OCTOBER 2004, VOL 80, NO 4 Smith

Preparing RNs for the OR Throuah a -. Certificate in Pen’operative Nursing Program

Sandra Smith, RN

ducating RNs to work in the OR is an expensive venture. In some E regions of the country, nursing

students’ only exposure to the OR dur- ing their clinical rotations is a day of observation. These days often are spent watching surgeons instead of what the circulating nurse and other members of the surgical team are doing.

Louisville, Ky, like many other US cities, has more than a dozen hospitals and ambulatory surgery centers. The need for qualified perioperative nurses is a constant issue, and many hospitals are training their own. Often after a hos- pital has invested time and money to train perioperative nurses, the hospital loses them to other ORs in the city. Spending thousands of dollars to train nurses only to have them go to work for competitors is not cost effective. This issue gave rise to a new concept of how hospitals in the city of Louisville could pool resources to prepare nurses for the OR without incurring such significant expenses.

ABSTRACT 0 THE NEED FOR QUALIFIED perioperative nurses is an ongoing issue, and many hospitals are training their own.

0 OFTEN, A FACILITY WILL INVEST time and money to train a perioperative nurse, only to have the nume leave to work for a competitor.

THIS ARTICLE describes how hospitals in the city of Louisville, Ky, pooled resources to devel- op a certificate in perioperative nursing program to address these issues. AORNJ 80 (October 2004) 690-698.

A CERTIFICATE I N PERIOPERATIVE NURSING

Perioperative educators in Louisville, along with some of the OR directors, met to discuss offering a certificate in periop- erative nursing continuing education class through a local university. The class would prepare RNs, at their own expense, to work in the OR.

None of the colleges or universities in Louisville offered a perioperative nurs- ing class. A certificate program was cho- sen because it would be less expensive for the students. The least expensive col- lege course for credit in Louisville was twice the cost of the certificate program.

Certificate programs provide nurses with an opportunity to gain experience and knowledge in areas they have never been exposed to and to decide whether these areas of nursing fit their goals. Employers see certificate programs as a way to improve expertise and compe- tency. Colleges and universities see cer- tificate programs as a way to encourage higher learning for nurses. Certificate programs also ease nurses back into studying and give them more confi- dence to complete a bachelor of science or master’s degree in nursing.’

THE PLANNING PROCESS The program coordinator, a perioper-

ative education coordinator at Baptist Hospital East, Louisville, approached the dean of nursing at one of the local universities with the idea of offering a certificate program in perioperative nursing. The dean was willing to add the program to the university’s School of Continuing Education and Studies. She and the program coordinator met with the director of the School of Continuing Education and Studies to discuss the process to go forward with the program.

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Both clinical OR educators and OR directors were invited to a meeting because it was important to get OR directors’ buy-in for the project. Without preceptors to conduct the clin- ical portion, the class would not be suc- cessful. In many ORs, preceptors are overworked and are not compensated for the extra teaching they are asked to do; as a result, finding qualified pre- ceptors can be difficult. The OR direc- tors saw the value of providing a class for motivated nurses and quickly offered support for the program. Each hospital estimated how many students it could accommodate. This helped deter- mine the number of students that could be accepted into the program. The group decided that a 20-student maxi- mum was a good starting point for the first class.

Clinical educators from area hospitals were asked whether they would be inter- ested in teaching the first class. Four perioperative clinical educators from four different health care facilities volun- teered to help develop the class curricu- lum. Another educator served as the pro- gram coordinator, an assistant to the four primary educators during class times when laboratories would be taught, and a back-up in case one of the instructors could not attend class. It was important to avoid interrupting the flow of the class. The class was fast paced, lasting only 11 weeks, and it had to move along consistently so students could build their basic skills from week to week.

FIN AN CI N G Cost was a major consideration. If

RNs were to pay for the class themselves, costs had to be kept down. The dean sug- gested obtaining grants to pay the instructors’ fees so the university would not have to add that expense to the tuition fee. The perioperative educators volunteered to supply any items needed from their ORs. All ORs have waste, and

many have unused, opened items that are collected to send to third-world countries. These were sources for sup- plies, such as prep trays, drapes, suture, and gowns, that could be used in the classroom.

The program coordi- nator sent a request for program funding to Ethicon Products World- wide, Somerville, NJ, a division of Johnson & Johnson, and received grant request forms to fill out and return to the company. The program was awarded a signifi- cant grant, which was used to pay the instruc- tors’ salaries and other expenses associated with the program. The cost for the class was set at $249, and students were asked to buy their own text- books. Some of the grant money, however, was used to purchase 20 copies of A0R”s Stun- dards, Recommended Prac- tices, and Guidelines for the students.

The local AORN chap- ter was asked to adminis-

In many ORs, preceptors are

overworked and are not

compensated for the extra

teaching they are asked to do;

as a result, finding qualified

preceptors can be difficult.

ter the funds. The chapter treasurer estab- lished an education account, and pro- gram instructors turned in time sheets and were paid through this account. Reports about the class were given at the chapter’s monthly meetings.

The university received the tuition money and provided continuing educa- tion units. The course was offered for 11 weeks, with four hours of class time and four hours of clinical lessons per week. Eighty-eight continuing education units were awarded at the completion of the class for a cost of approximately $3 per continuing education unit.

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TABLE 1 Sample Focus Sheet

Name Date

Objectives: 1. Demonstrate familiarity with the OR in the clinical site. 2. Differentiate between restricted and unrestricted areas of the suite. 3. Select proper OR attire according to facility policy. 4. Observe the preoperative assessment. 5. Observe latex versus nonlatex items.

Must be preceded by the following lessons: 1. Introduction to perioperative nursing 2. Surgical environment 3. Surgical attire 4. Preoperative assessment 5. Latex allergy

Performance expectations: 1. The preceptor introduces the student to the surgical team, nurse

2. The preceptor orients the student to the OR and familiarizes the

3. The student observes the surgical experience with the preceptor

manager, and resource people.

student with the surroundings and location of supplies.

from admission and reception of the patient into the OR through discharge to the postanesthesia care unit, identifymg the different phases of the perioperative experience.

4. The student assists the preceptor with tasks as appropriate. 5. The student discusses the roles of the circulating nurse, scrub nurse,

and anesthesia care provider with the preceptor.

Signature of preceptor

Focus sheet designed by and reprinted with permissionfiom Linda Boley, RN, BSN, perioperative educator, Jezuish Hospital, Louisville, Ky.

-

The class was offered through the university’s catalog for the School of Continuing and Professional Studies. It also was marketed in various nursing newsletters and magazines throughout Louisville. The class quickly filled to the 20-student limit, and a waiting list was started.

IMPLEMENTATION One area hospital provided a class-

room adjacent to a completely furnished OR for the class. Gowning and gloving, prepping and draping, and instrumenta- tion classes were held in the OR. Students learned about sterile fields and how to maneuver in an OR.

Textbooks used for the class were B e v y b Kohn’s Operating Room Technique, 10th edition, and the 2003 Standards, Recom-

mended Practices, nnd Guidelines. Students also were given focus sheets for their clinical lessons each week (Table 1). These included objectives the students were to meet for that weeks clinical hours.

When the educators and directors first met, they discussed the possi- bility of having all hospi- tals use the same interpre- tation of standards for their practices. Louisville physicians work at a vari- ety of hospitals; therefore, consistency in interpreting standards would be a ben- efit when dealing with issues that arise each day. Using AORN’s standards to teach the students was a first step in achieving con- sistency. A few months before the program began, the instructors met to com- plete the course syllabus (Table 2), using the appro-

priate standards to supplement each-les- son plan.

Students were given a list of local hospitals where they could perform their clinical practice. Students were encouraged to choose a hospital for their clinical experience, and if they did not have a preference, the program coordinator assigned them to a hospi- tal. Some students chose the hospital where they worked. Five students were sent to the class by their respective hos- pitals. At the time, they were being ori- ented to their hospitals’ ORs but were taking the class to learn theory. Two nurses were working in ambulatory sur- gery centers and were taking the class because they had never had formal classes on perioperative nursing. One nurse had not worked in nursing for a

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Topic

Introduction to perioperative nursing

Surgical environmen t

Latex allergy

TABLE 2 Excerpt from Class Syllabus

Standard

Perioperative model standards: Clinical prac- tice, patient outcomes, statement on entry into practice

Traffic patterns in the perioperative setting, surgical attire, environ- mental cleaning in the surgical practice setting

AORN latex guidelines

Objectives

1. Idenhfy the phases of the perioperative experience.

2. Describe the nursing process in relation to the periopera- tive role of the RN.

3. Identdy the roles of the circu- lating nurse, scrub person, and anesthesia care provider.

1. Describe components of the surgical environment.

2. Discuss the care of the surgi- cal environment before, dur- ing, and after the surgical procedure.

1. Recognize different types of latex reactions and their symptoms.

each reaction.

for latex allergy.

to decrease latex sensitivity.

2. Describe interventions for

3. Identdy groups at high risk

4. Discuss preventive measures

Materials

Berry 6 Kohn's Operating Room Technique, loth ed, chapter 2

Berry b Kohn's Operating Room Technique, 10th ed, chapters 12 and 13

Berry 6 Kohn's Operating Room Technique, loth ed, chapter 13, pages 226 and 227, handouts

few years and was taking the class as a refresher course. The remaining nurses were taking the class to see if they would be interested in perioperative nursing.

Students were assigned to the hospi- tals in a way that prevented smaller hos- pitals from being overwhelmed with stu- dents. There are five nursing schools in the Louisville area that send students to local hospitals for an observation day. In an effort to evenly distribute students and make sure they all had quality pre- ceptors, the program coordinator tried to send more students per week to a hospital with 25 O h than to a hospital with five ORs.

The program coordinator then con- tacted the educator at each hospital and gave him or her a list of students who would be using that hospital for their clinical practice. Only hospitals that had a clinical unit educator were used. The student was given the name of the edu- cator and was responsible for calling or sending an e-mail message each week

to set up the day and time for his or her clinical rounds. The educator then placed the student with a preceptor for that day.

COURSE WORK The class curriculum was outlined

by subject, standards, objectives, and chapters to be read before class. Students were given the assigned read- ing before the first class. The first night of class, students were prepared for discussion. Each student was asked to keep a personal journal of his or her experiences to be discussed during the first half hour of class. This proved to be an enjoyable part of the class for the students and instructors because the progression of the students' knowl- edge was apparent. The instructors were particularly impressed with how quickly students understood and could interpret the standards.

Many students had no preconceived notions of how things worked in the

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OR. These nurses were from all areas of nursing practice and were impressed with the fact that perioperative nurses had standards and recommended prac- tices to follow for their specialty.

OUTCOMES The class started with two men and 18

women and ended with two men and 14 women. The average length of the instructors’ OR experience was 26 years. The average student age was 35 years. Six students were in their 20s, five were in their 30s, three were in their 40s, and two were in their 50s. The students’ ages were significant-younger students are needed to help replace the fast-approach- ing retirement of Baby Boomers. Although many in the Baby-Boomer gen- eration spent time in the OR during their education, many members of the younger generation did not get that chance. Young nurses need to know what perioperative nurses do and become as captivated by the OR as the perioperative nurses who currently work there.

The 16 students who completed the program were interested in becoming perioperative nurses or believed the pro- gram was a positive nursing experience. Six of the students presently are working in five different area hospitals. Two others are employed by ambulatory surgery centers. Three others are hoping to find part-time positions in ORs. The other two students were not interested in pursuing perioperative nursing at the time but believed that completion of the program would help them in their current posi- tions. One said the course gave her confi- dence to reenter the nursing field after being absent from the workforce for seven years.

During the sign-up period, a prospec- tive student called with an interesting comment: “I’m not sure it is really nurs- ing you people do in the OR and I guess I would just like to see what exactly nurses do there.” On the final night of

the program, the students were told about the caller’s comment. Their responses were quick and to the point. Perioperative nurses encounter every aspect of nursing. It is much broader in scope than any of these inexperienced perioperative nurses had ever imagined. Comments included, “you see almost every disease process,” ”you are re- sponsible for so much more than just caring for the needs of the patient,” ”the safety of the patient takes on a whole new mean- ing,” ”the team approach to caring for a patient in surgery is greater than in any other area,“ “you are the last person to assess a patient before they be- come helpless; you better do it right,” ”lots of peo- ple are depending on you.“ It was obvious that the students understood that perioperative nurs- ing is real nursing.

The class evaluations were excellent. The stu- dents appreciated the instructors’ enthusiasm and expertise, and they

Young nurses need to become as captivated by

the OR as the perioperative

nurses who currently work

there.

made Gseful suggestions for the next class. One suggestion, which will be implemented, was that students spend more clinical time in the preoperative area and the postanesthesia care unit to get a broader picture of the perioperative experience.

Administrators at several hospitals in the city were so impressed with the class that they asked what they could do to ensure it would continue. They recognized the benefit of hiring nurses who already were educated about the perioperative setting because they did not have to invest time and money in the most critical stages of these nurses’ training. Additionally, the course gives hospital administrators an opportunity

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to observe student nurses in the periop- erative setting and evaluate their moti- vation and skills before hiring them.

A foundation to support the program was formed through the local AORN chapter. One thousand dollars that was left over from the initial grant was given to this foundation. The local AORN chapter donated $500, and sev- eral hospitals in the city also donated money. Area hospitals were asked to include this class in their tuition reim- bursement programs because if the cost to students was reasonable, the pro- gram would have a greater response. It is a win-win situation for the students and the hospitals.

The educators were asked if they were willing to continue overseeing the stu- dents. They all wanted to continue plac- ing students in their ORs. Some of the instructors have changed for the second class, and instructors will continue to rotate on a voluntary basis, which will help keep the subject matter fresh. Twenty new students signed up for the second class.

A SUCCESS STORY As reimbursement levels decline,2

the nursing shortage continues, and OR nurses age,’ educators have to find inventive ways to attract new and younger nurses to perioperative nurs- ing. Training a nurse only to have him or her decide not to work in the OR wastes time, effort, and money. The certificate in perioperative nursing program provides an opportunity for nurses to learn about what periopera- tive nurses do and gain the knowledge they need to work in the OR if they so desire. The class was deemed a success by students and local hospitals alike, and it is hoped there will be many more in the future. *:*

Sandra Smith, RN, BSN, CNOR, is perioperative education coordinator, Baptist Hospital East, Louisville, Ky.

Editor’s note: The author acknowledges Susan Davis, RN, EdD, dean, Lansing School of Nursing and Health Sciences, and Linda Bailey, director of continuing education, School of Continuing Education and Professional Studies, Bellarmine University, Louisville, Ky; Jenny Chandler, RN, MSN, perioperative clinical specialist, Nortons Hospital, Louisville; Linda Boley, RN, BSN, perioperative educator, Jewish Hospital, Louisville; Judy Hulbert, RN, BSN, CNOR, perioperative educator, Caritns Medical Center, Louisville; and Barbara Bunce, RN, BSN, CNOR, busi- ness system analyst, Baptist Hospital East, Louisville, for their support, encourage- ment, and assistance in developing the cer- tificate in perioperative nursing program.

NOTES 1. J Bernstein et al, “The MCH Certificate Program: A new path to graduate educa- tion in public health,“ Materrid & Child Health joirriial 5 (March 2001) 53-60. 2. K Traynor, “Hospitals’ reimbursement woes continue with 2004 OPPS,“ American Joiirrial of Health-System Pliarriacy 60 (December 2003) 2536-2538. 3. E E Cooper, “Pieces of the shortage puz- zle: Aging and shift work,” Nirrsing Ecorzoiiiics 21 (March/April 2003) 75-79.

RESOURCES Craven, R F; DuHamel, M P H.

“Certificate programs in continuing pro- fessional education,” Joirrnal of Continiring Education in Nursing 34 (January/February

.I .- 2003) 14-18.

Onstott, A T. “Hospital explores win- nine balance in uerioDerative education,” AOXN Joiirrial 6b (SeGtember 1998) 395- 399.

Ward, R P; Saylor C. “Nursing school curricula and hospital-based training pro- grams,” AORN Joiiriial 76 (July 2002) 51- 52.

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