Over 48 million invasive procedures are performed annually in the United States, which highlights the significant impact of surgical service lines on national health care (Hall, Schwartzman, Zhang & Liu, 2017). The Association of periOperative Registered Nurses (AORN), the national organization that provides standards for perioperative nursing care, states that operating departments are seeing 2% growth in demand annually, with 20% of currently employed operating department RNs expected to retire within the next 5 years (AORN, n.d.). New Jersey is projected to be one of the top three states to experience a shortage of RNs (U.S. Department of Health and Human Services, 2017). The New Jersey Collaborating Center for Nursing (2016) reports that the surgical RN is the third most vacant nursing position in the state. The delivery of care in the operating department requires an RN with specialized training. Closing the gap of the perioperative workforce is particularly challenging because among all nursing disciplines, this specialty is most difficult to recruit and one of the most expensive ones to train (AORN, n.d.).
The current practice of health care organizations providing their own education and training leads to variability of staff readiness, competence, and cost. Rutgers School of Nursing Center for Professional Development designed a collaborative regional academic–clinical practice partnership training model that prepares nurses with essential surgical competencies, increases the operating department workforce, and reduces the cost of orientation. The purpose of this article is to describe the design and implementation of this regional academic–clinical partnership training model with a pilot cohort.
Training Operating Department Nurses
The National League for Nursing (NLN) and the AORN recommended alternative approaches to perioperative nursing education and training, given that this preparation is not typically covered in schools of nursing (AORN, n.d.). The Institute of Medicine (IOM, 2011) recommended that nurses be prepared to meet population health needs, calling for an evaluation of nursing education programs and, subsequently, update approaches. The IOM further called for a smoother transition to practice for novice nurses and emphasized the importance of innovative methods for improving retention through enhanced preparation of nurses for their role in multidisciplinary teams. The Rutgers regional academic–clinical partnership model is an evidence-based, novel approach designed to face these demands by increasing consistency of education and reducing orientation time and costs.
Academic–Practice Partnership Model
According to the AORN (2015), now is the time for academic and perioperative clinical partners to transform nursing education using innovative teaching and learning strategies. The regional academic–clinical practice partnership model for perioperative nursing is a unique paradigm that extends the resources of the state's largest academic institution to New Jersey surgical facilities. In response to an identified need by nurse executives statewide, the university partnered with hospitals and surgical facilities to educate and train perioperative nurses. The collaborative partnership training program provides the essential components recognized in the literature as requirements for transition into operating department practice through an evidence-based training in a reduced time frame at a decreased cost.
Chief nursing officers in the state met regularly and identified the critical need for perioperative nurses and requested an innovative solution from the university. The project director, an academic educator experienced in continuing education, led the program development. Four master's-prepared perioperative nurses, hailing from multiple acute care hospitals, provided clinical expertise to help design the training program over the next 10 months, with input from the regional partners. The university worked with the statewide hospital association to recruit nurses to participate in the program. The team communicated well, using a shared vision and collectively approved goals, enhanced by the team members' sense of mutual trust and respect, all of which are key elements of a positive partnership (Beal, 2012). This enabled a smooth process for building the concept, curriculum, and design of a collaborative partnership program.
As operating department nursing training is routinely conducted within individual facilities and carries highly variable approaches to staff readiness, several steps were taken to combat these problems. The program director contacted New Jersey surgical facilities, posted detailed course information on the university website, sent e-mails to chief nursing officers, called human resource departments, and approached perioperative executives regarding the planned program. Perioperative leaders were the biggest supporters, and the educators also readily bought into the new training model. The standardized course used a consistent approach based on the AORN Periop101 curriculum (AORN, 2017) and included return demonstrations, simulation-based education, and trained preceptors using a core curriculum. The program mitigated possible variations in staff readiness, as the nurses received the core requirements of perioperative nursing, and practice partners were able to provide experiential training individual to their specific patient populations.
The RN participants included associate and baccalaureate nurses. For this pilot group, all participants (N = 7) were employed by a health care facility and registered for the course through the university. One community hospital sent (n = 4) nurses, a regional medical center sent (n = 2) nurses, and one surgical center sent (n = 1) nurse to the program. Each facility paid for its participants, receiving a discount for three or more registrants. In exchange, some facilities required a service commitment of 1 year. If employed, nurses were paid their full salary while attending the course.
Preceptor training is essential to the success of new operating department nurses (Gorgone, Arsenault, Milliman-Richard, & Lajoie, 2016). The sponsoring institutions identified preceptors at their facility to maintain an open channel of communication throughout the course to ensure consistency and continuity of training. A preceptor class was offered to one nurse from each of the three participating facilities at no additional charge. The training occurred over 3 days in September 2017 and included educating preceptors in roles and responsibilities, adult learning theory, domains of learning, feedback, reality shock, and evaluation. In addition, ongoing communication between faculty and preceptors, solidifying learning, and supporting the nurse's clinical experiences at their facility were integral to the training program.
The perioperative training program was implemented over 10 weeks beginning in October 2017, with a combination of didactic classroom teaching incorporating the AORN Periop101 curriculum and skills simulation laboratories held at the university. Each nurse participated in experiential training at the facility where they were employed. During the first half of the course, the participants attended 3 classroom days per week and one skills/simulation laboratory, completed 19 virtual Periop 101 modules, and participated in 2 clinical days per week at their home facility. In the second half of the course, participants attended 2 classroom days per week and one skills/simulation laboratory, completed seven virtual Periop 101 modules, and progressed to 3 clinical days per week at their home facility.
Course faculty included the four master's-prepared perioperative nursing experts who were working in surgical settings and were instrumental in designing the program. They were recommended by academic faculty and hired by the university as adjunct clinical instructors. Program faculty conducted biweekly conference calls with site preceptors to discuss student progress. Site visits by the project director and program faculty were also conducted to facilitate partner relationships and provide student support and mentorship.
The course was designed using adult learning theories, web-based technology, simulation, and integrated clinical practice experiences. The curriculum incorporated face-to-face classroom days, online AORN Periop 101 content modules, technical skills laboratory, and simulation scenarios. The course culminated in a mock emergency simulation scenario. The mock emergency simulation provided students with an opportunity to apply the skills learned. The program ended with a celebration luncheon to solidify the bond that developed among this new cohort of perioperative nurses, as well as the preceptor and the course faculty. In the future, two new cohorts per year will be planned, accommodating up to 20 students per session, with the ability to expand to additional sites across the state.
Feedback and Lessons Learned
A successful transition into the surgical setting requires novice RNs to perform technical and nontechnical skills in a highly complex, fast-paced, and multidisciplinary operating department. At the completion of the perioperative immersion course, the nurses were academically and experientially trained on the foundations of providing intraoperative patient care, with an emphasis on evidence-based practice, safety, and outcomes. This multifaceted approach promoted the development and reinforcement of attitudes, skills, and knowledge required for successful transition into the surgical environment (Mollon et al., 2012). The partnership model facilitates sustainability of the perioperative workforce and subsequent delivery of effective and cost-conscious surgical services.
Preliminary feedback has been positive overall at the completion of the first cohort. Initially, a few of the nurses had difficulty with skill application. The attitude and approach students brought to attend the course affected their engagement and ultimate experience. A small number of students expressed their hope that a change in practice would improve their job satisfaction; however, they did not acknowledge the complexity and scope of learning required. Recognizing the difficulty of the course material and the emotions this transition can elicit, the faculty held weekly meetings with the students and preceptors to discuss their perceptions and concerns. In doing so, faculty facilitated the students' and preceptors' transition into the perioperative setting.
It became increasingly clear as the course progressed that communication at all levels was key to sustain the momentum of learning and skills building. The communication took place among faculty-to-faculty, faculty-to-preceptor, and faculty-to-student on a daily or weekly basis. For instance, at the end of each day, the instructor debriefed with the incoming faculty member to smooth the transition to the ensuing teaching unit. Faculty would review students' progress and the specific skills learned. Although content was outlined in the syllabus and daily agenda, these debriefings ensured that material was covered, and skills were mastered progressively.
Program logistics had to be considered because the course was longer than typical continuing education classes. This required more complex scheduling of both faculty and instructional spaces. Inclement weather caused building closures, delayed learning, and created multiple scheduling challenges. The program development team applied systematic and continuous quality improvements to refine the curriculum, logistics, and student experience.
Next steps include a systematic evaluation of the program outcomes beyond the standard continuing education program evaluation. Nursing education programs must demonstrate a financial impact to organizations to demonstrate their value (Opperman, Liebig, Bowling, Johnson, & Harper 2016). To evaluate the efficacy and return on investment of the model, the program development team plans to assess clinical skill validation, pre- and posttest results, retention, cost per learner, and cost savings by partner organizations. The economic value of using the traditional approach to perioperative training by individual facilities needs to be determined and compared to current traditional methods of training.
The regional academic–clinical practice partnership model for perioperative nursing transformed the traditional approach for training novice perioperative nurses. The pilot program demonstrated positive outcomes, and in response a systematic evaluation with future cohorts is in development. This model has the potential for expansion to other nursing specialties, including intensive and emergency care, and has laid the framework for creation of a baccalaureate perioperative certificate program for academic credit.
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