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OR Nurse:
doi: 10.1097/01.ORN.0000446030.17570.82
Department: Smart Management

Where, oh where, are the OR nurses?

Dunn, Debra MSN, MBA, RN, CNOR

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Author Information

Debra Dunn is an OR nurse educator at Memorial Sloan Kettering Cancer Center, New York, N.Y.

The author has disclosed that she has no financial relationships related to this article.

There's a shortage of nurses in the workforce in almost all nursing venues.1 Not surprisingly, there's also a shortage of OR nurses working in the perioperative arena. Many factors are impacting the perioperative nursing shortage:

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* the number of college graduates who choose nursing as a career hasn't met the demand for nursing, in general, and OR nursing in particular (although recently there's been financial and governmental support to encourage more students to major in nursing)

* an aging workforce that's begun to retire–the average age of OR nurses is 47 to 52 years

* demand for nursing care, in general, is expected to rise by 2% to 3% each year as the Baby Boomer generation retires2

* the number of surgical procedures performed in the United States is increasing

* nursing schools promote basic nursing education aimed at the “generalist role,” resulting in an absence of in-depth perioperative curricula

* fewer nurses graduate with didactic education or observational experiences in the perioperative area

* cultural influences of Generation X

* the OR environment's level of complexity related to changing technologic advances that become more demanding over time

* stressful environment.1–7

The aging nursing workforce, without a sufficient number of nurses to replace them, has been a well-known issue for a while. Many programs were designed to encourage enrollment into nursing programs. Nursing schools, however, were unprepared for this increase in applications, resulting in prospective nursing students being turned away because of a deficit in nursing professors. In response to this need, albeit delayed, there are now government-sponsored tuition reduction programs and scholarships for nurses enrolled in nursing masters programs with a concentration in education.

Nursing as an academic profession began with diploma schools where nursing students spent many hours in clinical with hands-on training on the hospital units in tandem with classroom education. Today, the model has changed to one where the baccalaureate nursing degree is being discussed as entry into practice. One rationale for this requirement is that a baccalaureate degree provides a broader-based foundation for nurses to provide safe, interdisciplinary care than the diploma school or associate degree.7 In addition to the BSN as entry into practice, the rapid growth of knowledge in medicine, nursing research, and technology needs to be incorporated into nursing curricula. The cascading effect is that 4-year degree programs have had to eliminate various components of their teaching. In many cases, perioperative nursing was completely removed from their standardized nursing program, and in other programs, it consists of a few hours of didactic with 2 to 4 hours of observation of a surgical procedure.

Unfortunately, the need to coalesce course offerings has also resulted in the elimination of elective courses in some universities so that perioperative nursing could not even be offered as an elective course.8 In effect, nursing students are graduating as generalists with some clinical exposure along with increased education in improving decision making and interdisciplinary skills, working with diverse patient populations, integrating research and ethics into practice, and increasing community and public health education but without any depth to the coursework.7,8 This change is not detrimental in and of itself, but it results in the elimination of other topics or programs within the curricula. The decline of diploma schools with hands-on perioperative learning, limited exposure to the perioperative environment, and the absence of an in-depth perioperative nursing content in current nursing school curricula have contributed to a lack of interest in the perioperative specialty area among nursing students; few nurses are seeking this as a career alternative.1,7 How can a nursing student choose the OR as a career path when there hasn't been enough or any exposure to this specialty? This is a major reason for the OR staffing shortage.5

Diminished or nonexistent perioperative education can result in nursing students and experienced nurses to have misaligned, preconceived notions as to what an OR is “all about.” This lack of knowledge regarding the roles and responsibilities of the OR nurse can then result in the newly hired OR nurse to be disenchanted with their chosen profession once their “honeymoon phase” is over, resulting in a resignation letter. This scenario occurs when nurses don't have correct or adequate information to ask proper questions during the interviewing process or when the interview team doesn't conduct a proper interview by asking direct and relevant questions to ascertain whether the candidate is the right “fit” for the open position. Newly-hired nurses then embark on a lengthy orientation period (generally 6 to 9 months) only to realize that the OR was not what they had expected it to be, and they resign. This is a costly and frustrating experience for the orientee, preceptor, OR colleagues, and managers in the department.1,3,9

Nursing graduates don't choose perioperative nursing as a career because they don't have the prerequisite knowledge or skill needed to make such a choice. Thompson's research demonstrated that exposure to OR nursing directly impacts a nurse's decision to enter the perioperative specialty area.4 This research further demonstrated that any degree of exposure to the OR influences students to pursue careers in OR nursing. The consequence of eliminating perioperative nursing from nursing curricula, therefore, has a direct, negative impact on a nurse's desire to become an OR nurse. What is especially interesting is that nurses who chose the OR as a work environment were exposed to OR nursing while in school and were attracted to specific attributes that OR nursing had to offer.4 These attributes include the following:

* high-technology atmosphere

* ability to make a difference in people's lives and seeing immediate results from one's work

* stimulating, learning environment

* convenient work hours

* portability (ability to transfer skills to another place of employment)

* working as a team with other healthcare professionals.4

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The ins and outs of recruitment

Occasionally, an OR manager may be able to fill an open position in the OR with an experienced OR nurse. However, generally there are three types of nurses hired by OR managers: new graduates (novice nurse/novice OR nurse), experienced non-OR nurses (such as medical-surgical nurses), and experienced nurses with limited OR skills (such as cardiac catheterization or delivery room nurses). New graduates need to learn the most rudimentary processes and skills when they start working in an OR. For example, simply understanding the patient's chart (paper or electronic) can take some time. Another example is learning to communicate with physicians. Experienced nurses, on the other hand, bring this type of rudimentary knowledge to their new career. Their focus is on applying nursing experience to their new work environment and attaining OR knowledge, skills, and behaviors. The new graduate and the experienced non-OR nurse will require extensive resource utilization before they'll be able to perform in the circulating (and scrub, depending on the institution) role. Experienced nurses who were considered knowledgeable or even experts in their previous departments are, once again, considered novices.

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Selection process when hiring new graduates or experienced non-OR nurses

Institutions actively recruit new graduates and experienced, non-OR nurses for the OR by advertising, posting careers on their websites, hiring recruitment firms, working with traveler agencies, word-of-mouth/referral, and participating in college recruitment career fairs and education fairs. Before applicants are selected for an interview, the interview team should consider the following:

* have a clearly defined application process (for example, only interview nurses who passed their state boards)

* delineate the qualities desired in the candidates

* decide on a common list of questions to ask each candidate

* agree upon the selection process at the conclusion of interviewing (for example, develop a set of criteria for further interviewing and elimination of candidates).3

Developing interview/selection criteria makes the decision-making process objective, uniform, and relevant in that it will meet the needs of the various stakeholders in the department (educator, manager).3

The interviewing team will require an application and résumé from the applicant. Other organizations may also require an essay explaining why the candidate is interested in becoming an OR nurse (for example, two letters of recommendation and/or the nurse's grade point average). Some organizations will not interview the candidate if the person has not yet passed the state board exam. Applications should then be reviewed and scored with top candidates being invited for an interview.10,11

The interview team should consist of the OR manager(s)/director, one or more perioperative nursing staff members, and the OR educator. When possible, it would be advantageous to include a nurse from the last OR class in the institution.9

Each of these interviewers will bring different perspectives to the meeting, seeking unique characteristics from the candidates. During the interview, it's imperative to assess the candidate's level of knowledge regarding the perioperative environment. A lack of knowledge, glorified or unrealistic views and expectations, and misconceived notions should raise a red flag for the interviewer(s). Presenting an honest appraisal of the OR environment to a novice or experienced non-OR nurse during the interview is critical so that the candidate can reassess whether the OR is the right career for him or her. It's also incumbent upon the interview team to conduct an intensive assessment of the candidates to find congruence between the organization's/applicant's mission, vision, and values. Since it's very expensive to recruit, hire, and train new employees, it's crucial to hire the right individual(s) for the organization, which in turn will decrease attrition within the first year. The candidate selection process is a critical phase that requires directed attention–especially when hiring inexperienced nurses into the OR department.3,9

Trice developed intereview questions to determine the candidate's personality traits to see if they're the same as those required to be successful in the OR environment.3 The questions addressed the following traits or characteristics:

* ability to master complex subject matter

* demonstration of critical thinking skills

* level of assertiveness and self-confidence

* ability to admit an error

* willingness to be a patient advocate even in the face of adversity

* problem solver and ability to make decisions

* ability to be proactive

* level of patient safety consciousness

* ability to work in teams

* willing to facilitate and embrace change

* ability to communicate clearly, concisely, and effectively.3

The interview panel observes the demeanor of the applicant when asked the predetermined questions. Both content and quality of the candidate's responses are evaluated. As noted by Trice, the interview “is not designed to be “warm and fuzzy” or to make the applicant feel at ease. The intention of the interview is to test the mettle of the applicant.”3 Thompson believes that additional research is needed to investigate whether individuals with certain personality characteristics “fit” better into the social climate of perioperative nursing.4

At the conclusion of the interview, the manager should invite the candidates they're seriously considering to visit the OR for a half- or full-day tour and observation. This provides the applicant with a “real-life” view of the OR at that healthcare facility, and it gives the organization a chance to see how the applicant reacts and responds to the observation. Staff members who spend the day with this person can share the types of questions the person asked and whether the candidate seemed genuinely interested along with any other positive or negative feedback with the interviewing team. The interview meeting and the notes from nurses who were with the candidate during their observation should be rated or scored for desirability.9

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The minefield of retention: How to keep newly recruited staff

Aside from personal reasons, graduate nurses and experienced non-OR nurses leave the OR within the first year due to the following reasons:

* lack of structure, purpose, and/or clear focus in the orientation program (or lack of a program altogether)

* preceptor with inadequate experience, training, skills set, or willingness to participate

* insufficient collegial support system within the department leading to a sense of alienation

* disillusionment–mismatch between incoming nurses' ideas of OR nursing and reality.10

The general statistic of new graduate nurse attrition within the first year of employment is 35% to 60%, depending on the source.10,12–15 Healthcare organizations invest significant time, talent, energy, and money into recruiting, hiring, and training new graduates and experienced non-OR nurses into the OR.9,12 The OR is unique from other nursing specialty areas in that a nurse new to the environment will require at least 6 months of orientation (scrubbing and circulating), which can easily increase to 9 months or a year, depending on the educational program and the orientee. This orientee is paid at his or her full RN rate while being paired to a preceptor during the entire period. The actual costs for hiring an inexperienced nurse vary depending on the specific nursing department and the definitions of terms, time frames, and variables included in the equation. It's estimated to cost $22,000 to $67,000 per nurse to orient him or her to the department.1,9,10,14,16,17

The following list enumerates direct and indirect costs that should be included in the financial projection:

* time spent by the educator to develop or refine a perioperative curriculum or orientation program

* payment for the AORN Periop 101: A Core Curriculum modular program, if purchased

* payment to the new staff member who is paired with a preceptor and is not contributing to the department until off orientation (usually 6 to 9 months)

* time spent completing orientation paperwork

* time spent in meetings for orientee status updates (educator, preceptor, orientee)

* overtime pay or contracted agency nurse expenses to cover staff shortages until the orientee is off orientation

* possible increase in error rates as the learner acquires new knowledge

* potential decrease in patient satisfaction.9,13,16,18

Healthcare organizations obviously bear the cost of nurse attrition; it's in the organization's best interest to analyze their recruitment and interviewing processes as well as any issues that may occur during the orientation phase (for example, orientation program, integration into the unit) of the first year of working to mitigate the loss of manpower. It's important for organizations to not only recruit the best nurses possible but also implement strategies to retain them.12

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Negative outcomes from high attrition rates

Nurse turnover impacts the new nurse along with the nurses and other staff members in the unit. Aside from the financial concerns, nursing shortages and unsuccessful nursing orientation programs impact the organization in other ways:

* poor departmental staff retention, overall

* reduced quality of patient care

* potential decrease in staff morale

* potential decreased job satisfaction among remaining staff members.

The OR is a high-energy environment where skilled nurses manage heavy workloads with high patient-acuity levels (hospitals) or fast-paced, quick-turnaround surgeries (same-day surgeries). Environments like the OR are even more vulnerable to staffing shortages due to the stressful working environment and the required critical thinking skill set. High turnover rates negatively impact the staff as the newly oriented nurses leave the department.10 Selecting the right candidate for the OR position can help reduce the OR nurse turnover rate. Newly hired OR nurses who have positive orientation experiences will be inclined to tell their peers who also might be interested in a career in the perioperative area. Part 2 of the series will discuss how to create a healthy workplace environment and develop a formalized OR orientation program.

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REFERENCES

1. 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.

2. Young LE. Mentoring new nurses in stressful times. Can Oper Room Nurs J. 2009;27(2):6–7, 14–15, 28–30.

3. Trice LB, Brandvold C, Bruno E. Practice and education: partnering to address the perioperative nursing shortage. AORN J. 2007;86(2):259–264.

4. Thompson JA. Why work in perioperative nursing? Baby boomers and generation Xers tell all. AORN J. 2007;86(4):564–587.

5. Sigsby LM, Selzer J, Wilson TK. Successful nursing student practicum in an ambulatory surgery center. AORN J. 2006;84(2):219–220, 223–228, 231–232.

6. Pape TM. Creating an inviting perioperative learning experience. AORN J. 2007;85(2):354–366.

7. Page-Cutrara K. Perioperative nursing education in Canada: current and future perspectives. Can Oper Room Nurs J. 2007;25(1):10–12, 14–15, 18–19.

8. Sigsby LM. A voluntary summer program to expose nursing students to the perioperative specialty. AORN J. 2008;88(4):609–617.

9. Martin KK. Meeting the challenge of perioperative education. AORN J. 2011;94(4):377–384.

10. Hillman L, Foster RR. The impact of a nursing transitions programme on retention and cost savings. J Nurs Manag. 2011;19(1):50–56.

11. Courney TJ. A look at a successful perioperative nurse extern-intern program. AORN J. 2005;81(3):564–565, 568–574, 577–578.

12. Newhouse RP, Hoffman JJ, Suflita J, Hairston DP. Evaluating an innovative program to improve new nurse graduate socialization into the acute healthcare setting. Nurs Adm Q. 2007;31(1):50–60.

13. Golden TW. An outcomes-based approach to improve registered nurse retention. J Nurses Staff Dev. 2008;24(3):E6-E11.

14. Funderburk AE. Mentoring: the retention factor in the acute care setting. J Nurses Staff Dev. 2008;24(3):E1-E5.

15. Anderson T, Linden L, Allen M, Gibbs E. New graduate RN work satisfaction after completing an interactive nurse residency. J Nurs Adm. 2009;39(4):165–169.

16. Halfer D. A magnetic strategy for new graduate nurses. Nurs Econ. 2007;25(1):6–11.

17. Willemsen-McBride T. Preceptorship planning is essential to perioperative nursing retention: matching teaching and learning styles. Can Oper Room Nurs J. 2010;28(1):8, 10–11, 16 passim.

18. Rothrock JC. Attracting and keeping new graduates. AORN J. 2007;85(6):1063–1064.

© 2014 by Lippincott Williams & Wilkins, Inc.

 

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