An administrator returns to practice as a perioperative nurse

Ruth Waibel

Much attention has been drawn to the shortage of nurses in health care organizations today. Statistics show that the average age of nurses in the current nursing workforce is 45 years, and projections indicate that the number of younger students entering nursing programs will continue to decline. (1) Although the shortage is reported to be nationwide, nurse recruitment and retention issues are not the same throughout the country. (2) Executives have structured human resource plans to address the nursing shortage in their areas and improve staffing patterns in their respective organizations. A Missouri hospital recently asked retired nurses to return to work. (3) Although this may be a short-term strategy, it will increase the number of nursing staff members in departments with shortages. Other strategies have included offering sign-on bonuses, sometimes as high as $10,000. (4)

In the present health care environment, many nurses in leadership roles return to staff positions for various reasons, including lessening stress from administrative responsibilities, receiving personal fulfillment from a clinical practice role, or because their leadership positions are restructured. Exciting challenges exist for nurses with managerial experience who return to staff nurse roles.

FROM ADMINISTRATOR TO STAFF NURSE

I formerly was employed as an administrator in a children's hospital and became unemployed when the organization realigned managerial positions and implemented numerous cost-reduction strategies. I was going to school part-time and working full-time before the elimination of my job, so I was compelled to find employment that could provide an income to cover family expenses and costs of living.

Circumstances limited my opportunities for finding a new job. I did not plan to relocate, and there were no management positions available in the community. My license to practice nursing was current, however, which made a nursing position an option. Although my resume documented years of management experience and clinical practice, my OR experience was dated. I responded to advertisements for perioperative nurses in local hospitals and ambulatory surgery centers in the area, but no jobs were offered.

Colleagues from the local AORN chapter provided insight into the dilemma that perioperative directors face. They want to hire younger nurses they can train or nurses with recent OR experience to save on orientation costs. Hiring a former nurse manager may be considered a waste of time because the former manager is apt to leave a staff nurse position as soon as another management position becomes available. Nurses with managerial credentials might be perceived as threatening to other staff members and managers. Hiring a former manager into a staff member position, therefore, must be undertaken with care and insight, or the benefit to staffing structures will be short-lived.

A nursing colleague and friend offered me a position as a part-time perioperative staff nurse to supplement staffing and relieve full-time staff members for vacations or other time off. I would start with the easy procedures--those I had plenty of experience with in the past, such as pediatric otorhinolaryngology (ORL), general surgery, and ophthalmology procedures. She also suggested that I would serve the department best by managing procedures that had changed little during the past years. I had found a job, but more challenges lay ahead.

SUCCEEDING AS A STAFF NURSE

My first responsibility was to think as a staff nurse, not an administrator. Although both positions are imperative for organizational success, different foci are unique to each position. For example, the manager has responsibility for understanding and representing global patient and hospital needs and the perioperative nurse dedicates his or her time to specific patient care planning and managing a day's surgical schedule. Relationships in the OR are part of a successful team strategy. Nurses' relationships with colleagues and physicians are patient-focused and more collaborative than are relationships between those in managerial roles.

The process to learn or relearn how to structure time commitments, procedure management, patient priorities, nursing practice patterns, and team dynamics with various surgical professionals became a daily agenda. Basic surgical techniques and standards of nursing care that once had been well-developed routines would be tested. Meeting the challenges of daily schedules might be grueling at best. Practicing perioperative nursing under new standards surely would be a test.

KNOWLEDGE AND MASTERY OF PRACTICE

The anticipation of returning to work as a perioperative nurse when my skills were rusty evoked both feelings of joyful anticipation and tinges of nervous expectation. My experience during the past 25 years included working as a perioperative nurse and supervisor in two large community hospital ORs, two pediatric hospital ORs, and a freestanding ambulatory surgery center. Over time, my responsibilities focused first on surgical and then later on nonsurgical divisions where I developed and implemented health care businesses, such as an urgent care center, neonatal networks, and home health services.

The frightening part of returning to the OR was my lack of knowledge about all the changes in surgical practice, the highly technological and sophisticated surgical routines, new and updated AORN recommended practices, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards of patient care, and varied surgeon preferences. Laser beams, electronic surveillance of intraoperative routines, highly developed equipment, and computerized medical records were new to me. Anesthesia techniques also had changed. The incorporation of newer medication routines, increased numbers of monitoring systems, and the inclusion of family members in the induction process posed orientation challenges. Returning to the OR was a test of clinical competence, problem-solving skills, and implementation of nursing practice standards.

ORIENTATION

I was very concerned about whether I would pass the practice competency examinations. The OR orientation packet contained skill and proficiency checklists, JCAHO-required tests, general education materials, and OR-specific procedure information. After the initial orientation with the nurse educator was completed, staff nurses from the specialty rooms continued the process. Nurse preceptors were long-time employees and well-respected staff members and, therefore, were extremely helpful as I raised simple questions, including how to order laboratory tests on the computer, get extra supplies, find equipment, and anticipate the anesthesia care providers' preoperative routines. It seemed at every turn there was a procedure I did not know. The more proactive staff members reviewed information with me. With their expert assistance, I learned how to prepare the room for video equipment, how to organize table parts, which of the many tourniquets or microscopes were preferred, how to roll a special head ring for a premature neonate, which physicians were always early and which started late, and other known facts that did not appear on a preference card but were well-known cultural norms in the OR. Having this insider information increased my own sense of control and competence. Lack of it might have caused delays and failures.

My preceptors evaluated my orientation progress and indicated when demonstration of OR nursing competency items was completed. Specific OR orientation in which I was assigned to scrub or circulate in all the surgical specialty rooms, excluding cardiac, took place in the first month. My assignments were limited to ORL, ophthalmology, general, and urology procedures. It was a few weeks until my proficiency with the basics of these procedures increased to an independent level.

Skills, such as preparing and setting up the OR, following the surgical procedure, anticipating needs for basic supplies, and greeting students and orienting them to sterile and unsterile sections of the room, returned quickly or came as second nature. The details associated with greeting patients and their family members; verifying chart completeness; providing perioperative guidance and reassurance to patients about physician practice patterns; ensuring that ancillary departments, such as radiology and the laboratory, were available when needed; prepping the surgical site with the appropriate mix of solutions; and anticipating the course of events for the day's procedures took a bit longer.

The schedule was busy, and staff members were on vacation, so I worked nearly full time. By the third week, I was given select assignments to manage without assistance. My confidence to manage more difficult assignments increased, and, within six weeks, my orientation included orthopedic, neurologic, and plastic surgery procedures. By the time two months had passed, I was managing most procedures without difficulty.

OBSERVATIONS AND LESSONS RELEARNED

Almost immediately, I began to appreciate the minute details that perioperative nurses have mastered and realize their unique and almost effortless contributions to helping a team event unfold. Learning the fine details became a challenge as the days turned into weeks and months. Within the first few weeks, the first section of the OR demonstration of proficiency orientation checklist was completed, but it took me several months to feel comfortable.

Equipment and supplies. Not only did orientation provide tools for managing patient care, it gave an overview of where equipment and supplies could be found. Looking at shelves or rooms where supplies and equipment was stored did not provide instant recall when an item actually was needed. Often, the scrub person would indicate where to locate the item, but if he or she did not, finding a technician or clerk helped immensely. Although many staff nurses did not perceive the tasks of putting items back on the shelf as their role, the chore of replacing unused supplies was not only beneficial to reinforce learning, it allowed me and other new orientees to become familiar with supply distribution processes.

Breaks and lunches. The first day I worked in the OR, a relief nurse came to give me a break, and I began to look forward to the morning socialization and a cup of coffee. Lunches offered a relaxed time to visit with colleagues. Leaving the unit for lunch gave me an appreciation for the world outside the OR once again, but it also reminded me how some units, such as the OR, isolate themselves from the rest of the hospital, and in doing so, never reach out to the larger membership of professional colleagues outside their department.

Extra hours. As a staff nurse, I could accept after-hours or overtime assignments or work extra days as a way to earn extra income. I was attending school in the evenings, so it was convenient for me to stay several hours to finish the work of a particular room. This not only benefited me, but it also benefited the other perioperative nurses with family obligations who could leave at the appointed time to fulfill them while I finished the procedures.

Staff meetings. Every Thursday at 7 AM, staff members met for regular surgical department business meetings or special inservice programs. These forums were particularly informative and served as a conduit for additional information, which normally would not be covered in new employee orientations. It was time dedicated to improvement of OR staff members' education that was supported by hospital executives and medical staff members. This commitment was a particularly important aspect of the OR staff members' effectiveness.

Professionalism and teamwork. Caring for patients, implementing standards of perioperative nursing practice, and managing quality monitors with other staff members were among the highlights of my return to the OR. The nursing staff members' skills in every surgical specialty were demonstrated repeatedly as they interacted with residents, surgeons, anesthesia care providers, privately-employed personnel, laboratory assistants, and other personnel. My own proficiency and sense of well-being improved as these team members provided assistance in the orientation process. Giving reports about the patient to postanesthesia care unit and intensive care unit staff members and receiving feedback provided me with an understanding of their particular needs, work priorities, and interest in the welfare of our patients. This, in turn, reinforced the importance of perioperative practice patterns and the team approach to quality improvement.

NEW LESSONS LEARNED

My experience may provide information that nursing staff members, perioperative managers, and nurse educators can incorporate into their professional relationships with new employees. Some tips for orienting new employees who have previous OR experience are included in Table 1.

Throughout this experience, I learned the following lessons.

* Even after many years as an administrator, I had not forgotten the basic skills of perioperative nursing practice and sterile technique.

* Team dynamics in the OR are unlike any others in the hospital and should be valued, nurtured, and constantly improved to increase positive outcomes of surgical care.

* An "old" nurse can learn new tricks, but it takes work and time. In light of my two-year experience, however, I believe that orientation is no more time consuming for a returning older nurse than for a new employee who comes to the OR with recent surgical experience from another facility.

* The stress associated with orientation and wanting to be proficient and clinically competent exerts constant pressure on the nursing orientee and should be addressed with patience and understanding of this struggle.

* Perioperative nursing practice today is much more patient- and family-oriented than it was in the past, and this may require special attention for orientation of nurses in preoperative and postoperative activities.

* Technology does save time, energy, and lives; nurses may need additional orientation to become familiar with various applications. From an administrative view, however, the expense of training staff members and purchasing and maintaining newer, more sophisticated equipment may be well worth the investment when it results in better patient outcomes and effectiveness of surgical care.

* Perioperative nurses, as well as physicians and administrators, share a responsibility to manage care in the most cost-effective yet appropriate manner to ensure that the patient receives the best quality of surgical care.

CONCLUSION

As recently as September 2001, the house of delegates of the American Nurses Association met to address strategies to improve the nursing shortage. (5) The meeting was attended by AORN representatives, as well as representatives from other nursing organizations. Many new ideas have been and will be proposed. Some may require complex structural changes. Surely the employment of nurses who are older from various disciplines and with managerial experience will be suggested. Change is certain, but the challenge to find good perioperative nurses may be met with some simple strategies such as this.

Table 1
TIPS FOR INTRODUCING NEW STAFF MEMBERS
WITH PREVIOUS EXPERIENCE TO THE OR

Tip                          Rationale

Recognize the strengths      Basic concepts are
of the returning perioper-   ingrained and will return
ative nurse and reinforce    with repeated practice in
these areas during           the early phase of
orientation.                 orientation.

Build confidence through     Gaining confidence early
work schedules that          leads to greater self
allow basic skills to be     esteem for the orientee.
used.

Provide opportunities for    An atmosphere that
the orientee to discuss      allows for discussion of
fears and feelings of        feelings will increase
insecurily in a confiden-    potential for earlier
tial manner.                 success.

Assign orientees to          Having a mature preceptor
mature, well-disciplined,    builds a professional
yet sensitive preceptors.    bond that increases
                             efficiency.

Building upon previous       Technology that the
experiences, introduce       nurse had former
new technology early in      proficiency in can serve as
the orientation.             the catalyst for successful
                             management of
                             newer technology.

NOTES

(1.) The Registered Nurse Population. National Sample Survey of Registered Nurses, March 2000: Preliminary Findings, (Rockville, Md: US Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing, 2001).

(2.) Ibid.

(3.) M Waibel, personal communication with the author, North Kansas City, Mo, winter 2001.

(4.) P I Buerhaus, D O Staiger, D I Auerbach, "Why are shortages of hospital RN's concentrated in specialty care units?" Nursing Economic$ 18 (May/June 2000) 111-116.

(5.) D S Watson, "National labor assembly and the nursing shortage discussed at the American Nurses Association's house of delegates," AORN Journal 74 (September 2001) 379-380.

Ruth Waibel, RN, PhD, FACHE, is an assistant professor, health services administration, School of Health Sciences, Ohio University, Athens.

COPYRIGHT 2002 Association of Operating Room Nurses, Inc.
COPYRIGHT 2002 Gale Group