- Email: [email protected]
Our Students Wear White Hats
OUR STUDENTS WEAR WHITE HATS Barbara
R. Minckley, R.N., M.S. and Shonna Warner, R.N.
In the firm belief that every supervising operating room nurse must lend her energies toward helping to reverse the present decline in numbers of qualified OR staff nurses in the most expeditious and efficient manner, we have proposed a somewhat different method for teaching OR techniques to licensed personnel. We believe the postgraduate program, which we describe here, may be readily adapted to any hospital that maintains an OR suite of four or more operating rooms; and that increased numbers of qualified OR nurses can be prepared in nearly every such hospital, with more predictably satisfactory outcomes than are presently obtained. Because we, as OR nurses, are accustomed to technical innovation, and because for us the process of “operationalizing theory” is an almost daily affair, this program must appeal to the sense of economy of effort, time, and space. Few other areas in the hospital put such a premium on improved work patterns, more efficient use of time, and better teamwork as we do in the operating room. Barbara Blake Mincklcy, R.N., ORS a t Sequoia Hospital in Redwood City, Calif., is a graduate of Stanford University School of Nursing and received her M.S. degree (cum Laude) from the University of Calif. in San Francisco. She has worked a s staff nurse and head nurse in Stanford Hospital operating rooms and has assisted with cardiac research and open heart surgery at the VA Hospital in Palo Alto. Miss Minckley is presently engaged in promoting a program for teaching OR skills to licensed nursing personnel (LVN’s and RN’s). Shonna E. Warner, B.S.N., is a graduate of Hamline University, St. Paul, Minnesota. She has worked as an OR staff nurse at Anker Hospital in St. Paul and at Mt. Zion Hospital in San Francisco. At Sequoia Hospital, Redwood City, California, where she is now an inservice instructor in the operating room, she has been an OR staff nurse and an OR head nurse.
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Yet we do this continually without sacrificing safety or accuracy, maintaining the finest possible nursing care of which we are capable. Yes, we said nursing care! Basic nursing concepts are not, never have been, nor ever can be lost in the operating room. We have watched and worked with ICU nurses, PAR nurses, and ER nurses, and find our behavior is much the same as theirs in given situations. We all apply the same nursing concepts, but in different ways. However, for each nursing specialty, it takes training to become acceptably proficient. If the special training and guidance are not available, the beginning specialist must apply trial and error tactics to learn her field. How much longer it takes this way! One may compare the unguided student’s path to the random path of an ordinary electron beam, erratically bouncing from wall to wall in a chamber or tube; whereas a student in a smoothly-conducted postgraduate program is like an electron beam in a linear accelerator which is directed on a straighter path with accurately positioned klystron boosters to propel it faster and more powerfully along the way to the target area.’ In the latter case, the path is directed and the speed is increased by properly timed and spaced stimuli. The “target area” for OR students is the proven ability to scrub and circulate, if appropriate, for all routine surgical procedures with parallel understanding of the “whys” of OR nursing care. The random paths of some so-called “inservice orientation” programs in OR nursing are neither as successful nor as efficient as the linear path of a well-planned post-
AORN Jourriul
graduate program based on sound educational theory. For instance, let us look at four principles of learning theory expressed by Ralph W. Tyler2 and see how disregard of learning theory can negate the intended effect of teaching (principles one and two) ; and then, how implementation of learning theory can multiply and clarify learning outcomes (principles three and four). Principle one: “For a given objective to be attained, a student must have experiences that give him an opportunity to practice the behavior implied by the objectives.” If, on a certain day, the objective for the student is to learn the circulating responsibilities for open reduction of the tibia, and lectures are presented on the anatomy of the leg with a description of the surgical paraphernalia needed in this procedure, what purpose is served by assigning the student to circulate for gynecology cases on that day simply because the gynecology room needs coverage? The purpose served is the need of the department, not the need of the student. This student has suffered a fractured learning experience. Principle two: “Learning experiences must be such that the student obtains satisfaction from carrying on the kind of behavior implied by the objectives.” If a new student is industriously (and perhaps nervously) trying to open supplies as carefully as possible without dropping them or contaminating their edges, what purpose is served by the staff nurse who is scrubbed snarling at her to “Hurry up!”? The purpose served is to show the student that her ineptitude causes staff people to become irritable and impatient with her-hardly a positive learning experience. “If experiences are distasteful, the desired learning is not likely to take place. In fact, it is more likely that the student will develop the opposite from the desired objective. Traumatic experiences involving the intense emotional reactions are too hard to
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control to be used systematically in an educational program? How many students have we lost to OR nursing in the past due to such unpleasant traumatization? Needless to say, principles one and two should be fulfilled on every occasion-never ignored. In the selection of educational theory on which to base our OR program, principles three and four were seen as most important. Principle three: “Many experiences can be used to attain the same educational objective.” And the corollary to principle three principle four: “The same learning experience will u.wully bring about several outcomes.” Knowledge of disinfectant solutions, the function and principle of gas sterilization, the autoclave, and the high speed autoclave all serve to increase students’ understanding of the concept of asepsis (principle three). With blood agar plates, they may culture suspected areas to see if asepsis has or has not been achieved. Conversely (principle four), from one experience such as autoclaving a load of packs, the student learns about positioning supplies, the displacement of air in the autoclave, the necessary temperatures and steam pressures, the maintenance of the autoclave, etc.
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To multiply the outcomes and depth of experience even more, we utilized the tested theory of Hilda Taba,4 who said that: “Instruction groups with amenable interpersonal relations, open communication lines, and an ego-supportive climate, stimulate self-actualization and achievement motivation. Such a group is capable of task-centeredness and a sense of responsibility. Group thinking, by cross-stimulation, produces chains of ideas which reach a fullness and maturity no single individual could achieve alone, or with only the help of the teacher.” These same characteristics of group learning are described by Thelen and TylerG in relation to teaching adults. Since our learners are adults we found reassurance that this design was adapted to our students’ manner of
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AVOIDANCE OF TRADITIONAL “HANG-UPS” The combined forces of tension and critical actions involved in responsible surgical treatment have tended to sustain the existence of militant ‘‘aseptic behavior” in operating rooms on the assumption that if such patterns become behavioral habits, performed without conscious thought, there is less likelihood of an “aseptic error” (contamination of a sterile object). Errors are made apparent by breach of ritual rather than by real evidence of bacterial contamination. Everyone watches everyone else for such errors, truly to protect the patient undergoing surgery, but incidentally, and perhaps irreparably, causing the culprit some personal chagrin, embarrassment, or even despair if she is openly blamed for delaying the procedure while correction is made. Since errors by novices are not well-tolerated by the ritual initiates (the regular staff), the instructor’s effort to pave the way for her students among surgeons and experienced operating room personnel must be carefully, extensively, inclusively, and tactfully planned, prior to and continuously throughout the program.8 The chances for frustration, misunderstanding, inter- and intra-personal conflict are so high that sensitivity to developing crises of this sort must be acute on the part of the instructor so that she may quickly intervene to assuage wounded pride, redirect action, or clarify misunderstood communication at the slightest sign of trouble. Signed agreements by surgeons to participate in the program are needed to insure their continued tolerance and support; and in return the surgeons and anesthetists should be given a clear-cut explanation of the program in writing, with continuing opportunity and encouragement to provide suggestions for changes or adaptations in the program. If we have five students, each involved in
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a separate operative procedure, we will be unable to guide or support more than one at a time. We believe that other programs have failed because of this particular oversight. In the past, new OR students have been sent to work in separate OR’S selected on the basis of the expected simplicity of the surgical procedure and the amiability of the surgeons. It was implicitly assumed that the professional personnel in the room to which the student was assigned would show the student “how to do things” in the absence of the instructor. No thought was taken of the attitudes of other professional personnel in the room toward the new student, or the possibility that the new student might become the unwitting scapegoat for nurses and doctors whose insecurity causes them to use new personnel for relief of their own unresolved feelings. To solve this problem, we adopted the multiple-assignment method of Dr. Maura Carroll, assistant professor of medical-surgical nursing at the University of California Graduate School of Nursing. In her experimental approach, tested at Junior College of Manatee, Florida in 1964, each student in a group of beginning nursing students was assigned a portion of the total nursing care assignment. Carroll’s study indicated that by assigning five students to care for one patient, with each student responsible for a limited aspect of patient care, the learning outcomes appeared to be equal to those achieved by more traditional methods using a one-to-one teacherstudent rati0.O Dr. Carroll planned student assignments so that each student had only one facet of patient care to think about at a time. This appeared to ease some of the students’ initial apprehension and permit them to focus without confusion, and to relieve them of the feeling that they must learn everything all at once. In Carroll’s experiment in which five students cared for one patient, one student gave the patient his bed bath and morning
AORN Joirrn.al
STUDENT ROLES Role A: Anesthesia Assistant (unsterile) 1. Bring patient to surgery, check chart, identify and talk to patient. 2. Position patient on table. 3. Assist with I.V., observe intubation and administration of anesthetic, place Bovie plate. 4. With anesthesiologist, observe anesthesia and effects on patient. 5. Prep patient. 6. Assist with care of the waking patient; stay with patient through recovery room care. Role B: Circulating Nurse (unsterile) 1. Prepare room for surgery, insure a clean environment free of contaminants. 2. Open packs, gloves, supplies, sutures. 3. Assist with draping. 4. Chart essential information such as I.V. fluid used, specimens taken, sponge count, etc. 5. Clean room between cases, restock room supplies. Role C: First Scrub Nurse (sterile)
1. Set up sterile instruments and sup plies. 2. Gown and glove doctors. 3. Drape patient. 4. Hand instruments, sutures, dressings. 5. Clean room after case. Role D: Second Scrub Nurse (sterile) 1. Organize sutures and extra supplies. 2. Responsible for sponge count with Role B. 3. Hold retractors. 4. Observe the work of the surgeon. Role E: Student Observer-Evaluator (unsterile) 1. Choose all materials for the case, sterilize extra instruments or contaminated instruments. 2. Monitor for errors in aseptic technique. 3. Note reactions of patient, surgeons and nursing team. Identify problems as they occur, to b e reviewed in discussion later. 4. Run errands as necessary, such as getting blood and checking cross-match, taking cultures and specimens to laboratory.
Figure 1 care; another observed the patient to note his reactions or attitudes about his disease and his hospitalization; another studied the patient’s records to gather all the health information about the patient; another performed all treatments and gave medications to the patient; while the fifth studied the rehabilitative aspects of the patient’s care. These assignments were rotated among the five students during the school term so that each had many opportunities to perform all functions. Before and after every patient care experience, the students had a self-propelled planning and evaluation conference to which they all contributed their pieces of the total picture. They planned, worked, and evaluated their own work as a team with the instructor’s support, guidance, and participation. Together they acquired meaning of the whole from their discussion and performance of its parts. We adapted this method to our OR program in the following way: five OR student
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roles were defined at the outset, along with a four-week review of anatomy and orientation to principles of OR nursing. We provided a simulated OR, complete with dummy patient. Role-playing was utilized to practice and clarify what the five roles of the students were to be. The assignments were designated, somewhat prosaically, as A, B, C, D, and E. (See Figure 1). For each successive surgical procedure assigned to the student room, the student assumes the next successive role in the sequence from A to E. The instructor ostensibly circulates, but watches and guides the performance of all the students. In the students’ conference with the instructor before their assignment, they discuss anticipation of needs and clarification of expectation as well as the reason for the procedure and the condition of the patient. Following active participation of students in the day’s surgical procedures, another conference is held with the instructor to assess 1) what was done, 2) why it was done, 3)
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how it was done, 4) probable patient impressions, and 5) student reactions to what was done.
RATIONALE FOR THE PROGRAM’S PHILOSOPHY The curriculum of any program ideally must integrate the purposes of the institution in which the learning is to take place and the purposes or goals of the learners within the institution, and this within the framework of the professional criteria and the needs of society. In regard to this we hold the following to be basic truths:
1) OR nursing has, and will continue to become, less and less a part of undergraduate nursing education. To argue the desirability of this trend is to waste one’s breath. Schools of nursing simply haven’t the time to offer a realistic learning experience in all the nursing specialties, of which OR nursing is certainly the most demanding and anxiety-producing for the student.”, l1
2j OR nursing must be taught in OR suites. The classroom lecture cannot suffice for learning OR skills, although classroom understanding of bacteriology, histology, physiology, anatomy, etc. is necessary knowledge to be gained before the student comes to learn OR nursing. Fitness to begin OR training must include either professional or vocational education in the basic nursing sciences; but subsequent involvement in the “real thing” is essential for proficient application and performance.’**l3 3 ) A better method for achieving adequate training for beginning OR (RN and LVN) staff nurses is afforded by a postgraduate pr~gram.’~
4) No person who scrubs or circulates for surgery shall be unlicensed; the minimum acceptable level being LVN (or LPN), and that since no special licensure exists for “OR Technicians,” such lay persons will be required to be licensed as LVN or LPN before they may scrub or circulate.15*
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5) The scrub and circulating roles bolh involve direct nursing care of patients and that lay people, without some background of nursing education are rarely adequate even for the limited scrub roles.” 6) A trend toward unification of nurse licensing boards at the state level will combine all such licensure as inhalation therapy, physiotherapy, psychiatric nurse technician, as well as vocational nursing and the registration of nurses under one nursing board made up of representatives from each group of professional workers.18
7) OR nursing in postgraduate programs must be taught by qualified teachers; and a qualified teacher is one who: a) has had special education for teaching, M.S. in nursing or education; b) has experience in teaching groups; c ) has five years’ experience in OR nursing work; and d ) has scrubbed and circulated in the OR suite where she teaches in such a manner as to have gained the respect of surgeons, anesthetists, and staff for her knowledge and ability.
HOW WE DID IT In order to incorporate all these premises into one effort Loward education of new prospective OR nurses, we began our discussions and planning with the administrator three months before the program began. The administrator, his assistant, and the director of patient care were each given a copy of our detailed program plan, (detailed not so much for course-content as for the purpose, reason, and method of formation of the program). We based our proposal on the aforementioned premises and on the philosophy of our hospital, which is “to offer the best possible hospital service to residents of the dist ric t .” We requested stipends for five students at $320.00 a month each for a period of six months. By the end of the first month after receiving the initial proposal, the administrator sent us his letter of approval with addi-
AORN Journal
tional authorization to buy textbooks, student chairs, blackboards, a dummy (“Chase” doll) and other equipment needed for the program. We then began to advertise for students within the hospital and at the nearby Junior College, where a two-year program in nursing is offered, granting an associate of arts degree in nursing with RN licensure qualification. We received more applications than we could accept, and chose four LVN’s and one associate dgeree RN for our first pilot program. Copies of the program were given to the surgeons and anesthetists, with instructions to sign and return if they approved of the program and were willing to participate in the teaching. Thus we obtained their informed consent to allow students to provide OR nursing care for their patients. (Forty doctors’ signatures appeared on the copy of the program within a week.) The basic textbooks were identified and displayed.I0 The limitations of the program and of its students were clearly spelled out beforehand in the program description. Some of the “ground rules” were as follows: 1) “The students wear white caps while participating in surgery.” The staff normally wore green caps so this involved no change for the regular staff. Identifying students in this way had psychological implications. They learned teamwork by being a team.20 Their instructor also wore a white cap, and the group moved as a unit in their learning experiences. 2 ) “The cases to be assigned for student learning should be uncomplicated, basic, and routine in nature, as classified by the surgeons themselves.” 3) “The surgeon should make no direct requests for services from students except as agreed may be reasonably expected in each learning situation.” 4) “The instructor should be in constant attendance with the student group whenever they participate in surgical cases.”
November 1968
THE OUTCOME Total sick time of the five students was five days. None were late or showed any demonstrable evidence of lowered interest or decreased enthusiasm throughout the course. The minimal stipend and the pace of the program probably had a strong bearing on the motivation of each student. Toward the end of the fifth month, students were given more individual assignments. By then their knowledge and confidence had grown sufficiently to make them eager for this increased measure of responsibility. Intra-group frictions, competition, impatience, and frustration occurred, of course, but the necessity for each student to rely on the work of the others in order to complete the assignment successfully appeared to be a built-in factor to help them overcome their negative feelings and remain objective. The difference in status between the one RN and the four LVN’s caused some discomfort in the group but was chiefly promulgated by remarks of the regular staff overheard in the coffee lounge. We attempted to differentiate the roles of the LVN and RN by equating the function of LVN in the operating room with LVN function in intensive care and other hospital specialty areas. The LVN was not given independent decisions to make, or leadership roles of any kind. The RN was. During the sixth month, which happened to fall in June, 1968, the usual turnover of regular staff and the occurrence of vacations and leaves provided the students more opportunities for individual assignment without their seeming to usurp the more challenging assignments of the regular staff. The five students were not obligated to work at Sequoia following the program. Two were hired by a nearby hospital and two will remain on our staff. The fifth will work parttime in the recovery room until fall when she will return to work in the Sequoia operating room full-time.
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OBJECTIVES ACHIEVED 1) Five licensed personnel achieved basic and dependable capability in OR nursing techniques. There were no dropouts.
2 ) They achieved a creditable depth 01 understanding, demonstrably greater than many staff members possessed. Comments by staff members supported this observation, saying “These students really know why the surgeon does what he does.” In an incident of unexpected cardiac arrest, late in the program, one student who was assigned as a “second scrub” person was the first to perceive the arrest at the warning of the anesthetist. She initiated appropriate staff responses verbally while remaining sterile to receive needed emergency items for resuscitation. The student had every right to be proud of her actions that day, as the patient was successfully revived and surgery concluded.
3) The students experienced little threat or anxiety in their relationships with staff members. No staff member made any overt effort to “put down” the students, although some expressed a definite wish to have nothing to do with students because “students foul things up.” We respected the wishes of these staff members and did not assign students to work with them.
4) Surgeons who had not signed the program proposal were sometimes assistants to surgeons who had. On two occasions when the non-approving surgeon complained that the room was “too crowded,” the approving surgeon and the anesthetist defended the program and managed to gain qualified support from the nonapproving surgeons in a manner we ourselves could never have achieved.
5) The students themselves, in evaluating their experience in this program, recommended that four students at a time would be better; that in their estimation the “E” role was superfluous and could be assimilated into the other roles. On the basis of these students’
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evaluations we will reduce our next class to four students, without altering the group method of teaching.
STAFF INVOLVEMENT ESSENTIAL In generalizing about the entire process of devising, proposing, gaining acceptance, implementing, and fulfilling this pilot postgraduate program, the underlying mechanism of salesmanship was our enthusiastic acceptance of volunteered ideas. We called a meeting of all the staff interested in the OR teaching program. The ancillary staff was not treated as a separate entity; each was asked for ideas. We had to build our own classroom, post bulletin boards, and devise a screen for showing slides and films. The secretaries were invaluable when it came to organizing and printing a syllabus, the form of which included many of their own ideas. The leading statement of the first meeting was “We have the administration’s and the surgeons’ approval to start. the program; now, how are we going to start? What do we need first? If you were a new person coming in as a student, what would you want first?”
Someone said,
locker!” (and lockers for students were arranged by that person). Another said, “A syllabus, or an outline of the program, so they’ll know what they’re going to do.” (This person worked with the secretaries to produce a twelve-page sylla. bus.) “They’ll need a room to practice in,” said another. “You could use a dummy to show them draping and positioning.” (These people actually made a life-sized dummy out of cotton, rags, stockinette, buttons, and yarn, and presented the finished product to the instructor with much merriment.) By the time the students appeared, everything necessary was ready for use, and the staff was totally involved with the program and its purpose.
A 0 R N .loiirnal
ADVANTAGES OF PILOT PROGRAM 1) All five students were confined to one operating room during the first four months; all observed the same selected case rather than an assortment of different procedures for each student, which occurs with individual assignment to separate rooms.
CONCLUSIONS
Although a pilot program of such small scope cannot hope to be definitive for the purpose of setting standards, we feel that this program design has demonstrated more efficient attainment of certain beneficial objectives not possible with other designs. When the LVN’s are finished with the 2 ) The planning and evaluation of each learning experience involved all students on course, they are classified as OR staff LVN’s. the same problem with less dissipation of In this capacity (for elective procedures), the problem-solving efforts, more coherence and LVN should circulate or scrub with equal frequency. This insures her adaptability and clarity in what was learned. expands her role, but never leaves her without 3) The sum of all the students’ reactions direct guidance of surgeons, anesthetists and and responses brought varied but deeper in- nurses. We do not put two LVNs together vestigation of each aspect in relation to the on the same case, nor do we assign them to whole. call on weekend coverage without a charge 4) Group interaction became more efficient nurse with them. (The role with status, at least than individual action toward reaching the to lay observers, is the scrub role, and many task-centered goal. RN’s miss the opportunity to scrub. I feel 5) The instructor could bring to bear more that the roles should be shared by all who concise and inclusive guidance techniques give direct care in the operating room and that no one should be permitted to scrub or upon the learning of her students. circulate who does not have a nursing license, 6) The method reduced the ambiguity of either LVN or RN.) The differentiation the students’ function as pseudo-employees lies in the fact that RN’s develop into charge and placed them in the minds of the staff as nurses, head nurses, assistant instructors and a group of students who moved together, the like. RN’s are also assigned the major worked together, and supported each other. complicated cases and the emergencies of un7) The method was economical in using predictable nature. The RN is expected to the energies of students and teacher, less use judgment, whereas the LVN follows confusing for all the staff. routines and does not exercise the same de8) Each student derived more ego strength gree of independent nursing judgment. By having presented this report, the auwithin the protection of the group than she thors wish to encourage other hospitals to iniwould have by herself. Later in the program, when their ego strength had grown, single tiate their own postgraduate OR nursing programs. We feel that our experience can be assignments were made. 9) A last, and most important considera- duplicated in any similar hospital environtion was that in a small operating room suite ment, given a qualified OR nursing instructor and following these recammendations for such as Sequoia’s (seven rooms), this method eliciting administrative, medical, and OR staff allowed better latitude for assignment of r e g support. It is possible that such postgraduate ular staff members whose needs are just as programs will be devised for all the nursing important as the students’. OR staff nurses specialties; the so-called “nursing internship” who are not prepared to teach must never ar- period of practical experience necessitated bitrarily be forced into this responsibility by by the changing character of nursing educarandom assignment of students to their rooms. tion.
November 1968
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REFERENCES
1. Cinzton, E. L. and Kirk, W., “The Two-Mile Electron Accelerator,” Kepr. from Scientific American, Nov. 1961. 2. Tyler, R. W., Basir Principles of Curriculuni and Instruction, Chicago, Ill., The Univtmity I J f Chicago Press, 1957. 3. Ibid. 4. Taba, Hilda, Curriculum Development: Theory and Practice, New York, Harcourt, Brace, and World, Inc., 1%2, p. 165. 5. Thelen, H. A. and Tyler, K. W., “Implications for Improving Instruction in the High School,” In N. B. Henry (Ed.), Learning and Instruction, Part I, 49th Yearbook of the Nat’l Ass’n for the Study of Education, Chicago, Ill., The University of Chicago Press, 1950, pp. 304-335. 6. Gibb, J. R., “Learning Theory in Adult Education,” in M. S. Knowle’s (Ed.) Handbook of Adult Education in the United States, Chicago, Ill., Adult Education Ass’n of the U.S.A., 1960, pp. 54-64. 7. Luft, J., Group Processes: An Introduction to Group Dynamics, Palo Alto, Calif., The National Press, 1963. 8. Boyer, Sarah B., “Key Factors in Successful Program for OR Technicians,” Hospital Topics, Nov. 1966, Vol. 44, #11, pp. 113-116. 9. Carroll, Maura, “Report of a Workshop on Medical-Surgical Nursing,” sponsored by Manatee Junior College, Southern Regional Education Board Project in Nursing Education and Research, IJnpubl. doctoral thesis, Manatee, Fla., Sept. 28-Oct. 2, 1964. 10. “American Nurses’ Association First Position on Education for Nursing,” AJN, Dec. 1%5, Vol. 65, #12, pp. 106-111.
11. Peers, Jerry C., “Today’s Challenge to The Professional Operating Room Nurse,” AORN Journal. Jan.-Feb. 1964, Vol. 2, #l, pp. 69-73. 12. Op. Cit., Boyer. 13. Coakeley, Jacquelyn(:, “Operating I{ooni Inservice Education : Its Problems and Implications,” Hospital Topics, Oct. 1966, Vol. 44, #lo, pp. 107-111. 14. “L.P.N.’s for OR Service,” New York, Ethical Publications, lnc., Feb. 1967, Vol. 2, $2, p. 2. 15. Ibid. 16. West, Ethel I. “Supervisors Speak on Qualifications for OR Nurses, Use of Technicians,” Hospital Topics, Feb. 1961, Vol. 39, #2, pp. 90-93. 17. Op. Cit., Boyer. 18. CNA Bulletin, March 1968, Vol. 64, #3, p. 2. 19. Texts for the OR program were: a ) Berry, E. C. and Kohn, L., Introduction to Operating Room Technique, New York, McGraw Hill Book Co., 1966. b ) Bums, Margaret A., et al., Teaching the OR Technician, New York, Association of Operating Room Nurses, Inc., 1967. c ) Ginsberg, Brunner, and Cantlin, A Manual of Operating Room Technology, Philadelphia, J. B. Lippincott Co., 1966. d ) Programmed Instruction in Asepsis, Somerville, N. J., Arbrook, 1966. e ) Walter, C., Aseptic Treatment of Wounds, New York, The Macmillan Co., 1947. f ) Willingham, Jacqueline, Logic of Operating Room Nursing, New York, Springer Pub. Co., 1962. 20. Parker, J. C. and Rubin, L. J., Process as Content: Curricubm Design and the Application of Knowledge, Chicago, Ill., Rand McNally & Co., 1966.
EDITORS NOTE: The opinions expressed in this article a r e those of the authors a n d d o not necessarily represent the oficial opinion of the AORN. RECOMMENDATION FOR “ASSISTANTS I N THE HEALTH S E R V I C E OCCUPATIONS” Education for assistants in the health service occupations should be short, intensive preservice programs in vocational education institutions rather than on-the-job traini n g programs. Most of this preservice preparation must be done by vocational educators who may not necessarily be nurses; if they a r e nurses, they should meet the qualifications for teaching set by vocational education. In addition to general preservice preparation, workers assigned to nursing services should be given inservice orientation a n d on-the-job training t o perform specific tasks delegated by nurses. This rule, t h a t on-the-job orientation and continuing inservice education be followed through by t h e service to which the worker is assigned, should a p p l y not only to nursing services but also to other health services i n which these workers will assist. The current role of government in financing programs to train workers for the health fields requires the nursing profession t o enunciate standards for the education of all who s h a r e t h e activities of nursing. It should not, however, require t h a t nursing assume responsibility for t h e standards a n d preparations of those who function as assistants to personnel in other health professions. ANA Position P a p e r 1965
0
AORN J o u r n a l
R. Minckley, R.N., M.S. and Shonna Warner, R.N.
In the firm belief that every supervising operating room nurse must lend her energies toward helping to reverse the present decline in numbers of qualified OR staff nurses in the most expeditious and efficient manner, we have proposed a somewhat different method for teaching OR techniques to licensed personnel. We believe the postgraduate program, which we describe here, may be readily adapted to any hospital that maintains an OR suite of four or more operating rooms; and that increased numbers of qualified OR nurses can be prepared in nearly every such hospital, with more predictably satisfactory outcomes than are presently obtained. Because we, as OR nurses, are accustomed to technical innovation, and because for us the process of “operationalizing theory” is an almost daily affair, this program must appeal to the sense of economy of effort, time, and space. Few other areas in the hospital put such a premium on improved work patterns, more efficient use of time, and better teamwork as we do in the operating room. Barbara Blake Mincklcy, R.N., ORS a t Sequoia Hospital in Redwood City, Calif., is a graduate of Stanford University School of Nursing and received her M.S. degree (cum Laude) from the University of Calif. in San Francisco. She has worked a s staff nurse and head nurse in Stanford Hospital operating rooms and has assisted with cardiac research and open heart surgery at the VA Hospital in Palo Alto. Miss Minckley is presently engaged in promoting a program for teaching OR skills to licensed nursing personnel (LVN’s and RN’s). Shonna E. Warner, B.S.N., is a graduate of Hamline University, St. Paul, Minnesota. She has worked as an OR staff nurse at Anker Hospital in St. Paul and at Mt. Zion Hospital in San Francisco. At Sequoia Hospital, Redwood City, California, where she is now an inservice instructor in the operating room, she has been an OR staff nurse and an OR head nurse.
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Yet we do this continually without sacrificing safety or accuracy, maintaining the finest possible nursing care of which we are capable. Yes, we said nursing care! Basic nursing concepts are not, never have been, nor ever can be lost in the operating room. We have watched and worked with ICU nurses, PAR nurses, and ER nurses, and find our behavior is much the same as theirs in given situations. We all apply the same nursing concepts, but in different ways. However, for each nursing specialty, it takes training to become acceptably proficient. If the special training and guidance are not available, the beginning specialist must apply trial and error tactics to learn her field. How much longer it takes this way! One may compare the unguided student’s path to the random path of an ordinary electron beam, erratically bouncing from wall to wall in a chamber or tube; whereas a student in a smoothly-conducted postgraduate program is like an electron beam in a linear accelerator which is directed on a straighter path with accurately positioned klystron boosters to propel it faster and more powerfully along the way to the target area.’ In the latter case, the path is directed and the speed is increased by properly timed and spaced stimuli. The “target area” for OR students is the proven ability to scrub and circulate, if appropriate, for all routine surgical procedures with parallel understanding of the “whys” of OR nursing care. The random paths of some so-called “inservice orientation” programs in OR nursing are neither as successful nor as efficient as the linear path of a well-planned post-
AORN Jourriul
graduate program based on sound educational theory. For instance, let us look at four principles of learning theory expressed by Ralph W. Tyler2 and see how disregard of learning theory can negate the intended effect of teaching (principles one and two) ; and then, how implementation of learning theory can multiply and clarify learning outcomes (principles three and four). Principle one: “For a given objective to be attained, a student must have experiences that give him an opportunity to practice the behavior implied by the objectives.” If, on a certain day, the objective for the student is to learn the circulating responsibilities for open reduction of the tibia, and lectures are presented on the anatomy of the leg with a description of the surgical paraphernalia needed in this procedure, what purpose is served by assigning the student to circulate for gynecology cases on that day simply because the gynecology room needs coverage? The purpose served is the need of the department, not the need of the student. This student has suffered a fractured learning experience. Principle two: “Learning experiences must be such that the student obtains satisfaction from carrying on the kind of behavior implied by the objectives.” If a new student is industriously (and perhaps nervously) trying to open supplies as carefully as possible without dropping them or contaminating their edges, what purpose is served by the staff nurse who is scrubbed snarling at her to “Hurry up!”? The purpose served is to show the student that her ineptitude causes staff people to become irritable and impatient with her-hardly a positive learning experience. “If experiences are distasteful, the desired learning is not likely to take place. In fact, it is more likely that the student will develop the opposite from the desired objective. Traumatic experiences involving the intense emotional reactions are too hard to
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control to be used systematically in an educational program? How many students have we lost to OR nursing in the past due to such unpleasant traumatization? Needless to say, principles one and two should be fulfilled on every occasion-never ignored. In the selection of educational theory on which to base our OR program, principles three and four were seen as most important. Principle three: “Many experiences can be used to attain the same educational objective.” And the corollary to principle three principle four: “The same learning experience will u.wully bring about several outcomes.” Knowledge of disinfectant solutions, the function and principle of gas sterilization, the autoclave, and the high speed autoclave all serve to increase students’ understanding of the concept of asepsis (principle three). With blood agar plates, they may culture suspected areas to see if asepsis has or has not been achieved. Conversely (principle four), from one experience such as autoclaving a load of packs, the student learns about positioning supplies, the displacement of air in the autoclave, the necessary temperatures and steam pressures, the maintenance of the autoclave, etc.
...
To multiply the outcomes and depth of experience even more, we utilized the tested theory of Hilda Taba,4 who said that: “Instruction groups with amenable interpersonal relations, open communication lines, and an ego-supportive climate, stimulate self-actualization and achievement motivation. Such a group is capable of task-centeredness and a sense of responsibility. Group thinking, by cross-stimulation, produces chains of ideas which reach a fullness and maturity no single individual could achieve alone, or with only the help of the teacher.” These same characteristics of group learning are described by Thelen and TylerG in relation to teaching adults. Since our learners are adults we found reassurance that this design was adapted to our students’ manner of
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AVOIDANCE OF TRADITIONAL “HANG-UPS” The combined forces of tension and critical actions involved in responsible surgical treatment have tended to sustain the existence of militant ‘‘aseptic behavior” in operating rooms on the assumption that if such patterns become behavioral habits, performed without conscious thought, there is less likelihood of an “aseptic error” (contamination of a sterile object). Errors are made apparent by breach of ritual rather than by real evidence of bacterial contamination. Everyone watches everyone else for such errors, truly to protect the patient undergoing surgery, but incidentally, and perhaps irreparably, causing the culprit some personal chagrin, embarrassment, or even despair if she is openly blamed for delaying the procedure while correction is made. Since errors by novices are not well-tolerated by the ritual initiates (the regular staff), the instructor’s effort to pave the way for her students among surgeons and experienced operating room personnel must be carefully, extensively, inclusively, and tactfully planned, prior to and continuously throughout the program.8 The chances for frustration, misunderstanding, inter- and intra-personal conflict are so high that sensitivity to developing crises of this sort must be acute on the part of the instructor so that she may quickly intervene to assuage wounded pride, redirect action, or clarify misunderstood communication at the slightest sign of trouble. Signed agreements by surgeons to participate in the program are needed to insure their continued tolerance and support; and in return the surgeons and anesthetists should be given a clear-cut explanation of the program in writing, with continuing opportunity and encouragement to provide suggestions for changes or adaptations in the program. If we have five students, each involved in
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a separate operative procedure, we will be unable to guide or support more than one at a time. We believe that other programs have failed because of this particular oversight. In the past, new OR students have been sent to work in separate OR’S selected on the basis of the expected simplicity of the surgical procedure and the amiability of the surgeons. It was implicitly assumed that the professional personnel in the room to which the student was assigned would show the student “how to do things” in the absence of the instructor. No thought was taken of the attitudes of other professional personnel in the room toward the new student, or the possibility that the new student might become the unwitting scapegoat for nurses and doctors whose insecurity causes them to use new personnel for relief of their own unresolved feelings. To solve this problem, we adopted the multiple-assignment method of Dr. Maura Carroll, assistant professor of medical-surgical nursing at the University of California Graduate School of Nursing. In her experimental approach, tested at Junior College of Manatee, Florida in 1964, each student in a group of beginning nursing students was assigned a portion of the total nursing care assignment. Carroll’s study indicated that by assigning five students to care for one patient, with each student responsible for a limited aspect of patient care, the learning outcomes appeared to be equal to those achieved by more traditional methods using a one-to-one teacherstudent rati0.O Dr. Carroll planned student assignments so that each student had only one facet of patient care to think about at a time. This appeared to ease some of the students’ initial apprehension and permit them to focus without confusion, and to relieve them of the feeling that they must learn everything all at once. In Carroll’s experiment in which five students cared for one patient, one student gave the patient his bed bath and morning
AORN Joirrn.al
STUDENT ROLES Role A: Anesthesia Assistant (unsterile) 1. Bring patient to surgery, check chart, identify and talk to patient. 2. Position patient on table. 3. Assist with I.V., observe intubation and administration of anesthetic, place Bovie plate. 4. With anesthesiologist, observe anesthesia and effects on patient. 5. Prep patient. 6. Assist with care of the waking patient; stay with patient through recovery room care. Role B: Circulating Nurse (unsterile) 1. Prepare room for surgery, insure a clean environment free of contaminants. 2. Open packs, gloves, supplies, sutures. 3. Assist with draping. 4. Chart essential information such as I.V. fluid used, specimens taken, sponge count, etc. 5. Clean room between cases, restock room supplies. Role C: First Scrub Nurse (sterile)
1. Set up sterile instruments and sup plies. 2. Gown and glove doctors. 3. Drape patient. 4. Hand instruments, sutures, dressings. 5. Clean room after case. Role D: Second Scrub Nurse (sterile) 1. Organize sutures and extra supplies. 2. Responsible for sponge count with Role B. 3. Hold retractors. 4. Observe the work of the surgeon. Role E: Student Observer-Evaluator (unsterile) 1. Choose all materials for the case, sterilize extra instruments or contaminated instruments. 2. Monitor for errors in aseptic technique. 3. Note reactions of patient, surgeons and nursing team. Identify problems as they occur, to b e reviewed in discussion later. 4. Run errands as necessary, such as getting blood and checking cross-match, taking cultures and specimens to laboratory.
Figure 1 care; another observed the patient to note his reactions or attitudes about his disease and his hospitalization; another studied the patient’s records to gather all the health information about the patient; another performed all treatments and gave medications to the patient; while the fifth studied the rehabilitative aspects of the patient’s care. These assignments were rotated among the five students during the school term so that each had many opportunities to perform all functions. Before and after every patient care experience, the students had a self-propelled planning and evaluation conference to which they all contributed their pieces of the total picture. They planned, worked, and evaluated their own work as a team with the instructor’s support, guidance, and participation. Together they acquired meaning of the whole from their discussion and performance of its parts. We adapted this method to our OR program in the following way: five OR student
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roles were defined at the outset, along with a four-week review of anatomy and orientation to principles of OR nursing. We provided a simulated OR, complete with dummy patient. Role-playing was utilized to practice and clarify what the five roles of the students were to be. The assignments were designated, somewhat prosaically, as A, B, C, D, and E. (See Figure 1). For each successive surgical procedure assigned to the student room, the student assumes the next successive role in the sequence from A to E. The instructor ostensibly circulates, but watches and guides the performance of all the students. In the students’ conference with the instructor before their assignment, they discuss anticipation of needs and clarification of expectation as well as the reason for the procedure and the condition of the patient. Following active participation of students in the day’s surgical procedures, another conference is held with the instructor to assess 1) what was done, 2) why it was done, 3)
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how it was done, 4) probable patient impressions, and 5) student reactions to what was done.
RATIONALE FOR THE PROGRAM’S PHILOSOPHY The curriculum of any program ideally must integrate the purposes of the institution in which the learning is to take place and the purposes or goals of the learners within the institution, and this within the framework of the professional criteria and the needs of society. In regard to this we hold the following to be basic truths:
1) OR nursing has, and will continue to become, less and less a part of undergraduate nursing education. To argue the desirability of this trend is to waste one’s breath. Schools of nursing simply haven’t the time to offer a realistic learning experience in all the nursing specialties, of which OR nursing is certainly the most demanding and anxiety-producing for the student.”, l1
2j OR nursing must be taught in OR suites. The classroom lecture cannot suffice for learning OR skills, although classroom understanding of bacteriology, histology, physiology, anatomy, etc. is necessary knowledge to be gained before the student comes to learn OR nursing. Fitness to begin OR training must include either professional or vocational education in the basic nursing sciences; but subsequent involvement in the “real thing” is essential for proficient application and performance.’**l3 3 ) A better method for achieving adequate training for beginning OR (RN and LVN) staff nurses is afforded by a postgraduate pr~gram.’~
4) No person who scrubs or circulates for surgery shall be unlicensed; the minimum acceptable level being LVN (or LPN), and that since no special licensure exists for “OR Technicians,” such lay persons will be required to be licensed as LVN or LPN before they may scrub or circulate.15*
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5) The scrub and circulating roles bolh involve direct nursing care of patients and that lay people, without some background of nursing education are rarely adequate even for the limited scrub roles.” 6) A trend toward unification of nurse licensing boards at the state level will combine all such licensure as inhalation therapy, physiotherapy, psychiatric nurse technician, as well as vocational nursing and the registration of nurses under one nursing board made up of representatives from each group of professional workers.18
7) OR nursing in postgraduate programs must be taught by qualified teachers; and a qualified teacher is one who: a) has had special education for teaching, M.S. in nursing or education; b) has experience in teaching groups; c ) has five years’ experience in OR nursing work; and d ) has scrubbed and circulated in the OR suite where she teaches in such a manner as to have gained the respect of surgeons, anesthetists, and staff for her knowledge and ability.
HOW WE DID IT In order to incorporate all these premises into one effort Loward education of new prospective OR nurses, we began our discussions and planning with the administrator three months before the program began. The administrator, his assistant, and the director of patient care were each given a copy of our detailed program plan, (detailed not so much for course-content as for the purpose, reason, and method of formation of the program). We based our proposal on the aforementioned premises and on the philosophy of our hospital, which is “to offer the best possible hospital service to residents of the dist ric t .” We requested stipends for five students at $320.00 a month each for a period of six months. By the end of the first month after receiving the initial proposal, the administrator sent us his letter of approval with addi-
AORN Journal
tional authorization to buy textbooks, student chairs, blackboards, a dummy (“Chase” doll) and other equipment needed for the program. We then began to advertise for students within the hospital and at the nearby Junior College, where a two-year program in nursing is offered, granting an associate of arts degree in nursing with RN licensure qualification. We received more applications than we could accept, and chose four LVN’s and one associate dgeree RN for our first pilot program. Copies of the program were given to the surgeons and anesthetists, with instructions to sign and return if they approved of the program and were willing to participate in the teaching. Thus we obtained their informed consent to allow students to provide OR nursing care for their patients. (Forty doctors’ signatures appeared on the copy of the program within a week.) The basic textbooks were identified and displayed.I0 The limitations of the program and of its students were clearly spelled out beforehand in the program description. Some of the “ground rules” were as follows: 1) “The students wear white caps while participating in surgery.” The staff normally wore green caps so this involved no change for the regular staff. Identifying students in this way had psychological implications. They learned teamwork by being a team.20 Their instructor also wore a white cap, and the group moved as a unit in their learning experiences. 2 ) “The cases to be assigned for student learning should be uncomplicated, basic, and routine in nature, as classified by the surgeons themselves.” 3) “The surgeon should make no direct requests for services from students except as agreed may be reasonably expected in each learning situation.” 4) “The instructor should be in constant attendance with the student group whenever they participate in surgical cases.”
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THE OUTCOME Total sick time of the five students was five days. None were late or showed any demonstrable evidence of lowered interest or decreased enthusiasm throughout the course. The minimal stipend and the pace of the program probably had a strong bearing on the motivation of each student. Toward the end of the fifth month, students were given more individual assignments. By then their knowledge and confidence had grown sufficiently to make them eager for this increased measure of responsibility. Intra-group frictions, competition, impatience, and frustration occurred, of course, but the necessity for each student to rely on the work of the others in order to complete the assignment successfully appeared to be a built-in factor to help them overcome their negative feelings and remain objective. The difference in status between the one RN and the four LVN’s caused some discomfort in the group but was chiefly promulgated by remarks of the regular staff overheard in the coffee lounge. We attempted to differentiate the roles of the LVN and RN by equating the function of LVN in the operating room with LVN function in intensive care and other hospital specialty areas. The LVN was not given independent decisions to make, or leadership roles of any kind. The RN was. During the sixth month, which happened to fall in June, 1968, the usual turnover of regular staff and the occurrence of vacations and leaves provided the students more opportunities for individual assignment without their seeming to usurp the more challenging assignments of the regular staff. The five students were not obligated to work at Sequoia following the program. Two were hired by a nearby hospital and two will remain on our staff. The fifth will work parttime in the recovery room until fall when she will return to work in the Sequoia operating room full-time.
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OBJECTIVES ACHIEVED 1) Five licensed personnel achieved basic and dependable capability in OR nursing techniques. There were no dropouts.
2 ) They achieved a creditable depth 01 understanding, demonstrably greater than many staff members possessed. Comments by staff members supported this observation, saying “These students really know why the surgeon does what he does.” In an incident of unexpected cardiac arrest, late in the program, one student who was assigned as a “second scrub” person was the first to perceive the arrest at the warning of the anesthetist. She initiated appropriate staff responses verbally while remaining sterile to receive needed emergency items for resuscitation. The student had every right to be proud of her actions that day, as the patient was successfully revived and surgery concluded.
3) The students experienced little threat or anxiety in their relationships with staff members. No staff member made any overt effort to “put down” the students, although some expressed a definite wish to have nothing to do with students because “students foul things up.” We respected the wishes of these staff members and did not assign students to work with them.
4) Surgeons who had not signed the program proposal were sometimes assistants to surgeons who had. On two occasions when the non-approving surgeon complained that the room was “too crowded,” the approving surgeon and the anesthetist defended the program and managed to gain qualified support from the nonapproving surgeons in a manner we ourselves could never have achieved.
5) The students themselves, in evaluating their experience in this program, recommended that four students at a time would be better; that in their estimation the “E” role was superfluous and could be assimilated into the other roles. On the basis of these students’
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evaluations we will reduce our next class to four students, without altering the group method of teaching.
STAFF INVOLVEMENT ESSENTIAL In generalizing about the entire process of devising, proposing, gaining acceptance, implementing, and fulfilling this pilot postgraduate program, the underlying mechanism of salesmanship was our enthusiastic acceptance of volunteered ideas. We called a meeting of all the staff interested in the OR teaching program. The ancillary staff was not treated as a separate entity; each was asked for ideas. We had to build our own classroom, post bulletin boards, and devise a screen for showing slides and films. The secretaries were invaluable when it came to organizing and printing a syllabus, the form of which included many of their own ideas. The leading statement of the first meeting was “We have the administration’s and the surgeons’ approval to start. the program; now, how are we going to start? What do we need first? If you were a new person coming in as a student, what would you want first?”
Someone said,
locker!” (and lockers for students were arranged by that person). Another said, “A syllabus, or an outline of the program, so they’ll know what they’re going to do.” (This person worked with the secretaries to produce a twelve-page sylla. bus.) “They’ll need a room to practice in,” said another. “You could use a dummy to show them draping and positioning.” (These people actually made a life-sized dummy out of cotton, rags, stockinette, buttons, and yarn, and presented the finished product to the instructor with much merriment.) By the time the students appeared, everything necessary was ready for use, and the staff was totally involved with the program and its purpose.
A 0 R N .loiirnal
ADVANTAGES OF PILOT PROGRAM 1) All five students were confined to one operating room during the first four months; all observed the same selected case rather than an assortment of different procedures for each student, which occurs with individual assignment to separate rooms.
CONCLUSIONS
Although a pilot program of such small scope cannot hope to be definitive for the purpose of setting standards, we feel that this program design has demonstrated more efficient attainment of certain beneficial objectives not possible with other designs. When the LVN’s are finished with the 2 ) The planning and evaluation of each learning experience involved all students on course, they are classified as OR staff LVN’s. the same problem with less dissipation of In this capacity (for elective procedures), the problem-solving efforts, more coherence and LVN should circulate or scrub with equal frequency. This insures her adaptability and clarity in what was learned. expands her role, but never leaves her without 3) The sum of all the students’ reactions direct guidance of surgeons, anesthetists and and responses brought varied but deeper in- nurses. We do not put two LVNs together vestigation of each aspect in relation to the on the same case, nor do we assign them to whole. call on weekend coverage without a charge 4) Group interaction became more efficient nurse with them. (The role with status, at least than individual action toward reaching the to lay observers, is the scrub role, and many task-centered goal. RN’s miss the opportunity to scrub. I feel 5) The instructor could bring to bear more that the roles should be shared by all who concise and inclusive guidance techniques give direct care in the operating room and that no one should be permitted to scrub or upon the learning of her students. circulate who does not have a nursing license, 6) The method reduced the ambiguity of either LVN or RN.) The differentiation the students’ function as pseudo-employees lies in the fact that RN’s develop into charge and placed them in the minds of the staff as nurses, head nurses, assistant instructors and a group of students who moved together, the like. RN’s are also assigned the major worked together, and supported each other. complicated cases and the emergencies of un7) The method was economical in using predictable nature. The RN is expected to the energies of students and teacher, less use judgment, whereas the LVN follows confusing for all the staff. routines and does not exercise the same de8) Each student derived more ego strength gree of independent nursing judgment. By having presented this report, the auwithin the protection of the group than she thors wish to encourage other hospitals to iniwould have by herself. Later in the program, when their ego strength had grown, single tiate their own postgraduate OR nursing programs. We feel that our experience can be assignments were made. 9) A last, and most important considera- duplicated in any similar hospital environtion was that in a small operating room suite ment, given a qualified OR nursing instructor and following these recammendations for such as Sequoia’s (seven rooms), this method eliciting administrative, medical, and OR staff allowed better latitude for assignment of r e g support. It is possible that such postgraduate ular staff members whose needs are just as programs will be devised for all the nursing important as the students’. OR staff nurses specialties; the so-called “nursing internship” who are not prepared to teach must never ar- period of practical experience necessitated bitrarily be forced into this responsibility by by the changing character of nursing educarandom assignment of students to their rooms. tion.
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REFERENCES
1. Cinzton, E. L. and Kirk, W., “The Two-Mile Electron Accelerator,” Kepr. from Scientific American, Nov. 1961. 2. Tyler, R. W., Basir Principles of Curriculuni and Instruction, Chicago, Ill., The Univtmity I J f Chicago Press, 1957. 3. Ibid. 4. Taba, Hilda, Curriculum Development: Theory and Practice, New York, Harcourt, Brace, and World, Inc., 1%2, p. 165. 5. Thelen, H. A. and Tyler, K. W., “Implications for Improving Instruction in the High School,” In N. B. Henry (Ed.), Learning and Instruction, Part I, 49th Yearbook of the Nat’l Ass’n for the Study of Education, Chicago, Ill., The University of Chicago Press, 1950, pp. 304-335. 6. Gibb, J. R., “Learning Theory in Adult Education,” in M. S. Knowle’s (Ed.) Handbook of Adult Education in the United States, Chicago, Ill., Adult Education Ass’n of the U.S.A., 1960, pp. 54-64. 7. Luft, J., Group Processes: An Introduction to Group Dynamics, Palo Alto, Calif., The National Press, 1963. 8. Boyer, Sarah B., “Key Factors in Successful Program for OR Technicians,” Hospital Topics, Nov. 1966, Vol. 44, #11, pp. 113-116. 9. Carroll, Maura, “Report of a Workshop on Medical-Surgical Nursing,” sponsored by Manatee Junior College, Southern Regional Education Board Project in Nursing Education and Research, IJnpubl. doctoral thesis, Manatee, Fla., Sept. 28-Oct. 2, 1964. 10. “American Nurses’ Association First Position on Education for Nursing,” AJN, Dec. 1%5, Vol. 65, #12, pp. 106-111.
11. Peers, Jerry C., “Today’s Challenge to The Professional Operating Room Nurse,” AORN Journal. Jan.-Feb. 1964, Vol. 2, #l, pp. 69-73. 12. Op. Cit., Boyer. 13. Coakeley, Jacquelyn(:, “Operating I{ooni Inservice Education : Its Problems and Implications,” Hospital Topics, Oct. 1966, Vol. 44, #lo, pp. 107-111. 14. “L.P.N.’s for OR Service,” New York, Ethical Publications, lnc., Feb. 1967, Vol. 2, $2, p. 2. 15. Ibid. 16. West, Ethel I. “Supervisors Speak on Qualifications for OR Nurses, Use of Technicians,” Hospital Topics, Feb. 1961, Vol. 39, #2, pp. 90-93. 17. Op. Cit., Boyer. 18. CNA Bulletin, March 1968, Vol. 64, #3, p. 2. 19. Texts for the OR program were: a ) Berry, E. C. and Kohn, L., Introduction to Operating Room Technique, New York, McGraw Hill Book Co., 1966. b ) Bums, Margaret A., et al., Teaching the OR Technician, New York, Association of Operating Room Nurses, Inc., 1967. c ) Ginsberg, Brunner, and Cantlin, A Manual of Operating Room Technology, Philadelphia, J. B. Lippincott Co., 1966. d ) Programmed Instruction in Asepsis, Somerville, N. J., Arbrook, 1966. e ) Walter, C., Aseptic Treatment of Wounds, New York, The Macmillan Co., 1947. f ) Willingham, Jacqueline, Logic of Operating Room Nursing, New York, Springer Pub. Co., 1962. 20. Parker, J. C. and Rubin, L. J., Process as Content: Curricubm Design and the Application of Knowledge, Chicago, Ill., Rand McNally & Co., 1966.
EDITORS NOTE: The opinions expressed in this article a r e those of the authors a n d d o not necessarily represent the oficial opinion of the AORN. RECOMMENDATION FOR “ASSISTANTS I N THE HEALTH S E R V I C E OCCUPATIONS” Education for assistants in the health service occupations should be short, intensive preservice programs in vocational education institutions rather than on-the-job traini n g programs. Most of this preservice preparation must be done by vocational educators who may not necessarily be nurses; if they a r e nurses, they should meet the qualifications for teaching set by vocational education. In addition to general preservice preparation, workers assigned to nursing services should be given inservice orientation a n d on-the-job training t o perform specific tasks delegated by nurses. This rule, t h a t on-the-job orientation and continuing inservice education be followed through by t h e service to which the worker is assigned, should a p p l y not only to nursing services but also to other health services i n which these workers will assist. The current role of government in financing programs to train workers for the health fields requires the nursing profession t o enunciate standards for the education of all who s h a r e t h e activities of nursing. It should not, however, require t h a t nursing assume responsibility for t h e standards a n d preparations of those who function as assistants to personnel in other health professions. ANA Position P a p e r 1965
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