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The role of organisational commitment in facilitating assimilation of undergraduate nurses into the perioperative environment.

Introduction

Internationally, there are existing and increasing nursing workforce challenges which require a variety of innovative strategies. The baby boomer population is increasing the number of people who will require healthcare services. In addition, there is an ageing nursing workforce soon to retire or reduce their work hours within the next five to 15 years.

Nurses working in perioperative clinical environments are largely unseen by the general population and the complex nature of the role remains a relatively unknown area of nursing. Bachelor of Nursing students commonly have limited exposure to this clinical area and may not consider it as a graduate career option. A strategy that addresses students' cognitive, affective and normative needs in preparation for clinical and job placements provides both optimal learning experiences and a potential solution to these nursing workforce challenges.

Background

In 2002, 25.7 per cent of the Perioperative Nursing workforce was aged over 50. This had increased to 41.4 per cent by 2017. Current workforce statistics (Nursing Council of New Zealand, 2017) suggest that in the next five years, 16 per cent (593) of perioperative staff will be 65-years-old, and in 15 years, 41 per cent (1504) of the current staff could be retiring or reducing their work hours (see Table 1).

While many nurses choose to work beyond the retirement age of 65, not all want to nor are able to, due to health and lifestyle choices. Workforce challenges are not limited to nurses nearing the end of their career.

Since 2010, Nurse Entry to Practice (NEtP) programmes in New Zealand have been available both in District Health Board (DHB) regions and private surgical hospital settings to support new graduate nurses beginning their careers in specialty areas, including perioperative care. Consequentially, there was a marked increase in the number of under 25 and 25-29-year olds entering perioperative care settings following this initiative (see Table 1).

However, in 2015 the Ministry of Health (MoH) removed "Perioperative Nursing" from its "hard to staff" list of priority clinical areas. This meant that new graduates working in Perioperative Nursing were no longer eligible for the MOH voluntary bonding scheme to help cover student-loan repayments. Since this change, there has been a subsequent drop in new graduates beginning in perioperative care--92 under 25s (2015) dropping to 58 under 25s (2017). A similar decline, but to a lesser extent, can be seen in the 25 to 29-year old results. Given these declining numbers, it is imperative that Perioperative Nurses use every opportunity available to encourage undergraduates to become informed about Perioperative Nursing, have positive learning experiences within this area of nursing practice and are equipped to enter the workforce with more than just clinical skills.

Educational Experience

Creating a positive learning environment is essential for learners to acquire new knowledge. A learner's state of mind has a decisive influence on their perception of learning experiences. Positive experiences are seen to enhance learning whilst negatives are perceived as impeding learning. Senninger (2000, as cited in Kouvela, Hernandez-Martinez & Croft, 2018) proposed the learning zone model which identifies three phases in which learning may occur. In the comfort zone, learning activities are familiar such that a person is easily able to complete them and feels safe doing so. Challenge zone learning activities are less familiar and entail a higher level of risk and challenge which can contribute to a sense of excitement. Activities in the panic zone are unfamiliar and contain a high level of risk with excessive challenge which results in amygdala activation with a consequential fight or flight reaction. As such, learning whilst in the panic zone produces high levels of stress and is therefore unlikely to be effective.

For students to have an optimally positive experience in a new environment, Solinger, Van Olffen & Roe's (2008) reframing of Allen and Meyer's (1990) organisational commitment theory asserts that there are three key areas of need that must be addressed if they are to not only assimilate effectively into an organisation but be committed to stay.

The three needs are:

* cognitive--what needs to be known to be competent;

* affective--what aspects will assist the learner to feel more confident and comfortable going into the new environment; and

* normative--knowledge of the protocols, standards, expectations that need to be followed.

The author suggests that addressing these needs prior to exposure to a new learning environment will support students to anticipate a positive experience, support their socialisation into the perioperative environment and enhance their intention to remain in their role.

Identifying key learning aspects is important. When asked to rank essential perioperative skills for novice learners, a survey of New Zealand Perioperative Nurses identified that patient safety, role responsibilities, sterile field, scrubbing/gowning/gloving and knowing what to do when things get tense, were at the top of the list. In other words, a mixture of specific perioperative clinical skills and workplace attitudes and competencies.

The aspects highlighted by experienced Perioperative Nurses mirrored the pre-placement preparation topics that were included in the Massey University School of Nursing learning session.

Pre-placement preparation

Prior to the face-to-face session, students were sent an email welcoming them to the field of Perioperative Nursing, outlining potential topics that could be included in the session and providing a list of hyperlinks to freely available internet video tutorials. Students are asked to specify which topics would be most important for their learning. Table 3 outlines the topics and relevant details for each aspect.

This heutagogical (Blaschke, 2012) learning design with learner-directed learning experiences attends to each of Solinger et al's., (2008) organisational commitment needs. The provision of learning material ahead of time on specific topics directly addresses student cognitive needs and allows students to gain an understanding of important principles or normative needs, enabling them to feel competent with a few key aspects thus meeting their affective needs. Preparation such as this develops a level of skill that gives students a positive attitude that they can contribute and function safely in the perioperative environment from day one of their clinical placement. When these needs are attended to and the nursing student has a positive experience, they can develop increasing confidence within the organisational setting and are subsequently more likely to be committed to the organisation. This is important if the ultimate aim is for these students to come back as graduates into perioperative environments.

In addition to student experiences, the support and engagement of clinical staff is important. The clinical staff commented on the knowledge and skill the students displayed. "My experience of having a student in our facility has been a very positive one. We felt she had a good base knowledge of the sterility." (Clinical Manager). Effective pre-learning allows the students to begin their placement with a base-level of skill and competency that primarily supports challenge zone learning. "Students aren't normally prepped for theatre (e.g. scrubbing and sterility) before they come. So, it was easier to explain things to her than usual--it may be the preparation she has had and also, she is a clever student too" (Clinical Nurse Educator).

Implications

It is not enough to just introduce students to the perioperative environment. Creating an experience that supports their career pathway thinking is essential in addressing workforce challenges.

Undergraduate, pre-registration placement learning offers what Jablin (2001) defined as the first two stages of organizational assimilation: anticipatory socialisation with the provision of cognitive, affective and normative information so that students can gain confidence and in turn have a positive experience in the perioperative environment. By setting the stage for students beforehand and then having expectations or beliefs about an environment confirmed later, Jablin asserts the individual is more committed and engaged in the environment. This is exemplified in the comments from students and perioperative staff.

What can we do about this?

As Perioperative Nurses we need to use each interaction with students and other nursing colleagues to encourage them to come and check out Perioperative Nursing. If students visit the department for a patient follow through, look for opportunities to ensure this is a positive learning experience for them. Review their understanding of what is happening (cognitive); make them feel welcome and affirmed (affective); and reinforce the protocols and policies that are relevant to the situation (normative). It can be helpful to suggest they request their pre-registration placement in your department. Talk with them about new graduate and new-to-perioperative programmes available to support their move into this challenging yet rewarding nursing specialty. Contact your local school of nursing and discuss aspects that they could include in their student preparation and offer unsterile items for learning practice.

Conclusion

The provision of optimal undergraduate preparation for student perioperative clinical placements incorporating both clinical practice and organizational commitment aspects, has potential to increase the numbers of graduates choosing to enter Perioperative Nursing, thereby improving nursing workforce projections. By preparing undergraduates for their perioperative clinical environment in these ways, we can help them overcome the fear of the perioperative unknown.

Acknowledgement

I would like to acknowledge the presentation given by Marika Jenkins at the ACORN 2014 Conference, Melbourne, which initiated my thinking on this topic.

About the author

Jenny Green is a life-long learner, a registered nurse and a lecturer in the School of Nursing at Massey University, Auckland. Her research interests are in online learning, heutagogy, clinical education, interprofessional simulation and collaborative learning. Jenny is a Fellow of the Higher Education Academy and is currently a PhD candidate focusing on learning design in nursing education. This article is based on Jenny's presentation at the 45th Perioperative Nurses' Conference in Nelson, which won the Surgico Free Paper Award.

References

Blaschke, L. M. (2012). Heutagogy and lifelong learning: A review of heutagogical practice and self-determined learning. International Review of Research in Open and Distance Learning, 13(1), 56-71.

Jablin, F. M. (2001). Organizational entry, assimilation and disengagement/exit. In F. M. Jablin & L. L. Putnam (Eds), The new handbook of organizational communication: Advances in theory, research & methods (pp. 732--818). Thousand Oaks, CA: Sage Publications.

Kouvela, E., Hernandez-Martinez, P., & Croft, T. (2018). "This is what you need to be learning": An analysis of messages received by first-year mathematics students during their transition to university. Mathematics Education Research Journal, 30(2), 165-183.

Nursing Council of New Zealand. (2017). The New Zealand Nursing Workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2016-2017. Wellington: Author.

Solinger, O. N., van Olffen, W., & Roe, R. A. (2008). Beyond the Three-Component Model of organizational commitment. Journal of Applied Psychology, (1), 70. https://doi-org.ezproxy.massey.ac.nz/10.1037/0021-9010.93.1.70

By Jenny Green
Table 1: ENs & RNs in Perioperative Care 2002-2017. (Source NCNZ)

      <25  25-29  30-34  35-39  40-44  45-49  50-54  55-59  60-64  65+

2002   44    158    277    291    369    381    250    156    100   20
2010   90    270    276    450    482    506    515    337    203   68
2011   96    303    287    444    494    475    550    366    220   75
2013   61    290    330    339    496    477    484    469    276  153
2015   92    349    359    323    482    460    488    468    294  137
2017   58    335    529    329    386    492    440    471    378  215

      Total  Female  Male

2002   2046       0     0
2010   3197    2999   198
2011   3310    3096   214
2013   3375    3123   252
2015   3452    3196   256
2017   3633    3302   331

Table 2: Novice learners--Essential aspects. (Source: Author, 2018).

Novice learners--what's most important in perioperatve environments?

               Patient safety   1st
        Role responsibilities   2nd
                Sterile field   3rd
    Scrubbing Gowning Gloving   4th
   When things get intense...   4th
          Patient positioning   6th
             Patient transfer   7th
Principles of instrumentation   8th
        Opening sterile items   9th
              Tying up a gown  10th
                      Draping  10th

Table 3: Perioperative topics for the pre-placement session.

Pre-placement Perioperative Learning Topics

Patient safety:  - Preop checks
                 - Preventing infection
                 - Environmental factors
                 - Moving and handling
                 - TimeOut and surgical safety processes
Sterility:       - Sterile field: What's sterile? / What's not?
                 - How to open a sterile pack
                 - Tie up a gown maintaining asepsis/sterility
                 - How to do a surgical scrub
                 - How to don gown and gloves
Organisational:  - Names of the key people in the department
                 - Types of surgery carried out
                 - Parking, meals, scrubs
                 - Me.Inc
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Article Details
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Title Annotation:education
Author:Green, Jenny
Publication:The Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation
Date:Mar 1, 2019
Words:2004
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