Help Is on the Way


The largest nursing school in the U.S. is exposing students to careers in surgery while surgical leaders cope with critical staffing shortages.

Megan Muñoz is finishing up nursing school at Chamberlain University outside of Chicago. She just completed her clinical rotation and will graduate with her BSN in September. Unlike many nursing students, however, Ms. Muñoz is ready to hit the ground running in the OR thanks to a new evidence-based course created by the Association of periOperative Registered Nurses (AORN). The online education program exposes students to perioperative nursing practices with the goal of filling the pipeline with new surgical nurses who will someday help to alleviate severe staffing shortages at hospitals and ASCs across the country. Students who complete the program will begin their careers with relevant specialty-focused training and clinical experience, which will hopefully relieve some of the onboarding burden surgical facilities face when hiring first-time perioperative nurses.

AORN CEO/Executive Director Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, believes the program will create a successful pathway for nursing students to first experience and then commit to perioperative practice. “This model is an important solution for the recruitment challenges that are facing all facilities that provide surgical services,” she says.

There are 254 students enrolled in the program at eight Chamberlain campuses. Currently eight health systems have partnered with the program to provide the students with on-site learning opportunities — and potential future employment. 

Even though she wasn’t in a physical classroom, Ms. Muñoz always had support from an instructor who kept tabs on her progress and answered her questions. “The online modules are very interactive,” she says. “The course covered everything — safety, infection control, donning and doffing PPE, the sterile field, how nurses are supposed to document — everything that goes on in the OR.”

During Ms. Muñoz’s on-site training, she spent about 16 hours per week in the perioperative department — above the program’s recommendation of 12. “What was nice is that we got to rotate through different clinical areas,” says Ms. Muñoz. “We spent time in the OR, day surgery, the PACU and the cath lab.”

Beverly Evangelista, RN, who works in day surgery at Amita Health in Chicago, was one of Ms. Muñoz’s preceptors. “It was a great experience to work with the students, seeing their eagerness and motivation to learn new things,” she says. “This program is a wonderful opportunity for students to experience working side by side with their preceptor and knowing what’s involved in getting patients ready for surgery, being in the OR during procedures and recovering patients in the PACU.”

Ms. Muñoz says the program further convinced her that a career in surgery is right for her. “I’m going to end up working somewhere in the specialty,” she says. “I really liked same-day surgery, especially pre-op and recovery. Patients there are feeling anxious, so it’s nice to be able to talk to them about how they’re feeling, calm them down as best as you can.” Her dream position is to advance along her career path and become a registered nurse first assistant.

“The program has been a really wonderful experience, and other students should take advantage of it if they have the opportunity,” says Ms. Muñoz. “It’s a good chance to see what perioperative work is about and whether it’s something they’re interested in, because now would be the time.”

She’s speaking, of course, about nursing students who are pondering the future of their careers but she might as well have been referring to the current staffing climate and the urgent need for new nurses. McKinsey & Company, a global management consulting firm, has estimated there might be 200,000 to 450,000 fewer nurses available for direct patient care than what’s needed by 2025. “To meet this demand, the U.S. would need to more than double the number of new graduates entering and staying in the nursing workforce every year for the next three years,” says the firm.

Efforts to fill the pipeline with new nurses like Ms. Muñoz are critically important as a long-term solution to the nationwide staffing crisis, but today’s surgical leaders are dealing with more acute issues related to the shortages and must act with immediacy to keep their facilities operating at full capacity. In April, Outpatient Surgery Magazine surveyed 89 outpatient surgical leaders about how they are faring in terms of recruiting and retaining employees (see “Facilities Struggling to Remain Fully Staffed” below). The top-end result wasn’t pretty: a stunning 80% of respondents said their facilities are currently experiencing staffing shortages or retention issues.

When we scratched beneath the surface, however, we found outpatient facilities rapidly adapting and adjusting to navigate the most uncertain, volatile labor situation the surgical industry has seen in decades — and possibly ever. Some of the facilities are left to wonder if their efforts will be enough to stem the tide of a labor shortage that every day seems to be becoming less ephemeral and more institutionalized. 

Facilities Struggling to Remain Fully Staffed

Surgical leaders across the country are dealing with unprecedented staffing shortages, which have increased the importance of recruiting new workers and keeping current teams intact. Our recent survey of 89 surgical leaders in ASCs and HOPDs revealed the scope of the personnel challenges they face and how they’re working to retain their hardworking employees.

Overall, 80% of the facilities surveyed are experiencing staffing shortages or retention issues. Broken down further, 93% of HOPDs, 86% of hospital-owned/affiliated ASCs and 74% of physician-owned/independent ASCs reported staffing problems.

In terms of positions that facilities are finding difficult to retain and recruit, nurses led the way by far, with 73% of leaders reporting trouble finding enough of them. Scrub techs were close behind at 52%, while less acuity was reported for sterile processing techs (25%), anesthesia providers (22%), nonclinical staff (17%) and surgeons (9%).

When asked about the root causes of their hiring and retention problems, answers varied. The leading cause, cited by 52% of facilities, was staff leaving to make more money as travel clinicians. Other causes cited were uncompetitive compensation packages (47%), not enough qualified local candidates (44%), burnout (29%) and workplace culture issues (14%).

When asked how they make employees feel valued and appreciated, facilities cited positive reinforcement on the job (73%), free meals (69%), increased salaries/base pay (67%), parties and celebrations (48%), bonuses (46%), gift cards (38%), access to mental health experts (28%), mindfulness training (16%) and additional paid time off (6%). 

Joe Paone

HOME TEAM Deena Edwards, Madison Shannon, RN, and Michelle Benton, RN (left to right), cherish the family-like atmosphere at Dayton (Ohio) Eye Surgery Center.  |  Deena Edwards

Every area of health care is attempting to expand the nursing labor pool however it can. Numerous states are subsidizing hospitals with billions of dollars to help. For example, in January, Pennsylvania passed a $225 million relief package to help hospitals and health systems recruit and retain nurses and other healthcare workers.

Meanwhile, health systems, when they aren’t forced to pay well above market rate to acquire the services of travel nurses, are starting internal programs to retain the nurses they have. UPMC in Pittsburgh and Bon Secours Mercy Health in Cincinnati, for example, have started in-house travel agencies in hopes of providing more flexibility and opportunity for their nurses to work anywhere within their own systems.

The lack of qualified nurses is being felt at the individual facility level, as well. Ashley Tenbusch, BSN, RN, CNOR, clinical director at physician-owned Waverly Lake Surgery Center in Albany, Ore., is experiencing staffing shortages and staff retention issues. In April, she was short a full-time nurse and a part-time scrub tech. “Usually I’ll go work whatever shifts they need or scrub into surgery and do whatever is needed,” she says. “My assistant manager and I both fill in wherever the holes are.”

As an independent ASC in a semi-rural area, Waverly Lake is battling with geography and well-funded competition for increasingly scarce staff and lost a couple providers over the past year. “Good candidates around here generally leave for a more urban setting where they can get better pay,” says Ms. Tenbusch. “We try to compete. We match the local union contract at the local hospital, which has helped for retention. Because the hospital is a large entity, however, they offer their own comprehensive benefits package. They have low deductibles because everyone’s being seen by their own doctors.”

It’s also difficult for the small facility to match the paid time off that larger health systems provide. “If I’m a 10-year veteran nurse working at the hospital, I would probably accrue an eight-hour day of PTO for one week’s worth of work,” says Ms. Tenbusch. “At our center, everybody gets the same amount of PTO. It’s a set, flat rate for the first five years of service for nurses, techs and front office staff.”

Ms. Tenbusch believes her staffing crisis is not temporary but a new normal. “We have great staff, and they’re super loyal,” she says. “Unless there’s an absolute change in their life, they’ll probably stick with us. But when it comes to recruiting new hires, everywhere I look at job postings, the wages being offered are so high. With lots of nurses leaving and going to travel positions because they can work at the same hospital in the same place making double if not more than what they were making before as a staff nurse, I don’t know how you stop that.”

Deena Edwards, administrator and director of nursing at physician-owned Dayton (Ohio) Eye Surgery Center, has two open positions due to one nurse leaving to pursue another job opportunity and another leaving to make more money. Although the losses have been felt, the surgery center routinely crosstrains staff to ensure flexibility and morale remains upbeat. As a result, she hasn’t needed to cancel cases or shorten the facility’s hours.

The current staffing shortage is worse than any Ms. Edwards has seen throughout her career. With many baby boomer nurses retiring, and more of those same baby boomers driving up patient volumes, the numbers increasingly don’t add up in terms of staffing. “Due to emphasizing work-life balance as an employee benefit, we’re not struggling with the nursing shortage as much as I’ve had to in previous leadership positions,” says Ms. Edwards. “However, everybody’s struggling to find nurses and right now, if you’re a good nurse, you can pretty much name your price.”

Waverly Lake Surgery Center has made market corrections to its staff’s base pay and improved its benefits package, while also providing perks such as free meals and ice cream, positive reinforcement and early days off when possible. “We’ve found some better options for benefits and are working at that,” says Ms. Tenbusch. “We’re trying to match what the hospital offers, but I’m just not sure if we’ll be able to keep up.”

One recruiting tactic that hasn’t worked for her is offering bonuses to new hires. “During the salary negotiation process, people would rather have a higher wage than a bonus,” says Ms. Tenbusch, who adds that her center, with its solid reputation as a great place to work, had no problem attracting employees before the pandemic and the shutdown that came with it. Ever since, however, her staff’s morale has taken a beating from the stress of COVID, which at points has led them to question if their jobs at the small center will be viable in the long term.

Ms. Edwards believes her situation could be worse, as the facility’s culture has proven a solid retention tool. “We have about 45 employees and they’re a happy little family,” she says. “I’ve been a nurse for 25 years, and I’ve worked in all kinds of facilities. Hands down, this is the best job I’ve ever had, and the people I work with are very considerate of each other. When you’re a small place, it’s easy to become that way, and I think it’s helped a lot.” Ms. Edwards credits her ownership and leadership team for working hard to ensure employees feel valued and appreciated with gift cards, free meals and additional paid time off, as well as bonuses and increased base pay.

When Ms. Edwards arrived at the facility last October, she evaluated the facility’s benefit package and pay scales and made adjustments to try to stay ahead of the market. “The advantage we have, because we’re an ASC, is that we operate Monday through Friday — no weekends, no holidays, no night shift, no call — so it’s a pretty good deal for most people who have kids and families and are active,” she says. “However, employees with years of experience may be interested in benefits and retirement plans, while the goal of younger staff is usually to have more money in the bank and their bills paid. I wanted to make sure we addressed those factors and got ahead of them.”

Ms. Edwards went to the facility’s board to pitch proposed payroll and benefit adjustments and presented analysis that demonstrated the cost of having to close an OR for the day due to lack of staffing, as well as what it would cost to hire a traveler for an eight-week assignment. She compared those expenses to the expense of adjusting pay rates and other proposed benefits to maintain the facility’s current staffing levels.

Presenting the average salaries for similar employees in their state and in similar markets to the board was also important. “When I looked at the market, we were about $3 or $4 per hour behind the local hospitals,” she says. “Instead of making that kind of change all at once or trying to compete with the hospitals — which would have come to about $200,000 annually, making it difficult for the board to support — we increased salaries by about 50% of that, and then created incentives that allow the staff to earn more money by getting a certification.”

These corrective adjustments have helped Dayton Eye retain current employees — many of whom received significant raises, including longtime nurses at the facility who were due for a market increase to ensure they were making more than recently hired employees. “It’s hard to hire staff members when they’re coming from a hospital, where there are extra incentives and overtime pay,” she says. “We typically don’t lose employees because of those factors, but it’s hard to find people to fill open positions.”

Erin Duffy, RN, administrator at the physician-owned, ophthalmology-focused Ambulatory Surgery Center of Greater New York in the Bronx, says she is having difficulty recruiting nurses, medical transcriptionists and patient care associates. Like Ms. Edwards, she says retention is not as big an issue as recruitment.

“I’ve had almost the same core staff for a long time, with some OR and recovery room nurses working here for 10, 20 and even 30 years,” she says. “I retain them by keeping them informed and involved in the clinical decision-making process. Also, I ensure that the staff is aware that the shareholders and I appreciate their efforts and dedication.”

To lighten the load of her faithful nurses, Ms. Duffy has hired patient care associates to perform non-clinical but important tasks, such as enhancing the patient experience by taking the time to speak with them, handing them snacks and making them feel comfortable. “While their earnings are less than nurses, they are now an important part of our team,” says Ms. Duffy. “You just need to teach and in-service them.”

Ms. Duffy recognizes the need to increase her nurses’ salaries while adhering to a strict budget. She also is aware that ASCs must provide nurses salaries and benefits that compete with those offered by hospitals, which surround her facility. “We cannot match some of the benefits they offer,” she says, adding that she does have an advantage in her pocket. “Because we work specifically in ophthalmology on mostly elective cases in an organized and controlled environment, our ASC is not as intense as the hospitals where staff must manage many different types of patients and procedures.”

“I retain my staff by keeping them informed and involved in the clinical decision-making process.”
— Erin Duffy, RN

Ms. Duffy believes that in a volatile job market, a facility’s workplace culture can go a long way toward retaining existing staff and attracting new hires. “Surgery centers now are running on tight budgets, especially ones that are taken over by private equity,” she says. “You need to get creative to keep staff giving the care you expect and still make a profit, but it can be done.”
While the ASC offers competitive salaries, Ms. Duffy’s nurses sometimes still have a tough time resisting hospital sign-on bonuses and various other opportunities. In those cases, she supports the decisions of departing staff, as it sometimes brings excellent employees back to the ASC at a later date.

You can’t be resentful at staff who leave for better opportunities, because they’re often the ones who might come back on a per diem basis,” she says. “Quality employees should know that I’m not angry. I’ll give them a good reference and I’m not going to hold them back if they want to better themselves, which is human nature.”

Ms. Muñoz is ready. She says the Chamberlain program has brought clarity to her career plans. Diagnosed with a disease at an early age, she experienced her first surgery at 14. After high school, she considered a career in pharmacy, but she didn’t like the relative lack of patient care and interaction that comes with the specialty. Instead, she set her sights on nursing.

Ms. Muñoz is attracted to perioperative work in part because she likes to put her empathy to work wherever she can. “Patients are very vulnerable at this time,” she says. “They’re super scared and extremely nervous. I talk a lot, and I hope that helps to calm them down. It’s nice to be there when patients are in that state because I personally know how it feels to be waiting to go into surgery.”
She also appreciates the uniquely collaborative team-based approach in the OR. “I like the very controlled environment as opposed to other aspects of nursing,” she says. “You kind of know what to expect. I also like the camaraderie, which seems to be different from any other department. In the OR, everyone’s there for you, and you are all there working together to complete the procedure. You really feel it.” Her future teammates are waiting, and she can’t arrive soon enough. OSM

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