Improving the Onboarding Process in the EP Lab

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EP LAB DIGEST. 2023;23(10):22.

New hires in specialty health care, both in nursing and technician roles, typically learn through on-the-job training. They work alongside experienced mentors or preceptors who guide them through the challenges of the role, explain tasks in real time, and push them to demonstrate competence. However, many electrophysiology (EP) labs seem to lack resources to effectively onboard their staff. Why does an on-the-job training approach not work as well in the EP lab?

For one, EP is complicated. Even for a seasoned nurse or technician, simply acclimating to this unique environment can require weeks. One must become familiar with pacing, recording systems, ablators, sterile fields, mapping systems, pin blocks, cables, etc. It can be easy to feel overwhelmed. Getting comfortable with the electrocardiogram (EKG) sweep speed and not peeking at the anesthesia monitor for the comfort of a narrow QRS can take a few weeks. The experience of joining an EP lab can be intimidating and challenging.

A good preceptor should be patient, understand EP at a high level, love to teach, build confidence in EP brick-by-brick, and allow for questions in a safe learning environment. But even with a great preceptor and the motivation to learn, it can still take more than 6 months to be able to independently monitor, circulate, and scrub all EP cases. It is assumed that all EP labs have qualified preceptors to onboard new staff. But this is not always the case—especially with newly formed labs. Why don’t all labs have experienced staff eager to share their EP knowledge with the new EP staff member? One reason might be the demand for such expertise in the industry. For instance, if a nurse or tech reaches the level of understanding where they question a vendor about whether a premature ventricular contraction (PVC) is on the papillary muscle based on pre-case EKG readings, they might get a lucrative job offer from the vendor after the case, leaving a lab without their most experienced EP employee.

Another example could be the skilled nurse who chooses to maximize their earning potential by taking a 6-week contract in a highly desirable area, potentially earning their usual half-year salary in a much shorter period. However, this choice contributes to a cycle that puts labs in a difficult situation, as they find themselves needing contract labor to replace the very staff that have now entered the contract labor market.

Sometimes, even though a seasoned educator remains physically in the lab, they might mentally disengage from training due to high staff turnover. Initially, these educators put in a tremendous amount of effort into training new hires, dedicating 6 months or more to the new staff’s development, only to see them leave before their second year. As a result, this repetitive cycle of training and turnover can lead to burnout for the educators, who bear the constant responsibility of onboarding new hires with minimal support.

What if the lab does not have an expert educator? Where does the staff go to learn about EP? What if the staff is not motivated to learn on their own?

Inevitably, they go somewhere else. Unfortunately, this happens often, with 20% of turnover happening within the first 45 days.¹ This may happen because new hires (even those with experience) feel overwhelmed and incapable of grasping the necessary knowledge, ultimately choosing to leave. The consequence is a significant loss of time and money invested that yields no productive results.

Contrast this with the potential of a well-structured onboarding process. According to one study, 69% of employees who had a positive onboarding experience were more likely to stay with a company for 3 years or more.²

So what does great onboarding in the EP lab look like? How can EP knowledge be best translated to create a high-functioning EP team? Below are 5 ways to improve the EP onboarding process:

1. Start from square one: Presuming prior knowledge is dangerous, especially in health care. When a nurse is hired, it is assumed they understand the conduction system, cardiac A&P, how to respond in an emergency, and so on. Unfortunately, these topics are sometimes not sufficiently covered, leaving new hires struggling to comprehend other intricacies of the job. This can especially be true in the EP lab, where there is so much to learn in a short amount of time.

2. Focus on the “need to know” vs the “nice to know”: Let’s say a staff member wants to learn how to perform para-Hisian pacing. Before diving into this advanced technique, they must first be able to reliably explain and perform a basic EP study. They must concentrate on mastering the fundamental aspects of their role and develop the ability to explain these clearly to others. True proficiency is reflected in one’s capacity to share knowledge. Once the basics are firmly grasped, then it is time to tackle more complex topics. Doing so prematurely could lead to burnout and disengagement.

3. Support great preceptors: Even if the staff are able and willing to train new hires, they need support—external assistance, a steady curriculum, and sufficient time to teach outside of the pressure of live cases. Even the most willing preceptors can experience burnout, especially if turnover is high and a new group of nurses/technicians arrive every 6 months. Consider a mentorship program that can continue to support staff, from novice to expert.

4. Do not rely on physicians to provide orientation: Physicians have multiple competing priorities in their practice. Even with a desire to teach new staff, they might find it challenging to relate to the perspective of a fresh graduate who needs to grasp the EP basics. Their lectures should be considered an addition to an already structured onboarding process.

5. Cross-train current staff: Not all staff members aspire to become #EPeeps, research accessory pathways in their free time, or aim to identify the PVC origin before the physician does (and that is completely okay). One solution is to cross-train existing cath lab staff with sufficient practical knowledge to cover for dedicated EP staff during lunches and sick days. By teaching practical skills and maintaining simplicity in EP concepts, an effective cross-training program can be developed. This is an excellent way to promote interest in EP by “demystifying” what goes on in the lab. You may even find someone who desires to transition to EP but needed a trial run before fully committing to this subspecialty. 

References

1. Wright M. The first 45 days are crucial for new nurse retention. PressGaney. Published March 20, 2023. Accessed June 7, 2023. https://info.pressganey.com/press-ganey-blog-healthcare-experience-insights/the-first-45-days-for-new-nurses-are-crucial-for-retention

2. Hirsch AS. Don’t underestimate the importance of good onboarding. SHRM. Published August 10, 2017. Accessed June 7, 2023. www.shrm.org/resourcesandtools/hr-topics/talent-acquisition/pages/dont-underestimate-the-importance-of-effective-onboarding.aspx

Disclosure: Clayton Stiles, RN, BSN, RCES, discloses that he is the Chief Executive Officer of Lightbulb Cardiac.