Identifying Learning Experiences in the Operating Room for the Basic Nursing Student

IDENTIFYING LEARNING EXPERIENCES IN THE OPERATING ROOM FOR THE BASIC .NURSING STUDENT Florence M . Alexander, R.N., Ph.D.

“Wherever there are patients, awake or asleep, there should be professional nurses to assume responsibility for their nursing care.” This statement is the basis of my personal convic- tion that continuous, sequential operating room experience for the student is just as im- ‘portant as her experience in any other specialty in its own right as is psychiatric nursing. If this premise is sound, then student nurses should learn realistically about the care of patients during surgery and not through limited, intermittent, disconnected observations from afar. Students should be prepared, insofar as possible, to function in the operating room just as they are taught to function at beginning level in any other specialty, for example, medical-surgical nursing and pediatric nursing. Some educators contend that nursing in the operating room is not a clinical specialty. I cannot subscribe to this

Florence M. Alexander, R.N., Ph.D., received her Master’s degree in nursing from Yale University and her Doctorate degree in counseling psychology from Syracuse University. She is currently an associate professor in the Vanderbilt University School of Nursing and nursing consultant for the Tennessee Mid-South Regional Medical Program. She has taught and counseled in nursing schools throughout the country. She is an affiliate member of the American Medical Association, American Personnel and Guid- ance Association, and American Psychological Asso- ciation. She served on the hospital advisory council for the National Association for Practical Nurse Education from 1962.65, and in 1965 she was full- time consultant on nursing affiirs to the AMA and also awarded a medallion by the AMA Institute of Biomedical Research. Dr. Alexander has contributed extensively to nursing and medical journals and is listed in Who’s Who in American Women.

belief and furthermore would propose that some of those who take such a position are nurses who themselves either had a very in- adequate experience in the operating room or a very traumatic one with possibly poor in- struction and little or no supervision. It is possible to prepare the student in logical se- quences of learning experiences of gradually increasing difficulty, to function effectively in an operating room and yet not exploit her in terms of service. There will, of course, always be those students who do not particularly enjoy the nature of the work and who conse- quently may not perform as well as their class- mates. However, selected experiences for the latter type of student are still possible and as much “protection” as necessary can be provided for her. The members of the teaching staff, the supervisor, head nurse and, in fact, all of the personnel in the operating room, must share a common understanding of the objectives of the educational program, the progress of each student and the type of experience which each one is qualified to assume.

To personalize my remarks, I do not wish to have major or minor surgery without a professional nurse in attendance particularly in the capacity of a circlilating nurse to exercise judgment. Furthermore, I want to see patient care given that I would desire for myself and for my family. I firmly believe that a nurse, professional or practical, not an aide, should be with the patient from the time he leaves his room until he is wheeled through the doors of

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the operating room and turned over to the anesthesiologist.

I shall assume that clinical experience for the basic student in the operating room is as essential as any other experience in the education of a professional nurse. By clinical experience I do not mean the experiences of admitting a patient, caring for him preoperatively, accompanying him to the operating room, then to the recovery room and finally caring for him postoperatively in his room. This type of experience gives the student only one perspective of surgery-one largely concerned with the impact of surgery on the patient and his family as well as his nursing needs, preoperatively and postoperatively. This is a valuable experience; however, I should like to refer to a continuing experience on a day to day basis where the student is in the surgical suite for a block of time.

I shall now consider learning experiences in the OR from these points of view: 1) asepsis 2) teamwork 3) management of an operating room during surgery from the viewpoint of the circulating nurse, 4) supervision of technical and ancillary employees, 5 ) impact of surgery on a patient-during surgery, 6) stimulating the student nurse to consider operating room nursing as a career.

How else can a nurse learn about surgery than by actually experiencing and participat- ing as a member of the team during the course of an operation? How else, without being involved directly, can she get the feeling for what is happening to the patient? Where else can she better learn human anatomy, physiology and observe pathology than by observing, first hand, the surgeon as he makes the incision, cuts through muscle, fascia, peri- toneum or opens a uterus to deliver a baby by caesarean section? Where else can she learn so realistically about the reduction of compound fractures or the insertion of pros- thetic devices in repairing a hip fracture? Movies and closed circuit television and all the other audiovisual devices are splendid ad-

juncts to reality but are not the equivalent of personal involvement as a member of the surgical team. The satisfaction of accomplish- ment, of seeing the patient leave the operating room in good condition, especially after a difficult procedure, cannot be experienced as a bystander.

In the past fifteen years or so we have ob- served more and more schools of nursing either drastically reducing the operating room experience for students, reducing it to selected observations, or eliminating it entirely. From my conversations with deans and directors of schools I have learned that there is a common viewpoint that student experience in surgery is no longer an essential part of the student’s armamentarium as a future professional and that it is not vital to her knowledge of asepsis to have been assigned to an operating room for a continuous period. Very little research has been done on this entire subject, which would warrant the elimination of operating room experience from the basic nursing curriculum nor have studies made through ques- tionnaires to students and graduates negated the value of the experience.l

ASEPSIS It is possible, of course, to teach a student

nurse or a technician principles of asepsis through lectures, textbooks, teaching ma- chines and films. However, my many years of experience as staff nurse, a head nurse, an instructor and as an operating room supervisor lead me to firmly believe that no one really has a complete mastery of asepsis nor can apply it in other divisions of the hospital until he or she experiences the “process” in surgery. Only until one has to don gown and gloves, manipulate drapes, handle sterile instruments, ogerate an autoclave as well as use the other methods of sterilization, can she really be confident that she is carrying out safe technique. The practice of aseptic technique must be under the management and the control of well-prepared professional nurses.

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If the nurse does not have an opportunity to learn at least beginning skills as does the student engineer when he goes out into the field with his surveying instruments, then we have failed and are continuing to fail to meet the needs of our patients.

How can we develop valuable learning experiences? The objective, as I view it, is for the student to learn principles of asepsis and to apply these principles through supervised practice on a day to day basis. By day to day basis I do not mean a one or two hour ob- servation but rather a prolonged number of hours of practice and participation in one or more procedures from beginning to end. The student can learn a great deal as a second scrub nurse without being exposed to the critical times when the surgeon may be under duress. As she develops skills, she can, with the. support of the first scrub nurse, assist with the opening and closure or assume more responsibility insofar as the instructor feels she is qualified. This concept contains much of the earlier method of teaching students operating room nursing. The difference between the new and the old as far as I am concerned is the availability of the instructor. The latter must be free to remain with her student; her assistant must be free and not be assigned to a case because of shortage of staff. It is interesting to contrast the number of instructors, and the student-teacher ratio on the medical-surgical floors with those in the operating room. Perhaps we have been too un- imaginative in providing only one or two instructors for operating room teaching. Of course the supervisor and the head nurse must also be deeply committed to the student program. Highly skilled staff nurses who are in complete accord with the student program from time to time may certainly assist students and exercise judgment within the frame- work of the teaching program in permitting them to assume progressively more responsibility.

TEAMWORK It has been said that a student nurse learns

more about teamwork, and here I am speaking about the nurse-physician-anesthesiologist team exclusively, in the operating room than she does in any other part of her training. Again the success of the relationship is de- pendent on the climate created by the surgeons, the supervisor, instructors and staff. Not every surgeon is ready or willing to ac- cept student nurses on certain major operations nor should he be asked to do so. How- ever, agreement between the instructor and the surgeon as to the appropriateness of a procedure and the degree of skill the student has developed can be the determining factor in planning an experience for the student. In the old days, as we all know, students were assigned no matter what their skills to scrub on surgery because of staffing needs and lack of knowledge on the part of instructors of the learning theory. There must be, therefore, not only clear agreement in any operating suite that student and instructor hours are not to be included as part of the staffing or the coverage of the department and that the instructors must be educationally qualified to teach. Careful planning with physicians who enjoy the opportunity to teach nursing students can be very productive in terms of the student’s learning. Incidentally, the student, as a circulating nurse, has just as much opportunity to be a part of the total operating team as when she scrubs.

The major role of the professional nurse in the operating room in terms of the physical environment and related needs of the team is to manage, plan and coordinate the surgical procedure as the event moves along. The surgeon-the captain of the team-is not free to move about and must focus his attention exclusively on the surgery itself. His team members meet the patients’ needs through meeting his-the surgeons’ needs. Most surgeons will agree that they can get along with an inept scrub nurse. For instance, in an emergency

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situation, if she does not pass the right instru- ment, he can reach across and take it from her Mayo stand. However, he is completely iso- lated if he is without a qualified circulating nurse on whom he can depend to keep the supplies coming, additional instruments steri- lized, and the necessary blood and other supplies readily available. He relies on her, as does the anesthesiologist, to anticipate the needs of the operating team. In fact, as you well know, the competent circulating nurse has a sixth sense and can anticipate trouble before it occurs. Nine times out of ten she will have the needed equipment in the room before it is required, It is especially important that the student nurse has an opportunity to circulate with a qualified professional nurse on a variety of procedures to learn not only what is needed but also to learn, through working along with the graduate, some of the many danger signals. She begins to see, as she gains experience, the importance of proper positioning of the patient on the table to protect the shoulders in order to avoid the serious and unnecessary complications of a brachial plexus paralysis, the deleterious effects on an arm and hand improperly supported or other such results of unsafe positioning. This type of nursing care is good patient care even though some would deny that it is professional nursing per se because the patient is asleep and unaware of the nurse’s concern for him. Nevertheless, the nurse has grave re- sponsibilities in the area of positioning and safety factors in general. Another example of the need for the presence of a professional nurse was brought home to me not too long ago, when as a consultant, I was observing in an operating room. A patient was being laryngoscoped by the anesthesiologist prior to intubation. He was having considerable trouble getting the scope down and the more I watched the more I became concerned. The practical nurse who was circulating in the room was involved with other activities. I left the room, found a staff nurse and requested

that a tracheotomy tray be brought in im- mediately. Only a few seconds after the tray arrived the patient had become cyanotic, was barely breathing-an immediate tracheotomy was performed. It is obvious from this illus- tration that the professional nurse’s judgment is vital no matter how minor the procedure.

Here is another vivid example of the need for a professional nurse which I experienced when I served as an OR consultant. Two surgeons were scheduled to perform cholecystec- tomies on two female patients, one a white and one a negro. These cases were to start at 8 : O O a.m. in Rooms I and 11-adjacent to one another. Wrist tags had supposedly been carefully checked. However, the identification procedure evidently had not been followed through nor was it thorough enough at best. Both patients were positioned and draped- the internes made the skin incisions. As one of the surgeons entered, he stopped at the head of the table to look at his patient and noted that she was a white and not, as she should be, a negro patient. The teams changed rooms and the day was saved. In one room, a student was circulating-a graduate was scrubbing. In the other room, a student was scrubbing and a technician circulating. In both instances, the regulations of the Joint Commission on the Accreditation of Hospitals were, as you know, violated. This example, frightening though it is, illustrates the importance of constant vigilance of no diminu- tion of standards and of clear-cut precise policy and procedure for identification and room placement of patients.

SUPERVISION OF TECHNICAL AND ANCILLARY EMPLOYEES

You are all familiar with the splendid con- tribution that has been made to nursing by technicians and also by the invaluable services performed by the aides who serve in the work- room and the orderlies who help clean between cases, lift and help to position patients. They have become a permanent part of the

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operating room scene. However, they can neither be left with the major responsibility of decision-making, nor can they be left without the supervision of a professional nurse. The busy surgeon, deeply occupied with what he is doing, has no time to observe what the technician is doing nor has he time to correct him as needed. If there are fewer and fewer professional nurses on the scene, who is going to teach the technician and who will be available to guide him? As far as I know, there is no content in the student nurse’s curriculum which will help the student to understand the role of the technician and the aide and her responsibility for their performance. Equally important, there has been to date no explora- tion and clarification of the tone of her interpersonal relationships with these employees. It is exceedingly difficult for young staff nurses to assume supervisory responsibility for these employees. Very often the technician’s man- ual skills are more highly developed than her own. In addition, they frequently are in her age group and the temptation to treat them as professional peers is a very real one. Often one finds too much socializing in a department which cannot and should not be geared to such informality. Considerable clarification is needed in this whole area and the best time for clarification is at the beginning -in the early learning experiences of the nurse. She must be helped to understand the ramifications of such problems and assisted with ways to deal with what is bound to occur later.

RESERVOIR OF OPERATING ROOM NURSES FOR THE FUTURE

There is general agreement among psychol- ogists and sociologists that young people in their formative years emulate someone whom they admire. They need a model after whom to pattern themselves and these models very often have a deep and lasting influence on later career choice. If the student nurse is not given the opportunity to observe first hand the

skillful operating room nurse who gains many satisfactions from her work and who actively demonstrates her deep devotion not only to patients but to the many complex tasks that face her on a day to day basis, then how can the student be expected upon graduation to choose surgery as a field?

IMPACT OF SURGERY ON A PATIENT Earlier, I referred to the continuing experi-

ence whereby the student admits a patient, takes care of the patient preoperatively, ac- companies him to the operating room, ob- serves the surgery and follows through the convalescent period. Certainly from this experience she gains insight into the feelings and apprehensions of the patient and his family. She also learns the needs of the patient for particular nursing skills, psychological support and understanding. However, in this se- quence, she does not have enough opportunity to watch the surgeon who performs a procedure, e.g., a cholecystectomy, and to see more than once the size of the retractors and the weight upon the retractors as the surgeon probes deeply in preparing to remove the gall- bladder or to explore the common bile duct. Only after a student has seen such procedures and similar procedure time after time does she begin to understand the trauma to tissues and the subsequent pain the patient will experience after he returns to his room. When one talks about postoperative distention and then remembers how the tissues were trauma- tized, how the handling of the bowel, for example, was so extensive, then the reasons for patients’ postoperative pain can almost be visualized. This is a different perspective of the impact of surgery on a patient about which every nurse should be fully aware, and very different from the followingthrough with one patient for a single experience. It is not necessary to produce findings of research studies to document this kind of reality-only after having been there can one really understand the patient’s feelings.

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The question is how to change the curriculum in a meaningful way? How to change it in such a way that students can gain the maxi- mum of experience with the minimum of trauma? How to change the experience in light of the changing role of the operating room nurse? It is my belief that every nurse who works in the operating room needs to know certain basic principles and must have applied these principles before she can teach other personnel to perform certain tasks or to supervise their work. This is not to say that every student nurse should complete her experience fully equipped to function as an operating room staff nurse. However, she should complete such experience with sufficient knowledge to move rather easily into an ori- entation program for new staff nurses and to rotate through the various services in order to develop her skills. Therefore, I believe that she should have a consecutive experience of X number of weeks at a time when she does not have to leave for classes in other depart- ments. She should learn principles of asepsis, have an opportunity to practice these principles in the classroom and in surgery, gradually being introduced from the simple to the complex as she is able to absorb the knowledge and refine her skills. Some students will never be able to first scrub on major cases nor

student to the professional nurse’s responsibility for the guidance, direction and work as- signment of the operating room technician. There should be clarification of the nurse- physician relationship in the operating room with special attention being given to the amount of stress placed upon the physician at the time he is actually operating. Channels of communication, especially when there are problems with surgeons, should be carefully delineated for the student in order that she can develop judgment and appropriate be- havior at trying times, since there are many trying times which arise during the course of surgery.

In conclusion, I have made a case for the importance of student experience in the operating room with special emphasis on asepsis, teamwork with physicians, management of a room, supervision of technical and ancillary employees, impact of surgery on the patient and potential recruitment for students as graduate nurses in the operating room in the future. I have included some personal experiences and biases for which I have developed over a period of years both as an operating room nurse and as a director of nursing re- sponsible for staffing and other aspects of op. erating room management.

is it necessary hat all students must do this. However, since we know there are great in-

Objectives: Educational Program for Student Nurses in Operating Rooms I. Asepsis

dividual differences from person to person, A. To acquire knowledge of Drincioles of asewis. - . *

should there be a student who can move for- 1. To apply principles through experiences selected and supervised by instructors. ward, she be provided with B. To learn and use various methods of steriliza-

learning opportunities and concomitant mean- tion. - ingful experiences. Furthermore, I believe that emphasis should be placed on the management aspect itself in the operating room with special attention being given to the elements of the operative procedures which re- quire early anticipation of difficulties and exercising of professional judgment. Special attention must be given to safety factors. Most important in this whole area, as previously referred to, is the vital aspect of introducing the

11. Teamwork: Nurse-Surgeon-Anesthesiologist A. To acquire understanding of role and responsibility of professional nurses. B. To acquire understanding of role and responsibility of surgeons. C. To acquire understanding of role and responsibility of anesthesiologists and nurse anesthetists. D. To acquire understanding of the interdependen- cy of the aforementioned three groups.

A. To observe (and participate through selected experiences) the effect of surgery on tiaeue, muscle, bone etc. in order to understand the potential ex- tent of postoperative pain, course of recovery and

111. impact of Surgery on Patient

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possible complications. B. To provide supportive measures for patient ships among these groups of personnel. when he arrives in the operating room. C. To provide supportive measures to patient hav- . ing surgery under local or spinal anesthesia. D. To learn and enforce safety measures, e.g., prevention of burns from solutions, proper positioning on table, anesthesia hazards, etc. E. To identify patients accurately and further ment of the surgeon. determine that the identified patients are taken to the operating room assigned for their procedures.

A. To acquire understanding of the role and re- sponsibilities of technicians, aides and orderlies. B. To acquire an understanding of the professional nurse’s role and responsibility in the supervision, guidance and direction of the aforementioned employees with particular attention to appropriate interpersonal relationships.

C. To examine elements of interpersonal relation-

V. Operative Procedures A. To observe firsthand the anatomy, physiology and pathology involved in surgery.

1. Second scrub and, for those students who demonstrate aptitude, first scrub on procedures selected by instructor and supervisor with agree-

B. To acquire knowledge of the management of an operating room during surgery.

1. Circulate on procedures with qualified professional nurses selected by instructor and supervisor.

* This is not an exhaustive list but rather suggests some of the more important elements for considera- tion. It was prepared by Florence M. Alexander, R.N., Ph.D. for the Institute on Operating Room Administration, Dearborn, Mich., April, 1%.

IV. Surgical Technicians, Aides and Orderlies

REFERENCES 1. “Operating Room Nursing-Is It Professional 3. Young, Lucie S., R.N., B.S., “OR Experience for Nursing?” Am. I. of Nurs., Vol. 65, #58, August, Students,” Nurs. Outlook, Vol. 12, #47, December, 1965. 1964. 2. “Standards for Administrative and Clinical Prac- 4. GriRjn, Amy E., M.S., “Evaluation of the Experi- tice in the Operating Room,” AORN J., Vol. 3, ence in the Operating Room,” The Canadian Nurse, #115, March-April, 1%5. Vol. 56, #7&, August, 1960.

AWARDS FOR HEROISM TO NURSES During time of war, as well as peace, servicewomen have performed heroically. During World War I , four Navy nurses were awarded the Navy Cross, a decoration second in rank only to the Medal of

Honor. Four Navy nurses have been awarded the Purple Heart in Vietnam,

two the Vietnamese Medal of Honor, two Navy Commendation Medals, and one a Secretary of the Navy Commendation for Achieve- ment. Army nurses have earned more than one hundred medah in Vietnam including 39 Bronze Stars, six Legwns o f Merit, and a Soldier’s Medal.

One of these loyal leaders, Major Marie L. Rodgers, Army Nurse Corps, was recently awarded the Bronze Star Medal by President Johnson for “distinguished and outstanding meritorious service in connection with ground operations in Vietnam.”

Major Rodgers volunteered for duty in Vietnam and served as operating room supervisor at the 24th Evacuation Hospital in Long Binh.

For the first time in 20 years, an Army nurse was a w d e d the Distinguished Service Medal. Col. Mildred I. Clark, who served as chief of the Army Nurse Corps from 1963 to 1967, received the award from Army Surgeon General Leonard Heaton who recalled that they first worked together in Hawaii, where he was chief of surgery and she was his nurse anesthetist at the time Pearl Harbor was attacked. (Capitol Commentary)

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Documents

Identifying Learning Experiences in the Operating Room for the Basic Nursing Student