Operating Room New Hire Registered Nurses Training Program for the Outpatient Surgical Center

Download the full paper here: OSC Training Program

Training nurses when they come to a new department can have a strong impact on their job satisfaction and ultimate retention. With some facilities offering preceptor incentives and paying for two nurses to do the same job for a period of time, it can also be costly for healthcare organizations which leads them to push for training to occur in a timely manner. Cadmus & Roberts (2022) state that preceptors are vital for ensuring smooth transitions for new hire nurses, and their preparation, support, and recognition should be kept in mind by nursing leadership. With this in mind, it is important that preceptors are comfortable in their role, as well as feel supported through their efforts. In some cases, this can be best done through a team-precepting type approach, with several nurses in the same unit assisting in training the new hires together. Barrett (2020) points out that this has the same benefits as having a single preceptor without burdening a single staff member to spend all of their time with the preceptee, which can reduce preceptor burnout. This can also be beneficial to the preceptee as they can have a chance to orient with nurses who have different workflows and help them to figure out what works best for them in their own practice.

Keeping the preceptee themselves in mind, Barrett (2020) states that when preceptorship is done well it can positively affect staff retention. When nurses are trained well in new departments and feel empowered and supported in their work their job satisfaction increases and they are more likely to remain in that position longer. Structured training programs, such as nurse residency programs have been supported by organizations such as the Joint Commission and the American Academy of Nursing (Cadmus & Roberts, 2022). While nurse residency programs might not be applicable to smaller facilities or for training nurses transferring from another jobsite, the concepts and structure of these types of programs can still be utilized for smaller orientation processes. Preceptorships often have documents which contain competencies and objectives for trainees to achieve (Barrett, 2020), which are foundational components of nurse residency programs that can be carried over to all orientation periods for new hired staff.

Situation

As with many healthcare settings right now, the Outpatient Surgical Center (OSC) has been utilizing a lot of travelling nurses to fill the staffing gaps. When permanent staff members are hired, they go through four weeks of training to get adjusted to the surgical specialties that OSC offers. However, this training period is currently informal and disorganized. The new hire registered nurses (NHRNs) get time to shadow with other nurses to see how they are expected to position, prep, and chart for the different surgeons and specialties offered at this location but are often unable to have an opportunity to experience the full variety. In addition to this, the nurses at OSC often wear multiple hats, takings turns in the role of team leads which assist with room turnovers and case picking, charge nurse, in the minor procedure room when pre-op needs assistance, and even floating up to the main hospital. These axillary positions are often considered less important than trying to be with the numerous different surgeons and get less or no time for training during the orientation phase.

One asset that OSC has is that the permanent staff currently employed there are experts in different specialties, which can be useful to the NHRNs as they try to learn in a short period of time. This should be utilized better to help train the new nurses in all roles and specialties to ensure a well-rounded orientation.

The goal of this project is to create a standardized orientation procedure for operating room (OR) registered nurses (RNs) at OSC to ensure that adequate time is spent in all roles so that they feel prepared to be an independent RN at the end of their onboarding process.

Theory of Change

Lewin’s Change Model begins with the unfreezing step (see Figure 1). This is seen at OSC with the need for change as determined by some of OSC’s newest OR RNs still asking for time training or working with a partner in several specialties, or being unsure of what to do when they take a role outside of circulating after their training period is over. The need for change has been supported by management as the assistant nurse manager has added creating a new orientation process to her list of projects to work on. During the change step of this model, a new process must be created, which will involve the other interdepartmental staff in order to ensure that the training is wholistic for the needs and teaches effective interdepartmental flow. The refreezing stage will anchor the change by having written checklists for all future NHRN onboardings to be provided to both the new hires as well as the RNs training them in the OR.

Stakeholder Analysis

The stakeholders which should be engaged are the current OR RNs, current scrub techs, surgeons, Stephanie (OSC's nurse manager), and the pre-op/PACU nurses (see Table 1). The current OR RNs are the ones from which support is needed for the direct training of NHRNs and it should be ensured they have the training needed to use the new checklists, as well as the confidence in their own roles to be able to teach the new staff. The scrub techs and pre-op/PACU nurses have a more supportive role in this program, and it should be ensured that they feel valued and part of the team so that they can help teach the NHRNs how interdepartmental flow works best for everyone. The surgeons help provide the learning environment so they should be encouraged to assist in teaching their own preferences and should be provided with a strong team to assist the NHRN as they are learning to keep the days running smoothly. Lastly, Stephanie oversees OSC as a whole, so it is important to have her support with the new program and she should be worked with directly to ensure that it meets the needs from both a managerial perspective as well as for the staff on the floor.

Preparatory Information

Priorities

The priority of this project is that all NHRNs will be confident in their abilities to circulate all the specialties and surgeons at OSC, as well as comfortable working in the auxiliary roles expected of the nurses by the end of the four-week training period. Mastery in all areas is not expected, however the nurses should feel ready to work independently and know who and where the resources available to help them when needed are.

Assumptions

Several assumptions need to be made for the creation of this project. First, it is assumed that all NHRNs already have OR experience and don't need additional training as circulators, but only introductions to the OSC specialties and surgeon preferences. This can be assumed because OSC does not currently have a full OR training program in place to teach nurses the intricacies of the specialty. Another assumption is that both OSC and the NHRNs operate following the Association of Perioperative Registered Nurses (AORN) guidelines to provide the best patient care in the surgical setting. This follows the first assumption as the NHRNs should have experience and already be familiar with important aspects of perioperative care such as aseptic technique and proper surgical site prepping practices as outlined by AORN.

External Factors

One external factor that should be taken into consideration is that OSC is expanding the specialties offered and the surgeons who work there, which means this program will need continued development to grow with OSC. With the growth in surgeons, it may not be possible for NHRNs to work with every surgeon during their four weeks of orientation, and their training might have to focus on their getting familiar with each specialty rather than each surgeon, or that the orientation phase needs to be lengthened.

Another external factor to consider is that OSC operates as part of the main hospital down the road, which affects OSC's policies and procedures. There are certain parts of the current onboarding process that must remain in place due to the policies instated by the main hospital, such as the new employee orientation that happens off-site during NHRN’s first two days of employment. The timeline of the on-site training will need to take things like this into consideration.

Ethics and Equity Analysis

Considering the ethics and equity of this program leads to asking several questions about how it should be created and implemented. First, one should ask what are the potential harms of this program? This program is intended to aid in the training of NHRNs is a well-rounded way, which means focusing on each specialty in a wholistic way, which could potentially lead to less time dedicated to learning the preferences of the more difficult to work with surgeons. However, when reviewing the second ethical question of do the benefits outweigh the potential harms, the answer should be yes. Having each NHRN comfortable in the overall specialty should help them get comfortable over time with the workflow of each surgeon in that specialty.

The third question to be asked is are the burdens of implementing this program shared equitably? Since precepting can be a burden on the current RNs this should be handled by asking each of them if they are comfortable and have the desire to help with the NHRN’s training, and splitting the time of preceptorship between those who say yes. This will help to distribute the time the current RNs each spend precepting, as well as allow the NHRNs to be taught by a variety of their new coworkers and see different circulating styles. This leads to the fourth question posed, which is do all current staff members have the appropriate training for the implementation of this program? This should be able to be determined based off their answers from asking them if they feel comfortable training NHRNs. If there are nurses who would like to help with training, but don’t feel comfortable, the OSC management should investigate further as to why they don’t feel comfortable and what training is needed. Also, to help the entire OSC staff be ready for the rollout of the new training program and checklists, and in-service could be given on how the checklists work and the expectations of all staff members. This would also provide an equitable level of base training so that the entire department has a better understanding of the program and its goals.

The final question focused on equity of this program is to ask if the goals of the program will be equitable to all of the NHRNs who go through this training. This program is designed with this as an overarching goal in the first place; to prepare all NHRNs to be independent circulators at the end of the four weeks of orientation by standardizing the training they receive. Additional training can be provided to all staff who need it on an as needed basis based on the discretion of management and as staffing allows.

Program Details

To create this program, the Wisconsin Logic Model was adjusted and used to think about the important aspects needed for success (see Figure 2). This section breaks down the inputs, outputs, and outcomes evaluation.

Inputs

The main input needed for this project is the support of the current staff and management. No program can be successful without the support of those who are directly involved in its process, and this program is no exception. The current staff members are directly involved in the training of NHRNs and in order for this program to succeed they will all need to be onboard and comfortable with using the new training documents.

Outputs

The main outputs of this project are the new training checklists to ensure that the NHRNs get time in each of the specialties, skills, and roles which are expected of OSC OR RNs. In order to create these checklists, there was some background work that needed to be completed first. A list of all surgical specialties offered at OSC was compiled, including the surgeons in each specialty (see Table 2). Next, a list of the auxiliary roles expected of OSC RNs and the responsibilities of each of these roles was created (see Table 3). From this, the training checklist was created (see Table 4). While not all surgeons were included individually in the training checklist, the most complicated cases were in order to ensure that the NHRNs get a chance to work with them during their orientation to help ease their transition to independent work. The expectation is that NHRNs get 2 days of orientation in each specialty, with the exception of sports medicine orthopedics which gets 4 days due to the complicated nature of some of the cases. In addition to these days of circulating, the NHRNs should also get a day of orientation in each of the axillary roles for exposure to them as well. The auxiliary roles are ones that can be continued to be learned after the orientation phase, as opportunity and staffing allows. The charge nurse role was left out of the orientation phase as the charge role is filled by nurses who are already comfortable working at OSC, and any NHRNs who are interested in gaining this experience should be trained in this role at a later date.

The main activity of this program is utilizing the newly created training checklist to ensure the complete exposure of the NHRN to everything that OSC has to offer. Working under the assumption that all NHRNs have previous OR experience, it is reasonable to assume that the broad coverage of this orientation will ease them into their new positions. However, it is also assumed that it will take time for staff members to become fully knowledgeable about the locations of items at OSC and it is important to note that despite becoming independent at the end of the 4 weeks of orientation, there will still be staff around to help them as needed after this time.  

Outcomes

With the goal of this project being to prepare NHRNs to be independent circulators at OSC, the outcomes should be measured by the training checklist being completed, and a preparedness interview with the trainee at the end of their orientation phase. Management should meet with the trainee to ensure they feel ready to circulate cases on their own and discuss needs for additional future orientation in any areas as staffing allows.

Evaluation Plan

The program should be evaluated both during and after each NHRN’s training period for staff support and efficacy (see Table 5). This can be done by asking formative questions to the current staff about the ease of use of the checklists and taking feedback on changes that should be made, as well as questions to the NHRNs about their feelings towards their orientation and if they are getting enough time in each specialty and if they need additional time in certain roles. Summative questions should be asked after a NHRN has begun their independent working period to see if they still feel satisfied with their training, or if they still feel they need additional training in certain areas.

The questioning should be done via interviews with current staff and NHRNs by the nurse manager, assistant nurse manager, or the charge nurse as appropriate. The information gathered from these interviews should be analyzed to see if changes need to be made to the orientation process to increase all staff satisfaction and program efficacy. Any changes to the program should be communicated to the rest of the department via email or in-services as appropriate.

In order to keep the program up to date with the needs of the department, including any new surgeons or specialties added to OSC, an annual review of the program should be completed by the assistant nurse manager. This will decrease time needed for updates whenever a new nurse is hired who needs to go through training, as well as increase the productivity of the program by keeping it relevant even when it is not currently being used.

Timeline

The timeline for this project allows for its immediate use once current staff are prepared to use it and a NHRN is brought onto the OSC team (see Table 6). Assessment of the readiness and willingness of current staff to act as mentors should be assessed immediately to allow for any additional training time needed to get all current staff ready to participate in mentorship when applicable. This assessment can be done at any of the upcoming staff meetings as time allows and should be led by the nurse manager or assistant nurse manager. Training for the current staff should begin prior to the start date of the next NHRN so they are prepared when the time comes and can be completed at a staff meeting following the assessment of their readiness. Once all current staff have been trained in the use of the new program checklists and feel confident in their abilities to mentor a NHRN, this program is ready to be implemented when the next NHRN starts at OSC upon approval by the nurse manager and assistant nurse manager.

Budget

Overall, most of the costs associated with this program are costs already being spent on the current training program at OSC (see Table 7). This program's goal is to make the orientation phase more effective and avoid additional training costs after the orientation phase has officially ended, therefore saving the hospital money in the long run. A secondary goal of this training program is to increase staff job satisfaction and therefore increase retention, which would also save the hospital additional costs of training new staff in the future.

While there might be pushback on the float pay needed for sending the NHRN to the main hospital related to questioning if it is really necessary for someone hired at OSC to orient at the main, it should be noted that staff are floated between the two sites depending on staffing levels and daily caseloads at each location. It is beneficial for both the main hospital to have someone who is already oriented to the main OR when they need a staff member from OSC and not need to waste time or resources to orient them and assist them all throughout their shift, and for the staff member to not be walking into a new OR with no previous experience there and being expected to perform their job duties at the same level as at their home location.

The second potentially controversial line item might be the annual day of the assistant nurse manager to spend reviewing the training program after implementation. This is in place however to foresee potential growth at OSC and keep the program up to date with the specialties and surgeons at OSC so that it is ready for new hires at any time, rather than needing a larger overhaul when a new hire is brought onboard, which ultimately will save the assistant nurse manger time. This line item was written allowing the assistant nurse manager an entire shift to complete the annual review, however it is not expected to take the full day, which will also ultimately cut down on the annual costs of the program.

Communication Plan

By standardizing the training process for NHRNs at OSC, it can be assured that each nurse is comfortable functioning independently at the end of the orientation process in all surgical specialties and auxiliary roles. The costs associated with this project are comparable to the costs of the current training program and will save the department money incurred by additional training costs needed to cover things that get missed in the current unstructured training process. The timing of the suggested training program will also be the same as that of the current process, while again, saving the time of additional training days following the end of the current orientation process. The expectations of current staff with the new program will also be the same as the current process, only with the addition of filling in a checklist line item each day they work with the NHRN. The impact on the department will have minimal downsides, as the new process will work inside the constraints of the current process in matters of budget, timing, and staff resources, while the benefits will increase staff readiness and satisfaction.

By appealing to the stakeholders, namely the nurse manager and assistant nurse manager, in business terms of budgeting, time needed for the program, and staff resources, the project is able to highlight areas it will improve upon the current process without increasing resources needed. The program is designed to avoid placing additional strain on the department in any area, which increases its desirability, while still supporting an increase in positive returns from its use.

Summary

By ensuring that all NHRNs are trained in all areas they will be expected to function in independently at OSC, it follows that they will also have increased job satisfaction due to feeling empowered and prepared for their role. Confirming that each nurse knows their fellow coworkers and who are good resource people for different situations will also increase their feeling of preparedness to circulate all of the specialties at OSC. By standardizing the training process for all NHRNs, it can be easier to make sure that both of these come to fruition. When staff are appropriately prepared and supported in their roles and have good relationships with the others they work with, the morale of the department can increase, along with staff satisfaction, and ultimately retention. All of these promote a healthy workplace environment and will benefit OSC in the long run by decreasing turnover and saving additional training costs. These are the goals of the new training process suggested presented in this paper and reasons why it should be implemented at OSC.

References

Barrett, R. (2020). Changing preceptorship to achieve better quality training and less attrition in newly qualified nurses. British Journal of Nursing, 29(12), 706-709. https://doi-org.offcampus.lib.washington.edu/10.12968/bjon.2020.29.12.706

Cadmus, E., & Roberts, M. L. (2022). Program evaluation of a statewide nurse residency program. The Journal of Nursing Administration, 52(12), 672-678. Doi: 10.1097/NNA.0000000000001230