Costs associated with transitioning a new nurse to the practice area can be staggering, especially when that new nurse is hired to work in a highly specialized area such as perioperative services. Orientation with a preceptor can take from 7 months to a year, before the new perioperative resident can become fully productive in their role. This orientation period is much longer than other specialties, so it is imperative to offer a quality transition to practice program for the new perioperative nurse. Nursing professional development (NPD) practitioners must continuously audit and evaluate nurse transition to practice or nurse residency outcomes to ensure quality programs. The Association for Nurses in Professional Development discusses the need for quality in NPD practice in Standard 10 of the 2016 Nursing Professional Development: Scope & Standards of Practice. The NPD practitioner must lead quality improvement (QI) processes based on outcome analysis (Harper & Maloney, 2016). With the loss of just one perioperative resident costing potentially $88,000, QI activities must be at the forefront of NPD practice (Kovner, Brewer, Fatechi, & Jun, 2014).

A LOOMING PERIOPERATIVE CRISIS

Although all transition to practice and residency programs must be evaluated, it would behoove the NPD practitioner to pay close attention to perioperative services. A recent article shared compelling data from a 2016 Association of PeriOperative Registered Nurses survey: 48.3% of respondents were over the age of 50, perioperative nurses are older than other nursing specialties, 28% are likely to leave their place of employment in the next year, and perioperative vacancy rates are at 7.1% (Nash, Kamel, Sherer, & Nauer, 2018). These data also reflect what we are seeing in my organization. My organization's recruitment team shared the difficulty and cost in recruiting experienced perioperative nurses. In addition to these issues, we experienced a 55% first year turnover in the perioperative areas. All of these factors were pointing toward an organizational crisis if we did not address the situation.

QI METHODOLOGY

Although there are many QI models to choose from, Lee Health has adopted the Plan-Do-Study-Act (PDSA) model to guide QI activities. The first step in any QI initiative is to complete a gap analysis to determine the current state as it compares to the desired state (Smith & Harper, 2016). The steps in the PDSA cycle begins with determining a plan, developing and implementing the plan, auditing results, and either maintaining the results or, if results are not adequate, changing the plan (Smith & Harper, 2016). QI initiatives and plans should also include innovation. According to the Nursing Professional Development: Scope & Standards of Practice Standard 12, the NPD practitioner should encourage innovation and risk taking (Harper & Maloney, 2016). Creative problem solving and out-of-the-box thinking are also skills that need to be used when planning QI interventions. To address the organization's high turnover in the perioperative residency program, a formal PDSA project team was formed, with team leadership coming from both the NPD department and the Surgical Services division. The Human Resources (HR) recruitment team, HR business partners, and a Lean Coach from the Organizational Transformation department were also invited.

INNOVATION

We started with improving the perioperative residency curriculum and providing additional training for preceptors. The QI team also implemented a few innovative interventions to address the high perioperative turnover. First, the team felt that the selection process was not optimal in selecting the best candidates for the perioperative areas. A behavioral interview guide was created based on specific attributes a perioperative nurse would need to be successful in the operative environment. Interview questions that identified attributes and skills such as patient advocacy, conflict management, communication, team building, and resiliency were incorporated. To determine best fit, candidates were interviewed by multiple perioperative directors of our four acute care hospitals.

One of the most innovative tactics we incorporated was the decision to use a talent assessment. A consulting firm of industrial psychologists was engaged to assist with selection. Each perioperative residency candidate completed a talent assessment, which included a personality inventory and assessment of the candidate's critical thinking and problem solving. Although the cost of the assessment was high, the QI team felt we would see a return on investment with decreased turnover. The organization made the commitment to only hire candidates that the consultant group deemed acceptable into the perioperative residency. Since we started using this tool, 35 acceptable perioperative candidates were hired into the residency.

In addition to improving the selection process, we needed to increase the pool of newly licensed nurses applying to the perioperative residency and ensure that potential candidates knew the perioperative nurse's roles and responsibilities. Nursing students have minimal exposure to the perioperative areas during their clinical rotations, and they often have a misperception of what perioperative nursing entails. We worked with one of our academic partner schools to create a perioperative preceptorship to give students who were interested in perioperative nursing an opportunity to work side-by-side with a professional nurse for an extended period of time in the perioperative areas. Interested students receive an overview of the preceptorship provided by the System Director of Surgical Services, and they must submit an essay attesting to their interest in perioperative nursing. Students who are selected then complete the 96-hour preceptorship in the preoperative, operating room, and postanesthesia care units. Currently, 20 students completed the preoperative preceptorship, and of those, 40% were hired into the specialty.

The third innovative tactic was to develop a robust nurse rescue or recovery process. This is where the NPD Resident Development Specialist quickly identifies perioperative residents who are struggling or not a good fit for the perioperative residency. The Resident Development Specialist works with nursing leadership and HR to identify specific issues and provide a resident development plan and/or transfer to a more suitable unit. The goal is to identify these cases early and retain the nurse, albeit, sometimes elsewhere in the organization. For those perioperative nurse residents who chose to leave the organization during their first 2 years, we complete exit interviews. Traditionally, an HR representative would conduct the exit interview; instead, we have an NPD practitioner conduct it. The NPD practitioner reaches out to the ex-employees to meet in a neutral place to gather important qualitative data on opportunities for improvement for the perioperative residency program.

CONCLUSION

This initial perioperative QI project, using the PDSA cycle, started almost 3 years ago. The QI team has continued to audit and analyze multiple outcome measures. After implementation of all the changes, the perioperative first year voluntary turnover rate has remained below 10%. The innovative interventions, along with curriculum changes, and preceptor development activities have all contributed to this improvement. NPD practitioners must continue to audit and determine where QI activity efforts must be focused, and the NPD specialist must be prepared to lead QI activities to improve NPD programs such as transition to practice programs.

References