- Email: [email protected]
Educating Nurses into the Perioperative Arena
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MAY 2004,VOL 79, NO 5
Educating Nurses intothe Perioperative Arena
as evidenced by the number of listings on AORN 0nline.l5 Universities also have recognized a any nursing education pro- need for more perioperative nursing grams offer limited or no peri- content and have developed programs operative content; thus, pro- in response.I6 Distance learning is viding perioperative education for becoming more common. At least two nurses who have no previous perioper- online programs for perioperative eduative experience has become a need. cation currently are available, and othThis need has increased as the pool of ers are being deve10ped.I~In these proavailable experienced perioperative grams, the didactic content is presented nurses shrinks and available practice in self-pacedmodules. One of these proareas for perioperative nurses expand grams requires participants to arrange to include ambulatory surgery centers for their own clinical experiences, and and other facilities. then written materials are provided for The need for perioperative educa- the preceptor. The other program, tion has been addressed in a variety of which is offered through a university, ways. Many collaborative efforts has clinical experiences on campus. between universities and hospitals This limits the scope of the program have resulted in perioperative content geographically. for baccalaureate nursing students.'-8 Some of these courses have been initiat- AN EXAMPLE OF A PERIOPERATNE COURSE ed by hospital~,2~,' some by universiFor more than 30 years, a perioperaties,'" and some as AORN chapter ini- tive nursing course has been offered in t i a t i v e ~ ~(ie, , ~ , ~Project Alpha, out- the Minneapolis/St Paul metropolitan growths of Project Alpha). These pro- area. The 10-week course is offered grams contain varying amounts of through a community college twice a intraoperative content and offer one to four credit hours. ABSTRACT Other programs that have been developed for RNs seeking periopera0 PROVIDING PERIOPERATIVE experience for tive education include hospital-based those new to the OR is a vital necessity, especially programs, which have addressed the because many nursing schools provide limited need for perioperative education by OR experiences. developing internships or fellowships,g often in conjunction with a universi0 AN ALTERNATIVE to a traditional c o r n is a ty."," Some hospitals have developed a condensed version that incorporates the material longer, more structured orientation and for a 10-week course into a two-weekend format training program for staff members that encompasses both didactic and laboratory hired into available position~'~-'~ either experiences. by developing their own p~ograms'~J~ or 0 RESPONSE TO THIS CONDENSED program by incorporating AORN's Perioperative has been so positive that it has edged out the 10Nursing Course l O l . I 4 Many facilities week program in the curriculum. AORN J 79 (May are developing their own structured ori2004) 965-974. entation programs based on this course Paula Anne Latz, RN; Doris Nordbye, RN
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EDUCATION PROGRAMS
AORN Outreach Programs s the nursing shortage continues, the Ged for effecA tive perioperative nursing education programs has increased. AORN recognizes the importance of finding ways to encourage individuals t o enter the perioperative field. During the past year, the Association has formed task forces to look at ways to bring individuals into the OR. One result i s AORNs new Student Nurse Tool K i t (http://www. aom. org/Students/studentresourcekit.h tm) which AORN chapters and others can use to create programs to reach out to high school students and inform them about the many benefits of being a perioperative nurse. Another program developed by AORN i s the Primer for Perioperative Education, which was developed by AORNs National Committee on Education. The primer i s designed to help AORN members prepare to contact schools of nursing to encourage them t o develop a perioperative experience for nursing students. The primer identifies strategies for contacting schools of nursing and includes a sample letter of introduction, a scripted lecture on "Introduction to Penoperative Nursing," suggested texts and a bibliography, and suggested content for the course with identified outcome competencies. The scripted lecture i n the primer also i s suitable for other nursing audiences, including nurses new to the perioperative area. The primer i s available from AORN Customer Service a t (800) 755-2676 x 1.
year (ie, fall, spring) and grants college credit, as well as continuing education credit. The goal of the course is to provide an introduction to perioperative nursing concepts and skills. The target audience for the course is nurses currently practicing in other areas who are interested in learning about perioperative practice and nurses without previous perioperative nursing experience who have been hired into an OR. The class meets two evenings a week for three hours a night during the 10week course. One class session each week is didactic in a classroom setting. Theory and concepts underlying both the circulating nurse and the scrub person roles are covered and are consistent with those in most basic perioperative programs. The other weekly class session is a hands-on practice laboratory in an OR. Various hospitals in the area volunteer the use of their ORs as laboratory sites. In the laboratory setting,
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participantspractice the skills discussed in the classroom, including scrubbing, gowning, gloving, positioning, and prepping. There is no direct patient care experience. Class size usually is between 25 and 40 participants. All the students meet for the classroom session. They then are split into smaller groups (ie, eight to 10 per site) for the laboratory sessions. One instructor teaches the didactic sessions, and there are different instructors at the different laboratory sites. The classroom instructor has many years of perioperative experience in a variety of settings and roles, and the laboratory instructors generally are experienced staff nurses or educators who work at the various hospital laboratory sites. The course has been well received by the hospitals in the area, many of which have made attendance at the course a prerequisite for hiring nurses without previous OR experience or have sent new hires without previous experience to the class as a condition of employment. Establishing the course was not without difficulties, including coordinating and matching the content in the didactic and laboratory sessions for each week. The amount of time needed to cover content in the classroom and the length of time needed to cover comparable skills in the laboratory are not always equal, so there are times when the didactic and laboratory material covered in a particular week do not match. In addition, the gap between hearing the theory and having an opportunity to apply the theory in the laboratory setting creates a problem for the students. Although a variety of teaching methods, including lecture, discussion, videotapes, and samples of items, are used to present content, immediatehands-on learning is not possible in this format. The classroom content is presented at the college, so there is limited opportunity to have actual equipment and supplies readily
Latz - Nordbye
available during the sessions when students learn about them in the classroom. It also is difficult to coordinate content among the different instructors for the didactic and various laboratory sessions, which can lead to potential discrepancies in how the material is taught and, sometimes, what is taught. A further difficulty is the scheduling of the class. Two evenings a week for 10 weeks is a large time commitment, and it is difficult for those who live outside the metropolitan area and have to travel long distances to attend classes.
AN ALTERNATIVE In 1998, one of the course instructors was approached by an OR supervisor outside the metropolitan area with a request to share the content and format of the course with the goal of developing the same type of program at a community college in her area. The impetus was the need to educate several new hires at her facility, because it was too difficult for these people to drive several hours each way to take the existing course. The instructors developed a plan to provide the course in a two-weekend format instead of the usual 10-week format. This plan was presented to the community college involved and the facility whose OR supervisor had requested the program. Both agreed to support a trial of the revised format. Course content was resequenced to integrate didactic and laboratory practice time into a more congruent unit. The classes were designed to run during two weekends and were scheduled every other weekend. The choice of every other weekend was made based on several factors. First, many nurses outside of the perioperative area work every other weekend, and they would not have two consecutive weekends free to attend class. Another factor was that the instructors and many of the participants have full-time jobs, and
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two weekends in a row in conjunction with two full weeks of work was considered to be too long a period without a break. In addition, for those working in a perioperative setting, the break between weekends gives them an opportunity to apply concepts they have leamed and look at issues in their settings from a different perspective. It also gives participants an opportunity to assimilate what they have learned and to read the suggested materials. In the two-weekend format, classes are scheduled on Friday from 6 PM to 9 PM, Saturday from 8 AM to 430 PM, and Sunday from 8 AM to 4:30 PM. Ideallv, class size is limited to 16 participants to provide for group interaction and adequate hands-on experience in the laboratory The break setting. The format of the course is a mix of didacbetween tic and laboratory sessions. The course is weekends gives offered at a hospital, so it is possible to move easily students working from the classroom to the actual OR for the laborain the tory sessions. The faculty perioperative consists of two instructors who team teach the setting an content. Content is somewhat arbitrarily divided opportunity to between the instructors, and they alternate in the apply concepts presentation so that neither presents for long they have periods of time. This provides participants with learned. variety and also allows one of the instructors to set up the laboratories or suppiies for the next class while the other instructor is presenting. Depending on the size of the group, the laboratory session may be team taught, or the group may be split into two groups that alternate between laboratory stations. AORN JOURNAL
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The commitment of the sponsoring facility is to provide classroom space; an OR to be used as the laboratory; scrubs, masks, and hats for the participants and instructors; and basic equipment, such as positioning equipment and a set of basic instruments. In return for their support of the class, the sponsoring facility is allowed to have one of their staff members included at no cost to the facility or the participants. Students discuss The instructors provide disposable items, their feelings such as prep kits, basic packs, gowns, and and the gloves. These usually are donated by vendors and adjustments local hospitals. Some of the supplies, such as basic needed when packs, are put back together and reused a moving from number of times.
being proficient in their previous area of practice to being a novice in the perioperutive area.
COURSECONTENT AND STRUCTURE
The course content is based on A 0 R ” s standards and recommended practices and standard perioperative texts. The focus of the content the first weekend is basics of perioperative practice and content related to scrubbing. Content includes OR environment, sterilization and disinfection, aseptic technique, attire, scrubbing, gowning, gloving, creating and maintaining a sterile field, instrumentation, wound management, counts, and intraoperative equipment. During the second weekend, the content covered includes patterns of perioperative care, anesthesia and intraoperative medications, implants, positioning, prepping, communication, ethical and legal consider-
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ations, and the role of the perioperative nurse. During the class segment on the perioperative role, students discuss the transition from other areas of nursing practice to practice in the OR. They discuss their feelings and the adjustments needed when moving from being proficient in their previous area of practice to being a novice in the perioperative area. Friday evenings are dedicated to didactic content in the classroom. Saturdays and Sundays are split between the classroom and the laboratory. Some content is covered in the classroom and then practiced in the laboratory, and some content, such as operating the OR bed and other pieces of equipment, is taught diredly in the OR settingby demonstration and return demonstration.For positioning, volunteers from the group act as patients and are positioned by the others in the class under the supervision of the instructor. Often, the student patient is very instructive, giving feedback to the group about what is comfortable and what is not. Part of the laboratory involves clean up and making sure the OR is ready for the next patient. Content in the classroom is covered using a variety of modalities, including lectures, videotapes, passing examples of supplies and equipment around the room, and discussion. The instructors encourage questions, opinions, and shared experiences with the goal of making the experience interactive. One way this is encouraged is by configuring the room so that participants sit in a Ushape rather than in rows. Another way is by using a troll doll that is dressed in scrub attire. The troll starts out at the head of the room, but as people ask good questions or make good observations, the troll moves to them. Often, students’ responses to another student’s question or observation is “give that person the troll.” In some groups, friendly competition has developed to
get the troll. The purpose of these activities is to encourage learning in a relaxed, stress-free environment. Course materials include a detailed outline of the course content bound in book format. The outline includes the objectives of each class, the related AORN outcome standards for the class content, suggested readings for each class, and a bibliography. This outline includes most of the material covered during the course, so partiapants are free to listen and interact rather than focus on taking notes. The suggested text is Berry and Kohn’s Operating Room Technique,’8 which is available for purchase at the time of registration. Participants receive the outline and the text at the first class session.
ASSESSINGSTUDENTS The weekend course is offered for contact hours rather than college credit, so there is no formal grading of the participants; however, there are several methods of assessment. On the second weekend, the Friday session begins with an oral test of knowledge using a game show format. The group is split into two teams, and each team is given a noisemaker. One of the instructors asks questions and the other serves as a scorekeeper, although both will ask for expanded answers as needed. As questions are asked, the first team to use the noisemaker answers the question. Friendly competition quickly develops between the two teams, and team members help each other provide the correct answers. Answers frequently are challenged or expanded upon by the other team. Answers almost always are correct and very detailed. It quickly becomes obvious that the students have spent time reading the lecture notes or the recommended text. After the review questions have been covered, scores are added. Both teams get a small prize (ie, buttons that say
”excellent,” ‘W,” or “good job”). Each team receives different buttons. Partiapants frequently wear the buttons for the rest of the weekend. Discussion often evolves from the questions and answers and from practices participants have observed their practice setting since the previous class. Another method of The team is assessing learning is a given a compendium laboratory held on the last Sunday preference card morning. The group again is divided into a simple teams, usually of three to five people. Each person on the team is assigned a procedure and is role, such as scrub/set provided a up, scrub/pass instruments and count, circulaprocedure cart tor/position, circulator/ prep and count, or circuwith a basic lator/& up. If a person currently is working in an setup and basic OR setting, that person is assigned a different role supplies. They from the one he or she usually performs. are given a few “he team is given a preference card for a simminutes to ple procedure, such as an inguinal hernia repair, discuss how they and is provided a procedure cart with a basic will set up and setup and basic supplies. They are given a few perform the minutes as a team to discuss how they will set up procedure. and perform the procedure. Another team observes, and a member from that team will act as the patient. One of the instructors serves as the surgeon. The team then goes through setting up.and performing the procedure in a timed (eg, 45 minutes to one hour) format. During the procedure, problems are simulated. For example, the
for
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surgeon will say that the electrosurgical active electrode is not working or a sponge will disappear so that there is an incorrect count. The team then uses problem-solving skills to find a solution. After the first team has completed a procedure, the teams switch places. Although the focus of this exercise is on performing the procedure and providing quality patient care, the exercise takes place in a nonthreatening, teaching mode. When a mistake (eg, a break in technique) is made, the instructor addresses it by stopping the person who made the mistake and asking that person to think about what he or she just did. The instructor asks the individual to identify the problem and whether there would be a better way to handle it. Often, the erring individual or others in the group are able to identify the error and what should have been done. Again, the teams develop supportive group dynamics. They help each other with the various tasks and help each other remember what needs to be done. Those who have experience willingly share their knowledge with the others. After all the teams have completed their procedures, they return to the classroom for a discussion and debriefing session. They discuss what parts of the process were difficult and why and what went better than expected. One of the overall learning experiences is how fast things move and how much there is to do. This simulation gives students the opportunity to start to sequence and pull together the various skills they have practiced separately (eg, prepping, positioning, counts). The participants begin to see what they need to learn, but they also become aware of what they have learned and are able to apply. This is a learning experience for both those doing the procedure and those observing. It is interesting to hear the perspec-
tive of the “patients” about what was done or not done for them.
THERESULTS The course has been offered a number of times in the two-weekend format. Participants have included practicing RNs with no perioperative experience, RNs who had previous perioperative experiencebut have not practiced in the OR for some time, nursing students, and physician assistants who will be assisting in the OR. Initially, the instructors identified several concerns about the course. 0 Would the course meet the learners’ scheduling needs? 0 Could the content be covered adequately in The participants the time allotted? 0 Could the participants begin to see assimilate and be able to put into practice the what they need material presented? Formal and informal to learn, but feedback has provided answers to these questions. Interest in the class they also become has been high, and classes aware what generally fill rapidly. In response, the number of they have offerings has increased to three and sometimes four learned and are per year. Although the course originally was able to apply. designed for areas outside of the metropolitan area, there also is strong interest in the metropoiitan area to take the course in a two-weekend format rather than the 10-week format. In addition, demand for the 10-week program has decreased to the point that there have not been enough registrants to hold a class for two years. The weekend c o m e has been offered for the last few years in the metropolitan area, although many of the participants are from outside of the area. Responses on the written course
of
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evaluation have been positive. Students have commented that they ”enjoyed doing this in two weekends. When you live far away it is very impractical to drive. . .two times a week for 10 weeks” and they “really liked the opportunity for the weekend class-very convenient, and I like the quick learn method.” All of the content in the original course gets covered in the two weekends. Although sequencing remains constant, the exact amount of time spent on each topic may vary slightly, depending on the needs of the group. One consistent rule, especially on Friday night, is that the class ends on time. At the request of the students in one of the first classes, the instructors tried extending the Saturday class time so the class could finish earlier on Sunday; however, with this setup,participants were not able to absorb and retain the material, and the instructors had to review the material in depth.
CONCLUSION Assessment methods used during the course and anecdotal comments from participants indicate that they do learn the material and can apply it. Verbal feedback from a hospital-based instructor who has had participants in both the evening and the weekend programs indicates that she believes those in the weekend course came to the clinical setting more able to apply content. Students’ feedback on the evaluations indicates that they also get more out of the course because laboratory sessions immediately follow didactic session. ”[I] appreciated didactic and lab following-[it] helped me remember.” The feedback received by the instructors indicates that the weekend course is one way to meet the many challenges of providing perioperative education. This course provides students from a variety of backgrounds
an introduction to perioperative nursing in a timely format so they can be integrated quickly into the perioperative practice arena. *r
Paula Anne Latz, RN, MSN, CNOR, C, is a learning specialist at Fairview University Medical Center, and an instructor at the Minneapolis Community and Technical College, Minneapolis. Dons Nordbye, RN, BS, MA, is a nurse manager in anesthesia and surgery at St Luke’s Hospital, Duluth, Minn, and an instructor at the Minneapolis Community and Technical College, Minneapolis.
NOTES
1. L M Sigsby, “Avoidingproblems when establishinga student learning ex erience in perioperative nursing,”Nurse i?ducator 28 (January/Febma 2003) 1-2. 2. L Mitchell et al, “ztablishing a collaborative relationship with a college of nursing,” AORN Journal 76 (November 2002) 842-850. 3. A T Onstott, ”Hospitalexplores winnin balance in erioperative education,” A d 6 Journal 68 kptember 1998) 395-399. 4. M C Long, S E Geor e, H S Gulledge, ”Implementing a bacca aureate pen tive nursing elective, A O ~ (February 1995) 372-376. 5. S C Kurtz, L W Eichelberger, “Developin a perioperative nursing elective,” A8RN Journal 70 (November 1999) 879-886. 6. J M Beitz, P M Houck, “Advancedperioperative nursing elective for baccalaureate students,” AORN Journal 66 (July 1997) 119-126. 7. B H S kes, “A perioperative racticum,“ Nurse ELcutor 22 (September/&tober 1997) 35-39. 8. L L McCausland, “A precepted perioperative elective for baccalaureate nursing students,” AORN Journal 76 (December 2002) 1032-1040. 9. “Boston project prepares RNs for OR,” OR Manager 17 (January2001) 20. 10. A T Speers, “Operatingroom registered nurses internship program: A nxruitment and retention strate ’ JournalforNurses in Stuff Development 18f&ay/June 2002) 117-126. 11. B Penprase, ”Collaboratively developing
7
‘1
JournaET
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an orientation ro am for OR nurses," AORNJournal (Lober 2O00) 663-670. 12.P R Graling, B Rusynko, "Implementing a perio erative nursing fellowship program," AO& Journal 73 (May 2001) 939-945. 13. "A perio course from assroots," OR Manager 16 fanua 2OOO) 14. S J Giarrizzo-$*on, "From RN to enoperative nurse," (Human Resources) SM 7 (April 2001) 59-61. 15. 'Penoperative nursingprogram online
Ff2
g.
f
directory," AORN Online, http://zuww
.uom.org/education/coursedirectory. htrn
(accessed 23 Jan 2004). 16. S Millard, "Creative artnering in erio erative education," A8RN Journal 7r (Zptember 2001) 385-388. 17. S Ward, "Is distance learning an answer to the shortage of periop RNs," OR Mum er 18 (April 2002) 1,14,16. 18. dPhiUips, B 6 Kohn's Operutin Room Technrque, 1% ed (St Louis: Mos y, Inc, 2004).
i
Combining Exercise and Medication May Cure Depression ombining regular exercise with taking antidepressant medication may be more effective i n treating major depression than medication alone, according t o a Feb 2, 2004, news release from the University of Texas Southwestern Medical Center at Dallas. Researchers are conducfing a study t o determine whether augmenting medication treatment with exercise can eliminate a l l symptoms o f depression. Eligible participants are adults ages 18 t o 65 who have been treated with selective serotonin reuptake inhibitors (SSRIs) for eight t o 12 weeks but who continue t o experience symptoms of depression. Participants will complete a supervised 24-week exercise program and will be
C
trained on how t o exercise a t home. Exercise is a known stress reliever that can help fight symptoms of depression. Many people who take SSRIs obtain some relief from depression but do not experience full remission. Preliminary results from a pilot study indicate that patients respond favorably t o this treatment. The study i s funded by a $2.4 million grant from the National Institute for Mental Health. UT Southwestern Researchers Study Benefit of Exercise, Medication on Depression (news release, Dallas: The University of Tewas southwestern Medical Center at Dallas, Feb 2, 2004) http://www8.utsouthwestern.edu/utsw/cda /dept37389/files/148519.html (accessed 3 Feb 2004).
Increase in Nursing School Enrollments/Graduations preliminary report from the National League for Nursing (NLN) shows an increase in the number of RN nursing program admissions, enrollments, and graduations during academic year 2002-2003, according t o a Dec 13, 2003, news release from NLN. Graduations increased 6% over the previous year, which means that 73,000 new RNs potentially could enter the workforce if they all passed their licensure examinations. The report's projections are based on data analyzed by December 2003-about 30% of data potentially available-from the 3,017 nursing programs i n the United States and its territories. The preliminary results compare the 2002-2003 growth rates t o those of the previous year i n number of admissions, enrollments, and graduations i n diplo-
A
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ma and associate's and bachelots degree programs. Admission for all three types of programs increased approximately 6%. Enrollments i n diploma and associate's degree programs increased by 5%, while enrollments in bachelots degree programs increased by 21%. Despite these projedions, the shortage of nurses and nurse educators remains critical. The Joint Commission on Accreditation of Health Care Organizations reports that more than 126,000 nursing positions i n hospitals are not filled. NLN 2002-2003Survey of RN Nursing Programs Indicates Positive Upward Trends in the Nursing Workforce Supply (news release, New York: National League for Nursing, Dec 13, 2003).
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Educating Nurses intothe Perioperative Arena
as evidenced by the number of listings on AORN 0nline.l5 Universities also have recognized a any nursing education pro- need for more perioperative nursing grams offer limited or no peri- content and have developed programs operative content; thus, pro- in response.I6 Distance learning is viding perioperative education for becoming more common. At least two nurses who have no previous perioper- online programs for perioperative eduative experience has become a need. cation currently are available, and othThis need has increased as the pool of ers are being deve10ped.I~In these proavailable experienced perioperative grams, the didactic content is presented nurses shrinks and available practice in self-pacedmodules. One of these proareas for perioperative nurses expand grams requires participants to arrange to include ambulatory surgery centers for their own clinical experiences, and and other facilities. then written materials are provided for The need for perioperative educa- the preceptor. The other program, tion has been addressed in a variety of which is offered through a university, ways. Many collaborative efforts has clinical experiences on campus. between universities and hospitals This limits the scope of the program have resulted in perioperative content geographically. for baccalaureate nursing students.'-8 Some of these courses have been initiat- AN EXAMPLE OF A PERIOPERATNE COURSE ed by hospital~,2~,' some by universiFor more than 30 years, a perioperaties,'" and some as AORN chapter ini- tive nursing course has been offered in t i a t i v e ~ ~(ie, , ~ , ~Project Alpha, out- the Minneapolis/St Paul metropolitan growths of Project Alpha). These pro- area. The 10-week course is offered grams contain varying amounts of through a community college twice a intraoperative content and offer one to four credit hours. ABSTRACT Other programs that have been developed for RNs seeking periopera0 PROVIDING PERIOPERATIVE experience for tive education include hospital-based those new to the OR is a vital necessity, especially programs, which have addressed the because many nursing schools provide limited need for perioperative education by OR experiences. developing internships or fellowships,g often in conjunction with a universi0 AN ALTERNATIVE to a traditional c o r n is a ty."," Some hospitals have developed a condensed version that incorporates the material longer, more structured orientation and for a 10-week course into a two-weekend format training program for staff members that encompasses both didactic and laboratory hired into available position~'~-'~ either experiences. by developing their own p~ograms'~J~ or 0 RESPONSE TO THIS CONDENSED program by incorporating AORN's Perioperative has been so positive that it has edged out the 10Nursing Course l O l . I 4 Many facilities week program in the curriculum. AORN J 79 (May are developing their own structured ori2004) 965-974. entation programs based on this course Paula Anne Latz, RN; Doris Nordbye, RN
M
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965
MAY 2004, VOL 79, NO 5
Latz - Nordbye
EDUCATION PROGRAMS
AORN Outreach Programs s the nursing shortage continues, the Ged for effecA tive perioperative nursing education programs has increased. AORN recognizes the importance of finding ways to encourage individuals t o enter the perioperative field. During the past year, the Association has formed task forces to look at ways to bring individuals into the OR. One result i s AORNs new Student Nurse Tool K i t (http://www. aom. org/Students/studentresourcekit.h tm) which AORN chapters and others can use to create programs to reach out to high school students and inform them about the many benefits of being a perioperative nurse. Another program developed by AORN i s the Primer for Perioperative Education, which was developed by AORNs National Committee on Education. The primer i s designed to help AORN members prepare to contact schools of nursing to encourage them t o develop a perioperative experience for nursing students. The primer identifies strategies for contacting schools of nursing and includes a sample letter of introduction, a scripted lecture on "Introduction to Penoperative Nursing," suggested texts and a bibliography, and suggested content for the course with identified outcome competencies. The scripted lecture i n the primer also i s suitable for other nursing audiences, including nurses new to the perioperative area. The primer i s available from AORN Customer Service a t (800) 755-2676 x 1.
year (ie, fall, spring) and grants college credit, as well as continuing education credit. The goal of the course is to provide an introduction to perioperative nursing concepts and skills. The target audience for the course is nurses currently practicing in other areas who are interested in learning about perioperative practice and nurses without previous perioperative nursing experience who have been hired into an OR. The class meets two evenings a week for three hours a night during the 10week course. One class session each week is didactic in a classroom setting. Theory and concepts underlying both the circulating nurse and the scrub person roles are covered and are consistent with those in most basic perioperative programs. The other weekly class session is a hands-on practice laboratory in an OR. Various hospitals in the area volunteer the use of their ORs as laboratory sites. In the laboratory setting,
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participantspractice the skills discussed in the classroom, including scrubbing, gowning, gloving, positioning, and prepping. There is no direct patient care experience. Class size usually is between 25 and 40 participants. All the students meet for the classroom session. They then are split into smaller groups (ie, eight to 10 per site) for the laboratory sessions. One instructor teaches the didactic sessions, and there are different instructors at the different laboratory sites. The classroom instructor has many years of perioperative experience in a variety of settings and roles, and the laboratory instructors generally are experienced staff nurses or educators who work at the various hospital laboratory sites. The course has been well received by the hospitals in the area, many of which have made attendance at the course a prerequisite for hiring nurses without previous OR experience or have sent new hires without previous experience to the class as a condition of employment. Establishing the course was not without difficulties, including coordinating and matching the content in the didactic and laboratory sessions for each week. The amount of time needed to cover content in the classroom and the length of time needed to cover comparable skills in the laboratory are not always equal, so there are times when the didactic and laboratory material covered in a particular week do not match. In addition, the gap between hearing the theory and having an opportunity to apply the theory in the laboratory setting creates a problem for the students. Although a variety of teaching methods, including lecture, discussion, videotapes, and samples of items, are used to present content, immediatehands-on learning is not possible in this format. The classroom content is presented at the college, so there is limited opportunity to have actual equipment and supplies readily
Latz - Nordbye
available during the sessions when students learn about them in the classroom. It also is difficult to coordinate content among the different instructors for the didactic and various laboratory sessions, which can lead to potential discrepancies in how the material is taught and, sometimes, what is taught. A further difficulty is the scheduling of the class. Two evenings a week for 10 weeks is a large time commitment, and it is difficult for those who live outside the metropolitan area and have to travel long distances to attend classes.
AN ALTERNATIVE In 1998, one of the course instructors was approached by an OR supervisor outside the metropolitan area with a request to share the content and format of the course with the goal of developing the same type of program at a community college in her area. The impetus was the need to educate several new hires at her facility, because it was too difficult for these people to drive several hours each way to take the existing course. The instructors developed a plan to provide the course in a two-weekend format instead of the usual 10-week format. This plan was presented to the community college involved and the facility whose OR supervisor had requested the program. Both agreed to support a trial of the revised format. Course content was resequenced to integrate didactic and laboratory practice time into a more congruent unit. The classes were designed to run during two weekends and were scheduled every other weekend. The choice of every other weekend was made based on several factors. First, many nurses outside of the perioperative area work every other weekend, and they would not have two consecutive weekends free to attend class. Another factor was that the instructors and many of the participants have full-time jobs, and
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two weekends in a row in conjunction with two full weeks of work was considered to be too long a period without a break. In addition, for those working in a perioperative setting, the break between weekends gives them an opportunity to apply concepts they have leamed and look at issues in their settings from a different perspective. It also gives participants an opportunity to assimilate what they have learned and to read the suggested materials. In the two-weekend format, classes are scheduled on Friday from 6 PM to 9 PM, Saturday from 8 AM to 430 PM, and Sunday from 8 AM to 4:30 PM. Ideallv, class size is limited to 16 participants to provide for group interaction and adequate hands-on experience in the laboratory The break setting. The format of the course is a mix of didacbetween tic and laboratory sessions. The course is weekends gives offered at a hospital, so it is possible to move easily students working from the classroom to the actual OR for the laborain the tory sessions. The faculty perioperative consists of two instructors who team teach the setting an content. Content is somewhat arbitrarily divided opportunity to between the instructors, and they alternate in the apply concepts presentation so that neither presents for long they have periods of time. This provides participants with learned. variety and also allows one of the instructors to set up the laboratories or suppiies for the next class while the other instructor is presenting. Depending on the size of the group, the laboratory session may be team taught, or the group may be split into two groups that alternate between laboratory stations. AORN JOURNAL
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The commitment of the sponsoring facility is to provide classroom space; an OR to be used as the laboratory; scrubs, masks, and hats for the participants and instructors; and basic equipment, such as positioning equipment and a set of basic instruments. In return for their support of the class, the sponsoring facility is allowed to have one of their staff members included at no cost to the facility or the participants. Students discuss The instructors provide disposable items, their feelings such as prep kits, basic packs, gowns, and and the gloves. These usually are donated by vendors and adjustments local hospitals. Some of the supplies, such as basic needed when packs, are put back together and reused a moving from number of times.
being proficient in their previous area of practice to being a novice in the perioperutive area.
COURSECONTENT AND STRUCTURE
The course content is based on A 0 R ” s standards and recommended practices and standard perioperative texts. The focus of the content the first weekend is basics of perioperative practice and content related to scrubbing. Content includes OR environment, sterilization and disinfection, aseptic technique, attire, scrubbing, gowning, gloving, creating and maintaining a sterile field, instrumentation, wound management, counts, and intraoperative equipment. During the second weekend, the content covered includes patterns of perioperative care, anesthesia and intraoperative medications, implants, positioning, prepping, communication, ethical and legal consider-
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ations, and the role of the perioperative nurse. During the class segment on the perioperative role, students discuss the transition from other areas of nursing practice to practice in the OR. They discuss their feelings and the adjustments needed when moving from being proficient in their previous area of practice to being a novice in the perioperative area. Friday evenings are dedicated to didactic content in the classroom. Saturdays and Sundays are split between the classroom and the laboratory. Some content is covered in the classroom and then practiced in the laboratory, and some content, such as operating the OR bed and other pieces of equipment, is taught diredly in the OR settingby demonstration and return demonstration.For positioning, volunteers from the group act as patients and are positioned by the others in the class under the supervision of the instructor. Often, the student patient is very instructive, giving feedback to the group about what is comfortable and what is not. Part of the laboratory involves clean up and making sure the OR is ready for the next patient. Content in the classroom is covered using a variety of modalities, including lectures, videotapes, passing examples of supplies and equipment around the room, and discussion. The instructors encourage questions, opinions, and shared experiences with the goal of making the experience interactive. One way this is encouraged is by configuring the room so that participants sit in a Ushape rather than in rows. Another way is by using a troll doll that is dressed in scrub attire. The troll starts out at the head of the room, but as people ask good questions or make good observations, the troll moves to them. Often, students’ responses to another student’s question or observation is “give that person the troll.” In some groups, friendly competition has developed to
get the troll. The purpose of these activities is to encourage learning in a relaxed, stress-free environment. Course materials include a detailed outline of the course content bound in book format. The outline includes the objectives of each class, the related AORN outcome standards for the class content, suggested readings for each class, and a bibliography. This outline includes most of the material covered during the course, so partiapants are free to listen and interact rather than focus on taking notes. The suggested text is Berry and Kohn’s Operating Room Technique,’8 which is available for purchase at the time of registration. Participants receive the outline and the text at the first class session.
ASSESSINGSTUDENTS The weekend course is offered for contact hours rather than college credit, so there is no formal grading of the participants; however, there are several methods of assessment. On the second weekend, the Friday session begins with an oral test of knowledge using a game show format. The group is split into two teams, and each team is given a noisemaker. One of the instructors asks questions and the other serves as a scorekeeper, although both will ask for expanded answers as needed. As questions are asked, the first team to use the noisemaker answers the question. Friendly competition quickly develops between the two teams, and team members help each other provide the correct answers. Answers frequently are challenged or expanded upon by the other team. Answers almost always are correct and very detailed. It quickly becomes obvious that the students have spent time reading the lecture notes or the recommended text. After the review questions have been covered, scores are added. Both teams get a small prize (ie, buttons that say
”excellent,” ‘W,” or “good job”). Each team receives different buttons. Partiapants frequently wear the buttons for the rest of the weekend. Discussion often evolves from the questions and answers and from practices participants have observed their practice setting since the previous class. Another method of The team is assessing learning is a given a compendium laboratory held on the last Sunday preference card morning. The group again is divided into a simple teams, usually of three to five people. Each person on the team is assigned a procedure and is role, such as scrub/set provided a up, scrub/pass instruments and count, circulaprocedure cart tor/position, circulator/ prep and count, or circuwith a basic lator/& up. If a person currently is working in an setup and basic OR setting, that person is assigned a different role supplies. They from the one he or she usually performs. are given a few “he team is given a preference card for a simminutes to ple procedure, such as an inguinal hernia repair, discuss how they and is provided a procedure cart with a basic will set up and setup and basic supplies. They are given a few perform the minutes as a team to discuss how they will set up procedure. and perform the procedure. Another team observes, and a member from that team will act as the patient. One of the instructors serves as the surgeon. The team then goes through setting up.and performing the procedure in a timed (eg, 45 minutes to one hour) format. During the procedure, problems are simulated. For example, the
for
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surgeon will say that the electrosurgical active electrode is not working or a sponge will disappear so that there is an incorrect count. The team then uses problem-solving skills to find a solution. After the first team has completed a procedure, the teams switch places. Although the focus of this exercise is on performing the procedure and providing quality patient care, the exercise takes place in a nonthreatening, teaching mode. When a mistake (eg, a break in technique) is made, the instructor addresses it by stopping the person who made the mistake and asking that person to think about what he or she just did. The instructor asks the individual to identify the problem and whether there would be a better way to handle it. Often, the erring individual or others in the group are able to identify the error and what should have been done. Again, the teams develop supportive group dynamics. They help each other with the various tasks and help each other remember what needs to be done. Those who have experience willingly share their knowledge with the others. After all the teams have completed their procedures, they return to the classroom for a discussion and debriefing session. They discuss what parts of the process were difficult and why and what went better than expected. One of the overall learning experiences is how fast things move and how much there is to do. This simulation gives students the opportunity to start to sequence and pull together the various skills they have practiced separately (eg, prepping, positioning, counts). The participants begin to see what they need to learn, but they also become aware of what they have learned and are able to apply. This is a learning experience for both those doing the procedure and those observing. It is interesting to hear the perspec-
tive of the “patients” about what was done or not done for them.
THERESULTS The course has been offered a number of times in the two-weekend format. Participants have included practicing RNs with no perioperative experience, RNs who had previous perioperative experiencebut have not practiced in the OR for some time, nursing students, and physician assistants who will be assisting in the OR. Initially, the instructors identified several concerns about the course. 0 Would the course meet the learners’ scheduling needs? 0 Could the content be covered adequately in The participants the time allotted? 0 Could the participants begin to see assimilate and be able to put into practice the what they need material presented? Formal and informal to learn, but feedback has provided answers to these questions. Interest in the class they also become has been high, and classes aware what generally fill rapidly. In response, the number of they have offerings has increased to three and sometimes four learned and are per year. Although the course originally was able to apply. designed for areas outside of the metropolitan area, there also is strong interest in the metropoiitan area to take the course in a two-weekend format rather than the 10-week format. In addition, demand for the 10-week program has decreased to the point that there have not been enough registrants to hold a class for two years. The weekend c o m e has been offered for the last few years in the metropolitan area, although many of the participants are from outside of the area. Responses on the written course
of
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evaluation have been positive. Students have commented that they ”enjoyed doing this in two weekends. When you live far away it is very impractical to drive. . .two times a week for 10 weeks” and they “really liked the opportunity for the weekend class-very convenient, and I like the quick learn method.” All of the content in the original course gets covered in the two weekends. Although sequencing remains constant, the exact amount of time spent on each topic may vary slightly, depending on the needs of the group. One consistent rule, especially on Friday night, is that the class ends on time. At the request of the students in one of the first classes, the instructors tried extending the Saturday class time so the class could finish earlier on Sunday; however, with this setup,participants were not able to absorb and retain the material, and the instructors had to review the material in depth.
CONCLUSION Assessment methods used during the course and anecdotal comments from participants indicate that they do learn the material and can apply it. Verbal feedback from a hospital-based instructor who has had participants in both the evening and the weekend programs indicates that she believes those in the weekend course came to the clinical setting more able to apply content. Students’ feedback on the evaluations indicates that they also get more out of the course because laboratory sessions immediately follow didactic session. ”[I] appreciated didactic and lab following-[it] helped me remember.” The feedback received by the instructors indicates that the weekend course is one way to meet the many challenges of providing perioperative education. This course provides students from a variety of backgrounds
an introduction to perioperative nursing in a timely format so they can be integrated quickly into the perioperative practice arena. *r
Paula Anne Latz, RN, MSN, CNOR, C, is a learning specialist at Fairview University Medical Center, and an instructor at the Minneapolis Community and Technical College, Minneapolis. Dons Nordbye, RN, BS, MA, is a nurse manager in anesthesia and surgery at St Luke’s Hospital, Duluth, Minn, and an instructor at the Minneapolis Community and Technical College, Minneapolis.
NOTES
1. L M Sigsby, “Avoidingproblems when establishinga student learning ex erience in perioperative nursing,”Nurse i?ducator 28 (January/Febma 2003) 1-2. 2. L Mitchell et al, “ztablishing a collaborative relationship with a college of nursing,” AORN Journal 76 (November 2002) 842-850. 3. A T Onstott, ”Hospitalexplores winnin balance in erioperative education,” A d 6 Journal 68 kptember 1998) 395-399. 4. M C Long, S E Geor e, H S Gulledge, ”Implementing a bacca aureate pen tive nursing elective, A O ~ (February 1995) 372-376. 5. S C Kurtz, L W Eichelberger, “Developin a perioperative nursing elective,” A8RN Journal 70 (November 1999) 879-886. 6. J M Beitz, P M Houck, “Advancedperioperative nursing elective for baccalaureate students,” AORN Journal 66 (July 1997) 119-126. 7. B H S kes, “A perioperative racticum,“ Nurse ELcutor 22 (September/&tober 1997) 35-39. 8. L L McCausland, “A precepted perioperative elective for baccalaureate nursing students,” AORN Journal 76 (December 2002) 1032-1040. 9. “Boston project prepares RNs for OR,” OR Manager 17 (January2001) 20. 10. A T Speers, “Operatingroom registered nurses internship program: A nxruitment and retention strate ’ JournalforNurses in Stuff Development 18f&ay/June 2002) 117-126. 11. B Penprase, ”Collaboratively developing
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JournaET
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an orientation ro am for OR nurses," AORNJournal (Lober 2O00) 663-670. 12.P R Graling, B Rusynko, "Implementing a perio erative nursing fellowship program," AO& Journal 73 (May 2001) 939-945. 13. "A perio course from assroots," OR Manager 16 fanua 2OOO) 14. S J Giarrizzo-$*on, "From RN to enoperative nurse," (Human Resources) SM 7 (April 2001) 59-61. 15. 'Penoperative nursingprogram online
Ff2
g.
f
directory," AORN Online, http://zuww
.uom.org/education/coursedirectory. htrn
(accessed 23 Jan 2004). 16. S Millard, "Creative artnering in erio erative education," A8RN Journal 7r (Zptember 2001) 385-388. 17. S Ward, "Is distance learning an answer to the shortage of periop RNs," OR Mum er 18 (April 2002) 1,14,16. 18. dPhiUips, B 6 Kohn's Operutin Room Technrque, 1% ed (St Louis: Mos y, Inc, 2004).
i
Combining Exercise and Medication May Cure Depression ombining regular exercise with taking antidepressant medication may be more effective i n treating major depression than medication alone, according t o a Feb 2, 2004, news release from the University of Texas Southwestern Medical Center at Dallas. Researchers are conducfing a study t o determine whether augmenting medication treatment with exercise can eliminate a l l symptoms o f depression. Eligible participants are adults ages 18 t o 65 who have been treated with selective serotonin reuptake inhibitors (SSRIs) for eight t o 12 weeks but who continue t o experience symptoms of depression. Participants will complete a supervised 24-week exercise program and will be
C
trained on how t o exercise a t home. Exercise is a known stress reliever that can help fight symptoms of depression. Many people who take SSRIs obtain some relief from depression but do not experience full remission. Preliminary results from a pilot study indicate that patients respond favorably t o this treatment. The study i s funded by a $2.4 million grant from the National Institute for Mental Health. UT Southwestern Researchers Study Benefit of Exercise, Medication on Depression (news release, Dallas: The University of Tewas southwestern Medical Center at Dallas, Feb 2, 2004) http://www8.utsouthwestern.edu/utsw/cda /dept37389/files/148519.html (accessed 3 Feb 2004).
Increase in Nursing School Enrollments/Graduations preliminary report from the National League for Nursing (NLN) shows an increase in the number of RN nursing program admissions, enrollments, and graduations during academic year 2002-2003, according t o a Dec 13, 2003, news release from NLN. Graduations increased 6% over the previous year, which means that 73,000 new RNs potentially could enter the workforce if they all passed their licensure examinations. The report's projections are based on data analyzed by December 2003-about 30% of data potentially available-from the 3,017 nursing programs i n the United States and its territories. The preliminary results compare the 2002-2003 growth rates t o those of the previous year i n number of admissions, enrollments, and graduations i n diplo-
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ma and associate's and bachelots degree programs. Admission for all three types of programs increased approximately 6%. Enrollments i n diploma and associate's degree programs increased by 5%, while enrollments in bachelots degree programs increased by 21%. Despite these projedions, the shortage of nurses and nurse educators remains critical. The Joint Commission on Accreditation of Health Care Organizations reports that more than 126,000 nursing positions i n hospitals are not filled. NLN 2002-2003Survey of RN Nursing Programs Indicates Positive Upward Trends in the Nursing Workforce Supply (news release, New York: National League for Nursing, Dec 13, 2003).