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Developing an inservice program to meet accreditation requirements
JUNE 1994. VOL 59, NO 6 -
AORN JOURNAL
Practical Innovations Developing an inservice program to meet accreditation requirements
T
he term inservice training creates different impressions and emotions in individuals. Some staff members welcome the opportunity to increase their knowledge through inservice education, while others dread the idea of having to sit through another inservice session. Many staff members accept inservice training as a necessary entity without having either negative or positive feelings. Meeting the divergent needs of all these staff members is a challenge to the nurse educator. There are various definitions for inservice programs. One dictionary defines inservice programs as taking place while one is employed (ie, an inservice training program).’ The American Nurses Association defines inservice activities as a means of assisting the professional nurse in acquiring, maintaining, andlor increasing competency in fulfilling his or her assigned responsibilities specific to the employer’s expectatiom2 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) does not define inservice training; however, JCAHO does specify what criteria are to be covered and requires all special care unit personnel to participate in relevant inservice programs.’ AORN defines an inservice program as “a learning experience provided in the work setting to assist staff members in performing their assigned functions.” The goal of inservice education for employees, according to AORN, is “to improve daily working, thinking, and behaving by facilitating implementation of new nursing knowledge and skill^."^
When I assumed the role of education coordinator in our OR, I looked forward to the challenge of planning and implementing quality training sessions for our 17-member staff (ie, 11 RNs, one surgical technician, five nursing assistants). Because JCAHO would be visiting our facility the following year, it was important to have an inservice program that would meet the Joint Commission’s criteria.
Accreditation Criteria
0
ur facility is a 250-bed teaching hospital that provides a wide range of surgical services to a multicultural community. Our seven ORs and one cystoscopy room are used for approximately 450 cases a month, ranging from
Judith E. Brevik, RN, BSN, CNOR, is the OR education coordinator at Trinity Medical Center, Minot, ND. She earned her diploma in nursing at Touro Infirmary School of Nursing, NeM1 Orleans, and her bachelor of science degree in nursing from Minot (NO)State University. 1303
AORN JOURNAL
simple surgical procedures to open-heart and neurosurgery cases. The heaviest concentration of cases is in general surgery, gynecology, and orthopedics. The JCAHO requires inservice training for special care units (eg, ORs, intensive care units) and our facility requires all RNs to attend a one-hour inservice training session each month. My responsibility as education coordinator is to identify the JCAHO’s criteria for inservice education and to develop sessions that meet the training criteria for OR staff members. The JCAHO criteria for inservice programs state that “the organization provides for education and training designed to maintain and improve the knowledge and skills of all personel."^ The needs identified for training and education are based on, among other things, 0 information from quality assessment and improvement activities, findings from the organization’s plant, technology, and safety management programs, and findings from infection control activities.6 In addition, JCAHO requires that each individual in the organization be competent in 0 knowledge and skills required to perform his or her responsibilities, the effective and safe use of all equipment used in his or her activities, the prevention of contamination and transfer of infection, and cardiopulmonary resuscitation and other lifesaving interventions.’ The JCAHO expects inservice training to be based on staff members’ needs and to include accurate documentation and review of the educational offerings. The extent of participation is related to the size of the staff and the scope and complexity of the special care services provided by the unit.8 The JCAHO also looks for measurable learning objectives for inservice sessions. These objectives should be attainable and appropriate for the learning situation. The training provided to staff members should be based on effective instructional strategies to accomplish the specified learning objectives. A review of the 1304
JUNE 1994, VOL 59, NO 6
Accreditation Manual for Hospitals shows that, first and foremost, JCAHO inspectors look for the development and documentation of competence for health care providers. A crucial component of ensuring competence is an inservice program that offers quality educational offerings for staff member^.^
Identifying the Need for Change hen I reviewed our overall inservice program. 1 discovered several deficiencies. Regular monthly inservice sessions on a variety of topics were being presented, and different methods of presentation were being used to maintain staff interest. Documentation of the planning, presentation, and evaluation of the offerings was inadequate. The inservice program record form lacked significant information, making documentation impossible (eg, staff members failed to complete or file forms in the inservice record book). As a result, documentation of staff members’ competence was inadequate for JCAHO requirements. The documentation review also revealed the JCAHO inservice education criteria were not considered. Behavioral objectives were not written for inservice sessions, and learner evaluation forms were not used to critique inservice sessions. No formal system existed for staff members to obtain information if they were unable to attend the inservice session. Overall, no one person planned, implemented, or documented the OR’S education program. This responsibility was usually delegated to available staff nurses.
Developing a New Program
0
ur unit’s new inservice program required careful planning and documentation of our inservice sessions. New elements needed were forms for planning and documenting the inservice sessions, evaluating the inservice session, and 0 documenting attendance.
JUNE 1994, VOL 59, NO 6
I obtained staff members’ input to identify our unit’s educational needs (ie, the specific learning deficiencies that could be satisfied by a specific learning experience). According to one source, specific knowledge, skills, and attitudes that are lacking are capable of being satisfied by a learning experience.I0 After determining the unit’s and staff members’ educational needs, I set up a tentative schedule of monthly inservice sessions for a year. Inservice record form. I developed a new inservice record form that presents a clear picture of each inservice session. The form contains space to identify the topic, date, and person or persons presenting the inservice session and lists one to three learning objectives for the educational session. Learning objectives. Learning objectives are statements of what the learner will be able to do after participating in the educational activity. By accomplishing a behavioral change, it is assumed the attendee has gained new knowledge or learned new skills. Objectives represent the minimal level of desired learning for the majority of the learners. When objectives are not provided, the learner is faced with an uncertain situation. He or she must guess what the instructor considers important and what the instructor’s expectations are for the class participants. After objectives are set, the inservice program speaker uses the objectives to plan his or her presentation. Objectives also are used to develop the tool(s) for measuring the effectiveness of the inservice offering. Attendees use objectives to evaluate their individual learning experiences. I ’ Needs identification. The inservice record form also includes a section for needs identification. I use a variety of methods to identify our unit’s inservice training needs: staff suggestions (eg, training on procedures, instruments, equipment), quality assessment and improvement activities, and 0 learning needs prioritization by staff members. Evaluation form. I designed the evaluation
AORN JOURNAL
form to document the method(s) used in evaluating the inservice presentation (eg, pretest, posttest, evaluation form). The last space on the form asks for comments (eg, objectives met, staff members’ reception, overall presentation). The evaluation form gives managers a good idea of the overall effectiveness of the inservice session. Staff members evaluate inservice sessions based on the following statements: The speaker was knowledgeable about the topic. The topic was presented in an organized manner. The surroundings were conducive to learning. The audiovisual aids were used effectively. 0 The inservice session met my educational needs. Each criterion is rated from one to five (ie, 1 = strongly disagree, 2 = slightly disagree, 3 = slightly agree, 4 = agree, 5 = strongly agree). The staff member evaluates his or her own learning experience based on the stated objectives of the inservice session. Using this information, I tabulate and record the evaluation results, which are retained as a permanent part of the inservice training documentation. Documenting attendance. I file all inservice attendance records in an inservice record book that is readily available to staff members. The book is divided into two sections: the first section contains individual inservice training attendance records, and the second section records all inservice offerings in the month they are presented. The book is set up for one calendar year. At the end of a year, I file each employee’s records in his or her education file. I move the inservice offerings records to a binder and keep them for five years. The educational needs of the RN, the surgical technician, and the nursing assistant are different, so I set up separate books for each group. I developed an attendance form that contains the names of all the department personnel. The form has room for the title of the inservice session, the name of the person presenting the session, and the date. Each staff member who attends an inservice program initials the space 1307
AORN JOURNAL
JUNE 1994, VOL 59, NO 6
The inservice record form is a teaching tool used in writing measurable objectives for inservice sessions as well as a documentation form. next to his or her own name. I keep a permanent copy of this form with each person’s signature and initials in the front of the inservice record book for verification purposes. Each staff member is responsible for maintaining an individual record of all inservice offerings he or she attends throughout the year. A record of all departmental inservice and training sessions is kept in the front of the inservice record book as a reference for the staff. If a staff member cannot remember whether he or she attended a particular inservice offering, the list can be cross-referenced with the attendance forms filed behind the month the inservice session was presented. Our department’s inservice education policy requires that each staff member attend at least 75% of the yearly inservice sessions. Notes are taken on all inservice sessions and placed in the inservice record book along with any written handouts from the offering. Any staff member who misses an inservice session is required to read and initial these notes and handouts. If an inservice session is videotaped or tape recorded, absent staff members must view or listen to the tape. After the absent staff member has completed these requirements, he or she is given credit for attendance. I also developed a form to track attendance at inservice sessions. The names of the staff members are listed down the left side of the page, and the titles of required inservice sessions are listed across the top (ie, the page is a grid of squares). A square filled in with a yellow marker denotes attendance at the inservice session. A reddened square denotes reading and initialing of notes for a missed session. A blank square indicates the person still needs to do the required makeup work for a missed inservice offering. This has proven to be a convenient method for tracking attendance. 1308
Educating Stuff
F
amiliarizing staff members with the department’s new inservice program proved to be a bigger challenge than I expected. They were relieved to be free of the old format, but they were a little reluctant to try the new system. I began the education process by presenting the new forms and answering questions during routine staff meetings. It took several group and individual training sessions to implement the new system. I also used one-on-one teaching to educate staff members about using the new forms. When a nurse presents an inservice session, he or she uses an inservice record form to prepare the presentation. Most staff members are not accustomed to developing a session from objectives, so this form becomes a teaching tool as well as a documentation form. As the nurse presenters become accustomed to using the inservice record form for preparing inservice sessions, they feel more comfortable with it. They now ask for the form if I fail to offer it to them. When I ask a physician or someone from outside the department to present an inservice session, I discuss session objectives with him or her, and the inservice record form is completed by our department. The inservice record form also encourages presenters to consider different methods of presenting and evaluating the inservice offering. I encourage the use of pretests and posttests in conjunction with the evaluation form.
Implementation, Benefits of the New Program
T
he new program has significantly improved our inservice education. The inservice sessions are now well-planned with measurable objectives, and because the offerings are based
JUNE 1994, VOL 59, NO 6
on identified needs of the department and staff members, people are generally satisfied with the program. With the new system, staff members can refer to the inservice record book at any time and have access to the information necessary for updating their personal inservice attendance sheets. The monthly inservice records are thorough, and personnel who miss an inservice offering are able to obtain the information by reading handout materials or viewing tapes. By using the inservice attendance record, we can track attendance and remind absent staff members when they fail to read inservice handout materials. This documentation has demonstrated an increase in the number of staff members who receive the information presented at inservice education sessions.
Ongoing Evaluation of Inservice Program
M
aintaining a quality inservice program requires ongoing evaluation and implementation of needed changes. I use the inservice evaluation forms for evaluating individual learning and the comments and suggestions as feedback for planning future inservice sessions. Staff members overcame their initial reluctance to change from the old system to the new system. Staff members frequently make topic suggestions and suggest ways to improve our inservice offerings. Staff nurses are willing to present inservice sessions when asked, and presenters use the inservice record form to prepare and present quality sessions. I continue to develop a flexible, tentative schedule of inservice sessions for the year. Using this system, I can change tentative inservice sessions and times, or replace sessions with topics that better meet the needs of the department or staff members. Rapid changes in technology and the increased demands for knowledge in the OR have necessitated an increase in the number of inservice sessions presented in our department. We often present two or more mandatory inservice sessions a month, and we find that some
AORN JOURNAL
staff members are willing to come in on their days off to attend. We also have noted better compliance with making up missed sessions. Due to the success experienced in our OR, other departments in the hospital have requested to use our inservice system and forms.
Summary
T
oday’s OR challenges the nurse manager to offer inservice sessions that expand the knowledge base of staff members who provide patient care. A well-planned inservice program that is based on the assessed needs of the department and staff members can help meet this challenge. The program must have inservice sessions with stated, measurable learning objectives; a method of evaluation; and a means of documenting the inservice offering. The overall inservice program must be evaluated continuously and changed as needed. Above all, the program must be geared toward establishing and maintaining the competence of OR staff members. Only then can managers be sure that patients are receiving the best possible nursing care. JUDITHE. BREVIK, RN Notes 1. The Random House Dictionary of the English Language, second ed, sv “inservice program.” 2. American Nurses Association, Standards for Continuing Education in Nursing (Kansas City, Mo: American Nurses Association, 1984) 5. 3. Joint Commission on Accreditation of Healthcare Organizations, Accreditation Manual for Hospitals, Vol I: Standards (Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, 1993) 149-150. 4. L Brazen, Perioperative Nursing Staff Education (Denver: Association of Operating Room Nurses, Inc, 1990) 5. 5. Joint Commission on Accreditation of Healthcare Organizations, Accreditation Manual for Hospitals, Vol I : Standards, 149-150. 6. Ibid. 7. h i d . 8. Ibid. 9. Ibid. 10. Brazen, Perioperative Nursing Staff Education, 10. 11. Ibid, 11. 1311
AORN JOURNAL
Practical Innovations Developing an inservice program to meet accreditation requirements
T
he term inservice training creates different impressions and emotions in individuals. Some staff members welcome the opportunity to increase their knowledge through inservice education, while others dread the idea of having to sit through another inservice session. Many staff members accept inservice training as a necessary entity without having either negative or positive feelings. Meeting the divergent needs of all these staff members is a challenge to the nurse educator. There are various definitions for inservice programs. One dictionary defines inservice programs as taking place while one is employed (ie, an inservice training program).’ The American Nurses Association defines inservice activities as a means of assisting the professional nurse in acquiring, maintaining, andlor increasing competency in fulfilling his or her assigned responsibilities specific to the employer’s expectatiom2 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) does not define inservice training; however, JCAHO does specify what criteria are to be covered and requires all special care unit personnel to participate in relevant inservice programs.’ AORN defines an inservice program as “a learning experience provided in the work setting to assist staff members in performing their assigned functions.” The goal of inservice education for employees, according to AORN, is “to improve daily working, thinking, and behaving by facilitating implementation of new nursing knowledge and skill^."^
When I assumed the role of education coordinator in our OR, I looked forward to the challenge of planning and implementing quality training sessions for our 17-member staff (ie, 11 RNs, one surgical technician, five nursing assistants). Because JCAHO would be visiting our facility the following year, it was important to have an inservice program that would meet the Joint Commission’s criteria.
Accreditation Criteria
0
ur facility is a 250-bed teaching hospital that provides a wide range of surgical services to a multicultural community. Our seven ORs and one cystoscopy room are used for approximately 450 cases a month, ranging from
Judith E. Brevik, RN, BSN, CNOR, is the OR education coordinator at Trinity Medical Center, Minot, ND. She earned her diploma in nursing at Touro Infirmary School of Nursing, NeM1 Orleans, and her bachelor of science degree in nursing from Minot (NO)State University. 1303
AORN JOURNAL
simple surgical procedures to open-heart and neurosurgery cases. The heaviest concentration of cases is in general surgery, gynecology, and orthopedics. The JCAHO requires inservice training for special care units (eg, ORs, intensive care units) and our facility requires all RNs to attend a one-hour inservice training session each month. My responsibility as education coordinator is to identify the JCAHO’s criteria for inservice education and to develop sessions that meet the training criteria for OR staff members. The JCAHO criteria for inservice programs state that “the organization provides for education and training designed to maintain and improve the knowledge and skills of all personel."^ The needs identified for training and education are based on, among other things, 0 information from quality assessment and improvement activities, findings from the organization’s plant, technology, and safety management programs, and findings from infection control activities.6 In addition, JCAHO requires that each individual in the organization be competent in 0 knowledge and skills required to perform his or her responsibilities, the effective and safe use of all equipment used in his or her activities, the prevention of contamination and transfer of infection, and cardiopulmonary resuscitation and other lifesaving interventions.’ The JCAHO expects inservice training to be based on staff members’ needs and to include accurate documentation and review of the educational offerings. The extent of participation is related to the size of the staff and the scope and complexity of the special care services provided by the unit.8 The JCAHO also looks for measurable learning objectives for inservice sessions. These objectives should be attainable and appropriate for the learning situation. The training provided to staff members should be based on effective instructional strategies to accomplish the specified learning objectives. A review of the 1304
JUNE 1994, VOL 59, NO 6
Accreditation Manual for Hospitals shows that, first and foremost, JCAHO inspectors look for the development and documentation of competence for health care providers. A crucial component of ensuring competence is an inservice program that offers quality educational offerings for staff member^.^
Identifying the Need for Change hen I reviewed our overall inservice program. 1 discovered several deficiencies. Regular monthly inservice sessions on a variety of topics were being presented, and different methods of presentation were being used to maintain staff interest. Documentation of the planning, presentation, and evaluation of the offerings was inadequate. The inservice program record form lacked significant information, making documentation impossible (eg, staff members failed to complete or file forms in the inservice record book). As a result, documentation of staff members’ competence was inadequate for JCAHO requirements. The documentation review also revealed the JCAHO inservice education criteria were not considered. Behavioral objectives were not written for inservice sessions, and learner evaluation forms were not used to critique inservice sessions. No formal system existed for staff members to obtain information if they were unable to attend the inservice session. Overall, no one person planned, implemented, or documented the OR’S education program. This responsibility was usually delegated to available staff nurses.
Developing a New Program
0
ur unit’s new inservice program required careful planning and documentation of our inservice sessions. New elements needed were forms for planning and documenting the inservice sessions, evaluating the inservice session, and 0 documenting attendance.
JUNE 1994, VOL 59, NO 6
I obtained staff members’ input to identify our unit’s educational needs (ie, the specific learning deficiencies that could be satisfied by a specific learning experience). According to one source, specific knowledge, skills, and attitudes that are lacking are capable of being satisfied by a learning experience.I0 After determining the unit’s and staff members’ educational needs, I set up a tentative schedule of monthly inservice sessions for a year. Inservice record form. I developed a new inservice record form that presents a clear picture of each inservice session. The form contains space to identify the topic, date, and person or persons presenting the inservice session and lists one to three learning objectives for the educational session. Learning objectives. Learning objectives are statements of what the learner will be able to do after participating in the educational activity. By accomplishing a behavioral change, it is assumed the attendee has gained new knowledge or learned new skills. Objectives represent the minimal level of desired learning for the majority of the learners. When objectives are not provided, the learner is faced with an uncertain situation. He or she must guess what the instructor considers important and what the instructor’s expectations are for the class participants. After objectives are set, the inservice program speaker uses the objectives to plan his or her presentation. Objectives also are used to develop the tool(s) for measuring the effectiveness of the inservice offering. Attendees use objectives to evaluate their individual learning experiences. I ’ Needs identification. The inservice record form also includes a section for needs identification. I use a variety of methods to identify our unit’s inservice training needs: staff suggestions (eg, training on procedures, instruments, equipment), quality assessment and improvement activities, and 0 learning needs prioritization by staff members. Evaluation form. I designed the evaluation
AORN JOURNAL
form to document the method(s) used in evaluating the inservice presentation (eg, pretest, posttest, evaluation form). The last space on the form asks for comments (eg, objectives met, staff members’ reception, overall presentation). The evaluation form gives managers a good idea of the overall effectiveness of the inservice session. Staff members evaluate inservice sessions based on the following statements: The speaker was knowledgeable about the topic. The topic was presented in an organized manner. The surroundings were conducive to learning. The audiovisual aids were used effectively. 0 The inservice session met my educational needs. Each criterion is rated from one to five (ie, 1 = strongly disagree, 2 = slightly disagree, 3 = slightly agree, 4 = agree, 5 = strongly agree). The staff member evaluates his or her own learning experience based on the stated objectives of the inservice session. Using this information, I tabulate and record the evaluation results, which are retained as a permanent part of the inservice training documentation. Documenting attendance. I file all inservice attendance records in an inservice record book that is readily available to staff members. The book is divided into two sections: the first section contains individual inservice training attendance records, and the second section records all inservice offerings in the month they are presented. The book is set up for one calendar year. At the end of a year, I file each employee’s records in his or her education file. I move the inservice offerings records to a binder and keep them for five years. The educational needs of the RN, the surgical technician, and the nursing assistant are different, so I set up separate books for each group. I developed an attendance form that contains the names of all the department personnel. The form has room for the title of the inservice session, the name of the person presenting the session, and the date. Each staff member who attends an inservice program initials the space 1307
AORN JOURNAL
JUNE 1994, VOL 59, NO 6
The inservice record form is a teaching tool used in writing measurable objectives for inservice sessions as well as a documentation form. next to his or her own name. I keep a permanent copy of this form with each person’s signature and initials in the front of the inservice record book for verification purposes. Each staff member is responsible for maintaining an individual record of all inservice offerings he or she attends throughout the year. A record of all departmental inservice and training sessions is kept in the front of the inservice record book as a reference for the staff. If a staff member cannot remember whether he or she attended a particular inservice offering, the list can be cross-referenced with the attendance forms filed behind the month the inservice session was presented. Our department’s inservice education policy requires that each staff member attend at least 75% of the yearly inservice sessions. Notes are taken on all inservice sessions and placed in the inservice record book along with any written handouts from the offering. Any staff member who misses an inservice session is required to read and initial these notes and handouts. If an inservice session is videotaped or tape recorded, absent staff members must view or listen to the tape. After the absent staff member has completed these requirements, he or she is given credit for attendance. I also developed a form to track attendance at inservice sessions. The names of the staff members are listed down the left side of the page, and the titles of required inservice sessions are listed across the top (ie, the page is a grid of squares). A square filled in with a yellow marker denotes attendance at the inservice session. A reddened square denotes reading and initialing of notes for a missed session. A blank square indicates the person still needs to do the required makeup work for a missed inservice offering. This has proven to be a convenient method for tracking attendance. 1308
Educating Stuff
F
amiliarizing staff members with the department’s new inservice program proved to be a bigger challenge than I expected. They were relieved to be free of the old format, but they were a little reluctant to try the new system. I began the education process by presenting the new forms and answering questions during routine staff meetings. It took several group and individual training sessions to implement the new system. I also used one-on-one teaching to educate staff members about using the new forms. When a nurse presents an inservice session, he or she uses an inservice record form to prepare the presentation. Most staff members are not accustomed to developing a session from objectives, so this form becomes a teaching tool as well as a documentation form. As the nurse presenters become accustomed to using the inservice record form for preparing inservice sessions, they feel more comfortable with it. They now ask for the form if I fail to offer it to them. When I ask a physician or someone from outside the department to present an inservice session, I discuss session objectives with him or her, and the inservice record form is completed by our department. The inservice record form also encourages presenters to consider different methods of presenting and evaluating the inservice offering. I encourage the use of pretests and posttests in conjunction with the evaluation form.
Implementation, Benefits of the New Program
T
he new program has significantly improved our inservice education. The inservice sessions are now well-planned with measurable objectives, and because the offerings are based
JUNE 1994, VOL 59, NO 6
on identified needs of the department and staff members, people are generally satisfied with the program. With the new system, staff members can refer to the inservice record book at any time and have access to the information necessary for updating their personal inservice attendance sheets. The monthly inservice records are thorough, and personnel who miss an inservice offering are able to obtain the information by reading handout materials or viewing tapes. By using the inservice attendance record, we can track attendance and remind absent staff members when they fail to read inservice handout materials. This documentation has demonstrated an increase in the number of staff members who receive the information presented at inservice education sessions.
Ongoing Evaluation of Inservice Program
M
aintaining a quality inservice program requires ongoing evaluation and implementation of needed changes. I use the inservice evaluation forms for evaluating individual learning and the comments and suggestions as feedback for planning future inservice sessions. Staff members overcame their initial reluctance to change from the old system to the new system. Staff members frequently make topic suggestions and suggest ways to improve our inservice offerings. Staff nurses are willing to present inservice sessions when asked, and presenters use the inservice record form to prepare and present quality sessions. I continue to develop a flexible, tentative schedule of inservice sessions for the year. Using this system, I can change tentative inservice sessions and times, or replace sessions with topics that better meet the needs of the department or staff members. Rapid changes in technology and the increased demands for knowledge in the OR have necessitated an increase in the number of inservice sessions presented in our department. We often present two or more mandatory inservice sessions a month, and we find that some
AORN JOURNAL
staff members are willing to come in on their days off to attend. We also have noted better compliance with making up missed sessions. Due to the success experienced in our OR, other departments in the hospital have requested to use our inservice system and forms.
Summary
T
oday’s OR challenges the nurse manager to offer inservice sessions that expand the knowledge base of staff members who provide patient care. A well-planned inservice program that is based on the assessed needs of the department and staff members can help meet this challenge. The program must have inservice sessions with stated, measurable learning objectives; a method of evaluation; and a means of documenting the inservice offering. The overall inservice program must be evaluated continuously and changed as needed. Above all, the program must be geared toward establishing and maintaining the competence of OR staff members. Only then can managers be sure that patients are receiving the best possible nursing care. JUDITHE. BREVIK, RN Notes 1. The Random House Dictionary of the English Language, second ed, sv “inservice program.” 2. American Nurses Association, Standards for Continuing Education in Nursing (Kansas City, Mo: American Nurses Association, 1984) 5. 3. Joint Commission on Accreditation of Healthcare Organizations, Accreditation Manual for Hospitals, Vol I: Standards (Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, 1993) 149-150. 4. L Brazen, Perioperative Nursing Staff Education (Denver: Association of Operating Room Nurses, Inc, 1990) 5. 5. Joint Commission on Accreditation of Healthcare Organizations, Accreditation Manual for Hospitals, Vol I : Standards, 149-150. 6. Ibid. 7. h i d . 8. Ibid. 9. Ibid. 10. Brazen, Perioperative Nursing Staff Education, 10. 11. Ibid, 11. 1311