The Perioperative Nursing Dilemma

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

There are wicked problems in nursing and then some very wicked problems. Over the past two months, I have interviewed and worked with perioperative nurse leaders on their recruitment and retention efforts. There is a sense of urgency in health systems to have their operating rooms running full steam ahead because they are economic engines for revenue. There is also a great deal of pent-up patient demand for surgeries that were postponed during COVID.

It is not unusual to hear that 40-60% of nurses in operating rooms today are travelers, as are the surgical technicians who work with them. In an area that depends on seamless teamwork, this endless rotation of staff through OR teams is taking a toll on leaders, full-time staff, surgeons, and ultimately quality and safety.

As a specialty, perioperative nursing was hit hard during COVID, which accelerated trends already predicted by OR managers 10 years ago when I studied the perioperative nursing workforce. More than 50% of leaders surveyed then already were experiencing shortages and 70% predicted shortages within five years. For years, perioperative nursing had a very stable workforce with nurses working decades in the same setting. As these Baby Boomer nurses began to age – leaders saw trouble on the horizon.

When COVID struck in March of 2020, many perioperative nurses accelerated their retirement plans. With the shut down of elective surgeries, some perioperative nurses were either furloughed or redeployed to clinical areas way outside their comfort zone. In a series of leadership forums that I did for AORN in 2020 and 2021, perioperative leaders struggled to deal with staff anger and negativity. Redeployments sometimes happened abruptly with little consideration of the nurse’s experience. Perioperative nurses began to feel very psychologically unsafe in their roles.

Fast forward to today, some nurses who worked for decades in hospital ORs have taken travel assignments when they lost trust in their organizations. Others retired or now work in ambulatory surgical centers with Monday through Friday schedules and no call. Experienced surgical techs are now also traveling and some programs have declining enrollment when students decide the return on investment is just not strong enough. Even with high sign-on bonuses, experienced perioperative staff are not applying for positions and are in short supply.

Perioperative leaders now find themselves rebuilding their workforces and it is not easy. Although there are some programs (Chamberlain, Case Western, University of Nebraska) where students are exposed to perioperative areas, most new graduates have never been in an OR and it is not on their radar screen as they seek employment. Generation Z and Millennial nurses see their careers in a much different way – as tours of duty. The idea that a nurse will apply to an OR, get oriented, and stay 10-15 years is probably very unrealistic. One OR director told me she was shocked that one of her new graduates told her preceptor that she must really lack ambition if she worked in the same place for 20 years.

So here is the dilemma – orienting a nurse with no perioperative experience to the OR is time-consuming and expensive. A best practice is to use the AORN Perioperative curriculum and develop an orientation that could range from six months to a year. At the end of this very intensive residency (or maybe even in the middle), the new graduate may decide to travel or even try another specialty. Smaller and rural hospitals are often unable to even provide an orientation leading to the endless use of travelers.

When I ask perioperative leaders about the future of perioperative nursing, most tell me that it is too early to know if the trends they see will continue. All agree that safe surgery should be the priority and these trends make that difficult. There is good reason for optimism as some perioperative leaders are doubling down on their efforts to attract and retain new staff. Incivility and bullying are being more quickly addressed because young nurses will not put up with them.

On a recent AORN webinar, Sharon Bestle Perioperative VP at Albany Medical Center shared a remarkable story of how her team successfully retained almost every new graduate recruited in the summer of 2021. It takes a village. The plans focused on building competency, teamwork, connection, and community using a high tech/high touch plan with daily check-ins, coaching, and opportunities for new nurses to talk openly about their challenges. With so little exposure to the OR in school, Sharon emphasized the need to let new graduates shadow experienced nurses and try out the OR.  When it is not a good fit, she coaches them to find a specialty area within her medical center that plays to their strengths and talents. The goal is to keep them in nursing and at Albany Med.

Like other OR leaders, Sharon is working hard to develop enough grow-in-place activities to provide career growth for these young nurses. She is also seeking creative ways to deal with perioperative on-call requirements knowing they are a huge dissatisfier for younger staff. The jury is still out as to whether these nurses will see perioperative nursing as a long-term career path. Meanwhile, many perioperative leaders like Sharon continue to develop creative strategies to solve this wicked dilemma.