practice is being done. They’re looked to as the training for new folks coming into the setting, so that consistency is there when you retain highly skilled APNs and PAs.

Dr. McLaughlin: And that doesn’t even really discuss, even though there are financial implications, the amount of experience that you’re losing every time this happens.

Dr. Chavez: Correct. That experience, in addition to the finances, is that safety. You’re having that experience of folks who are familiar with the protocols and the procedures that the organization is doing or the unit is doing, so their experience is invaluable. You’re saving not on just the turnover but you’re also saving on complications that can happen for new folks. If you have a fast turnover, there are going to be more complications that happen and more issues that clinically can put the organization at risk.

Dr. Constantine: It’s all about developing strong teams, we’ll reemphasize that: strong collegial interdisciplinary teams as well. It’s not that easy to put the right practitioners in a unit at a set time because people have different levels of experience or different skill sets as well. So there’s a tremendous impact there. How disruptive it is that basically you don’t have that skill set that Jose talks about and that recognition of having that dynamic team in your unit. That’s a safety issue. Definitely.

Dr. McLaughlin: Well, I like that you are talking about the team as a whole. Can you talk about when turnover occurs, how exactly that impacts the overall functioning and the morale of the team?

Dr. Constantine: It’s very difficult. First of all, I want to recognize Ruth Kleinpell, Rob Grabenkort, and all the work they’ve done, not only in our publications, they have a white paper that’s out for NPs and PAs, Concise Review of the Literature, and those authors, April Kapu and Corinna Sicoutris, and also the textbook that we have from the Society with Neil Halpern and Corinna again.

What happens basically in these units, if you want to provide the appropriate services with the appropriate skill sets that are there and you want to maintain a set of employees actually who are geared up to policy and procedure as well, who are aligned with what the needs are of the physicians and the departments are there as well. If you have rapid turnover and you don’t have people who are aware of all the ins and outs of managing those patients, then you can have something that could result in a bad outcome.

Then it does become demoralizing for the team as well. They’re trying their best to perform, but many times it’s frowned upon and it’s looked down on. That’s the reason why we want to build these strong programs and we want to make sure that everybody that we have, the key thing is to maintain that so that we have retention. We want to build strong retention and build strong programs.

Dr. Chavez: Definitely, I totally agree, especially for new folks who are trying their best, and they’re coming on to an organization. Even with a solid onboarding training program, those mistakes will happen and they’re going to be unhappy in their setting. There’s no way going around that unless over time they develop that experience, they develop the practice and getting used to the organization that does take time and that will improve over time. But initially that will affect their happiness in the facility.

Dr. McLaughlin: In order to grow, you need to have a sense of stability, in order to push past what standard is. Without that, nobody’s really getting better, everybody’s just staying status quo because it’s safe. What can we do to retain these experienced providers or even new providers who are coming on?

Dr. Constantine: There are just basic retention strategies that have to be applied in order to support continuous growth and development. I onboard many advanced practice providers. Even though they come from phenomenal programs, I tell them maybe it’ll be two years until you just begin to feel comfortable, four years to when you really say, I really have a good understanding of the physiology and all the ins and outs of managing these critically ill patients, six years or more, you know what I mean? We reinforce that with, one simple method is continuing medical education, making sure that’s there upfront and supporting that through their professional education and training opportunities.

Dr. Chavez: Just to piggyback on that, that professional development is very big, especially when the organizations make that a priority for this group. They prioritize the professional development of the APNs and PAs. Those will likely stay. And the better the onboarding as well, I know that at my current facility that we started a fellowship program, which is brand-new so we’re still waiting to see the results of the longevity of these APNs and PAs. But the professional development and the financial support for them to go to conferences to maintain the knowledge that’s coming out, the newest evidence being up to date with all of that. The better the support, the happier they’ll be. We’ve seen this before. We’ve seen this in keeping and maintaining our experienced APNs and PAs.

Dr. McLaughlin: You both talk specifically about career development or professional development. Would you say there’s a mix of both in-house opportunities in addition to financial support to go to professional conferences outside the facility? Or is it more encouraging outside? How do you guys approach that from a leader’s standpoint?

Dr. Constantine: Well, listen, from a leader’s standpoint, I want every employee that I hire to be a subject matter expert in their field. What does it take to do that? OK, everybody strives to be a good clinician. But there are other elements, even Jose and I know this, going through SCCM, where people are not good in public speaking, people are not good in publishing. The Society does lend to that in order to enhance those skill sets, ok?

Because what I would like to see is that everybody become a subject matter expert in a specific field within critical care. Then they could be an expert speaking about it and representing that. From a personal level, that’s quite rewarding for me as an educator. From an organizational standard, I mean, it’s just phenomenal to do something like that.

Dr. Chavez: Yes, definitely a combination of both. You know, the internal, you need to have an organization that supports that type of drive, you know, someone who’s constantly setting up some type of journal club or some type of evidence-based review within that organization themselves. That’s one way of developing them. But yes, the outside for sure is one of the bigger factors that plays into professional development when it comes to the APNs and PAs.

Like Roy said, SCCM really looks at all those different factors on being able to teach and being able to present and being able to publish. That really highlights that extra development that the APNs and PAs can achieve. They can go down that route that the organization that they’re at doesn’t provide that well-balanced development that SCCM has as a criterion.

Dr. McLaughlin: Let’s say you hit the jackpot and you get a whole team full of subject matter experts, everybody in their field, and due to staffing constraints, your subject matter expert in neuro has to be floated to cardiac or something like that. Are there actual data that say retaining experienced APPs impacts patient outcomes? How do the realities of day-to-day staffing influence how do we keep these?

Dr. Constantine: If we want to talk about the pilot project, that was what happened with COVID. And not everybody was able to manage in critical care. How do you align someone to have oversight? And how do you have someone who’s a mentor? And how do you determine who has basic core privileges versus complex privileges?

Retaining experienced APNs and PAs, they just allow for greater continuity of care. There’s improved care coordination. Then you can develop these other initiatives. And you’re talking about hybrid models as well, I think you’re kind of hinting. With the rapid response teams, we’ve created that, critical care activation teams focus on other groups as well. But there is a level of the financial factor that Jose talked about too, where we’re focusing on readmissions and flowthrough as well.

I think that the roles of leaders like ourselves are changing every day. How do you put the combination of practitioners together in order to provide the best care that you can and have the best outcomes? We have many metrics that now we have to look at as well, you know, reduced time on mechanical ventilation, our laboratory usage, and again, our length of stay, readmission rates, and our discharge time. For the most part, you have to have a feel for who your players are within your team and you know their skill sets. That’s one of the key components there so that you can place them appropriately.

Dr. Chavez: Yeah, you really hit the nail there on the team aspect right there. That team is going to be important, especially if you have to move an APN from neuro to cardiac. That team needs to be very supportive and show how much resources they can have to support a person coming from a different specialty and coming on to a new specialty.

Like you said, we saw that during COVID, we saw that we needed people to step into places that they weren’t specialized in. They had to really rely on a team that was specialized. Having that team is very important in those types of situations and those types of environments. The team will support the new person coming on, the new APN or PA, and that will benefit them. Now without that, there will be consequences to that and you will see some bad outcomes. But that team is very important.

Dr. McLaughlin: Fostering that culture of support and adequate resources and encouraging growth via these additional opportunities that may present out of necessity rather than desire.

Dr. Chavez: Correct.

Dr. Constantine: Yeah.

Dr. McLaughlin: You both talked about some of these metrics, but are there specific patient metrics or outcomes that seem to be most affected when there are high turnover rates?

Dr. Constantine: I always say that the paint on the wall is just the paint on the wall. It’s the people that you employ in the organization and how you align that with the mission and vision of that organization. There are many demands on us aligned with efficiency measures. Definitely organizational capacity and throughput are those key measures. It’s not physician-based. It’s now patient- and family-centric-type processes. I want to emphasize that.

But if you have Press Ganey and you look at the elevation of everyone’s experience and you’re looking at the quality measures there, and if you look at HCAPs and you’re looking at the domains, especially the communication measures that are there, and Leapfrog. Leapfrog definitely with critical care, preventable injuries, infections, looking at your mortality rates. Then we focus on the HACs day in and day out. CLABSIs, CAUTIs, MRSA, C diff, and others as well. So those are really, I think, the bread-and-butter metrics that we’re looking at right now.

Dr. Chavez: Yeah. And when dealing with high turnover, you will see that correlation. You will see all those escalate. Now, when you have retained folks, of course, you can sustain that change of keeping those numbers down, but you also have the opportunity of those folks who have been there for a number of years that have a mature look at the outcomes.

Even though we’re maintaining our rates at a low level or all of those metrics, CLABSI, CAUTI, you can actually start looking at innovative ways to not only just maintain those low numbers, but also including work with family, including innovative ways to educate and to make sure that outcomes continue on well past the ICU into the outpatient setting or even into the med-surg floors.

But that type of outlook comes with retaining those folks because they develop a better sense of, okay, we maintain the low number here. We know how to take care of patients, most central lines, and we can see that quality improvement projects have improved. Those really come out of those folks who stay. You’ll see the innovative approaches from folks who have been on those units for a number of years, and that just improves morale of the unit.

Dr. McLaughlin: We know that the patients we’re seeing in the hospital now are sicker than ever and that there are more challenges now than there have been in the past. Burnout has been a hot topic in critical care. Can you talk about any strategies that you’ve noticed seem to work well to mitigate this?

Dr. Constantine: There’s a lot of literature on burnout. First and foremost, you have to develop an environment that’s a supportive environment. I think Jose and I have hinted and elaborated on that. I am going to recommend an excellent publication by Amy Edmondson called The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. In that publication, we want to unleash our collective talents of our workers, but we need to be in environments that are nonpunitive environments. When errors do occur, they usually align with process errors, and they should not be aligned with individual errors.

When we go back to work-related stress and we talk about burnout, we want to have job satisfaction. There’s been a lot of literature that talks about what are the elements that people are looking for in job satisfaction. First of all, they’re working in an environment, and there was a publication that came out in the Journal of American Academy of Business.

They want stable and secure futures. They want friendly and collegial associations. They want an organization where they learn things, and they show a benefit to what they’re doing, and they’re part of a team. And if those elements are not there, then immediately that can affect the relationship of having increased stress and associated burnout with that as well. You don’t want emotional exhaustion or depersonalization.

Maslach in the burnout inventory talks all about that. That’s how you do the survey analysis associated with that. You need to develop strong collegial teams and supportive mechanisms to minimize that burnout. In my facility, we developed clinical education simulation centers where we come together as collegial teams, and we discuss all these things as well.

Dr. Chavez: I know, with the American Association of Critical-Care Nurses, they have the Healthy Work Environment campaign that is really taking off, and it’s really picking up in places where it needed to be. It’s something that we’ve talked about within our committee, ways to address their burnout.

We’ve seen things as far as organizations that prioritize the health and safety of their employees and being one way of looking at how we decrease burnout. Like Roy said, the organization has to really look at how to keep them safe and make sure that they are financially taken care of. That’s a big satisfier for employees.

Dr. McLaughlin: Are there any other emerging trends that you’ve noticed in terms of workforce retention in healthcare?

Dr. Constantine: I think that when COVID occurred across the board in my facilities, many people did not want to work in healthcare anymore. Those who were eligible to retire retired, many of them. We’re in a rebuilding phase right now.

I think where I work, Catholic Health has made tremendous efforts in the focus of burnout or being a second victim as well, creating relaxation centers, emphasizing that any employee can escalate to any executive within the organization and speak to them in transparency. I think that it’s important for organizations to strive to become high reliability and emphasize that they want to approach these zero-harm initiatives and that punitive actions, bullying, will not be tolerated. I think those are positive interventions. Believe me, the staff will see that.

Dr. Chavez: Oh, yeah. Big time. That’s huge there. When the organizations really make that a priority of decreasing lateral violence, workplace violence, employees will see that and they will stay. They’ll be much happier.

Dr. McLaughlin: Does it seem like this newer generation is a little less likely to tolerate things that they find unacceptable? Is that a good practice or a bad practice?

Dr. Constantine: Let me just say that I think it’s quite rewarding because I’ve been in the health profession for a long time. I love watching the growth and development of all the new hires. You know what? They look at wellness and they look at time that they can have for themselves with their personal interests or with their family.

It was very different when I practiced. I was working in a hospital almost every single day with even night call and night coverage and everything. There are more flexible hours now. The staff is looking at that. The markets are very competitive out there. So if you’re not providing these type of services where they truly respect the leaders and they respect the organization as being one of the best places to work at, that would be another reason why they would want to go to another organization as well, especially if you have competing organizations in a tight geographic area.

It is different. I do agree with you. But you know what? I enjoy hearing their voice. The educational standards in our academic programs have advanced tremendously. They’re very, very bright when they come out and very knowledgeable. I want to try to support that as much as we can.

Dr. McLaughlin: Jose, do you have anything to add?

Dr. Chavez: Yes. It shows where we’ve come from where we used to be. Like Roy said about being at the hospital every day and now being aware of your work-life balance and bringing up concerns faster, it just shows where we’ve grown as a profession in the healthcare profession. I think that we’re going to continue to evolve in a way that things will get safer, things will be brought up quicker. I believe it’s a great practice to continue on with what we’re seeing now and what we’re seeing with this newer generation of practitioners.

Dr. McLaughlin: Well, despite it being a challenging time to be an APP, it’s also a very exciting time. Hearing you talk about the importance and value of the APP within the team and some of the current strategies to try to retain them makes me feel like the professions are going to continue to grow. Do you guys have any final thoughts or comments about APP practice and how to retain them?

Dr. Constantine: These are great professions. I think, again, critical care has been fantastic in integrating all the different disciplines. I think that’s just a tremendous process. Even in my own facility, we try to do the same. I think when we bring on these new candidates as well, these new employees, we can’t frustrate them. We as an organization have to make sure that we have everything up front so that there’s a smooth initial transition.

The first six months is that FPPE period, focused professional. Peer evaluation as well. We don’t want to be the ones who hamper their progress as well. We want to make sure the technology is there for them. They understand the policies. We want to make sure they have email, simple as that. They’re able to do things with communication, good IT accessibility, and that they understand how to integrate in the IT applications.

We want to continue to reinforce that this is a nonpunitive environment, like if you see something, say something, like Amtrak. And don’t be afraid, especially when we’re onboarding you during the orientation period. I also want to reinforce that these great ideas don’t necessarily come from top down, they come from bottom up as well. That’s where we get these terrific ideas. Then we have these inside-out processes. As organizations, we need to support appropriate staffing ratios as well to provide the best care and then integrate all these technologies and these related policies. Really, thank you for the opportunity to speak.

Dr. Chavez: One last word I’d like to also say, just piggybacking off Roy again, is: listen, having the organization leadership listen. SCCM is definitely one of those things that they want to be listening to. All these podcasts that are being published are all giving out great information. Not just great information, but great resources that organizations can use to improve their retention of their staff. This is one way that they can listen to folks, and not just their folks, but just having their ears opened and listening to or reading all the latest evidence that’s allowing our staff to stay and retain.

I also appreciate the time for speaking on this. For those out there listening, the Quality and Safety Committee of SCCM is a great committee to join. We talk about stuff like this. We address very similar situations, and we’re working on improving that within that committee.

Dr. McLaughlin: Well, thank you both for being here. This will conclude another great episode of the Society of Critical Care Medicine Podcast. For more, please listen to the series. And don’t forget, if you’re listening on your favorite podcast app, and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Dianne McLaughlin. Thank you.

Announcer: Diane C. McLaughlin, DNP, AGA, CNP, BC, CCRN, FCCM, is a neurocritical care nurse practitioner at University of Florida Health Jacksonville. She is active within SCCM, serving on both the APP resource and ultrasound committees, and is a social media ambassador for SCCM.

Join or renew your membership with SCCM, the only multiprofessional society dedicated exclusively to the advancement of critical care. Contact a customer service representative at +1 847 827-6888 or visit sccm.org/membership for more information. The SCCM Podcast is the copyrighted material of the Society of Critical Care Medicine, and all rights are reserved. Find more episodes at sccm.org/podcast.

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