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The Ambulatory Surgery Unit as a Learning Experience
-
NOVEMBER 1999, VOL 70. NO 5 Fanwtt 9
The Ambulatory Surgery Unit as a Learning Experience
I
n today's rapidly changing health care environment, graduate nurses are expected to practice at higher levels of competence, possess increased knowledge and skills, and have greater experience in both structured and unstructured settings.' Employers expect new graduates to enter their institutions with expanded skill sets and the ability to think critically. This expectation, combined with decreased hospital stays and an institutional focus on cost cutting, can leave nurse educators with the overwhelming task of identifying clinical sites that will provide student nurses with the necessary learning experiences. Through a combination of legislative trends, changes in technology, a more knowledgeable society, and a greater emphasis on economic incentives, attitudes toward health care have changed. The ideal of providing the best care possible has changed to providing the best care at the lowest price. In response to this, ambulatory surgery has become an established mode of meeting health care needs. In fact, the proportion of ambulatory surgical procedures has grown from 16% in 1980 to 75% in 1995.'
Ambulatory surgery care occurs in a decreased time frame, which means that ambulatory nurses must be able to perform tasks quickly and efficiently to ensure positive patient outcomes. Based on this, the ambulatory surgery unit offers student nurses a wide variety of experiences conducive to enhancing skills and practice. Nursing students engaged in a clinical experience in an ambulatory surgery setting are able to provide direct and indirect care to patients. Competencies acquired during an ambulatory rotation include the ability to gather information from patients and family members, make accurate judgments, use critical thinking skills, and prioritize. Moreover, students develop communication skills based on interaction with patients and family members, nurses, physicians, and ancillary staff members. Students learn to handle multiple demands and patients, while ensuring a safe environment. Principles of growth and development are enhanced as students provide care for pediatric patients, as well as adult and geriatric patients. In addition to honing their cognitive skills, students A B S T R A C T Today's graduate nurses are expected to enter the work envi- also improve their clinical skills ronment at increased levels of competence. Skills are expected to by performing a wide variety of be ingrained, and health care administrators expect new graduates tasks (Table I). Instructors in the ambulatory to be able to think critically. Nurse educators often are looking for new and creative ways to educate students. The ambulatory surgery unit further promote the learning setting can provide a plethora of clinical tasks and situations that process by guiding students to teach students how to gather information, make judgments, priori- consider patients as a whole, the tize, handle multiple demands and patients, and perform clinical goal of the care being provided, skills quickly and efficiently. This article describes a pilot project in the best way to meet the goal, and which eight nursing students learned valuable clinical and critical how they can provide the most thinking skills in the fast-paced world of ambulatory care. AORN J positive outcomes for patients. The combined skill of instructors 70 (NOV 1999) 782-790. DEBRA L. FAWCETT, RN
782 AORN JOURNAL
NOVEMBER 1999. VOL 70, NO 5 Fawcett
Table 1 and ambulatory nurses allows students to repetitively practice core competencies needed for safe and effective nursing practice.
CLINICAL SKILLS PRACTICED IN THE AMBULATORY SURGERY SEITING
PILOT PROJECT
At Indiana University, Kokomo, eight junior baccalaureate students were assigned to a busy ambulatory unit for their first medical surgical experience. Before being assigned to the pilot project, each student had to successfully complete a fundamental skills laboratory. In addition, students had to complete a laboratory on standard precautions, aseptic technique, expectations, and objectives of each ambulatory area. Students were given a list of medications commonly used in the OR and taught how to complete medication cards. At the hospital, students were rotated throughout the areas of preadmission, admission, preoperative holding, primary postanesthesia care unit (PACU), and secondary PACU. As these students had no previous hospital experience, the instructor ensured that the students understood their assignment was part of a pilot project, feedback was necessary each day, and the goal of the project was to focus on enhancement of skills and nursing assessment. Each week, students were given reading assignments related to preoperative preparation of surgical patients, discharge teaching, and specific skills. In all of the assigned ambulatory areas, students were accompanied by the instructor the first time they performed each activity. Students also were asked to identify procedures being performed in their areas the next day so that they could better understand the possible fears and concerns of patients. Nurses in the unit were informed of the project and encouraged to make suggestions and provide feedback to the instructor. The following describes information and learning strategies for each of the assigned areas. PREADMISSION AREA
Students spent at least four days within a twoweek period in the preadmission area. In this area, students worked with a preceptor to review charts, laboratory values, electrocardiogram (ECG) results, medications, and previous surgeries and illnesses of patients scheduled for surgery. They also supported the preadmission nurses by calling patients before surgery to ensure that they understood the arrival time and physician’s orders and by calling postoperative patients within 24 hours of their procedures to
a
Performing complete physical assessments
a
Discharge teaching
a
Administering injections
a
Performing strengthening exercises
a
Monitoring vital signs
a
Monitoring oxygen saturation levels
a
Reading pulse oximew monitoring sensors
a
Starting and discontinuing IV lines
a
Applying electrocardiogram strips and electrodes
a
Preparing surgical preps
a
Charting
a
Using standard precautions
a
Administering medications
a
Collecting specimens
a
Learning proper body mechanics
a
Using and mointaining tubes and drains
a
Applying dressings
identify any problems or needs. Students also helped determine patients’ laboratory values, whether the values were within normal limits, and the consequences of both normal and abnormal results (Figure 1). They were able to judge whether to report laboratory findings to physicians and to determine the proper lines of that communication. It was extremely important that the instructor asked questions to ensure that students understood the meaning of the laboratory values. As in many clinical situations, if questions are not asked, students may not understand the entire situation, may make wrong decisions, and may ultimately decrease the possibility of positive patient outcomes. In one situation in this area, a student discovered a low potassium level in a patient scheduled for a laparoscopic cholecystectomy. The student referred to her laboratory manual and medical-surgical textbook before deciding to inform the anesthesia care provider. After hearing the report, the anesthesia care provider talked with the patient regarding any previous illnesses, and the student was allowed to listen and observe. The anesthesia
783 AORN JOURNAL
NOVEMBER 1999, VOL 70, NO 5 Fuwcett
care provider ultimately canceled the procedure pending further tests. In this situation, the instructor asked the students the following questions. What are the physiologic purposes of potassium? Why is this important to the surgical patient? What are the potential consequences of low potassium? Who should be informed of the results and why? What is the expected treatment of low potassium? Why is it necessary to perform further tests? ADMISSION AREA
Students were assigned to the admission area for a minimum of two days. Here, students had the opportunity to enhance communication with patients and their family members by completing the admission assessment, charting, and monitoring routine vital signs (eg, blood pressure, pulse, respiration, temperature). Students determined if the information received was accurate, and if all preoperative orders were followed. Students also made judgments as to the importance of the information received, how to prioritize the information, and if the information should be forwarded to the intraoperative team members. During one student’s rotation in the admission area, a female patient who was scheduled for surgery involving monitored anesthesia presented with extremely elevated blood pressure. By communicating with the patient and using proper skill in taking vital signs, the student determined that there was a problem. The student further questioned the patient and found that the patient was currently on blood pressure medicine but had not taken it that morning. Despite her physician’s instruction to take her medications, the patient did not do so because she was afraid she would become ill after surgery. The problem was reported to the surgeon, and the procedure was canceled. The instructor took this opportunity to ask the students the following questions. What are the consequences of extremely elevated blood pressure? Why is this information important to the surgeon and anesthesia care provider? Who should be notified’? Should any teaching be accomplished with the patient‘! What are the physiologic parameters of blood pressure‘?
PREOPERATIVE HOLDING AREA
Perhaps due to its faster pace and the fact that it allowed students to practice “real nurse’’ responsibilities, the preoperative holding area was students’ favorite assignment. Here, students learned how to perform complete physical assessments, monitor vital signs (eg, breath sounds, heart sounds, skin conditions), administer medication (eg, eye drops), complete preoperative preps, dress patients for surgery, start IV lines, and prepare charts (Figures 2 and 3). During these activities, principles of safety and use of standard precautions were reinforced. To provide a more realistic experience, students oversaw at least three patients at one time; as one patient was transported to the OR, the next would be admitted to the preoperative holding area. The maximum number of patients any student cared for at one time was five. While assigned to this area and performing a complete physical assessment of a patient scheduled for surgery with general anesthesia, one student could not locate breath sounds in a patient’s right lower lobe of the lung. The student believed she was not performing the skill correctly. After contacting the instructor, they both proceeded to auscultate the patient’s lungs. They heard wheezing in the upper and middle lobes with absent breath sounds in the lower lobe. With encouragement from the instructor, the student continued communicating with the patient until he revealed that he suffered from asthma and was a heavy smoker. The student then
785 AORN JOURNAL
Figure 1 A student assigned to the preadmission area investigates a laboratory value to determine if it is normal.
NOVEMBER 1999, VOL 70. NO 5 Fanwtt
Figure 2 In the preoperative holding area, a student practices assessing breath sounds. (lor right) She also learns how to administer eye drops.
What are the signs and symptoms of poor perfusion? PRIMARY PACU
Figure 3 Another student on rotation in the preoperative holding area is taught how to start an IV line.
contacted the physician, who immediately ordered breathing treatment and oxygen. The student auscultated the lungs after treatment and was amazed to find that all wheezing had stopped, and that faint breath sounds could be heard in the right lower lobe. In response to this situation, the instructor asked the following questions. What are some of the causes of diminished or absent breath sounds? Why might a patient forget to inform the health care provider of chronic disease processes? What is the proper procedure for providing oxygen? What functions are nurses responsible for in providing a positive outcome for this type of patient? Who should be informed of the patient’s condition?
Students were assigned to the primary PACU for four days within a two-week period. In this area, students learned to focus on more acutely ill patients. Direct patient care tasks included performing immediate postoperative assessments, reapplying ECG leads, applying pulse oximeter monitoring sensors, and securing lines, tubes, and drains. Postanesthesia patients in this hospital typically are not discharged to the PACU with endotracheal tubes in place; therefore, students in this area did not learn how to remove endotracheal tubes. Skills practiced in the primary PACU included setting up patient-controlled analgesia equipment, providing IV push medications, charting, using sequential antiemboli stockings, reading pulse oximeter monitoring sensors, applying dressings, and assessing wounds. As many patients in the PACU had undergone total knee replacement procedures, students had the opportunity to work with positioning devices. Again, use of standard precautions was enforced during patient care activities. In addition, students were 786
AORN JOURNAL
NOVEMBER 1999, VOL 70, NO 5 Fawcert
provided opportunities to make decisions related to patients’ needs. Students frequently arrived for their clinical experience in this area before patients were admitted to the PACU. As a result, students were allowed to enter the OR and observe the procedures of patients for whom they would be caring. This provided them with a well-rounded experience, helping them further comprehend the surgical procedures, expected outcomes, and potential complications. By offering students an intraoperative experience, they better understood why patients feel pain, why they may be nauseated, and what medications were used during the procedures. During one rotation in this area, two students had the experience of caring for a patient who had a latex allergy. Although this was prepared for in advance, the students had to work with the latexfree cart and supplies. The students remarked that having supplies located in one cart was easier than constantly remembering to not inadvertently reach for the necessary supplies. The instructor took advantage of the situation to provide all the students with information on latex allergies, treatments, and possible outcomes. The ambulatory nurses believed that the students should be aware of products available, and they provided them with a list of approved materials and suppliers. Documents on latex allergies also were provided to the students for future reference.
their feet, and how certain procedures (eg, cataract removals) may influence patients’ balance . This was also the area in which gerontologic considerations were most prevalent. Following hospital guidelines, students learned how to provide discharge instructions based on the individual needs of each patient (Figure 5). Completing medication cards before their clinical experience enabled students to more effectively teach patients about safety, nutrition, and postoperative expectations. While performing postoperative teaching in this area, one student gave an older adult patient who had undergone cataract surgery a written copy of the discharge instructions. The patient looked at
SECONDARY PACU
In this area, students had the opportunity to enhance their discharge teaching skills, provide for patient safety, and practice clinical skills, such as helping patients ambulate, discontinuing IV lines, monitoring postoperative physical status (eg, skin integrity, neurologic condition, bowel sounds), and applying dressings (Figure 4). Although safety was emphasized in all hospital areas, it was of particular importance in the secondary PACU. As students moved patients to and from the restroom and recliners, it was imperative that they understood the effects of the medications patients had received, why patients may be unsteady on 789 AORN JOURNAL
Figure 4 A student in the secondary postoperative care unit practices monitoring a patient‘s bowel sounds.
.
Figure 5 A student provides discharge instructions to an older adult patient in the secondary postanesthesia care unit.
-
NOVEMBER 1999. VOL 70. NO 5 Fau,i.err
the instructions and said, “Dear, this writing is too small, and I can’t see it very well. Even if I had my glasses on I couldn’t see it. Could you write it bigger?” The student explained that she had told the patient everything that was on the document, but the patient said she often forgot things and would like the instructions written larger. This situation was perfect for learning the special needs of older adult patients, and the instructor drew the following from the incident. - auestions . How does age affect the visual acuity of patients? How can we ensure that patients understand directions? Why should older adult patients have someone at home with them postoperatively? If a patient’s vision is diminished already, how would it be affected by surgery? Is safety at home a concern for postoperative older adult patients? Should any changes be made when caring for older adult patients? INDIVIDUALIZED LEARNING
The situations encountered in the pilot project, along with the instructor’s questions, helped guide the students’ learning in this project. All nurse educators and instructors should keep in mind that learning is an active exercise, and that each participant learns differently. Each care situation should be viewed individually, and questions should reflect the knowledge and level of thinking needed for each patient. If NOTES 1. American Association of
Colleges of Nursing, The Essentials of
Baccalaureate Education
(Washington, DC: American Association of Colleges of Nursing, 1998). 2. H Meyer, “Out of the hospital
nursing instructors gear their questions to make students think and come to conclusions, students will be better prepared to practice nursing after graduation. CONCLUSION
As today’s health care environment changes, it is imperative that nurse educators look closely at the clinical experience. How can we provide the most opportunity for students and encourage critical thinking? Learning can be enhanced by taking advantage of ambulatory settings that present both challenges and opportunities.‘ It is the goal of all nurse educators to prepare nurses of the future with sufficient skills and cognitive processes to practice nursing at a high level and in a professional manner. When used creatively, teaching can help students develop not only clinical skills, but also critical thinking skills. Clinical opportunities should provide ample stimulation to cause students to reflect and make decisions.a Ambulatory surgery units can provide that stimulation. Basic skills can be practiced repetitively, communication can be encouraged, and, as a result, accurate decision making and critical thinking can abound. A
into an unknown future,” American Medical News 38 (1995) 13. 3. American Association for
Debra L. Fawcett, RN. MSNEd. is an educator at Indiana University. Kokomo. Learning (Washington, DC:
Higher Education, American College Personnel Association, National Association of Student Personnel Administrators, PoweQl Partner-
American Association for Higher Education, June 2, 1998) Available from http://www.aahe.org/assessment/ tsk-frce.htm. Accessed 23 Sept 1999. 4. American Association of Colleges of Nursing, The Essentials
ships: A Shared Responsibility for
of
790 AORN JOURNAL
Baccalaureate Educution.
NOVEMBER 1999, VOL 70. NO 5 Fanwtt 9
The Ambulatory Surgery Unit as a Learning Experience
I
n today's rapidly changing health care environment, graduate nurses are expected to practice at higher levels of competence, possess increased knowledge and skills, and have greater experience in both structured and unstructured settings.' Employers expect new graduates to enter their institutions with expanded skill sets and the ability to think critically. This expectation, combined with decreased hospital stays and an institutional focus on cost cutting, can leave nurse educators with the overwhelming task of identifying clinical sites that will provide student nurses with the necessary learning experiences. Through a combination of legislative trends, changes in technology, a more knowledgeable society, and a greater emphasis on economic incentives, attitudes toward health care have changed. The ideal of providing the best care possible has changed to providing the best care at the lowest price. In response to this, ambulatory surgery has become an established mode of meeting health care needs. In fact, the proportion of ambulatory surgical procedures has grown from 16% in 1980 to 75% in 1995.'
Ambulatory surgery care occurs in a decreased time frame, which means that ambulatory nurses must be able to perform tasks quickly and efficiently to ensure positive patient outcomes. Based on this, the ambulatory surgery unit offers student nurses a wide variety of experiences conducive to enhancing skills and practice. Nursing students engaged in a clinical experience in an ambulatory surgery setting are able to provide direct and indirect care to patients. Competencies acquired during an ambulatory rotation include the ability to gather information from patients and family members, make accurate judgments, use critical thinking skills, and prioritize. Moreover, students develop communication skills based on interaction with patients and family members, nurses, physicians, and ancillary staff members. Students learn to handle multiple demands and patients, while ensuring a safe environment. Principles of growth and development are enhanced as students provide care for pediatric patients, as well as adult and geriatric patients. In addition to honing their cognitive skills, students A B S T R A C T Today's graduate nurses are expected to enter the work envi- also improve their clinical skills ronment at increased levels of competence. Skills are expected to by performing a wide variety of be ingrained, and health care administrators expect new graduates tasks (Table I). Instructors in the ambulatory to be able to think critically. Nurse educators often are looking for new and creative ways to educate students. The ambulatory surgery unit further promote the learning setting can provide a plethora of clinical tasks and situations that process by guiding students to teach students how to gather information, make judgments, priori- consider patients as a whole, the tize, handle multiple demands and patients, and perform clinical goal of the care being provided, skills quickly and efficiently. This article describes a pilot project in the best way to meet the goal, and which eight nursing students learned valuable clinical and critical how they can provide the most thinking skills in the fast-paced world of ambulatory care. AORN J positive outcomes for patients. The combined skill of instructors 70 (NOV 1999) 782-790. DEBRA L. FAWCETT, RN
782 AORN JOURNAL
NOVEMBER 1999. VOL 70, NO 5 Fawcett
Table 1 and ambulatory nurses allows students to repetitively practice core competencies needed for safe and effective nursing practice.
CLINICAL SKILLS PRACTICED IN THE AMBULATORY SURGERY SEITING
PILOT PROJECT
At Indiana University, Kokomo, eight junior baccalaureate students were assigned to a busy ambulatory unit for their first medical surgical experience. Before being assigned to the pilot project, each student had to successfully complete a fundamental skills laboratory. In addition, students had to complete a laboratory on standard precautions, aseptic technique, expectations, and objectives of each ambulatory area. Students were given a list of medications commonly used in the OR and taught how to complete medication cards. At the hospital, students were rotated throughout the areas of preadmission, admission, preoperative holding, primary postanesthesia care unit (PACU), and secondary PACU. As these students had no previous hospital experience, the instructor ensured that the students understood their assignment was part of a pilot project, feedback was necessary each day, and the goal of the project was to focus on enhancement of skills and nursing assessment. Each week, students were given reading assignments related to preoperative preparation of surgical patients, discharge teaching, and specific skills. In all of the assigned ambulatory areas, students were accompanied by the instructor the first time they performed each activity. Students also were asked to identify procedures being performed in their areas the next day so that they could better understand the possible fears and concerns of patients. Nurses in the unit were informed of the project and encouraged to make suggestions and provide feedback to the instructor. The following describes information and learning strategies for each of the assigned areas. PREADMISSION AREA
Students spent at least four days within a twoweek period in the preadmission area. In this area, students worked with a preceptor to review charts, laboratory values, electrocardiogram (ECG) results, medications, and previous surgeries and illnesses of patients scheduled for surgery. They also supported the preadmission nurses by calling patients before surgery to ensure that they understood the arrival time and physician’s orders and by calling postoperative patients within 24 hours of their procedures to
a
Performing complete physical assessments
a
Discharge teaching
a
Administering injections
a
Performing strengthening exercises
a
Monitoring vital signs
a
Monitoring oxygen saturation levels
a
Reading pulse oximew monitoring sensors
a
Starting and discontinuing IV lines
a
Applying electrocardiogram strips and electrodes
a
Preparing surgical preps
a
Charting
a
Using standard precautions
a
Administering medications
a
Collecting specimens
a
Learning proper body mechanics
a
Using and mointaining tubes and drains
a
Applying dressings
identify any problems or needs. Students also helped determine patients’ laboratory values, whether the values were within normal limits, and the consequences of both normal and abnormal results (Figure 1). They were able to judge whether to report laboratory findings to physicians and to determine the proper lines of that communication. It was extremely important that the instructor asked questions to ensure that students understood the meaning of the laboratory values. As in many clinical situations, if questions are not asked, students may not understand the entire situation, may make wrong decisions, and may ultimately decrease the possibility of positive patient outcomes. In one situation in this area, a student discovered a low potassium level in a patient scheduled for a laparoscopic cholecystectomy. The student referred to her laboratory manual and medical-surgical textbook before deciding to inform the anesthesia care provider. After hearing the report, the anesthesia care provider talked with the patient regarding any previous illnesses, and the student was allowed to listen and observe. The anesthesia
783 AORN JOURNAL
NOVEMBER 1999, VOL 70, NO 5 Fuwcett
care provider ultimately canceled the procedure pending further tests. In this situation, the instructor asked the students the following questions. What are the physiologic purposes of potassium? Why is this important to the surgical patient? What are the potential consequences of low potassium? Who should be informed of the results and why? What is the expected treatment of low potassium? Why is it necessary to perform further tests? ADMISSION AREA
Students were assigned to the admission area for a minimum of two days. Here, students had the opportunity to enhance communication with patients and their family members by completing the admission assessment, charting, and monitoring routine vital signs (eg, blood pressure, pulse, respiration, temperature). Students determined if the information received was accurate, and if all preoperative orders were followed. Students also made judgments as to the importance of the information received, how to prioritize the information, and if the information should be forwarded to the intraoperative team members. During one student’s rotation in the admission area, a female patient who was scheduled for surgery involving monitored anesthesia presented with extremely elevated blood pressure. By communicating with the patient and using proper skill in taking vital signs, the student determined that there was a problem. The student further questioned the patient and found that the patient was currently on blood pressure medicine but had not taken it that morning. Despite her physician’s instruction to take her medications, the patient did not do so because she was afraid she would become ill after surgery. The problem was reported to the surgeon, and the procedure was canceled. The instructor took this opportunity to ask the students the following questions. What are the consequences of extremely elevated blood pressure? Why is this information important to the surgeon and anesthesia care provider? Who should be notified’? Should any teaching be accomplished with the patient‘! What are the physiologic parameters of blood pressure‘?
PREOPERATIVE HOLDING AREA
Perhaps due to its faster pace and the fact that it allowed students to practice “real nurse’’ responsibilities, the preoperative holding area was students’ favorite assignment. Here, students learned how to perform complete physical assessments, monitor vital signs (eg, breath sounds, heart sounds, skin conditions), administer medication (eg, eye drops), complete preoperative preps, dress patients for surgery, start IV lines, and prepare charts (Figures 2 and 3). During these activities, principles of safety and use of standard precautions were reinforced. To provide a more realistic experience, students oversaw at least three patients at one time; as one patient was transported to the OR, the next would be admitted to the preoperative holding area. The maximum number of patients any student cared for at one time was five. While assigned to this area and performing a complete physical assessment of a patient scheduled for surgery with general anesthesia, one student could not locate breath sounds in a patient’s right lower lobe of the lung. The student believed she was not performing the skill correctly. After contacting the instructor, they both proceeded to auscultate the patient’s lungs. They heard wheezing in the upper and middle lobes with absent breath sounds in the lower lobe. With encouragement from the instructor, the student continued communicating with the patient until he revealed that he suffered from asthma and was a heavy smoker. The student then
785 AORN JOURNAL
Figure 1 A student assigned to the preadmission area investigates a laboratory value to determine if it is normal.
NOVEMBER 1999, VOL 70. NO 5 Fanwtt
Figure 2 In the preoperative holding area, a student practices assessing breath sounds. (lor right) She also learns how to administer eye drops.
What are the signs and symptoms of poor perfusion? PRIMARY PACU
Figure 3 Another student on rotation in the preoperative holding area is taught how to start an IV line.
contacted the physician, who immediately ordered breathing treatment and oxygen. The student auscultated the lungs after treatment and was amazed to find that all wheezing had stopped, and that faint breath sounds could be heard in the right lower lobe. In response to this situation, the instructor asked the following questions. What are some of the causes of diminished or absent breath sounds? Why might a patient forget to inform the health care provider of chronic disease processes? What is the proper procedure for providing oxygen? What functions are nurses responsible for in providing a positive outcome for this type of patient? Who should be informed of the patient’s condition?
Students were assigned to the primary PACU for four days within a two-week period. In this area, students learned to focus on more acutely ill patients. Direct patient care tasks included performing immediate postoperative assessments, reapplying ECG leads, applying pulse oximeter monitoring sensors, and securing lines, tubes, and drains. Postanesthesia patients in this hospital typically are not discharged to the PACU with endotracheal tubes in place; therefore, students in this area did not learn how to remove endotracheal tubes. Skills practiced in the primary PACU included setting up patient-controlled analgesia equipment, providing IV push medications, charting, using sequential antiemboli stockings, reading pulse oximeter monitoring sensors, applying dressings, and assessing wounds. As many patients in the PACU had undergone total knee replacement procedures, students had the opportunity to work with positioning devices. Again, use of standard precautions was enforced during patient care activities. In addition, students were 786
AORN JOURNAL
NOVEMBER 1999, VOL 70, NO 5 Fawcert
provided opportunities to make decisions related to patients’ needs. Students frequently arrived for their clinical experience in this area before patients were admitted to the PACU. As a result, students were allowed to enter the OR and observe the procedures of patients for whom they would be caring. This provided them with a well-rounded experience, helping them further comprehend the surgical procedures, expected outcomes, and potential complications. By offering students an intraoperative experience, they better understood why patients feel pain, why they may be nauseated, and what medications were used during the procedures. During one rotation in this area, two students had the experience of caring for a patient who had a latex allergy. Although this was prepared for in advance, the students had to work with the latexfree cart and supplies. The students remarked that having supplies located in one cart was easier than constantly remembering to not inadvertently reach for the necessary supplies. The instructor took advantage of the situation to provide all the students with information on latex allergies, treatments, and possible outcomes. The ambulatory nurses believed that the students should be aware of products available, and they provided them with a list of approved materials and suppliers. Documents on latex allergies also were provided to the students for future reference.
their feet, and how certain procedures (eg, cataract removals) may influence patients’ balance . This was also the area in which gerontologic considerations were most prevalent. Following hospital guidelines, students learned how to provide discharge instructions based on the individual needs of each patient (Figure 5). Completing medication cards before their clinical experience enabled students to more effectively teach patients about safety, nutrition, and postoperative expectations. While performing postoperative teaching in this area, one student gave an older adult patient who had undergone cataract surgery a written copy of the discharge instructions. The patient looked at
SECONDARY PACU
In this area, students had the opportunity to enhance their discharge teaching skills, provide for patient safety, and practice clinical skills, such as helping patients ambulate, discontinuing IV lines, monitoring postoperative physical status (eg, skin integrity, neurologic condition, bowel sounds), and applying dressings (Figure 4). Although safety was emphasized in all hospital areas, it was of particular importance in the secondary PACU. As students moved patients to and from the restroom and recliners, it was imperative that they understood the effects of the medications patients had received, why patients may be unsteady on 789 AORN JOURNAL
Figure 4 A student in the secondary postoperative care unit practices monitoring a patient‘s bowel sounds.
.
Figure 5 A student provides discharge instructions to an older adult patient in the secondary postanesthesia care unit.
-
NOVEMBER 1999. VOL 70. NO 5 Fau,i.err
the instructions and said, “Dear, this writing is too small, and I can’t see it very well. Even if I had my glasses on I couldn’t see it. Could you write it bigger?” The student explained that she had told the patient everything that was on the document, but the patient said she often forgot things and would like the instructions written larger. This situation was perfect for learning the special needs of older adult patients, and the instructor drew the following from the incident. - auestions . How does age affect the visual acuity of patients? How can we ensure that patients understand directions? Why should older adult patients have someone at home with them postoperatively? If a patient’s vision is diminished already, how would it be affected by surgery? Is safety at home a concern for postoperative older adult patients? Should any changes be made when caring for older adult patients? INDIVIDUALIZED LEARNING
The situations encountered in the pilot project, along with the instructor’s questions, helped guide the students’ learning in this project. All nurse educators and instructors should keep in mind that learning is an active exercise, and that each participant learns differently. Each care situation should be viewed individually, and questions should reflect the knowledge and level of thinking needed for each patient. If NOTES 1. American Association of
Colleges of Nursing, The Essentials of
Baccalaureate Education
(Washington, DC: American Association of Colleges of Nursing, 1998). 2. H Meyer, “Out of the hospital
nursing instructors gear their questions to make students think and come to conclusions, students will be better prepared to practice nursing after graduation. CONCLUSION
As today’s health care environment changes, it is imperative that nurse educators look closely at the clinical experience. How can we provide the most opportunity for students and encourage critical thinking? Learning can be enhanced by taking advantage of ambulatory settings that present both challenges and opportunities.‘ It is the goal of all nurse educators to prepare nurses of the future with sufficient skills and cognitive processes to practice nursing at a high level and in a professional manner. When used creatively, teaching can help students develop not only clinical skills, but also critical thinking skills. Clinical opportunities should provide ample stimulation to cause students to reflect and make decisions.a Ambulatory surgery units can provide that stimulation. Basic skills can be practiced repetitively, communication can be encouraged, and, as a result, accurate decision making and critical thinking can abound. A
into an unknown future,” American Medical News 38 (1995) 13. 3. American Association for
Debra L. Fawcett, RN. MSNEd. is an educator at Indiana University. Kokomo. Learning (Washington, DC:
Higher Education, American College Personnel Association, National Association of Student Personnel Administrators, PoweQl Partner-
American Association for Higher Education, June 2, 1998) Available from http://www.aahe.org/assessment/ tsk-frce.htm. Accessed 23 Sept 1999. 4. American Association of Colleges of Nursing, The Essentials
ships: A Shared Responsibility for
of
790 AORN JOURNAL
Baccalaureate Educution.