Why New Graduate Nurses in the Post-Anesthesia Care Unit (PACU)?
In 2001, a PACU expansion was being planned by the new MedStar executive team. The expansion would double the number of bays that would obviously create a dramatic and immediate need for new staff. The entire hospital was under a hiring mandate to increase the number of nurses, and one strategy to increase staffing was to hire new graduate nurses.
In the summer of 2002, the leadership of the PACU participated in the hospital’s new graduate program that had been implemented in 2001. The PACU leadership hired one new graduate nurse as a test. The first PACU new graduate successfully became a PACU nurse. The following year (summer of 2003), the PACU manager and educator gave the program more structure and hired six additional graduate nurses, and by the end of the orientation, the PACU had six more licensed nurses to care for patients.
The Foundation for a Success
The success of the new graduate orientation program starts with recruitment. Georgetown University Hospital (GUH) has a dedicated and active nurse recruitment program. The Nurse Recruitment and Retention Department hosts the New Graduate Interview Day once or twice a year. Applicants for this event are heavily screened, and only the brightest of student nurses and recently graduated nurses are chosen to interview for a nursing position. Managers and educators from every nursing department are present to meet and greet the potential hires, enjoy a lunchtime meal and then interview any potential hires for their department. By the end of the day, nurse recruitment gets a list of job offers to be made and written offer letters are mailed out as soon as the next business day. Nurse Recruitment’s ability to bring in excellent candidates and our leadership team’s ability to choose the best fit for our department creates the foundation for optimal outcomes later.
The Nurse Recruitment and Retention Department maintains continuous communication and provides support to the newly hired graduate nurses until their start date. The staff provides resources and answers questions concerning living arrangements, relocation assistance, passing the nursing boards and things to do in the metropolitan DC area. This creates a warm tone and sets the foundation for a welcoming atmosphere as well as inducts them into Georgetown’s culture before they arrive.
The continued success is dependent upon the support of nursing leadership. An orientation program may have great ideas, a great group of motivated new graduates and even a state of the art facility, but the absence of support from nursing leadership can derail any program. Nursing leadership’s desire to have a successful program must match with resources and a commitment to build and maintain the program.
A Great Beginning
As with any new hire, the new graduate nurse’s first day is hospital orientation in which the new hire is introduced to the culture of the hospital. The next two days are nursing orientation, and these two days are specifically catered to the new graduate nurse. The nursing education department hosts a breakfast meet and greet where the managers and educators are able to connect with the new hire, give the new hire their work schedule and have a preliminary discussion about what they should expect of the coming weeks.
GUH obtained and has maintained Magnet designation since 2004. ‘The Magnet Recognition Program® was developed by the American Nurses Credentialing Center (ANCC) to recognize health care organizations that provide nursing excellence’ [ANCC, 2009: 1]. The new graduate is introduced to the Magnet nursing culture at Georgetown during nursing orientation. The Chief Nursing Officer interacts with the nursing graduates and sets expectations of being a nurse at Georgetown. The new nurses meet with several leaders of departments that collaborate with nursing on a daily basis, including international services, nursing quality, risk management, blood bank, the diabetes educator, food and nutrition, the transplant community, infection prevention, nursing research, patient advocacy and pastoral care. The new graduates are also welcomed by the Magnet Director who introduces them to how nursing at Georgetown follows the ANCC Magnet principles, and some clinical skills are introduced including blood glucose point of care testing, restraints and medication administration. Lastly, each new grad fills out a biography sheet and has their picture taken. The pictures are used, so that each new graduate can be easily identified by the program leadership, and the biography sheet helps in the determination of whether the new graduate’s educational needs are met by the end of the program.
At the completion of hospital and nursing orientation, the new graduates come to the clinical area. Our perianesthesia education department has a busy day planned for them. First, the new graduates explore perioperative services and the hospital through a ‘Seek and Find.’ Next, the education leadership introduces the new graduates to service’s leadership structure and culture, conducts the intake process including security access and identification badges and reviews the entire internship program in detail including expectations. Lastly, lunch is served! The primary preceptors, the operating room orientees and all the clinical managers throughout perioperative services are invited. This is an opportunity for orientee to meet and connect with their preceptor as well as the departmental leadership. Once lunch has ended, the interns report to the clinical area to shadow their preceptor for the remainder of the day.
The Perianesthesia Orientation Program
The orientation program is divided into four distinct class sessions. Each class is independent of the other yet each class builds on each other for a comprehensive experience.
The clinical topic classes
The clinical topic classes are the first classes that the new graduate nurse attends. In the clinical classes, demonstration and instruction are conducted concerning basic clinical skills including IV therapy, chest tubes, oxygen therapy, bladder scanner, blood transfusion and code response. The classes are held over three days and each class is eight hours in length.
Basic electrocardiogram class
The perianesthesia interns attend a two-day basic electrocardiogram class. These classes are for all new graduates who are hired into the critical care areas including the PACU and emergency department. The basic electrocardiogram class covers cardiac rhythm interpretation as well as electrical and mechanical heart movement. In order to evaluate learning, an examination is given to the participants of the class, which they must pass with a score of at least 80% to stay in the orientation program.
The critical care course
The instruction of basic critical care knowledge is addressed by each new graduate participating in the American Association of Critical-Care Nurses (AACN) Essentials of Critical Care Orientation Program (ECCO). ECCO is a sixty-nine hour online course that instructs in the basic fundamentals of critical care nursing. Many of the new graduates have personal computers, which allow them the option of doing the course work from the comfort of their own home. In addition, they are provided with a notebook outline of the course for notetaking. Besides successfully passing the ECCO assessments, the new graduate must pass a non-comprehensive mid-term and final examination with a score of 80% or better.
As an institution, the need was discovered to supplement the online learning with classroom presentations. Supplemental learning classes were incorporated throughout the program to adjunct the instruction provided through ECCO. During the supplemental classes, specific hospital policies and practice case studies are covered, and the classes are taught by specialist physicians, nurse practitioners and nursing educators in their specialties.
The perianesthesia classes
The perianesthesia classes are held concurrently during the critical care course. The perianesthesia educator and a few staff nurse volunteers teach about twenty-two hours of perianesthesia-focused classes. The classes include professionalism and American Society of Perianesthesia Nurses (ASPAN) standards, physical assessment of the PACU patient, pre-anesthesia pharmacology, airway management, pain and comfort and fluid management and resuscitation. A variety of teaching methods are used to teach each topic including structured lectures, ASPAN purchased DVDs and case studies presentations. In addition, the interns have an opportunity to ask questions or seek clarification of all class content delivered during the orientation program.
The Extras
Each nurse in the perianesthesia orientation program rotates through various departments within and outside of perianesthesia services. One week is spent on a surgical inpatient unit to observe and learn medical surgical skills including time management skills. One shift is spent in the pediatric intensive care unit and another is spent in one of the adult intensive care units to observe and participate in the care of the critical care inpatient as well as pediatric respiratory and cardiac assessment. Lastly, each intern spends a total of two weeks rotating through the various units within perianesthesia services including pediatric surgery, pre-surgical testing, pre-operative care and phase II discharge.
The Heart of the Program
The success of the Perianesthesia Orientation Program is relies upon the ability to effectively convey practical general nursing knowledge and skill, while also teaching the unique perianesthesia specialty. The PACU at GUH orientation program’s success relies heavily on the competency and effectiveness of the preceptors. The knowledge and competency of the preceptors in coaching, critiquing, directing, evaluating and supporting is vitally important.
In April 2007, an opportunity to enhance the Perianesthesia Orientation Program was recognized due to a unique situation. Many of the nursing staff had less than five years of nursing experience, most nurses had not functioned as a preceptor and a few of the nurses had minimal understanding of the role of a preceptor. With the direction and support of the clinical educator and perianesthesia leadership, Ann Principe RN, MSM, CPAN created a proposal for a program to develop the skills and expertise of the preceptor. Upon acceptance of the proposal, the Preceptor Development Group was created to educate preceptor on how to precept effectively, provide support for the preceptor, and to build more standardization and objective measurement into the orientation program.
The Preceptor Development Group was representative of all the units within pre- and post-operative services and represented a mix of all nursing experience levels. The goal was to utilize the staff who had progressed from the stage of novice nurse to competent nurse and instruct them through a formal preceptor training program on how to precept properly. In addition, the formal training was to equip the nurse to mentor and precept nurses new to the specialty. The group’s motto is We exist to precept the preceptor.
The initial preceptor training covered various topics including communication, critical thinking, teaching and learning styles, post-anesthesia assessment, evaluation and roles and responsibilities of the preceptor. Nursing staff new to precepting attends a hospital-facilitated preceptor workshop and are required to meet with the educator to review the role and responsibilities of the preceptor. In addition, each preceptor must agree and ‘buy-in’ to this process of precepting as outlined by the Preceptor Development Group, attend the monthly Preceptor Development Group meetings and agree to undergo performance evaluation by the orientees.
How is success measured? Standardized and objective measurements have been built into the program. The Preceptor Development Group developed assessment and evaluation tools that are used to evaluate the progress of the orientee throughout the orientation period as well as the readiness to come off of orientation. The preceptor’s written evaluation is given to the educator at various times throughout the orientation period, and the educator keeps track of the progression of the orientee. In addition, the orientee must successfully pass the electrocardiogram examination and the two examinations administered during the critical care course, or he or she can not continue in the orientation program.
The orientee is instructed to write in his or her diary after each clinical shift focusing on what went well, what did not go well and the goal for the next clinical shift. The educator has formal and informal meetings with the orientee to evaluate how he or she feels, he or she is doing and to review the evaluations from his or her preceptors. The ASPAN Competency Based Orientation Program is a useful tool to evaluate the acquisition of perianesthesia nursing knowledge. Each orientee must complete the checklist and pass each examination with an 80% or greater before completing their orientation.
Challenges and Rewards
Rewards and challenges exist in any program. One specific challenge is how to assure each new graduate gets a broad but comprehensive experience. The post-anesthesia nursing specialty is a ‘jack of all trades’ type of nursing. The nurse needs to be able to perform safe nursing care for the post-anesthesia adult and pediatric patient, the post-procedure endoscopy, interventional radiology, critical care patients and patients who have transitioned to inpatient level of care due to a lack of inpatient beds.
One frustrating challenge is the struggle with being respected as a critical care area. Historically, post-anesthesia units are not always respected as critical care units. The post-anesthesia nurse is looked upon by some nursing staff who works in intensive care units as a nurse who is not capable to perform various levels of nursing care including critical care. This could not be more wrong, but it is difficult to change mind-sets. This lack of respect is experienced when the orientee ‘shadows’ in the intensive care unit and at times the orientee is not permitted to observe or participate in high-acuity clinical situations.
The last challenge is the assessment of the orientee’s readiness to ‘come off’ orientation. As mentioned earlier, the orientation process of our new graduates includes various assessment and evaluation tools. In spite of the tools, the assessment of the nurse to come off orientation remains a challenge mostly due to the lack of consistent use of the preceptee evaluation tool by the preceptor. Members of the Preceptor Development Group continue to encourage and remind the preceptors to provide timely and accurate assessments so that readiness to complete orientation can be assessed with all the information that is available.
The rewards have been just as encouraging. New graduate nurses bring enthusiasm and fresh energy to the unit. The thirst for learning and excitement for nursing is a breath of fresh air. In addition, new graduates bring a larger pool of potential candidates to the specialty of perianesthesia nursing. Experienced perianesthesia who are looking for employment are difficult to find in some markets within the United States and the recruitment of new graduate nurses creates a larger pool of nurses to pull from.
The growth of the preceptor is another reward of the orientation program. Since the start of the program, the perianesthesia preceptors are growing professionally in many areas including mentorship and teaching. The preceptors are becoming role models for others in the department and recognize the value and importance of their role as preceptors.
Summary
In summary, GUH Perianesthesia Orientation Program has four characteristics that have helped in its success. Nursing Recruitment’s commitment to hiring the best candidate for the specialty creates the foundation for success and Perianesthesia leadership’s commitment to supply resources and support to ensure the success of the orientation program. Perianesthesia leadership’s support was vital, but the success of the new graduates in the program was also depended upon the existing staff owning their success as well.
The heart of the program is the preceptors. The willingness and effectiveness of the preceptors is a major factor in the success of Georgetown’s program. The preceptor is the link for the new graduate nurse to the reality of quality patient care and professional nursing. Lastly, consistent evaluation is important to a successful orientation program and without a effective evaluation process, progress throughout orientation and readiness to complete orientation can be difficult to determine. By the end of the journey, the investment of time and resources is perceived as worthy because a viable and capable perianesthesia nurse exists to care for the patients in the perianesthesia areas.
