Partnerships and New LearningModels to Create the FuturePerioperative Nursing WorkforceSABRINA GREGORY, MSN, RN, CNML; DEBORAH R. BOLLING, MS, RN, NE-BC, NEA-BC;

NANCY F. LANGSTON, PhD, RN, FAAN, ANEF

ABSTRACT

To create new and sustainable approaches for development of the perioperative

nursing workforce, perioperative nursing leaders at a hospital collaborated with

administrators and faculty at a school of nursing to create an innovative learning

model that reintroduces perioperative experiences to students in a nursing bacca-

laureate program. Key components of the initial approaches included an externship

for nursing students and a revised internship for experienced nurses who wished to

work in perioperative nursing. Project leaders then expanded the nursing student

learning opportunity by adding two additional elective perioperative courses to the

curriculum. Formation of perioperative clinical placement sites within the senior-

level adult acute care course was an additional positive outcome of these initial

initiatives. These initiatives resulted in decreased use of agency nurses at the clinical

site where the externships take place and increased numbers of younger nurses

working in the perioperative areas where they externed, with high levels of satis-

faction reported by nurses involved in the program. Through this innovative

collaboration, the perioperative nurse shortage at the hospital has abated, and the

opportunity to continually recruit new colleagues into the practice of perioperative

nursing has been established. AORN J 99 (January 2014) 96-105. � AORN, Inc,

2014. http://dx.doi.org/10.1016/j.aorn.2013.10.012

Key words: perioperative nursing shortage, nursing externship, baccalaureate

clinical experiences.

The demise of perioperative courses as a part

of nursing education has been identified as

a significant factor in the perioperative

nurse shortage.1 Happell2 asserts that the absence

of perioperative experiences in schools directly

results in a decrease in student interest in pursuing

a career in the specialty after graduation. Partner-

ships between educational institutions and nursing

96 j AORN Journal � January 2014 Vol 99 No 1

services, particularly perioperative units, can create

new models that effectively address this issue while

simultaneously addressing the problem of ensuring

sufficient quality clinical experiences to enable

schools to expand enrollment.

Based on mutual goals, organizations like

AORN and the National League for Nursing (NLN)

have indicated that they could benefit their

http://dx.doi.org/10.1016/j.aorn.2013.10.012

� AORN, Inc, 2014

CREATING THE FUTURE PERIOPERATIVE WORKFORCE www.aornjournal.org

respective members, and hence nursing globally,

by collaborating to study the issue of little or no

perioperative education in bachelor of science in

nursing (BSN) programs and the effect on the

overall shortage of nurses as well as the shortage

of nurses entering the perioperative profession.

Hence, the AORN Foundation sponsored a think

tank3 composed of nurse educators and perioper-

ative nurse leaders to identify whether the mutual

interests of AORN and NLN could be used as a

platform to transform thinking about the appro-

priateness of perioperative units as units in which

to provide clinical education for undergraduate

nursing students. This think tank released a white

paper, which was published in AORN Journal,3

that demonstrated the majority of skills expected of

a new graduate could be gained through clinical

experiences in perioperative settings. In fact, skills

expected of new graduatesdsuch as teamwork and

safety, including handwashing and sterile tech-

nique and continual assessment of patients who are

in unstable conditionsdare an inherent part of the

perioperative practice environment and therefore

provide quality experiences for students.3 Articles

appearing in AORN Journal subsequent to the

release of the white paper4-6 extended the under-

standing of the competencies of perioperative

practice in a way that affirms the appropriateness

of the perioperative setting for acquisition of skills

expected of a new generalist entry-level nurse.

This understanding is important because under-

graduate nursing programs are designed to prepare

a generalist nurse and not a specialist nurse.

SETTING

At the Medical College of Virginia Hospitals of the

VCU Health System of Virginia Commonwealth

University, Richmond, Virginia, which is a part of

a comprehensive health science campus of the uni-

versity, nursing leaders of the School of Nursing

and Nursing Services of the hospital recognized the

emerging national trend toward developing orga-

nizational partnerships between nursing schools

and nursing services7,8 and specific collaborative

efforts to support perioperative nursing (eg, the

think tank sponsored by the AORN Foundation3).

Beginning in early 2003, leaders of the school (ie,

dean, associate dean for academic programs, asso-

ciate dean for research) and of nursing services (ie,

chief nursing officer [CNO], director of medicine

and pediatric nursing, director of professional

development) began meeting to discuss how nurs-

ing’s relationship within the academic health sci-

ence center should or could be transformed. The

relationship between the medical school and the

hospital was clear to the nursing services leaders

and the school leaders, including the CNO of the

hospital and the dean of the School of Nursing, who

believed nursing would benefit from such clarity.

An 18-month dialogue by the formal leadership

team resulted in creation of a proposal for the top-

level university and hospital administrators that

identified the purpose and goals of nursing’s formal

partnership between the school and nursing ser-

vices and developed titled administrative positions

(eg, the CNO would hold the title of associate dean

for clinical operations of the School of Nursing,

and the dean would hold the title of executive di-

rector of academic nursing of the VCU Health

System) between the two entities. In 2003, the

board members of the health system and the pres-

ident of the university formally endorsed the part-

nership and administrative structure.

Simultaneously, the dean and associate dean of

academic programs of the school and leaders of

perioperative nursing (eg, director, clinical nurse

manager) initiated discussions regarding concerns

about an adequate current and future supply of

perioperative nurses. Medical College of Virginia

Hospitals’ staffing model of practice was similar

to most perioperative areas and was based on re-

cruitment of experienced RNs only. These experi-

enced RNs are transformed into perioperative nurses

after receiving didactic and clinical education in a

perioperative RN internship program. However, the

yearly attrition rate of these new nurses was 45%,

and the hospital’s staffing model routinely resulted

in a shortage of perioperative nurses and inadequate

AORN Journal j 97

January 2014 Vol 99 No 1 GREGORYeBOLLINGeLANGSTON

staffing ratios for the level one trauma center. As a

result, the hospital was increasingly reliant on

agency nurses, which resulted in an additional

personnel expense of approximately $1.2 to $2

million each year. In addition, during this time,

turnover and vacancy rates were skyrocketing,

which negatively affected staff morale and nurse

satisfaction and caused nurse and patient satisfac-

tion scores to plunge lower than national bench-

marks every quarter.

The hospital’s reliance on recruitment of expe-

rienced nurses resulted in the average staff peri-

operative nurse being 56 years of age, which was

significantly older than the national average age of

46.8 years.9 Perioperative nursing leaders identified

Critical thinking is known to be an essentialcharacteristic of a competent nurse, regardlessof his or her practice area, and is a relevantexperience for preparing entry-level nurses.

an initiative to develop

nurses for periopera-

tive surgical services,

whereby concerns

related to the current

and future supply

of perioperative

nurses also would

be addressed. One prong of the initiative was to

strengthen the hospital’s internship program for

experienced RNs, and the second was to partner

with the university in creating an externship course

for prelicensure baccalaureate nursing students. As

a result of the established organizational partner-

ship with the university, creation of a nursing stu-

dent extern course was seen as a viable venture.

From that initial vision emerged an expansive

collaboration that embedded perioperative nursing

within the structure of the prelicensure program of

the school.

LITERATURE REVIEW ON PERIOPERATIVENURSING IN THE CURRICULUM

As the perioperative staff nurses and the associate

dean of academic programs began the work of

developing a perioperative experience, they un-

dertook a review of the existing literature. From

that review, they determined that the idea of iden-

tifying and defining perioperative competencies is

98 j AORN Journal

not new. Gillespie et al4 identified domains of

perioperative competency, the vast majority of

which (ie, teamwork, communication, coordina-

tion, clinical leadership) are also expectations for

new generalist nurses as developed by the Amer-

ican Association of Colleges of Nursing.10 Critical

thinking is known to be an essential characteristic

of a competent nurse, regardless of his or her

practice area, and is a relevant experience for pre-

paring entry-level nurses. Jones5 discussed the

significance of instructional strategies designed to

develop and enhance critical thinking by nursing

students when in clinical placements in the peri-

operative environment, and Taber et al6 described

the use of the perioperative setting for a precepted

research experience

for senior-level honors

nursing students en-

rolled in an introduc-

tory research course.

Although not all

nursing programs

require a practicum in

research, BSN programs require a quality assurance

or quality improvement project that relates to re-

search to meet the American Association of Col-

leges of Nursing characteristics of a baccalaureate

graduate.10

Several articles11-14 have described various

educational models that reintroduce perioperative

coursework to the BSN curriculum, such as

learning activities designed to enhance periopera-

tive observation experiences already within cour-

ses, development of elective courses, and clinical

experience options within existing courses. For

those learning activities focused on enhancing the

quality of perioperative observation, authors

describe the development of structured orientation

experiences before the student’s observation

day.11,12 In addition to the structured orientation,

Castelluccio12 expanded the observation experi-

ence from one to two days. Mott13 described

modification of a previously offered 64-hour clin-

ical preoperative and postoperative experience to

CREATING THE FUTURE PERIOPERATIVE WORKFORCE www.aornjournal.org

include eight hours of OR experience. In addition

to the clinical experience within the OR, Mott

added a skill training period in the school labora-

tory and an on-site orientation to the OR before the

beginning of the clinical experience.13 Messina

et al14 described the introduction of two new ex-

periences: a 15-week clinical experience for stu-

dents as an elective course and development of a

clinical placement in perioperative units as one of

the clinical placement options within a senior-level

Capstone practicum.

Although none of the literature described expe-

rience with an externship, the review of the literature

supported perioperative nursing as an appropriate

practice area for student learning. Because the fac-

ulty of the school had indicated that current medical-

surgical courses were already filled with content,

semesters were already heavy in credit hours, and the

VCU nursing students could take an upper-division

elective, it was decided to design an elective course

in the form of a summer externship.

DEVELOPMENT PROCESS

In spring 2005, the associate dean, the director, and

the nurse manager from perioperative nursing began

developing a nursing student extern course program

with the purpose of building a pipeline for periop-

erative nurses through collaboration and teamwork

with the School of Nursing. The associate dean for

academic programs at the School of Nursing and two

nurse leaders in perioperative services collaborated

to design and gain university approval for offering a

clinical practicum course (ie, an extern course). The

development team created the course as an upper-

division clinical elective worth 1.5 credits to be

offered in the summer between the students’ junior

and senior years. The students completed 180 hours

of clinical practicum as a part of the externship. The

team designed a perioperative extern course in a

manner that would provide a platform for developing

a comparable course for any clinical specialty

practice area. The associate dean identified that this

strategy would demonstrate to the total faculty of the

school, who had to approve the offering of the

course, that there was potential that their specialty

clinical areas also could develop such an elective

and that it would have academic rigor. The first

cohort of students enrolled in the extern course in

summer 2005.

Another integral component to establish for the

extern program was the faculty of record. The two

perioperative unit leaders who collaborated on de-

veloping the course were appointed to the School of

Nursing as adjunct faculty members and served as

the faculty of record for the course. Both faculty

members held master’s degrees in nursing, and one

also held a post-master’s certificate in nursing ed-

ucation. This academic preparation made them

ideal candidates for this role because the school

requires that all employed faculty members hold

master’s degrees at a minimum. This is necessary

to meet national nursing education accreditation

standards.15 These adjunct faculty members served

as coaches and mentors to staff nurses who served

as preceptors for the daily clinical practicum ac-

tivities of the students.

Course Content and Expectations

The course consisted of 180 hours of clinical ex-

perience, and the objectives for the successful stu-

dent were to

n demonstrate beginner clinical competency in a

specialized area of clinical practice;

n apply theoretical and research knowledge to

practice;

n collaborate with health care team members to id-

entify, analyze, and resolve patient care problems;

n use effective communication skills in thementor-

student relationship; and

n apply standards of practice in the assigned clin-

ical area.

We used Benner’s From Novice to Expert: Excel-

lence and Power in Clinical Nursing Practice16 as

the textbook for the extern course because the

principles outlined in it already were used as the

foundation for the hospital’s clinical ladder for

professional advancement of clinical nurses.

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January 2014 Vol 99 No 1 GREGORYeBOLLINGeLANGSTON

Precourse Requirements

To start their perioperative extern experience, stu-

dents were required to participate in the hospital’s

orientation designed for all care partners. Addi-

tionally, all externs had to complete the perioper-

ative unit orientation, which included observation

and return demonstration of competencies on med-

ication labeling.

Clinical Experiences and Learning Activities

Externs participated in scenarios in the simula-

tion OR, where they reviewed patient assess-

ments and 12-lead electrocardiograms. They also

learned about instrumentation, scrubbing, gown-

ing, and gloving. During the course, students

rotated through all areas of perioperative surgical

services: the acute inpatient OR and postanesthesia

care unit (PACU), the ambulatory care OR and

PACU, the perisurgical unit, and the preanesthesia

clinic. During each clinical rotation, every student

In preparation for clinical care and clinicalobservations, students attended departmentmorning report and safety huddles, duringwhich they helped review the patients’ history,physical, consent, site marking, and proposedsurgical procedures.

actively participated

in direct clinical pa-

tient care experi-

ences, in addition to

spending assigned

time with a staff

nurse and a charge

nurse. These assign-

ments provided stu-

dent externs with

opportunities to observe and understand the re-

levance of effective communication within and

outside the department and to observe and ask

questions regarding different perspectives of

responsibility and delegation.

Perioperative surgical services routinely admits

patients on the day of their surgical experience.

Team members print a final schedule of impending

surgical procedures at 5:30 AM the day of surgery,

and thus the students were able to participate in

daily debriefing conferences and in reading and

assessment assignments that provided them with

tools necessary to assess their patients in a timely,

thorough manner. In preparation for clinical care

100 j AORN Journal

and clinical observations, students attended de-

partment morning report and safety huddles.

They reviewed the patients’ history, physical,

consent, site marking, and proposed surgical pro-

cedures with the RN circulator and/or the preop-

erative care nurse. During the morning safety

huddles, the student externs review the OR

schedule more closely as part of an interdisci-

plinary care team. This process identifies potential

safety concerns (eg, inadequate supplies or staffing

levels, look-alike patient names, latex allergies).

During the huddle, the team also reviewed the

scheduled patients; specific student assignments;

goals and objectives for the assignments; and skills

and knowledge needed to ensure continuous, safe,

effective outcomes for the assigned patients.

Preceptors and Clinical Guidance

Each student in the extern program was assigned

to a preceptor. The preceptor and the student

extern scheduled a

daily post-clinical

conference to reflect

on the assignment and

the clinical experi-

ence. The debriefing

focused primarily on

the student’s clinical

experience in relation

to meeting the defined

objectives and identified accomplishments and any

barriers to meeting them. The student and preceptor

reviewed areas of concerns related to safety, effi-

ciency, and productivity and identified the stu-

dent’s objectives for the next assigned clinical

experience, as agreed to by the student, faculty

members, and the preceptor. The entire cohort of

students met with the faculty of record every Friday

to discuss their clinical week.

Evidence-Based Projects

Another requirement of enrollment in this clinical

elective was for the student extern to have com-

pleted an evidence-based project course, which

CREATING THE FUTURE PERIOPERATIVE WORKFORCE www.aornjournal.org

provided the student with the foundational knowl-

edge and skills to successfully investigate and

complete an evidence-based project in one of the

extern program’s clinical assigned units. The ex-

ternship’s evidence-based project requirements

comprised a poster and an oral presentation of the

project to the clinical staff members and fellow

students. Students identified projects based on their

clinical observations and interests and were ap-

proved by the preceptor as appropriate for a quality

initiative for the unit. Examples of the students’

projects included the following:

n Immediate use steam sterilization. These pro-

jects led to an overall reduction in the use of

immediate use steam sterilization from 59% to

5%.

n Effectiveness of teamwork in the perioperative

environment. The focus of this project was the

development of a safe surgery process based on

the book The Checklist Manifesto: How to Get

Things Right,17 which presents compelling

stories of the need for use of checklists in health

care as well as other industries and the World

Health Organization guidelines for the surgical

safety checklist.18

n Effectiveness of color-coded armbands. The

focus of this project was the use of standardized

colored armbands to identify allergies, surgical

packing, and non-lateral site markings.

Preceptors served as evaluators of the students’

clinical performance, with review by the faculty

member of record, and the faculty member of

record evaluated the evidence-based project. Fac-

ulty graded the course on a pass/fail basis.

RESULTS

The overwhelming interest by nursing students in

the first extern course resulted in offering a second

session of the extern course in 2007 and a third

session in 2008. As a result, we added the intro-

ductory extern course to the course schedule for

all three semesters of the academic year and added

two upper-division elective courses in the fall and

spring semesters for extern students who desire

more in-depth perioperative nursing experiences.

The extern course was designed to accommodate

a maximum of 10 students each semester, and a

minimum of three students was required to offer the

course. For the other two upper-division electives,

student enrollment is a maximum of six and a

minimum of three in each course. The maximum

number for each of these two courses is adjusted

based on the enrollment in the extern course and

enrollment in the other elective. Each of these

additional elective courses can be taken for one to

five credit hours; however, the total for the two may

not exceed five credits because five hours of upper-

division elective credit is the program of study for

all students. As with the introductory extern course,

these additional courses required completion of 180

clinical hours and an evidence-based research

project. Unlike with the introductory extern course,

however, for the first of these courses, nursing

students selected a specific clinical area from those

through which they rotated as externs. In this first

course, they became active participants in devel-

opment and implementation of the patients’ plans

of care. Additionally, they completed an evidence-

based project specific to their unit and were re-

quired to present it to an interdisciplinary group of

health professionals. The second of the upper-level

extern courses focused on leadership and manage-

ment of the intraoperative unit. Students were able

to facilitate care of patient groups, including

scheduling of surgeries, acting in the charge role

with the charge nurse, and communicating with all

interdisciplinary team members and all levels of

personnel. Most importantly, the course allowed

students to develop an understanding of how suc-

cessful interdisciplinary teams promote optimal

patient outcomes.

From spring 2007 to fall 2011, 120 students

completed the introductory extern course. Since the

addition of the second-semester extern course in

2007, 45 students have completed the course, and

since the addition of the third-semester extern

course in 2008, 15 students have completed the

AORN Journal j 101

January 2014 Vol 99 No 1 GREGORYeBOLLINGeLANGSTON

course. Since 2009, approximately nine to 13 stu-

dents are completing the entire three-course series

each semester. The students who have completed

the three courses have excelled in their roles as

Faculty members have come to understand thequality of the perioperative environment andthe nature of professional nursing practice asappropriate clinical experiences in preparing anew generalist nurse.

nurses. Two students

are nurse practitioners,

and one is currently

completing school to

become a midwife. In

addition, another stu-

dent who was our

champion for adding

the third additional

section is currently in our OR internship. Another

student is returning to our department and will be

working in our PACU.

Students who have completed the extern course

shared comments about their experiences, such as

the following that were shared with the dean of the

School of Nursing:

n “If I decide not to pursue a career in periop-

erative nursing, it has been an excellent expe-

rience to prepare me to be a nurse.”

n “We learn constant assessment of our patients,

how to assess a total environment beyond the

patient, teamwork, advocacy, and a lot about

patient safety.”

In March 2006, AORN held its annual confer-

ence in Washington, DC. A group of nursing

students who had completed the extern course

were invited by members of the Richmond

Chapter of AORN to attend this national con-

vention. The students attended the student pro-

gram, and they attended other convention sessions

with chapter members. The School of Nursing

underwrote the cost for six nursing students to

attend the conference, and perioperative nurses

from the hospital served as mentors and coaches

for the students at the conference. The nursing

students returned with accolades for the experi-

ence and indicated that the opportunity was a

positive experience in their development as pro-

fessionals. One student reported that it was career

102 j AORN Journal

transforming in terms of his critical thinking and

ability to set priorities.

A positive but unanticipated consequence of

introducing the extern course was the extension

of the collaboration

beyond the extern and

elective perioperative

courses. Faculty mem-

bers at the school who

were unfamiliar with

the substantive nature

of the perioperative

clinical experiences

available to students have come to understand the

quality of the perioperative environment and the

nature of professional nursing practice as appro-

priate clinical experiences in preparing a new

generalist nurse. Faculty members understood that

the perioperative environment provides a clinical

learning environment as appropriate as that of an

intensive care unit that provides clinical placements

for the senior-level acute care course.

As a direct result of the faculty members’ new

understanding of perioperative clinical care, with the

first offerings in 2007 each semester, a clinical group

of eight to 10 senior-level students who were

enrolled in the required senior-level acute clinical

course had their entire 15-week clinical experience

in the perioperative surgical service units. This

clinical course section was originally developed

for students who specifically had selected peri-

operative surgical services. Furthermore, the school

faculty member of the course individually inter-

viewed the students to ensure that they understood

the nature of the experience, in that students would

be in multiple perioperative units rather than one unit,

as they would be if selecting a traditional intensive

care unit for their placement. Furthermore, she at-

tempted to ensure that the students selecting the

perioperative placement were adaptable to the fast

pace and constant change in the patients for whom

they would be providing care and that they evidenced

a level of maturity important for the constantly

changing environment of the perioperative units.

CREATING THE FUTURE PERIOPERATIVE WORKFORCE www.aornjournal.org

Now the perioperative placement process emulates

all other clinical course placements at the school.

Perioperative surgical services became a routine

clinical placement within the required senior-level

acute care course that is offered twice a year, which

allows 16 to 20 students to have a 15-week place-

ment of a minimum of six hours a week in the

perioperative units.

RESTRUCTURED RN INTERNSHIP

As described earlier, perioperative nursing leaders

identified a two-pronged approach to addressing

recruitment problems. The second approach was to

focus on strengthening the hospital’s existing RN

internship for experienced nurses.

New Components

To strengthen the RN internship program, the

clinical director and clinical nurse leader undertook

several initiatives, including

n increasing the duration of the program from six

months to nine months,

n decreasing the number of interns per session

from 10 to six,

n increasing the number of student cohorts admitted

into the program each year from four to 10,

n using behavioral interview techniques to inter-

view qualified applicants, and

n expanding clinical rotations to include the PACU.

Lengthening the duration of the intern program

to nine months provided time for the interns to

rotate through various specialized services such as

cardiac, neurology, and orthopedics. Experiences

also were added for evening shifts that allowed the

interns to have experiences with trauma patients

who were brought in during the evening. By de-

creasing the number of interns in each session, we

could provide each individual with more clinical

opportunities and hands-on time. Using behavioral

interview techniques enabled the selection com-

mittee members to determine which applicants

recognized that the primary role of the OR nurse

was to advocate for the patient and that being an

OR nurse also includes accountability, teamwork,

communication, unpredictable workloads, and

conflict resolution. Additionally, the applicants

submit an essay, unofficial transcripts, and two

clinical references. These application processes

allowed us to admit only the most qualified appli-

cants. Initially, in 2006, we set the class size for this

program at 10 participants to offset anticipated

attrition. Beginning in 2007, the cohort size was

reduced to six interns, which has provided the op-

portunity for the hospital to consistently maintain a

minimum of four viable OR nurses. With six nurse

intern slots, the units could plan for inevitable

attrition and still be able to sustain an adequate

number of new nurses in the OR to safely staff the

unpredictable workload of this level one medical

center. Also, interns rotated through all units of the

department (ie, the perisurgical unit, ambulatory

care center, preoperative assessment communica-

tion education) and not just the OR, so that their

perioperative exposure could be enhanced to in-

clude the entire perioperative patient experience.

Input from student externs resulted in the revision

of the PACU internship to a perioperative nurse

internship program.

Results

As of March 2012, the applicant pool for the RN

internship program was 40 to 60 applicants for a

cohort size of six. From spring 2007 to fall 2011,

45% of the nurses enrolled in the RN internship

have been baccalaureate graduates who completed

the perioperative extern course. Students who

completed the perioperative extern course consis-

tently have shared their positive experiences with

their peers and friends. This has created a market-

ing and public relations campaign that has resulted

in a productive, effective pipeline for the RN in-

ternship program.

The overwhelming success of the revised in-

ternship program is illustrated by the fact that, as of

2011, 45% of the hospital’s OR nurses in the am-

bulatory center and 70% of OR nurses in the crit-

ical care hospital have completed the OR nurse

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January 2014 Vol 99 No 1 GREGORYeBOLLINGeLANGSTON

internship program. Two years after the revision of

the RN internship and the creation of perioperative

education as a separate accounting unit with

budgeted positions to educate and orient new in-

terns and new hires, use of agency personnel was

totally eliminated. Although the intern program

was successful in attracting nurses into periopera-

tive practice areas, numerous personnel factors

This postanesthesia care unit (PACU) internshippromoted teamwork, collaboration, and nursesatisfaction and, as a result, the overall turnoverrate for the PACU slowly declined from 15.9%in 2008 to 9.2% in 2011.

created by having a

bimodal age distribu-

tion of younger and

older nurses resulted

in pregnancies and re-

tirements that in-

creased our turnover

rate once again in

summer 2011. How-

ever, because of the success of the revised RN

intern program and the pipeline of nurses created by

the extern course, the number of intern classes that

were graduated that year was increased from two

to four to again eliminate the need for agency

personnel. Our success has become a conversa-

tion piece in many professional venues and has

resulted in nurses from hospitals in the community

applying for slots in our perioperative RN intern-

ship programs.

PACU INTERNSHIP

In 2007, we developed the first nurse internship

in the PACU to address similar attrition issues in

partnership with the pediatric intensive care unit

(PICU). This two clinical specialty focus was

developed to provide experiences that would pre-

pare the nurse for another clinical practice area in

the event the intern decided that the PACU was not

really where he or she wanted to practice. Re-

quirements of the program included that the PACU

nurse intern spend six months in the PICU, while

simultaneously having assigned preceptors in both

the PACU and PICU. This new collaboration en-

sured that the PACU nurse intern received tools

necessary to successfully orient to the clinical

culture and environment of the PACU and that the

104 j AORN Journal

nurse intern acquired critical care skills needed in the

PICU. At the end of the six months, the intern could

choose either to remain in the PICU or to complete

the remainder of the program in the PACU.

Despite the decision made by the RN interns, the

managers and clinicians from both departments met

every two weeks to continue to provide support to

the interns and to monitor their progress. Nursing

preceptors in both de-

partments attended

staff meetings, partici-

pated in weekly safety

checks, and were

committed to the in-

terns’ successful

completion of the

program. At the suc-

cessful completion of the nine-month program, in-

terns had the option to transfer to the PICU as their

clinical practice unit or to remain in the PACU.

This PACU internship promoted teamwork,

collaboration, and nurse satisfaction. As a result,

the overall turnover rate for the PACU slowly

declined from 15.9% in 2008 to 9.2% in 2011. Our

institution participates in the National Database of

Nursing Quality Indicators, and in 2010 and 2011,

our participation by PACU nurses in the nurse

satisfaction survey was 100%. Furthermore, the

scores on six of the quality indicators, including job

satisfaction, were above the national means for

both years. The success of this endeavor was

attributed to the collaborative relationships among

the nurse leaders of the two departments.

CONCLUSION

Partnerships, such as those between AORN and the

NLN, also can occur between educational institutions

and perioperative units to effectively address the

perioperative nursing shortage by creating new

models of education for nursing students. The part-

nership between the School of Nursing and Nursing

Services of the hospital resulted in an innovative

learning program that can be used to sustain a future

supply of nurses for perioperative practice and that

CREATING THE FUTURE PERIOPERATIVE WORKFORCE www.aornjournal.org

was successful for faculty, hospital staff, students,

and administrators alike. These efforts not only

addressed the issue of providing perioperative courses

at the nursing school but also provided a sufficient

number of quality clinical experiences to enable the

School of Nursing to expand its enrollment. Collab-

orative partnerships like the one between the school

and nursing services also can result in significant

outcomes not originally envisioned by either party.

National and local accrediting bodies such as the

Magnet� program, the National League for Nursing

Accrediting Commission, and the Virginia Board

of Nursing have cited the partnership between the

School of Nursing and Nursing Services as note-

worthy, characterized the success as “nirvana” and

“inspiring,” and identified the partnership as a model

to be emulated nationwide. Here at VCU, whether at

the School of Nursing or Nursing Services ofMedical

College of Virginia Hospitals, we believe that the

“time is now”4 for creating new models of academic

and practice partnerships to strengthen the perioper-

ative workforce throughout the country.

Editor’s note: Magnet is a registered trademark of

the American Nurses Credentialing Center, Silver

Spring, MD.

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Sabrina Gregory, MSN, RN, CNML, is a nurse

manager, Perioperative Surgical Services, at the

Medical College of Virginia Hospitals of VCU

Health System of Virginia Commonwealth

University Health System, Richmond, Virginia.

Ms Gregory has no declared affiliation that

could be perceived as posing a potential conflict

of interest in the publication of this article.

Deborah R. Bolling,MS, RN, NE-BC, NEA-BC,

is nursing director, Perioperative Surgical Ser-

vices, at theMedical College of Virginia Hospitals

of VCU Health System of Virginia Common-

wealth University Health System, Richmond,

Virginia. Ms Bolling has no declared affiliation

that could be perceived as posing a potential

conflict of interest in the publication of this article.

Nancy F. Langston, PhD, RN, FAAN, ANEF, is

emeritus professor and dean at the Virginia

Commonwealth University School of Nursing,

Virginia Commonwealth University, Richmond,

VA. Dr Langston has no declared affiliation that

could be perceived as posing a potential conflict

of interest in the publication of this article.

AORN Journal j 105