The Battle for Talent: How Nemours Children’s Hospital Solved Perioperative Staffing Woes
In August 2022, the RN staffing vacancy rate in perioperative services at Nemours Children’s Hospital, Delaware, was 30%. Unfortunately, they were not alone. Vaccine mandates, competition with nurse travelers, vaccine clinic jobs that paid $70/hour, and mass retirements made it difficult for hospitals to attract and retain full-time staff.
But by July 2023, that 30% was down to 2.8%. As of this writing, only two FTEs are open, with a surplus of candidates. Dr. Edna Gilliam, Assistant VP of Perioperative Services and SPD at Nemours, Delaware, breaks down how they turned these numbers around in less than a year, turning a famine into a feast. You’ll want to read on if you’re a leader of any level in perioperative services.
Insights from Exit Interviews
Once the pandemic became less of an emergency and elective surgeries returned, Gilliam says there was a lot of pressure to get ORs up and running. She started to rethink the execution of their Periop 101 course.
“Many of the new graduates we hired were not making it off orientation or were leaving shortly after,” Gilliam says. “So, we had to regroup and figure out what was happening.”
The first order of business was to get additional information, namely from stay and exit interviews. The number one roadblock that sent new perioperative nurses running for the hills was their interactions with experienced staff. They felt overly criticized and an absence of patience while they were learning. Nurses coming into perioperative services from other specialties felt they had even less leeway, as it was assumed they should have a running start. The bottom line: there was a bit of a culture problem.
“I think [experienced staff] were overburdened with constantly orienting new grads and not getting results,” Gilliam says. “I also think that they were just tired. We offered plenty of incentive shifts and the staff was burning out.”
In addition, some new grads had certain expectations of what perioperative nursing would be like. Many were shocked at how little patient interaction there was in the perioperative setting. Unfortunately, nursing schools give students few opportunities to dip their toes into perioperative services.
“Nursing school curriculums are geared towards content that will be on the NCLEX, and perioperative services is not included,” Gilliam says.
Historically, new nurses were encouraged to work two years in med-surge before transitioning to a specialty like perioperative nursing. Perioperative nursing is typically where nurses ended up, not where they started, says Gilliam. More and more nurses want to pursue perioperative nursing right out of nursing school. With zero exposure to the specialty, this becomes a challenge.
A Revolutionary Idea
Nemours CNO organized an innovation meeting where leaders came to the table with novel ideas to share. Gilliam’s idea was to create a simulated operating room. A minor investment, they retrofitted an old GI suite they used for motility studies. It was a success. Staff and surgeons would stop by in between cases to assist in teaching the new grads. So far, they have oriented nearly 20 new nurses utilizing the sim lab.
“My objective was to decrease stress of the experienced staff from constantly orienting the fundamentals of perioperative services,” Gilliam says. “I thought that if we could take some of that fundamental teaching from our preceptors and do it in the sim lab, our new graduate nurses would have more knowledge when they go into the OR. They would know what an Allis is. They know what a Babcock is. They can speak to the sterile field and know how to gown and glove themselves.”
Finding the Perfect Fit
Hiring managers realized they need to change how they conducted interviews. They needed candidates who genuinely understood perioperative services. Unlike bedside nursing, there is limited interaction with patients. Candidates must know what scrubbing and circulating is. They are also required to come in and shadow before receiving any offer of employment.
“We had to be very honest with ourselves and understand that it might take some time before we found the best candidate,” Gilliam says. “But it was worth it in the long run. AORN estimates that it costs $120,000 to orient a new nurse. There are six months of nonproductive time while they’re training. When you make that investment, and then they leave or don’t make it off orientation, that wastes time and money. Finding the right candidate and developing a strong team is important.”
Communication and Connection
Gilliam also began hosting a Lunch with Nurse Leaders for staff. The goal was to create a support system, tell stories, find out what things were going well (or not so well), and lighten the environment to help reduce anxiety.
Often, when a new perioperative nurse walks into the OR, no one will speak to or greet them. The surgeon may not acknowledge them. Gilliam says just taking a few minutes to make introductions will make a lasting impact.
“A piece of feedback we received from a new nurse during one of these luncheons is that she thought it would be nice to have an existing staff member have lunch with them daily. From her perspective, this was a great way to develop a relationship with a colleague before they become her preceptor. This kind of feedback we received during these luncheons allowed us to course correct early instead of finding out six months later they are unhappy,” Gilliam says.
Increasing Access to Perioperative Training
Another solution is to increase perioperative exposure and build a pipeline to the OR. Nemours built a partnership with the University of Delaware’s School of Nursing to create an elective course for perioperative nursing taught by a Nemours employee. Expecting to get less than ten students, we were pleasantly surprised when 39 students signed up for their first course. Gilliam plans to contact Delaware State, an HBCU (Historically Black Colleges and Universities), to forge a similar collaboration.
“The goal is to keep this pipeline going so we can continue filtering those students into our system,” Gilliam says. “The onus is on us to address the fact that nursing students are not getting exposure to perioperative services. If a university can provide the students in the room, we’ll teach it, and that’s exactly what we did. We’ll keep this going for as long as we can.”
From Scarcity to Abundance
An observable shift began in July of 2023. Gilliam says they were not playing “Staffing Tetris”, the familiar struggle to have enough nurses to cover breaks and lunches. Then, suddenly, they had more candidates than they had open positions.
“Right now, we have two FTEs open, and we’re getting so many applicants,” Gilliam says. “We have 11 applicants for our director of nursing position at one of our ASCs.”
Gilliam says it’s imperative to peel the layers of onion back to see where issues and challenges originate. Understand culture problems and be willing to address them. Engage all disciplines within perioperative services, including SPD, surgeons, and anesthesia. In a presentation she gave this year at the OR Manager Conference in October and the OR Management Summit in July, she summarizes her approach, “1-2-3 Response to the Staffing Crisis in Perioperative Services.”
“Use stay and exit interviews to find out why nurses aren’t staying, change the way you interview candidates to pick out the best match and solve for the minimal perioperative exposure nursing students receive,” Gilliam says.
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