By Don Sadler
The number and variety of professional, ancillary and support positions within perioperative services far exceeds any other department in the hospital. These range from surgical technologists, first assistants and perfusionists to radiology and instrument room techs, aides, orderlies, transporters and more.
This presents challenges for health care facilities when it comes to onboarding perioperative personnel and ensuring their competency. The goal should be to provide creative, individualized education and training so each member of the perioperative team is equipped to provide safe, high-quality patient care.
Challenges Ramped Up
The challenges of onboarding perioperative staff aren’t new, but they’ve been ramped up over the past few years, says Amanda Heitman, BSN, RN, CNOR, perioperative educational consultant for Periop Anew.
“There has been a tremendous amount of pressure to bring in ‘capable’ staff as quickly as possible, especially since COVID-19,” says Heitman. “This pressure for fast-paced orientation creates extra challenges for health care facilities.”
“New perioperative staff require and deserve the time to fully orient and onboard,” says Dawn Whiteside, MSN-Ed, CNOR, NPD-BC, RNFA, director of education at CCI. “Regardless of the specialty, the novice perioperative nurse must first learn the foundations of perioperative nursing before they are moved to the beginner or advanced beginner stages of Benner’s model.”
Colleen Becker, Ph.D., MSN, RN, CCRN-K, director of perioperative education for the Association of periOperative Registered Nurses (AORN), agrees.
“The pandemic resulted in turnover and fatigue among veteran staff, which triggered the need to bring on more travelers and new hires to fill gaps,” says Becker.
“At the same time, acuity of surgical procedures is on the rise, requiring higher nursing skills,” Becker adds. “But tightening budgets have reduced the ranks of clinical educators and it’s difficult to fully staff while also asking experienced nurses to precept and train new team members.”
According to Jane Flowers, MAN, RN, CNOR(e), CRCST, a common onboarding challenge is when multiple practitioners are all starting on the same day.
“This is great for things like tours through the department and giving employees a buddy to go through orientation with,” says Flowers. “But it can be challenging if the folks being oriented are not all RNs. Many facilities are lucky to have one educator, let alone a whole team to divide and orient different populations who all show up at the same time.”
Even if you’re lucky enough to have only RNs as orientees, there are many other potential challenges. “Are your orientees all novices or is there a mix of skill levels and experience?” asks Flowers. “What previous experiences do the orientees have? And what types of learners are they?”
Impact of Technology and Productivity Drive
Bill Duffy, RN, MJ, CNOR, FAAN, the former program director for the Nursing and Healthcare Administration Masters of Science in Nursing program at Loyola University of Chicago, identifies two main challenges to successful perioperative staff onboarding. The first is the advancement of technology.
“Medical device manufacturers continue to develop new devices to improve care, but they are limited for use in specific specialties,” says Duffy. “This means perioperative staff must learn the proper care, setup, use, decontamination and sterilization for each device.”
To put this into perspective, Duffy says there were 442 different pieces of equipment that his perioperative team needed to be familiar with. “To try and manage this, we would put our team members into specialties to give them the opportunity to grow from novice to expert on their specialty’s equipment,” he says. “However, this is only a partial fix.”
The second challenge is the drive for productivity.
“Health care organizations are under immense pressure to control their expenses and almost every nursing leader has been given productivity targets to meet in their staffing patterns,” says Duffy.
“This puts enormous pressure on the perioperative educator and the preceptors who must get new staff functional in a specialty in just a few weeks,” says Duffy. “But this often leads to folks teaching the ‘how to’ and not the ‘why’ behind the actions.”
Of course, the financial side of the equation also comes into play.
“The finance department is always concerned with the time it takes to onboard a new nurse,” says Duffy. “They generally understand the investment, but they are acutely aware that we are paying double to have a nurse partnering with a preceptor.”
According to Becker, health care facilities must pay new nurses and preceptors for up to a six-month orientation to the OR, which is considered non-productive time in most budgets. “Many cannot provide incentives or additional pay for staff nurses to be preceptors, so they tap experienced travel nurses,” she says. “They have clinical knowledge but may lack facility policy or procedure knowledge.”
It can be difficult to get experienced contract and travel nurses to adapt to facility procedures, says Patsy Davis, BA, RN (retired), CNORe.
“They usually prefer to do things the way they have always done them,” she says. “I did find that travel nurses could bring very good suggestions and ideas for improving practice in my facility, and the exchange of ideas often helped obtain compliance.”
Providing consistent preceptors is another onboarding challenge. “Retirements and resignations among experienced nurses and fatigue caused by the continual need to onboard new team members have created a shortage of experienced preceptors to provide clinical orientation and training in the OR,” says Becker.
“With many senior staff leaving, precepting can be an added burden for the remaining staff,” adds Flowers. “It seems that the staff are always orienting someone.”
Innovative Onboarding Techniques
With all of these challenges hitting at once, Becker says that facilities are seeking innovative ways to onboard new perioperative staff in more condensed and efficient ways. Nationally, there’s a focus aimed at growing the pipeline of perioperative nurses in undergraduate schools, which currently provide students very little exposure to various nursing specialties.
“Facilities are actively encouraging colleges to offer Introduction to Perioperative Nursing, which AORN provides to the schools for a nominal cost of just $20 per student,” says Becker. She points to a study in the AORN Journal by one school of nursing that found that 38% of nursing school graduates who had participated in a perioperative elective between 2017 and 2021 entered perioperative nursing practice.
Another focus has been to provide emotional and wellbeing support to new nurses via mentorship programs. “Orientees are matched with experienced nurses from the time of hire through their first year or so,” says Becker. “This sets up a more connected relationship outside of education and training.”
“Periop 101: A Core Curriculum,” AORN’s evidence-based education program, is one of the most effective strategies used by many health care facilities to onboard new perioperative staff. According to Becker, Periop 101 uses a structured format that includes a perioperative leader in the program so nursing best practices are implemented consistently from cohort to cohort.
Duffy hosted the first Periop 101 at his facility. “Periop 101 allows a large number of new hires to get educated by one preceptor, which allows the clinical preceptors to focus on the ‘how to,’ ” he says. “Clearly, the idea is sound because Periop 101 is a popular service utilized by many health care organizations across the country.”
“The utilization of programs such as Periop 101 is an enormous help when orienting new RNs to the operating room,” adds Flowers. “This program is valuable as AORN constantly updates the content so that it’s current, which allows educators to focus on the needs of the orientee.”
According to Becker, the reason Periop 101 has been adopted so widely is because AORN continually updates it to reflect current evidence-based practice.
“And we surround Periop 101 RN learners with a support system that includes peer networking, mentorship and clinical learning resources through their complimentary membership during the course, as well as while they transition through their first year of practice,” says Becker.
“AORN provides the largest catalogue of perioperative-specific resources and continuing education for all levels of nursing through our eGuidelines Plus online platform, monthly webinars, regional in-person conferences, clinical tool kits and our annual Global Surgical Conference & Expo,” adds Becker.
More Perioperative Onboarding Tips
Heitman suggests developing a nurse educator who is solely responsible for initiating orientation and competency development. “Depending on your needs, he or she could even continue to be partially involved in staffing and precepting,” she says. “The educator could eventually help develop a structured orientation process and a new-to-the-OR program to grow your own staff.”
Another idea is to create a structured novice-to-expert orientation checklist that encompasses all details of the roles. “There is usually a lot of crossover between circulating and scrubbing,” says Heitman.
At the hospital where Davis worked before retiring, they developed an onboarding competency checklist for each category of employee. “This allowed for ongoing evaluation by preceptors as the nurse progressed through orientation,” she says.
“Periodically, the preceptor and educator would review the list with the nurse and devise a plan for further education if indicated,” adds Davis. “At completion of orientation the preceptor(s), educator and nurse would sign the checklist, which then became a part of the nurse’s file.”
Some nurses and preceptors were reluctant to complete the checklist, and checklists sometimes got lost as they followed nurses through the department. “You have to be firm and consistent in meeting with nurses to review their progress and adaptation to your facility, policies and procedures,” says Davis.
Whiteside stresses the importance of executive leadership fully understanding how long it takes to orient the specialty of perioperative nursing. “It is essential that leadership support the educators and the required level of training for each individual,” she says.
“I have found that many times, leadership is encouraging novice perioperative nurses to be counted as staff with the assurance that someone would be available to help if needed,” Whiteside adds. “This is a patient safety concern and ultimately sets the novice nurse up for failure.”
Flowers points out that given staffing shortages, most facilities want to onboard new nurses as quickly and efficiently as possible.
“At smaller facilities, orientation does not have the advantage of having sim labs, so hands-on practice sessions are done in the actual OR,” she says. “There are advantages as the orientee experiences the real OR, seeing and learning with the actual equipment that they will utilize in their practice once orientation is complete.”
In her experience, Flowers discovered that if several orientees start at the same time, they automatically have an orientation buddy who frequently stays with them throughout their career. “They can compare notes and experiences and generational diversity can be exciting as the orientees learn from each other,” she says.
At his facility, Duffy worked to allow nurses to periodically scrub in cases. “To be an effective circulator you need to know what it’s like to be at the surgical table,” he says. “Participating in the procedure allows the nurse to see what’s happening inside the patient and feel how the instruments work and where they are optimally placed.”
Build a Collaborative Practice
Whiteside recommends building a truly collaborative practice with educators. “Build a united plan to support orientees in being successful in their profession and ultimately providing safe competent care to our patients,” she says.
“Utilize resources both within and outside of your facility,” says Flowers. “One of the greatest benefits of being involved in AORN is that I have always known that I’m never alone. I’ve networked with other facility educators, with the Clinical Nurse Educators Specialty Assembly and with my colleagues all over the country in AORN.”
Flowers stresses the importance of staying positive and showing excitement when onboarding new perioperative nurses.
“Be present and attentive to the orientees,” she says. “Always be fair and clear in your expectations. Address issues promptly and always share all of your knowledge.”
“Remember that you are developing the next generation of perioperative nurses,” Flowers adds. “You have the opportunity to make a difference in their career development and help them become the best they can be.”
