PERIOPERATIVE SUCCESSION PLANNING: Theoretical Learning, Clinical Opportunities, and Residencies

AORN Transition to Practice Ad Hoc Committee | November 2015

PROBLEM Aging demographics has contributed to a widespread of periOperative Registered Nurses (AORN) Salary shortage of perioperative nurses. Survey (n=3,437), approximately 13% of respondents While some Registered Nurses (RNs) are delaying were at least 60 years of age; 38% were in their 50s; retirement due to the deep impact of the 2008 27% in their 40s with only 23% under 40 years old.2 economic recession, that will soon change. Mass Sherman found that 64% of perioperative nurses she perioperative nurse retirements are predicted in surveyed plan to be retired by 2022.3 the next five years, which would cause the current shortage to escalate. This will leave a serious loss Formal Education of perioperative nursing knowledge and experience In 2013, Sherman and colleagues4 reported 56% of critical to safe patient care and optimal outcomes. OR nurse leaders said they were currently experiencing recruitment challenges and 68% expected recruitment Nursing students have minimal exposure to perioperative challenges in the next five years. Reasons cited were content and to clinical rotations in operative settings as nurses’ lack of exposure to the OR during academic part of traditional baccalaureate education. This means preparation, no perioperative nursing content in novice nurses are often unfamiliar with perioperative baccalaureate and other degree programs, a need for nursing as a realistic employment option after graduation. residency programs after graduation, and a lack of In addition, many nurse leaders are reluctant to hire organizational commitment (time and money) to train new graduates into the perioperative arena due to their inexperienced staff. minimal exposure to the setting and limited theoretical knowledge of the specialty area. The lack of perioperative content in nursing curricula is a long-standing problem, and has been recognized as a barrier for perioperative nurse succession since the early BACKGROUND 1970s. In 1973, the AORN House of Delegates passed a Aging perioperative nursing workforce Position Statement for the “necessity for nursing student As far back as 2000, Buerhaus and associates reported participation in operating room nursing”,5 p. 187. In the Operating Room (OR) had the most diploma- 1980, AORN’s Project Alpha was first published and prepared nurses and these nurses represented the most provided a set of guidelines to foster communication senior cohort of RNs. They also noted the perioperative between perioperative nurses and academic leaders setting had the second lowest percentage of RNs about integrating perioperative content into school of under age 40.1 According to the 2014 Association nursing curriculum.6 In 1981, the AORN House of

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Page 1 Delegates adopted Project Alpha to promote nursing OR, where orientation time can extend from 6 to 12 students’ education in the perioperative setting.7 months to allow for adequate experiential and theoretical Project Alpha initiatives involving hospital and learning on the part of the novice nurse. Surgical services academic partnerships to promote perioperative nursing and interventional care typically accounts for up to 60% included: (a) developing electives that were offered in of a facility’s revenue.16 Nurse turnover and baccalaureate programs,7-8 (b) offering a post-graduate associated orientation costs can significantly affect the course in perioperative nursing to RNs,9 and (c) offering profit margin. a perioperative nursing internship.10 Clearly, perioperative nurses are aging. It has been 34 In 2004, leaders from the National League for Nursing years since Project Alpha was adopted and 11 years post- (NLN) and AORN came together in a Think Tank Think Tank, yet the same problems remain. Perioperative to address perioperative nursing succession. Members content is not integrated in undergraduate curricula, concluded essential nursing knowledge and skills perioperative settings are not being used as a reasonable could be obtained through learning experiences in alternatives for clinical learning, and perioperative perioperative care. Think Tank members recommended residencies are not widespread. Costs associated with incorporating OR theoretical content and perioperative orienting new nurses to the perioperative specialty as a clinicals as alternatives to traditional medical/surgical result of impending mass retirements could cripple an 11 experiences, rather than adding more content. institution’s bottom line and have deleterious, widespread More recent seminal works have called for a radical effects on perioperative patient safety. transformation in nursing education12, including learning in action by integrating classroom and clinical learning. The Institute of Medicine13 called for a smoother transition SOLUTION to practice for new nurses with an emphasis on residencies, and noted the importance of interprofessional education Considering the current and increasing shortage of to best prepare nurses to function in multidisciplinary perioperative nurses, the wealth of experience that will teams providing patient-centered care. The American be lost when large numbers of perioperative nurses retire Association of Colleges of Nursing (AACN) recognizes in the next five to seven years, and the profound impact interprofessional education as an essential component of this could have on safe perioperative care, the time is baccalaureate nursing education.14 now to adopt a comprehensive and strategic succession plan to address the problem. We are recommending a Cost of Turnover threefold approach to solving the problem: The AORN Recruitment Center experienced a 15% increase in perioperative nursing job postings for Integrating OR Content into Baccalaureate Education the period 1/1/2015 to 6/30/2015 as compared to AORN’s vision is to “be the indispensable resource for the same period in 2014 (personal communication, evidence-based practice and education that establishes Susan Becia, August 18, 2015), clearly supporting the standards of excellence in the delivery of perioperative the need for perioperative registered nurses. Open nursing care.”17 AORN advocates for learning activities positions correlate with the time and cost associated in the perioperative setting to be included in all with nursing turnover. undergraduate professional nursing curricula. The perioperative setting is a prime area to apply the nursing Nursing orientation costs in any setting are reported to process. Integrating the Fundamentals of Perioperative be as high as $65,000 to $75,000 per nurse in some Practice into existing curricula can comprehensively parts of the county.15 These costs are even higher in the contribute to desired end-of-program outcomes.18

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Page 2 The perioperative setting is an area with a tremendous providers, and other professionals providing emphasis on patient safety. There are countless operative patient-centered care. Using the Fundamentals opportunities to explore human factors and concepts of Perioperative Practice course would assure students related to health and disease. The course also provides came to clinical prepared with the theoretical knowledge a well-defined foundation of perioperative nursing necessary as a foundation for safe practice. Exposing concepts and gives students basic information about students to perioperative theoretical and clinical learning asepsis and teamwork that can be translated into a while in school could translate into orientation cost-savings myriad of clinical experiences.18 if these students go on to practice in the operative setting.

Since there is a fee associated with using the Fundamentals Perioperative Nurse Residencies of Perioperative Practice course, we advocate for funding Offering residencies to new graduates and using the opportunities including: (a) allowing academic leaders Periop 101: A Core CurriculumTM course ensures evidence to apply for AORN Foundation Scholarships to cover based-teaching and learning practices are employed. the per student cost at their institutions, and (b) having New nurse success in residency programs has been well AORN leaders seek external funding to support using the documented.20-51 Opening perioperative areas for nurse Fundamentals of Perioperative Practice course in academic residencies would meet the IOM13 recommendations settings at a nominal cost. The current fee is not affordable for smother transition to practice, ease nurses into the and cannot reasonably be passed onto the student. OR specialty, and potentially increase retention of new nurses. Perioperative practice nicely affords itself to We also advocate for AORN leaders to seek funding interprofessional, patient-centered care. from sources like the Robert Wood Johnson Foundation to support surgical technicians returning to school to become registered nurses in return for a commitment to SUMMARY work in the perioperative setting. Surgical technicians With projected retirements of a large percentage of are an untapped resource to reduce the perioperative the perioperative nursing workforce in the next five to . Innovative arrangements could be seven years, immediate attention to succession planning made with academic partners for the surgical technicians is critical. Operative settings must be staffed with to complete perioperative nursing clinical rotations as academically and experientially qualified nurses who can part of their baccalaureate education. provide high quality, safe care to ensure optimal patient Using Perioperative Sites for Clinical Learning outcomes. Integrating perioperative content in the Perioperative areas are severely underutilized as clinical nursing curricula, and using perioperative sites for clinical sites, often used for observation-only experiences. The learning and residency sites after graduation, could create 1:8 faculty-to-student clinical ratio is prohibitive in the a greater interest in the perioperative specialty. These OR. Now is the time for academic and perioperative strategies could avert a national crisis due to a shortage clinical partners to transform nursing education and of perioperative registered nurses, which could have develop more precepted, intern, or extern experiences for catastrophic effects on aggregate surgical outcomes. It is students, using innovative teaching and learning strategies time to stop 35 years of talking about a plan and begin to meet clinical objectives. Students can be offered implementing concrete strategies to avert a perioperative precepted perioperative experiences as an alternative to nursing crisis. medical/surgical “ward” rotations.19 In the perioperative setting, students can participate in interprofessional learning to a much greater degree in teams with surgeons,

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Page 3 REFERENCES 1. Buerhaus, P.; Staiger, D.; Auerbach, D. Why Are Shortages of 15. Arnold, J. (2012). Cost of hiring new nurses. Advance Healthcare Hospital RNs Concentrated in Specialty Care Units? Nursing Network for Nurses. http://nursing.advanceweb.com/Features/ Economics: May-June 2000, Vol. 18, No. 3. Articles/cost-of-hiring-new-nurses.aspx. Accessed June 6, 2014).

2. Bacon, D. et al. Results of the AORN Salary and Compensation 16. Randa, K., Heiser, R., Gill, R. (2009) as cited in Sherman, Survey. AORN Journal, 100(6), 570-585. R. (2014). Perioperative nurse leader perspectives on succession planning: A call to action. Nursing Economics, 32(4), 186-203. 3. Sherman, R. (2014). Perioperative nurse leader perspectives on succession planning: A call to action. Nursing Economics, 32(4), 17. AORN.org http://www.aorn.org/FormSec. 186-203. aspx?ekfrm=22932&terms=vision Accessed September 3, 2015.

4. Sherman, R., Dyess, S., Hannah, E., Prestia, A. Succession planning 18. AORN.org http://www.aorn.org/Secondary. for the future through academic-practice partnership: A nursing aspx?id=25524&terms=Perioperative%20Fundamentals administration master’s program for emerging nurse leaders. Nurs Accessed September 3, 2015. Adm Q. 2013; 37(1) 18-27. Accessed 30 August 2013. 19. Chappy, S., Madigan, P., Doyle, D., Conradt, L., Tapio, N. (in 5. Delegates approve statements of RN and nursing student in OR, press). Preparing the next generation of perioperative nurses: BSN institutional licensure, abortion. AORN Journal, April 1973, 187-191. Clinical Immersion, AORN Journal.

6. Flatt, V., Gunter, S., Nelson, J., Thomson, E. (1980). Project 20. Anderson, T., Allen, M., Linden, L., & Gibbs, E. (2009). Alpha provides guidelines, model for chapter action. AORN New graduate RN work satisfaction after completing an interactive Journal, 32(5) 867-875. nurse residency. Journal of Nursing Administration, 39(4), 165-169.

7. Young R, Takahashi J, Cheney A. Project Alpha goes into action... 21. Bratt, M. (2009). Retaining the next generation of nurses: to promote the student perioperative experience. AORN Journal The Wisconsin nurse residency program provides a continuum [serial online]. November 1981; 34:920. Available from: CINAHL of support. The Journal of Continuing Education in Nursing, 40, Plus with Full Text, Ipswich, MA. Accessed November 9, 2014. 416-425. DOI: 10.3928/00220124-20090824-5

8. Beitz J. Project Alpha: a nursing elective implemented in a 22. Bratt, M. & Felzer, H. (2011). Perceptions of professional general systems theory curriculum. AORN Journal [serial online]. practice and work environment of new graduates in a nurse May 1992; 55(5):1218-1218-22, 1224, 1226 passim. Available residency program. The Journal of Continuing Education in from: CINAHL Plus with Full Text, Ipswich, MA. Accessed Nursing, 42, 559-568. DOI: 10.3928/00220124-20110516-03 November 9, 2014. 23. Berkow, S., Stewart, J., Virkstis, K., & Conway, L., (2008). 9. Takahashi J, Benotti D, Shea K, Young R. Project Alpha: Assessing new performance. The Journal of Nursing designing courses that recruit and retain OR nurses. AORN Administration, 38, 468-474. Journal [serial online]. February 1990; 51(2):497-497-9, 501, 504- 5 passim. Available from: CINAHL Plus with Full Text, Ipswich, 24. Casey, K., Fink, R., Krugman, M., & Propst, J. (2004). The MA. Accessed November 9, 2014. graduate nurse experience. The Journal of Nursing Administration, 34, 303-311. 10. Markey B, Wolfe M, Miller L. Perioperative internship for college credit: a Project Alpha activity. AORN Journal [serial 25. Fink, R., Casey, K., Krugman, M., Goode, C. (2008). The online]. June 1990; 51(6):1575-1579. Available from: CINAHL graduate nurse experience qualitative residency program outcomes. Plus with Full Text, Ipswich, MA. Accessed November 9, 2014. Journal of Nursing Administration, 38, 341-348.

11. Think tank on perioperative learning experiences in the nursing 26. Friedman, M.I., Cooper, A., Click, E., & Fitzpatrick, J. (2011). curriculum. (2004). Summary report. Co-sponsored by the AORN Specialized new graduate RN critical care orientation: Retention and and NLN. financial impact.Nursing Economics, 29(1), 7-14.

12. Benner, P; Sutphen, M.; Leonard, V.; & Day, L. (2010). 27. Goode, C.J., Bednash, G.D., Lynn, M.R., Murray, B., & Educating nurses: A call for radical transformation. Stanford, CA: McElroy, D. (2013). Lessons learned from 10 years of research Josey-Bass. on a post-baccalaureate nurse residency program. Journal of Nursing Administration, 43(2), 73-79. DOI: 10.1097/ 13. Institute of Medicine (2010). The future of nursing: Leading NNA.0b013e31827f205c change, advancing health. Washington, DC: The National Academies Press. 28. Goode, C. & Williams, C. (2004). Post-baccalaureate nurse residency program. Journal of Nursing Administration, 34(2), 71-77. 14. AACN. The Essentials of Baccalaureate Education Available from: http://www.aacn.nche.edu/education-resources/ 29. Halfer, D. (2007). A magnetic strategy for new graduate nurses. BaccEssentials08.pdf Accessed September 3, 2015. Nursing Economics, 25(1), 6-12.

Page 4 30. Halfer, D & Graf, E. (2006). Graduate nurse perceptions of 43. Pine, R. & Tart, K. (2007). Return on investment: Benefits the work experience. Nursing Economics, 24(3), 150-155. and challenges of a baccalaureate nurse residency program. Nursing Economic$, 25, 13-18. 31. Herdrich, B. & Lindsay, A. (2006). Nurse residency programs redesigning the transition into practice. Journal for Nurses in Staff 44. Pittman, P., Herrera, C., Bass, E., & Thompson, P. (2013). Development, 22(2), 55-62. Residency programs for new nurse graduates how widespread are they and what are the primary obstacles to further adoption. The 32. Hillman, L., & Foster, R. (2011). The impact of a nursing Journal of Nursing Administration, 43, 597-602. transitions program on retention and cost savings. Journal DOI: 10.1097/01.NNA.0000434507.59126.78 of , 19, 50-56. DOI:10.1111/j.1365- 2834.2010.01187.x 45. Poynton, M., Madden, C., Bowers, R., Keefe, M., & Peery, L.H. (2007). Nurse residency program implementation: The Utah 33. Keller, J.L., Meekins, K., & Summers, B.L., (2006). Pearls and experience. Journal of Healthcare Management, 52, 385-397. pitfalls of a new graduate academic residency program. Journal of Nursing Administration, 36, 589-598. 46. Rosenfeld, P., Smith, M.O., Iervolino, L., & Bowar-Ferres, S. (2004). Nurse residency program a 5 year evaluation from the 34. Kowalski, S. & Cross, C.L. (2010). Preliminary outcomes of participants’ perspective. Journal of Nursing Administration, 34, a local residency programme for new graduate registered nurses. 188-194. Journal of Nursing Management, 18, 96-104. DOI:10.111/j.1365- 2834.2009.01056.x 47. University HealthSystem Consortium & American Association of Colleges of Nursing. (2008). Executive Summary of the 35. Kramer, M., Halfer, D., Maguire, P., & Schmalenberg, C. Post-Baccalaureate Residency Program. Retrieved from: http:// (2012). Impact of healthy work environments and multistage www.aacn.nche.edu/leading-initiatives/education-resources/ nurse residency programs on retention of newly licensed RNs. NurseResidencyProgramExecSumm.pdf Journal of Nursing Administration, 42(3), 148-159. DOI:10.1097/ NNA.0b013e31824808e3 48. Ulrich, B., Ashlock, C., Krozek, C., Africa, L., Early, S. & Carmen, M.L. (2010). Improving retention, confidence, and 36. Krugman, M., Bretschneider, J., Horn, P.B., Krsek, C.A., competence of new graduate nurses: Results from a 10-year Moutafis, R.A. & Oare Smith, M. (2006). The national post- longitudinal database. Nursing Economics, 28(6), 363-375. baccalaureate graduate nurse residency program a model for excellence in transition to practice. Journal for Nurses in Staff 49. Versant. (2013). Outcomes. Retrieved from https://www. Development, 22(4), 196-205. versant.org/research/outcomes.html

37. Little, J.P., Ditmer, D., & Bashaw, M.A. (2013). New 50. Williams, C.A., Bednash, G.D., Goode, C.J., Lynn, M.R., graduate nurse residency a network approach. Journal & Krsek, C. (2007). Post baccalaureate nurse residency 1-year of Nursing Administration, 43, 361-366. DOI:10.1097/ outcomes. Journal of Nursing Administration, 37, 357-365. NNA.0b013e3182942c06 51. Zinn, J.L., Guglielmi, C.L., Davis, P.P. & Moses, C. 38. Maxwell, K. (2011). The implementation of the UHC/AACN (2012). Addressing the nursing shortage: The need for nurse new graduate nurse residency program in a community hospital. residency programs. AORN Journal, 96, 652-656. http://dx.doi. Nurse Clinician North America, 46, 27-33. DOI:10.1016/j. org/10.1016/j.aorn.2012.09.011 cnur.2010.10.013

39. Nadler-Moodie, M. & Loucks, J. (2011). The implementation of a new-graduate nurse residency training program directly into psychiatric-mental health nursing. Archives of Psychiatric Nursing, 25, 479-484. DOI:10.1016/j.apnu.2011.03.002

40. Newhouse, R.P., Hoffman, J.J., Suflita, J. & Hairston, D. (2007). Evaluating an innovative program to improve new nurse graduate socialization into the acute healthcare setting. Nursing Administration Quarterly, 31(1), 50-60.

41. Nursing Solutions. (2013). 2013 National healthcare & RN retention report. NSI Nursing Solutions, Inc. Retrieved from: www. nsinursingsolutions.com.

42. Olson-Sitki, K., Wendler, M.C., & Forbes, G. (2012). Evaluating the impact of a nurse residency program for newly graduated registered nurses. Journal for Nurses in Staff Development, 28(4), 156-162. DOI:10.1097/NND.0b013e31825dfb4c

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