OCTOBER 1998, VOL 68, NO 4 Watts Taylor Taylor -

ORBIS-Training Nurses Worldwide in Ophthalmic Care

o understand the unique training platform that ORBIS offers nurses, one has to first under- stand ORBIS and the two-way exchange of knowledge it offers. As a humanitarian, non- profit, nonsectarian, international organiza-

tion, ORBIS’s mission is to combat unnecessary blindness worldwide through the training and educa- tion of nurses, physicians, and other health care pro- fessionals in developing countries. This training takes place both on-board the ORBIS flying eye hos- pital, in off-plane programs at local facilities, and at land-based training centers.

INTRODUCTION The organization was conceived by David

Paton, MD, in 1982. The first ORBIS flying eye hos- pital was a DC-8 jet donated by United Airlines. The DC-8 jet was retired in 1992 and replaced with a DC-10 jet. This was made possible through private donations and gifts-in-kind from many individuals and organizations around the world. Since its incep- tion, ORBIS has traveled to more than 78 countries promoting its teaching mission.

The DC-10 has a fully functional OR, substerile room, postanesthesia care unit (PACU), laser room, and audiovisual center (Figure 1). The first-class sec- tion of the aircraft has been modified and now is a

48-seat classroom. If a larger space is needed, as often is necessary in countries like China, the audio- visual department can use an infrared transceiver system to expand the classroom capabilities to accommodate more than 300 people by linking to a terminal building. Biomedical engineering and flight operations ensure the smooth running of the program and are located in the belly of the aircraft.

The ORBIS DC-10 is supported in the field by a crew of 23 professionals from 13 countries (ie, Australia, Bulgaria, Canada, England, France, Ire- land, Myanmar, Philippines, Scotland, Sweden, Pakistan, Wales, United States). The crew includes ophthalmologists, nurses, a nurse educator, biomed- ical engineers, an anesthesiologist, a nurse anes- thetist, audiovisual specialists, flight mechanics, and administrators. The cross-cultural nature of the crew spans religious, political, and cultural boundaries with ease, but more importantly, greatly enhances the method, content, and level of the teaching because of the many different experiences offered by each crew member.

The ORBIS nursing program is divided into two components. The first component consists of hands- on clinical experience combined with related work- shops and mini-lectures. The second component is a lecture program for local nursing students, general

nurses, and nurses specialized in ophthalmology. This component of the nursing program is carried

T

A B S T R A C T The unique nature of the ORBIS teaching mission is reflected in

many arenas. The ORBIS organization recognizes that the nurse’s role is critical to achieving their mission of preventing blindness through education, hence the emphasis on nurse education. The roles of the head nurse, nurse educator, staff nurses, and the bio- medical engineering department are discussed briefly with emphasis on the needs assessment and the different programs offered to meet the identified needs. AORN J 68 (Oct 1998) 628-633.

out by the nurse educator.

NURSE EDUCATOR’S ROLE The key to a successful

ORBIS mission rests with an accu- rate needs assessment. The needs assessment is conducted at least six months before the airplane’s

K A R E N W A T T S , R N ; H E L E N T A Y L O R , R N ; K E V I N T A Y L O R

628 AORN JOURNAL

OCTOBER 1998, VOL 68, NO 4 * Wutts * Taylor - Taylor *

arrival. After it is determined that the country meets the requirements for an ORBIS program, a staff oph- thalmologist, a nurse (usually the nurse educator), and an administrative coordinator visit the program site to begin structuring the program format with the hosts. The team members return one week before the airplane’s arrival to finalize details.

Needs assessment. The nursing needs assess- ment involves making contact with local nurses, directors of nursing, and their ministerial counter- parts. Local nursing schools and associations also are approached. At this time, the education level of the host country nurses is assessed and the available equipment and resources are determined. It is impor- tant that the ORBIS nurses understand the status of the host country nurses and the conditions under which they work before beginning the program so that the program can be adjusted accordingly.

In many countries, nurses have very little access to new information and techniques. Consequently, the ORBIS program is perceived as a wonderful opportunity for them to interact with nurses from other countries and to exchange experiences and information. The nurse educator’s first contact with local nurses is crucial to promoting this information exchange. At this time, the teaching mission of ORBIS is introduced, and the opportunities for nurs- es are outlined. It is a delicate time as ORBIS staff members need to recognize the steps the local nurses have made and support their plans for the future while recommending changes. The diplomatic role that all ORBIS staff members must undertake is evi- dent during this time.

After the needs assessment has been completed, the information is sent to the ORBIS International

New York office and to the nurses on the plane. Five local nurses work with ORBIS nurses on the plane each week and receive training in OR skills, steril- ization, and care of instruments and PACU nursing care of ophthalmic patients. These nurses are select- ed by the local nurses on the basis of the guidelines given by ORBIS team members.

Lectures. The nurse educator conducts lec- tures off the plane in a central venue for nurses who are not involved in the on-plane program (Fig- ure 2). These lectures cover topics from infection control to specialized ophthalmic surgery and nurs- ing care. The number and type of lectures depends on the needs of the local nurses and the times they have available.

In addition, the nurse educator works with the local nursing college by lecturing in the ophthalmic curriculum and advising on the creation of oph- thalmic specialty courses. Educational resources are left with local schools in the form of lecture materi- als, journals, and videotapes. A regular contact with the nurses in each country via a newsletter and jour- nal donation has been proposed, as many of the countries that ORBIS staff members travel to have limited resources.

The nurse educator’s role is multifaceted-this person needs to conduct a complete needs assess- ment in cultures different from his or her own and recognize and establish an effective means of com- munication. The nurse educator also needs to have a high level of ophthalmic knowledge and teaching skills to pass on this knowledge to all levels of nurses. Perioperative knowledge and skills are helpful, as the ORBIS program is surgically based. The nurse educator lectures to groups of different

Figure 1 Diagram of ORBIS plane modified to accommodate an OR, substerile room, postanesthesia care unit, laser room, and audio-visual center. (Reprinted with permission from ORBlS International, New York)

629 AORN JOURNAL

OCTOBER 1998, VOL 68, NO 4 Watts Tuylor * Taylor *

and changes in the future.

NURSE TRAINING ON THE DC-10 In addition to the nurse edu-

cator, there are four staff nurses, one head nurse, and a nurse anes- thetist on each trip. The ORBIS staff nurses and head nurse are responsible for working in all sections of the surgical area. A five-week rotation (ie, one week floating, one week in the PACU, one week in the substerile room, two weeks in the OR) is fol- lowed. In each area, nurses from the host country work alongside

the ORBIS nurses to gain practical experience that they can pass on to their fellow nurses. Each week of a three-week country program, five different local nurses attend the plane program. These nurses may practice in the OR, substerile room, or PACU.

The plane program runs from Tuesday through Friday. Screening and patient selection is held at the local hospitals on Mondays. Each Tuesday morning, a nursing orientation workshop is present- ed by either the nurse educator or float nurse. This workshop is designed to familiarize the nurses with topics such as scrubbing, gowning, gloving, aseptic technique, and standard precautions (Figure 3). The workshop is a nonstressful learning environment that provides an opportunity for discussion; intro- duces AORN standards, recommended practices, and guidelines that are followed; and allows for an assessment of local nurses’ learning needs. All of the nurses are given a brief overview of each area before beginning work in their assigned area.

The organization prefers to have local nurses spend the entire week in one area to benefit fully and to be able to implement any new ideas that they have learned; however, the schedule frequently is adapted to meet their needs. For example, during the January to March 1997 schedule in Cuba, El Sal- vador, and Trinidad, the nurses’ higher knowledge and skill levels, combined with their high interest in all areas, made it feasible for nurses to rotate through each area. Regardless of the nurses’ work areas, they are encouraged to spend time in and observe each area. There are monitors located in the PACU and substerile rooms that can be patched to the OR, laser/examination room, or classroom. The nurses then can observe procedures in progress on

Figure 2 9

Nurses from Hefei, China,

listen to an off- plane lecture.

sizes (eg, group of 300 nurses in China, group of 14 nurses in Krygysztan). The majority of lectures are through interpreters, so critical information must be sorted out and simplified-without losing the importance or context-to maintain the interest of the audience.

Program development week. On the plane, the nurse educator is responsible for coordinating pro- gram development week, which is held at least once during each three-month block. The purpose of pro- gram development week is to

introduce topics of relevance to multinational crew members who work in a variety of cultures, ensure all crew members complete mandatory fire and electrical safety training and basic life sup- port and infection control updates, and work on projects that will benefit the organization now and in the future.

Continuous quality improvement. The continu- ous quality improvement (CQI) process is coordinat- ed partially by the nurse educator, as all crew mem- bers must be familiar with this to work for ORBIS. Educating new staff members to this concept is the nurse educator’s responsibility, along with helping or participating on teams and keeping the crew up- to-date with the latest CQI plans for the organization. The nurse educator sits on the CQI council, which comprises representatives from all ORBIS offices as well as those in the field.

The nurse educator also is involved with design- ing and implementing evaluation tools, core curricu- lums, and any other issues that need nursing input. It is a challenging role-the nurse educator must be prepared to work autonomously and in a self-direct- ed way. This is a critical role as ORBIS develops

630 AORN JOURNAL

OCTOBER 1998, VOL 68, NO 4 Watrs Taylor * Taylor *

these monitors. Videotaped inser- vice programs also can be shown on the monitors.

The PACU has a dual pur- pose in that it also serves as the preoperative area. The room has a three-bed capacity with suc- tion, oxygen, and patient moni- tors located at each bed. Stan- dard emergency equipment (eg, crash cart, defibrillator) is pre- sent. The two local nurses work- ing with the ORBIS PACU nurse have the opportunity to learn and practice both preoperative and postoperative care of the ophthalmic patient (Figure 4). The role of the nurse in patient education is an important one, so the local nurses become increasingly responsible for patient education throughout the week. Nurses are instructed how to teach patients what to expect pre- operatively and postoperatively, proper application of topical eye drops and medications, signs of post- operative symptoms, and activity restrictions. The nurses are encouraged to participate in all aspects of patient care. An ORBIS nurse and translator is pre- sent at all times to answer any questions.

One local nurse works alongside an ORBIS nurse in the substerile room (Figure 5). The proper cleaning, care, and sterilization of microsurgical instruments is emphasized. Methods of sterilization and decontamination often are topics of discussion. Discussions center around common misconceptions concerning relationships between sterilization meth- ods, packaging, and shelf life. During a surgical procedure is an ideal time to discuss a variety of general nursing topics using the mini-lecture format in the subster- ile room. Each ORBIS nurse is responsible for developing and giving these talks when feasible. In addition, staff members in the nursing and biomedical engineer- ing departments cooperate to give mini-lectures on the use of the ethylene oxide gas sterilizer and its safety precautions.

In the OR, the two local nurses are exposed to a variety of ophthalmic procedures, with the exception of refractive surgeries,

Figure 3 Nurse educator Helen Taylor, RN (far right), conducts a nursing work- shop in Tashkent, Uzbekistan.

which are not performed by ORBIS. Each week there are three visiting faculty members representing three ophthalmic subspecialties. A variety of tech- niques and equipment may be used as the local doc- tors are being taught. Working with an ORBIS nurse, local nurses alternate between scrubbing and circulating duties. Areas emphasized in the OR train- ing are the practices of aseptic technique and stan- dard precautions and how to effectively and safely handle and pass microsurgical instruments.

Surgical procedures taking place at local hospi- tals are an excellent opportunity to demonstrate to the host physicians and nurses that the same surgery performed on the plane often can be performed in their facilities, using their equipment (Figure 6). A technologically advanced QR is not always neces- sary. The surgical procedures completed in hospitals also provide an opportunity to suggest ways to implement change (Figure 7). The ORBIS float

Figure 4 Head nurse Karen Watts, RN (center), teach- es nurses from Tashkent, Uzbekistan, preoperative and postopera- tive care of the ophthalmic patient.

631 AORN JOURNAL

OCTOBER 1998, VOL 68, NO 4 Watts Taylor - Taylor

Figure 5 Staff nurse Leonard0 Mercado, RN (fuf fight), demonstrates proper care of instruments to nurses from Damascus, Syria, in the substerile room.

nurse assisting in a local hospital surgical procedure can observe firsthand the practices of the hospital OR and make suggestions. This may be something as simple as suggesting OR staff members use a puncture resistant, leak-proof plastic bottle for the safe disposal of sharps. The standards learned on the plane that are directly applicable to the host coun- try’s OR environment are not always easy for the local nurses to implement for several reasons (eg, a lack of basic supplies, nurses believing that they do not have the power or authority to change practices).

It is the float nurse’s responsibility to maintain ORBIS standards while working in the local hospi- tal. Recognizing that more than one surgery being performed concurrently may be the norm, the ORBIS nurse can use this opportunity to discuss methods for ensuring that the principles of aseptic technique and standard precautions are adapted in the most beneficial way. The ORBIS nurse must work within and be sensitive to the limitations in the host country hospitals. As on the plane, a local nurse is encouraged to scrub alongside an ORBIS nurse. Some of the best teaching can take place in the hospital setting. The ORBIS organization real- izes the importance of working more within the host hospital’s environment and is increasing the number of surgeries performed in the local hospi- tals.

Many of the countries where ORBIS has held programs have had very skilled, knowledgeable nurs- es. When questioned as to how they are benefiting from the ORBIS program, the nurses often answer that they are learning a great deal just from observing.

Figure 6 Staff nurse Carol Adlam, RN (fight, fore- ground), teaches local nurses in the OR at Guiyang Medical College Hospital, China.

Figure 7 Head nurse Karen Watts, RN (center, fight), teaches local nurses from ShantOU, China, during an off-plane inservice program.

Figure 8 Biomedical engineer Kevin Taylor (left) teaches laser safety to staff nurse Linda McGreal, RN (centeo, while Sandra Robinson (fighfj, ORBIS bio- medical staff member, helps.

632 AORN JOURNAL

OCTOBER 1998, VOL 68, NO 4 Watts - Taylor - Taylor

Local nurses can observe how the ORBIS nurses inter- act with surgeons, work with the biomedical engineers when there are equipment problems, interact with the patients, and handle other everyday actions (eg, orga- nizational skills, decision-making skills). It is neces- sary for ORBIS nurses to be aware that they may be continuously placed in a leadership role by the local nurses and other health care professionals participat- ing in the ORBIS training program.

The ORBIS training program is not strictly a one-way transfer of knowledge. The ORBIS nurses have several opportunities to enhance their own skills in addition to training local nurses. The ORBIS nurses

participate on or chair CQI teams (eg, laser safe- ty, infection control), are involved actively in the writing and revision of nursing policies, share responsibility for a portion of the medical inventory, and help develop and implement both patient and local nurse education objectives.

In the absence of the nurse educator, an ORBIS staff nurse also presents off-the-plane lectures. The ORBIS environment is small, and all departments are able to interact closely. Additional learning opportunities exist for ORBIS nurses by attending the weekly lectures given by visiting ophthalmic professors to the local ophthalmologists or by attend- ing anesthesia department lectures.

the life of what are scarce medical devices. By understanding the technology, nurses often

can solve problems that are minor at the onset but could become significant if left unattended. Dust, fungus, heat, and an unreliable power supply are environmental realities in developing countries and can wreak havoc on medical equipment. If local nurses have a simple understanding of the technolo- gy, they can watch for and correct environmental problems before they become disastrous.

SUMMARY The relationship between the ORBIS nursing

and biomedical engineering departments is multifac- eted. It demonstrates how much can be achieved when staff members interact and help each other in promoting education as a means for preventing blindness. The training of nurses is one of the most significant avenues for achieving a sustainable change in the health care system of developing coun- tries. The ORBIS nurses recognize this and are com- mitted to providing the most effective and appropri- ate training possible in ophthalmology and the pre- vention of blindness. A

NURSING AND THE ROLE OF MEDICAL TECHNOLOGY An often overlooked aspect of nurse training in

developing-and even in developed-countries is nurses' appreciation of the role of medical technolo- gy and its effect on patient care. In many developing countries, there are no biomedical engineers or tech- nicians to service equipment. Consequently, servic- ing falls into the responsibility of the user-if users do not maintain or service the equipment, it will fall into disrepair far more quickly than necessary.

A good portion of most equipment problems can be corrected through proper user training and user maintenance (Figure 8). Nurses work with med- ical equipment more consistently than any other medical professional and have a better understanding of what is normal equipment performance. If nurses gain a basic understanding of the technology and the proper training to know what to expect from the equipment, they can be an integral part of expanding

Karen Watts, RN, is the head nurse for ORBIS International, New York.

Helen Taylor, RN, MRCNA, is a level one RN, cardiac theatres, at the Royal Hobart Hospital, Tasmania. At the time this article was written, she was the nurse educator for ORBIS International, Mew York.

Kevin Taylor, MScEng, is a clinical engineer at Brigham and Women's Hospital, Boston. At the time this article was written, he was the senior biomedical engineer for ORBIS International. New York.

633 AORN JOURNAL