Organizational Change Models applied to Program Design: A Simulation-based Perioperative Nurse Residency Program

Liana Kappus1, Sarah Hirx2, Frank Balisciano2, Susan Maxwell2, Judith Hahn3, Stephanie Sudikoff 1

1 SYN:APSE Center for Learning, Transformation and Innovation, Yale-New Haven Health System, New Haven, CT, United States 2 Perioperative Services, Yale-New Haven Hospital, New Haven, CT, United States

3 Center for Professional Practice and Education, Yale-New Haven Hospital, New Haven, CT

PO.ID 14-5

Context

The simulation-enhanced Perioperative Nurse Residency Program at Yale New Haven Hospital was developed to address a high vacancy rate due to aging workforce and applicant pool with limited operating room experience; and a need to decrease cost of orientation. The goals of the program were to decrease length of orientation, improve retention rate and train perioperative nurses who are competent and confident. The structure of the program allows educators to train newly hired nurses on basic skill sets that transcend adult and pediatric patient populations but also explore the nuances of pediatric, adult, and each surgical subspecialty.

Description

An inter-professional design team comprised of simulation experts, nursing leadership, and key stakeholders from perioperative nursing used organizational change models to design the program. Over several sessions, the team brainstormed ideal structure and support; and defined essential content, organization of content, learning modalities, and methods to assess learning. Following these sessions, a smaller working group was formed to continue to build.

The program spans 12 weeks followed by a unit specific orientation and focuses on core concepts and skills for new hires who are new graduate or experienced nurses transitioning to perioperative nursing practice. Learners are hired directly into a service-line and assigned a primary preceptor narrowing the focus to several surgical subspecialties. The content is divided into 5 five phases of care (See Figure 2). These phases of care, or Entrustable Professional Activities (EPAs) are clusters of interconnected competencies that require the learner to possess knowledge, skill and attitude and apply these within context related to the profession.1,2 High reliability organization concepts, teamwork skills, and patient safety initiatives are integrated throughout the program.

Each phase offers multiple learning modalities including: on-line learning modules, interactive didactic sessions, guest speakers, skills practice, observations in the clinical environment, simulations that increase in complexity, and application of skills within context in the clinical environment with a preceptor. Each phase culminates with a milestone check during a simulation to identify performance gaps. The simulations are designed using the SMARTER approach with clearly defined expected actions and embedded “triggers” within the scenario script.3

The program is further supported by trained preceptors, celebrations of milestones, and dedicated and protected time to reflect, set goals, and evaluate performance with managers, preceptors, and educators.

Observation / Evaluation

The program is evaluated at four levels focused on fiscal and learner outcomes. The following data is tracked to document return on investment: length of orientation, retention rate, and costs. In the pilot program, 7 out of 9 orientees completed orientation in 7 months with a 90% retention rate compared to an average of 12-month orientation and a 57% retention rate in the previous cohort. To evaluate learners’ self-efficacy, the validated Casey-Fink Graduate Nurse Experience Survey instrument is utilized. 100% of RNs from the pilot program agreed or strongly agreed with the following statement from the Casey-Fink Survey: I feel prepared to complete my job responsibilities. Additionally, learners are evaluated and given feedback during milestone checks in simulation and by preceptors in the actual clinical environment.

Discussion

In August 2015, the first group of 10 learners began the pilot program. Feedback is that simulation experiences and milestone checks help learners identify performance gaps and assist preceptors with goal setting during the preceptorship. Further evaluation data from two full cycles will be available by IPSSW2016. The collaborative design process can be utilized by simulation practitioners to create programmatic solutions at their home institutions.

Figure 1. Organizational Change Models for Program Design - Utilizing concepts from The Change Acceleration Process Model4 (Figure 1A), a design team comprised of key stakeholders was convened to build the program. This group met over several sessions beginning with a kick-off to create a shared need. Together the key stakeholders utilized CAP tools to brainstorm (Figures 1B), shape a vision of the program and began building content and structure. ( Figure 1C).

Abstract

Methods

Results

8th International Pediatric Simulation Symposium and Workshops 2016

9-11 May, Glasgow, UK

Objectives

Acknowledgements

References

Discussion

To create a financially sound, simulation-enhanced perioperative nurse residency program that results in higher quality graduates.

Structure and Support Content •  Hire into specialty •  Assign dedicated educator •  Enhance preceptor training •  Provide preceptor guides •  Embed time for reflection / goal

setting with preceptor, educator, and manager

•  Include celebrations

•  Build from simple to complex •  Structure using EPAs •  Incorporate simulation •  Design milestone assessments

Organizational Change Models for Program Design

C

A

Program Description: 5 Phases of Care

A

C

B

D

E

Figure 2. Program Description: 5 Phases of Care – The 12-week program is divided into 5 phases of care that mimic the workflow of the operating room. A. Preoperative Assessment – the nursing educator is able to view the new-hire conducting a preoperative interview with an actor in the simulation laboratory. B. The Scrub Role – new-hires spend time learning sterile technique followed by a two-week rotation shadowing a scrub technician in order to learn instrumentation. C. Receiving the Patient – new-hires practice safe transfer of patients and positioning techniques in the simulation laboratory. D. Intra-operative - during this phase, new-hires practice skills including: time-out, surgical pause, and documentation. E. Turnover – during the last phase, new-hires practice room turnover in the actual clinical environment

Reactions Participant reaction to the program is evaluated through surveys

Evaluation is evaluated at 4-levels (Figure 3). Length of orientation (Figure 4), retention rate, and costs are tracked to document return on investment. In the pilot program, 7 out of 9 new-hires completed orientation in 7 months with a 90% retention rate compared to an average of 12-month orientation and a 57% retention rate in the previous cohort. To evaluate learners’ self-efficacy, the validated Casey-Fink Graduate Nurse Experience Survey instrument is utilized. 100% of RNs from the pilot program agreed or strongly agreed with the following statement: I feel prepared to complete my job responsibilities.

Learning Learning is evaluated throughout the course with assessments and simulations

Behavior Application of knowledge and skills in the OR is evaluated through manager & preceptor feedback

Results Organizational impact and financial results including retention rate, length of orientation, and effect on vacancy rate are evaluated.

B

Previous Program 6-months followed by unit-based orientation.

Current Program 12-weeks followed by unit-based orientation.

Figure 3: Four Levels of Evaluation – The Perioperative Nurse Residency Program is evaluated at four levels.5

Figure 4: Length of Orientation– The figure above illustrates the previous program versus the newly designed simulation-enhanced nurse residency program.

Length of Orientation

4 Levels of Evaluation

1.  Ten Cate O, Snell L, Carraccio C. Medical competence: the interplay between individual ability and the health care environment. Medical teacher. 2010;32(8):669-75.

2.  Carraccio CL, Englander R. From Flexner to competencies: reflections on a decade and the journey ahead. Academic medicine : journal of the Association of American Medical Colleges. 2013;88(8):1067-73.

3.  Rosen MA, Salas E, Silvestri S, Wu TS, Lazzara EH. A measurement tool for simulation-based training in emergency medicine: the simulation module for assessment of resident targeted event responses (SMARTER) approach. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare. 2008; 3(3):170-9.

4.  Becker B, Huselid M, and Ulrich D. The HR Scorecard: Linking People, Strategy, and Performance. Harvard Business School Press, Boston, MA. 2001.

5.  Kirkpatrick D. Evaluating training programs: The four levels. Berrett-Koehler, San Francisco, CA. 1994.

In August 2015, the first group of 10 learners began the pilot program. Feedback is that simulation experiences and milestone checks help learners identify performance gaps and assist preceptors with goal setting during the preceptorship. The collaborative design process can be utilized by simulation practitioners to create programmatic solutions at their home institutions.

The authors would like to acknowledge the leadership and support of Susan Maxwell, Vice President, Perioperative Services at Yale-New Haven Hospital and Judith Hahn, Director of Professional Practice and Education at Yale-New Haven Hospital.