Staffing the Operating Room
READY TO SCRUB IN BC Children's Hospital operating room nurses Nartila Romansini, Tina McVeigh, Madeline Ramos and Hannah Egan are just four of the hundreds of nurses taking advantage of the province's new perioperative education model that's designed to address BC's chronic shortage of specialized OR staff.
New perioperative education model is helping to address BC's nursing shortage
Sandra Meeres remembers the spring of 2016 like it was yesterday. The BC Children's Hospital nurse watched helplessly as nurse after nurse served notice and left one of the busiest operating rooms in the province.
The exodus forced the closure of two of the hospital's eight pediatric operating rooms in May of that year, and resulted in some 60 families having scheduled surgeries postponed. The crisis made headline news, with then-health minister Terry Lake informing the media that it would be nine to 10 months before the facility would be back to a full operating schedule.
Lake also characterized the hospital's OR as having a "tense work environment" — with nurses vulnerable to burnout and difficult to replace.
None of this came as a surprise to Meeres. The general duty nurse has worked in the surgical suite at Children's Hospital for 17 years, and she's served as a BCNU steward for the past five.
"Before 2016 the OR was staffed," she says. "Then management began to reduce the number of nurses to an amount they thought was adequate. We went from three to two nurses per shift – but that makes no sense because a trauma could come through the door and you would need that third nurse," she explains. "They were trying to save money."
Meeres attributes the sudden loss of 20 percent of the staff to a 2015 staffing model that used fewer nurses and put increased pressure on those who remained.
"A number of seasoned nurses were lost and they were not replaced," she says. "The management team were saying that two nurses in a room is fine, and no nurses on nights or one nurse at night is fine," she recalls. "I'm pretty sure that working alone in a tertiary care centre at night should not be an option."
Meeres says nurses wrote many notices of complaint over their employer's unwillingness to comply with negotiated staffing agreements, but between nurses quitting, moving, getting sick and retiring, the effort had little effect.
However, the crisis of May 2016 also became a catalyst for creative problem solving at the hospital. Within a year, the operating room that was once the epicentre of the province's nursing shortage became the poster child for constructive collaboration and problem solving to address the crisis.
With a new management team in place, the challenge lay in finding the number of nurses needed to bring the OR back up to baseline staffing levels and ensuring those staff were adequately educated. But obstacles were in the way. The perioperative program at BCIT did not have additional capacity and other health authorities were unable to assist with training because they were dealing with their own OR nurse shortages.
The logical solution lay in providing in-house education. Unfortunately, this approach often does not qualify nurses to work in other facilities. If the hospital were to provide perioperative training that would attract nurses, it would need to have standardized core content that's portable across the province.
Meeres says educators at the hospital had become aware of a program developed by the Association of periOperative Registered Nurses (AORN). It had met with success in other jurisdictions and was soon chosen for Children's Hospital.
"It's a hands-on training program and it's very intense."
Based on AORN Periop 101TM curriculum, the program offers site-based integrated perioperative training. It is currently being used by more than 2,500 facilities across Canada and the US and combines a standardized, evidence-based online curriculum with hands-on skills labs, in-situ OR experiences and clinical practicums.
"It makes sure that standards are followed and standard practices maintained – it's a great program that's worked well for us," says Meeres, who credits nurse educators Vanja Ryan and Kat Lidstone as instrumental in getting the program off the ground. "Vanya and Kat did the work," she says. "They got everyone on board with it. It's a hands-on training program and it's very intense."
The first group of nurses to go through the AORN program started in June 2016 and Meeres says they have been a success. "The nurses have worked really hard and we have some fabulous OR nurses as a result."
PROVINCE-WIDE CRISIS
Despite this recent success, the Children's Hospital OR is still dealing with the same challenges facing other ORs in BC. The province is experiencing the most acute shortage of specialty trained nurses in over 20 years. Any acute care nurse working in BC today knows all too well about the chronic and ongoing nurse retention and recruitment problems plaguing the operating rooms in hospitals across the province. Vacant lines are considered normal and minimum staffing levels are only being maintained through the consistent use of overtime that comes at the cost of nurses' health.
As nurses leave their units, the inadequate supply of qualified OR nursing staff only gets smaller, and employers have little success finding nurses willing to work under the current conditions.
SOLUTIONS AT THE BARGAINING TABLE
Without the education investments that are needed, the problem will remain. BCNU is committed to ensuring the province invests in the nurses required for safe patient care. In the last round of Nurses' Bargaining Association (NBA) negotiations the union secured an agreement to increase BC's education capacity by 850 full-time specialty-educated positions across the province, which includes operating room nurses.
The last round of bargaining also saw BCNU negotiate a provincial contact that further promotes the professional practice of nursing while advancing nurses' professional influence within the health-care system. One of these advances was the creation of the Nursing Policy Secretariat (NPS) within the Ministry of Health which now allows unprecedented BCNU involvement in the development of nursing and health service policies.
The NPS mandate allows it to deal with a variety of issues, from the expansion of nursing practice in response to population health needs, to the resolution of inconsistencies in permitted scopes of practice and enabling expanded scopes.
The creation of the NPS established the groundwork for meaningful change, and it wasn't long after the current NBA agreement was ratified in May 2016 that the Ministry of Health requested that the NPS lead work to establish a provincial model of care and education in perioperative settings in order to help address the urgent need for nurses in the OR.
Representatives from each health authority and the NBA met to discuss the options. A key requirement voiced by BCNU was that the education should allow for portability throughout the province and that nurses would receive certification.
Discussions with health authority Chief Nursing Officers, Chief Operating Officers, VPs of Human Resources and health ministry staff were held soon after. And based on the success at Children's Hospital the decision was made to use the AORN framework as the provincial model for perioperative nursing education in BC. There was also a recognition that the care model must be built on strong, collaborative relationships that focus on meeting the needs of patients wherever services are provided while at the same time optimizing the practice of both RNs and LPNs in OR settings. This also meant that the education would be geared to meet the tier level of the relevant OR, and if a nurse moved to a higher tiered OR, they would build on their foundational education to meet higher level requirements.
STORIES OF SUCCESS
Update Magazine talked to four RNs in the first cohort of nurses who have completed the AORN program and who have all been on staff in the Children's Hospital OR since June 2016.
Hannah Egan started working full time at Children's Hospital in February after completing her AORN program over a six-month period.
She's now working in general surgery. "We essentially do everything other than cardiac and spines. Anything from neuro to general surgery to urology," she explains.
Egan says she sent out many resumés after graduating from Trinity Western University in April 2016 but didn't receive any calls. A friend then told her that PHSA was hiring. "They told me about this big OR nursing shortage," she recalls. But Egan felt that, as a new grad with limited work experience, she might not qualify. "But I was told they were taking new grads. They were really looking for anybody. So I thought I would interview and see how it goes. I ended up getting hired and started the program."
Nartila Romansini began working at Children's Hospital during her preceptorship. "A year and a half ago they had an open house where they were trying to recruit people," she recalls. But as a third-year student at the time, Romansini said she wasn't sure if she could start working in the OR before graduating.
"But they said absolutely – that is actually the best thing. They introduced the AORN program during my preceptorship, so I did three months of the program as a student and upon my graduation I received an offer and I accepted it while I continued with my course."
Romansini graduated from the AORN program in July and now works full time while she prepares for her NCLEX exam.
Madeline Ramos worked as nurse in Arizona for three years before moving to Vancouver to live with her Canadian husband last year. "I was a float nurse. I worked all through pediatrics – in the PICU, NICU and med/surg – anywhere they were short."
She says she discovered the AORN program by happenstance. "I was just walking along one day around the hospital and I saw an advertisement for OR nurses, so I went to a presentation and actually met some people who worked in the OR," she recalls. "That intrigued me quite a bit and it felt like all the stars aligned for me to apply to this program."
"This model has given me a much broader foundation than just pediatrics."
Before coming to Children's Hospital, Tina McVeigh worked on the general surgical unit at St. Paul's Hospital since graduating in 2013. "We were taking care of patients pre- and post-op. So this is a nice circle for me – doing inter-op," she says of her new role in the OR.
McVeigh was already looking for a change before she heard about the perioperative program. "My manager at St. Paul's moved to Children's and she told me to let her know if I was looking for something else," she says. "I have a daughter and the schedule and hours also worked better for me."
The group have all remarked on the supportive learning environment they encountered while working through the program.
McVeigh, who has a small child, was drawn to the program because the course is taught at the hospital and worked with her busy schedule.
She also appreciated the course's multiple modalities. "You'd have days where you did your modules and another day where you did your skills and another day where you did your practice," she explains. "I like that it was broken up and that it was self-led, because even though I did my module work on site, I could choose which chapters I wanted to do and which to set aside if I wanted to do them at home in the evenings – it was very flexible."
Egan says she really appreciates how many nurses in the OR stepped up to teach her.
"A lot of people were willing to teach and help out," she says. "After the first seven weeks we would just kind of go into a room and get paired up with whoever was there.
"We got a lot of variation being paired up with different nurses, and a lot of them were willing to teach because they saw that in the future we were going to be co-workers."
Ramos concurs. "The support from senior nurses here was beyond amazing – everybody was just so happy that there were more nurses coming to help. They understood that we were going to be their colleagues, so they really invested a lot of their time and energy into helping mold us into the nurses we are."
Did any of the nurses have concerns about working in an OR that had just gone through a fairly high-profile staffing crisis?
"I had some trepidation about whether I should make the decision to come over, because I just felt like it was going to be a lot of pressure," admits McVeigh. "But I knew that I was going to make a difference. It was scary but also exciting to know that eventually I would be part of a group that would help get the OR working again."
"I know that there can be a stigma associated with the OR, as a place where there is bullying, but I'm lucky to say that Children's is not like that in any way," says Ramos. "Everyone is very supportive here and I have not come to work one day feeling that I wasn't able to handle anything that came to me because I knew I would be 100 percent supported in any position I was in."
Romansini feels like the Children's Hospital OR has already turned a corner despite the recent difficulties.
"Going to an OR that's experiencing a shortage is challenging because the senior nurses need to take their time to teach the new nurses coming in," she admits. "I'm here in training and I'm being a little bit of a weight on those people right now, but as soon as I finish I'll be there to help them. It goes two ways – they give to me by training me and supporting me and I'll give it back to them by helping them as well. So it's very fulfilling to be part of a team that has been struggling but coming out of this stronger."
AORN's standardized core content and portability was a key draw for all of the nurses.
"I was thankful that the AORN framework was not just for kids. It's for adults, for the whole spectrum," says Egan. If the focus was just on children I think I would be less prepared to go to other places – so this model has given me a much broader foundation than just pediatrics."
"I like that too," says McVeigh. "It's portable across the province and North America and if I wanted to take my practice elsewhere I wasn't limited to just Canada."
McVeigh says she now feels like she could comfortably work in another OR in the province. "And now that more hospitals are starting to adopt the AORN program that'll make me feel more comfortable. I like that it goes with the NCLEX – it's standardized," she adds.
Meeres agrees that nurses' ability to work in different OR settings makes the AORN program a good opportunity. "Life changes, people move," she says. "We wanted our nurses to be certified [to work in multiple settings] and gain a broad knowledge base about being a good perioperative nurse, being able to identify issues and having a surgical conscience."
All of the nurses report being happy with their decision to work in the OR and feel like there is no shortage of opportunity and rewarding challenges in the years ahead.
The new perioperative training program is just one more tool to encourage nurses to work in the OR, and it promises to be effective in helping address many of the staffing challenges operating rooms are experiencing across the province.
"Without this program having been introduced into our OR, we would still be struggling to fill the need for trained perioperative nurses, and I do believe ORs would still be closed," says Meeres.
Utilizing the AORN curriculum, Fraser Health began offering a 10-month in-house education program this November to both RNs and LPNs working at Royal Columbian and Eagle Ridge hospitals. A second implementation is planned for Surrey Memorial Hospital in 2018.
Children's Hospital has now educated four cohorts, and the nurses working there encourage others who are curious to consider applying when the program is rolled out in other health authorities.
"There's so much nursing care that we can apply within the OR context," says Romansini. "Nursing isn't limited at all in the OR." She encourages those who have any doubts to ask their employer for an orientation. "Maybe it will open a new door for you," she says. "The OR is a great place where we can actually provide meaningful care for vulnerable patients – just be open and curious about it and go check it out." •
UPDATE (Dec 2017)