Staffing Shortages and Nurse Burnout

By Don Sadler

The nursing shortage in the U.S. has been well-publicized for years. This includes a shortage of perioperative nurses.

According to data compiled by OR Manager, the turnover rate for perioperative nurses increased during most years over the past decade, nearly tripling from 6% in 2014 to 16% in 2023. Last year, 44% percent of OR leaders said that their turnover rate increased over the previous 12 months. This was down from 56% who said this in 2022 but more than double the 20% who said so in 2020.

Also, more than 40% of OR leaders last year said that the percentage of open perioperative nurse positions increased over the previous 12 months. And 70% of leaders last year said that recruiting experienced OR nurses was more difficult, while fewer than 10% said that recruiting is easier.

What’s more, first-year turnover among OR nurses was nearly 30% last year, outpacing all other tenure categories, according to the 2023 NSI National Health Care Retention & RN Staffing Report. It currently takes an average of 98 days to fill an open OR nurse position.

Turnover Nears Historic Highs

According to James X. Stobinski, Ph.D., RN, CNOR, CSSM(E), CNAMB(E), the director of education for the National Institute of First Assisting (NIFA), OR nurses have traditionally enjoyed long careers and perioperative nurse turnover rates have been low compared to other nursing specialties.

“But now it appears that our turnover rates are near historic highs,” says Stobinski. “I do not see any meaningful change in this situation unless we can address the staffing shortfalls on a permanent basis.”

Exacerbating the perioperative nursing shortage is the spike in surgical volume over the past few years. Sixty-seven percent of OR leaders last year said that the volume of surgical procedures in their ORs increased over the previous 12 months, which was up from just 26% who said this in 2021 at the height of the pandemic. Just 7% last year said their volume of surgical procedures decreased over the previous 12 months.

“Surgical volume has rebounded after the pandemic and we have now returned to a slow, steady increase in volume,” says Stobinski. “Shortages of both OR nurses and surgical techs are really starting to bite and limit surgical capacity.”

One problem is that education and training programs for perioperative nurses and surgical technologists are long and resource intensive.

“Even if we had a wealth of candidates who wished to fill in these roles, it would take a long time to fill the positions that are now open,” says Stobinski. “Recruiting, orientation and retention are all linked, and we must devote resources in all areas to keep adequate staffing.”

Delayed or cancelled surgical procedures are one significant effect of perioperative nurse shortages, says Tammy Hanks, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN).

“It’s also important to consider the effect shortages have on quality concerns such as near misses and occurrences of critical or sentinel events,” says Hanks. “Experienced OR nurses play a critical role in training new staff to ensure quality patient care.”

Impact of High Stress and Burnout
The nursing shortage has been attributed to a number of different factors, including the retirement of many baby boomer nurses. High levels of stress and burnout are another cause, especially among perioperative nurses.

In a survey conducted by the American Nurses Foundation and McKinsey, more than half (56%) of nurses said they are experiencing symptoms of burnout, such as emotional exhaustion. Twenty percent said they feel completely burned out and may need to seek professional help, or that their symptoms of burnout won’t go away and they think about work frustrations a lot.

“We know that a large number of experienced OR nurses left the profession during the pandemic and these losses made the staffing shortages worse,” says Stobinski. “This has fed into a spiral effect where staff shortages fuel stress and burnout, which leads to more staff leaving and the cycle continues.”

Stress and burnout may be the result of poorly executed onboarding, insufficient resources and support, and workplace environment and culture.

“OR nurses often must stay until the case is finished, especially when they work in facilities that don’t have set shifts or leaders with perioperative experience who can step in and take over a case,” says Hanks. “There’s a lot of stress that comes with not knowing how long your workday is going to last, and this can lead to burnout.”

As the co-founder of Good Company Consulting, Lisa Walden has worked with hospitals to help them create a better workplace culture in order to reduce stress and burnout and lower nurse turnover.

“There are certain dynamics at play in many ORs that can lead to unhealthy cultures so these need to be watched carefully,” says Walden. “As one of my nurse interviewees said to me, ‘You need to inspect what you expect.’ In other words, if you expect great culture, you need to be tending to it on a daily basis.”

Walden lists a number of things that can lead to an unhealthy culture in the OR: poor communication, overwork due to short staffing, lack of accountability for those in positions of authority (i.e., surgeons), and bullying behaviors that have become accepted.

“Bullying will be no surprise to anyone familiar with an OR, and yet it still remains the area that requires the most attention,” says Walden. “Without a baseline of psychological safety, it’s impossible to build a great hospital culture.”

Walden encourages hospitals to root out toxic behaviors that she says have been normalized for too long. “For example, nurses should not be eating their young. And surgeons should not be shielding or participating in bullying, which includes intimidation, verbal abuse and disrespect toward other team members. All of these actions undermine psychological safety and erode trust in the OR environment.”

During one interview, a perioperative nurse told Walden her team’s psychological safety had gotten so bad that they didn’t trust staff members to speak up if the surgeon was operating on the wrong leg.

“Clearly, this dynamic threatens more than just workplace culture – it also threatens patient safety,” says Walden. “It’s critical to dismantle this in order to build a strong OR culture.”

Drivers of Stress and Burnout

Labor Management Institute President and CEO ChrysMarie Suby, RN MS, has helped many health care organizations overcome perioperative staffing challenges. She identifies three key drivers of work-related stress and burnout leading to staffing challenges:

1. Unpredictable workloads (e.g., patient ratios, cases, deliveries) – When workloads are unpredictable, schedules are published with shortages and overages due to the imbalance of full-time to part-time employees, employee requests, and limitations in employee experience and skills. “Scheduled nurses scramble to cope with the amount of work to complete and the safety and quality of the work delivered,” says Suby.
2. Less intra-shift indirect support – This support includes shift charge nurses, educators, clinical nurse specialists, clerks and supply clerks. “When this kind of support is reduced or removed, this adds to nurses’ workloads, which increases their stress and burnout,” says Suby.
3. Dissatisfaction with scheduling – This includes shift lengths, consecutive shifts worked, shift and team coverage, and replacement coverage. Schedules with less than 11.5 hours off between shifts; more than three consecutive 12-hour shifts, four consecutive 10-hour shifts or five consecutive 8-hour shifts; and overtime/premium hours exceeding 4.9% of total hours worked during the period (e.g., week or pay period) are especially undesirable.

“When nurses believe their schedules are fair and equitable, demonstrate best practices and ensure their individual needs and their unit’s needs are met, this builds trust and satisfaction,” says Suby.

Build Your Talent Pipeline
Stobinsky believes that the first step to meeting the perioperative nurse staffing challenge is acknowledging that the recruiting processes that have been used for decades are no longer sufficient.

“We can’t assume that just advertising open positions and offering a hiring bonus will yield sufficient staffing,” he says. “Facilities need to proactively build their pipeline of talent.”

One idea is to serve as a clinical site for education programs.

“Training programs are always open to adding clinical sites – this gives the facility a pipeline of potential hiring prospects,” says Stobinski. “We should also devote more resources to upskilling current staff to new roles. For example, a good employee working in environmental services might progress to a registered nurse role if we can provide meaningful tuition assistance and a flexible schedule.”

Hospitals can also do a better job of supporting new staff as they come into surgical services.

“Orientation programs are long and resource intensive, and socialization into the OR is a difficult process,” says Stobinski. “These new nurses are in a fragile place and we risk losing them, perhaps forever, if we don’t support them well.”

Transitioning to practice programs like nurse residencies is a well-documented way to support new nurses. “The investment in high quality, accredited programs pays clear dividends in terms of higher retention rates,” says Stobinski.

Vangie Dennis, MSN, RN, CNOR, CMLSO, assistant vice president of perioperative services with AnMed, says that her facility has taken a number of concrete steps to recruit and retain perioperative nurses, including the following:

• Eliminating call for the PACU and OR and establishing call teams.
• Developing Tier 5 and Tier 6 Nurses. “Tier 5 nurses can scrub and circulate so they are paid more,” says Dennis. “Tier 6 nurses can float through every department in perioperative services: pre-op, surgical assessment, PACU and OR.”
• Monthly town hall meetings so staff can speak directly to perioperative managers.
• One-to-one meetings with all staff. “This can be tough as I have 300 full-time employees, but I make it a priority,” says Dennis.
• Rounding every day just to check on staff needs.
• Staff celebrations and luncheons for birthdays and Employee of the Month, with pictures and a gift for each department.

Promote Work-Life Balance
Hanks stresses the importance of providing flexible work shifts and promoting work-life balance when it comes to combating stress and burnout and lowering staff turnover.

“We see nurses increasingly prioritizing these areas so perioperative leaders need to prioritize them as well to ensure a healthy work environment and retain top talent,” says Hanks.

Walden emphasizes culture when helping hospitals with recruiting and retention strategies. “It starts with dismantling whatever is getting in the way of building psychological safety,” she says. “I know this is easier said than done, especially with the hierarchical nature of hospitals and the positions of power surgeons hold, but it’s where the work begins.”

Hospitals should also focus on awareness and understanding across different perspectives, including those of experienced and novice OR nurses. “In the OR there seems to be a tendency to have the newest nurses learn via trial by fire,” says Walden. “However, I believe this tradition is contributing to an erosion of psychological safety and helping normalize a culture of disruptive and potentially disrespectful behaviors.”

One technique Walden uses to ease intergenerational tensions is to create reverse mentorship opportunities. “This sets up a two-way flow of learning where more tenured nurses learn from newer nurses and vice-versa,” she says. “This can be a powerful way to knock down the all-too-prevalent generational stereotypes.

“Older, more experienced nurses can learn about new technology and tools while younger nurses get a crash course in the institutional knowledge that tenured nurses have in spades,” says Walden.

Walden describes one hospital that has created its own “OR Olympics.”

“They work together to come up with fun, creative games like kick bucket bowling and case cart relay,” she says. “The winner gets a ceremonial gold leaf crown and the chance to donate to a charity of choice. This a great example of the power of bringing intentionality to team gatherings.”

Create a Positive Perioperative Environment
According to Hanks, creating a positive perioperative environment not only helps limit OR staffing shortages and burnout, but it also positively impacts quality patient care.

“We must invest in our perioperative nursing workforce to ensure that we can meet the needs of our patients while supporting a positive practice environment,” she says.

“There’s no short-term magic bullet that will quickly solve our staffing challenges,” says Stobinski. “But we have opportunities for greater collaboration to bring stakeholders together to work on the issue and develop innovative solutions. Big issues like this can foster new thinking and allow new leaders to emerge with fresh ideas.”