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A Competency-Based Orientation (CBO) Protocol Enhances Competency Among Newly Hired Perianesthesia Nurses

      Abstract

      Purpose

      The purpose of this quality improvement project was to develop a competency-based orientation (CBO) protocol based on the American Society of PeriAnesthesia Nurses Nursing Standards and CBO for perianesthesia nurses.

      Design

      Feasibility study with pre–post survey design.

      Methods

      A CBO protocol that included nursing care workflows for 11 common surgical cases was developed and used in orienting newly hired perianesthesia nurses. Newly hired nurses completed a pre–post self-assessment on their level of competency in caring for surgical patients.

      Findings

      Using Wilcoxon signed rank test, improved competency was found in all service areas except for pediatric care.

      Conclusions

      Nursing competency in the perianesthesia area is critical in fulfilling one's role as a nurse. A robust CBO protocol for the perianesthesia nurse is important when integrating an employee into the organization and preparing the nurse for success.

      Keywords

      Objectives–1. Discuss perianesthesia competencies. 2. Describe how to utilize perianesthesia nursing standards and competencies. 3. Describe methods to demonstrate perianesthesia nursing competencies.
      The World Health Organization attributes negative patient outcomes to a lack of competence among health care providers.
      • Church C.D.
      Defining competence in nursing and its relevance to quality care.
      For this reason, in the United States, the Joint Commission (TJC) mandates all health care facilities to assess competencies of health care personnel including nurses, on hire, and annually.
      • Church C.D.
      Defining competence in nursing and its relevance to quality care.
      • Whittaker S.
      • Carson W.
      • Smolenski M.C.
      Assuring Continued Competence- Policy Questions and Approaches; How should the profession respond? Online Journal of Issues in Nursing (OJIN). Am Nurses Assoc 2000; 5.
      • Fey M.
      • Mittner R.A.
      Competency-based orientation program for new graduate nurse.
      • Hodges J.
      • Hansen L.
      Restructuring a competency-based orientation for registered nurses.
      Although many hospitals comply with the annual assessment of nursing competencies, wide variability exists on how competencies are promoted and assessed during new nurses' orientation.
      The Bureau of Labor Statistics predicted in 2018 that the nursing shortage would reach 400,000 in 2020, and would rise to 1.09 million in 2022 in North America.
      • Van Patten R.
      • Bartone A.S.
      The impact of mentorship, preceptors, and debriefing on the quality of program experience.
      ,
      • Acuna G.K.
      • Yoder L.H.
      • Madrigal-Gonzalez L.
      • Yoder-Wise P.S.
      Enhancing transition to practice using a valid and reliable evaluation tool: Progressive orientation level evaluation (POLE) tool.
      This is compounded by the global shortage of nurses to 12.9 million nurses in 2035 as predicted by the World Health Organization.
      • Van Patten R.
      • Bartone A.S.
      The impact of mentorship, preceptors, and debriefing on the quality of program experience.
      The nursing shortage will greatly impact perianesthesia nursing because it is a specialized area.
      • Symmerman L.
      • Kuhns K.A.
      • Crocket J.
      • Slade M.
      Rethinking perianesthesia orientation.
      Hospitals conduct orientations for new nurses in various ways.
      • Hodges J.
      • Hansen L.
      Restructuring a competency-based orientation for registered nurses.
      ,
      • Lott T.
      Moving forward: Creating a new nursing services orientation program.
      • Hagler D.
      • Wilson R.
      Designing nursing staff competency assessment using simulation.
      • Sorrentino P.
      Preceptor: blueprint for successful orientation outcomes.
      • Wilgis M.
      • McConnell J.
      Concept mapping: An educational strategy to improve graduate nurses’ critical thinking skills during a hospital orientation program.
      • Zigmont J.
      • Wade A.
      • Edwards T.
      • Hayes K.
      • Mitchell J.
      • Oocumma N.
      Utilization of experiential learning, and the learning outcomes model reduces RN orientation time by more than 35%.
      Some follow a nonstructured schedule that relies on availability and willingness of senior nurses to mentor. Other hospitals offer instructor-led classes using lecture slides.
      • Lott T.
      Moving forward: Creating a new nursing services orientation program.
      Many hospitals rely on classroom teaching for orientation.
      • Lott T.
      Moving forward: Creating a new nursing services orientation program.
      Unstructured orientations contribute to increased nurse turnover, dissatisfaction, lack of confidence, poor skill performance among new nurses, and decreased patient care and safety.
      • Lott T.
      Moving forward: Creating a new nursing services orientation program.
      ,
      • Wilgis M.
      • McConnell J.
      Concept mapping: An educational strategy to improve graduate nurses’ critical thinking skills during a hospital orientation program.
      Without the use of orientation protocols, assessment of competencies for the performance of safe nursing care is often missed.
      • Karami A.
      • Farokhzadian J.
      • Foroughameri G.
      Nurses’ professional competency and organizational commitment: Is it important for human resource management?.
      This is particularly concerning given that competencies are vital in promoting the high quality of care and safe practice in hospital settings.
      • Church C.D.
      Defining competence in nursing and its relevance to quality care.
      ,
      • Andrews S.M.
      • Cartwright S.M.
      Management and Policies.
      • Beagley L.
      • Casey D.
      Safety in the PeriAnesthesia Setting.
      • Krenzicheck D.
      Safety.
      Competency-based orientation (CBO) focuses on the nurses' ability to carry out the role expectations for which they have been hired
      • Hodges J.
      • Hansen L.
      Restructuring a competency-based orientation for registered nurses.
      ,
      • Andrews S.M.
      • Cartwright S.M.
      Management and Policies.
      and provides tools to improve clinical judgment, accountability, empowerment, confidence, improved performance, and effective work interactions.
      • Church C.D.
      Defining competence in nursing and its relevance to quality care.
      In contrast to unstructured orientations, CBO is associated with increased nurse retention, decreased orientation cost, and decreased duration of the orientation period.
      • Hodges J.
      • Hansen L.
      Restructuring a competency-based orientation for registered nurses.
      ,
      • Sorrentino P.
      Preceptor: blueprint for successful orientation outcomes.
      ,
      • Wilgis M.
      • McConnell J.
      Concept mapping: An educational strategy to improve graduate nurses’ critical thinking skills during a hospital orientation program.
      CBO is particularly important in perianesthesia nursing as perianesthesia care heavily relies on clinical skills and coordinated efforts from multidisciplinary team members to promote a culture of collaboration and safety.
      • Beagley L.
      • Casey D.
      Safety in the PeriAnesthesia Setting.
      • Krenzicheck D.
      Safety.
      • Nilsson U.
      • Gruen R.
      • Myles P.S.
      Postoperative recovery: the importance of the team.
      Competencies in airway management, advanced cardiac life support, hypothermia, and quick identification of serious complications from procedures and anesthetic agents are crucial.
      • Andrews S.M.
      • Cartwright S.M.
      Management and Policies.
      • Beagley L.
      • Casey D.
      Safety in the PeriAnesthesia Setting.
      • Krenzicheck D.
      Safety.
      • Nilsson U.
      • Gruen R.
      • Myles P.S.
      Postoperative recovery: the importance of the team.
      In 2019, the American Society of PeriAnesthesia Nurses (ASPAN) released the Competency-Based Orientation (CBO) Program for Registered Nurses in the PeriAnesthesia Setting,
      American Society of PeriAnesthesia Nurses
      Competency Based Orientation (CBO) Program for Registered Nurse in the PeriAnesthesia Setting.
      their latest set of guidelines that direct orientation in perianesthesia nursing. Incorporated into the ASPAN CBO are the 2019 to 2020 Perianesthesia Nursing Standards, Practice Recommendations, and Interpretive Statements. Reviewed every 2 years, this manual is a collaborative work of expert perianesthesia nurses who incorporate the most recent evidence and recommendations from the perianesthesia literature and the American Society of Anesthesiologist practice guidelines. A review of publicly accessible Web sites revealed that only a few hospitals, such as Johns Hopkins Hospital, Cedar Sinai Medical Center, University of Maryland Medical Center, and Brant Community Healthcare System, use CBO based on the manual by ASPAN. Therefore, efforts are needed to increase the number of hospitals where perianesthesia units adopt this manual to develop a CBO program for their newly hired perianesthesia nurses.

      Purpose

      The purpose of this project was to develop, implement, and evaluate a CBO protocol for onboarding new nurses in a perianesthesia unit based on both the ASPAN CBO and 2019 to 2020 ASPAN standards. Specific aims for this project included: developing a CBO protocol for implementation, testing its feasibility, and evaluating its impact on new nurses' level of competency in perianesthesia care. The overall goal of this project was to provide a model for replication by other hospitals that wish to implement CBO for newly hired perianesthesia nurses.

      Methods

      This quality improvement (QI) project was conducted as a capstone project for a Doctor of Nursing Practice (DNP) student. The DNP student was the project's leader. This project was determined not to be research by the Kaiser Permanente Institutional Review Board and was given an exempt status.

      Setting and Participants

      The project was conducted in a perianesthesia unit of a tertiary hospital in the western part of the United States. The 287-bed teaching hospital had 14 preoperative bays, 12 operating rooms, and 19 postoperative bays. Approximately 30 surgical cases were scheduled per day with an average of 10 additional emergent surgical cases per week in the past 12 months before project implementation. The perianesthesia unit had 55 staff (46 registered nurses, five nursing assistants, and four unit secretaries). New nurses hired to this unit in June and July 2019 participated in this project.
      Before the project was implemented, orientation for new perianesthesia nurses consisted of a 2-day instructor-led lecture on infection control, hospital administration, policy, and procedures. Thereafter, each new nurse was paired with a senior perianesthesia nurse for approximately 2 weeks of shadowing experience. Senior perianesthesia nurses were either of level 3 or 4 designations (the top two highest nurse designations) who had been working on the unit for more than 3 years. Each new nurse's orientation experience was mostly influenced by the preceptor's enthusiasm and competence in precepting. Consequently, several recently hired perianesthesia nurses had expressed a knowledge gap regarding anesthesia and surgical procedures, such as craniotomy, flap, and laminectomies. Feedback from these newly hired nurses drove the implementation of this project.

      Development and Implementation of CBO Protocol for New Perianesthesia Nurses

      A perianesthesia preceptor committee comprised of five level 4 nurses was formed. The committee's charge was to develop nursing care workflows for surgical procedures commonly performed within the last year in the project setting. Procedures identified included breast reconstruction surgeries; ear, nose, and throat surgeries; general surgeries (ie, laparoscopic or open appendectomies, cholecystectomies, etc.), orthopaedic surgeries, gynecology and obstetrics surgeries, urology surgeries, special procedures (magnetic resonance imaging, etc.), vascular surgeries, neurologic surgeries, orthopaedic spine surgeries, and pediatric surgeries (tonsillectomies and adenectomies, etc.). Each senior nurse developed a one-page nursing care workflow for two surgical procedures. A workflow consisted of procedure-specific hospital policy, surgeon's orders and preferences, and expectations for the care of the surgical patient. The one-page nursing workflow (Table 1) consisted of a description of the surgery, focus of nursing care, and documentation items for charting in the electronic health record. Nursing care included information on assessments, monitoring, and management of patients for that specific surgical procedure including protocols for discharge or transfer. The project leader also developed one of the nursing care workflows and reviewed all workflow protocols to ensure readability and consistency of format.
      Table 1One-Page Nursing Workflow
      Orthopaedic patients

      Types of surgery: ERAS joint replacements (hips, knees, and shoulders); hand, elbow, and ankle surgeries.

        Patient assessment and monitoring:

      • 1.
        Follow standard PACU assessment
      • 2.
        Check drains if present:
        • Check orders if drains are to be compressed/to gravity or partial suction.
        • Do not hook up to wall suction unless ordered.
        • If >200 cc drainage in 15 min, contact MD for orders to put drain on gravity for a period.
      • 3.
        Neurovascular status. Monitor and document CSM and pulses of affected limb.

        Treatment:

      • 1.
        X-rays: check for orders for postoperative X-rays.
      • 2.
        Pain management:
        • Call anesthesia to place blocks (knees/shoulders, etc.) when patient has sensation if not done in the preoperative area.
        • Administer pills by mouth first when patient is able.
        • Check patient orders for when next dose of antibiotics, TXA, and tylenol are due.
      • 3.
        Mobility:
        • Release PT orders on patient arrival to PACU.
        • Administer fluid bolus and dangle patients before calling PT for assessment and training.
        • Place patient back on bed after dangle.
      • 4.
        Iceman therapy: provide iceman therapy to patient.
      • 5.
        Voiding status:
        • Determine when patient last voided.
        • Bladder scan patient to determine need to void.
        • Get order from PA for I/O catheter if needed.
      • 6.
        Nourishment:
        • Feed patient and document percentage of food taken.

        Protocol for discharge/transfer:

      • 1.
        Home:
        • Discharge instructions discussed with the family and patient.
        • Pick up DC medications from pharmacy
      • 2.
        SNF:
        • Keep prescription scripts with the patient's record and send to SNF.
        • The discharge packet should include face sheet, DC planner's note, DC instructions, and MD orders.
      Call discharge planner for information regarding SNF and transport
      ERAS, enhanced recovery after surgery; PACU, postanesthesia care unit; MD, doctor of medicine; CSM, circulation, sensation, and movement; TXA, tranexamic acid; PT, physical therapy; PA, physician assistant; I/O, in and out; DC, discontinue; SNF, skilled nursing facility.
      In addition to overseeing the development of one-page nursing care workflows, the project leader reviewed the ASPAN CBO (Table 2) and chose competency statements relevant to this project. The project leader then developed competency checklists (Table 3) for competencies related to the 11 surgical procedures. The CBO protocol also incorporated the relevant content in the orientation time line from ASPAN's 2019 to 2020 PeriAnesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, into the project setting that describes the professional behaviors inherent in a perianesthesia nurse.
      American Society of PeriAnesthesia Nurses
      2019-2020 PeriAnesthesia Nursing Standards, Practice Recommendations and Interpretive Statements.
      Table 2Competency Statements
      Competency statements

      Adapted from ASPAN's CBO manual for perianesthesia nurses
      • The perianesthesia nurse will:
        • 1.
          Promote safety
        • 2.
          Prepare the patient for surgery
        • 3.
          Demonstrate knowledge and skill in airway management
        • 4.
          Demonstrate knowledge and skill in cardiovascular management
        • 5.
          Demonstrate knowledge and skill in neurologic assessment and management
        • 6.
          Demonstrate knowledge and skill in urologic assessment and management
        • 7.
          Monitor and provide care to patients receiving moderate sedation and analgesia
        • 8.
          Demonstrate knowledge in anesthesia agents and adjuncts pertaining to perianesthesia nursing
        • 9.
          Provide correct and appropriate fluid management and resuscitation for the patient in the perianesthesia period
        • 10.
          Demonstrate knowledge and skill in pain and comfort management
        • 11.
          Provide nursing management for the patient undergoing medical imaging procedures and/or radiologic interventions
        • 12.
          Provide perianesthesia management of PONV
        • 13.
          Demonstrate appropriate understanding and management of malignant hyperthermia
        • 14.
          Demonstrate care for the patient who is hypothermic
        • 15.
          Perform nursing assessment of the geriatric patient
        • 16.
          Provide pertinent postoperative and postprocedure education and training to the patient and the responsible adult
        • 17.
          Demonstrate knowledge on legal issues and skills in clinical documentation
        • 18.
          Perform a basic cultural assessment
      ASPAN, American Society of PeriAnesthesia Nurses; CBO, competency-based orientation; PONV, postoperative nausea and vomiting.
      American Society of PeriAnesthesia Nurses. A Competency-Based Orientation Program for the Registered Nurse in the Perianesthesia Setting. Cherry Hill, NJ: ASPAN; 2019. Copyright © ASPAN. All rights reserved.
      Table 3Sample of Competency Checklist
      Competency ChecklistDatePrecepteePreceptor
      Perform patient admission/assessment and document in KPHC (at least two patients/surgical category)
      • GI
      • Spine patients
      • ERAS joint patients
      • Pediatric patients
      • DBS patients—Parkinson's medications
      • Craniotomy/neuro patients
      • Urology patients
      • OB-GYN/oncology patients
      • Vascular patients
      • FLAPS
      • ENT patients
      Perform preoperatively for dialysis patient:
      • Perform I-Stat
      • Use microdrip tubing
      • Use normal saline fluid
      Perform patient recovery and document in KPHC:
      Recover vented patients:
      • Know vent settings
      • Recover transsphenoidal patients:
        • Set up T mist
        • Monitor for urine output
      • Recover neuro patients
        • Neuro assessments
        • Know types of neurodrains and how to assess/monitor
        • Set up ventriculostomy/EVD
      • Recover GYN/ONC patients
        • Packing/pink band/RF wand
        • Postvoid residual
      • Recovery ERAS joint replacement patients
        • On-q pumps (DC lines at home, education)
        • Ice man therapy
      KPHC, Kaiser Permanente Health Connect; GI, gastrointestinal; ERAS, enhanced recovery after surgery; DBS, deep brain stimulation; OB-GYN, obstetrics and gynecology; FLAPS, surgical technique where tissue is lifted from a donor site and moved to a recipient site while maintaining its own blood supply; ENT, ear, nose, and throat; I-Stat, a point-of-care blood analyzer; EVD, external ventricular drain; GYN/ONC, gynecology/oncology; RF, radiofrequency; DC, discontinue.
      The perianesthesia manager and perioperative director, the director of clinical education practices and informatics, the preceptor committee, and volunteer perianesthesia nurses reviewed the first draft of the CBO protocol. Recommendations from the reviewers were incorporated into the protocol revision. Thereafter, approval from the chief nursing officer was obtained before protocol implementation.
      Each perianesthesia senior nurse who had been identified as a potential preceptor for new nurses was given a copy of the CBO protocol. The project leader and members of the Preceptor Committee had individual discussions with the preceptors assigned to newly hired nurses on how to use the CBO protocol. The preceptors were informed of the importance of following and discussing the CBO protocol, signing and dating the respective competencies met for that day, and adhering to the 30-minute post-debriefing at the end of each orientation day. The debriefing consisted of discussions on competencies met, knowledge and skills, and discussion of the surgical cases for the next day's orientation. Preceptors were instructed to review events that occurred during the day and identify gaps related to expected competencies. Preceptors validated the competencies of the newly hired nurse related to their ability to use tools, devices, or equipment that were used in the care of the patients, such as the arterial line or the capnography device as well as application of the nursing care workflows. Discussions also included critical thinking decisions identified during the course of nursing care. A copy of the CBO protocol manual was also made available in the unit as a resource for the other staff nurses.
      After completion of 1.5 days of general hospital orientation, the newly hired nurse was given a copy of the CBO protocol and met with the project leader regarding a schedule for orientation in the department, and the implementation of the CBO protocol. The project leader then matched the newly hired nurse with the available preceptor from department's pool of preceptors, whoever was scheduled on the day of their orientation.
      The newly hired nurse shadowed the preceptor on the first day of the department orientation. The preceptor would demonstrate and discuss the routine postoperative nursing care of the surgical patient. The preceptor would also discuss the relevant care specific to the surgical case based on the CBO protocol (Table 1), as well as the use and monitoring of the equipment or device for the specific care, such as the arterial lines, bladder scans, tissue oximeter monitor, and others. After the shadowing experience of a specific surgical case with the preceptor, the newly hired nurse was given the opportunity to do the primary care of the patient with the preceptor's guidance and following the CBO protocol. The preceptor was always at the patient's bedside monitoring the care and the nursing skill demonstrated by the newly hired nurse. The CBO protocol requires return demonstrations of the specific nursing care for at least two patients per surgical case for competency to be met (Table 3). The process of shadowing and demonstrating is repeated for every surgical case available in the surgery schedules during the orientation period both for the preoperative and postoperative phases.
      The orientation period was about 3 weeks. It was anticipated that not all surgical cases would be available during the orientation period. Planning is key in making sure the nurse will get all the opportunity to care for all the surgical cases mentioned in the CBO protocol. At the end of the orientation period, an evaluation was done to determine if the newly hired nurse was given the opportunity to meet the competencies mentioned in the CBO protocol. When this was not met, further opportunities were given to the nurse to demonstrate the nursing care and competency missing in the orientation time line.

      Data Collection and Analysis

      Each newly hired nurse completed a survey (Table 4) by electronic mail before and after orientation. The survey measured competency on an interval scale based on self-assessment of nurses' competency and knowledge in caring for the patient. Demographic data were also collected from each nurse including educational background and nursing experience. The data were analyzed using IBM 2017 SPSS Statistics software for Windows, version 25 (Armonk, NY).
      Table 4Pre–Post Survey Questions
      Category12345678910
      Competency: How would you rate your current knowledge and skill of the following items on a scale of 1–10, where 1 is the lowest and 10 is the highest?
       Anesthesia
       General surgeries
       Podiatry
       Orthopaedic surgeries/ERAS
       OB/GYN surgeries
       Urology procedures
       Pediatric care
       Vascular surgeries
       Special procedures (MRI, IR, cardiac catheterization, and GI)
       FLAPS (breast and neck)
       ENT surgeries
       Neurosurgeries
       Spine surgeries
      ERAS, enhanced recovery after surgery; OB/GYN, obstetrics/gynecology; MRI, magnetic resonance imaging; IR, interventional radiology; GI, gastrointestinal; FLAPS, surgical technique where tissue is lifted from a donor site and moved to a recipient site while maintaining its own blood supply; ENT, ear, nose, and throat.

      Results

      The CBO protocol developed for this study was a 43-page document and included a welcome letter to the newly hired nurse with a short description of the CBO protocol, the surgical population being served, and the expectation to submit the presurvey and postsurvey. The CBO protocol also outlined the orientation time line, competency checklist, and deliverables for each week during the orientation. It also included postorientation activities such as the 90-day evaluation, pediatric advanced life support, and a hospital-designed scavenger hunt orientation form. The bulk of the CBO protocol was nursing care workflows for 11 surgical cases. Finally, the CBO protocol contained a survey that asked newly hired nurses to rate the orientation program from not satisfactory to excellent and to rate the preceptors from poor (1) to excellent (5) with regard to their communication skills, leadership ability, teaching ability or effectiveness, dependability, collaboration, role modeling, and expertise.
      A total of four nurses were hired in the perianesthesia unit in June and July 2019 and participated in this project. All four nurses had a bachelor's degree in nursing with one of them transitioned from an associate degree to a bachelor's degree. Their most recent nursing experiences were from the intensive care unit, emergency department, and postoperative care. One had experience working in utilization review, medical surgical, call center, and home health. The average years of nursing experience was 14.12 years. The results of the competency survey before and after orientation are provided in Table 5. Because of the small sample size, significance testing was not done. Instead, we looked at the changes in scores after the orientation. All competency scores increased except for pediatric care.
      Table 5Median Scores and Wilcoxon Signed Rank Test Results (N = 4)
      Service AreaPrePostP
      Median (Minimum, Maximum)
      Anesthesia7 (5, 9)8 (8, 10).059
      General surgeries8 (7, 9)9 (8, 10).046
      Podiatry7 (5, 9)8 (7, 10).102
      Orthopaedic surgeries7.5 (5, 9)9 (4, 10).461
      OB/GYN surgeries7.5 (4, 9)9.5 (7, 10).059
      Urology procedures7 (4, 9)9.5 (7, 10).066
      Pediatric care8 (5, 9)7 (6, 9).785
      Vascular surgeries6 (4, 8)8 (6, 9).197
      Special procedures (MRI, IR, cardiac catheterization, GI)6.5 (5, 8)7 (6, 8).593
      FLAPS4.5 (3, 8)6 (1, 8).655
      ENT surgeries7 (5, 9)8 (6, 10).102
      Neurosurgeries6.5 (5, 8)7 (6, 10).102
      Spine surgeries7 (5, 9)8.5 (8, 10).066
      OB/GYN, obstetrics/gynecology; MRI, magnetic resonance imaging; IR, interventional radiology; GI, gastrointestinal; FLAPS, surgical technique where tissue is lifted from a donor site and moved to a recipient site while maintaining its own blood supply; ENT, ear, nose, and throat.

      Discussion

      This project developed and implemented a CBO protocol for new nurses' orientation in a perianesthesia unit. CBO provided the perianesthesia nurse with a framework for essential performance criteria needed in the perianesthesia setting.
      • Godden B.
      Standards for ethical practice.
      CBO also informed nurses about expectations of the facilities' policies and professional nursing standards. Studies have shown that those who had previously experienced CBO demonstrated more organizational commitment.
      • Krenzicheck D.
      Safety.
      In addition, adopting a competency-based approach to orientation of new nurses is one strategy to sustain evidence-based practice in nursing.
      • Fisher C.
      • Cusack G.
      • Cox K.
      • Feigenbaum K.
      • Wallen G.R.
      Developing competency to sustain evidenced-based practice.
      Results of this project revealed improvements in perianesthesia nursing competency in all surgical areas except for pediatric care. Because the project setting was an adult health care facility, this may explain the lack of improvement in pediatric care. Incorporating ASPAN's nursing standards and using ASPAN's CBO as a guide, the facility developed a CBO protocol that provided structured orientation activities for new nurses to prepare them to deliver safe perianesthesia nursing care.
      This project demonstrated how new nurses' orientation can be enhanced by targeting competencies for safe perianesthesia nursing care. The one-page nursing workflows developed for this project were especially helpful for nurses to operationalize how these competencies can be achieved. Because nursing competencies have to be evaluated annually per TJC,
      • Church C.D.
      Defining competence in nursing and its relevance to quality care.
      ,
      • Whittaker S.
      • Carson W.
      • Smolenski M.C.
      Assuring Continued Competence- Policy Questions and Approaches; How should the profession respond? Online Journal of Issues in Nursing (OJIN). Am Nurses Assoc 2000; 5.
      ,
      • Andrews S.M.
      • Cartwright S.M.
      Management and Policies.
      the workflows and checklist created for this project can also be used for conducting the annual performance evaluation as well.

      Limitations

      The CBO protocol was piloted for implementation for only 2 months, thus the sample was very small. However, the intent of this project was to test the feasibility of using the CBO protocol, and this purpose was met within 2 months of implementation. To date, the project setting continues to use the CBO protocol for their new nurse orientation. Because of the project setting's restrictions in using patient data for this project, no patient outcomes were collected. However, a similar project reported by Killian and Hoffman
      • Killian R.
      • Hoffman T.L.
      Integration of the ASPAN CBO into a successful orientation curriculum. ASPAN National Conference Abstracts.
      revealed improved patient outcomes for 3 years after CBO implementation as measured by Hospital Consumer Assessment of Health Care Providers and Systems scores. In the same study, perianesthesia length of stay decreased for 3 years after project implementation, from 156.48 minutes to 134.30, 131.35, and 140.97 minutes. Thus, this project has the potential to improve patient outcomes, which should certainly be measured in future similar projects.

      Conclusion

      In summary, nursing competency is significant in performing one's role as a nurse.
      • Fukada M.
      Nursing competency: definition, structure and development.
      A robust CBO protocol for perianesthesia nurses is important in integrating an employee into the organization and preparing nurses for success. This project demonstrated that CBO for new perianesthesia nurses is feasible and associated with increased level of overall competency in perianesthesia care. Further QI projects need to be conducted to assess the association of competency in perianesthesia care with patient outcomes, including patient satisfaction. Long-term outcomes of CBO should be gathered as well as nurse retention and overall job satisfaction.

      Acknowledgments

      The authors acknowledge the contribution of statistician Dr Julie Thompson and Elena Turner (Duke University), Kaiser Permanente Leadership in Sacramento, CA, the participants in this QI study, and the Preceptor Committee members: Noelle LaTona, Diana Gudeman, Sherry Gold, Cecilia Wolff, and Olga Bodnar, who submitted the one-page nursing workflow for the CBO protocol.

      Test ID W012021 – Expiration Date January 31, 2023

      A Competency-Based Orientation (CBO) Protocol Enhances Competency Among Newly Hired Perianesthesia Nurses

      1.25 Contact Hours
      Purpose of the Journal of PeriAnesthesia Nursing: To facilitate communication about and deliver education specific to the body of knowledge unique to the practice of perianesthesia nursing.
      Outcome of this CNE Activity: To enable the nurse to increase knowledge on the effectiveness of a competency-based orientation
      Target Audience: All perianesthesia nurses
      Article Objectives
      1. Discuss perianesthesia competencies
      2. Describe how to utilize perianesthesia nursing standards and competencies
      3. Describe methods to demonstrate perianesthesia nursing competencies
      Accreditation
      American Society of Perianesthesia Nurses is accredited with distinction as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.
      Provider approved by the California Board of Registered Nursing, Provider Number CEP5197, for 1.25 contact hours.
      Additional provider numbers: Alabama #ABNP0074
      Contact hours: Registered nurse participants can receive 1.25 contact hours for this activity.
      Disclosure
      All planners and authors of continuing nursing education activities are required to disclose any significant financial relationships with the manufacturer(s) of any commercial products, goods or services. Any conflicts of interest must be resolved prior to the development of the educational activity. Such disclosures are included below.
      Planners and Author Disclosures
      The members of the planning committee for this continuing nursing education activity do not have any financial arrangements, interests or affiliations related to the subject matter of this continuing education activity to disclose.
      The authors for this continuing nursing education activity do not have any financial arrangements, interests or affiliations related to the subject matter of this continuing nursing education activity to disclose.
      Requirements for Successful Completion: To receive contact hours for this continuing nursing education activity you must complete the registration form and payment, read the article, complete the online posttest and achieve a minimum grade of 100%, and complete the online evaluation.
      Directions
      A multiple-choice examination, designed to test your understanding of A Competency-Based Orientation (CBO) Protocol Enhances Competency Among Newly Hired Perianesthesia Nurses according to the objectives listed, is available on the ASPAN website: https://learn.aspan.org/
      To earn contact hours from the American Society of Perianesthesia Nurses (ASPAN) Continuing Nursing Education Accredited Provider Unit go to the ASPAN website: (1) select the article, complete the registration form and payment; (2) read the article; (3) complete the posttest on the ASPAN Website and achieve a minimum score of 100%; and (4) complete the online evaluation.
      This all must be completed prior to the expiration date of January 31, 2023.
      Your certificate will be available for you to print upon successful completion of the activity and completion of the online evaluation.
      Online payment is required: ASPAN member: FREE per test; nonmember: $15.00 per test.

      References

        • Church C.D.
        Defining competence in nursing and its relevance to quality care.
        J Nurses Prof Dev. 2016; 32: E9-E14
        • Whittaker S.
        • Carson W.
        • Smolenski M.C.
        Assuring Continued Competence- Policy Questions and Approaches; How should the profession respond? Online Journal of Issues in Nursing (OJIN). Am Nurses Assoc 2000; 5.
        (Accessed at:)
        www.ojin.nursingworld.org
        Date accessed: January 30, 2020
        • Fey M.
        • Mittner R.A.
        Competency-based orientation program for new graduate nurse.
        J Nurs Adm. 2000; 30: 126-132
        • Hodges J.
        • Hansen L.
        Restructuring a competency-based orientation for registered nurses.
        J Nurses Staff Dev. 1999; 15: 152-158
        • Van Patten R.
        • Bartone A.S.
        The impact of mentorship, preceptors, and debriefing on the quality of program experience.
        Nurse Educ Pract. 2019; 35: 63-68
        • Acuna G.K.
        • Yoder L.H.
        • Madrigal-Gonzalez L.
        • Yoder-Wise P.S.
        Enhancing transition to practice using a valid and reliable evaluation tool: Progressive orientation level evaluation (POLE) tool.
        J Contin Educ Nur. 2017; 48: 123-128
        • Symmerman L.
        • Kuhns K.A.
        • Crocket J.
        • Slade M.
        Rethinking perianesthesia orientation.
        J Perianesth Nur. 2017; 32: 631-635
        • Lott T.
        Moving forward: Creating a new nursing services orientation program.
        J Nurses Staff Dev. 2006; 22: 214-221
        • Hagler D.
        • Wilson R.
        Designing nursing staff competency assessment using simulation.
        J Radiol Nurs. 2013; 32: 165-169
        • Sorrentino P.
        Preceptor: blueprint for successful orientation outcomes.
        J Emerg Nurs. 2013; 39: e83-e90
        • Wilgis M.
        • McConnell J.
        Concept mapping: An educational strategy to improve graduate nurses’ critical thinking skills during a hospital orientation program.
        J Contin Ed Nurs. 2008; 39: 119-126
        • Zigmont J.
        • Wade A.
        • Edwards T.
        • Hayes K.
        • Mitchell J.
        • Oocumma N.
        Utilization of experiential learning, and the learning outcomes model reduces RN orientation time by more than 35%.
        Clin Simul Nurs. 2015; 11: 79-94
        • Karami A.
        • Farokhzadian J.
        • Foroughameri G.
        Nurses’ professional competency and organizational commitment: Is it important for human resource management?.
        PLoS One. 2017; 12: e0187863
        • Andrews S.M.
        • Cartwright S.M.
        Management and Policies.
        in: Odom-Forren J. Drain’s PeriAnesthesia Nursing: A Critical Approach. 7th Edition. Elsevier, 2018: 18-33
        • Beagley L.
        • Casey D.
        Safety in the PeriAnesthesia Setting.
        in: Allen J. Orbell S. American Society of PeriAnesthesia Nurses. Competency Based Orientation (CBO) Program for Registered Nurses in the PeriAnesthesia Setting. ASPAN, Cherry Hill, NJ2019: 59-75
        • Krenzicheck D.
        Safety.
        in: Schick L. Windle P.E. PeriAnesthesia Core Curriculum. 2nd Edition. Elsevier, St. Louis, MO2010: 82-89
        • Nilsson U.
        • Gruen R.
        • Myles P.S.
        Postoperative recovery: the importance of the team.
        Anesth 2020. 2020; 75: e158-e164
        • American Society of PeriAnesthesia Nurses
        Competency Based Orientation (CBO) Program for Registered Nurse in the PeriAnesthesia Setting.
        ASPAN, Cherry Hill, NJ2019
        • American Society of PeriAnesthesia Nurses
        2019-2020 PeriAnesthesia Nursing Standards, Practice Recommendations and Interpretive Statements.
        ASPAN, Cherry Hill, NJ2018
        • Godden B.
        Standards for ethical practice.
        in: Schick L. Windle P.E. PeriAnesthesia Core Curriculum. 2nd Edition. Elsevier, St. Louis, MO2010: 13-22
        • Fisher C.
        • Cusack G.
        • Cox K.
        • Feigenbaum K.
        • Wallen G.R.
        Developing competency to sustain evidenced-based practice.
        J Nurs Adm. 2016; 46: 581-585
        • Killian R.
        • Hoffman T.L.
        Integration of the ASPAN CBO into a successful orientation curriculum. ASPAN National Conference Abstracts.
        J Perianesth Nurs. 2017; 32: e22
        • Fukada M.
        Nursing competency: definition, structure and development.
        J Med Sci. 2018; 61: 1-7