Implementing a Perioperative Nursing Fellowship Program

MAY 2001, VOL 73,NO 5 Graling Rusynko

Implementing a Perioperative Nursing Fellowship Program

M

any articles have been written recently about the changes in health care delivery and the nursing shortage. The American Nurses Association held a staffing summit in May 2000 to highlight staffing issues. It is clear that the population of nurses in the United States is aging. According to one author, the most important factors contributing to the aging of the nursing workforce include the long-term trend of declining interest in nursing by women, who today enjoy a wide choice of career opportunities, and the decrease in the number of individuals born after 1955 who have enrolled in nursing school.' The perioperative specialty is affected further by the fact that an OR curriculum usually is not part of undergraduate programs; therefore, employment in the specialty usually requires some type of postgraduate education.

Hospital, Fairfax, Va; Inova Fairfax Hospital for Children, Falls Church, Va; and Inova Fairfax Hospital (IFH), Falls Church, Va. The system has many ORs throughout its hospitals with 17,152procedures being performed in the largest OR in 1999. This tertiary care suite, located at IFH, is the tower OR, thus named because it is located in a tower. During 1997, the IFH tower OR continued its historical trend of high procedure volume. Repeated efforts to recruit experienced OR nurses yielded few results. Many who responded to recruitment efforts and scheduled interviews did not possess the necessary skills to work in a level one trauma and multiorgan transplantation center. To staff the ORs, administrators turned to a nursing staffing agency. With a perioperative nurse vacancy rate of 37% in 1997, use of the nursing staffiig agency increased to 11,065 hours for the year. In 1998, agency hours dropped to 6,976, in part due to bonus shift implementation and some nursing fellows becoming inteSHORTAGE OF ~ O P E R A T I V L grated into staffing patterns. NURSES AT INOVA HWTH SYSTEM The Inova Health System (IHS) has a long hisAlso in 1998, IFH began a construction project tory of providing progressive, state-of-the-art care to meet the needs of expanded tertiary surgical servfor the northern Virginia suburban community. The ices within the hospital and to accommodate ambusystem comprises five hospitals, including Inova latory surgery service on campus. The project is Alexandria Hospital, Alexandria, Va; Inova Mt scheduled in three phases. Overall, the hospital will Vernon Hospital, Alexandria, Va; Inova Fair Oaks experience a net increase of six ORs, which will need to be staffed when construction is complete. The average age of the periA B S T R A C T The population of nurses in the United States is aging. After suf- operative nurse within the sysfering high OR nurse vacancy rates for several years, leaders at the tem is rising, and many nurses Inova Health System implemented a nurse fellowship program. This are approaching retirement age. six-month didactic and precepted learning program is aimed at expe- In 1998, one nurse retired from rienced RNs who do not have OR experience but would like to work IHS perioperative services. In in the OR. lko years after implementation,the OR nurse vacancy rate 1999, three more retired, not In the health system has decreased from 27% to 15.5%. AORN J73 only because of age eligibility but also because of a change in (May 2001) 939-945. PAULA R . G R A L I N G , R N ; BARBARA R U S Y N K O , RN

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retirement benefits. In 2000, two more perioperative nurses retired, with three expected to retire in one to two years. D

W

N r0 W T E A ~UOWSHIP PROGRAM

In 1997, the nursing vacancy rate in the IFH tower OR was at its peak at 37%.Recruitment efforts yielded little, with the vacancy rate declining only to 27%in 1998. The need for perioperativenurses, however, was not unique to the IFHtower OR. Other IHS hospitals and hospitals in the immediate area outside the system had similar needs. These internal and external system needs influenced the decision to create a fellowship program. The four main internal factors that guided the decision to create a fellowship program included the inability to hire experiencednurses, the cost of nursing staffing agency use, a construction project adding additionalOR suites, and

Table 1 DIDACTIC PROGRAM OUTLINE

I. Fundamental knowledge and skills A. Introduction B. The OR environment

C. Patient and environmental safety D. Typical patient flow through the surgical process E. Infection control F. Anesthesia

G. Positioning of the patient for surgery H. Wound management I. J. K. L.

M. N. 0. P. Q.

R. S.

T.

U.

the anticipated retirement of several seasoned staff members. The goal of the program was to reduce RN vacancy rates in the OR.

Instrumentation The Circulating role Advanced safety Basic powered surgical equipment Endoscopic surgery General surgery Vosculor surgery Thoracic surgery Gynecological surgefy Orthopedic surgery The SCNb role Automation-information and documentation Surgical terminology

II. Advanced knowledge and skills A. Monitoring the patient undergoing loco1 anesthesia B. Service specialty surgery overview 111. Professional issues of OR nursing A. How to use the health sciences library B. LegaWethical aspects of OR nursing C. Nursing research in the perioperative arena

CREAllON OF TnR -IP

PROQIull

As planning began, a collaborative assessment of learning needs took place. This was done by the Inova Learning Network (EN)(ie, the education arm of the MS)education coordinator, an MS pioperative clinical specialist, and MS ORinstructors. A review of the specialty mix in each M S hospital found a diverse variety. Some surgical suites were used for surgical procedures in every specialty, including transplantation. Some suites had cystoscopy ORs or cardiothoracic ORs. Other surgical suites were small, having four ORs used for limited types of surgery. The challenge was determining the scope, focus, and format for a program that would meet the needs of these differing ORs, both in the IHS and in other systems. This diversity of needs led to the development of a fellowship program that would focus on the fundamentals of OR nursing, including aseptic technique, patient safety, the role of the circulating nurse, the role of the scrub person, and attaining patient outcomes that focus on keeping the patient free from injury and infection while in the OR. Table 1 depicts a didactic program outline. Adult learning theory has identified that learners retain more of what they are taught if it is heard, seen, and performed versus using only one mode of leaming in the process. The decision to include both didactic and precepted leaming in the program was based on this theory. The program includes didactic classes in different specialty areas of surgery. These classes provide an overview as an introduction to the specialty. The goal is to instill in fellows the fundamentals of OR nursing and expose them to the clinical setting of the high-volume specialities at their home facilities. The total didactic portion encompasses 160 hours of the six-month fellowship, with the remaining hours spent in precepted learning in the home OR clinical arena. Additional weeks of clinical specialty orientation may be required by specific ORs to address specific specialty mixes. For instance, the IFH tower OR requires an additional two months of specialty clinical orientation, thus increasing the program for these students from six to eight months. The ILN education coordinator is responsible for planning, programming, designing, implementing, and coordinating the program. A variety of diverse health care professionals teach classroom sessions and skills laboratories. Teachers indude OR nurses and surgeons, as well as sterile processing staff members, radiation

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affectively for the fellowship. Several weeks before the start of the fellowship, fellows attend a one-half day orientation to review the program, including class schedule, reading assignments, fellows’ expectations for the program, and grading structure. This session begins with introductions, and fellows are asked to state what they think will be the greatest challenge they will face in the program. These challenges are listed on a flip chart and then discussed during the orientation. This exercise focuses on affective preparation by allaying learner anxiety and promoting a posCOLLEGE ACCRBDITXIlON As a learning organization, ILN representatives itive attitude for beginning the program. During this value recognition of the program, and they pursued dialogue, fellows learn that other students have simiacquiring college credit for the fellowship. The lar concerns about the chaIlenges they will face, and course information was presented to Lorna Facteau, program strategies used to support students’ needs are RN, DNSc, director of the ILN,and Beverly Boyd, reviewed to reduce anxiety. RN, MN Ed, director of nursing professional develOne common anxiety-provoking challenge is opment at George Mason University (GMU), Fairfax, learning the names of instruments. During orientation, Va. Dr Facteau and Boyd agreed the course merited learning strategies for this need are reviewed. The procollege credit. The application process at GMU gram includes an instrument learning experience that ensued, and the program was granted three credits in begins the first day of the program and provides a the bachelor of science nursing program at GMU. broad variety of learning methods. A self-directed, computer-based training (CBT) program leads students on a visual and auditory review of instruments APPLYING FUR A PBUOWSHIP The fellowship is a didactic and precepted learn- and includes a posttest (Figure l).3Cognitive learning ing program for experienced RNs who do not have strategies include a basic instrumentation class that any OR experience but would like to work in the OR. features a reading assignment, didactic presentation, Prospective candidates apply for a vacant position in and introduction to basic general surgery instruments. the OR of their choice and are interviewed. If chosen Weekly reviews of approximately 10 new instruments to become fellows, they are hired into the OR where occur during classroom sessions. Actual instruments they will be working. Their pay rate is based on expe- are passed around the class, and their uses and names rience in relation to the OR nursing position. At IFH, are discussed. Biweekly quizzes of the instrument each fellow is hired as a clinician II, an entry-level names are given to foster the learning process. Selfposition. Most of the hospitals participating in the fel- directed learning from poster presentations reinforces lowship incorporate a contract that specifies the time the weekly classroom introduction to new instrucommitment the fellow will make as an employee of ments. Posters with actual instruments and instrument the department after the completion of the six-month names are kept in the classroom so students may fellowship. This time commitment varies from one to review them periodically (Figure 2). two years, depending on the hiring health care system.

safety staff members, pathology staff members, and physical therapy staff members. The c h c a l coordination of preceptors, clinical assignments, clinical evaluations, and clinical performance is handled by each home hospital’s clinical instructor,clinical specialist, or assigned experienced OR nurse. The instructor coordinates assignments, plans clinical rotations, and monitors progress toward competence, which are keys to successful development of fellows’ proficiency.

OF RUOWSHlP PROCRAM ColyTMcc Adult learning theory has documented successful outcomes when the learning process encompasses the three learning domains? These three domains include cognitive, affective, and psychomotor. The cognitive domain relates to intellectual learning and concept building. The affective domain refers to feelings in learning or one’s attitudes, emotions, and selfesteem. The psychomotor domain includes learning by doing or hands-on experiences. The program strives to include all three domains in learning activities. Program orientation provides a framework to allow fellows to begin their learning journeys in the field of OR nursing. This orientation is fashioned to prepare the learner both cognitively and D-N

Figure 1 Alternative learning methods for recognition of instruments via a self-directed, computer-based training program are used.

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fellows regarding their progress toward competence. The fellowship program design reflects the notion of learning as an experiential process and the notion of reflection in a c t i ~ nFellows .~ are assigned to the clinical area during the second week of the program so that they can connect didactic contentto concrete experience,thus linking theory to clinical experience. Fellows are asked to keep a learning jownal that discusses clinical experiences. In this journal, they are to identify the skills, principles, and practices they perform or observe. Fellows then are asked to reflect upon the learning encounter and identify through self-evaluation the practices they need to improve to attain competence. This exercise encourages critical thinking and promotes self-direction in planning for individual learning needs:

Figure 2 Posters are used to enhance the learner‘s ability to recognize instrument names and uses.

The final component of the orientation is directed at enhancing awareness of alternative androgogical (ie, adult learning) resources. Adult learning theorists support the notions of having learning be self-directed, pacing learning to meet learners’ needs, and providing learning mechanisms that support various learning styles4A class on introduction to available learning resources in the Inova Fairfax Health Sciences Library supports these notions. Library staff members introduce fellows to available resources, including journals, textbooks, videotapes, CBT programs, and the Internet. The library encounter includes a self-paced learning worksheet to facilitate fellows’ guided tours about interacting with various self-directedlearning media. This activity introduces learners to opportunities for life-long learning that are part of the OR nurse’s responsibility in this changing environment. A learning plan is designed for each classroom segment to provide fellows a guide in preparing for the class and using each learning domain (Table 2). The learning plan is divided into several sections. A reading assignment is identified for each class as part of the cognitive domain and includes classroom objectives to help fellows prepare for the classroom experience. Classroom activities are listed and may include psychomotor exercises related to the cognitive content, such as a skills laboratory where students demonstrate perioperative skill sets (eg, scrubbing, gowning, gloving, counts, aseptic technique, preps) in the nonthreatening environment of the classroom (Figure 3). Another section of the plan connects classroom events to the practice area. This section (ie, practical application) asks learners and preceptors to move the classroom content to the OR environment, providing an opportunity for fellows to transfer the knowledge acquired in the classroom to the clinical nursing arena of surgical patient care. The final section of the plan asks preceptors to provide feedback and evaluation to

PROQRaM COST

The cost to prepare a nurse to work in the OR is dependent upon regional salary scales and the depth of preparation required for competency in the specific OR. A nurse being prepared for an ambulatory surgery center where limited types of surgeries are performed may need fewer hours of preparation than a nurse who is expected to function in a level one trauma center and take call. A new graduate may q u i r e more hours of preparation than a nurse with several years of experience. All of these factors affect the cost to prepare a nurse for competency in perioperative nursing. The estimated cost for preparing a nurse in the eight-month fellowship program at IFH is W O , OO. This includes a fellow’s salary and benefits for eight months, supplies used for the class, and instructor and education coordinator hours for the program. The majority of this cost is the fellow’s salary (ie, $32,000). The instructor’s and education coordinator’s salaries are represented as a total and have not been spread because of the variation in class size. No dollars are estimated in this cost for preceptors, as they are considered staff members, regardless of whether they have a fellow with them. Currently, preceptors’ salaries are not different from nonpreceptor staff members’ salaries. This cost may be higher than other regions of the United States. The recent OR Directors Study states that the average hourly pay rate of an OR nurse is $19.89.7 The average hourly rate used for the instructor is $27.00, and the average rate for fellows is $19.00. Published estimates of the cost to train new graduate nurses for the OR are as high as $60,800 for a one-year preparation time.8 P R 0 0 R a M 0 ~

In 1999, after the graduation of the first fellowship program students and the opening of three of the six new ORs, the OR nurse vacancy rate decreased

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Table 2 LEARNING PIAN

Program segment &Positioning

G. Knee-chest H. Jackknife

of the patient tor surgery

1. Kidney lateral J. Sitting 8. Discuss and demonstrate the following positioning devices. A. Braces

Classroom segment Date and t i m e J u l y 1, 2000, 8 AM to 4 PM Speaker-Nancy Blasko, RN, MA, CNOR Reading requirements"Positioning the patient in the perioperative practice setting," in Standurds, Recommended Pfuctices, and Guidelines (Denver: AORN, Inc, 2000) 31 1-316.

6. Rolls-chest, axillaty

C. Padding

B J Gruendemann, Positioning Plus (Chatsworth, Calif Education Department of Devon Industries, 1987).

D. Pillows E. Arm boards

E L Alexander, M H Meeker, J C Rothrock, Alexander's Cure of the Pufienf in Sufgefy, 1 1th ed (St Louis: Mosby, 1999) 153-172.

F. Stirrups G. Vacuum packs H. Safety belts

Classroom objectives The learner will be able to:

I. Head rests

1. List desired patient outcomes relative to positioning.

9. Identify vulnerable patients who require special considerutions for surgical positioning, including the older adult, the obese, and the malnourished debilitated patient.

2. Identify 6 criteria for evaluating achievement of desired patient outcomes relative to positioning of the patient in surgery. 3. Discuss the responsibilities of the perioperative nurse in patient positioning. 4. Describe the impact of surgical positioning on

the respiratory, circulatory, musculoskeletal, and integumentary systems. 5. Identify body structures at risk in supine, prone, lateral, lithotomy, Trendelenburg's, and sitting positions. 6. Describe nursing interventionsto prevent patient injury in supine, prone, lateral, lithotomy, Trendlenburg's, and sifting positions. 7. Describe and demonstrate the f0llOWing frequently used surgical positions, including the supplies and equipment needed.

A. Supine 6. Prone

Classmom activities 1. Practice proper body mechanics when moving and positioning patients. 2. Return demonstration of positioning patients in supine, lateral, and lithotomy positions.

3. View videotape on positioning.' 4. Complete written test on positioningthe surgical patient.

Practical application segment4R clinical preceptor Is responsible for this section in the clinical area 1. Reviews any department policies and procedures that apply to the body of knowledge and skills regarding positioning. 2. Demonstrates patient positioning according to department procedures and policies.

3. Shows location of positioning devices, supplies, and equipment.

C. Lateral

4. Mentordcoaches trainee to competency in positioning.

D. Trendelenburg's

Competency

E. Reverse Trendelenburg's

See departmenthervice specific skills checklist or competency for this section.

F. Lithotomy

NOTE 1 Pain Munugement: lntraoperatiive Positioning (Dallas: Baylor Surgical Services Institute, Baylor University Medical Center, 1993) Videotape. ~

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Figure 3 Fellows participate In hands-on learning during a skills laboratoly.

from 27% to 19%. The continued mobility of the northern Virginia community, with its high-tech business, federal government, and military presence, caused IHS to sustain a vacancy rate of 15.5% into the first half of 2000. Typical indicators of success that have been reviewed include retention rates for fellowship graduates, OR department vacancy rates, and changes in use rates of nursing staffing agency personnel. Retention rates were reviewed as of June 2000 for 1998 and 1999 graduates. During 1998, three fellowship classes were taught. One began in January with eight fellows, one in July with 14 fellows, and one in October with 12 fellows. The retention rate as of June 2000 for the 1998 classes is 73%. This rate reflects how many fellows currently are employed in OR nursing within the health care system they were hired into. If fellows hired for the IFH tower OR transferred to the Inova Mt Vernon OR, they are considered retained. If fellows have left the system they were hired for, moved to an OR outside the hiring health system, or left the system for other reasons, they are not considered retained. In 1999, two classes were taught, one in January with 10 fellows, and one in June with eight fellows. As of June 2000, the retention rate for the 1999 classes was 83%. The overall average retention rate for 1998 and 1999 is 76% for the 52 fellows enrolled in the program. Students leaving their hiring health system departed for a variety of reasons, including moving to another geographic location, enrolling in certified RN anesthetist school, the inability to meet performance expectations of the department, and various personal reasons. These retention rates are reflective of all hospitals that had fellows in the program, not just IHS hospitals. Other considerations include examining vacancy rates pre- and postprogram. Since 1998, the vacancy rate has declined steadily in the IFH tower

OR. In 1999, the rate was 19%, and as of May 2OO0, the rate was 15.5%. This decreased vacancy rate reflects the impact of the program because the tower OR opened three new ORs during this time and hired only a few experienced OR nurses. When considering all hospitals that placed nurses in the program during 1998 and 1999,40 fellows remain employed in the health system they were hired for originally when entering the class, which ultimately has affected OR RN vacancy rates. Also, nursing staffimg agency hours from 1999 to 2000 have declined as more fellows have been incorporated into staffing patterns (Table 3). As IHS continues to evaluate where to invest recruitment and retention efforts and monies in pursuit of filling OR nurse vacancies, administrators seek data to guide them. A 1997 article states that the average length of stay for nurse interns is three years, whereas the average length of stay for nurses hired with outside OR experience is 13 months? Based on this, administrators turned to their own data to determine the retention rate of nurses who completed the ILN fellowship versus that of hired experienced OR nurses. They hypothesized that the retention rates of nurses attending the fellowship are higher than those of experienced OR nurses, based on the aforementioned data. During 1998 and 1999, only nine experienced OR nurses were hired in the tower OR, and of those, 55.5% remain employed in the tower OR, and 44.5% left as of July 2000. The retention rate of these nurses may be attributed to retention and sign-on bonuses. This data is difficult to compare to the 1997 findings, as it is not known whether nurses in the 1997 article received retention and sign-on bonuses or if this affects retention. Also, current environmental situations in northern Virginia may have affected the retention rate of experienced OR nurses at MS because one local hospital closed and some of these

Table 3 TOWER OR VACANCY AND NURSING STAFFING AGENCY USE RATES

Year

Vacancv rate'

Aaencv use hours'

1997

37%

1 1,065

1998

27%

6,976

1999

19%

13,983

2000

15.5'/0

6,992

'As of May 2000. +Annualizedbased on year-to-date data.

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nurses were hired into the system. This data can be compared to the 87% retention rate of the 31 fellows who completed the program from January 1998 through July 2000 in the tower OR (Table 4). This data may suggest that the retention of experienced OR nurses is less than that of OR nurse fellows.

rmw Do m Bo FROM HERE7 Retention issues remain a focus as double digitvacancy rates continue in the tower OR. As of June 2000, the retention rate for all fellows who attended the program was 76%. One action for further evaluation may be to pursue why fellows and experienced nurses leave MS by facilitating focus groups or collecting exit data to determine causes for leaving and to formulate strategies for increasing retention. Recruitment of the best candidates for the fellowship program continues to be a challenge. Throughout the years, a decline in student nurse exposure to perioperative nursing has affected the interest level of new graduates in OR nursing. Recruitment strategies should be developed, including collaboration with local colleges in promoting OR nursing as a valued and esteemed specialty. One method is to promote and recruit nurses to the OR with some type of rotation, practicum, or internship for senior year students.’” Along with recruitment strategies, candidate selection is another focal point for successful vacancy

Table 4 FELLOW Rt3ENTION RATE AS OF MAY 2000

Class

January 1998

6

24.6 months

8

19 months

October 1998

4

19 months

January 1999 June 1999

5 4

16 months 12 months

This data retikc13only the tower OR at lnova Faiflax Hospital. reduction. Researchers have stated that interviews are only 14% accurate in selecting excellent employees.” Developing candidate selection techniques that support a successful selection process of the best nurses for the OR is necessary. A

Paula R. Graling,RN,MSN, CNS, CNOR, is a clinical nurse specialist and management coordinator at Inova Faigm Hospital, Falls Church, Va.

Barbara Rusynko, RN,MSEd, CNOR, is an education coordinator at lnova Learning Network, Falls Church,Va.

Development, fifth ed (Houston: Gulf Publishing CO,1998) 146-149;

supply of registered nurses: Inevitable future or call to action?’ JAMA 283 (June 14,2000) 29852987. 2. K B Gaberson, M H Oermann, “Preparing for clinical learning activities,’’ in Clinical Teaching Strategies in Nursing (New York Springer Publishing Co Inc, 1999) 31-33. 3. General Surgical Surgery Instruments, version 2.0 (Kdama, Wash Watson Enterprises, 1995-

“Adult leaming concepts important to precepting,” in The Role of the

Josey Bass Publishers, 1999) 288-317. 5. M S Knowles, E F Holton, R A Swanson “New perspectives on andragogy,” in The Adult Learner: The Dgnitive Classic in Adult Education and Human Resource

of months retained

July 1998

NOTES 1. G Bednash, “The decreasing

1998). 4. S B Memam, R S Caffmlla, “Self-directed learning,” in Learning in Adulthood: A Comprehensive Guide, second ed (SanFrancisco:

Average number

Number of fellows

Preceptor: A Guidefor Nurse Educators and Clinicians,ed J P Flynn, (New York Springer Publishing Co Inc, 1997) 40-42. 6. C Riley-Doucet, S Wilson, “A

three-step method of self-reflection using reflective journal writing,” Journal of Advanced Nursing 25 (May 1997) 964-968. 7 . 0 Giorgianni, ‘“The OR directors study,” Surgical Services Management 6 (June 2900) 46-48. 8. L Kautztnan, L H Miller, “Growing replacements for our ‘graying’ periopemive nurses,” Today‘s Surgical Nurse 2 1 (M~~h/April 1999) 22-25. 9. J Strauss, “An OR nurse internship program that focuses on retention,” AORN Journal 66 (September 1997) 455-463.

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10. K Gray-Siracusa, “The roller coaster is running: Shortages in specialty nurses are happening again,” Advancefor Nurses (September 20, 1999) 13. 11. L Furlow, M A Hoglan, “How to hire a star: Job profiling,” in 2000 Congress Resources (Denver: AORN, Inc, 2000) 37. RESOURCES Malignant Hyperthermia Association of the United States,

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