New nurse graduates could be a great solution to filling staff needs at ASCs. However, surgery centers should start by establishing thorough training programs.

  • Increasingly, new nursing graduates show an interest in working in ambulatory settings, including ASCs.
  • Residency programs can provide structured, consistent training for new nurses.
  • Preceptors can work with new nurses, guiding and supporting them as they gain confidence and stronger work experience.

As ASCs compete with hospitals, physician offices, and other providers for nurses, they also might consider new nurse graduates.

“Our workforce is changing, and we have to look at things very differently,” says Deena Gilland, MSN, RN, NEA-BC, vice president and chief nursing officer at Emory Ambulatory Care in Atlanta. “Our newer generation of nurses has a lot of interest in ambulatory settings; they come in thinking about care across the continuum. Those of us who graduated years ago were more narrowly focused in our thoughts.”

ASCs and other ambulatory settings need RNs who are skilled and knowledgeable about ambulatory care, says June Levine, MSN, BSN, RN, patient-centered medical home director at Southside Coalition of Community Health Centers in Los Angeles. Levine has helped develop a residency program for nurses in ambulatory settings. (See story on strategies to prepare new nurses for ASC work in this issue.)

“The RN workforce needs to be built up in numbers, quality, and in leadership skills,” Levine says. “The numbers are irrelevant if they’re not qualified or if they don’t know how to lead.”

This directional change among new nurses is positive, and surgery centers should take advantage of the interest new graduates show in their work setting. In large urban areas, there’s huge growth and a great need for experienced nurses in ambulatory care. The current supply and pipeline is not enough to meet the need, so something has to change, Levine adds.

“My question was: ‘Why are we not taking new graduates in ambulatory care,’” Gilland recalls. “I looked at the literature, and there is some evidence that new graduates can thrive in ambulatory care.”

Gilland answered that question two years ago with a plan to build a pipeline from nursing school to ambulatory settings, including ASCs. After one year of planning, in March 2017 the first group of 11 new nursing graduates found jobs in a formal residency program for ambulatory settings. Five new nurses chose surgery centers. At the one-year mark, Gilland could see that the program worked well. The resident nurses received the support and training they needed to succeed in their roles, and the program has continued to enroll new nursing graduates.

The program worked so well that Gilland cites that as one of the lessons learned.

“When we first started this, my goal was, literally, to enroll one new graduate,” she explains. “My lesson learned was that there was a lot more interest in ambulatory care than I’d ever anticipated.”

How It Works

Prepare well. “We worked on this a year before we started the residency program,” Gilland says. “We were very intentional, taking our time, because we wanted new nurses to flourish.”

The first step was to build ambulatory curriculum at the Emory’s nursing school. There, students learn not only how important nursing care is in an ambulatory setting, but also about population health.

“No matter how much we planned, we didn’t think we planned early enough,” Gilland notes.

For the next round of nursing graduates, planning began the day after the first group became residents.

“There are 250 nursing students a year taking an ambulatory care course,” Gilland says. Students rotate through ASCs, clinics, and other ambulatory sites. “As senior students, they can help in a surgery center with patient education,” she says. “They do a full PACU, pre-op assessments, and medicate patients.”

Build curriculum. “We decided to use the Vizient nurse residency program,” Gilland says. “I told Vizient what I’d like to do for ambulatory care, and they were very excited about that, partnering with us to do that.”

The Vizient/American Association of Colleges of Nursing Nurse Residency Program claims on its website that it maintains a first-year nurse retention rate of 95%.1 The residency curriculum that Gilland helped develop includes a monthly didactic classroom meeting. These classes cover communication skills, occupational injury, evidence-based practice, and other topics. The program requires all residents to complete an evidence-based practice project.

“Residents identify a problem or issue in their area, like in an ASC, and then they work with their mentor to address the problem,” Gilland explains.

They make a change and collect data after the change. Residents also can present their projects.

“Two of our residents will present their projects at the program graduation,” Gilland adds.

Obtain buy-in. Directors and nurse managers at Emory’s seven surgery centers had to decide if their unit was ready for a new graduate. There would need to be a preceptor and a buy-in culture for the residency program, Gilland says.

“So, directors would talk with their staff and providers, saying, ‘We want to bring a new graduate into this environment. What do you think?’” she says. “Everybody had to have buy-in.”

Some ASCs decided the program was not a good fit for them, maybe because of their size or for other reasons. But those who decided to hire new nurse residents were very engaged with the process, she says.

“We wanted the program to be successful and keep going, so we had to have current staff buy-in,” Gilland adds.

Train preceptors. The Emory residency program includes boot camp training for preceptors, covering their roles as educators, coaches, advocates, and role models, Gilland says.

“When talking about communication, we brought in experts from the patient and family experience department to talk about building tools,” she explains. “Most new graduates are millennials, and so we focus on that piece about how to best communicate with them.”

The boot camp occurs over one day, and 70 nurses volunteered for the first one.

“We also talk about how to handle challenging situations,” she says. “And we have an interactive part with real-life scenarios, asking how they would handle those.”

Lastly, preceptor training focuses on how to ease a recent nursing school graduate into the role of an autonomous nurse. “How do you let go? You have to begin with the end in mind,” Gilland says. “So, how do you nurture them and then step back from that? You want this person to be a successful surgery center nurse.”

Provide structure. The residency program offers curriculum that reflects each nursing setting. Nurse leaders and an education coordinator wrote a checklist and skills for the first 16 weeks of the residency program. They developed an onboarding process and an orientation.

“Nurse leaders and ASC leaders decided they wanted new grads to be well-rounded and have experiences in all areas,” Gilland says. “They can have experience in the surgery center’s operating room and touch on all of the other areas, too.”

This helps new nurses understand the entire ASC workflow, but it also gives them an idea of which area in which they would most like to work. A program supervisor makes sure preceptors are ready to take on the role, and she checks on them to make sure they are checking in with their residents weekly.

“It’s written into the preceptor structure that there are weekly check-ins and that preceptors know what their residents’ goals are for the week,” Gilland says.

The residency program also includes a competency assessment and validation tool that is completed by the orientee and the preceptor. (See sample competency assessment at the end of this article.)

Preceptors and residents complete a list of skills and competencies that were built into the program. The goal was to help the new graduates become independent.

By the time the new graduate has been on the job for four months, they might be ready for more autonomy and less preceptor oversight.

“The program is very structured with a lot of rigor to make sure they’re practicing safely and have the skills they need,” Gilland says. “We have weekly sheets to show the competencies they’re working with and the goals set for the next week.”

Complete the follow-up. For the last eight or so months of the residency year, preceptors and orientees engage in sit-down meetings to go over skills and goals. These meetings are not necessarily weekly, as they were for the first few months.

“The preceptor lets them work on their own, and checks in with them, but not at as frequent intervals,” Gilland explains. “The preceptor is there as a resource, but not to work as intensely side by side with them.”

The goal is to help the new nurses flourish and grow, she adds.

Tweak program. After the first group of nursing graduates entered the residency program, the program team decided to make changes for the next round. They planned to add simulation lab work.

“New nurses might learn about codes by having a mock code blue,” Gilland says. “They’d practice in the simulation lab to be part of the team.”

As nurses graduate from the residency program, Gilland will continue collecting information about their retention rates and career growth, hoping the metrics will confirm what she’s heard anecdotally about the residents.

“Everyone who works with them thinks they’re doing great work as part of the team,” she says.


  1. Vizient. Vizient/AACN Nurse Residency Program. Available at: http://bit.ly/2CoOgy6. Accessed Feb. 21, 2018.

Sample Items From Residency Competency Tool

Both residency program nurses and their preceptors complete the four-page Emory Clinic of Atlanta ASC BSN Residency Competency Assessment and Validation Tool. The new nurses and their preceptors complete the self-assessment part, judging the new nurse’s skills according to these three levels: Level 1 (limited experience and knowledge, competent in basic skills, has theory base, is task-oriented), Level 3 (acceptable competency and proficiency, minimum of one year experience and knowledge), and Level 5 (mastery experience, knowledge, competency; able to teach and supervise others). Below are some expected nursing competencies:

  • Pre-op Patient Assessment: Patient identification, correct surgical site, H&P (less than 30 days), consent (dated and timed), allergies documented, DVT assessment.
  • Physician Orders: Sign off, read back and verify for verbal order, physician signature and date for standing order.
  • Emergency Protocol: Defibrillator, crash cart location, Pediatric cart if applicable, Jump bag location (if applicable), AED (if applicable), malignant hyperthermia supplies, emergency number (for your site).
  • Documentation: Pre-assessment, pre-op, post-op, post-op phone calls.
  • Test Equipment for Safe and Proper Functioning: Overhead lights, electric equipment, suction equipment, mechanical equipment, OR furniture, oxygen and nitrous tank levels, check integrity of tourniquet cuff, proper handling/transporting of sterilized instruments, assessing sterilized package integrity and expiration date prior to opening.
  • Create and Maintain a Sterile Field: Maintains adequate distance when passing sterile field, reports any break in sterile technique with proper follow-up, opens sterile supplies to field without contamination after verifying sterile indicators and dates.