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Partnerships and New Learning Models to Create the Future Perioperative Nursing Workforce
Partnerships and New Learning Models to Create the Future Perioperative Nursing Workforce SABRINA GREGORY, MSN, RN, CNML; DEBORAH R. BOLLING, MS, RN, NE-BC, NEA-BC; NANCY F. LANGSTON, PhD, RN, FAAN, ANEF
ABSTRACT To create new and sustainable approaches for development of the perioperative nursing workforce, perioperative nursing leaders at a hospital collaborated with administrators and faculty at a school of nursing to create an innovative learning model that reintroduces perioperative experiences to students in a nursing baccalaureate program. Key components of the initial approaches included an externship for nursing students and a revised internship for experienced nurses who wished to work in perioperative nursing. Project leaders then expanded the nursing student learning opportunity by adding two additional elective perioperative courses to the curriculum. Formation of perioperative clinical placement sites within the seniorlevel adult acute care course was an additional positive outcome of these initial initiatives. These initiatives resulted in decreased use of agency nurses at the clinical site where the externships take place and increased numbers of younger nurses working in the perioperative areas where they externed, with high levels of satisfaction reported by nurses involved in the program. Through this innovative collaboration, the perioperative nurse shortage at the hospital has abated, and the opportunity to continually recruit new colleagues into the practice of perioperative nursing has been established. AORN J 99 (January 2014) 96-105. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2013.10.012 Key words: perioperative nursing shortage, nursing externship, baccalaureate clinical experiences.
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he demise of perioperative courses as a part of nursing education has been identified as a significant factor in the perioperative nurse shortage.1 Happell2 asserts that the absence of perioperative experiences in schools directly results in a decrease in student interest in pursuing a career in the specialty after graduation. Partnerships between educational institutions and nursing
services, particularly perioperative units, can create new models that effectively address this issue while simultaneously addressing the problem of ensuring sufficient quality clinical experiences to enable schools to expand enrollment. Based on mutual goals, organizations like AORN and the National League for Nursing (NLN) have indicated that they could benefit their http://dx.doi.org/10.1016/j.aorn.2013.10.012
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CREATING THE FUTURE PERIOPERATIVE WORKFORCE respective members, and hence nursing globally, by collaborating to study the issue of little or no perioperative education in bachelor of science in nursing (BSN) programs and the effect on the overall shortage of nurses as well as the shortage of nurses entering the perioperative profession. Hence, the AORN Foundation sponsored a think tank3 composed of nurse educators and perioperative nurse leaders to identify whether the mutual interests of AORN and NLN could be used as a platform to transform thinking about the appropriateness of perioperative units as units in which to provide clinical education for undergraduate nursing students. This think tank released a white paper, which was published in AORN Journal,3 that demonstrated the majority of skills expected of a new graduate could be gained through clinical experiences in perioperative settings. In fact, skills expected of new graduatesdsuch as teamwork and safety, including handwashing and sterile technique and continual assessment of patients who are in unstable conditionsdare an inherent part of the perioperative practice environment and therefore provide quality experiences for students.3 Articles appearing in AORN Journal subsequent to the release of the white paper4-6 extended the understanding of the competencies of perioperative practice in a way that affirms the appropriateness of the perioperative setting for acquisition of skills expected of a new generalist entry-level nurse. This understanding is important because undergraduate nursing programs are designed to prepare a generalist nurse and not a specialist nurse. SETTING At the Medical College of Virginia Hospitals of the VCU Health System of Virginia Commonwealth University, Richmond, Virginia, which is a part of a comprehensive health science campus of the university, nursing leaders of the School of Nursing and Nursing Services of the hospital recognized the emerging national trend toward developing organizational partnerships between nursing schools and nursing services7,8 and specific collaborative
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efforts to support perioperative nursing (eg, the think tank sponsored by the AORN Foundation3). Beginning in early 2003, leaders of the school (ie, dean, associate dean for academic programs, associate dean for research) and of nursing services (ie, chief nursing officer [CNO], director of medicine and pediatric nursing, director of professional development) began meeting to discuss how nursing’s relationship within the academic health science center should or could be transformed. The relationship between the medical school and the hospital was clear to the nursing services leaders and the school leaders, including the CNO of the hospital and the dean of the School of Nursing, who believed nursing would benefit from such clarity. An 18-month dialogue by the formal leadership team resulted in creation of a proposal for the toplevel university and hospital administrators that identified the purpose and goals of nursing’s formal partnership between the school and nursing services and developed titled administrative positions (eg, the CNO would hold the title of associate dean for clinical operations of the School of Nursing, and the dean would hold the title of executive director of academic nursing of the VCU Health System) between the two entities. In 2003, the board members of the health system and the president of the university formally endorsed the partnership and administrative structure. Simultaneously, the dean and associate dean of academic programs of the school and leaders of perioperative nursing (eg, director, clinical nurse manager) initiated discussions regarding concerns about an adequate current and future supply of perioperative nurses. Medical College of Virginia Hospitals’ staffing model of practice was similar to most perioperative areas and was based on recruitment of experienced RNs only. These experienced RNs are transformed into perioperative nurses after receiving didactic and clinical education in a perioperative RN internship program. However, the yearly attrition rate of these new nurses was 45%, and the hospital’s staffing model routinely resulted in a shortage of perioperative nurses and inadequate AORN Journal j 97
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not new. Gillespie et al4 identified domains of staffing ratios for the level one trauma center. As a result, the hospital was increasingly reliant on perioperative competency, the vast majority of agency nurses, which resulted in an additional which (ie, teamwork, communication, coordinapersonnel expense of approximately $1.2 to $2 tion, clinical leadership) are also expectations for million each year. In addition, during this time, new generalist nurses as developed by the Amerturnover and vacancy rates were skyrocketing, ican Association of Colleges of Nursing.10 Critical which negatively affected staff morale and nurse thinking is known to be an essential characteristic satisfaction and caused nurse and patient satisfacof a competent nurse, regardless of his or her tion scores to plunge lower than national benchpractice area, and is a relevant experience for premarks every quarter. paring entry-level nurses. Jones5 discussed the The hospital’s reliance on recruitment of expesignificance of instructional strategies designed to rienced nurses resulted in the average staff peridevelop and enhance critical thinking by nursing operative nurse being 56 years of age, which was students when in clinical placements in the perisignificantly older than the national average age of operative environment, and Taber et al6 described 9 46.8 years. Perioperative nursing leaders identified the use of the perioperative setting for a precepted research experience an initiative to develop for senior-level honors nurses for perioperanursing students entive surgical services, Critical thinking is known to be an essential whereby concerns characteristic of a competent nurse, regardless rolled in an introducof his or her practice area, and is a relevant tory research course. related to the current experience for preparing entry-level nurses. Although not all and future supply nursing programs of perioperative require a practicum in nurses also would research, BSN programs require a quality assurance be addressed. One prong of the initiative was to or quality improvement project that relates to restrengthen the hospital’s internship program for search to meet the American Association of Colexperienced RNs, and the second was to partner leges of Nursing characteristics of a baccalaureate with the university in creating an externship course graduate.10 for prelicensure baccalaureate nursing students. As a result of the established organizational partnerSeveral articles11-14 have described various ship with the university, creation of a nursing stueducational models that reintroduce perioperative dent extern course was seen as a viable venture. coursework to the BSN curriculum, such as From that initial vision emerged an expansive learning activities designed to enhance perioperacollaboration that embedded perioperative nursing tive observation experiences already within courwithin the structure of the prelicensure program of ses, development of elective courses, and clinical the school. experience options within existing courses. For those learning activities focused on enhancing the quality of perioperative observation, authors LITERATURE REVIEW ON PERIOPERATIVE describe the development of structured orientation NURSING IN THE CURRICULUM experiences before the student’s observation As the perioperative staff nurses and the associate day.11,12 In addition to the structured orientation, dean of academic programs began the work of Castelluccio12 expanded the observation experideveloping a perioperative experience, they unence from one to two days. Mott13 described dertook a review of the existing literature. From modification of a previously offered 64-hour clinthat review, they determined that the idea of idenical preoperative and postoperative experience to tifying and defining perioperative competencies is 98 j AORN Journal
CREATING THE FUTURE PERIOPERATIVE WORKFORCE include eight hours of OR experience. In addition to the clinical experience within the OR, Mott added a skill training period in the school laboratory and an on-site orientation to the OR before the beginning of the clinical experience.13 Messina et al14 described the introduction of two new experiences: a 15-week clinical experience for students as an elective course and development of a clinical placement in perioperative units as one of the clinical placement options within a senior-level Capstone practicum. Although none of the literature described experience with an externship, the review of the literature supported perioperative nursing as an appropriate practice area for student learning. Because the faculty of the school had indicated that current medicalsurgical courses were already filled with content, semesters were already heavy in credit hours, and the VCU nursing students could take an upper-division elective, it was decided to design an elective course in the form of a summer externship. DEVELOPMENT PROCESS In spring 2005, the associate dean, the director, and the nurse manager from perioperative nursing began developing a nursing student extern course program with the purpose of building a pipeline for perioperative nurses through collaboration and teamwork with the School of Nursing. The associate dean for academic programs at the School of Nursing and two nurse leaders in perioperative services collaborated to design and gain university approval for offering a clinical practicum course (ie, an extern course). The development team created the course as an upperdivision clinical elective worth 1.5 credits to be offered in the summer between the students’ junior and senior years. The students completed 180 hours of clinical practicum as a part of the externship. The team designed a perioperative extern course in a manner that would provide a platform for developing a comparable course for any clinical specialty practice area. The associate dean identified that this strategy would demonstrate to the total faculty of the school, who had to approve the offering of the
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course, that there was potential that their specialty clinical areas also could develop such an elective and that it would have academic rigor. The first cohort of students enrolled in the extern course in summer 2005. Another integral component to establish for the extern program was the faculty of record. The two perioperative unit leaders who collaborated on developing the course were appointed to the School of Nursing as adjunct faculty members and served as the faculty of record for the course. Both faculty members held master’s degrees in nursing, and one also held a post-master’s certificate in nursing education. This academic preparation made them ideal candidates for this role because the school requires that all employed faculty members hold master’s degrees at a minimum. This is necessary to meet national nursing education accreditation standards.15 These adjunct faculty members served as coaches and mentors to staff nurses who served as preceptors for the daily clinical practicum activities of the students. Course Content and Expectations The course consisted of 180 hours of clinical experience, and the objectives for the successful student were to n n n n n
demonstrate beginner clinical competency in a specialized area of clinical practice; apply theoretical and research knowledge to practice; collaborate with health care team members to identify, analyze, and resolve patient care problems; use effective communication skills in the mentorstudent relationship; and apply standards of practice in the assigned clinical area.
We used Benner’s From Novice to Expert: Excellence and Power in Clinical Nursing Practice16 as the textbook for the extern course because the principles outlined in it already were used as the foundation for the hospital’s clinical ladder for professional advancement of clinical nurses. AORN Journal j 99
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Precourse Requirements To start their perioperative extern experience, students were required to participate in the hospital’s orientation designed for all care partners. Additionally, all externs had to complete the perioperative unit orientation, which included observation and return demonstration of competencies on medication labeling.
GREGORYeBOLLINGeLANGSTON and clinical observations, students attended department morning report and safety huddles. They reviewed the patients’ history, physical, consent, site marking, and proposed surgical procedures with the RN circulator and/or the preoperative care nurse. During the morning safety huddles, the student externs review the OR schedule more closely as part of an interdisciplinary care team. This process identifies potential safety concerns (eg, inadequate supplies or staffing levels, look-alike patient names, latex allergies). During the huddle, the team also reviewed the scheduled patients; specific student assignments; goals and objectives for the assignments; and skills and knowledge needed to ensure continuous, safe, effective outcomes for the assigned patients.
Clinical Experiences and Learning Activities Externs participated in scenarios in the simulation OR, where they reviewed patient assessments and 12-lead electrocardiograms. They also learned about instrumentation, scrubbing, gowning, and gloving. During the course, students rotated through all areas of perioperative surgical services: the acute inpatient OR and postanesthesia care unit (PACU), the ambulatory care OR and Preceptors and Clinical Guidance PACU, the perisurgical unit, and the preanesthesia Each student in the extern program was assigned clinic. During each clinical rotation, every student to a preceptor. The preceptor and the student actively participated extern scheduled a in direct clinical padaily post-clinical tient care expericonference to reflect In preparation for clinical care and clinical ences, in addition to observations, students attended department on the assignment and spending assigned the clinical experimorning report and safety huddles, during time with a staff which they helped review the patients’ history, ence. The debriefing physical, consent, site marking, and proposed focused primarily on nurse and a charge surgical procedures. nurse. These assignthe student’s clinical ments provided stuexperience in relation dent externs with to meeting the defined opportunities to observe and understand the reobjectives and identified accomplishments and any levance of effective communication within and barriers to meeting them. The student and preceptor outside the department and to observe and ask reviewed areas of concerns related to safety, effiquestions regarding different perspectives of ciency, and productivity and identified the sturesponsibility and delegation. dent’s objectives for the next assigned clinical Perioperative surgical services routinely admits experience, as agreed to by the student, faculty patients on the day of their surgical experience. members, and the preceptor. The entire cohort of Team members print a final schedule of impending students met with the faculty of record every Friday surgical procedures at 5:30 AM the day of surgery, to discuss their clinical week. and thus the students were able to participate in daily debriefing conferences and in reading and Evidence-Based Projects assessment assignments that provided them with Another requirement of enrollment in this clinical tools necessary to assess their patients in a timely, elective was for the student extern to have comthorough manner. In preparation for clinical care pleted an evidence-based project course, which 100 j AORN Journal
CREATING THE FUTURE PERIOPERATIVE WORKFORCE provided the student with the foundational knowledge and skills to successfully investigate and complete an evidence-based project in one of the extern program’s clinical assigned units. The externship’s evidence-based project requirements comprised a poster and an oral presentation of the project to the clinical staff members and fellow students. Students identified projects based on their clinical observations and interests and were approved by the preceptor as appropriate for a quality initiative for the unit. Examples of the students’ projects included the following: n
Immediate use steam sterilization. These projects led to an overall reduction in the use of immediate use steam sterilization from 59% to 5%. n Effectiveness of teamwork in the perioperative environment. The focus of this project was the development of a safe surgery process based on the book The Checklist Manifesto: How to Get Things Right,17 which presents compelling stories of the need for use of checklists in health care as well as other industries and the World Health Organization guidelines for the surgical safety checklist.18 n Effectiveness of color-coded armbands. The focus of this project was the use of standardized colored armbands to identify allergies, surgical packing, and non-lateral site markings. Preceptors served as evaluators of the students’ clinical performance, with review by the faculty member of record, and the faculty member of record evaluated the evidence-based project. Faculty graded the course on a pass/fail basis. RESULTS The overwhelming interest by nursing students in the first extern course resulted in offering a second session of the extern course in 2007 and a third session in 2008. As a result, we added the introductory extern course to the course schedule for all three semesters of the academic year and added two upper-division elective courses in the fall and
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spring semesters for extern students who desire more in-depth perioperative nursing experiences. The extern course was designed to accommodate a maximum of 10 students each semester, and a minimum of three students was required to offer the course. For the other two upper-division electives, student enrollment is a maximum of six and a minimum of three in each course. The maximum number for each of these two courses is adjusted based on the enrollment in the extern course and enrollment in the other elective. Each of these additional elective courses can be taken for one to five credit hours; however, the total for the two may not exceed five credits because five hours of upperdivision elective credit is the program of study for all students. As with the introductory extern course, these additional courses required completion of 180 clinical hours and an evidence-based research project. Unlike with the introductory extern course, however, for the first of these courses, nursing students selected a specific clinical area from those through which they rotated as externs. In this first course, they became active participants in development and implementation of the patients’ plans of care. Additionally, they completed an evidencebased project specific to their unit and were required to present it to an interdisciplinary group of health professionals. The second of the upper-level extern courses focused on leadership and management of the intraoperative unit. Students were able to facilitate care of patient groups, including scheduling of surgeries, acting in the charge role with the charge nurse, and communicating with all interdisciplinary team members and all levels of personnel. Most importantly, the course allowed students to develop an understanding of how successful interdisciplinary teams promote optimal patient outcomes. From spring 2007 to fall 2011, 120 students completed the introductory extern course. Since the addition of the second-semester extern course in 2007, 45 students have completed the course, and since the addition of the third-semester extern course in 2008, 15 students have completed the AORN Journal j 101
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transforming in terms of his critical thinking and course. Since 2009, approximately nine to 13 stuability to set priorities. dents are completing the entire three-course series A positive but unanticipated consequence of each semester. The students who have completed introducing the extern course was the extension the three courses have excelled in their roles as of the collaboration nurses. Two students beyond the extern and are nurse practitioners, and one is currently Faculty members have come to understand the elective perioperative courses. Faculty memcompleting school to quality of the perioperative environment and bers at the school who become a midwife. In the nature of professional nursing practice as appropriate clinical experiences in preparing a were unfamiliar with addition, another stunew generalist nurse. the substantive nature dent who was our of the perioperative champion for adding clinical experiences the third additional available to students have come to understand the section is currently in our OR internship. Another quality of the perioperative environment and the student is returning to our department and will be nature of professional nursing practice as approworking in our PACU. priate clinical experiences in preparing a new Students who have completed the extern course generalist nurse. Faculty members understood that shared comments about their experiences, such as the perioperative environment provides a clinical the following that were shared with the dean of the learning environment as appropriate as that of an School of Nursing: intensive care unit that provides clinical placements n “If I decide not to pursue a career in periopfor the senior-level acute care course. erative nursing, it has been an excellent expeAs a direct result of the faculty members’ new rience to prepare me to be a nurse.” understanding of perioperative clinical care, with the n “We learn constant assessment of our patients, first offerings in 2007 each semester, a clinical group how to assess a total environment beyond the of eight to 10 senior-level students who were patient, teamwork, advocacy, and a lot about enrolled in the required senior-level acute clinical patient safety.” course had their entire 15-week clinical experience in the perioperative surgical service units. This In March 2006, AORN held its annual conferclinical course section was originally developed ence in Washington, DC. A group of nursing for students who specifically had selected peristudents who had completed the extern course operative surgical services. Furthermore, the school were invited by members of the Richmond faculty member of the course individually interChapter of AORN to attend this national conviewed the students to ensure that they understood vention. The students attended the student prothe nature of the experience, in that students would gram, and they attended other convention sessions be in multiple perioperative units rather than one unit, with chapter members. The School of Nursing as they would be if selecting a traditional intensive underwrote the cost for six nursing students to care unit for their placement. Furthermore, she atattend the conference, and perioperative nurses tempted to ensure that the students selecting the from the hospital served as mentors and coaches perioperative placement were adaptable to the fast for the students at the conference. The nursing pace and constant change in the patients for whom students returned with accolades for the experithey would be providing care and that they evidenced ence and indicated that the opportunity was a a level of maturity important for the constantly positive experience in their development as prochanging environment of the perioperative units. fessionals. One student reported that it was career 102 j AORN Journal
CREATING THE FUTURE PERIOPERATIVE WORKFORCE Now the perioperative placement process emulates all other clinical course placements at the school. Perioperative surgical services became a routine clinical placement within the required senior-level acute care course that is offered twice a year, which allows 16 to 20 students to have a 15-week placement of a minimum of six hours a week in the perioperative units. RESTRUCTURED RN INTERNSHIP As described earlier, perioperative nursing leaders identified a two-pronged approach to addressing recruitment problems. The second approach was to focus on strengthening the hospital’s existing RN internship for experienced nurses. New Components To strengthen the RN internship program, the clinical director and clinical nurse leader undertook several initiatives, including n n n n n
increasing the duration of the program from six months to nine months, decreasing the number of interns per session from 10 to six, increasing the number of student cohorts admitted into the program each year from four to 10, using behavioral interview techniques to interview qualified applicants, and expanding clinical rotations to include the PACU.
Lengthening the duration of the intern program to nine months provided time for the interns to rotate through various specialized services such as cardiac, neurology, and orthopedics. Experiences also were added for evening shifts that allowed the interns to have experiences with trauma patients who were brought in during the evening. By decreasing the number of interns in each session, we could provide each individual with more clinical opportunities and hands-on time. Using behavioral interview techniques enabled the selection committee members to determine which applicants recognized that the primary role of the OR nurse was to advocate for the patient and that being an
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OR nurse also includes accountability, teamwork, communication, unpredictable workloads, and conflict resolution. Additionally, the applicants submit an essay, unofficial transcripts, and two clinical references. These application processes allowed us to admit only the most qualified applicants. Initially, in 2006, we set the class size for this program at 10 participants to offset anticipated attrition. Beginning in 2007, the cohort size was reduced to six interns, which has provided the opportunity for the hospital to consistently maintain a minimum of four viable OR nurses. With six nurse intern slots, the units could plan for inevitable attrition and still be able to sustain an adequate number of new nurses in the OR to safely staff the unpredictable workload of this level one medical center. Also, interns rotated through all units of the department (ie, the perisurgical unit, ambulatory care center, preoperative assessment communication education) and not just the OR, so that their perioperative exposure could be enhanced to include the entire perioperative patient experience. Input from student externs resulted in the revision of the PACU internship to a perioperative nurse internship program. Results As of March 2012, the applicant pool for the RN internship program was 40 to 60 applicants for a cohort size of six. From spring 2007 to fall 2011, 45% of the nurses enrolled in the RN internship have been baccalaureate graduates who completed the perioperative extern course. Students who completed the perioperative extern course consistently have shared their positive experiences with their peers and friends. This has created a marketing and public relations campaign that has resulted in a productive, effective pipeline for the RN internship program. The overwhelming success of the revised internship program is illustrated by the fact that, as of 2011, 45% of the hospital’s OR nurses in the ambulatory center and 70% of OR nurses in the critical care hospital have completed the OR nurse AORN Journal j 103
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nurse intern acquired critical care skills needed in the internship program. Two years after the revision of PICU. At the end of the six months, the intern could the RN internship and the creation of perioperative choose either to remain in the PICU or to complete education as a separate accounting unit with the remainder of the program in the PACU. budgeted positions to educate and orient new inDespite the decision made by the RN interns, the terns and new hires, use of agency personnel was managers and clinicians from both departments met totally eliminated. Although the intern program every two weeks to continue to provide support to was successful in attracting nurses into perioperathe interns and to monitor their progress. Nursing tive practice areas, numerous personnel factors preceptors in both decreated by having a partments attended bimodal age distribution of younger and This postanesthesia care unit (PACU) internship staff meetings, participated in weekly safety older nurses resulted promoted teamwork, collaboration, and nurse in pregnancies and re- satisfaction and, as a result, the overall turnover checks, and were rate for the PACU slowly declined from 15.9% committed to the intirements that inin 2008 to 9.2% in 2011. terns’ successful creased our turnover completion of the rate once again in program. At the sucsummer 2011. Howcessful completion of the nine-month program, inever, because of the success of the revised RN terns had the option to transfer to the PICU as their intern program and the pipeline of nurses created by clinical practice unit or to remain in the PACU. the extern course, the number of intern classes that This PACU internship promoted teamwork, were graduated that year was increased from two collaboration, and nurse satisfaction. As a result, to four to again eliminate the need for agency the overall turnover rate for the PACU slowly personnel. Our success has become a conversadeclined from 15.9% in 2008 to 9.2% in 2011. Our tion piece in many professional venues and has institution participates in the National Database of resulted in nurses from hospitals in the community Nursing Quality Indicators, and in 2010 and 2011, applying for slots in our perioperative RN internour participation by PACU nurses in the nurse ship programs. satisfaction survey was 100%. Furthermore, the scores on six of the quality indicators, including job PACU INTERNSHIP satisfaction, were above the national means for In 2007, we developed the first nurse internship both years. The success of this endeavor was in the PACU to address similar attrition issues in attributed to the collaborative relationships among partnership with the pediatric intensive care unit the nurse leaders of the two departments. (PICU). This two clinical specialty focus was developed to provide experiences that would preCONCLUSION pare the nurse for another clinical practice area in Partnerships, such as those between AORN and the the event the intern decided that the PACU was not NLN, also can occur between educational institutions really where he or she wanted to practice. Reand perioperative units to effectively address the quirements of the program included that the PACU perioperative nursing shortage by creating new nurse intern spend six months in the PICU, while models of education for nursing students. The partsimultaneously having assigned preceptors in both nership between the School of Nursing and Nursing the PACU and PICU. This new collaboration enServices of the hospital resulted in an innovative sured that the PACU nurse intern received tools learning program that can be used to sustain a future necessary to successfully orient to the clinical supply of nurses for perioperative practice and that culture and environment of the PACU and that the 104 j AORN Journal
CREATING THE FUTURE PERIOPERATIVE WORKFORCE was successful for faculty, hospital staff, students, and administrators alike. These efforts not only addressed the issue of providing perioperative courses at the nursing school but also provided a sufficient number of quality clinical experiences to enable the School of Nursing to expand its enrollment. Collaborative partnerships like the one between the school and nursing services also can result in significant outcomes not originally envisioned by either party. National and local accrediting bodies such as the MagnetÒ program, the National League for Nursing Accrediting Commission, and the Virginia Board of Nursing have cited the partnership between the School of Nursing and Nursing Services as noteworthy, characterized the success as “nirvana” and “inspiring,” and identified the partnership as a model to be emulated nationwide. Here at VCU, whether at the School of Nursing or Nursing Services of Medical College of Virginia Hospitals, we believe that the “time is now”4 for creating new models of academic and practice partnerships to strengthen the perioperative workforce throughout the country. Editor’s note: Magnet is a registered trademark of the American Nurses Credentialing Center, Silver Spring, MD. References 1. Holmes SP. Implementing a perioperative nursing elective in a baccalaureate curriculum. AORN J. 2004;80(5):902-910. 2. Happell B. Student interest in perioperative nursing practice as a career. AORN J. 2000;71(3):600-605. 3. Girard NJ. Perioperative educationdperspective from the think tank. AORN J. 2004;80(5):827-838. 4. Gillespie BM, Chaboyer W, Wallis M, Werder H. Education and experience make a difference: results of a predictor study. AORN J. 2011;94(1):78-90. 5. Jones JH. Developing critical thinking in the perioperative environment. AORN J. 2010;91(2):248-256. 6. Taber K, Taber R, Galante L, Sigsby LM. Engaging undergraduate nursing students in perioperative research. AORN J. 2011;93(2):249-258. 7. Beal JA, Green A, Bakewell-Sachs S. The time is right dthe time is now ... academic-service partnerships need to be revisited. J Prof Nurs. 2011;27(6):330-331. 8. Hirschoff A, ed. Building Bridges: Toward More Productive Hospital-Nursing School Partnerships. Washington, DC: Advisory Board Co; 2001. 9. Stokowski LA. Old, but not out: the aging nurse in today’s workplace. http://www.medscape.com/viewarticle/ 585454. Published December 29, 2008. Accessed October 8, 2013.
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10. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing. Washington, DC: AACN; 2008. 11. Ricketts DL, Gray SE. Improving associate degree nursing students’ perioperative clinical observation experiences. AORN J. 2010;91(3):383-389. 12. Castelluccio D. Educating for the future. AORN J. 2012; 95(4):482-491. 13. Mott J. Implementation of an intraoperative clinical experience for senior level baccalaureate nursing students. AORN J. 2012;95(4):445-452. 14. Messina BA, Ianniciello JM, Escallier LA. Opening the doors to the OR: providing students with perioperative clinical experiences. AORN J. 2011;94(2):180-188. 15. Accreditation Manual. Atlanta, GA: Accreditation Commission for Education in Nursing; 2013. 16. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: AddisonWesley Publishing Co; 1984. 17. Gawande A. The Checklist Manifesto: How to Get Things Right. Tomball, TX: Metropolitan Publishing; 2010. 18. WHO Surgical Safety Checklist and Implementation Manual. Geneva, Switzerland: World Health Organization; 2008. http://www.who.int/patientsafety/safesurgery/ ss_checklist/en/. Accessed September 25, 2013.
Sabrina Gregory, MSN, RN, CNML, is a nurse manager, Perioperative Surgical Services, at the Medical College of Virginia Hospitals of VCU Health System of Virginia Commonwealth University Health System, Richmond, Virginia. Ms Gregory has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Deborah R. Bolling, MS, RN, NE-BC, NEA-BC, is nursing director, Perioperative Surgical Services, at the Medical College of Virginia Hospitals of VCU Health System of Virginia Commonwealth University Health System, Richmond, Virginia. Ms Bolling has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Nancy F. Langston, PhD, RN, FAAN, ANEF, is emeritus professor and dean at the Virginia Commonwealth University School of Nursing, Virginia Commonwealth University, Richmond, VA. Dr Langston has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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ABSTRACT To create new and sustainable approaches for development of the perioperative nursing workforce, perioperative nursing leaders at a hospital collaborated with administrators and faculty at a school of nursing to create an innovative learning model that reintroduces perioperative experiences to students in a nursing baccalaureate program. Key components of the initial approaches included an externship for nursing students and a revised internship for experienced nurses who wished to work in perioperative nursing. Project leaders then expanded the nursing student learning opportunity by adding two additional elective perioperative courses to the curriculum. Formation of perioperative clinical placement sites within the seniorlevel adult acute care course was an additional positive outcome of these initial initiatives. These initiatives resulted in decreased use of agency nurses at the clinical site where the externships take place and increased numbers of younger nurses working in the perioperative areas where they externed, with high levels of satisfaction reported by nurses involved in the program. Through this innovative collaboration, the perioperative nurse shortage at the hospital has abated, and the opportunity to continually recruit new colleagues into the practice of perioperative nursing has been established. AORN J 99 (January 2014) 96-105. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2013.10.012 Key words: perioperative nursing shortage, nursing externship, baccalaureate clinical experiences.
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he demise of perioperative courses as a part of nursing education has been identified as a significant factor in the perioperative nurse shortage.1 Happell2 asserts that the absence of perioperative experiences in schools directly results in a decrease in student interest in pursuing a career in the specialty after graduation. Partnerships between educational institutions and nursing
services, particularly perioperative units, can create new models that effectively address this issue while simultaneously addressing the problem of ensuring sufficient quality clinical experiences to enable schools to expand enrollment. Based on mutual goals, organizations like AORN and the National League for Nursing (NLN) have indicated that they could benefit their http://dx.doi.org/10.1016/j.aorn.2013.10.012
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CREATING THE FUTURE PERIOPERATIVE WORKFORCE respective members, and hence nursing globally, by collaborating to study the issue of little or no perioperative education in bachelor of science in nursing (BSN) programs and the effect on the overall shortage of nurses as well as the shortage of nurses entering the perioperative profession. Hence, the AORN Foundation sponsored a think tank3 composed of nurse educators and perioperative nurse leaders to identify whether the mutual interests of AORN and NLN could be used as a platform to transform thinking about the appropriateness of perioperative units as units in which to provide clinical education for undergraduate nursing students. This think tank released a white paper, which was published in AORN Journal,3 that demonstrated the majority of skills expected of a new graduate could be gained through clinical experiences in perioperative settings. In fact, skills expected of new graduatesdsuch as teamwork and safety, including handwashing and sterile technique and continual assessment of patients who are in unstable conditionsdare an inherent part of the perioperative practice environment and therefore provide quality experiences for students.3 Articles appearing in AORN Journal subsequent to the release of the white paper4-6 extended the understanding of the competencies of perioperative practice in a way that affirms the appropriateness of the perioperative setting for acquisition of skills expected of a new generalist entry-level nurse. This understanding is important because undergraduate nursing programs are designed to prepare a generalist nurse and not a specialist nurse. SETTING At the Medical College of Virginia Hospitals of the VCU Health System of Virginia Commonwealth University, Richmond, Virginia, which is a part of a comprehensive health science campus of the university, nursing leaders of the School of Nursing and Nursing Services of the hospital recognized the emerging national trend toward developing organizational partnerships between nursing schools and nursing services7,8 and specific collaborative
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efforts to support perioperative nursing (eg, the think tank sponsored by the AORN Foundation3). Beginning in early 2003, leaders of the school (ie, dean, associate dean for academic programs, associate dean for research) and of nursing services (ie, chief nursing officer [CNO], director of medicine and pediatric nursing, director of professional development) began meeting to discuss how nursing’s relationship within the academic health science center should or could be transformed. The relationship between the medical school and the hospital was clear to the nursing services leaders and the school leaders, including the CNO of the hospital and the dean of the School of Nursing, who believed nursing would benefit from such clarity. An 18-month dialogue by the formal leadership team resulted in creation of a proposal for the toplevel university and hospital administrators that identified the purpose and goals of nursing’s formal partnership between the school and nursing services and developed titled administrative positions (eg, the CNO would hold the title of associate dean for clinical operations of the School of Nursing, and the dean would hold the title of executive director of academic nursing of the VCU Health System) between the two entities. In 2003, the board members of the health system and the president of the university formally endorsed the partnership and administrative structure. Simultaneously, the dean and associate dean of academic programs of the school and leaders of perioperative nursing (eg, director, clinical nurse manager) initiated discussions regarding concerns about an adequate current and future supply of perioperative nurses. Medical College of Virginia Hospitals’ staffing model of practice was similar to most perioperative areas and was based on recruitment of experienced RNs only. These experienced RNs are transformed into perioperative nurses after receiving didactic and clinical education in a perioperative RN internship program. However, the yearly attrition rate of these new nurses was 45%, and the hospital’s staffing model routinely resulted in a shortage of perioperative nurses and inadequate AORN Journal j 97
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not new. Gillespie et al4 identified domains of staffing ratios for the level one trauma center. As a result, the hospital was increasingly reliant on perioperative competency, the vast majority of agency nurses, which resulted in an additional which (ie, teamwork, communication, coordinapersonnel expense of approximately $1.2 to $2 tion, clinical leadership) are also expectations for million each year. In addition, during this time, new generalist nurses as developed by the Amerturnover and vacancy rates were skyrocketing, ican Association of Colleges of Nursing.10 Critical which negatively affected staff morale and nurse thinking is known to be an essential characteristic satisfaction and caused nurse and patient satisfacof a competent nurse, regardless of his or her tion scores to plunge lower than national benchpractice area, and is a relevant experience for premarks every quarter. paring entry-level nurses. Jones5 discussed the The hospital’s reliance on recruitment of expesignificance of instructional strategies designed to rienced nurses resulted in the average staff peridevelop and enhance critical thinking by nursing operative nurse being 56 years of age, which was students when in clinical placements in the perisignificantly older than the national average age of operative environment, and Taber et al6 described 9 46.8 years. Perioperative nursing leaders identified the use of the perioperative setting for a precepted research experience an initiative to develop for senior-level honors nurses for perioperanursing students entive surgical services, Critical thinking is known to be an essential whereby concerns characteristic of a competent nurse, regardless rolled in an introducof his or her practice area, and is a relevant tory research course. related to the current experience for preparing entry-level nurses. Although not all and future supply nursing programs of perioperative require a practicum in nurses also would research, BSN programs require a quality assurance be addressed. One prong of the initiative was to or quality improvement project that relates to restrengthen the hospital’s internship program for search to meet the American Association of Colexperienced RNs, and the second was to partner leges of Nursing characteristics of a baccalaureate with the university in creating an externship course graduate.10 for prelicensure baccalaureate nursing students. As a result of the established organizational partnerSeveral articles11-14 have described various ship with the university, creation of a nursing stueducational models that reintroduce perioperative dent extern course was seen as a viable venture. coursework to the BSN curriculum, such as From that initial vision emerged an expansive learning activities designed to enhance perioperacollaboration that embedded perioperative nursing tive observation experiences already within courwithin the structure of the prelicensure program of ses, development of elective courses, and clinical the school. experience options within existing courses. For those learning activities focused on enhancing the quality of perioperative observation, authors LITERATURE REVIEW ON PERIOPERATIVE describe the development of structured orientation NURSING IN THE CURRICULUM experiences before the student’s observation As the perioperative staff nurses and the associate day.11,12 In addition to the structured orientation, dean of academic programs began the work of Castelluccio12 expanded the observation experideveloping a perioperative experience, they unence from one to two days. Mott13 described dertook a review of the existing literature. From modification of a previously offered 64-hour clinthat review, they determined that the idea of idenical preoperative and postoperative experience to tifying and defining perioperative competencies is 98 j AORN Journal
CREATING THE FUTURE PERIOPERATIVE WORKFORCE include eight hours of OR experience. In addition to the clinical experience within the OR, Mott added a skill training period in the school laboratory and an on-site orientation to the OR before the beginning of the clinical experience.13 Messina et al14 described the introduction of two new experiences: a 15-week clinical experience for students as an elective course and development of a clinical placement in perioperative units as one of the clinical placement options within a senior-level Capstone practicum. Although none of the literature described experience with an externship, the review of the literature supported perioperative nursing as an appropriate practice area for student learning. Because the faculty of the school had indicated that current medicalsurgical courses were already filled with content, semesters were already heavy in credit hours, and the VCU nursing students could take an upper-division elective, it was decided to design an elective course in the form of a summer externship. DEVELOPMENT PROCESS In spring 2005, the associate dean, the director, and the nurse manager from perioperative nursing began developing a nursing student extern course program with the purpose of building a pipeline for perioperative nurses through collaboration and teamwork with the School of Nursing. The associate dean for academic programs at the School of Nursing and two nurse leaders in perioperative services collaborated to design and gain university approval for offering a clinical practicum course (ie, an extern course). The development team created the course as an upperdivision clinical elective worth 1.5 credits to be offered in the summer between the students’ junior and senior years. The students completed 180 hours of clinical practicum as a part of the externship. The team designed a perioperative extern course in a manner that would provide a platform for developing a comparable course for any clinical specialty practice area. The associate dean identified that this strategy would demonstrate to the total faculty of the school, who had to approve the offering of the
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course, that there was potential that their specialty clinical areas also could develop such an elective and that it would have academic rigor. The first cohort of students enrolled in the extern course in summer 2005. Another integral component to establish for the extern program was the faculty of record. The two perioperative unit leaders who collaborated on developing the course were appointed to the School of Nursing as adjunct faculty members and served as the faculty of record for the course. Both faculty members held master’s degrees in nursing, and one also held a post-master’s certificate in nursing education. This academic preparation made them ideal candidates for this role because the school requires that all employed faculty members hold master’s degrees at a minimum. This is necessary to meet national nursing education accreditation standards.15 These adjunct faculty members served as coaches and mentors to staff nurses who served as preceptors for the daily clinical practicum activities of the students. Course Content and Expectations The course consisted of 180 hours of clinical experience, and the objectives for the successful student were to n n n n n
demonstrate beginner clinical competency in a specialized area of clinical practice; apply theoretical and research knowledge to practice; collaborate with health care team members to identify, analyze, and resolve patient care problems; use effective communication skills in the mentorstudent relationship; and apply standards of practice in the assigned clinical area.
We used Benner’s From Novice to Expert: Excellence and Power in Clinical Nursing Practice16 as the textbook for the extern course because the principles outlined in it already were used as the foundation for the hospital’s clinical ladder for professional advancement of clinical nurses. AORN Journal j 99
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Precourse Requirements To start their perioperative extern experience, students were required to participate in the hospital’s orientation designed for all care partners. Additionally, all externs had to complete the perioperative unit orientation, which included observation and return demonstration of competencies on medication labeling.
GREGORYeBOLLINGeLANGSTON and clinical observations, students attended department morning report and safety huddles. They reviewed the patients’ history, physical, consent, site marking, and proposed surgical procedures with the RN circulator and/or the preoperative care nurse. During the morning safety huddles, the student externs review the OR schedule more closely as part of an interdisciplinary care team. This process identifies potential safety concerns (eg, inadequate supplies or staffing levels, look-alike patient names, latex allergies). During the huddle, the team also reviewed the scheduled patients; specific student assignments; goals and objectives for the assignments; and skills and knowledge needed to ensure continuous, safe, effective outcomes for the assigned patients.
Clinical Experiences and Learning Activities Externs participated in scenarios in the simulation OR, where they reviewed patient assessments and 12-lead electrocardiograms. They also learned about instrumentation, scrubbing, gowning, and gloving. During the course, students rotated through all areas of perioperative surgical services: the acute inpatient OR and postanesthesia care unit (PACU), the ambulatory care OR and Preceptors and Clinical Guidance PACU, the perisurgical unit, and the preanesthesia Each student in the extern program was assigned clinic. During each clinical rotation, every student to a preceptor. The preceptor and the student actively participated extern scheduled a in direct clinical padaily post-clinical tient care expericonference to reflect In preparation for clinical care and clinical ences, in addition to observations, students attended department on the assignment and spending assigned the clinical experimorning report and safety huddles, during time with a staff which they helped review the patients’ history, ence. The debriefing physical, consent, site marking, and proposed focused primarily on nurse and a charge surgical procedures. nurse. These assignthe student’s clinical ments provided stuexperience in relation dent externs with to meeting the defined opportunities to observe and understand the reobjectives and identified accomplishments and any levance of effective communication within and barriers to meeting them. The student and preceptor outside the department and to observe and ask reviewed areas of concerns related to safety, effiquestions regarding different perspectives of ciency, and productivity and identified the sturesponsibility and delegation. dent’s objectives for the next assigned clinical Perioperative surgical services routinely admits experience, as agreed to by the student, faculty patients on the day of their surgical experience. members, and the preceptor. The entire cohort of Team members print a final schedule of impending students met with the faculty of record every Friday surgical procedures at 5:30 AM the day of surgery, to discuss their clinical week. and thus the students were able to participate in daily debriefing conferences and in reading and Evidence-Based Projects assessment assignments that provided them with Another requirement of enrollment in this clinical tools necessary to assess their patients in a timely, elective was for the student extern to have comthorough manner. In preparation for clinical care pleted an evidence-based project course, which 100 j AORN Journal
CREATING THE FUTURE PERIOPERATIVE WORKFORCE provided the student with the foundational knowledge and skills to successfully investigate and complete an evidence-based project in one of the extern program’s clinical assigned units. The externship’s evidence-based project requirements comprised a poster and an oral presentation of the project to the clinical staff members and fellow students. Students identified projects based on their clinical observations and interests and were approved by the preceptor as appropriate for a quality initiative for the unit. Examples of the students’ projects included the following: n
Immediate use steam sterilization. These projects led to an overall reduction in the use of immediate use steam sterilization from 59% to 5%. n Effectiveness of teamwork in the perioperative environment. The focus of this project was the development of a safe surgery process based on the book The Checklist Manifesto: How to Get Things Right,17 which presents compelling stories of the need for use of checklists in health care as well as other industries and the World Health Organization guidelines for the surgical safety checklist.18 n Effectiveness of color-coded armbands. The focus of this project was the use of standardized colored armbands to identify allergies, surgical packing, and non-lateral site markings. Preceptors served as evaluators of the students’ clinical performance, with review by the faculty member of record, and the faculty member of record evaluated the evidence-based project. Faculty graded the course on a pass/fail basis. RESULTS The overwhelming interest by nursing students in the first extern course resulted in offering a second session of the extern course in 2007 and a third session in 2008. As a result, we added the introductory extern course to the course schedule for all three semesters of the academic year and added two upper-division elective courses in the fall and
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spring semesters for extern students who desire more in-depth perioperative nursing experiences. The extern course was designed to accommodate a maximum of 10 students each semester, and a minimum of three students was required to offer the course. For the other two upper-division electives, student enrollment is a maximum of six and a minimum of three in each course. The maximum number for each of these two courses is adjusted based on the enrollment in the extern course and enrollment in the other elective. Each of these additional elective courses can be taken for one to five credit hours; however, the total for the two may not exceed five credits because five hours of upperdivision elective credit is the program of study for all students. As with the introductory extern course, these additional courses required completion of 180 clinical hours and an evidence-based research project. Unlike with the introductory extern course, however, for the first of these courses, nursing students selected a specific clinical area from those through which they rotated as externs. In this first course, they became active participants in development and implementation of the patients’ plans of care. Additionally, they completed an evidencebased project specific to their unit and were required to present it to an interdisciplinary group of health professionals. The second of the upper-level extern courses focused on leadership and management of the intraoperative unit. Students were able to facilitate care of patient groups, including scheduling of surgeries, acting in the charge role with the charge nurse, and communicating with all interdisciplinary team members and all levels of personnel. Most importantly, the course allowed students to develop an understanding of how successful interdisciplinary teams promote optimal patient outcomes. From spring 2007 to fall 2011, 120 students completed the introductory extern course. Since the addition of the second-semester extern course in 2007, 45 students have completed the course, and since the addition of the third-semester extern course in 2008, 15 students have completed the AORN Journal j 101
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transforming in terms of his critical thinking and course. Since 2009, approximately nine to 13 stuability to set priorities. dents are completing the entire three-course series A positive but unanticipated consequence of each semester. The students who have completed introducing the extern course was the extension the three courses have excelled in their roles as of the collaboration nurses. Two students beyond the extern and are nurse practitioners, and one is currently Faculty members have come to understand the elective perioperative courses. Faculty memcompleting school to quality of the perioperative environment and bers at the school who become a midwife. In the nature of professional nursing practice as appropriate clinical experiences in preparing a were unfamiliar with addition, another stunew generalist nurse. the substantive nature dent who was our of the perioperative champion for adding clinical experiences the third additional available to students have come to understand the section is currently in our OR internship. Another quality of the perioperative environment and the student is returning to our department and will be nature of professional nursing practice as approworking in our PACU. priate clinical experiences in preparing a new Students who have completed the extern course generalist nurse. Faculty members understood that shared comments about their experiences, such as the perioperative environment provides a clinical the following that were shared with the dean of the learning environment as appropriate as that of an School of Nursing: intensive care unit that provides clinical placements n “If I decide not to pursue a career in periopfor the senior-level acute care course. erative nursing, it has been an excellent expeAs a direct result of the faculty members’ new rience to prepare me to be a nurse.” understanding of perioperative clinical care, with the n “We learn constant assessment of our patients, first offerings in 2007 each semester, a clinical group how to assess a total environment beyond the of eight to 10 senior-level students who were patient, teamwork, advocacy, and a lot about enrolled in the required senior-level acute clinical patient safety.” course had their entire 15-week clinical experience in the perioperative surgical service units. This In March 2006, AORN held its annual conferclinical course section was originally developed ence in Washington, DC. A group of nursing for students who specifically had selected peristudents who had completed the extern course operative surgical services. Furthermore, the school were invited by members of the Richmond faculty member of the course individually interChapter of AORN to attend this national conviewed the students to ensure that they understood vention. The students attended the student prothe nature of the experience, in that students would gram, and they attended other convention sessions be in multiple perioperative units rather than one unit, with chapter members. The School of Nursing as they would be if selecting a traditional intensive underwrote the cost for six nursing students to care unit for their placement. Furthermore, she atattend the conference, and perioperative nurses tempted to ensure that the students selecting the from the hospital served as mentors and coaches perioperative placement were adaptable to the fast for the students at the conference. The nursing pace and constant change in the patients for whom students returned with accolades for the experithey would be providing care and that they evidenced ence and indicated that the opportunity was a a level of maturity important for the constantly positive experience in their development as prochanging environment of the perioperative units. fessionals. One student reported that it was career 102 j AORN Journal
CREATING THE FUTURE PERIOPERATIVE WORKFORCE Now the perioperative placement process emulates all other clinical course placements at the school. Perioperative surgical services became a routine clinical placement within the required senior-level acute care course that is offered twice a year, which allows 16 to 20 students to have a 15-week placement of a minimum of six hours a week in the perioperative units. RESTRUCTURED RN INTERNSHIP As described earlier, perioperative nursing leaders identified a two-pronged approach to addressing recruitment problems. The second approach was to focus on strengthening the hospital’s existing RN internship for experienced nurses. New Components To strengthen the RN internship program, the clinical director and clinical nurse leader undertook several initiatives, including n n n n n
increasing the duration of the program from six months to nine months, decreasing the number of interns per session from 10 to six, increasing the number of student cohorts admitted into the program each year from four to 10, using behavioral interview techniques to interview qualified applicants, and expanding clinical rotations to include the PACU.
Lengthening the duration of the intern program to nine months provided time for the interns to rotate through various specialized services such as cardiac, neurology, and orthopedics. Experiences also were added for evening shifts that allowed the interns to have experiences with trauma patients who were brought in during the evening. By decreasing the number of interns in each session, we could provide each individual with more clinical opportunities and hands-on time. Using behavioral interview techniques enabled the selection committee members to determine which applicants recognized that the primary role of the OR nurse was to advocate for the patient and that being an
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OR nurse also includes accountability, teamwork, communication, unpredictable workloads, and conflict resolution. Additionally, the applicants submit an essay, unofficial transcripts, and two clinical references. These application processes allowed us to admit only the most qualified applicants. Initially, in 2006, we set the class size for this program at 10 participants to offset anticipated attrition. Beginning in 2007, the cohort size was reduced to six interns, which has provided the opportunity for the hospital to consistently maintain a minimum of four viable OR nurses. With six nurse intern slots, the units could plan for inevitable attrition and still be able to sustain an adequate number of new nurses in the OR to safely staff the unpredictable workload of this level one medical center. Also, interns rotated through all units of the department (ie, the perisurgical unit, ambulatory care center, preoperative assessment communication education) and not just the OR, so that their perioperative exposure could be enhanced to include the entire perioperative patient experience. Input from student externs resulted in the revision of the PACU internship to a perioperative nurse internship program. Results As of March 2012, the applicant pool for the RN internship program was 40 to 60 applicants for a cohort size of six. From spring 2007 to fall 2011, 45% of the nurses enrolled in the RN internship have been baccalaureate graduates who completed the perioperative extern course. Students who completed the perioperative extern course consistently have shared their positive experiences with their peers and friends. This has created a marketing and public relations campaign that has resulted in a productive, effective pipeline for the RN internship program. The overwhelming success of the revised internship program is illustrated by the fact that, as of 2011, 45% of the hospital’s OR nurses in the ambulatory center and 70% of OR nurses in the critical care hospital have completed the OR nurse AORN Journal j 103
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nurse intern acquired critical care skills needed in the internship program. Two years after the revision of PICU. At the end of the six months, the intern could the RN internship and the creation of perioperative choose either to remain in the PICU or to complete education as a separate accounting unit with the remainder of the program in the PACU. budgeted positions to educate and orient new inDespite the decision made by the RN interns, the terns and new hires, use of agency personnel was managers and clinicians from both departments met totally eliminated. Although the intern program every two weeks to continue to provide support to was successful in attracting nurses into perioperathe interns and to monitor their progress. Nursing tive practice areas, numerous personnel factors preceptors in both decreated by having a partments attended bimodal age distribution of younger and This postanesthesia care unit (PACU) internship staff meetings, participated in weekly safety older nurses resulted promoted teamwork, collaboration, and nurse in pregnancies and re- satisfaction and, as a result, the overall turnover checks, and were rate for the PACU slowly declined from 15.9% committed to the intirements that inin 2008 to 9.2% in 2011. terns’ successful creased our turnover completion of the rate once again in program. At the sucsummer 2011. Howcessful completion of the nine-month program, inever, because of the success of the revised RN terns had the option to transfer to the PICU as their intern program and the pipeline of nurses created by clinical practice unit or to remain in the PACU. the extern course, the number of intern classes that This PACU internship promoted teamwork, were graduated that year was increased from two collaboration, and nurse satisfaction. As a result, to four to again eliminate the need for agency the overall turnover rate for the PACU slowly personnel. Our success has become a conversadeclined from 15.9% in 2008 to 9.2% in 2011. Our tion piece in many professional venues and has institution participates in the National Database of resulted in nurses from hospitals in the community Nursing Quality Indicators, and in 2010 and 2011, applying for slots in our perioperative RN internour participation by PACU nurses in the nurse ship programs. satisfaction survey was 100%. Furthermore, the scores on six of the quality indicators, including job PACU INTERNSHIP satisfaction, were above the national means for In 2007, we developed the first nurse internship both years. The success of this endeavor was in the PACU to address similar attrition issues in attributed to the collaborative relationships among partnership with the pediatric intensive care unit the nurse leaders of the two departments. (PICU). This two clinical specialty focus was developed to provide experiences that would preCONCLUSION pare the nurse for another clinical practice area in Partnerships, such as those between AORN and the the event the intern decided that the PACU was not NLN, also can occur between educational institutions really where he or she wanted to practice. Reand perioperative units to effectively address the quirements of the program included that the PACU perioperative nursing shortage by creating new nurse intern spend six months in the PICU, while models of education for nursing students. The partsimultaneously having assigned preceptors in both nership between the School of Nursing and Nursing the PACU and PICU. This new collaboration enServices of the hospital resulted in an innovative sured that the PACU nurse intern received tools learning program that can be used to sustain a future necessary to successfully orient to the clinical supply of nurses for perioperative practice and that culture and environment of the PACU and that the 104 j AORN Journal
CREATING THE FUTURE PERIOPERATIVE WORKFORCE was successful for faculty, hospital staff, students, and administrators alike. These efforts not only addressed the issue of providing perioperative courses at the nursing school but also provided a sufficient number of quality clinical experiences to enable the School of Nursing to expand its enrollment. Collaborative partnerships like the one between the school and nursing services also can result in significant outcomes not originally envisioned by either party. National and local accrediting bodies such as the MagnetÒ program, the National League for Nursing Accrediting Commission, and the Virginia Board of Nursing have cited the partnership between the School of Nursing and Nursing Services as noteworthy, characterized the success as “nirvana” and “inspiring,” and identified the partnership as a model to be emulated nationwide. Here at VCU, whether at the School of Nursing or Nursing Services of Medical College of Virginia Hospitals, we believe that the “time is now”4 for creating new models of academic and practice partnerships to strengthen the perioperative workforce throughout the country. Editor’s note: Magnet is a registered trademark of the American Nurses Credentialing Center, Silver Spring, MD. References 1. Holmes SP. Implementing a perioperative nursing elective in a baccalaureate curriculum. AORN J. 2004;80(5):902-910. 2. Happell B. Student interest in perioperative nursing practice as a career. AORN J. 2000;71(3):600-605. 3. Girard NJ. Perioperative educationdperspective from the think tank. AORN J. 2004;80(5):827-838. 4. Gillespie BM, Chaboyer W, Wallis M, Werder H. Education and experience make a difference: results of a predictor study. AORN J. 2011;94(1):78-90. 5. Jones JH. Developing critical thinking in the perioperative environment. AORN J. 2010;91(2):248-256. 6. Taber K, Taber R, Galante L, Sigsby LM. Engaging undergraduate nursing students in perioperative research. AORN J. 2011;93(2):249-258. 7. Beal JA, Green A, Bakewell-Sachs S. The time is right dthe time is now ... academic-service partnerships need to be revisited. J Prof Nurs. 2011;27(6):330-331. 8. Hirschoff A, ed. Building Bridges: Toward More Productive Hospital-Nursing School Partnerships. Washington, DC: Advisory Board Co; 2001. 9. Stokowski LA. Old, but not out: the aging nurse in today’s workplace. http://www.medscape.com/viewarticle/ 585454. Published December 29, 2008. Accessed October 8, 2013.
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10. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing. Washington, DC: AACN; 2008. 11. Ricketts DL, Gray SE. Improving associate degree nursing students’ perioperative clinical observation experiences. AORN J. 2010;91(3):383-389. 12. Castelluccio D. Educating for the future. AORN J. 2012; 95(4):482-491. 13. Mott J. Implementation of an intraoperative clinical experience for senior level baccalaureate nursing students. AORN J. 2012;95(4):445-452. 14. Messina BA, Ianniciello JM, Escallier LA. Opening the doors to the OR: providing students with perioperative clinical experiences. AORN J. 2011;94(2):180-188. 15. Accreditation Manual. Atlanta, GA: Accreditation Commission for Education in Nursing; 2013. 16. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: AddisonWesley Publishing Co; 1984. 17. Gawande A. The Checklist Manifesto: How to Get Things Right. Tomball, TX: Metropolitan Publishing; 2010. 18. WHO Surgical Safety Checklist and Implementation Manual. Geneva, Switzerland: World Health Organization; 2008. http://www.who.int/patientsafety/safesurgery/ ss_checklist/en/. Accessed September 25, 2013.
Sabrina Gregory, MSN, RN, CNML, is a nurse manager, Perioperative Surgical Services, at the Medical College of Virginia Hospitals of VCU Health System of Virginia Commonwealth University Health System, Richmond, Virginia. Ms Gregory has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Deborah R. Bolling, MS, RN, NE-BC, NEA-BC, is nursing director, Perioperative Surgical Services, at the Medical College of Virginia Hospitals of VCU Health System of Virginia Commonwealth University Health System, Richmond, Virginia. Ms Bolling has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Nancy F. Langston, PhD, RN, FAAN, ANEF, is emeritus professor and dean at the Virginia Commonwealth University School of Nursing, Virginia Commonwealth University, Richmond, VA. Dr Langston has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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