INTRODUCTION:

The nursing workforce in Singapore has been highly depended on foreign nurses to fill its nursing shortfalls¹. The recent SARS-CoV-2 pandemic has further exacerbated issues of global nursing shortage onto the Singapore nursing workforce. This was reflected by the recent 1,500 healthcare workers, which included nurses, that have left the workforce entirely in the first half of 2021 due to the physical toll such pandemics had on the healthcare workforce². The fear grew as Singapore’s highest nursing immigrants, the Philippines, were temporarily stopped from working overseas to help their domestic nursing workforce battle the SARS-CoV-2 pandemic in their country^3,4. Besides, with the former known issues of recruiting nurses within Singapore’s own population and poor nursing students' enrolment rate in Singapore nursing school has further burdened the republic's nursing workforce¹. Furthermore, the expansion of the Singapore healthcare sector that had to be mandated over the decade because of the rapid growth in the ageing population and the increasing prevalence of complex long-term diseases^5,6. The aim of these expansions was to service patients in regional areas in Singapore which included building integrated healthcare campuses to ease transferring care within the same hospital campus^5,6. Thus, hospitals in Singapore, especially newly established healthcare campuses, might not be ready or have enough workforce when business normalise after SARS-CoV-2 has been resolved.

Within the operating room (OR) units, similar insights behind the nursing shortfall globally have been discussed in the extant literature. This was reflected recently by 21 (77.8%) perioperative nursing leaders who were interviewed in the United States (US) who shared the challenges faced in retaining and recruiting nurses were contributed byretiring OR workforce and the requirement of having 1-2 years of medical surgical experience to be recruited in the OR unit⁷. Furthermore, the lack of OR nursing practice exposure during baccalaureate nursing programs have deprived newer generation of nurses from experiencing OR nursing before graduation and consider it as a future career option.^7,8,9 These issues however, lacked exploration in the Singapore nursing literature. Thus, the purpose of this paper was to investigate factors associated with operating room nurses’ professional transition in Singapore health system. This paper will be a paramount contribution to OR nursing in Singapore and will help recognition of the need to sustain and retain more local nurses in line with the Singapore government’s plans. Additionally, it would provide more insights on how reducing clinical stress by making guided learning in specialised nursing fields available would better prepare newer OR nurses for their new full-time roles.

MATERIALS AND METHODS:

The approach to investigate this paper’s topic used the cohort study design. A descriptive self-administered quantitative survey was administered to obtain data. The From Novice to Expert theory by Benner and Conceptual Model of Nursing Motivation designed by Warren and Mills were adopted as theoretical frameworks to guide the study.

The researcher developed aself-developed instruments questionnaire. It wastitled the ‘Impacts on Operating Room Nurses with Transitional Support Programmes’ (IORNTSP) survey. The quantitative study tool was self-developed as there were no existing validated surveys that explored factors associated with nursing retention in the OR units in Singapore. The researcher used the MEASURE Approach by Kalkbrenner to aid in the construction of the survey instrument. The finished questions were finalised after fine-tuning based on feedback by expert reviewers. Overall, there were 43 items in the quantitative survey questionnaires. Items in the questionnaires would include demographic andtime data with four operational variable data; behaviour presentation, causes, effects, and types to help identify issues based on its theme. A Cronbach's alpha analysis was performed to ensure the survey tool's reliability. The analysis found that the reliability coefficient ranged between 0.74-0.81 during the pre-testing of the quantitative instrument and 0.76 - 0.88 for the actual study which were within acceptable range.

Data collection commenced after Unicaf University's ethical board granted ethical approval on the April 8th, 2022. No further ethical approval was required as convenience and snowball sampling were used to recruit participants for the study. The data collection process occurred between April 8th 2022 and May 20th 2022. A participant information sheet and informed consent was issued via a Google Forms link to participants by gatekeepers from Singapore OR units who were approached by the researcher.The gatekeepers were issueda gatekeeper’s letter to provide information about the research objectives and their role in assisting in the data collection. Snowball sampling supplemented the participant recruitment effort by forwarding the research information to participant’s fellow colleagues who metdemographics of thestudy’s inclusion criteria. These included OR nurses who were in their unit for not more than three years, aged 19 to 45 years old, registered as nurse under the Singapore Nursing Board and were nurses who were participating in direct patient care within the OR unit. To ensure confidentiality and anonymity, participants’ and organisational names were excluded during the data collection. Data analysis for the quantitative research was completed using SPSS Statistics version 28.0.1 which included descriptive analysis, measures of central tendencyand Spearman’s correlation.

RESULTS:

At the time of the study, 91 of 96 responses received met the inclusion criteria. Respondents came from across majority of OR units in Singapore. 75.3% (n = 75) of respondents had worked in their OR unit for less than two years. Of the 91 respondents, 35.2% (n = 32) were males and, 64.8% (n = 59) were females with the largest group of respondents aged between 20 – 23 years old (n = 52). Table 1 provides the general demographics of respondents.

Table 1: Mean, median and mode of the general demographics

Variable	Range	Mean	Median	Mode
Age	19-45years old	24.5	23	21^a
Gender	Male (1), Female (2) or Others (3)	1.65	2	2
Job rank	EN (1), RN (2)	1.65	2	2
Job title	Admission Nurse (1), Anaesthetic Nurse (2), Post-Anaesthesia Care (3) and Scrub and Scout nurses (4)	3.16	4	4
Qualifications	Nitec (1), Diploma (2), Bachelor’s degree (3), Master or equivalent (4)	2.19	2	2

To help investigate the factors associated with nursing retention in the OR units in Singapore health system, OR nursing induction programmes (IPs) was used as a foundation to understand whether overall the IPs OR nurses received were helpful in job role preparation and job role suitability. The hypotheses were outlined to help boost the investigation. These included:

H1₀: Having an OR unit-specific specialised nursing IP would not result in the enhancement of OR NJNs in Singapore's knowledge and skills in performing their new job roles.

H1_a: Having an OR unit-specific specialised nursing IP would result in the enhancement of OR NJNs in Singapore's knowledge and skills in performing their new job roles.

H2₀: OR unit-specific specialised nursing IPs did not affect Singapore OR NJNs' challenges with their ability to perform their roles.

H2_a: OR unit-specific specialised nursing IPs affected the challenges Singapore OR NJNs faced with their ability to perform their roles.

13 questions from the IORNTSP survey were used to identify relationships that existed between variables that affected OR nurses because of the IP they received. The survey used a 5-point Likert scale. The variables included from “Strongly agree = 1”, “Agree = 2”, “Neutral = 3”, “Disagree = 4”, “Strongly disagree = 5”. A sixth point was included to allow an option for participant who did not experience a particular phenomenon. It was label as N.A. (not applicable). Participants who selected this option were subsequently excluded from the main analysis. It resulted with the researcher having to run four separate analyses to ensure validity and reliability of the results.

The first Spearman’s rank-order correlation was run to examine the relationship between job description (Q26), team acknowledgement (Q28), inability to put theory into practice based (Q29), lack of adaptation time (Q30), facilitator guidance (Q31), insufficient topic coverage during IP (Q32), seeking understanding and clarity of contents during IP (Q33), challenges in reaching competence level due to lack of time given during probation (Q36), IP was overall helpful in job role preparation (Q38), and overall job role suitability after undergoing IP (Q39). There test results showed strong positive correlation and statistical significance between Q30 and Q32, r_s = .62, n = 84, p = <.001, Q30and Q36, r_s = .62, n = 84, p = <.001, Q31 and Q38, r_s = .60, n = 84, p = <.001, and Q32 and Q36, r_s = .61, n = 84, p = <.001. Also, there were moderate positive correlation and statistical significance between Q26 and Q28, r_s = .42, n = 84, p = <.001, Q38 and Q39, r_s= .54, n = 84, p = <.001. Additionally, there were moderate negative correlation and statistical significance between Q30 and Q31, r_s = -.43, n = 84, p = <.001., Q30and Q38, r_s = -.56, n = 84, p = <.001, Q30 and Q39, r_s = -.43, n = 84, p = <.001, Q32 and Q38, r_s = -.54, n = 84, p = <.001, Q31 and Q36, r_s = -.40, n = 84, p = <.001, and Q36and Q38, r_s = -.52, n = 84, p = <.001. Table 2 presents the results for the first set oftestsran that had no missing values in its data set.

Table 2: Spearman Rank-order Correlations between Q26, Q28, Q29, Q30, Q31, Q32, Q33, Q36, Q38 and Q39

	Q26	Q28	Q29	Q30	Q31	Q32	Q33	Q36	Q38	Q39
Q26		.42**	-.33**	-.04	.08	-.12	-.02	-.00	.16	.24*
Q28	.42**		-.09	-.14	.11	-.14	-.04	-.25*	.11	.17
Q29	-.33**	-.09		.30**	-.26*	.16	.03	.20	-.18	-.24*
Q30	-.04	-.14	.30**		-.43**	62**	.20	.62**	-.56**	-.43**
Q31	.08	.11	-.26*	-.43**		-.29**	.16	-.40**	.60**	.36**
Q32	-.12	-.14	.16	.62**	-.29**		23*	.61**	-.54**	-.32**
Q33	-.02	-.04	.03	.20	.16	.23*		.14	.02	-.24**
Q36	-.00	-.25*	.20	.62**	-.40**	.61**	.14		-.52**	-.30**
Q38	.16	.11	-.18	-.56**	.60**	-.54**	.02	-.52**		.54**
Q39	.24*	.17	-.24*	-.43**	.36**	-.32**	-.24**	-.30**	.54**

Correlation is significant at the 0.01 level (2-tailed).**

Correlation is significant at the 0.05 level (2-tailed).*

n = 84

Next, Spearman’s rank-order correlation was run to examine the relationship between a lack in receiving the necessary and sufficient technical skills (Q27), Q38, and Q39. The results showed that there was a strong negative correlation and statistical significance between Q27 and Q38, r_s = -.62, n = 84, p = <.001, and weak negative correlation and statistical significance between Q27 and Q39, r_s = -.62, n = 84, p = .005. Table 3 presents the results for the second test of group data that had no missing values in its data set.

Table 3: Spearman Rank-order Correlations Q27, Q38 and Q39

	Q27	Q38	Q39
Q27		-.62**	-.30**
Q38	-.62**		.54**
Q39	-.30**	.54**

Correlation is significant at the 0.01 level (2-tailed) **

n = 84

Subsequently, a Spearman’s rank-order correlation was run to examine the relationship between seeking understanding and clarity of contents after IP (Q34), challenges in self-confidence in job role due to lack of skills and knowledge received (Q37), Q38, and Q39. There was moderate positive correlation and statistical significance between Q34and Q37, r_s = .50, n = 83, p = <.001, and Q37and Q38, r_s= -.56, n = 83, p = .005. Table 4 presents the results for the third test ran that had no missing values in its data set.

Table 1: Spearman Rank-order Correlations between Q34, Q37, Q38 and Q39

	Q34	Q37	Q38	Q39
Q34		.50**	-.36**	-.37**
Q37	.50**		-.56**	-.40**
Q38	-.36**	-.56**		.54**
Q39	-.37**	-.40**	.54**

Correlation is significant at the 0.01 level (2-tailed) **

n = 83

Lastly, Spearman’s rank-order correlation was run to examine the relationship between providing sufficient time to reach competence level before role confirmation (Q35), Q38, and Q39. There was moderate negative correlation and statistical significance between Q35and Q38, r_s= -.41, n = 83, p = <.001, and weak negative correlation and statistical significance between Q35 and Q39, r_s= -.28, n = 83, p = .011. Table 5 presents the results for the fourth test ran that had no missing values in its data set.

Table 5: Spearman Rank-order Correlations between Q35, Q38 and Q39

	Q35	Q38	Q39
Q35		-.41**	-.28*
Q38	-.41**		.54**
Q39	-.28*	.54**

Correlation is significant at the 0.01 level (2-tailed)**

Correlation is significant at the 0.05 level (2-tailed)*

n = 84

DISCUSSION:

To address the study’sphenomenon, the null and alternative hypotheses were established. Spearman’s rank-order correlation was used to establishthe relationships between Q26 to Q39. Firstly, the results indicated a strong positive correlation and statistical significance between Q30 and Q32, Q30 and Q36, Q31 and Q38, and Q32 and Q36. The result of the first Spearman test ran suggested that as lack of adaptation time increased, so did insufficient topic coverage during IP and challenges in reaching competence level due to lack of time given during probation. Similarly, as facilitator guidance grew, so did IP's overall helpfulness in job role preparation. Also, as insufficient topic coverage during IP increased, so did challenges in reaching competence level due to lack of time given during probation. On the other hand, the results also indicated a strong negative correlation and statistical significance between Q27 and Q38. It suggested that when the lack of receiving the necessary and sufficient technical skills for the respondent’s role at their level increased, the overall helpfulness in job role preparation after IP decreased and vice-versa.

Secondly, the results for the Spearman test ran indicated a moderate positive correlation and statistical significance between Q26 and Q28, Q34 and Q37, and Q38 and Q39. The results suggested when that team acknowledgement increased so did an adequate explanation of job roles during IP. Similarly, as the overall helpfulness of IP in job role preparation increased, so did overall job role suitability after undergoing IP. In contrast, there were moderate negative correlation and statistical significance in Q30 and Q31, Q30 and Q38, Q30 and Q39, Q32 and Q38, Q31 and Q36, Q35 and Q38, Q36 and Q38, and Q37 and Q38. The results suggested that as one variable increased, the other decreased. However, it did not present a cause-and-effect relationship between the variables but, indeed, a noticeable one. For example, the results reflected that as challenges in reaching competence level due to lack of time given during probation increased, the IP was helpful in job role preparation after IP decreased and vice-versa.

Lastly, the Spearman’s rank-order correlation results indicated a weak negative correlation and statistical significance between Q27 and Q39 and Q35 and Q39. The results suggested that when one variable increased, the other decreased. For example, when provided sufficient time to reach competence level before role confirmation increased, the overall job role suitability after undergoing IP decreased and vice-versa. However, despite the existence of a relationship, it existed unreliably.

The study looked to the theoretical and conceptual foundations of Benner’s From Novice to Expert theory and Warren and Mills’s Conceptual Model of Nursing Motivation. The foundations of these models helped the researcher recognisedthis paper’s purpose: investigating factors associated with operating room nurses’ professional transition in Singapore health system. Benner shared that individuals would undergo five stages of skills and knowledge acquisition when entering nursing practice. These included novice, advanced beginner, competent, proficient, and expert. The findings from the Spearman’s test upheld Benner’s notion. Similarly, Warren and Mills’s Conceptual Model of Nursing Motivation, the authors shared that certain perceived efforts were the bearing of nurses’ actions to return to school. This study reflected similar concepts between the variables in terms of OR nurses’ performance motivation when IP was received.

Lack of adaptation time:

IPs has been reflected to affect the adaption of nurses into their new roles¹⁰. The results in this study indicated the strong positive relationships between lack of adaptation time and insufficient topic coverage during IP, and lack of adaptation time and challenges in reaching competence level due to lack of time given during probation. This reflected that OR nurses struggled to adapt in their roles because of the insufficient topics covered during their IPs. Additionally, it resultedin them facing challenges in reaching competence level during their probation period. However, it did not affect theoverall purpose of the IPs received in job suitability and helping prepare them for their job roles. The findings could be understood from the extant literature where researchers explained that a systemic approach and the availability of IPs were beneficial in nurses’ retention. For example, recent researchmentioned that the participants in their study agreed that having a structured nursing orientation programme (OP) correlated to having a positive experience with adaptation, work satisfaction, and a support system.¹¹ It was further shared that the high correlation between support and satisfaction was related to the OP design within an organisation tailored for new employees such as graduates.¹¹ It was helpful for this group of nurses as their individual needs were supported by good mentors, increasing their satisfaction level thus resulting in a better retention rate.¹¹

Similarly, other recent researchers shared that most graduate nurses that were interviewed felt more confident with their nursing skills after a 12-month transition to practice programme.¹² It was despite the many new demands that came with a new professional role. However, with positive and constructive reinforcements, it enhanced the positive emotional responses of new graduate nurses, thus, transitional experiences were positively enhanced.¹² Thus, the researchers acknowledged that nursing IPs were the bearing fruit to graduate nurses’ positive retention rate. This was reflected by the responses from the participant of this study.

Furthermore, OR nurses with more years of working experience were more resilient towards independently nurturing their skills. They also shared that a systemic approach to the delivery of IPs would have been beneficial. The extant literature supported this notion stating that nursing transitional support programmes (TSPs) lacked organisation.^13,14,15 Thus, it hasled to issues with formal preparation for their roles. Furthermore, other authors have mentioned in the literature that due to the slow adaptation, incidences of transition shock among new nurses in Singapore have led to a prevalence of workplace bullying.¹⁶ Nonetheless, new nurses still viewed IPs as valuable assets to adapt to their new positions.

Facilitators guidance:

Acknowledging the struggles of professional transition is one of the challenges nurses faced that impacted their jobs performance. The literature shared the importance of strong support systems during nurses’ transition as the nursing practice arena present many new practical situations new nurses were not previously exposed to.¹⁷ Thus, the guidance of an expert in the clinical area is vital when new nurses are transitioning to their professional practice. In this study, it was observed that when facilitators guidance was positive, so did the IPs overall helpfulness in job role preparation for OR nurses.

The Association of periOperative Registered Nurses shared that OR nurses faced constraints with OR nursing education.⁹ As with other speciality care settings, OR nursing practices possess unique technical proficiencies¹⁷and due to its complicated professional nature of practice, it made transition to practice particularly difficult even with expert nurses with other previous nursing unit experiences. These nurses must inevitably unlearn previous practices and revert to novice nurses as they learn to adapt to a new clinical speciality.¹⁸Furthermore, mastering machinery and equipment while focusing on surgical procedures has become the reality of perioperative nursing practice. Thus, the demand tointeract with technology to provide holistic nursing care has recently increased.¹⁸This interaction has become a crucial aspect in OR nursing practice because a lack of competencies and confidence might affect nurses’ ability to work and collaborate with other staff and technologies and potentially put patients at risk.¹⁷ Thus, it was essential for nurses’ keen to join or be placed in the OR nursing unit to equip themselves with an OR nursing background to build a foundation to practice in the OR competently.¹⁹

The guidance of OR facilitators provide nurses to overcome such complexity of present-day healthcare and the overwhelming workload related to unpreparedness during their first year of transitional practice.²⁰Such efforts have helped integrate behaviours, knowledge, skills, and values learned in nursing schools and has been crucial for professional practice success especially in OR units.

Topic and skills insufficiency leading towards challenges reaching competence:

The extant literature shared that workplace nursing competencies that has helped measure nurses' competence level was not comparable to nursing exams that measure nurses’ education as professional nursing competencies go beyond student nursing clinical placement practice objectives.^21,22 Furthermore, the most significant disadvantage of such competency measuring tools for novice nurses joining the OR unit was how nursing educational institutes have reduced or removed OR nursing rotation from the curricula to focus on other nursing areas.⁷ It added to the misinterpretation of OR nursing by other nursing experts as a profession that acted only as a surgeon's assistant.²² The ignorance was due to these nursing experts’ lack of exposure to the OR units.²² Therefore, the technical proficiencies that underpinned OR nursing practices and the procedural and medical aspects that embodied the dynamics of OR competencies became unknown to novice OR nurses.¹⁹ In addition, the broad uncertainty of the OR environment that required OR nurses to be ready to make prompt clinical decisions to reverse patient harm was also affected by a lack of situational awareness and experience.^21,23 Hence, OR nursing competencies, like other speciality care units, became indispensable to practice in the area.²¹

The result from this study reflected that most nurses agreed that they faced challenges during their probation toreach their competence levelas contents were not sufficiently covered to help in their roledevelopment despite eventually agreeing that their IPs were overall helpful. It was informed in the literature that this was because existing IPs were not uniquely designed for each speciality care unit.²⁴ Furthermore, other researchers shared that IPs could vary in content, duration, and structure²⁵ in different healthcare institutes²⁶. Nevertheless, those efforts were the bearing of each speciality unit and healthcare institute to enhance the transition experience of their new nurses.

However, new graduates found it incredibly challenging to set daily priorities when they did not possess the necessary elements for competent patient care as they were cast out during their transitional period.²⁷This was reflected in the results of this study where nurses agreed that when the lack of receiving the necessary and sufficient technical skills for the respondent’s role at their level increased, the overall helpfulness in job role preparation after IP decreased and vice-versa. For example, the literature stated that clinical errors leading to a sense of guilt have led numerous novices OR nurses to resign from their roles due to the lack of education provided during their IPs.²⁸ It was further affected by their lack of clinical decision-making skills in different clinical scenarios that expert OR nurses possessed.²³ It was because competent nursing care would require time, an appropriate learning environment and recourses.²⁹ Thus, acknowledgement and support from employers regarding new nurses in a clinical area were vital.²⁷ Strauss et al. also pointed out that TSPs tailored to acknowledging nurses learning disabilities and needs saw better professional satisfaction than TSPs that were informal or overlooked those issues.¹¹Thus, challenges with patient safety that new OR nurses experience during IPs could be overcome with the right resources and support when acknowledged.

CONCLUSION:

The findings of this quantitative study called for the review of the contents outlined in existing OR nursing IPs in Singapore. While the survey respondents mainly acknowledged that they were satisfied with their OP, responses in the survey outlined those nurses’ faced challenges with knowledge and skills acquired during their IPs. The extant literature noted that tailoring TSPs to acknowledge nurses' learning disabilities and needs showed better professional outcomes than unorganised TSPs.¹¹ Nursing researchers also believed that competent nursing care required time, appropriate recourses, and an appropriate and supportive learning environment.^29,30 Other authors have also expressed in the literature that redesigning TSPs for new employees in speciality care areas to eliminate training information redundancies could improve nurses' ability to gain the appropriate knowledge and clinical skills to help transfer it to their assigned job role.³¹

Recent literature provided some recommendations for the review of contents for OR nursing IPs. These included instead of nursing IP facilitators teaching content based on personal experience, remediation should be made for instructors to deliver standardised content.³¹ There were also recommendations to have clinical competence development to ensure competent patient care in the OR unit.²² Nurses acknowledged that supplementing them with such competence development after completing their IPs would equip them with the required competencies for their job functions. Research focusing in Singapore nursing added that to improve the transition of nursing graduates in Singapore, nursing faculties and healthcare industries should actively communicate to seek revision and align their prescribed programme contents relevant to current clinical needs and skill requirements.^32,33 Other researchers in the literature also believed that healthcare organisations' efforts to re-evaluate their nursing IPs continuously were vital to keeping novice nurses updated with the latest evidence-based practices to allow competent patient care.³³

Recommendations arising from this study sought address the contents of recent OR nursing IPs in Singapore to recognise when healthcare organisations and nursing faculties were cognisant of the unique skills and knowledge required for OR nursing practice, it would allow them to focus on core nursing skills required for different OR nursing professionals and be flexible in delivering each core component. It was the opinion of multiple respondents in the study for less content bias as their IPs majorly cover the role of scrub and scout nurses. Thus, the researcher would recommend that health groups among the Singapore hospitals collaborate among their organisations to deliver similar content programmes. For example, providing an anaesthetic nursing theoretical content programme collaboratively on the same days as a health group to standardise content and better human resource management for educators. It would also allow nurses to be more involved in the lessons as their content relates to their assigned job roles. However, it sufficed to say that OR nurses should be deprived of knowing the job functions of their other OR professionals by the segregation of participatory experience. The recommendations arose to help nurses adapt to their job role confidently and competently before progressing to learning different job scopes with OR nursing. Also, roles assigned should be notified before the commencement of work so nurses could clarify their roles and ease the pressure when starting a new job. It would further allow nurses to build relationships within their OR and individualise learning needs when more time was given to adapt without the constraint of time.¹¹

Furthermore, the study cannot be generalised as it was undertaken during a significant health crisis which changed the structure of IPs delivered. Nonetheless, it was not the intention for this study to be generalised as nursing demographics differs. Also, as healthcare industries have learnt during recent global pandemics, the cultural shifts of how healthcare functions must be transparent to better the workforce.⁵ Researchers also expressed in the literature that changes over time in evidence-based practices and advancing technologiesmeans perceptions were due to change.³³ Thus, contents shared during IPs and nurses' perceptions and how it impacted them remain volatile. However, if the structure of IPs were solid, such issues could be overcome. Future research to invest in the study’s topic could further explore NJNs' insights and insights of NJNs of different nursing generations necessary to find solutions to address cultural shifts in the healthcare state.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

The authors would like to thank Unicaf University for their kind support during the process of undergoing this study.

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Received on 08.03.2024 Modified on 03.06.2024

Int. J. Nur. Edu. and Research. 2024; 12(3):157-164.

DOI: 10.52711/2454-2660.2024.00034