An Action Plan to Enhance Clinical Competence of Cardiac Care Unit Nurse within Current Resources

Improving the competence of a workforce is a challenging task that requires innovative strategies consistent with the available resources. While limited availability of resources jeopardize delivery of quality care and patient safety, strategies that focus on the workforce improvement can prevent adverse events and facilitate smooth operation of a healthcare facility. This paper discusses strategies that can be applied to increase competencies of CCU nurse to facilitate favorable patient outcomes. These strategies focus on management and ward development in four perspectives; that is, expansion of cardiac catheterization laboratory; allocation of labor and rotation programs; effective communication amongst team members; and building the team spirit.

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Expansion of Cardiac Catheterization Laboratory, and Manpower

Expansion of cardiac catheterization laboratory requires the administration of the CCU to train registered nurses to advance them to levels of a practice nurse, so that they will be competent to execute the tasks associated with catheterization lab. The RN nurses may conduct all aspects of catheterization corresponding to their current level until they attain the relevant competence. Thus, they cannot undertake the core operations and must work under the supervision of the operating physician. Nurse practitioners in conjunction with physician assistants will help in pre- and post-procedural assessment and follow-up. In this regard, the trained RN can directly assist the key operators in the procedures, but in monitored conditions.

Consequently, a supervising nurse will manage the RN and the technical personnel to optimize patient care. The RNs will be trained appropriately. With the current trend in technology of digital storage, it is necessary to set up a computer technical support to facilitate the internalization of the skills taught during the training of the RN to a practicing nurse.

The catheterization laboratory implies increased risks to patient and staff; therefore, training of RNs on basic skills associated with radiological devices is important. It will be expedient for the health physicists to train the RN on basic safety procedures to ensure their safety in the laboratory. In addition to this training, the RNs will be trained on basic life support in cardiopulmonary resuscitation (CPR) methods.

The expansion of the catheterization lab will entail converting it into a hybrid catheterization laboratory. A hybrid catheterization lab includes an integrated procedural set that incorporates the tools and equipment that exists in cardiac catheterization laboratory with anesthesia and surgical facilities. The hybrid lab must satisfy all the standards features of an OR and a cardiac catheterization facility. Consequently, the RNs in the CCU must then be trained to improve the competencies that match the procedures that characterize hybrid catheterization laboratory. In this light, a practice nurse will train the RNs on special skills, including abdominal or thoracic stented grafts, percutaneous valve replacement, and large-bore percutaneous ventricular assist devices. These procedures require surgical access. Other trainings will involve those that may require conversion to an open surgical procedure, such as percutaneous ventricular septal defect closure, vascular plug deployment in paravalvular prosthetic valve regurgitation, and apical or bailout approach to percutaneous aortic valve replacement. Further training of the RNs will involve teaching hybrid treatments, electrophysiology device placement or removal, and specific emergency procedures including emergent thoracotomy or ECMO insertion.

The working hours for the new catheterization laboratory will be increased from the initial work schedule of 9am to 5pm to a new work hour of 8am to 8pm.

Allocation of Manpower and Rotation Program

Manpower Allocation

The nursing staff allocated to this unit will be divided into three based on the three shift patterns. An expert nurse will then be assigned to each team, to act as its leader. The director of the unit must take caution to ensure for flexibility, in the manner the team is comprised, so as to facilitate acuity for the patient, alteration in skill mix, and to compensate for inconveniences such as sick leave. In the event that there is absence of enough expert RNs to occupy leadership position for each team, the director may be forced to change team assignments. Consequently, a single expert RN be elected to lead the entire team.

The new working hours, that are 12 hours, will be divided into three unequal shifts. The shifts will be from 8am to 1pm, 1pm to 5pm, and 5pm to 8pm, for the first, second, and third shifts, respectively. Because of the limited number of nursing staff, the pattern of allocation will be such that every nurse goes through a complete cycle. A complete cycle starts from the first and then the third (same day), and the second shift the next day. Then the cycle repeats on the third day after the start of the first cycle.

Rotation Program

Another strategy that will enhance competence of nurses in terms of time management is following a rotation program. To facilitate learning of essential skills to meet the demands of the new catheterization laboratory, the management will arrange a rotation programs to provide RNs to learn the essential skills in different settings. The first phase of the rotation program will involve arranging for an expert from a developed cardiac care institution, such Houston Heart Center and other centers in Europe. This cardiac expert, who is specialized in a specific aspect of cardiac care, such catheterization be invited to provide instructions on catheterization. Thus, the RNs will get the opportunity of learning new skills necessary to facilitate proper care of catheterized patients.

A second phase of the rotation program will involve sending RNs to other cardiac care units in the United States, Europe or Japan and China, to learn the practice in catheterization laboratory. In these centers, the RNs will be taken through key procedures to gain experience of practice relating to a specific procedure.

The last phase of the rotation program, involves placing RNs in other wards in the hospital to learn practice on procedures that relate to cardiac care. Under this plan, the RNs will be exposed to ambulatory units where they would land pre- and post-operative patient care. Once they complete rotation program, RNs will have acquired essential skills to perform specific procedures in catheterization laboratory. Under the same arrangement, the director will arrange with other cardiac centers within the US or in international areas to have their experienced RNs visit the new Cath. Lab to facilitate skill transfer necessary for RNs in the CCU to enhance their care provision.

Effective Communication between Team Members

Communication between cardiac care team members is expedient to facilitate safety of the patient and favorable patient outcome. The first skill set that will facilitate effective communication between team members relate to ability to record every nursing intervention clearly and accurately, using local communication devices such as written, and computerized. The RN will be taught the ability to communicate with affiliates members of the multidisciplinary team.

The RNs will be taught what a local proforma looks like, that is, the one they will use to report care, and learn the professional and legal requirements for proper record-keeping. The professional and legal responsibilities that will be taught to the RNs include confidentiality, and Data Protection Act. In addition, the RNs will be taught to differentiate between the responsibilities and roles of distinct multidisciplinary team. The RNs will be taught how to communicate explicitly and proficiently with other members of team, in different circumstances, including ward rounds, case conferences, presentation in reviews of continued professional education, and emergencies.

Nurses will be taught the skills to appreciate verbal and non-verbal cues, including body posture, and professional problems influencing communication techniques. By the end of this training, the RN must demonstrate ability to apply a number of communication skills with organizational structures.

How to Enhance the Team Spirit

The directors and nurse leaders can employ innovative strategies to improve team spirits among the nursing staff. Some of these strategies include journal-sharing, discussion of case, and setting up guidelines and protocols to enhance collaboration among workers. The member of the disciplinary teams will be encouraged to share their journals between themselves so that when RNs encounter a new case they will be guided by the actions expert nurses recommend in their journals. Journal sharing will facilitate passing of skills or evidence based knowledge from expert RNs to junior RNs.

Another strategy that is expedient in team building involves case discussion. The director or subordinates should encourage an organizational culture of case discussion. Case discussion offers the RNs an opportunity to learn existing evidence-based practices. Case discussion will increase the knowledge of RNs on a certain aspect of cardiac care so that when they are in health care setting, they will be able to maneuver through the problem.

A third strategy involves designing clinical guidelines for common practices. The director can mobilize the members of multidisciplinary team to meet and discuss the formulation of a clinical guideline to guide practice. Once a guideline is completed, it can be compiled and placed on various strategic to aid RNs when they get stack in the course of a procedure.


Enhancing CCU nurse competence within limited resource is challenging. Thus, it requires a deeper understanding of the nature of human interaction, and key procedures typical of cardiac care unit. The main approach to enhancing competence of the RNs to practice nurses involves exposing them to the procedures and expert nurses so that they learn essential technique in delivery of care.

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