A precepted perioperative elective for baccalaureate nursing students

Linda L. McCausland

Much has been written about the recruitment crisis in perioperative nursing. The current perioperative RN workforce is aging, and the former major source of replacements, the diploma nursing program, is almost extinct. (1) Perioperative nurses fear that the shortage of nurses interested in working in the OR will make it easier for managers to hire staff members who are not nurses to perform duties nurses traditionally perform. (2) This scenario is not unlike that in other practice areas experiencing a shortage of nurses. One important difference, however, is the lack of perioperative clinical experiences for student nurses, which could stimulate students' interest in perioperative nursing as a career. Those graduates who pursue perioperative nursing may be disillusioned with the role if they have not had previous perioperative clinical experience. Loss of a newly hired nurse during the lengthy orientation process is very costly for the hospital and frustrating to the perioperative manager. (3) Additionally, the contemporary roles of perioperative nurses and nurse managers are so demanding, BSN graduates are needed to fill them. (4)

Authors of perioperative nursing literature have provided many explanations for the decline of perioperative experiences in nursing education programs. (5) Some of the influencing factors identified are the

* basic nursing program emphasis on generalist rather than specialist preparation,

* removal of perioperative content from nursing education due to overcrowded curricula,

* inaccurate perception of the perioperative role as purely technical rather than professional,

* view of the traditional role of the perioperative nurse as handmaiden to the surgeon, and

* lack of nursing faculty members qualified to teach a perioperative elective.

More than two decades ago, AORN initiated a project to promote perioperative nursing and encourage nursing student experiences in the OR. Since then, various courses, programs, and experiences have been launched and described in the literature. (6) Several models have been implemented, and most include both didactic and hands-on experiences. Nursing school faculty members and perioperative nurses have formed collaborative relationships to provide basic and advanced electives. Some are offered during summers, some between semesters, and others during the school year.

Today, the shortage of perioperative nurses remains, and most nursing education programs still provide very limited exposure to perioperative nursing, despite student interest in the perioperative role. The presence of a faculty member in the OR during student rotations has not been feasible for many reasons, such as necessary university faculty-to-student ratios and difficulty accommodating and supervising multiple students in the setting. One-to-one precepted experiences seem to be a more feasible alternative, assuming qualified perioperative nurses have the time and are willing to oversee student experiences.

That very interest was expressed in one community through an AORN chapter initiative to increase recognition of perioperative nursing and inclusion of perioperative nursing experiences in nursing school programs. Faculty members from local nursing schools were invited to a program that addressed these goals. A faculty member in a baccalaureate nursing program was inspired to collaborate with nurses from the chapter to develop a perioperative experience for interested nursing students. The faculty member contacted the chairperson of the educational initiative and became the faculty facilitator for a precepted perioperative nursing elective.

DESCRIPTION OF THE PERIOPERATIVE ELECTIVE

A one-credit elective clinical experience in perioperative nursing was arranged for students in a baccalaureate nursing program during the spring semester of their junior year. The students' schedules allowed one full weekday without classes to participate in the experience.

Goals and requirements. The goals of the experience were to increase students' knowledge of the perioperative nursing role and to allow interested students to determine whether they wanted to pursue a career in perioperative nursing. The three domains of learning (ie, cognitive, psychomotor, affective) were to be addressed during this educational opportunity. In the cognitive domain, students would gain knowledge and understanding of perioperative nursing by observing, participating in, and discussing the role. Psychomotor learning would take place by performance of basic perioperative skills in the actual setting under preceptor supervision. As students gained knowledge and skills, they would form beliefs and attitudes about perioperative nursing (ie, affective learning). Documentation of affective learning becomes evident when students reflect on the experience and compose their thoughts in log entries.

Before this experience, students received 13 hours of lecture on perioperative content in their fundamentals course. A one- or two-day observational experience in the OR was provided during their medical-surgical and pediatric rotations. The pediatric experience allowed students to accompany and observe patients through the preoperative, intraoperative, and postoperative phases of care. The opportunity to observe a cesarean section was provided to some students during their maternity rotation. Some students attended an open house program presented by the local AORN chapter in which a variety of surgical procedure setups were simulated and tours of the OR suite were conducted. Students were able to handle instruments and view equipment demonstrations.

Students who enrolled in the elective were expected to complete three requirements, including

* developing a greater understanding of the role of the RN in the OR,

* assisting the preceptor with some of his or her duties in the OR, and

* describing how perioperative nurses use the nursing process.

Completion of the requirements would be documented in a log of experiences kept by each student. Students also were encouraged to propose any additional activities they wished to accomplish related to their particular interests. Typical optional experiences requested by students included

* scrubbing in on a procedure;

* accompanying a patient through the preoperative holding area, the OR, and to the postanesthesia care unit; and

* observing an anesthesia care provider for one day.

The focus of the experience was on learning and participating in the role of the circulating nurse rather than on simply observing the surgical procedure.

Student participants. Students learned of this elective offering through an announcement in one of their classes. After the first program was offered, however, students often sought information before the announcement was made because of the favorable reputation of the experience. In addition to the junior students, senior students often enrolled, as did one RN student who had no previous exposure to perioperative nursing in her basic program.

At times, there were students whose actual interest was in the nurse anesthetist role. Preceptors were participating in this program to attract students to perioperative nursing, so students with an interest in anesthesia were discouraged from taking this elective. Often it was possible to arrange a similar clinical experience for these students with a nurse anesthetist later in their program while they were learning critical care concepts. At least one perioperative nurse preceptor telephoned the faculty facilitator to complain that her student was not interested in being a perioperative nurse because the student gravitated to the anesthesia end of the table.

Faculty members were consulted to recommend students for the course. Students with a reputation for having problems with professional expectations (eg, punctuality, attendance, dependability) were excluded from this program. This practice was considered important because the experience was precepted.

Sites and preceptors. The faculty facilitator made arrangements for preceptors by calling nurse liaisons who scheduled nursing student experiences in the OR. At first this was a very time-consuming process. Nurses who were interested in participating as preceptors were identified through contact with the chairperson of the AORN chapter initiative. Perioperative nurse managers in hospitals throughout the area were contacted. Some would not allow students in the OR without an instructor, despite perioperative nurses' willingness to participate as preceptors. The necessity of making many telephone calls made the process inefficient.

A better method evolved in which the liaisons identified those who were willing to precept students at participating facilities. Eventually, those nurses who were excellent, interested preceptors continued to take students each year when their schedules allowed. Excellent relationships continued with five hospitals. Arrangements with two additional sites provided the ability to accommodate students' special interests in pediatrics and oncology.

Orientation. Two hours were spent on campus with the faculty facilitator to clarify expectations, have students write their own objectives for additional activities they wanted to accomplish, and prepare for the experience. A videotape, Perioperative Nursing Practice: Intraoperative Phase, (7) which emphasizes the use of the nursing process in perioperative nursing, was shown. Some basic supplies were available for students to examine. These were provided by the AORN chapter and included various types of suture, a staple gun, electrosurgical unit tips and a dispersive pad, sponges, sterile impermeable adhesive drapes, a self-regulating suction drainage device, and disposable gowns. At the request of the students, gowning and closed gloving demonstrations and practice were added to the orientation.

Beginning with the second offering of the course, the facilitator read excerpts from previous students' written logs to the group as part of the orientation. These excerpts were selected to demonstrate the types of experiences and personal reactions that could be expected. Some showed the perioperative nurse's caring manner and patient advocacy role. Students also became aware of the types of log entries necessary to show completion of their requirements. By the end of the orientation, the excitement and eagerness to begin were obvious.

The clinical experience. Students made arrangements with their preceptors to complete a minimum of 36 hours of clinical experience, and many worked additional hours. Some worked the entire shift; others worked partial shifts, depending on mutual hours of availability. One nurse regularly changed her work schedule to accommodate her student. Preceptors were asked to notify the faculty facilitator regarding any concerns about students' experiences or behaviors.

The experiences were varied. Some preceptors required students to view videotapes on pertinent topics (eg, scrubbing, safety). Some gave reading assignments. Others began with a tour of the facilities or observation of a procedure. Many of the preceptors specialized in specific types of surgeries (eg, orthopedics, gynecology). At times, they would arrange for their students to observe or work with other types of surgeries to accommodate student interests.

During the course of nine years, 67 students completed this elective, with one to 16 students enrolled per semester. The experience eventually was offered in both the spring and fall semesters to accommodate student schedules. The types of skills students frequently were able to perform or assist with are shown in Table 1. This information was obtained at the end of the experience on the course evaluation. A checklist was provided with an option to specify other skills not listed. Other skills and tasks performed by some students were skin prep, catheterization, holding retractors, assisting with closure, helping to gown surgeons, retrieving equipment and supplies, documentation, connecting equipment, and checking emergency equipment.

Students were expected to keep a log of their experiences to submit to the faculty facilitator after each clinical day. The emphasis was on describing how each of the goals was being met. To document affective learning, students were encouraged to express their feelings and reactions to the experience. The actual description of the surgical procedure was not required. Eventually, students found that sending their logs to the instructor via e-mail was more convenient.

Evaluation and grading. A letter grade was given to comply with the university grading policy. The following grading criteria were used.

* A--All requirements were met. The student followed through with the schedule as planned with the preceptor; the student received a satisfactory evaluation from the preceptor.

* B--The student experienced some difficulty following through with the criteria to receive an A.

* C--The preceptor expressed concerns regarding the student's accomplishment of the criteria.

* D or F--The student was unable to complete the requirements or exhibited unprofessional behavior.

Student logs also were used to determine whether requirements had been met. The faculty facilitator's feedback helped students address requirements in their logs. Additionally, each preceptor completed a two-page evaluation for his or her student. The faculty facilitator determined the letter grade based on the grading criteria. A great majority of the students received an A. Some students were unsuccessful because they failed to complete the experience without notifying the preceptor or instructor. Occasionally, students were assigned a grade of "incomplete" until they could finish their clinical hours.

Students were asked to complete a course evaluation at the end of the experience using a five-point Likert-type scale that included a neutral or not applicable option (Table 2). Overall, this course received a highly favorable rating, with 85% of students strongly agreeing that the course was valuable and all students indicating they would recommend this program to others. Preceptors were aware of and helpful regarding students' learning needs (96%), and the patient care that was learned extended beyond the confines of the OR (ie, items 4, 5, 11). Students fulfilled the requirement of learning about the role of the perioperative nurse (100%) and the nurse's use of the nursing process (99%). In general, students felt that the 36 hours of clinical experience were sufficient for their learning (86%); however, 28% did not get to do as much as they had hoped to do.

This was a group of students who indicated interest in being perioperative nurses; therefore, the experience may have helped clarify whether this is the career they wish to pursue. After this experience, 17% indicated they did not want to be perioperative nurses, but 65% still were interested, with 36% indicating a strong interest. Seventy-four percent of the students were satisfied with the amount of nurse-patient interaction in the OR. Statistically, there was a slight but significant relationship between student satisfaction with the amount of nurse-patient interaction in the OR and interest in being a perioperative nurse (r = 0.48, df = 66, P < .001). On the negative side, a few students stated in their comments that they no longer were interested in perioperative nursing because there was not enough nurse-patient interaction.

DISCUSSION

One of the benefits of this clinical offering was that students got to experience the role of the nurse in the OR rather than to strictly observe as they previously had done. One student even got to work one day with her preceptor in a management role. This was particularly valuable to this student who has good leadership potential.

Although this brief experience confirmed interest in perioperative nursing for many, it also helped some students learn that perioperative nursing was not for them. As one student stated, "I learned that being an OR nurse is not enough patient interaction for me; but I would not have learned that without this experience." Whether or not they ultimately maintained an interest in perioperative nursing, students benefited because they could transfer the skills and knowledge they learned to other areas of nursing practice. A few students received job offers based on this experience. Some students attended a local AORN meeting at the urging of their preceptor and faculty members. They were received warmly and were impressed with the meeting and program. Another positive effect was the response from

preceptors regarding the experience. When asked whether they would like to precept students in the future, the response was always "yes" or "definitely." Many expressed how much they enjoyed working with the students, how they learned from each other, and how they felt this was an opportunity to recruit new perioperative nurses.

Most students were able to achieve all of their requirements. The requirement to describe how perioperative nurses use the nursing process often was not addressed in the students' logs. This required that the faculty facilitator teach students to look for evidence of nursing diagnosis identification, treatment, and evaluation of expected outcomes. The nursing process terminology familiar to students was not as obvious in the practice setting. They were well aware of assessments performed, especially in the preoperative holding room, but in most settings, they did not see actual nursing diagnoses identified. With encouragement, they were able to identify common nursing diagnoses, such as knowledge deficit, anxiety, risk for injury, and pain, that nurses were using but not necessarily documenting as such. The interventions and evaluations also were clear after students applied the nursing process thought pattern. The faculty facilitator insisted on the inclusion of that requirement so students would see the comprehensive role of the RN in the OR; otherwise, students tended to focus on technical skills, just as they do in many other clinical experiences.

Problems encountered. Considering the large number of students (ie, 67) who have completed this elective, the problems and concerns were minimal. Two of the concerns already have been mentioned (ie, student interest in anesthesia, failure to follow through with arrangements). Additionally, in one setting, a student did not have a set preceptor but was assigned to several different nurses by the OR liaison. This limited the student's experience because each nurse was unaware of what the student already had learned and done, which kept the student from moving forward. That problem was related to staffing circumstances at the time and has not occurred again.

Other difficulties encountered were that some students did not call the preceptor when they were absent, and one of them showed up at a time not planned. This happened despite instructions to be on their best behavior so as not to ruin this experience for others. These instances required counseling; grades and references reflected this lack of professionalism. In another instance, a preceptor did not bring a problem to the attention of the faculty facilitator until the preceptor evaluation was completed. To prevent this from reoccurring, the facilitator recommends contacting each preceptor for feedback at least once during the experience.

The facilitator's role. The amount of work required of the faculty facilitator decreases after students complete the on-campus orientation. Before the semester begins, several telephone calls and follow-up letters are necessary to make arrangements at each hospital. Some hospitals required special forms and contact with multiple staff members. Initially, the usual university-agency contract had to be arranged at several hospitals. Quite often, the on-campus orientation has to be offered more than once to accommodate students' schedules.

After students make contact with their preceptors, share their objectives and interests, and plan a schedule, the facilitator's role is that of reading logs and giving feedback to ensure that students are meeting their requirements. Only occasionally does a preceptor call the facilitator with a concern. Notes regarding each requirement are made from the student logs. A grade is assigned when clinical hours and logs are completed and when preceptor and student course evaluations are received. This faculty facilitator is a clinical and classroom instructor with a full teaching load; the perioperative elective is offered on a voluntary basis by the instructor, without benefits or rewards, except students' expressed appreciation.

Other observations. Although the student participants express an interest in perioperative nursing by taking this course, other motives may prompt some to select this experience. The required course load for some students is one credit short of full-time enrollment status, which is necessary to receive scholarships and financial aid. Also, during a time period when the job market tightened, students may have viewed the perioperative elective as a method of increasing their marketability.

A shortcoming of this clinical elective endeavor is the lack of follow-up to know how many student participants actually pursued perioperative nursing as a career. Follow-up surveys of baccalaureate graduates traditionally have very poor response rates; but follow-up was not attempted. At the very least, students should be asked their intentions at the time of graduation.

One final consideration to note is the suggestion of some of the students who scrubbed to learn basic OR instruments in the on-campus orientation. This never was attempted because the facilitator lacked the expertise and access to instruments.

CONCLUSION

Student nurses expressing an interest in perioperative nursing should have their interest fostered and maintained to help recruit them into the field. (8) A brief, precepted perioperative clinical elective can help students decide whether this role is one they want to pursue further. Given that perioperative content is already in the curriculum (ie, covered in most major medical-surgical nursing texts), provision for an elected, precepted clinical experience in the OR is a feasible endeavor. Students acknowledge that one credit hour is adequate to meet their learning needs. The preceptor arrangement makes the time commitment minimal for a faculty member interested in meeting students' needs by providing perioperative clinical experiences. A good working relationship between nurses in the practice setting and nurse educators is required, and this relationship must be fostered and maintained. Preceptors who enjoy the teaching role are given the opportunity to teach and recruit students into their specialty.

Those students who decide that perioperative nursing is not for them avoid wasting time and resources; however, they still can benefit from the experience by transferring what they have learned about perioperative nursing to other practice areas. To better evaluate the recruitment success of the experience, follow-up is needed to determine how many students who participate in perioperative electives become perioperative nurses. Regardless, the perioperative elective is a valuable learning experience for student nurses.

Table 1
SKILLS FREQUENTLY PERFORMED
DURING THE PERIOPERATIVE EXPERIENCE

                                    Percentage of
Skill                             students (n = 67)

Assisting with room setup               100%

Positioning the patient                  97%

Assessing the incoming patient
and chart                                95%

Counts (ie, sponge, needle,
instruments)                             89%

Sending specimens to
pathology                                79%

Preoperative visit in the surgical
holding area                             73%

Scrubbing                                70%

Accompanying the patient to
the postanesthesia care unit             56%

Patient teaching                         35%

Table 2
STUDENTS' EVALUATIONS OF PERIOPERATIVE ELECTIVE COURSE (N = 67) *

                                          Neutral/
                        Strongly            not                Strongly
Course evaluation item   agree    Agree  applicable  Disagree  disagree

 1. This was a
    valuable
    experience.           85%      15%

 2. My preceptor was
    aware of and
    helpful regarding
    my learning needs.    79%      17%       2%         3%

 3. I was able to ask
    questions and
    received answers.     89%      9%        2%

 4. I am better able
    to prepare
    patients for
    surgery as a
    result of this
    experience.           79%      17%       5%

 5. I am better able
    to care for
    postoperative
    patients as a
    result of this
    experience.           65%      27%       6%                   2%

 6. I gained knowledge
    of the role of the
    RN in the OR.         94%      6%

 7. I gained knowledge
    of how the nursing
    process is used in
    the OR.               76%      23%                  2%

 8. I did not get to
    do as much as I
    had hoped during
    this experience.       3%      25%       3%        43%       26%

 9. The 36 hours
    provided
    sufficient time to
    accommodate my
    learning needs.       44%      42%       5%         8%        2%

10. I am satisfied
    with the amount of
    nurse-patient
    interaction in the
    OR.                   35%      39%       9%        15%        2%

11. I have a better
    understanding of
    things covered in
    class now that I
    I have seen the
    surgical
    procedure             70%      29%                  2%

12. I am interested in
    being a
    perioperative
    nurse                 36%      29%      18%        12%        5%

13. I would recommend
    this experience to
    other students.       85%      15%

* Some percentages exceed 100% due to rounding.

NOTES

(1.) V D Wagner, D D Kee, D P Gray, "A historical decline of educational perioperative clinical experiences," AORN Journal 62 (November 1995) 771-782.

(2.) B Happell, "Student interest in perioperative nursing practice as a career," AORN Journal 71 (March 2000) 600-605.

(3.) A T Onstott, "Hospital explores winning balance in perioperative education," A ORN Journal 68 (September 1998) 395-399.

(4.) J M Beitz, P M Houck, "Advanced perioperative nursing elective for baccalaureate students," AORN Journal 66 (July 1997) 119-130.

(5.) Ibid; Happel, "Student interest in perioperative nursing practice as a career," 600-605; Wagner, Kee, Gray, "A historical decline of educational perioperative clinical experiences," 771-782; S C Kurtz, L W Eichelberger, "Developing a perioperative nursing elective," AORN Journal 70 (November 1999) 879-886.

(6.) Onstott, "Hospital explores winning balance in perioperative education," 395-399; Kurtz, Eichelberger, "Developing a perioperative nursing elective," 879-886; L Kautzman, L H Miller, "Growing replacements for our `graying' perioperative nurses," Today's Surgical Nurse 21 (March/April 1999) 22-25; Beitz, Houck, "Advanced perioperative nursing elective for baccalaureate students," 119-130; G Peters, M Frazer, "Implementing a perioperative nursing elective for bachelor of nursing students," ACORN Journal 12 (Winter 1999) 24-30.

(7.) C A Hyer, Perioperative Nursing Practice; Intraoperative Phase (Danbury, Conn: Davis + Geck, 1986) Videotape.

(8.) Happel, "Student interest in perioperative nursing practice as a career," 600-605.

The author acknowledges Mary S. Beiter, RN, CNOR, Sisters of Charity Hospital, Buffalo, NY, and Yvonne K. Scherer, RN, EdD, School of Nursing, University at Buffalo, NY, for their review of and suggestions in writing this article.

Linda L. McCausland, RN, EdD, is a clinical associate professor, School of Nursing, University at Buffalo, State University of New York.

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