The urological assistant

The urological assistant

Russell T. Church,

RN and

C l y d e E. Blackard, MD

There is a great need in the hospital and office practice of the urologist for an assistant who can care for urological instruments, change urethral and suprapubic catheters, assist with cystoscopic examinations, and perform basic laboratory and other diagnostic procedures. This assistant could precede the urologist to the hospital, check his instruments, prepare and drape his patient, and remain there to assist with the operation. Some of the postoperative care of the urological patient could be delegated to the assistRussell T. Church, assistant

program

RN, i s director of the urological a t the

Minneapolis Veterans’

Administration H o s p i t a l and a member of AORN

of Twin Cities. C l y d e E. Blackard, MD, i s chief of urology a t Minneapolis V A , and overall supervisor of the program. The Minneapolis program is, according t o the authors, one of the t w o programs i n the United States which are training paramedical personnel strictly t o assist urologists.

April 1971

ant. This is the concept of the urological assistant. Conceived at a time when health is on the verge of becoming this nation’s largest industry, the urological assistant program is a recent addition to the growing list of sub-specialties as performed by paramedical personnel. Established in 1968 at the Minneapolis Veterans’ Administration Hospital by George T. Mellinger, MD, and Russell T. Church, RN, the program has graduated five urological assistants and currently has four more students in training. Urology seems to lend itself particularly well to the utilization of paramedical personnel. Shortage of health manpower does exist, and it will probably grow worse. Urology is not immune. The answer will not come from the nursing profession, for these ranks are already thinned. Operating room experience (and with it training in the cystoscopy suite)

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has been eliminated from the curriculum of many nursing schools. Nursing itself is undergoing current change and upheaval.’ Much of the delegated work in urology already is being done by hospital aides, technicians and other nonprofessional personnel. Admission for urological disease alone accounts for more than 117h of the total number of hospital admissions.’ Frequently, patients admitted for other reasons develop urological problems while in the hospital. The health manpower shortage is a current problem. At the present time, there are over 20 physician’s assistant programs in operation.3 Some of these are four-year programs leading to a baccalaureate degree and preparing people to go into public health or hospital administration. Many of the assistant programs require a preparatory period of two years of junior college or two years of “medical experience.” The overall objectives of these type programs have been adequately stated by E. A. Stead, Jr., MD, in an article written to introduce the physician’s assistant program at Duke University. He stated “the objective of this program is to teach excellence in the performance of certain skills and to provide fundamental knowledge necessary for understanding and developing additional skills. The emphasis should be placed on on-the-job-training where experience in depth can be obtained and where the student would rapidly reach a level of performance which makes him an asset rather than a liability to the area providing the in~truction.~ The urological assistant program a t Minneapolis VA Hospital is cur-

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rently a one-year course. The only prerequisite to entering the program is previous experience in any hospital setting for one-and-a-half years. This is a civil service requirement. Candidates are asked to complete a personal qualifications statement, references are checked, and a personal interview is conducted. Complying with present regulations, two students are admitted to the program in January and two in July; therefore, there are four students in training a t any one time. The course is designed to offer at least 250 hours of didactic material. This material is concentrated in the beginning of the year with a gradual shift toward “on-the-job-training” as tlie year ends. Because the entire program is devoted to one specialtyurology-emphasis is placed on the following subjects:

1. embryology, anatomy, physiology and pathology of the genitourinary tract-edocrinology is a 1s o taught, but is limited to study of the pituitary, adrenals and testes. 2. care and use of catheters, urinary appliances and devices-the proper technic of catheterization is stressed. 3. care of cystoscopes and other urological instruments-this includes learning the proper names of instruments, instrument combinations and substitutions, and the best methods of handling, cleaning and sterilizing these instruments to minimize replacement and repair (Fig 1).

4. operating room technics-all basic principles as applies to main operating room (MOR) technic are covered.

AORN Journal

Fig I

Students learn the proper name of urological instruments and how to set up a room for endoscopic procedures.

The accent is upon urological cases with emphasis on safe positioning, preparing and draping of the patient, and urological instruments used during open surgery. It must be emphasized that the urological assistant is not expected to function a s an instrument or scrub nurse. His role in the MOR is that of an assistant to the urologist (Fig 2). Fig 2

Students are taught to assist the urologist with open surgery.

5. urological radiographic technics -urological radiographic technics are taught so that the urological as-

April 1971

sistant can assist the x-ray technologist. There is absolutely no intention of replacing an x-ray technologist in any situation. We feel compelled to acquaint the trainee with the basic essentials of good quality urological radiography with complete safety to the patient and personnel. The patient becomes the focal point of another phase of the program. This area concerns itself with patient observation and reporting of these observations both pre and postoperatively. For example, the patient’s general appearance, vital signs, and fluid intake and output are stressed, and the art of proper charting is emphasized. Preoperative care is studied beginning with the reading and understanding of the doctor’s orders. Ideally, the student will be able to explain any procedure to the patient. The student is taught the surgical preparations pertaining to most urological procedures. Postoperative care consists of checking vital signs and recognizing variations as they relate to the procedure and to the anesthetic agent utilized. Again, catheter care is very important (Fig 3). The appearance of the catheter drainage fluid as an aid in evaluation of postoperative bleeding, the condition of the wound, the changing of dressings, and the removal of sutures and drains are taught. One final but important part of this training is patient teaching. Many patients are discharged from the hospital with urinary diversion appliances, indwelling catheters, irrigation equipment and incontinence devices,

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without any previous instruction on their care. It is imperative that the patient understand the importance of the care of these devices, and the urological assistant can often perform this task. The course material is presented utilizing conventional m e t h o d s , namely lectures, demonstrations and conferences (Fig 4). Examinations are given periodically to evaluate the student’s progress. The urology section has its own reference library of over 100 volumes pertaining to urology. Audio-visual equipment, anatomical models and charts are kept in the urological conference classroom locate in the section. A collection of over 4,000 35mm urological slides is owned by the section. The course director is a registered male nurse with a BS degree in professional nursing from the University of Minnesota. He has had 18 years of background experience both in practicing and teaching urological care. Assisting with the training a r e a hospital aide with nearly 30 years experience, of which 13 years were spent in urology; five resident physicians in urology; and personnel from the nursing, radiology, pharmacy and laboratory service. The entire program is under the supervision of Clyde E. Blackard, MD, chief of urology a t the Minneapolis VA Hospital. George T. Mellinger, MD, chief of staff a t the Kansas City Veterans’ Administration Hospital, is senior consultant. Additional experience has been obtained by affiliating with private hospitals. Two metropolitan area hospitals, St. Mary’s and Fairview, Minne-

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Fig 3

Students receive instruction on postoperative catheter care and on observation of drainsge fluid following TUR. Fig 4

Students are required t o attend lectures, dernonstrations and conferences in urology.

apolis, are presently participating, as a r e the University of Minnesota Hospitals. This affiliation period is flexible and presents additional material involving female and pediatric patients in a private hospital setting. Problems are an inherent part of any program, especially during its infancy. The urological assistant program is no exception. The three questions most often asked are: 1. How much should the urological assistant be paid?

AORN J o u i m l

2. To whom should he be responsible? 3. What are the legal risks involved? In the brochure describing the program it states that salaries depend upon the individual’s demonstrated abilities and should range from $5,000 to $10,000 annually. As in any economic endeavor, salary will depend upon supply and demand, geographic locality, “the times” and other variables. There is neither a recognizable supply nor demand for the urological assistant as yet, and the reason is simple: there are only three formal courses in operation today. They are the United States Navy’s 26-week course in urologic technics;g a twoyear program for the urological assistant offered by the University of Cincinnati Medical Center;6 and our program. Along with salary, another question often asked refers to the line of authority; ie, to whom should these people bc responsible? This would have to be resolved by mutual agreement, and again, the area of assignment and “who pays the salary” enter into the picture. At our hospital the trainees are responsible to the surgery service. In the affiliating hospitals, they report to the nursing service through the operating room supervisor. The legal definition of the urological assistant is the most difficult problem. Although a dependent assistant has traditionally performed certain delegated tasks for the physician, this new category may push into areas hitherto reserved for the physician.

April f 971

In an article prepared for the American Medical Association Law D i ~ i s i o n , Richard ~-~ P. Bergen states, “For the protection of the patient, medical functions can be delegated to paramedical personnel only if they are performed under the direction and supervision of a physician. A physician employer is always liable for injury caused to his patients by the negligence of one of his employees regardless of whether the employee has some recognized status under state law. In considering the risks of liability in the use of new kinds of paramedical personnel, it is inevitable that risks must increase, but the risk is less if: 1. the a s s i s t a n t is thoroughly trained and carefully supervised; 2. a formal training program is established and effectively operated by a medical school o r a teaching hospital;

3. appropriate medical and specialty societies establish standards for training and a program for private certification of students who satisfactorily complete the approved training.” The American Urological Association, Inc., has indicated its interests in the concept of the urological assistant by sponsoring Para-Urologic Seminars Philadelphia, May 1970 and Chicago, May 1971. Logically we look for guidance and direction from the AUA and seek their assistance for the establishment of standards, for the content of the curriculum, evaluation of trainees and publicity. The Urological Assistant concept may well be an important advance in urology. Properly n u r t u r e d and

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guided, this program should grow t o be an important contributing part of this nation's health industry.

0

4. Stead, E. A,: Conserving costly talents-pro198:l 108, physician's assistants, JAMA

vidinq 1966.

5. United States Navy, NEC: HM-8486, BUMEDIST 1510.9B, N o v 15, 1967.

References

..

I. Bennett, L. R.: This I believe . that nurses AORN J , I1:57 ( A p r i l ) 1970.

may become extinct,

6. American Urological Association Sponsored Urologic Assistant prepared

2. Clarke, B. G.: The relative frequency and age incidence o f principal urological disease,

J Urol,

Training Program

b y Arthur

T.

Evans,

MD,

(brochure), division

of

urology, University o f Cincinnati Medical Center, Cincinnati, O h i o 45229.

98:701, 1968.

3. Selected Training Programs for Physician Sup-

7. Bergen, R. P.: Use o f irregular paramedical personnel,

JAMA 207: 1027, 1969.

p o r t Personnel, June 1970, compiled by: Department of HEW, Bureau o f Health Professions, Education and Manpower Training, Bethesda,

Md 20014.

8. Bergen, R. P.: Irregular assistants and legal risks, JAMA 207:1231, 1969.

The Purdue Frederick Fellowship For Graduate Training in Operating Room Nursinq Requirements: -The

applicant must be in need of financial assistance t o continue her education.

-The

applicant must be pursuing a degree/diploma/certificate

which will benefit the appli-

cant in the field of OR nursing. -The

applicant must be endowed with the attributes for success i n the practice o f operating

room nursing. -The applicant must have been a member of the Association o f Operating Room Nurses for a minimum o f one year. -The

applicant must submit a paper (500 words or less) on how this educational experience

will be o f benefit, personally and professionally. -Three letters of recommendation shall be submitted as to why the applicant should b e considered (one letter from current employer.) Methods of Selection and Payment: The Committee i s composed of four members of the Association, one each representing the East, Middle West, West, and South. The Director o f Education o f the Association o f Operating Room Nurses chairs the committee and recipients are selected b y majority vote.

I. Applications together with letters of recommendation and paper must be submitted t o the committee by Jan I of the year in which the award will b e made. 2.

The committee will choose the recipients by Feb I.

3. The Awards will be paid in one lump sum of $500, and announcements made a t the annual meeting of the Association. The role of the Purdue Frederick Company in regard t o these fellowships i s limited t o providing Award funds and consultation t o the Association of Operating Room Nurses. The selection

of recipients i s made by the Association of Operating Room Nurses.

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AORN Journal