The Diversification Debate, Or What is the Significance of Institutional Cultures?

The appropriateness of staffing a cardiac cath lab with diversified specialties is an issue that has been debated and continues to be widely so. A diversified team, made up of various credentials but united through the Registered Cardiovascular Invasive Specialist (RCIS) credential and thus, fully cross-trained, is a good idea for cath labs that respect a wide knowledge base. However, it has been increasingly difficult to create a culture of mutual respect as cath lab teams become more diversified in facilities without professional integration (i.e., cross-training and/or mandating achievement of the RCIS credential). What does this mean for facilities on both sides of the issue? Cath labs are filling staff positions with registered nurses, radiology technologists, and cardiovascular technologists and technicians with varying experience levels and clinical skills. Mixing all three specialties can create a cohesive team with many intellectual resources from which to draw. Specialties such as interventional radiology, hemodynamic and ECG monitoring, and critical care or step-down nursing, are very valuable to any cath lab team. The value of such a team cannot be stressed enough, but problems may arise in attempting to integrate such specialties. Interdependence is and ought to be as much the ideal of man as self-sufficiency. Mahatma Gandhi ¹ Maybe the worst thing a manager can do is to hire personnel without regard to professional background and institutional or department culture, and hope to make a tasty cath lab stew. The policies of your department must first mandate specific practice stipulations for your cath lab professionals, before considering whether or not to provide special consideration for the RCIS credential. This may require some research not just in your local area, but statewide or even nationwide. For example, one popular dispute among cath lab professionals is whether non-nurses may administer medication. In western Pennsylvania, there aren’t any institutions, with the exception of a few trained individuals, committed to this practice. Yet, if you look deeper into the issue, you will find that there are institutions in the state of Pennsylvania which routinely allow non-nurses to administer medication. What causes this variation within the same state? It is the interpretation of the law, the hiring practices within individual institutions, and the culture and traditions of each cath lab. Cultural Diversity and Task-Specific Teams Are there institutions that refuse to hire cardiovascular technologists? The answer is yes, and there may be a legitimate reason why it may not fit the culture of the department or institution. Cath labs are comprised of a closely bound group of people with their own unifying traditions and practices. These traditions and practices are incredibly diverse, even within close geographic regions. Radiology technologist schools, nursing schools, and their graduates are more prevalent in the marketplace, and thus have obtained more widespread cultural acceptance. If a particular hospital traditionally hired all registered nurses, all radiation technologists, or a mixture of both, then their policies and procedures may not accommodate the cardiovascular technologist. Are staff members in your lab allowed to perform certain nontraditional tasks or favorably compensated for having the RCIS credential? If not, the policy, procedures, and culture of your institution may not support the RCIS and the credential’s benefits will be minimized. The CVT profession itself is still considered a new way of doing things because it is a crossbreed between traditional backgrounds. For many, accepting the CVT or RCIS is congruent to accepting an outsider. Change does not happen easily, or overnight. Nurses and radiology technologists have traditionally worked in task-specific roles in the cath lab environment. The advantage of task-specific roles is that they are well-defined and performed to encourage proficiency at a specific set of tasks. Theoretically, a task-specific team member can perform his or her defined role better than cross-trained personnel at the same task, who may not perform a particular task often enough to gain time-won efficiency and effectiveness. Two common examples of task-specific efficiency are gaining arterial access and closure of arterial access. The more one does, the better one becomes. Task-specific teams also can: Save time through faster room turnover times everyone has his or her own role. Save money through less waste in equipment only staff who know the technical aspects of products open equipment. Have better quality due to higher quantity of specific tasks i.e., those who use the most closure devices have less complications. Quality is a measure that is tracked effortlessly and continuously in today’s healthcare settings. A quality product is a sum of the individual performances in a cath lab. If the culture of your facility cannot accept diversification, you may create an unstable (quality-adverse) work environment by not specifically delineating individual tasks in the cath lab. Can task-specific labs produce the quality of fully integrated (i.e., cross-trained) labs? They will say yes, but I do not believe that to be true. However, if your environment is fundamentally task-specific, it is important to acknowledge your culture and focus on efficiency and effectiveness through specifically delineated tasks. However, If Your Culture is Ready¦ The RCIS Credential and an Integrated Team The RCIS credential was created as a minimum requirement for the credentialing of cardiac cath lab personnel. Some institutions do set the RCIS credential for all of its staff members as a high priority (regardless of whether or not staff are already CVT, RN, or RT), while other institutions don’t recognize this credential. Or, at least, don’t mandate its achievement, don’t compensate for its achievement, and continue to grandfather staff as a means of promotion instead of proven clinical competence. These facilities typically have task-specific teams. The flaw inherent in task-specific teams is that they may not achieve an appropriate range of knowledge for the individual member of the team. Case in point: If you’re an RN and your role is to assess the patient and administer medication, What happens if you don’t know which equipment to open up in an emergency situation? The patient isn’t treated in a timely manner. What happens if you cannot recognize an improper hemodynamic waveform? You can’t anticipate and identify the problem adequately. What if you don’t know the difference between monorail and over-the-wire? You waste money by opening the wrong equipment. The RCIS credential is a measure of the holistic knowledge of cardiac cath lab procedures. A professional from any educational background who achieves the RCIS credential is considered to be cross-trained to the many disciplines involved in cardiac catheterization and intervention. Regardless of the institutional culture, the RCIS credential represents the integration of traditional educational disciplines within the cardiovascular setting. In the cardiac cath lab, you never know when a nurse may need to power up the x-ray tube because your designated person cannot beat the snowstorm. You never know when your nurse may need an extra pair of hands to administer lidocaine for an arresting patient. In any situation, it’s nice to have that reassurance and the support of the person next to you. For some institutions, it works to be part of an integrated team. However some may downplay its significance, it remains hard to deny the value of the RCIS once you have integrated the credential into your cath lab culture. As anyone might suspect, developing an integrated team does not come without dedication to process improvement and training. Overall performance cannot be developed or implemented overnight. Annual competencies should reflect the need for ongoing education and clinical ladders should be multidisciplinary. I would suggest at least five levels of laddering to accommodate new staff at the lowest level, the most advanced at the highest level, and three levels of achievement in-between. Applied training could be done by ad hoc in-services from existing staff with advanced training, or by asking clinical specialists from various vendors to in-service techniques as well as clinical theory. The goal for a cross-trained lab should be versatile, interchangeable parts (RNs who can run the x-ray equipment, RTs who can get an IV, etc.). Important benefits include career development for staff, and ultimately, a higher standard of quality care for the patient. It is also crucial that every specialty involved recognizes the common goal as a synergized team and the highest quality of patient care. If Change is to Occur In deciding whether or not to hire or support a diversified team, cath lab managers may want to initially consider whether such an idea is prudent. Can the culture of your existing program embrace diversity? Can existing policy, procedures, and clinical ladders endorse the growth and development of a diversified clinical team? If the proper environment does not exist, the feasibility of such hiring practices may not make sense without a steadfast commitment from management to nurture change. To what degree and how to integrate cultures remains a secondary issue. In addition, prospective employees have a right to know cultural issues and institution-wide scope of practice prior to any employment commitments. Prospective employees should protect themselves by making sure the institution fits their needs as well as their professional background fitting the institution. Ask yourself this question: Why would you want to work for a facility in which you weren’t accepted as a peer, as an asset, or even as a professional? Existing staff need to know their scope of practice so as not to take undue risk and liability. A properly laid out plan could double as a performance evaluation tool. The employee will know their current status while striving for advancement. Cath lab managers would also be nicely served by planning for potential problems in clinical competence before such problems occur, instead of dealing with conflicts as they develop or even advance into more serious controversies.

1. The Essential Gandhi, edited by Louis Fischer (New York: Vintage, 1962). p. 193.