- Email: [email protected]
Nurturing the nurse: OR orientation
Shirley M Humphries, RN
Nurturing the nurse: OR orientation As an inservice instructor, I teach new employees about working in an operating room. In exchange, they have taught me about the fragility, the facades, and the fears of new graduates, as well as their resilienc;, determination, and nursing instincts. When I was first asked to take over this position, one cause for hesitation was how far away I would be from patient care. However, I discovered the tools of nursing are as applicable to other nurses as they are to patients, and it is possible to nurture the nurse. The nursing process, as in SOAPIER charting and nursing involvement, has become an essential tool for me as I plan the orientation of the new nurse. While we have a general format for orientation, I tailor it to individual needs as
Shirley M Humphries, R N , is OR instructor, The Methodist Hospital, Houston. She is a diploma graduate of Michael Reese Hospital and Medical Center School of Nursing, Chicago.
64
they are presented, both initially and daily. It is sometimes hard to discern where orientation stops and continuing or staff education begins. Our initial orientation covers six weeks. Then the new employee concentrates on learning the specialties of surgery and associated nursing responsibilities. Even for the new employee with experience, this will take about a year. The new graduate must be given even longer. Two to three months on each service stretches their primary orientation to from 18 months to two years. Informal classes are also held for new graduates t o explain reasons f o r actions. This prepares them for decision making and nursing judgment. One of the pleasures of this position is finding that each new person is fresh and different. One of the most fulfilling aspects of my job description is to get to know the new nurse well enough for her to trust my teaching and for me to give the rest of the staff an accurate description of her. We all view the same person differently from our own perspectives. The many strong personality types working in the OR look at that new nurse from different directions. Assertiveness is the “in” communications method, but sometimes we come on too strongperhaps even aggressively. This does not enhance the new nurse’s first experience. Because many staff members are quick to make judgments, I t r y very
AORN Journal, July 1979,V o l 3 0 , No 1
early in the orientation to establish rapport with the nurse so I can effectively be her advocate. OR nurses tend to resist change, and that includes a change in personnel. Many times they will be socially pleasant but professionally suspicious until the new nurse has proven herself to be proficient, capable of great dexterity, hardworking, and knowledgeable about all aspects of nursing except OR nursing. In that area, they expect the new nurse to recognize her gaps, and they are eager to give instructions and guidance. The new graduate has certain needs. Maslow’s hierarchy of needs is a good point to start planning the orientation of the new employee. According to Abraham Maslow, people must have their basic needs met before they can progress to higher level needs. The hierarchy progresses from physiological needs, at the lowest level, to safety and security needs, love and belongingness needs, self-esteem needs, and selfactualization, at the highest level.‘ The physiological needs must be met first. The new employee is likely to ask these questions: Where is the bathroom? Where is the cafeteria? Where is the pop or coffee machine? And to attend to survival needs in our OR, she will also probably ask, Where is a warm-up jacket? The initial tour of the OR and associated departments lasts about one hour, so it does not take long for them to request a jacket if I have overlooked getting one for them. They are nervous, frightened-and not about to admit it! And they are more than a little unsure about what they can and should ask for. On this tour, time is spent giving them a background on the OR and anecdotal information about the hospital. The Methodist Hospital, Houston, is one part of the Texas Medical Center. The hospital-one of 11 in the medical
center-consists of several buildings with about 1,200patient beds. Virtually every type of diagnostic facility is available. There are 45 operating rooms divided among four suites. The cardiovascular service is the most well-known, but areas for eye; ear, nose, and throat; orthopedic; and plastic surgery are almost as busy. Our patients come from all over the world; often Houston patients are in the minority. We have a cosmopolitan staff, with nurses from many countries. In the main OR suite, the staff is primarily registered nurses. The tour is casual and relaxed because I spend much time observing. Do new nurses seem eager to look into all the rooms? Do they seem to be listening to what I am saying about their positions and the work they’ll be doing? Can they ask questions or are they like an empty pitcher waiting to be filled? Do they avoid or seek eye contact? I do not take them into the rooms during operations in the interest of traffic control for the surgical teams. It is also frustrating for the newcomer to be introduced to staff they’ll never recognize later. The second step on Maslow’s pyramid is safety and security needs. It is hoped that many of these will be met during the tour as they gain security in knowing where they will be working within the hospital. Because our hospital is particularly large and confusing, I confine the initial tour to only the second floor of the main building, where the operating room suite is located. The tour includes the x-ray department, pathology labs, and family waiting area so the new nurses have a knowledge of the departments most critical to their functioning well in the OR. Locations of other departments will be learhed gradually throughout their employment. I stress to them it will take time to learn. I emphasize that we look
AORN Journal, July 1979,Vol30, No 1
65
reasons Ithelisten individuals choose operating room. to
forward to their being part of our staff for a long time, so the many things to learn can be approached gradually. The “sensory overload syndrome is possible. This occurs when an individual’s receptors become supersaturated with information and cannot absorb any more. The clues are a slightly glazed look, a fixed smile, an apparent loss of hearing, and/or a tendency to stop and read almost anything-bulletin boards, posters, and so on. When this occurs, I stop talking and let them rest mentally. After the tour of the OR, we go into the lounge where I introduce them to a few members of the staff. We have over 100 people employed in our suite. The only way the new nurse can be expected to remember staff is to have her meet a few at a time, be personally introduced, and be given an opportunity for conversation. My intention is to help the new nurse progress to the next step up on the hierarchy of needs. Of course, there is movement back and forth in the hierarchy during the first few months the nurse is working. Eventually, they will achieve the fourth level. As their skills become second nature, they will reach the final level, when they are ready for certification and an ongoing commitment to the surgical patient. Once we have cleared away the basic necessities of employment (paychecks, duty hours, and so on), the new nurse and I talk. As you get to know a person, your perceptions about them change.
Although this changing view is always important to recognize, it is particularly important in the operating room where team effort is paramount. I listen to reasons why individuals choose the operating room as a place to practice nursing. For example, they may say, “This is where it’s at” or “It seems this is where you really care for the patient” or “It is such a challenge to be really doing something for the patient.” After my initial assessment, I begin to plan more for the particular nurse. I review several routine procedures, which we have on slides-sponge counts, needle counts, gowning and gloving, and our septic case procedure. This information is combined with written material, which I give them for later reference on policies and procedures. In our classroom, I maintain a box of OR supplies-sponges, sutures, blades, scalpel handles, grounding pads, and so on. These are examples of products we use in our suite. If I am dealing with a new graduate, I give additional information and education about each topic: for example, types and sizes of sutures and reasons for their use. I always tell what happened to me as a young graduate when I received several packets of silk sutures on my back table when I scrubbed on a kidney procedure. When the surgeon asked for a 3-0 silk on a needle was the first time I realized that all those black strands were different sizes.
d+ 66
AORN Journul, July 1979,Vol30, No 1
Fig 1
Rotation card Name: Title: Dates
“Buddy”
General: Vascular: Plastic: Neuro: Ortho:
Oral: Urology:
Desk: Processing area:
Because the new graduate has many fears about her ability to perform in the technical world, she is first assigned to the processing and assembly area. This assignment alternates with discussions and planning for nursing responsibilities. It is valuable to keep this in mind: that adults learn only a small amount of what they are exposed to. We remember 10% of what we read, 20% of what we hear, 30% of what we see, 50% of what we see and hear, 8Wo of what we say, and 9Wo of what we say as we do a task.2 As she progresses on Maslow’s hierarchy of needs, the new nurse moves toward a comprehensive involvement in the perioperative role of the operating room nurse. Almost all new graduates arrive in the OR with little expertise in the skills requiring manual dexterity. As with the SOAPIER concept, I objectively assess each new nurse. Using the samples of items from the OR is helpful in determining their abilities to adapt to the
environment they have chosen. One nurse needed to be shown only once how to place a needle in a needleholder and only once how to put a knife blade onto a handle. She has fit into the staff exceptionally well and is making rapid strides. Another nurse came with no evidence of a natural dexterity. While she is improving, it is slow and difficult for both the staff and her. Before any new nurse is tested in the fires of the sterile field, she spends about five days assembling sets and learning the instruments in the basic sets. Then they begin their “card rotation” through the seven specialty areas in our OR-cardiovascular, general, urology, orthopedics, oral, neurosurgery, and plastic surgery-spending a few days in each department. Assignments are made on 3 x 5 cards the day before the assignment begins (Fig 1). I try to give each new person the same number of days as we have ORs in each specialty area.
d) AORN Journal, July 1979,Vol30, No 1
71
Fig 2
Back of rotation card Name: Previous experience: Date Physical aspects of the OR: Scrub lesson: Case set-up: Follow-through procedure: Cleaning of room: Cardiac arrest procedure: Charges: Charting: Narcotics: Septic case: Blood transfusions:
We have a “buddy” system since we have nurses permanently assigned to each room as well as a head nurse for each department. I bypass the head nurse because she is busy overseeing the specialty department needs. The charge nurse, who is directly involved with the patients, has much to teach the new graduate and new employee. For three or four days, they work together, coordinating times, equipment, and care for patients. The charge nurse also introduces the new nurse to other staff members and surgeons. The back of the 3 x 5 card has the list of procedures and routines that are particularly important for them to learn about (Fig 2). Because the card rotation covers about 25 working days and because there may be two or more new employees at different levels, the card is necessary. It also provides for planning according to what they may have already been exposed to. At the completion of the card rotation,
74
employees are assigned-t o a specialty area for two or three months. The card is placed on the employee’s page in the loose-leaf notebook that is used for determining overall staff rotations. Favorable comments lead me to believe the experts who have advocated this method in orientation have been right. Another reason this works for us is because it assigns a specific responsibility to the charge nurses, which they enjoy. Their feedback has been worthwhile. If they identify a situation where the new nurse feels frustrated, I take the new nurse back to my conference room for counseling. Frustration is no less common for the new graduate than it is for the experienced nurse, but the reasons are different. The new graduate often feels inferior because of her lack of knowledge about procedures. I encourage her to use the OR library and give her a copy of a suture manual andNursing Care of the Patient in the OR (Ethi-
AORN Journal, July 1979, Vol30, N o 1
con). I encourage them to recognize their professional responsibilities toward continuing education, which they should have started as soon as they complete their generic education. I stress the importance of having their own professional library, which should start with Alexander’s Care of the Patient in Surgery (Mosby, 1978). Membership in AORN is also discussed because chapter meetings provide education as well as opportunities to get to know professional colleagues. After the new graduate works in the operating room for a few days, we go back to the classroom to review filling in records. Our hospital uses an intraoperative record that is long and requires explanations about what is appropriate and what is unnecessary. This instruction usually leads to a discussion of the perioperative role and its definition. Because this talk comes at a time when the nurse’s head is reeling with new technical information, they gladly listen to the familiar talk of nursing care plans, assessment, and evaluation. There is a preoperative interview course that all nurses must take before they begin to conduct preoperative visits. We discuss this course and encourage the individual to participate in the voluntary program. Personality conflicts are discussed openly and completely. If the conflict has been a t all serious, I discuss it with the more experienced employee separately. On one occasion, a few experienced employees had mentioned problems with a new nurse. I talked to her about any conflicts or frustrations she had encountered from the new position and a new city. Many issues arose during that conversation. After a more thorough discussion, her rotation seemed to go more smoothly. A willingness to listen is of course the most important aspect of counseling a new graduate. They are caught in a system
where they must listen all the time, so it is good for them to have someone listen to them. Our staffing pattern is designed so that we do not have to rely on the new graduate for room coverage to complete our schedule. In fact, the staff has become insistent about having time to teach the new nurse. They complain when their schedule does not permit teaching of the quality they intend. All staff nurses are my assistants and are called on to help. Because of the size of the OR, we also assign the new graduate to work at the control desk, learning supervisory and administrative duties. It is probably here where she gains the most insight and learns to deal with the other departments. This assignment takes place just before the end of her card rotation and the last few days in the processing area, where she will be able to better correlate the sets of instruments with the specialty areas she has been working in. After the rotation, I sit down with the new nurse for a last conference. We discuss what they perceive their strengths and weaknesses to be, what I have observed about them as they have rotated, and their goals. We ask them t o fill out an evaluation form anonymously. From this information, I make changes to improve the program. As we review their OR nursing progress, they should feel they have at least a slight grasp of the various levels of technical skills and basic nursing knowledge. They should feel accepted by the staff and comfortable with perioperative nursing. 0 Notes 1. Lyle E Bourne, Jr, Bruce R Ekstrand, Psychology: Its Principles and Meanings (Hinsdale, Ill: Dlyden Press, 1973) 179. 2. Diane F Schoenrock,Julia A Kneedler, Operating Room Orientation Program for the New Graduate Nurse (Denver: Association of Operating Room Nurses, 1974) 17.
AORN Journal, July 1979, V o l 3 0 , NO 1
75
Nurturing the nurse: OR orientation As an inservice instructor, I teach new employees about working in an operating room. In exchange, they have taught me about the fragility, the facades, and the fears of new graduates, as well as their resilienc;, determination, and nursing instincts. When I was first asked to take over this position, one cause for hesitation was how far away I would be from patient care. However, I discovered the tools of nursing are as applicable to other nurses as they are to patients, and it is possible to nurture the nurse. The nursing process, as in SOAPIER charting and nursing involvement, has become an essential tool for me as I plan the orientation of the new nurse. While we have a general format for orientation, I tailor it to individual needs as
Shirley M Humphries, R N , is OR instructor, The Methodist Hospital, Houston. She is a diploma graduate of Michael Reese Hospital and Medical Center School of Nursing, Chicago.
64
they are presented, both initially and daily. It is sometimes hard to discern where orientation stops and continuing or staff education begins. Our initial orientation covers six weeks. Then the new employee concentrates on learning the specialties of surgery and associated nursing responsibilities. Even for the new employee with experience, this will take about a year. The new graduate must be given even longer. Two to three months on each service stretches their primary orientation to from 18 months to two years. Informal classes are also held for new graduates t o explain reasons f o r actions. This prepares them for decision making and nursing judgment. One of the pleasures of this position is finding that each new person is fresh and different. One of the most fulfilling aspects of my job description is to get to know the new nurse well enough for her to trust my teaching and for me to give the rest of the staff an accurate description of her. We all view the same person differently from our own perspectives. The many strong personality types working in the OR look at that new nurse from different directions. Assertiveness is the “in” communications method, but sometimes we come on too strongperhaps even aggressively. This does not enhance the new nurse’s first experience. Because many staff members are quick to make judgments, I t r y very
AORN Journal, July 1979,V o l 3 0 , No 1
early in the orientation to establish rapport with the nurse so I can effectively be her advocate. OR nurses tend to resist change, and that includes a change in personnel. Many times they will be socially pleasant but professionally suspicious until the new nurse has proven herself to be proficient, capable of great dexterity, hardworking, and knowledgeable about all aspects of nursing except OR nursing. In that area, they expect the new nurse to recognize her gaps, and they are eager to give instructions and guidance. The new graduate has certain needs. Maslow’s hierarchy of needs is a good point to start planning the orientation of the new employee. According to Abraham Maslow, people must have their basic needs met before they can progress to higher level needs. The hierarchy progresses from physiological needs, at the lowest level, to safety and security needs, love and belongingness needs, self-esteem needs, and selfactualization, at the highest level.‘ The physiological needs must be met first. The new employee is likely to ask these questions: Where is the bathroom? Where is the cafeteria? Where is the pop or coffee machine? And to attend to survival needs in our OR, she will also probably ask, Where is a warm-up jacket? The initial tour of the OR and associated departments lasts about one hour, so it does not take long for them to request a jacket if I have overlooked getting one for them. They are nervous, frightened-and not about to admit it! And they are more than a little unsure about what they can and should ask for. On this tour, time is spent giving them a background on the OR and anecdotal information about the hospital. The Methodist Hospital, Houston, is one part of the Texas Medical Center. The hospital-one of 11 in the medical
center-consists of several buildings with about 1,200patient beds. Virtually every type of diagnostic facility is available. There are 45 operating rooms divided among four suites. The cardiovascular service is the most well-known, but areas for eye; ear, nose, and throat; orthopedic; and plastic surgery are almost as busy. Our patients come from all over the world; often Houston patients are in the minority. We have a cosmopolitan staff, with nurses from many countries. In the main OR suite, the staff is primarily registered nurses. The tour is casual and relaxed because I spend much time observing. Do new nurses seem eager to look into all the rooms? Do they seem to be listening to what I am saying about their positions and the work they’ll be doing? Can they ask questions or are they like an empty pitcher waiting to be filled? Do they avoid or seek eye contact? I do not take them into the rooms during operations in the interest of traffic control for the surgical teams. It is also frustrating for the newcomer to be introduced to staff they’ll never recognize later. The second step on Maslow’s pyramid is safety and security needs. It is hoped that many of these will be met during the tour as they gain security in knowing where they will be working within the hospital. Because our hospital is particularly large and confusing, I confine the initial tour to only the second floor of the main building, where the operating room suite is located. The tour includes the x-ray department, pathology labs, and family waiting area so the new nurses have a knowledge of the departments most critical to their functioning well in the OR. Locations of other departments will be learhed gradually throughout their employment. I stress to them it will take time to learn. I emphasize that we look
AORN Journal, July 1979,Vol30, No 1
65
reasons Ithelisten individuals choose operating room. to
forward to their being part of our staff for a long time, so the many things to learn can be approached gradually. The “sensory overload syndrome is possible. This occurs when an individual’s receptors become supersaturated with information and cannot absorb any more. The clues are a slightly glazed look, a fixed smile, an apparent loss of hearing, and/or a tendency to stop and read almost anything-bulletin boards, posters, and so on. When this occurs, I stop talking and let them rest mentally. After the tour of the OR, we go into the lounge where I introduce them to a few members of the staff. We have over 100 people employed in our suite. The only way the new nurse can be expected to remember staff is to have her meet a few at a time, be personally introduced, and be given an opportunity for conversation. My intention is to help the new nurse progress to the next step up on the hierarchy of needs. Of course, there is movement back and forth in the hierarchy during the first few months the nurse is working. Eventually, they will achieve the fourth level. As their skills become second nature, they will reach the final level, when they are ready for certification and an ongoing commitment to the surgical patient. Once we have cleared away the basic necessities of employment (paychecks, duty hours, and so on), the new nurse and I talk. As you get to know a person, your perceptions about them change.
Although this changing view is always important to recognize, it is particularly important in the operating room where team effort is paramount. I listen to reasons why individuals choose the operating room as a place to practice nursing. For example, they may say, “This is where it’s at” or “It seems this is where you really care for the patient” or “It is such a challenge to be really doing something for the patient.” After my initial assessment, I begin to plan more for the particular nurse. I review several routine procedures, which we have on slides-sponge counts, needle counts, gowning and gloving, and our septic case procedure. This information is combined with written material, which I give them for later reference on policies and procedures. In our classroom, I maintain a box of OR supplies-sponges, sutures, blades, scalpel handles, grounding pads, and so on. These are examples of products we use in our suite. If I am dealing with a new graduate, I give additional information and education about each topic: for example, types and sizes of sutures and reasons for their use. I always tell what happened to me as a young graduate when I received several packets of silk sutures on my back table when I scrubbed on a kidney procedure. When the surgeon asked for a 3-0 silk on a needle was the first time I realized that all those black strands were different sizes.
d+ 66
AORN Journul, July 1979,Vol30, No 1
Fig 1
Rotation card Name: Title: Dates
“Buddy”
General: Vascular: Plastic: Neuro: Ortho:
Oral: Urology:
Desk: Processing area:
Because the new graduate has many fears about her ability to perform in the technical world, she is first assigned to the processing and assembly area. This assignment alternates with discussions and planning for nursing responsibilities. It is valuable to keep this in mind: that adults learn only a small amount of what they are exposed to. We remember 10% of what we read, 20% of what we hear, 30% of what we see, 50% of what we see and hear, 8Wo of what we say, and 9Wo of what we say as we do a task.2 As she progresses on Maslow’s hierarchy of needs, the new nurse moves toward a comprehensive involvement in the perioperative role of the operating room nurse. Almost all new graduates arrive in the OR with little expertise in the skills requiring manual dexterity. As with the SOAPIER concept, I objectively assess each new nurse. Using the samples of items from the OR is helpful in determining their abilities to adapt to the
environment they have chosen. One nurse needed to be shown only once how to place a needle in a needleholder and only once how to put a knife blade onto a handle. She has fit into the staff exceptionally well and is making rapid strides. Another nurse came with no evidence of a natural dexterity. While she is improving, it is slow and difficult for both the staff and her. Before any new nurse is tested in the fires of the sterile field, she spends about five days assembling sets and learning the instruments in the basic sets. Then they begin their “card rotation” through the seven specialty areas in our OR-cardiovascular, general, urology, orthopedics, oral, neurosurgery, and plastic surgery-spending a few days in each department. Assignments are made on 3 x 5 cards the day before the assignment begins (Fig 1). I try to give each new person the same number of days as we have ORs in each specialty area.
d) AORN Journal, July 1979,Vol30, No 1
71
Fig 2
Back of rotation card Name: Previous experience: Date Physical aspects of the OR: Scrub lesson: Case set-up: Follow-through procedure: Cleaning of room: Cardiac arrest procedure: Charges: Charting: Narcotics: Septic case: Blood transfusions:
We have a “buddy” system since we have nurses permanently assigned to each room as well as a head nurse for each department. I bypass the head nurse because she is busy overseeing the specialty department needs. The charge nurse, who is directly involved with the patients, has much to teach the new graduate and new employee. For three or four days, they work together, coordinating times, equipment, and care for patients. The charge nurse also introduces the new nurse to other staff members and surgeons. The back of the 3 x 5 card has the list of procedures and routines that are particularly important for them to learn about (Fig 2). Because the card rotation covers about 25 working days and because there may be two or more new employees at different levels, the card is necessary. It also provides for planning according to what they may have already been exposed to. At the completion of the card rotation,
74
employees are assigned-t o a specialty area for two or three months. The card is placed on the employee’s page in the loose-leaf notebook that is used for determining overall staff rotations. Favorable comments lead me to believe the experts who have advocated this method in orientation have been right. Another reason this works for us is because it assigns a specific responsibility to the charge nurses, which they enjoy. Their feedback has been worthwhile. If they identify a situation where the new nurse feels frustrated, I take the new nurse back to my conference room for counseling. Frustration is no less common for the new graduate than it is for the experienced nurse, but the reasons are different. The new graduate often feels inferior because of her lack of knowledge about procedures. I encourage her to use the OR library and give her a copy of a suture manual andNursing Care of the Patient in the OR (Ethi-
AORN Journal, July 1979, Vol30, N o 1
con). I encourage them to recognize their professional responsibilities toward continuing education, which they should have started as soon as they complete their generic education. I stress the importance of having their own professional library, which should start with Alexander’s Care of the Patient in Surgery (Mosby, 1978). Membership in AORN is also discussed because chapter meetings provide education as well as opportunities to get to know professional colleagues. After the new graduate works in the operating room for a few days, we go back to the classroom to review filling in records. Our hospital uses an intraoperative record that is long and requires explanations about what is appropriate and what is unnecessary. This instruction usually leads to a discussion of the perioperative role and its definition. Because this talk comes at a time when the nurse’s head is reeling with new technical information, they gladly listen to the familiar talk of nursing care plans, assessment, and evaluation. There is a preoperative interview course that all nurses must take before they begin to conduct preoperative visits. We discuss this course and encourage the individual to participate in the voluntary program. Personality conflicts are discussed openly and completely. If the conflict has been a t all serious, I discuss it with the more experienced employee separately. On one occasion, a few experienced employees had mentioned problems with a new nurse. I talked to her about any conflicts or frustrations she had encountered from the new position and a new city. Many issues arose during that conversation. After a more thorough discussion, her rotation seemed to go more smoothly. A willingness to listen is of course the most important aspect of counseling a new graduate. They are caught in a system
where they must listen all the time, so it is good for them to have someone listen to them. Our staffing pattern is designed so that we do not have to rely on the new graduate for room coverage to complete our schedule. In fact, the staff has become insistent about having time to teach the new nurse. They complain when their schedule does not permit teaching of the quality they intend. All staff nurses are my assistants and are called on to help. Because of the size of the OR, we also assign the new graduate to work at the control desk, learning supervisory and administrative duties. It is probably here where she gains the most insight and learns to deal with the other departments. This assignment takes place just before the end of her card rotation and the last few days in the processing area, where she will be able to better correlate the sets of instruments with the specialty areas she has been working in. After the rotation, I sit down with the new nurse for a last conference. We discuss what they perceive their strengths and weaknesses to be, what I have observed about them as they have rotated, and their goals. We ask them t o fill out an evaluation form anonymously. From this information, I make changes to improve the program. As we review their OR nursing progress, they should feel they have at least a slight grasp of the various levels of technical skills and basic nursing knowledge. They should feel accepted by the staff and comfortable with perioperative nursing. 0 Notes 1. Lyle E Bourne, Jr, Bruce R Ekstrand, Psychology: Its Principles and Meanings (Hinsdale, Ill: Dlyden Press, 1973) 179. 2. Diane F Schoenrock,Julia A Kneedler, Operating Room Orientation Program for the New Graduate Nurse (Denver: Association of Operating Room Nurses, 1974) 17.
AORN Journal, July 1979, V o l 3 0 , NO 1
75