Staff Training Is Paramount To Outpatient Facilities' Success

Staff Training Is Paramount To Outpatient Facilities' Success

By Kathy Dix

The newest generation of ambulatory surgery centers (ASCs) are generally free-standing, which means they have no "backup" in an emergency. Thus, their staff must be of the highest caliber. But how do ASCs attract the best, most competent healthcare personnel in this era of staffing shortages?

THE BASICS

A greater degree of training is paramount to nursing in an ASC. Hiring staff that is already skilled is crucial, but so is training them to keep their proficiencies sharp.

New nurses are expected to come to the table with more than just textbook learning; they must be able to think critically. But how does a student nurse get from "beginner" stage to competence? Nursing educators try to assign their student nurses to clinical locations that allow them the necessary learning experiences; an ASC is potentially a gold mine of experience for beginners. But oftentimes, ASCs avoid new graduates in favor of experienced nurses.

Because procedures in these facilities have such short turnaround times, nurses in such settings are required to perform tasks rapidly and competently. A nurse-in-training could feasibly be exposed to an extensive array of clinical experiences that lead to improved skills. A training program at Indiana University, for example, assigned eight junior baccalaureate students to an ASC for their first medical surgical experience. These students were given the opportunity to learn core competencies that are necessary to good nursing practice.¹

Nursing skills acquired or enhanced in an ASC can include the following: ¹

• Information-gathering from the patient and patient's family
• The ability to make accurate judgments
• Critical thinking skills
• Prioritization

Students are also better able to interrelate with patients and their family members as well as other healthcare staff. Multiple tasks and patients are part of the day-to-day routine and the patient base includes an age range from pediatric to geriatric.

Clinical skills acquired or enhanced in an ASC can include:

• Performing complete physical assessments
• Discharge teaching
• Administering injections
• Performing strengthening exercises
• Monitoring vital signs
• Monitoring oxygen saturation levels
• Reading pulse oximetry monitoring sensors
• Starting and discontinuing IV lines
• Applying electrocardiogram strips and electrodes
• Preparing surgical preps
• Charting
• Using standard precautions
• Administering medications
• Learning proper body mechanics
• Using and maintaining tubes and drains
• Applying dressings

Students are also encouraged to "consider patients as a whole" and to focus on the objective of the ambulatory procedure, as well as the most effective means of achieving the best possible result for the patient.

A recent listing of job openings in Oregon listed the following skills under various openings for an ambulatory surgery day stay unit, a GI-Lab day-stay unit, and a short-stay unit: "Must have excellent interpersonal/communication skills. Must be able to work with others as part of a team. Must have the ability to lift, bend, stoop, stand, reach, carry, push, pull and walk throughout the work period. Must be able to assist with/or perform gastrointestinal manometry; ERCP; EGD; colonoscopy; flexible sigmoidoscopy. Able to use computers to access patient information and process orders. Endoscopy experience. Experience with conscious sedation."²

Obviously, day-to-day skills in an ASC involve more than just good charting and an awareness of vital signs. Nurses must develop skills in the areas of communication, logic, medicine, technology, even personal fitness, in order to remain "sharp."

Continuing education abounds for nurses; however, there are so many areas in which they must stay proficient that continuing education is just that -- continuing. The educational process is neverending; by the time one skill is updated, it is necessary to move onto another. Facilities generally are accommodating to educational needs, however.

At the Department of Nursing at the University of California, San Francisco (UCSF), for example, where nurses assist in ambulatory surgery as well as in-house and critical care procedures, "Weekly inservice is presented to all staff. Up to 10 CEUs are given yearly during inservice. In addition, nurses have up to five educational days a year to attend outside programs."³

THE GOLD STANDARD IN EMPLOYEES

ASC staff members have to be of the highest caliber, but surgicenters need to attract the best, most competent nurses in an era of staffing shortages. "I think this really is true in many surgery centers (or should be), that the staff have to be competent and able to handle just about any emergency or have referral plans to handle emergencies," says Libby Chinnes, RN, BSN, CIC, an infection control consultant with IC Solutions in Mount Pleasant, S.C.

More procedures are being transitioned from inpatient to outpatient as technology improves, says Chinnes. "You never know how each patient is going to react to the surgery or anesthesia. I think the staff have to be trained and be ready for any complication."

Although overall, staffing is an issue for healthcare, ASCs seem to have little trouble filling their rosters. "My experience has been that the centers don't have trouble attracting the best and brightest staff who have often worked for years in an inpatient OR," Chinnes affirms. "They have accumulated years of experience there in many areas and are able to move into the fast pace of outpatient surgery. With no weekends, nights, or 'call' in most places, these are great incentives too."

Another benefit that nurses may find attractive is the level of interaction with patients and their families. Patient teaching becomes crucial because the patient and family are only available for a short time. "You want to make sure that they have verbal as well as written instructions for care at home," stresses Chinnes. "The patient may not remember all that he/she is taught; but most of these centers are wonderful about patient follow-up to determine if there are any problems. Patients need education about their medicines, diet, how to take care of their wounds, and what they can do activity-wise. The ambulatory surgery center nurse is an advocate for the patient and provides much reassurance during a stressful time for the patient and family."

KEEPING STAFF COMPETENT

One way to ensure a high skill level in staff members is to hire only those with experience. Maria Sample, executive director of the Roper West Ashley Surgery Center in South Carolina, says that they avoid hiring new graduates. "A considerable factor here is hiring competent staff initially," she states. "In considering staff for the operating room, we look for someone who has had prior surgery experience, with all the fundamental skills already in place. This also applies to our recovery room and other clinical areas. We require prior experience in a recovery room or critical care area."

That surgicenter requires its nurses to be trained in advanced cardiac life support every two years, and basic cardiac life support each year. "All of our nurses are required to complete a basic cardiology class," Sample adds. "We decided a couple of years ago to have all of our clinical staff obtain advanced cardiac life support certification and the recovery staff obtain pediatric advance life support certification in addition to the basic cardiac life support."

Generally, Sample says, a high level of expertise is nearly universal in ASC nurses. "It is this level of expertise that allows us to operate efficient facilities and maintain the high level of quality associated with the ASC experience," she confirms. "Nurses in this environment must be experts in many areas, able to wear several hats and function in multiple capacities. Typically, ASCs do not have the support services found in the hospital setting, making self-sufficiency another important characteristic of ASC nurses."

That self-sufficiency leads to a widespread effort to keep up with the ever-evolving healthcare industry.

"Many of the staff members belong to the Association of periOperative Registered Nurses (AORN) and stay abreast of changes in their environment through this means also," Chinnes says. "Often a 'point person' attends a conference or seminar and brings the info back to the other staff at the center. The centers have their own internal competencies that staff are checked off on each year."

In an era of public awareness, patients are much more in-tune with their medical care. "I would certainly want my family to go to a center where I knew they not only had state of the art technology but also people who were well-trained and had ongoing training in today's complex medical environment," adds Chinnes.

State and national associations are a boon to well-honed skills, too. "We have -- and I'm sure other states do too -- a state association of ambulatory surgery centers. They're meeting and sharing concerns, and they're essentially developing the industry standard as they go," Chinnes remarks. "Nationally, I know that there is the Federated Ambulatory Surgery Association (FASA) and an ambulatory healthcare association. Not only do we have state guidance, we have national guidance. I think people that are in tune are probably members of state and national associations, are active and attending conferences, and are taking part in order to stay abreast of what other folks are doing."

Being accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and other national associations is a means of demonstrating proven competency. "Accreditation is another way of comparing yourself with other people around the country. By receiving accreditation, you can market your center and your care," Chinnes concludes.

"Standards and benchmarks are developing to guide and evaluate care in our specific niche," Sample says. "Accreditation associations specific to ASCs are now available along with professional associations at the federal and state levels. All of this attests to an industry that has evolved and gained acceptance by regulatory agencies and the public as a whole."

STAFFING SHORTAGES

Surgicenters may have less trouble attracting staff members than facilities that are inpatient-based. Shorter hours and a five-day work week can be enticing for nurses accustomed to being on-call and working nights and weekends. In fact, shares Chinnes, one facility with which she is familiar says nurses vie for those positions.

"Usually you have a limited amount of staff, and you make sure what you have is a really good staff," confirms Sample. "We don't have a lot of turnover."

One difference between a surgicenter and a standard operating room is the fast pace. There is rapid turnover in a surgicenter, Chinnes affirms; one case follows right after another all day long. "They do have to adjust their staffing up and down, so they may have a PRN pool of nurses," Chinnes says. "If somebody's out sick today, they have a whole pool of nurses they can call. Because these staff are carefully chosen and they have good hours and good working conditions, they're pretty close-knit and just cover for each other."

Those ideal working conditions and the growing popularity of outpatient surgery suggest more growth in the future. "The industry as a whole is growing by leaps and bounds and gaining considerable recognition as a valuable resource in the healthcare arena," Sample says. "ASCs offer a cost-effective alternative to patients and insurers without compromising safety or quality. Each year the federal government adds more and more procedures to the list of approved procedures for ASCs, acknowledging the safety afforded and savings to be obtained by performing these procedures in ASCs."

Surgicenters have benefit for the community at large because patients prefer to recover at home rather than in a hospital anyway. "Many patients can now have many more complicated procedures done on an outpatient basis and be back at home sooner and hopefully heal quicker," notes Chinnes. "They are not being exposed to lengthy stays or as many hospital bugs, and many times, if they have a laparoscopy rather than an open procedure, then they're going back to work a lot sooner than somebody who's had major surgery."