The clearest sign that Adventist Health’s rebuilt nurse competency checks were working might seem counterintuitive: nurses started failing.
However, exposing the failure was the point, said Amy Buckingham, DNP, RN, patient care executive for the North Coast Service Area of Roseville, Calif.-based Adventist Health. Her region includes four hospitals in Northern California, including three critical access hospitals. Adventist Health operates 27 hospitals and more than 430 clinics.
On a Nov. 2 panel at Becker’s CMO + CNO Summit, Dr. Buckingham described scrapping the familiar check-the-box competency fair for a dyad model that grades new nurses on two metrics at once: how well they document care, and whether they can actually perform the clinical skill in front of an evaluator.
Nurses are handed real scenarios and have to demonstrate how they would treat the patient. New hires are revalidated at 30, 60 and 90 days.
Why ‘showing up’ stopped counting
Adventist Health moved to the model around the start of the pandemic, when it became clear new graduates were arriving to the system with a knowledge gap the old sign-off process never caught.
“We’ve all seen the nurse in the back of the room at the competency fair who gets signed off because they showed up,” Dr. Buckingham said. “Or you respond to a code blue and the nurse has no idea how to run the Zoll [resuscitation device]. That’s our fault, because we’re not watching.”
Under the scenario-based checks, some nurses did not pass. Dr. Buckingham called that a breakthrough.
“I actually saw nurses fail,” she said, adding that she can then “create a training plan for them and show them exactly what they need to do.”
The overhaul leaned on experienced staff. Rather than lose nurses nearing retirement, Adventist Health brought some back in per diem educator roles to keep their knowledge in the building. Dr. Buckingham said she also reads every incident report herself to find where retraining is needed.
A gap other systems are seeing
The deficit Dr. Buckingham described is by no means exclusive to Adventist Health. It is showing up across other health systems and hospitals, as well. Other panelists traced it to the same source: seasoned nurses leaving the workforce faster than new ones can absorb the knowledge and wisdom of their elder counterparts.
“We’re losing a lot of our senior nurses from the workforce,” said Terry McDonnell, DNP, RN, senior vice president and chief nurse executive at Duke University Health System in Durham, N.C.
New nurses are not being exposed to the scenarios that build intuition, Dr. McDonnell said, and systems have to both accelerate that exposure and redesign the work so senior nurses stay long enough to pass it on.
Competency alone is not the finish line, according to Kevin Zeng, MSN, RN, chief nurse executive at Alta Bates Summit Medical Center in Berkeley, Calif., part of Sacramento, Calif.-based Sutter Health.
“Competency does not equal mastery,” Mr. Zeng said, arguing systems need transition-of-practice programs that move experienced nurses toward mastery, not just orientation for new ones.
Tracie Thigpen, MSN, RN, chief nursing officer at CareSouth Carolina, a rural health center based in Hartsville, S.C., said senior nurses now run observations and hands-on audits of newer staff, and every incident report routes to her for sign-off.
For Dr. Buckingham, the new rigor is less a program than a standing obligation. She closed with a challenge to the executives in the room: “When was the last time you showed up to a code, to a resuscitation? How are you auditing, how are you validating, how are you monitoring what’s going on?”
