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Recently the ICU where I work has had a number of new hires not work out and make it past probation despite efforts to correct their deficiencies in patient care.  
 

Members of the critical care team have generally been asked to partake in the interview with the candidates and be part of the panel.  I am not part of the management but occasionally with other PAs as part of that panel.  
 

Unfortunately, the large majority of candidates are new grads.  The pandemic has significantly impacted the learning during some of their rotations and likely affected their readiness to begin learning/ practicing critical care.

Typical check into a candidates references, work history, GPA, etc.  are done prior to an offer.  
 

During the 2-3 rounds of interview a few clinical scenarios are presented to evaluate reasoning and fund of knowledge.  


I have heard some companies (ie Google) testing applicants.  Have you ever encountered or employed such methods and do you find them helpful in your search?  Any other ideas?

Thank you   

 

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What kind of training do these new grads get? If your organization wants them up and running in 30 days, you have to hire someone with experience and pay them accordingly. If there is a 6 month training period and they are still failing, then maybe try to hire someone who did a rotation in critical care. Whatever their deficiencies in training due to covid, all these people were smart enough to get into PA school, successfully complete 2-3 years of intense training, and pass the PANCE.

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Yeah, we need more information. How long is this “probation” period, and what kind of support are you giving new people? If the hospital is wanting these folks up to 100% capacity, and if they’re hiring new grads without a proper plan, then it’s not the applicants’ fault. Especially because you say this has happened a number of times now.

I would go so far as to say, it could be the hospital that is failing. Sounds like they are just hoping eventually someone will come along who miraculously has the ability to absorb and retain and hang in there at a superhuman level. That’s not a great plan.

So, as AtB said above, either they need to hire people with experience (and pay enough that it conveys respect for that experience), or they need a well-designed roadmap that can take the kind of applicants they have been seeing, and support them through the long process of getting ready. That means paying well from the start, setting aside time for teaching and mentorship, and providing good mentors.

Edited by Febrifuge
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I would think that the only new grads who would do well in the ICU (aside from critical care residency grads) are folks with significant prior ICU experience and rotations in the ICU, like former critical care nurses, paramedics, and resp therapists. PA school really prepares anyone to walk into supervised practice in primary care(including peds and ob) or internal medicine and its subspecialties, urgent care, or surgery. To start in almost any other setting, significant prior experience, dedicated rotations, or a residency seems like a reasonable minimum. I am sure our resident critical care guru, MediMike , will have productive thoughts on this matter. From my perspective(granted, I do EM, not full time critical care), at a minimum I would want someone in an adult ICU to have ACLS, FCCS(critical care course), ATLS, and a difficult airway course. I would also expect no one to jump right into solo coverage unless they had worked in that capacity before. One of the better EM groups in the country has everyone go through a progression from EMPA1 to EMPA2 to EMPA3, regardless of prior experience. Only the threes can work alone and unsupervised.  Something like this makes sense. Someone with a wealth of experience might go from 1 to 3 in a month if their colleagues felt it appropriate, while a new grad might take a few years.

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5 hours ago, polarbebe said:


I have heard some companies (ie Google) testing applicants.  Have you ever encountered or employed such methods and do you find them helpful in your search?  Any other ideas?

Testing applicants in what way?

You are already offering clinical scenarios that they are presumably passing during the interview. What kind of written testing could you possibly require that would be more rigorous than the PANCE? I suppose you could ask hyper-focused ICU questions, but that doesn't seem entirely reasonable when you're going to be training these people anyway, right?

When "a number of new hires don't work out" you should start looking at deficiencies in your onboarding and orientation and feedback process instead of trying to find new ways to whittle down your applicant pool.

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4 hours ago, Febrifuge said:

Yeah, we need more information. How long is this “probation” period, and what kind of support are you giving new people? If the hospital is wanting these folks up to 100% capacity, and if they’re hiring new grads without a proper plan, then it’s not the applicants’ fault. Especially because you say this has happened a number of times now.

I would go so far as to say, it could be the hospital that is failing. Sounds like they are just hoping eventually someone will come along who miraculously has the ability to absorb and retain and hang in there at a superhuman level. That’s not a great plan.

So, as AtB said above, either they need to hire people with experience (and pay enough that it conveys respect for that experience), or they need a well-designed roadmap that can take the kind of applicants they have been seeing, and support them through the long process of getting ready. That means paying well from the start, setting aside time for teaching and mentorship, and providing good mentors.

Thanks for everyone’s comments and suggestions.
 

I’ve been in critical care for 11 years across five ICUs and aware of the breadth of knowledge, mindset and work ethic that is required to successfully work in this field.  I have been training experienced and new grad PAs alike for several years and familiar with the long path it takes to become a competent critical care provider.  
 

Nobody is expecting a competent critical care provider after 6 months… in my experience it takes 10 years to know what you are doing in an ICU.  Competence perhaps at 2 years (if dedicated to self learning and an supportive work environment).   


From 3 years up to the pandemic this ICU where I have worked had no significant issues with new hires.  Training actually was extended from 3 months to 6 months and I am part of the new hire training committee that helped develop the curriculum that they go through.  

 

As mentioned since mid 2020 a number of new hires have not passed their probation of 6 months.  The new hire PAs prior to this have worked out well and even some exceptional PAs.

There are certain system issues (salary being a factor) that are out of my control which certainly can affects the quality of  the new hire.  
 

What I am asking is anybody encountered any “outside the box” methods to evaluate job candidates?  
 

Thanks for your time.  

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On a related topic, the pandemic burnout led to half the ICU PAs leaving over the past year.  
 

Over 60% of the ICU RNs have left.  
 

85% med/surg RNs have left.  
 

The dedicated nurse educator at my hospital told me this week that some new RNs never have seen a live patient their clinical a were with a dummy or virtual.  They don’t know how to talk to or greet a patient.  
 

Unfortunately, the PA students that rotate through my ICU, honestly at this point are a second thought.  First priority is patient care, second to train the never ending new hires and third PA students (who just overhear any dedicated teaching for the new hires).  
Far fewer opportunities for direct teaching to PA students using the Socratic method.  In addition to each ICU PA now having 50% more workload due to the short staffing.   

Clearly the pandemic has affected the “finished product” that health programs produce at some level.  Just anecdotally it seems to have affected where I work more as this region has been one of the hardest hit in the pandemic each year.  
 

Finding new ways to evaluate a candidate could be helpful.  
 

Also is there a clinical scenario that you ask which is particularly helpful in determining  a candidate is a good fit?  You can message if you like.

 

Thank you.  
 

 

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I don’t want to sound unsympathetic, but by your own description, the quality of the education and training for students has taken a major hit, you’ve suffered serious attrition as experienced people have left, and your hospital/ system/ leadership has continued to treat the training of new folks as a relatively low priority. You’ve also mentioned that the pay might not be great.

I get that a lot of this is out of your control, but it just strikes me that in response to all of the above, which has resulted in several of your last batch of new hires not being able to cut it, you’re asking about a better way to identify people who can succeed. I really, REALLY don’t think this is a problem that’s going to be solved that way. 

You could ask “what are your thoughts about joining an organization that has shown little to no interest in supporting new hires” or “how good are you at operating with minimal support and direction” or “assuming you can tolerate these conditions, would you still feel obligated to work here even though you could get better pay elsewhere?” …But I rather doubt that’s what you’re looking for.

Truly, I feel for you, and I know you’re looking for ideas and answers within the sphere of your own control. That’s not a bad thing. But I do get the feeling that the best way to get the next batch of new people to do well, and become capable of staying, is going to be to push back on the higher-ups. This is what I would tell the people in charge:

If the training of PA students is not a priority, and if staffing is that much of a problem, then STOP TAKING PA STUDENTS. They’re not learning, and you’re not getting a good chance to audition them for possible fellowship or job offers later. Put that whole thing on pause for now. Come back to it when you can do it right.

Next, stop hiring new grads. If that means you need to offer better pay, then that’s what needs to happen. Full stop. What you’ve been doing isn’t working. Doesn’t matter if you somehow developed the best possible screening tool and could spot a “good fit” with 100% accuracy within 3 questions. Why should that person accept an offer, based on the situation you describe? 

Way too many employers are wondering “why can’t we find any good workers” right now. Way too few of them are examining the question from the right angle. 

 

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"your hospital/ system/ leadership has continued to treat the training of new folks as a relatively low priority"

Perhaps, I led you to believe this is the case but it is not.  

Thank you for all your suggestions, all valid and 100% applicable to any institution that values and wants to retain highly skilled/experienced clinicians.  

I originally posted to get advice from some experienced veteran PAs regarding one aspect of hiring. 

This back and forth is not helpful or productive for me but your post does have excellent points that may be helpful to others who are less experienced.

The location of the ICU where I work in a major metropolitan area with most of them being teaching hospitals, a PA run ICU with significant privileges is most uncommon.  We are privileged to intubate, bronch, CVLs, a-line, thoras, paras.  We respond to RRTs and run codes.  Compensation has improved through continuous dialogue with HR and the compensation department.  

Despite the reduced one on one teach for PA students, I guarantee that this rotation is if not the top rotation for those interested in inpatient care, at least one of their top three rotations.  A board with thank you notes from PA students in our call room attests to that as do a number of new hires from former PA students.  

Again, I am looking to any experienced PAs that may have some advice on hiring.  

Thank you.

 

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5 hours ago, Febrifuge said:

If the training of PA students is not a priority, and if staffing is that much of a problem, then STOP TAKING PA STUDENTS. They’re not learning, and you’re not getting a good chance to audition them for possible fellowship or job offers later. Put that whole thing on pause for now. Come back to it when you can do it right.

I dunno, depending on the program a less than ideal rotation is better than no rotation at all. I get what you're saying but even the best programs are struggling to get clinical rotations, obviously the rate limiting step in clinical year.

On 2/5/2022 at 5:57 AM, polarbebe said:

Recently the ICU where I work has had a number of new hires not work out and make it past probation despite efforts to correct their deficiencies in patient care.  
 

Members of the critical care team have generally been asked to partake in the interview with the candidates and be part of the panel.  I am not part of the management but occasionally with other PAs as part of that panel.  
 

Unfortunately, the large majority of candidates are new grads.  The pandemic has significantly impacted the learning during some of their rotations and likely affected their readiness to begin learning/ practicing critical care.

Typical check into a candidates references, work history, GPA, etc.  are done prior to an offer.  
 

During the 2-3 rounds of interview a few clinical scenarios are presented to evaluate reasoning and fund of knowledge.  


I have heard some companies (ie Google) testing applicants.  Have you ever encountered or employed such methods and do you find them helpful in your search?  Any other ideas?

Thank you   

Hiring in critical care is one of the hardest things I've run across these last couple years.  The people that have experience are normally such high value  items that their institutions have a tendency to hold on to them regardless of the cost. We have had positions posted with no applicants for months at a time, likely because we don't take new grads. 

This led to us developing a residency.  It was that or a dedicated 6mo onboarding process (which it seems you're doing).  We're having pretty good luck with their learning at this point.

In regards to "testing" people during the interview process, I've not seen nor heard of anything which would prove beneficial in this scenario.  I've always enjoyed asking which article was most practice changing for them in the past 5 years, but it's hit or miss and kind of messed up when you're looking at new grads.

Can I ask what part of "probation" these folks are failing? Is it interpersonal relationships? Knowledge? Procedural? Managing the vent? Are you able to find a common theme or a facet that you can really hammer down on? Honestly as long as it's not a personality issue it makes more sense to keep them on and work on those knowledge/procedural deficiencies than start from scratch all over again.

 

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Unfortunately, these team members are failing at the fundamentals that can not be taught (responsibility, maturity and priorities in life).  The margin of error in an ICU is seconds or minutes from death.  When the ventilator alarms and the minute ventilation is 2 liters per minute and the pulse ox is 70% on FiO2 100% PEEP 16 on the vent; ICU PA is expected to troubleshoot the issue  eg. in-line suction, ascultate, feel for crepitus, order/interpret CXR, BVM, POCUS for lung sliding, etc. 

The acuity of these patients should generate fear or at least anxiety in a novice critical care provider and compel them to seek out and improve their knowledge and skill set.  PAs that see this as a "9 to 5" job and collect a paycheck, that don't seek to self learn outside of work will not be successful in this field.  Its simply impossible outside of a residency that a novice critical care PA can be taught everything they need to know at work while maintaining patient safety.

Our training/probation is 6 months.  First week, cover 1 patient with a veteran ICU PA, second week 2 patients, third week about 3-4 patients and by the 6-8 weeks covering a "usual" ICU PA load with a veteran PA supporting them.  We provide resources prior to a new hire starting for them to read, we have a training curriculum and check off topics we have reviewed with them individually.  I personally have created 5 powerpoint lectures that I have given to the hospital staff and individual ICU PAs (in addition to lecturing at an ER PA conference and a state society PA conference).  We have grand rounds via Zoom broadcast from a quaternary hospital, local monthly PA/MD CME accredited lectures and every 1-2 weeks an ICU PA/MD gives a talk.  

 

Finally, interviewing like anything else is a skill, a skill that is learned and practiced.  It is a high stakes skill (much like palliative care discussions regarding end of life and goals of care). 

The hospital I work at provided a free seminar on how to increase the likelihood of interviewing successfully.  It was helpful and deviated from the usual "What is your greatest weakness" which every applicant worth their salt has already prepared for and generally a useless question.  

I am looking "outside the box" to improve the quality of new hires and to improve interviewing skills.

Thank you.

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This may be overly simple, but I've always thought that the most important question in the interview is "Why critical care/EM/surgery/etc?". I would spend the majority of the interview on this topic. It gets asked every time and there are the regular answers "I like procedures/seeing sick patients/the pathology". But what have they done that proves this? Have they sought out experiences in the past that build on their interest in the field? The day of the interview shouldn't be the first time that they've considered working in critical care. Pre-PA CC experience would be the gold-standard. A candidate without any pre-PA CC experience, can become a great CC PA. But they should have at a minimum, a CC rotation with a great reference, elective rotations in acute care fields, a research project that was CC focused, taken FCCS after the PANCE, something. Think of what you would do if you were a new grad trying to break into the field. You want a new hire that will go above and beyond in the pursuit of independent learning so they should be able to show that they've done just that in the past. 

My organization is probably similar to yours. Academic, low starting salary, the tertiary care center for the county with very complex patients. I work in EM and have noticed that the new grads that stick around longer than a year are the ones that have previous experience in EM. It's part of their self identity. Those without a passion for EM or who don't enjoy the complexity of the patient population move on to greener pastures. 

Again, this may be overly simple, but it the lens that I look through when first speaking with students or new hires

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48 minutes ago, Randito said:

I work in EM and have noticed that the new grads that stick around longer than a year are the ones that have previous experience in EM. It's part of their self identity. Those without a passion for EM or who don't enjoy the complexity of the patient population move on to greener pastures. 

Again, this may be overly simple, but it the lens that I look through when first speaking with students or new hires

Yup, there are PAs who think of themselves as specialists and stick to one field or within closely related specialties and those who are just chasing a better schedule, more money, etc who change specialties frequently. One of the few PAs I know who failed panre worked urgent care, STI clinic, women's health, and endocrinology all within a span of 2 years, chasing the best "deal" each time. Yes, we are trained as generalists, but that doesn't mean we actually can step into a new field and be competent day 1. I think I could hold my own on a trauma service or as a med/surg hospitalist because of the overlap with EM, but would need a residency to do more than be a human retractor in the O.R.

I certainly would want a mentor if I started working in the ICU. Both for procedures I rarely do and to cement the new meds, vent management, etc into my head before being independent in that setting. And I say this as someone who did icu and trauma rotations in school 26 years ago and has taken pretty much every EM cert course available. ICU is not a place to fake it until you make it.

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Reach out to schools and colleagues and let them know what you're looking for.

Ask "out of the box" questions. To spitball: ask about their hobbies, what is a struggle they've dealt with and/or faced in their life, where do they see themselves in 5 years, what can they contribute to a team, what can the team contribute to them, what can they contribute to a patient, what can they contribute to medicine, what is their personal mission, what kind of responsibilities did they have prior to PA school, what kind of leadership roles did they carry, describe a time when they went above and beyond. 

These all sound pretty basic but their answers can speak volumes, IMO.

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