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First Assisting for RNs
AUGUST 1985, VOL 42, NO 2
AORN JOURNAL
First Assisting for RNs PLANNING AND IMPLEMENTING A COURSE
Jane Stover k k e , RN; Elizabeth A. McKnight, RN
T
he “AORN Official Statement on RN First Assistants,” approved by the House of Delegates in 1984, was followed up at Community Memorial Hospital, Menomonee Falls, Wis, by a first assistant course. The course was designed in the fall of 1984 to incorporate the RN first assistant guidelines into perioperative nursing. The course was developed specifically for nursing staff members who had one year intraoperative experience, could demonstrate perioperative nursing practice as both scrub and circulator, and were proficient in cardiopulmonary resuscitation. These prerequisites were meant to assure a minimum of common knowledge and experience among the participants.’ The ultimate goal of the course was to provide the RN first assistants with the knowledge and technical skills necessary to safely assist during an operation with optimal results for the patient. We used the steps of the nursing process to develop a course that would support the perioperative framework. The major benefit of using the nursing process is that most nurses are familiar with the assessment, planning, implementation, and evaluation steps.2
Assessment
A
comprehensive assessment was obtained to gain an accurate view of the program’s needs. This prerequisite information ensured the success of the course. Three groups’ needs were assessed: physicians, nursing staff, and hospital administrators.
We surveyed the hospital staff physicians to learn the need for and anticipated use of RN first assistants. The survey results indicated that some of the physicians would use a first asssistant if one were available. Other physicians indicated they were not sure if they would use a first assistant; nevertheless, they supported developing the role at the hospital. We asked the nursing staff if they would be interested in incorporating first assisting into their perioperative duties. Their responses indicated definite interest in broadening perioperative responsibilities. The next step was to assess the hospital administrators’ attitudes toward RN first assisting, because a first assistant program has a direct impact on staffing. The daily surgery schedule may require additional nursing staff members to fulfill requests for first assistants. It may be impractical for some hospitals to provide first assistants for scheduled operations and not provide them for unscheduled or emergency cases;and other hospitals may only need a first assistant on a regularly scheduled basis. Jane Stover Leske, RN, MSN, is msistant professor at the University of Wisconsin School of Nursing, Milwaukee. She teaches the advanced practicum in clinical nursing at Community Memorial Hospital, Menomonee Falls, Wis. She earned her MSN and her BSN from Marquette University, Milwaukee. Elizabeth A. MeKnight, W ,,5 assistant director of nursing-surgery services at Community Memorial Hospital, Menomonee Falls, W,5. She earned her diploma from St Mary’s School of Nursing, Wausau, Wis.
d) 1a5
AUGUST 1985, VOL 42, NO 2
AORN J O U R N A L
A first assistant program requires forming institutional guidelines into policy. Our policy was developed by a committee of various disciplines, ranging from the perioperative health care team to the hospital management representatives. We corresponded with professional groups, such as the state board of nursing and the American College of Surgeons, to ensure that our policy followed practice guidelines? We developed a policy before developing a course.
Planning n the early stages of planning the course, we followed guidelines set forth by hospital policy. We developed the didactic content of the course from a literature review and with the aid of a multidisciplinary committee. Our terminal objectives (didactic and supervised intraoperative experience), stated that after the course the participant would be able to 1. demonstrate proper wound exposure 2. demonstrate correct tissue handling 3. use techniques to maintain hemostasis 4. close subcutaneous and incisional sites 5. suture drains to skin edges 6. apply drapes to operative area 7. apply postoperative dressings 8. apply knowledge of infection control and aseptic principles 9. employ preventative and/or corrective action in regard to safety hazards 10. demonstrate professionalism throughout the procedure as a team member 11. use effective methods in handling stressful and emergent situations. Next, we created an outline for course content to meet each terminal objective. This outline guaranteed that the subject matter would be taught. An example of the third terminal objective and a brief description of its content is illustrated in Table 1. Also shown is an example of the techniques that may be used to teach the class, such as a lecture, demonstration, and/or discussion, and the faculty facilitator and estimated class time required. Each participant received a binder containing the complete didactic content of the course.
I
188
Table 1
Classroom Content Example I. Employ Methods of Maintaining Hemostasis a. Anatomy and physiology of blood vessels b. Natural method of hemostasis (coagulation process) c. Artificial method hemostasis I. Instruments 2. Pressure 3. Heat 4. Bonewax 5. Ligating clips 6. Thrombostat 7. Absorbable gelatin powder 8. Oxidized cellulose (surgical) 9. Microfibrillar collagen d. Types of clamps e. Practice in clamping 1. Manipulation of hemostat during vessel ligation 2. Clamp removal 3. Typing vessels clamped by hemostats 4. Instrument ties f. Cautery 1. Types 2. Modes 3. Techniques Demonstration-Clamp Vessel Tie Stick Tie Cautery
Ligation
Facilitator-Physician Time-ne hour
Selected articles, such as the newly developed hospital policy and established AORN guidelines, were also i n ~ l u d e dSpace .~ was left on each page for notes or writing remarks. Numerous illustrations showed how to clamp a vessel, perform a stick or instrument tie, and tie a two-hand and one-hand knot. Visual aids were also developed to help the participant master the appropriate psychomotor skills. After this planning was complete, we met with the O R nursing staff to review the course. Their comments helped us finalize the course content. Physicians also reviewed the proposed course, because they would supervise the first assistants. Following these meetings, we developed a tentative timetable for implementing the course.
AUGUST 1985, VOL 42, NO 2
AORN JOURNAL
Table 2
Surgical First Assistant Skill Sheet
Clamps blood vessel Ties vessel Cauterizes vessel Stick ties vessel Two-hand knot Surgeon’s knot One-hand knot Interrupted Stitch
I
I
I
I
I
I I
Over-and-over stitch Vertical mattress Horizontal mattress Subcuticular Skin staples Continuous Stirch
Over-and-over Vertical mattress Horizontal mattress Subcuticular ~~~
~
Cuts suture Sews drain to skin Drapes operative area Applies postoperative dressings
Implementation
T
he Surgical Department Committee decided that it could support an initial class of 10 participants from our operating room nursing staff. Because we anticipated that more than 10 participants would be interested, we announced when the course sign-up sheet would be available. The first 10 eligible staff members were accepted. We scheduled the eight-hour didactic content for the hospital classroom on two Saturday mornings, as had been requested. Physician faculty presented the first four-hour session, which
included wound exposure, tissue handling, hernostasis, wound closure, and drains. Personnel from the specialized areas of nursing management, nursing education, infection control, and occupational health taught the second session, which covered draping, dressings, infection control, safety hazards, professional conduct, and stress. We videotaped the didactic classes to encourage independent study when first assistants would be needed in the future. After these classes had been completed, we distributed a surgical first assistant skill sheet (Table 2). Because of cost-containment concerns, we needed an economical but effective way to ensure 189
AUGUST 1985, V O L 42. NO 2
AORN J O U R N A L
Fig 1. Independent practice of psychomotor skills.
competent performance. Therefore, every participant was instructed to practice skills independently, and then to demonstrate skills and competency in the presence of an RN faculty facilitator. In this way, participants mastered psychomotor skills at their own pace, were actively involved in the learning process, and were given responsibility for learning. After the laboratory practice section, each participant was scheduled for intraoperative experiences. Each participant’s performance was observed by a surgeon to determine whether a skill had been mastered.
Evaluation
E
valuation of a course such as ours can be difficult. We asked staff members to keep notes regarding their first assistant experiences during the first month of implementation of the program and asked each participant for ways to improve the course. Within one month, we held a follow-up meeting with staff to solve any problems. Program evaluation also depended upon a credentialing process and a method of continued assessment of skill proficiency.
AUGUST 1985, VOL 42, NO 2
AORN JOURNAL
Fig 2. Demonstrating learned psychomotor skills intraoperatively.
Credentialing Process. The surgical first assistant skill sheet is a major part of this process. Motor skills are best learned by breaking a complex task into smaller parts, mastering each part, and then practicing the entire task? The laboratory practice section required participants to demonstrate their knowledge to the RN facilitator. Direct observation is the best way to evaluate psychomotor skills. The surgeon validated the accomplishment of each skill by initialing the skill sheet. Once the skill sheet had been completed, the participant had to obtain a hospital credential
form. The form included authorization of the participant’s role as first assistant from the assistant director of nursing/surgery services, the patient care coordinator/surgery services, the director of nursing, the vice-president of nursing, and the chairman of the department of surgery. Participants obtained these signatures by presenting evidence of attendance at the eight-hour didactic session and the completed skill sheet demonstrating knowledge in the laboratory and surgical settings. The credential form was then placed in the participant’s personnel file, and a completed nonphysician first assistant privilege card was kept 191
AORN JOURNAL
in the OR for quick reference. This credentialing process ensured that the first assistant was qualified to function following the institution’s guidelines? Continued Assessment of Proficiency. The Surgical Department Committee can assist in developing guidelines for continuing assessment of first assistant proficiency. Currently, we plan to solicit suggestions and concerns from both surgeons and first assistant participants. Nurse managers, with surgeons’ assistance, will monitor proficiency. We plan to schedule evaluations to coincide with annual performance evaluations. We are also currently developing a procedure to facilitate proficiency assessment. Practice privileges for the nonphysician first assistants were established by the hospital. The process of granting privileges includes assessing individuals’ qualifications for practice and continued proficiency and evaluating performance annually? Our program is too new to state definite evaluation and outcomes. We are promoting communication between staff, physicians, and hospital administrators, and we realize that evaluation is a continuous process of reassessment, replanning, and modification. The four steps of assessment, planning, intervention, and evaluation were helpful in organizing and developing our program. It has been a timeconsuming task, not without anxieties and apprehensions. Nevertheless, a commitment to support this concept of increased perioperative responsibility for the nursing staff has been 0 established. Notes 1. John M Clochesy, “Preparing senior nursing students through optional clinical experiences,” Dimensions in Critical Care Nursing 2 (NovemberDecember 1983) 366-370. 2. Catherine Nuss Kotecki, “Planning critical care experiences for students,” Dimenswns in Critical Care Nursing 2 (January-February 1983) 50-55. 3. Ellen K Murphy, “When is the RN first assistant protected by institutional policy?“ AORN Journal 40 (September 1984) 436-440. 4. “AORN Official Statement on RN First Assistants,” AORN Journal 40 (September 1984) 441443. 5. Phyllis Wells, “Evaluating learning: A teaching plan for emergency procedures.’’ AORN Journal 38 192
AUGUST 1985, VOL 42, NO 2
(July 1983) 125-130. 6, Ellen K Murphy, “When is the RN first assistant practicing within the scope of nursing?” AORN Journal 40 (August 1984) 257. 7. Colleen K Harvey, “Clinical Issues,” AORN Journal 40 (December 1984) 832-834.
Treatment for Neonatal Chlamydia1 Infections Oral erythromycin was 93% effective in eliminating chlamydial infections in newborns, according to a study reported in the June issue of the American Journal of Dkeaes of Children. Alfred D. Heggie, MD, and colleagues from Case Western University School of Medicine, Cleveland, compared oral erythromycin estolate with 10%sulfacetamide sodium ophthalmic solution in the treatment of chlamydial conjunctivitis. The ophthalmic solution was only 43% effective. In addition, the researchers said the ophthalmic solution “may result in persistent conjunctival infection and nasopharyngeal colonization.” If untreated, the conjunctivitis can spread to the respiratory tract and cause chlamydial pneumonia.
New Director Named for Student Nurse Group The National Student Nurses’Association, Inc (NSNA), New York City, has announced that Robert Piemonte, EdD, RN, has assumed the position of executive director. Since 1983, Dr Piemonte has been director of the division of house, board, and cabinet affairs for the American Nurses’ Association, Kansas City, Mo, and was adjunct assistant professor at the University of Kansas College of Nursing. He was deputy executive director of the NSNA from 1980 to 1983. Dr Piemonte has a doctorate in nursing education, as well as master’s degrees in medicalsurgical nursing supervision and nursing service administration.
AORN JOURNAL
First Assisting for RNs PLANNING AND IMPLEMENTING A COURSE
Jane Stover k k e , RN; Elizabeth A. McKnight, RN
T
he “AORN Official Statement on RN First Assistants,” approved by the House of Delegates in 1984, was followed up at Community Memorial Hospital, Menomonee Falls, Wis, by a first assistant course. The course was designed in the fall of 1984 to incorporate the RN first assistant guidelines into perioperative nursing. The course was developed specifically for nursing staff members who had one year intraoperative experience, could demonstrate perioperative nursing practice as both scrub and circulator, and were proficient in cardiopulmonary resuscitation. These prerequisites were meant to assure a minimum of common knowledge and experience among the participants.’ The ultimate goal of the course was to provide the RN first assistants with the knowledge and technical skills necessary to safely assist during an operation with optimal results for the patient. We used the steps of the nursing process to develop a course that would support the perioperative framework. The major benefit of using the nursing process is that most nurses are familiar with the assessment, planning, implementation, and evaluation steps.2
Assessment
A
comprehensive assessment was obtained to gain an accurate view of the program’s needs. This prerequisite information ensured the success of the course. Three groups’ needs were assessed: physicians, nursing staff, and hospital administrators.
We surveyed the hospital staff physicians to learn the need for and anticipated use of RN first assistants. The survey results indicated that some of the physicians would use a first asssistant if one were available. Other physicians indicated they were not sure if they would use a first assistant; nevertheless, they supported developing the role at the hospital. We asked the nursing staff if they would be interested in incorporating first assisting into their perioperative duties. Their responses indicated definite interest in broadening perioperative responsibilities. The next step was to assess the hospital administrators’ attitudes toward RN first assisting, because a first assistant program has a direct impact on staffing. The daily surgery schedule may require additional nursing staff members to fulfill requests for first assistants. It may be impractical for some hospitals to provide first assistants for scheduled operations and not provide them for unscheduled or emergency cases;and other hospitals may only need a first assistant on a regularly scheduled basis. Jane Stover Leske, RN, MSN, is msistant professor at the University of Wisconsin School of Nursing, Milwaukee. She teaches the advanced practicum in clinical nursing at Community Memorial Hospital, Menomonee Falls, Wis. She earned her MSN and her BSN from Marquette University, Milwaukee. Elizabeth A. MeKnight, W ,,5 assistant director of nursing-surgery services at Community Memorial Hospital, Menomonee Falls, W,5. She earned her diploma from St Mary’s School of Nursing, Wausau, Wis.
d) 1a5
AUGUST 1985, VOL 42, NO 2
AORN J O U R N A L
A first assistant program requires forming institutional guidelines into policy. Our policy was developed by a committee of various disciplines, ranging from the perioperative health care team to the hospital management representatives. We corresponded with professional groups, such as the state board of nursing and the American College of Surgeons, to ensure that our policy followed practice guidelines? We developed a policy before developing a course.
Planning n the early stages of planning the course, we followed guidelines set forth by hospital policy. We developed the didactic content of the course from a literature review and with the aid of a multidisciplinary committee. Our terminal objectives (didactic and supervised intraoperative experience), stated that after the course the participant would be able to 1. demonstrate proper wound exposure 2. demonstrate correct tissue handling 3. use techniques to maintain hemostasis 4. close subcutaneous and incisional sites 5. suture drains to skin edges 6. apply drapes to operative area 7. apply postoperative dressings 8. apply knowledge of infection control and aseptic principles 9. employ preventative and/or corrective action in regard to safety hazards 10. demonstrate professionalism throughout the procedure as a team member 11. use effective methods in handling stressful and emergent situations. Next, we created an outline for course content to meet each terminal objective. This outline guaranteed that the subject matter would be taught. An example of the third terminal objective and a brief description of its content is illustrated in Table 1. Also shown is an example of the techniques that may be used to teach the class, such as a lecture, demonstration, and/or discussion, and the faculty facilitator and estimated class time required. Each participant received a binder containing the complete didactic content of the course.
I
188
Table 1
Classroom Content Example I. Employ Methods of Maintaining Hemostasis a. Anatomy and physiology of blood vessels b. Natural method of hemostasis (coagulation process) c. Artificial method hemostasis I. Instruments 2. Pressure 3. Heat 4. Bonewax 5. Ligating clips 6. Thrombostat 7. Absorbable gelatin powder 8. Oxidized cellulose (surgical) 9. Microfibrillar collagen d. Types of clamps e. Practice in clamping 1. Manipulation of hemostat during vessel ligation 2. Clamp removal 3. Typing vessels clamped by hemostats 4. Instrument ties f. Cautery 1. Types 2. Modes 3. Techniques Demonstration-Clamp Vessel Tie Stick Tie Cautery
Ligation
Facilitator-Physician Time-ne hour
Selected articles, such as the newly developed hospital policy and established AORN guidelines, were also i n ~ l u d e dSpace .~ was left on each page for notes or writing remarks. Numerous illustrations showed how to clamp a vessel, perform a stick or instrument tie, and tie a two-hand and one-hand knot. Visual aids were also developed to help the participant master the appropriate psychomotor skills. After this planning was complete, we met with the O R nursing staff to review the course. Their comments helped us finalize the course content. Physicians also reviewed the proposed course, because they would supervise the first assistants. Following these meetings, we developed a tentative timetable for implementing the course.
AUGUST 1985, VOL 42, NO 2
AORN JOURNAL
Table 2
Surgical First Assistant Skill Sheet
Clamps blood vessel Ties vessel Cauterizes vessel Stick ties vessel Two-hand knot Surgeon’s knot One-hand knot Interrupted Stitch
I
I
I
I
I
I I
Over-and-over stitch Vertical mattress Horizontal mattress Subcuticular Skin staples Continuous Stirch
Over-and-over Vertical mattress Horizontal mattress Subcuticular ~~~
~
Cuts suture Sews drain to skin Drapes operative area Applies postoperative dressings
Implementation
T
he Surgical Department Committee decided that it could support an initial class of 10 participants from our operating room nursing staff. Because we anticipated that more than 10 participants would be interested, we announced when the course sign-up sheet would be available. The first 10 eligible staff members were accepted. We scheduled the eight-hour didactic content for the hospital classroom on two Saturday mornings, as had been requested. Physician faculty presented the first four-hour session, which
included wound exposure, tissue handling, hernostasis, wound closure, and drains. Personnel from the specialized areas of nursing management, nursing education, infection control, and occupational health taught the second session, which covered draping, dressings, infection control, safety hazards, professional conduct, and stress. We videotaped the didactic classes to encourage independent study when first assistants would be needed in the future. After these classes had been completed, we distributed a surgical first assistant skill sheet (Table 2). Because of cost-containment concerns, we needed an economical but effective way to ensure 189
AUGUST 1985, V O L 42. NO 2
AORN J O U R N A L
Fig 1. Independent practice of psychomotor skills.
competent performance. Therefore, every participant was instructed to practice skills independently, and then to demonstrate skills and competency in the presence of an RN faculty facilitator. In this way, participants mastered psychomotor skills at their own pace, were actively involved in the learning process, and were given responsibility for learning. After the laboratory practice section, each participant was scheduled for intraoperative experiences. Each participant’s performance was observed by a surgeon to determine whether a skill had been mastered.
Evaluation
E
valuation of a course such as ours can be difficult. We asked staff members to keep notes regarding their first assistant experiences during the first month of implementation of the program and asked each participant for ways to improve the course. Within one month, we held a follow-up meeting with staff to solve any problems. Program evaluation also depended upon a credentialing process and a method of continued assessment of skill proficiency.
AUGUST 1985, VOL 42, NO 2
AORN JOURNAL
Fig 2. Demonstrating learned psychomotor skills intraoperatively.
Credentialing Process. The surgical first assistant skill sheet is a major part of this process. Motor skills are best learned by breaking a complex task into smaller parts, mastering each part, and then practicing the entire task? The laboratory practice section required participants to demonstrate their knowledge to the RN facilitator. Direct observation is the best way to evaluate psychomotor skills. The surgeon validated the accomplishment of each skill by initialing the skill sheet. Once the skill sheet had been completed, the participant had to obtain a hospital credential
form. The form included authorization of the participant’s role as first assistant from the assistant director of nursing/surgery services, the patient care coordinator/surgery services, the director of nursing, the vice-president of nursing, and the chairman of the department of surgery. Participants obtained these signatures by presenting evidence of attendance at the eight-hour didactic session and the completed skill sheet demonstrating knowledge in the laboratory and surgical settings. The credential form was then placed in the participant’s personnel file, and a completed nonphysician first assistant privilege card was kept 191
AORN JOURNAL
in the OR for quick reference. This credentialing process ensured that the first assistant was qualified to function following the institution’s guidelines? Continued Assessment of Proficiency. The Surgical Department Committee can assist in developing guidelines for continuing assessment of first assistant proficiency. Currently, we plan to solicit suggestions and concerns from both surgeons and first assistant participants. Nurse managers, with surgeons’ assistance, will monitor proficiency. We plan to schedule evaluations to coincide with annual performance evaluations. We are also currently developing a procedure to facilitate proficiency assessment. Practice privileges for the nonphysician first assistants were established by the hospital. The process of granting privileges includes assessing individuals’ qualifications for practice and continued proficiency and evaluating performance annually? Our program is too new to state definite evaluation and outcomes. We are promoting communication between staff, physicians, and hospital administrators, and we realize that evaluation is a continuous process of reassessment, replanning, and modification. The four steps of assessment, planning, intervention, and evaluation were helpful in organizing and developing our program. It has been a timeconsuming task, not without anxieties and apprehensions. Nevertheless, a commitment to support this concept of increased perioperative responsibility for the nursing staff has been 0 established. Notes 1. John M Clochesy, “Preparing senior nursing students through optional clinical experiences,” Dimensions in Critical Care Nursing 2 (NovemberDecember 1983) 366-370. 2. Catherine Nuss Kotecki, “Planning critical care experiences for students,” Dimenswns in Critical Care Nursing 2 (January-February 1983) 50-55. 3. Ellen K Murphy, “When is the RN first assistant protected by institutional policy?“ AORN Journal 40 (September 1984) 436-440. 4. “AORN Official Statement on RN First Assistants,” AORN Journal 40 (September 1984) 441443. 5. Phyllis Wells, “Evaluating learning: A teaching plan for emergency procedures.’’ AORN Journal 38 192
AUGUST 1985, VOL 42, NO 2
(July 1983) 125-130. 6, Ellen K Murphy, “When is the RN first assistant practicing within the scope of nursing?” AORN Journal 40 (August 1984) 257. 7. Colleen K Harvey, “Clinical Issues,” AORN Journal 40 (December 1984) 832-834.
Treatment for Neonatal Chlamydia1 Infections Oral erythromycin was 93% effective in eliminating chlamydial infections in newborns, according to a study reported in the June issue of the American Journal of Dkeaes of Children. Alfred D. Heggie, MD, and colleagues from Case Western University School of Medicine, Cleveland, compared oral erythromycin estolate with 10%sulfacetamide sodium ophthalmic solution in the treatment of chlamydial conjunctivitis. The ophthalmic solution was only 43% effective. In addition, the researchers said the ophthalmic solution “may result in persistent conjunctival infection and nasopharyngeal colonization.” If untreated, the conjunctivitis can spread to the respiratory tract and cause chlamydial pneumonia.
New Director Named for Student Nurse Group The National Student Nurses’Association, Inc (NSNA), New York City, has announced that Robert Piemonte, EdD, RN, has assumed the position of executive director. Since 1983, Dr Piemonte has been director of the division of house, board, and cabinet affairs for the American Nurses’ Association, Kansas City, Mo, and was adjunct assistant professor at the University of Kansas College of Nursing. He was deputy executive director of the NSNA from 1980 to 1983. Dr Piemonte has a doctorate in nursing education, as well as master’s degrees in medicalsurgical nursing supervision and nursing service administration.