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Perioperative Nursing Education: Rejuvenating a Vanishing Curriculum

By Kathy Dix

Training nurses in the perioperativearena has been a dying mission since the 60s. Penny Boone, who graduatednursing school in 1968, wrote a senior paper on the changes occurring inoperating room (OR) nursing and her conclusions still apply today. ORnurses today face vast challenges, the largest problem of which is the shortageof well-trained, educated nursing personnel, Boone wrote. The OR experience was or is being eliminated from manynursing programs. The role of the OR nurse in patient care extends outside ofthe operating suite. However, the trend in collegiate nursing education today istoward the elimination of the OR experience as part of the basic clinicalpreparation of nurses. Those responsible for directing collegiate programs haveassumed that operating room nursing is not patient-centered and that onlyconscious patients can receive such care.

Boone received a call to arms last summer, when she was askedto assist with perioperative education in Arizona. The Arizona Hospital andHealthcare Association (AzHHA) sponsored a Day of Dialogue during which thelocal Association of periOperative Registered Nurses (AORN) chapter addressedthe nursing shortage. Boone had also become associated with the national chapteron this subject, and the association provided funding and a speaker for thedialogue, Debra Fawcett, an expert on the topic. Local hospitals are nowoffering clinical experience to basic nursing students.

We OR nurses have shot ourselves in the foot, becausehistorically, the OR has been a very closed and unwelcoming place to new people, says Boone. In the old days, the concept was that you hadto have at least three years of experience on the fl oor before you could workin the OR. Im here to tell you that its critical patient care. Being undera general anesthetic what could be more critical than that? The nurse is theadvocate for the patient.

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But there are now many programs to educate nurses inperioperative work.

Since 1999 we have had a six-month registered nurse ORinternship, says Alice Speers MEd, RN, BC, an education specialist insurgical services at William Beaumont Hospital in Royal Oak, Mich. Since there were inadequate numbers of availableexperienced OR nurses, the hospital decided that an internship would help tomeet this need. At the beginning of the program, only nurses with at least twoyears clinical experience as a registered nurse were considered for theprogram. However, in 2002, the program was extended to include new graduates.

In preparation for our expansion and addition of 16 ORs andfour procedure suites, there was a need for continued preceptor development andenrichment, Speers says. Basic preceptor classes are held four times peryear and an advanced preceptor class was developed and is offered with the samefrequency. And in addition to the internship, we provide orientation programsfor experienced OR nurses new to our hospital.

When asked how he attracts nurses to his OR, I would makethem aware of our fellowship of $7,000 per year to become an RN, says Alan Beatty, Shore Memorial Hospitals vice presidentof human resources. The onsite perioperative training program at Shore Memorialbegan in 1999; its first four graduates were all RNs, but in 2002, the programwas opened to licensed practical nurses (LPNs).

The first four graduates in May 2000 were all registerednurses, but in 2002 the program was opened to LPNs, adds Maggie Sterling,LPN, CST, CRCST, MA, educational coordinator of the OR at the hospital. Being an OR nurse is not for everyone. A good OR nurseneeds a personality that enables them to work in a very regulated, oftenstressful environment and as part of a team.

The Northeastern University Perioperative Nursing Certificate Program is an intensive continuing education program that prepares RNs totransition into the perioperative nursing role, says Lea Johnson, MSN, MS,MS, RN, ANP, perioperative program director and director for the Institute forHealthcare Leadership and Professional Development at Northeastern University inBoston. This program is unique in that it uses a collaborative approach tothe educational process we call the Boston Model. Our program is guided byan advisory board with members representing the perioperative clinicalleadership from a dozen area hospitals. Advisory board members provide inputregarding curriculum, recommend faculty, and also provide closed OR settingsthat are used as learning labs at the beginning of the program.

The program is currently not for credit, but is a 500-hour CEUprogram. Nurses come to campus for their didactic one evening per weekfor the duration of the program. In the future, we hope to offer a distanceeducation component to meet the needs of outlying areas within the region,Johnson says. Ideally, perioperative nursing should be included in theundergraduate nursing curriculum; however, until perioperative undergraduateeducation becomes a national reality, continuing education opportunities like the Boston Modelserve an important role in educating tomorrows perioperative nurses andnursing leadership.

The fellowship I teach is nine months in length, and wetake an RN, a graduate or with experience, and teach them how to be an OR nursefrom the bottom up, says Belinda Alt, RN, a nurse at St. Johns MercyMedical Center in St. Louis, which teaches the AORN module, PerioperativeNursing 101. This course covers only the role of circulating nurse. Alt hastherefore created her own course for the role of surgical scrub nurse. On oneday of the course, a registered nurse first assistant (RNFA) takes trainees foran entire day, during which they set up an OR and tear it down multiple times.On another day, a charge nurse has them choose a card from basket that lists aprocedure; the students must then pull every item appropriate for the casewithin a set time.

This is an entirely different kind of nursing, she adds. Weget our attaboys [in a different way] we are the patients advocatein [the OR]. You make sure everything is sterile when it goes on that fi eld sothey wont get an infection. Youre the one making sure theres a safetystrap so their foot wont fall off the bed when theyre asleep and cause apressure sore, or edema. Youre the one positioning the patient properly sothey wont have problems later on with a muscle or nerve entrapment. Itslike having a baby, because babies are helpless. These people are helpless; youhave to take care of them.

George Washington University Hospital has recently made itsinformal program formal; what used to be one-on-one precepting has now evolvedto classroom lectures and clinical experience with multiple students.

We try to get them to scrub first, because then they canlearn to anticipate what a surgeon needs, says Mary Ellen Hutchins, at GeorgeWashington University Hospital in Washington, D.C. They also are able toexperience the actual procedure. And technology has changed how they train aswell. Youre doing more than nursing, you have to understand [technology],she adds.

The facility is a teaching hospital, which makes trainingnurses easier; The surgeons are teaching residents, so the nurse can learnat the same time. The surgeons are a little more patient also, Hutchinsquips.

There may be a shortage of nurses for the OR, but a morepressing need is that of educators, she points out. The problem is thatuniversities dont pay as well. Therefore, the colleges dont have enoughfaculty to teach; they have to limit class size.

When I went to nursing school back in the late 60s, itwas really all about the instruments. Today its all about the patient,says Christine Smith, RN, MSN, CNOR, clinical nurse specialist of perioperativeservices at Fox Chase Cancer Center in Philadelphia.

Smith also teaches at Delaware County Community College, whichhas been somewhat the Mecca of perioperative education in this perspective.AORN offers a preceptor course for nurses who want to be clinical preceptors.There are still some hospitals that have enough staff and enough seasoned staffthat they can take on new graduate nurses or nurses without OR experience. Theyeducate them in the theoretical knowledge, but primarily in the skill sets.

Smith sat on an educational summit earlier this year thatlooked at nursing education across the country. Many of the people on thepanel were nursing educators and deans from across the country, she says. We looked at ways we could reintegrateperioperative nursing and interventional procedural nursing into basic nursingeducation. When I speak of interventional procedural nursing, Im alsoincluding under that umbrella, nurses in endoscopy, interventional radiology,interventional cardiology. Those are areas that, like perioperative nursing, arenot typically included in primary nursing education.

We were looking at a module system, where, say,perioperative and interventional procedural nursing could be a separate moduletaken as a senior elective. The nurse would get fundamental skills in the basicprogram. We looked at options for courses given online, where the nursingstudent would take the theoretical knowledge piece as an online course, and thenwould be assigned to the clinical area under the direct guidance of clinicalpreceptors. Were very concerned, because we know between 2010 and 2020, weregoing to lose a significant number of our perioperative nursing population toretirement. At this point, we are not appreciating the entry into thisparticular realm.

Were also looking at ergonomic strategies, staffing andscheduling strategies to try to keep these older nurses in the perioperativesetting, for their wisdom, their critical decision-making skills, and to be hereto precept the younger nurses. There are hours of standing, lifting, pushing andshoving of heavy equipment, long hours, night call, and many older nurses areleaving because they find it difficult to withstand the demands, and there areother areas in nursing that are more forgiving for older nurses. Some oldernurses would like to not have to take call, or work a late shift, or theydlike to work half days, do lunch and coffee relief and go home at 3, shesays.

Smith agrees that nursing faculty are in short supply, adding,Were trying to encourage more young nurses to become engaged in formalteaching, either as a teacher, or a mentor, or teaching part-time. Weretrying to encourage more nurses to consider working part time in their clinicalspecialty in nursing education, rather than having academic faculty, who havedoctoral degrees or no field experience. If somebodys going to teach me howto be a PACU nurse, Id rather learn that from a PACU nurse than from anacademic faculty person who hasnt worn scrubs in four years, she says.

Mount Sinai Hospital in Chicago is running all its currentexperienced OR nurses through the AORN course as a refresher, so people willunderstand about cutting corners, says Val Campbell, human resources nurserecruiter at the hospital.

Theyve hired nurses who do not have a med/surg background,and those nurses have been put through a rotation of each perioperative area,including PACU, preadmission testing, outpatient surgery and then the OR. Oncewe get our existing nurses through Perioperative Services 101, [our goal is to]hire new grads. To be honest, we have not taken new grads in the OR; wevetaken them into those areas that have an impact on the OR. They first learnthose areas, then slowly integrate into the OR, she explains.

At the national level, there are several things [to helpnurses transfer to the OR], says Pauline Robitaille, vice president and chiefnursing officer of AORN. When I was president of my local chapter, we gavestudents scholarships to local chapter meetings, to our workshops, a coupletimes a year. On the national level, there is a student nurse membership at areduced cost, and at our annual meeting, there is a student nurse program forthem.

Programs are available to members as well as non-members, shepoints out, ideal for those just getting into the specialty. For moreinformation, visit www.aorn.org.