An Orientation Program for Unlicensed Assistive Personnel

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An Orientation Program for Unlicensed Assistive Personnel

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o keep pace with the evolving health care cli- on issues related to work flow and patients' expectamate, Children's Hospital Medical Center tions and needs. The team's charge was to examine and (CHMC), Cincinnati, developed a strategic streamline the entire perioperative system from patient initiative to augment staffing in clinical areas entry to discharge. while maintaining the organizational goals of The work redesign task force members studied quality patient care delivery, staff efficiency, and ways to reduce room turnover time, streamline cost containment. This initiative called for the devel- processes, eliminate redundant activities, and improve opment and implementation of multidimensional resource use and customer satisfaction. Parameters personnel (ie, unlicensed assistive personnel [UAP]). preset by the CHMC administrators stated that no Several years ago, the readditional personnel could be gional center for neonatal intensive allotted to the perioperative sercare within CHMC introduced the A B S T R A C T vices and support staff departUAP role as part of its clinical care The nursing profession has ments. As a result, the redesign team. Unlicensed assistive person- worked with unlicensed assis- task force members developed and nel assist RNs, licensed practical tive personnel (UAP) for dec- defined the role of a multiskilled nurses (LPNs), and respiratory ades; however, with the budget worker who was cross-trained to therapists in delivering care to cuts resulting from health care perform many tasks within the OR neonatal patients. As a result of redesign, some health care environment. changes in the health care arena, providers have expressed appreCHMC was challenged to improve hension about UAP roles (eg, CANDIDATE SELECTION PROCESS the quality and efficiency of care in nurse aides, orderlies, unit An interviewer and each its perioperative services depart- clerks). Staff members in the CDT applicant discussed the spement. Members of an OR work perioperative services depart- cific type of patients the CDT redesign task force considered the ment at Children's Hospital would be working with; that development of the UAP role with- Medical Center, Cincinnati, have the CDT might be exposed to in the OR setting and developed a defined a UAP role that en- graphic sights and strong smells; title for the OR multiskilled work- hances the OR'S efficiency in and any concerns that the applier: clinical department technician patient care and maintains the cant might have about handling cost-effective measures outlined blood products, tissue, or other (CDT). in the facility's strategic goals. A laboratory specimens. All CDT key element in the success of applicants were offered a tour of WORK REDESIGN The OR work redesign task this perioperative UAP role the OR and an observational visit force comprised 16 members from implementation has been the of at least one hour to assess three perioperative staff groups (ie, development of a competency- their potential working environenvironmental services personnel, based orientation program that ment. This experience prompted surgeons, and nurses). The team helps UAP develop and main- important questions that were not members studied data gathered tain their specific skills. AORN J considered during the interview. The first 12 staff members from perioperative staff members 66 (Sept 1997) 445-454. DENISE BAUER NYBERG. RN: JAMIE L. CAMPBELL. RN

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hired to fill the CDT roles were employees who transferred from other departments within CHMC. These 12 staff members included OR and postanesthesia care unit orderlies, clinical support sterilization and decontamination technicians, a pharmacy technician, a radiology clerk, an anesthesia technician, a child care assistant, and a receiving clerk. IMPLEMENTATION PHASE

A key element in the success of the CDT program was the development of a competency-based orientation program. Another task force was created to design the CDT job description and competencybased orientation program. The existing perioperative services department RN/surgical technologist orientation program, which consisted of 23 competencies and associated resources, was used as a template for the new program. The new task force consisted of an OR orderly, decontamination room technician, perioperative education coordinator, OR clinical coordinator, OR director, an OR staff nurse, and two perioperative service coordinators, who also served as preceptors for the current RN/surgical technologist orientation program. The orientation program task force began its charge by refining the original draft of the CDT job description. Job duties previously performed by the existing OR orderly role were expanded, which resulted in the orderly’s being an assigned room team member along with the scrub person and circulating nurse. Other orderly responsibilities included stocking OR supplies and equipment, delivering specimens, transporting patients, retrieving ordered medications from the pharmacy and blood from the blood bank, performing clerical work, and conducting OR suite supply checks. The task force members grouped the distinct components of the CDT job description together by similar tasks and developed an outline of potential competencies. These competencies then were incorporated into an 11-part orientation manual that reflected the major job categories outlined in the CDT job description. The orientation manual included sections perioperative overview, daily operations,

pediatric growth and development, professional behaviors, interpersonal communication, OR safety, perioperative documentation, sterilization and disinfection, supplies and equipment, surgical asepsis, and intraoperative care. THE COMPl3ENCIES

A competency-based orientation program provides a structured, comprehensive approach to the orientation process that ensures that employees can perform the activities required in their daily roles. In a competency-based orientation program, emphasis also is placed on the achievement of outcomes, not on the process.2 Goals for a competency-based program include developing an efficient method for inexperienced personnel to learn about their roles and responsibilities within the surgical environment, ensuring a standard orientation that can be measured, providing documentation of competent performance, determining learning needs and planning for remedial education if needed, addressing learning needs of potential staff members, and setting objective standards of performance that managers can use for performance evaluation.3 Measurement of staff members’ competency is essential to ensure the delivery of quality perioperative patient care. The measurement of competency begins during orientation and continues throughout a staff member’s employment. The CHMC perioperative services competencies have parallel content for all RNs, surgical technologists, and CDTs. Each competency format is divided into three sections: the description of goals for the staff member, learning activities required to develop competency, and the evaluation that documents competency (Table 1). Each competency contains resources to help the staff member complete the competency requirements. Other learning tools that enhance orientation (eg, guest speakers, videotapes, clinical supplies) are provided by the perioperative education coordinator. Applicants for the CDT role are required to have a

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Table 1 INTRAOPERATIVE CARE COMPITENCV EVALUATION

Employee name: Preceptor name:

Competency The orientee will be able to develop a general understanding of selected medical terminology, anatomy, and physiology concepts as they pertain to the OR setting; understandthe rationale of preoperative skin preps and draping; identify types of preoperative skin preps; demonstrate the role of assisting the nurse with patient preparation; identify basic surgical positions and types of OR beds; identify common injuries related to positioning; demonstrate proper patient transfer technique; demonstrate knowledge of the types of surgical draping used at Children’s Hospital Medical Center; understand the rationale of latex allergy precautions and locate the latex allergy cart; and identify and locate the unit resource for latex protocol.

Learning activities Review and discuss selected medical terminology, anatomy, and physiology concepts as they pertain to the OR setting. Read OR policy VI-104: Skin Prep for Sufgery Attend lectures, discussions, and demonstrations on positioning, different types of OR beds, positioning equipment (eg, arm board), and patient transfer. Read Children’s Hospital Medical Center protocol 1-2 1 8: Latex Allergy Protocol. Attend lecture and discussion on and review latex allergy cart.

Evaluation

Date met

Preceptor initials

The orientee verbalizes understanding of selected medical terminology, anatomy, and physiology concepts and relates them to the OR setting, participates in discussions and demonstrations, successfully completes return demonstration of assisting with preoperative skin prep, completes the positioning posttest, and completes the latex allergy posttest.

minimum of a general equivalency diploma or high school diploma. This requirement necessitated that all reading material provided have the minimum of a ninth-grade reading level. The first two competencies (ie, perioperative services, daily operations) focus on the daily business of the OR. The perioperative overview competency reviews organization and unit logistics. The daily operations competency allows us to review unit and CHMC policies and procedures and to conduct

the daily business (eg, OR schedule and staff assignments, clerical activities, personnel issues). The next competencies involve fundamental attributes of daily perioperative practice, including a review of medical terminology, anatomy, and physiology. The growth and development competency outlines the importance of the family-centered care philosophy and reviews appropriate play intervention skills to use with children. The professional behaviors and practices competency encompasses risk manage448

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ment issues (eg, patient care in the OR, diversity, accountability, ethics, confidentiality, delegation). The interpersonal communication and conflict resolution competency reviews appropriate and inappropriate verbal and nonverbal communication within the perioperative workplace. In this section, CDTs are asked to identify their own areas of needed growth and methods for managing conflict. Team building is emphasized, and each CDT attends two programs to enhance those skills. The first is a crisis intervention program that stresses nonviolent resolution and teaches attendees how to manage stressed and inappropriate behaviors of patients and family members. The second program is the “Lifo” training program, which is conducted by a formally trained, objective facilitator. This class provides a safe environment for participants to delve into their own communication patterns and interpersonal communication issues with peers. The final competencies focus on the technical aspects of the CDT role. The safety in the OR competency reviews the physical, chemical, and biologic hazards and their management in the perioperative setting. Universal blood and body fluid precautions and the Safe Medical Devices Act are emphasized. The perioperative documentation competency allows the CDT to identify the basic components of the surgical chart. The CDT learns to review the preoperative checklist and the patient’s consent form for completeness and accuracy. The principles of sterilization and disinfection competency compares sterilization and disinfection techniques and criteria. Demonstration of safe autoclave use, operation of the peracetic acid sterilizer, and gluteraldehyde solution mixing are required. The CDT also learns to check for the sterility integrity of items in hard containers, peel packs, and wrapped packages. Environmental services personnel provide an overview on the OR suite cleaning procedures. For the supplies and equipment competency, the CDT must demonstrate knowledge and understanding of the principles of maintaining adequate stock and storage of various surgical supplies and equipment. Each CDT also learns to retrieve surgeons’ preference cards and pull supplies for procedures. The successful completion of a scavenger hunt is required for evaluation of this competency. The principles of surgical asepsis competency reviews aseptic body language andtechnique, proper hand-washing procedures, isolation precautions, donning of sterile gloves, and

Simulated clinical settings are used to help evaluate the

orientee’s knowledge of the perioperative process.

opening sterile packages and supplies while maintaining a sterile field. The intraoperative care competency is a capstone experience that pulls together the competencies previously learned and reviews basic knowledge that the new CDT must have to function within the OR suite. In this competency, the CDT reviews principles of prepping, draping, and positioning; transfer techniques; and the latex allergy protocol delegated. Simulated clinical setting models are used to demonstrate and evaluate the CDT orientee’s acquired comprehensive knowledge of the perioperative process. The preceptor or perioperative education coordinator and orientee sign and date each competency as the CDT completes it. The completed packet is removed from the orientation manual and placed in the CDT’s unit personnel file. This document serves as the basis for the 90-day probationary and future evaluations. DlDACTlC AND CLINICAL ORlENTATlON STRUCTURE

The CDT begins studying the competency manual during a two-and-one-half-week didactic phase of the orientation program that includes formal classroom lectures and discussions, simulated clinical settings, and observational experiences. The CDT then moves into an intensive two-week clinical preceptorship with an RN preceptor who functions strictly in the capacity of a CDT. After this initial learning experience, the CDT continues to fulfill the remainder of the probationary period by working in the clinical setting with other preceptors and staff members who function in scrub person and circulating nurse roles. This clinical orientation plan is designed to foster the CDT’s independence in clinical practice and decisionmaking processes. Together, the RN preceptor and the

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Our clinical orientation plan

by the circulating nurses. The planning team members also explored how much patient care the CDT should perform, whether the orientation program was too broadbased or was specific enough to prepare the CDT effectively for his or her new responsibilities, whether the CDT would enjoy the confinement of his or her assignments to an individual OR suite and team, and whether the CDT role should become service specific or reflect a more general practice like that of other OR staff members.

is designed to foster independence in clinical practice and decision making.

EVAWATlON DURING IMPLEMENTATION

CDT assess the CDT's ongoing clinical needs and determine when the new CDT can function independently from the preceptor. The perioperative education coordinator frequently collaborates with the OR charge nurse and the preceptor/orientee pair to create the most effective learning assignments for the CDT orientee and lend continual support to the preceptor. PREPROGRAM EVALUATION

The successful use of assistive personnel requires perioperative nurses to examine and understand the issues of their practice, education, delegation, and liability as they relate to the use of UAP in perioperative care settings.l This new process for the CHMC perioperative services department raised a number of concerns from the planning team members, staff members, and ultimately the new CDT orientees during preprogram implementation planning sessions. A primary concern involved effective use of CDTs within the clinical coordinator's daily staffing plans. The planning team members discussed assigning CDTs in specifically grouped areas (ie, zones) of the OR versus using a 1:l CDT:OR suite or 1:2 CDT:OR suite ratio. The team members assessed which shifts would best be served by the CDT assignments. The planning team members also explored expanding the existing CDT job description to include cross-training in central sterile processing to fully decontaminate, terminally process, and set up instrument trays; participating in anesthesia technician role responsibilities (eg, stocking and maintaining anesthesia machines and carts with supplies and appropriate equipment); and performing OR suite clinical tasks such as preoperative skin preps-a task previously performed

Since the CDT role was created and implemented at CHMC, CDTs, other OR staff members, managers. and planning team members have continued to discuss issues and concerns related to this role. Operating room staff members. The OR staff members have been concerned about delegation issues. The CHMC OR has primarily an RN-dominated staff; therefore, staff members have indicated they are unsure of the delegation process. Questions raised include the following. Will CDTs be able to meet other OR staff members' needs? Will the CDT orientation plan contain enough information to prepare the CDT adequately for clinical responsibility and delegated tasks? What tasks can be delegated safely to the CDT? What happens if an RN chooses not to delegate these tasks? Will the CDT eventually replace the perioperative RN? The issue of CDTs performing preoperative skin prepping has been referred to the perioperative services department's nurse practice council because CHMC has a shared governance structure for the nursing division. The council has declined to expand the CDT role to include preoperative skin preps at this time because it believes the CDT role is still relatively new and needs to become more fully integrated within the department. To alleviate staff members' concerns during implementation of the CDT role, CHMC held staff development sessions. Through OR inservice programs, the planning team members introduced the work redesign plan, explored and defined the new CDT role and its integration into the OR team, discussed delegation issues pertaining to perioperative RN practices, and gave a summary of the development of the CDT orientation program's components 452

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Table 2 EVALUATION TOOL FOR CLINICAL DEPARTMENT TECHNICIANS

Assists OR team in Datient care

Weight Performance level* Total

Comments

Transports patients safely to and from OR. Checks patient‘s medical record for completion (eg, consent, allergies, medication administration record, nursing assessment, patient identification stamp). Assists in the OR anesthesia induction room and escorts parents to the OR waiting room or same day surgery unit. Assists with interdepartmental transportation of patients and family members. Comforts patients and families using open communication, reassurance, and diversianal activities as needed. Assists OR team members with positioning of patients. Assists in placing intraoperative anesthesia monitors as needed. Assists circulating nurse with preoperative skin prep as necessary, Displays proactive behavior and anticipatory skills/ initiative with assignments and OR team members. *E = excels; A = achieves; C = contributes; NI = needs improvement; DN = does not meet

and implementation plan. This process allowed existing nursing and ancillary staff members to begin to process the impending change and verbalize concerns about implementation issues. Implementation of the CDT role also was an opportunity for staff members to provide written additions or suggest deletions to the CDT training program. Clinical department technicians. Many CDTs questioned whether staff members would accept the new CDT role. This role was very different for OR staff members; therefore, impromptu meetings for CDTs, preceptors, staff members, planning team members, the education coordinator, and managers were held to decrease anxiety and increase the overall OR team performance. These meetings were regarded as interpersonal and role-conflict resolution sessions and usually were held at the end of the working day. At these meetings, participants evaluated the implementation process and staff members’ acceptance of the CDT role. Preceptors. The planning team members realized that a key to the success of this program was the recruitment of supportive preceptors who were open

to change and the new CDT role. The selected preceptors were experienced in precepting RNs and surgical technologists and possessed vast OR skill levels and knowledge of their peers’ practices. They embraced the challenge of performing as CDTs for the first time while teaching new CDT orientees. POSTPROGRAM EVALUATION

The education coordinator, managers, and some planning team members held monthly meetings to evaluate the CDT program. In addition to the weekly impromptu conflict and role resolution sessions, the information shared in the monthly meetings was valuable in revising the orientation process as needed and in integrating the CDT role into the staffing mix. Based on our evaluation, we would recommend a few changes in CDT orientation and role implementation that our facility would change. One person suggested that more preprogram implementation preparation for staff members might have been helpful. The planning team members responded that many staff members appeared ready to hear

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only some of what was presented early in the process. Staff members now, however, appear more comfortable with examining elements of the CDT role thoroughly and how it could be used within the OR setting. Many RNs identified how important it is to articulate what their work responsibilities are and how these responsibilities fit within the scope of perioperative nursing practice. As a result, they have begun conducting focus groups to analyze their contributions to the perioperative setting and discuss methods to use CDTs in patient care delivery more effectively. Although these focus groups might have been conducted in the preprogram implementation phase, we believe that issues discussed in earlier focus groups would have been speculative and conceptual. Discussion among the RNs is more effective now because issues explored are grounded on experiential data. We suggest that a preemployment literacy assessment be conducted of potential candidates to forestall any conflicts that may arise regarding orientation comprehension and clinical performance secondary to reading illiteracy. A committee that included a perioperative service coordinator, education coordinator, clinical coordinator, staff nurse, CDT preceptor, and two CDTs was formed after the program’s implementation. This committee was charged with developing an evaluation tool for CDTs (Table 2). The committee members defined a method for evaluating CDT’s performance, which includes maintaining supplies and equipment; assisting OR team members in patient care; ensuring a safe environment; and practicing effective communication, clerical,

and self-development skills. SUMMARY

As the scope of perioperative nursing practice changes, so will the activities delegated to UAP. Perioperative nurses must design work systems that incorporate UAP as one group that provides safe, accessible, and affordable perioperative patient care.5 Developing a competency-based orientation program for perioperative UAP ensures a strong knowledge base from which these employees may begin safe practice alongside multidisciplinary perioperative personnel.6 Our facility’s CDTs have shown great enthusiasm for learning new and existing duties within the OR setting. They have used their experience and maturity to help refine the orientation program on many levels. The presence of these enthusiastic individuals has presented OR staff members with many opportunities for personal and professional growth. The implementation of the CDT role has contributed to the overall progress of the teams that work interdependently within the penoperative setting. The CDT role implementation has helped the perioperative services department and the overall organization achieve the goal of enhancing the delivery of care for the patients and family members who visit CHMC. A Denise Bauer Nyberg, RN, BSN, CNOR, is the perioperative education coordinator at Children’s Hospital Medical Center, Cincinnati. Jamie Louise Campbell, RN, is a perioperative coordinator I I . otorhinolaryngology, at Children’s Hospital Medical Center, Cincinnati.

NOTES 1. J Wurstner, F Koch, “Role

ment 27 (August 1996) 35-38. 4. M L Phippen, C Applegeet,

redesign in perioperative settings,”

“Assistive personnel in the perioperative setting: Changing the paradigm,”

AORN Journal 61 (May 1995) 834844. 2. S Staab, S Granneman, T

Page-Reahr, “Examining competency-based orientation implementation,” Journal of Nursing Staff Development 12 (May/June 1996) 139143. 3. M Voorhees, “Using competency-based education in the periop erative setting,”Nursing Manage-

Seminars in Perioperative Nursing 1 (April 1992) 103-120. 5. Ibid. 6. Ibid. SUGGESTED READING Abbott, C A. “Intraoperative nurs-

ing activities performed by surgical technologists.” AORN Journul60 (September 1994) 382-393.

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American Nurses Association. “Position statement on registered nurse utilization of unlicensed assistive personnel.” American Nurse 25 (February 1993) 8. Phippen, M L; Applegeet, C . “Unlicensed assistive personnel in the perioperative setting.” AORN Journal 60 (September 1994) 455-457. Schrarmn, C A; Hoshowsky, V M. “Developing competency-based perioperative orientation programs.” AORN Journal 62 (October 1995) 579-590.