A didactic and experiential approach to nursing education

AORN Journal,  August, 2003  by Janet Rosentreter,  Mary Lynn Talboy

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Perioperative nursing care is a continuum. From anxious beginnings through the procedure behind closed doors to the bustle of awakenings, the perioperative nurse guides a surgical patient's experience with sensitivity, safety, and evidence-based skills. (1) How can postanesthesia care unit (PACU) RNs best be prepared to continue patient advocacy through the perianesthesia period where "dramatic and life-threatening changes can occur rapidly?" (1(p256))

Historically, to work in the PACU, nurses were required to have experience, complete six to eight weeks of orientation, obtain advanced cardiac life support certification, and complete a skills laboratory. In spite of these rigorous requirements, many nurses believed that more was needed to ensure the success of a nurse learning to work in this specialty area. Patient care in the PACU is complex because of anesthetic agents used, surgical procedures performed in the OR, and patients' health status. This patient care setting lends itself to errors, so patient safety is of the utmost importance. Vigilance and appropriate clinical decision making are essential to positive patient outcomes.

   Perioperative nurses have a long and
   distinguished tradition of promoting
   patient safety by intervening to minimize
   the risks related to surgical infection
   and injury. (2(p1005))

STATEMENT OF THE PROBLEM

The PACU education committee at St Luke's Regional Medical Center, Boise, Idaho, wanted to furnish nursing staff members with a unique learning experience that uses a didactic and experiential approach to enhance their existing knowledge base. The program took place at St Luke's Regional Medical Center, a tertiary care facility with more than 300 beds. The medical center was recently awarded magnet status through the American Nurses Credentialing Center, a subsidiary of the American Nurses Association. The magnet award recognizes "hospitals that meet quality standards and provide nurses with more responsibilities, autonomy, and opportunities to participate in policy decision." (3(p1764-1765))

The need for increased understanding of anesthetic agents and their perioperative administration and effects were recognized after the hospital administered an annual educational needs questionnaire. Administrators believed that minimal exposure to perioperative settings available in most nursing education programs was a contributing factor for a perceived lack of knowledge and experience.

LITERATURE REVIEW

The consensus of learning theorists is that adult learners

* possess prior knowledge and experience,

* are self-directed learners,

* have the ability to reflect critically, and

* are experiential learners. (4)

These adult learning attributes were incorporated in the anesthesia agents module and the intraoperative observation experience developed at St Luke's.

An extensive review of the literature yielded few current articles that described intraoperative observations and the development of a nursing guide to anesthesia as part of an orientation program to the PACU. In discussing skilled clinical knowledge, one group of researchers noted, "Nursing is not alone in misunderstanding and overlooking the knowledge embedded in skilled performance or experiential learning." (5((p32)) In summary, this study concludes that theoretical and practical domains of knowledge are equally important. (5)

One researcher reviewed a competency-based perianesthesia orientation program that used adult learning principles and concluded that learners must assume an active role in their learning and thus, be responsible for their own educational process. (6) The program reviewed included a PACU reference guide, learning modules, and a clinical practice component provided by preceptors. The outcomes of this orientation appeared to result in more confident nurses who were able to transfer theory into practice.

The Canadian Operating Room Nurses Association envisioned a curriculum developed to support the expanded role of the perioperative anesthesia nurse and the perioperative surgical nurse. The perioperative anesthesia nurse is defined as an

   RN with advanced perioperative
   nursing education and skills ...
   [who] functions collaboratively with
   the anesthetist to provide care for the
   patient undergoing anesthesia during
   the preoperative, intraoperative, and
   postoperative phases. (7(p17))

The course content includes advanced didactic courses in pathophysiology and pharmacology as they relate to anesthesia administration, as well as postanesthetic patient care management.

Results from a current study on nurse staffing levels indicates that

   among surgical patients,
   a higher portion of care
   provided by registered
   nurses was associated
   with lower urinary tract
   infection, and was associated
   with lower rates
   of failure to rescue.
   Failure to rescue was
   defined as death from
   pneumonia, shock, or
   cardiac arrest, upper GI
   bleeding, sepsis or deep
   venous thrombosis....
   It is possible that the
   outcomes for which we found significant
   associations may be more sensitive
   to the contributions that the
   skills and education of registered
   nurses, in particular make to patient
   care. (8(p1715,1720))