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Baccalaureate Education of Nurses vs OR Experience
BACCALAUREATE EDUCATION OF NURSES vs OR EXPERIENCE Jeanne Riddle, R.N. As a director of nursing service I feel great concern as to who will be in charge of the operating room ten years from now. If we continue in the direction we are going there will be no nurses there! For some time now, those responsible for directing collegiate programs have assumed that operating room nursing is not patientcentered and that only the conscious patient can be the recipient of such patient care. Some nurse educators believe that this job is purely technical, with no relation to nursing care and that consequently, it needs no nurse. Miss Riddle is a graduate of Indiana University Training School of Nursing at Indianapolis, and has a B.S. in Nursing Education from Indiana University, Bloomington, Indiana. Currently Miss Riddle is Director of Nursing Service at Norfolk General Hospital, Norfolk, Virginia. For nine years Miss Riddle served the Veterans Administration in furthering nursing education and administration, with posts in Indianapolis, New Orleans, La., and Dallas, Texas. She has also held nursing directorships in the R e x Hospital, Raleigh, N.C.; Memorial Hospital of W a k e County, Raleigh, N.C.; and Moses Cone Memorial Hospital, Greensboro, N.C. This article b y Miss Riddle is based on her talk at the A O R N Regional Institute on Operating Room Nursing in Norfolk, Virginia, November, 1964.
Sept-Oct 1965
The bright, alert OR nurses are presently being withdrawn from the operating room table to circulate, supervise or instruct. Comprehensive nursing care is now safeguarded by the nurse whose responsibility is centered around the use of technicians. Yet there is a steady increase in the number of operating rooms, the number of surgical operations, and the number of times the operating room space is used.1 Professional schools of nursing have added courses in the social and behavorial sciences as well as in liberal education. These additional hours of classes make it difficult to include all subjects formerly taught. Thus, operating room nursing has been omitted from such programs. This omission has been justified in a variety of claims: 1 ) That aseptic technique taught in surgery can be provided for in conjunction with other learning experiences without expenditure of time in the operating room. 2) That surgery is a specialty, the basic skills of which are not needed by a nurse in other clinical areas. 3) That the philosophy of basic nursing programs is not to prepare nurses to specialize. 4) That all specialization, functional or clinical, belongs to the post-baccalaureate level.2 The baccalaureate program fosters a program in observation. This includes having the student prepare the patient for surgery,
79
accompany him to the OR, observe the operation and, go with him through the recovery room and back to the floor, and there care for him on the ward unit each day until discharge. Some schools send the student on follow-up calls into the home of the patient. This extends the experience further, noting the patient’s return to home, family and community. As a consumer of the services of professional registered nurses, what does all of this mean to me? It means that fewer nurses are interested in the operating room, and fewer nurses are prepared for this important area of the hospital-for which I am responsible. Patients in the OR need just as good care as those on the floors. We all know that since World War I1 we have had to utilize the operating room product of that era and that we have come to use more and more OR technicians. With the population explosion, need for more hospital beds, and necessity for more surgery, the number of rooms in operating suites have been greatly increased. We can all remember when four to six rooms were average. Now it is not unusual to have a surgery suite with ten to 20 operating rooms. Each year fewer graduates apply for the operating room, one reason being the lack of emphasis placed on this area of nursing in the baccalaureate program and another, a decrease in such experience in all other nursing programs. A new graduate going into the OR walks into a very difficult situation. She has no confidence in her ability to function with so little basic preparation. Since she lacks the competence she needs, she has no feelings of security. A new graduate often feels inferior to the trained technician. Such a situation can be very traumatic. A nurse who understands what takes place in the OR will be much less fearful. She does not have such an understanding unless she has been a member of the team and learned to appreciate how this complex unit
80
is organized and how it functions. Let us suppose that this new graduate aspires to become an operating room nurse. The nurse educator answers this way, “Let her go and take a supplemental course in operating room work.” There are, however, only a few such programs, and for a very good reason. Such programs are usually situated in a hospital that is basically using these graduate nurses for the service they render. There is little regard for the educational aspect of that experience. In many such programs, classes are cancelled during a busy operative day, since these hospitals do not employ much in the way of graduate staff but rely on these “students” for service. I said there are few such programs, for today young women refuse to be exploited. Another alternative for this graduate who might like to try the operating room is to set up a program of supervised experience within the surgery unit. This is very expensive in time, for both the graduate and the hospital instructor. Many hospitals maintain an on-going inservice program which includes a good orientation program for new nurses in the department, but this particular graduate does not fit into such a scheme. She must be taught from the beginning. Each faculty must determine sound objectives and goals for its students. A curriculum which sets up a designated plan for student experience in the operating room assures the student a wealth of specialized knowledge, added to her general education. The prime objective of OR nursing should be the contribution made to the welfare of the surgical patient during his hospitalization. The student’s role in surgery should be visualized in relation to the patient’s return to good health. The experience will aid the student to become a better nurse. Another goal includes the learning of basic aseptic technique which can be applied to other phases of nursing care. In addition, anatomical structures and the principles of
AORN Journal
physiology are better understood. The student should have the opportunity to practice whatever she learns. In the OR, the application of aseptic technique is practiced in the fullest sense. Operating room experience is essential for the student if she is to learn fully the nursing care of the surgical patient. She learns the importance of being a member of a team where the element of time is precious. She participates in emergency situations and recognizes the value of emotional stability and mental alertness. Further, the student receiving OR experience will appreciate the professional nurse’s responsibility for maintaining a well organized unit, setting a good example, and knowing underIying safety measures which dictate the technique of every procedure in providing safe care. The prime purpose of operating room experience should be that the student nurse thoroughly understand the reasons for conscientious preoperative preparation, and realize the effect surgery has on the postoperative, rehabilitative, and convalescent care of the patient. It is true that all these goals may be reached elsewhere in the curriculum-to some degree. However, now that many OR supplies are sterilized outside of the unit, and with the advent of prepackaged sterile supplies, there is little opportunity elsewhere in the hospital to learn about sterilization techniques, or what a sterile field really is. When the student nurse is oriented to the operating room and is guided in such experiences, she will acquire basic concepts and understanding which she cannot acquire as fully in any other experience. Yes, she can be exposed to these concepts, but she cannot acquire them as fully as she will in surgery. In a recent article, Sister M. Evangelist of San Antonio outlined the reasons for experience in the clinical areas, saying that the instructor selects patients for students on
Sept-Oct 1965
the basis of certain criteria.3 These are: 1) The experience should provide an opportunity for the student to practice the behavior as implied in the objectives of the course. 2) The student should have an opportunity to apply her knowledge in the situation. 3 ) The experience should be satisfying, meaningful, and sufficiently varied to provide a challenge. 4) The student should feel her personal objectives are being met. I ask you, cannot these criteria, every one, be fulfilled in the operating room? I say they can! In this same article, Sister Evangelist says : “We have taken away most nursing techniques from the professional nurse and given them to the technician and the practical nurse. We have failed to fill this void with professional nurse functions. We have delegated paper work, managerial duties and a host of unrelated tasks to the nurse. She is unable to practice comprehensive nursing care today as we desire it and in turn is blamed for this inability.” Early in this paper, mention was made of the operating room technician. How do the nurses and doctors feel about this person? Is there a place on the OR team for such a member? My answer is “Yes.” Just as the practical nurse is a much needed member on the ward unit, the operating room technician can contribute effectively and serve a real purpose as a member of the surgical team. However, the presence of the technician does not take away the need for the professional nurse. When the technician is brought in, the OR nurse becomes even more important. The role of the professional nurse must develop into one of leadership. She will assume duties of a guide and teacher. Her competence as an operating room nurse has long been graded and measured by the degree of her manual dexterity. Now she must accept the fact that her importance is measured by her leadership ability, and she must realize how her talent can best serve the
81
surgeon and patient in this role. In Missouri, the operating room technician is doing work in the afternoons formerly done by nurses, such as picking instruments, folding linen, and preparing packs. Thus, the nurse is freed to make rounds with the anesthesiologist, meeting and getting acquainted with patients who are being prepared for surgery the following day. With such shifted emphasis to patient-centered care and teaching, these nurses do better work, they are getting more job satisfaction, and are remaining longer in their jobs. The operating room nurse has to be a special kind of person. This job makes great physical, mental and emotional demands. It is more than technical skill, it is truly a specialty that requires dedication. It demands good relationships and understanding between nurse and semi-conscious patient, nurse and surgeon, nurse and anesthetist, nurse and technician. Now, to answer the second question propounded earlier-“How does the doctor feel about the OR technician?” Even though many doctors are of necessity being assisted at the table by the technician, I would like to refer you to Dr. Ernest A. Gould, a surgeon who speaks for many surgeons in his She paper “The Operating Room Nurse-Is a Dying Species?” In this article, Dr. Gould says that the facts are: “1) a surgical nurse is the product of the professional background of nursing and has an interest in surgical pathology, plus acquired technical proficiency
that takes years to develop; 2) the surgical nurse looks at her profession with pride and with a feeling of responsibility and concern for the patient undergoing surgery; 3) the surgical nurse, because of the aforementioned, is therefore an important member of a professional team treating a patient, and, who because of her background and humanity, adds to the probability of a successful outcome from the surgical adventure.”4 In closing, I would like to compliment each of you who belong to this Association which has been organized especially for you as an operating room nurse. You are a forceful group. I am sure you do not want the operating room to be void of nurses in the future. Therefore, I challenge you, through your organizational strength, to make it known that operating room nursing is essential in the students’ experience. We must recognize the subtle changes that take place. It may be that emphasis on words should be changed-let us not talk about the “scrub nurse” but the surgical nurse, one who is not only proficient but one who takes her place on the surgical team as a necessary part of the total professional hospital team. You must remember that many agree with Dr. Gould, who believes operating room nurses are not a dying species, but that they will be back brighter than ever. So I challenge you-go to work on this. We must all increase our willingness to be involved. We must all share in this responsibility.
REFERENCES 1. de Takats, Geza, M.D., “The Scrub Nurse, a Vanishing Species,” Hospital Management, Vol. 92, August 1961, p. 80. 2. Terrien, H. Joyce Ayrault, “Professionalism in Operating Room Nursing,” Hospital Topics, Vol. 4t, June 1963, p. 79.
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3. Sister M. Evangelist, “Competent Clinical Nursing Courses,” Hospital Progress, Vol. 43, August 1962, p. 136. 4. Gould, Ernest A., M.D., “Operating Room Nurse -1s She a Dying Species?”, AORN Journal, Vol. 1, Maroh/April 1963, p. 47.
AORN Journal
Sept-Oct 1965
The bright, alert OR nurses are presently being withdrawn from the operating room table to circulate, supervise or instruct. Comprehensive nursing care is now safeguarded by the nurse whose responsibility is centered around the use of technicians. Yet there is a steady increase in the number of operating rooms, the number of surgical operations, and the number of times the operating room space is used.1 Professional schools of nursing have added courses in the social and behavorial sciences as well as in liberal education. These additional hours of classes make it difficult to include all subjects formerly taught. Thus, operating room nursing has been omitted from such programs. This omission has been justified in a variety of claims: 1 ) That aseptic technique taught in surgery can be provided for in conjunction with other learning experiences without expenditure of time in the operating room. 2) That surgery is a specialty, the basic skills of which are not needed by a nurse in other clinical areas. 3) That the philosophy of basic nursing programs is not to prepare nurses to specialize. 4) That all specialization, functional or clinical, belongs to the post-baccalaureate level.2 The baccalaureate program fosters a program in observation. This includes having the student prepare the patient for surgery,
79
accompany him to the OR, observe the operation and, go with him through the recovery room and back to the floor, and there care for him on the ward unit each day until discharge. Some schools send the student on follow-up calls into the home of the patient. This extends the experience further, noting the patient’s return to home, family and community. As a consumer of the services of professional registered nurses, what does all of this mean to me? It means that fewer nurses are interested in the operating room, and fewer nurses are prepared for this important area of the hospital-for which I am responsible. Patients in the OR need just as good care as those on the floors. We all know that since World War I1 we have had to utilize the operating room product of that era and that we have come to use more and more OR technicians. With the population explosion, need for more hospital beds, and necessity for more surgery, the number of rooms in operating suites have been greatly increased. We can all remember when four to six rooms were average. Now it is not unusual to have a surgery suite with ten to 20 operating rooms. Each year fewer graduates apply for the operating room, one reason being the lack of emphasis placed on this area of nursing in the baccalaureate program and another, a decrease in such experience in all other nursing programs. A new graduate going into the OR walks into a very difficult situation. She has no confidence in her ability to function with so little basic preparation. Since she lacks the competence she needs, she has no feelings of security. A new graduate often feels inferior to the trained technician. Such a situation can be very traumatic. A nurse who understands what takes place in the OR will be much less fearful. She does not have such an understanding unless she has been a member of the team and learned to appreciate how this complex unit
80
is organized and how it functions. Let us suppose that this new graduate aspires to become an operating room nurse. The nurse educator answers this way, “Let her go and take a supplemental course in operating room work.” There are, however, only a few such programs, and for a very good reason. Such programs are usually situated in a hospital that is basically using these graduate nurses for the service they render. There is little regard for the educational aspect of that experience. In many such programs, classes are cancelled during a busy operative day, since these hospitals do not employ much in the way of graduate staff but rely on these “students” for service. I said there are few such programs, for today young women refuse to be exploited. Another alternative for this graduate who might like to try the operating room is to set up a program of supervised experience within the surgery unit. This is very expensive in time, for both the graduate and the hospital instructor. Many hospitals maintain an on-going inservice program which includes a good orientation program for new nurses in the department, but this particular graduate does not fit into such a scheme. She must be taught from the beginning. Each faculty must determine sound objectives and goals for its students. A curriculum which sets up a designated plan for student experience in the operating room assures the student a wealth of specialized knowledge, added to her general education. The prime objective of OR nursing should be the contribution made to the welfare of the surgical patient during his hospitalization. The student’s role in surgery should be visualized in relation to the patient’s return to good health. The experience will aid the student to become a better nurse. Another goal includes the learning of basic aseptic technique which can be applied to other phases of nursing care. In addition, anatomical structures and the principles of
AORN Journal
physiology are better understood. The student should have the opportunity to practice whatever she learns. In the OR, the application of aseptic technique is practiced in the fullest sense. Operating room experience is essential for the student if she is to learn fully the nursing care of the surgical patient. She learns the importance of being a member of a team where the element of time is precious. She participates in emergency situations and recognizes the value of emotional stability and mental alertness. Further, the student receiving OR experience will appreciate the professional nurse’s responsibility for maintaining a well organized unit, setting a good example, and knowing underIying safety measures which dictate the technique of every procedure in providing safe care. The prime purpose of operating room experience should be that the student nurse thoroughly understand the reasons for conscientious preoperative preparation, and realize the effect surgery has on the postoperative, rehabilitative, and convalescent care of the patient. It is true that all these goals may be reached elsewhere in the curriculum-to some degree. However, now that many OR supplies are sterilized outside of the unit, and with the advent of prepackaged sterile supplies, there is little opportunity elsewhere in the hospital to learn about sterilization techniques, or what a sterile field really is. When the student nurse is oriented to the operating room and is guided in such experiences, she will acquire basic concepts and understanding which she cannot acquire as fully in any other experience. Yes, she can be exposed to these concepts, but she cannot acquire them as fully as she will in surgery. In a recent article, Sister M. Evangelist of San Antonio outlined the reasons for experience in the clinical areas, saying that the instructor selects patients for students on
Sept-Oct 1965
the basis of certain criteria.3 These are: 1) The experience should provide an opportunity for the student to practice the behavior as implied in the objectives of the course. 2) The student should have an opportunity to apply her knowledge in the situation. 3 ) The experience should be satisfying, meaningful, and sufficiently varied to provide a challenge. 4) The student should feel her personal objectives are being met. I ask you, cannot these criteria, every one, be fulfilled in the operating room? I say they can! In this same article, Sister Evangelist says : “We have taken away most nursing techniques from the professional nurse and given them to the technician and the practical nurse. We have failed to fill this void with professional nurse functions. We have delegated paper work, managerial duties and a host of unrelated tasks to the nurse. She is unable to practice comprehensive nursing care today as we desire it and in turn is blamed for this inability.” Early in this paper, mention was made of the operating room technician. How do the nurses and doctors feel about this person? Is there a place on the OR team for such a member? My answer is “Yes.” Just as the practical nurse is a much needed member on the ward unit, the operating room technician can contribute effectively and serve a real purpose as a member of the surgical team. However, the presence of the technician does not take away the need for the professional nurse. When the technician is brought in, the OR nurse becomes even more important. The role of the professional nurse must develop into one of leadership. She will assume duties of a guide and teacher. Her competence as an operating room nurse has long been graded and measured by the degree of her manual dexterity. Now she must accept the fact that her importance is measured by her leadership ability, and she must realize how her talent can best serve the
81
surgeon and patient in this role. In Missouri, the operating room technician is doing work in the afternoons formerly done by nurses, such as picking instruments, folding linen, and preparing packs. Thus, the nurse is freed to make rounds with the anesthesiologist, meeting and getting acquainted with patients who are being prepared for surgery the following day. With such shifted emphasis to patient-centered care and teaching, these nurses do better work, they are getting more job satisfaction, and are remaining longer in their jobs. The operating room nurse has to be a special kind of person. This job makes great physical, mental and emotional demands. It is more than technical skill, it is truly a specialty that requires dedication. It demands good relationships and understanding between nurse and semi-conscious patient, nurse and surgeon, nurse and anesthetist, nurse and technician. Now, to answer the second question propounded earlier-“How does the doctor feel about the OR technician?” Even though many doctors are of necessity being assisted at the table by the technician, I would like to refer you to Dr. Ernest A. Gould, a surgeon who speaks for many surgeons in his She paper “The Operating Room Nurse-Is a Dying Species?” In this article, Dr. Gould says that the facts are: “1) a surgical nurse is the product of the professional background of nursing and has an interest in surgical pathology, plus acquired technical proficiency
that takes years to develop; 2) the surgical nurse looks at her profession with pride and with a feeling of responsibility and concern for the patient undergoing surgery; 3) the surgical nurse, because of the aforementioned, is therefore an important member of a professional team treating a patient, and, who because of her background and humanity, adds to the probability of a successful outcome from the surgical adventure.”4 In closing, I would like to compliment each of you who belong to this Association which has been organized especially for you as an operating room nurse. You are a forceful group. I am sure you do not want the operating room to be void of nurses in the future. Therefore, I challenge you, through your organizational strength, to make it known that operating room nursing is essential in the students’ experience. We must recognize the subtle changes that take place. It may be that emphasis on words should be changed-let us not talk about the “scrub nurse” but the surgical nurse, one who is not only proficient but one who takes her place on the surgical team as a necessary part of the total professional hospital team. You must remember that many agree with Dr. Gould, who believes operating room nurses are not a dying species, but that they will be back brighter than ever. So I challenge you-go to work on this. We must all increase our willingness to be involved. We must all share in this responsibility.
REFERENCES 1. de Takats, Geza, M.D., “The Scrub Nurse, a Vanishing Species,” Hospital Management, Vol. 92, August 1961, p. 80. 2. Terrien, H. Joyce Ayrault, “Professionalism in Operating Room Nursing,” Hospital Topics, Vol. 4t, June 1963, p. 79.
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3. Sister M. Evangelist, “Competent Clinical Nursing Courses,” Hospital Progress, Vol. 43, August 1962, p. 136. 4. Gould, Ernest A., M.D., “Operating Room Nurse -1s She a Dying Species?”, AORN Journal, Vol. 1, Maroh/April 1963, p. 47.
AORN Journal