Kicking it up a notch—successful teaching techniques

AORN Journal, Sept, 2004 by Paula Graling, Barbara Rusynko

Leaders in today's ORs face the challenge of preparing nurses to work in highly technical and demanding environments in which the need for competent, experienced nurses exceeds the supply. Perioperative staff nurses face daily demands for continuous coaching and mentoring of novice nurses. Many nurses who choose to work in the OR have no experience in the specialty and, thus, are confronted with the need to learn new cognitive and technical skills. As a result, they are faced with the anxiety of once again being a novice nurse.

Various programs, including internships, training programs, and fellowships, have evolved to prepare nurses to care for perioperative patients successfully and safely. One such program--the perioperative nurse fellowship program offered by Inova Health System, Falls Church, Va--is the focus of this article.

Inova's perioperative nurse fellowship program was developed in 1997, and the first class was held in January 1998. As of June 2003, more than 130 nurses had entered the program. The fellowship, which is designed to provide novice perioperative nurses with basic fundamental knowledge and skills for perioperative nursing, consists of 160 hours of classroom instruction in concert with clinical precepted experience. (1)

CHALLENGES

Nursing educators in the OR often are asked, "Why does it take so long to prepare a perioperative nurse?" There are several reasons. First, some ORs expect perioperative nurses to be able to function in both the scrub and circulator roles. These are two separate and distinct roles, and although they have similar competencies, each requires unique skills and knowledge. Second, the amount of time it takes a novice nurse to develop into a competent perioperative nurse depends on the breadth of knowledge and skills required for the specialty surgeries for which he or she may be required to circulate or scrub. Examples of these required skills include

* knowledge of anatomy and physiology, perioperative protocols, surgical procedures, and unique surgeon preferences;

* proficiency with high-tech OR equipment;

* precise and surgically technical team coordination;

* critical thinking and analysis of the surgical environment; and

* a variety of surgical specialty skills to support patient care needs for any procedural case that enters the OR.

Third, many ORs require that the nurse "take call," a role that calls for an expanded knowledge and skill set of independent nursing actions for urgent and emergent situations. Examples of emergent situations in which patients would be transferred immediately to the OR from the emergency department include

* motor vehicle accidents;

* ruptured aneurysms;

* fractured bones;

* head injuries;

* injuries involving equipment, such as lawn mowers; and

* violent injuries (eg, from stabbings and shootings).

Another factor affecting the amount of time needed for an novice perioperative nurse to become competent is the unique working environment. Perioperative nursing is enacted on stage with an audience for most of the working hours of the nurse's day.

Nurses in the Inova Learning Network fellowship program are required to complete a learning journal of procedures they encounter during their clinical experience in the OR. This journal is a reflection of what they learned, what they discovered they need to learn, and how they plan to learn what they need to know. The journal places them in the process of self-directing their individual learning based on the needs assessment and plan they develop through their own reflection on the clinical experience.

Novice nurses report in their learning journals that their level of anxiety is high when they have to perform even the simplest task in the OR in front of an audience. A frequently cited example that reflects this on-stage climate is inserting a Foley catheter. Many nurses in the Inova fellowship program have accomplished this task successfully in other practice areas, but they feel insecure with physicians and other nurses watching them in the OR. The patient care environment for most Foley catheter insertions outside the OR is one in which the nurse is working only with the patient. Nurses have noted in their journals that they experience a very high level of anxiety when performing the same task in the OR and cite the cause of the heightened anxiety as the number of people in the room watching them perform the procedure. They also state that they have great difficulty accomplishing a Foley catheterization because of the heightened anxiety. One fellow's journal entry read,

   I ran into problems when I was asked
   to place the Foley while the whole
   team, including the surgeon, surrounded
   me with scrutinizing eyes
   ... just waiting for me to get this
   done so they could begin. I was so
   nervous that my focus was not on
   my hands but on all the eyes staring
   at me. I contaminated my left hand
   while putting on my sterile gloves. I
   felt like I was two inches tall. I had to
   go get a new pair [of gloves] and
   start over. It is amazing how such a
   simple task on the floor is like the
   biggest deal in the OR--it's a totally
   new environment.