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Perioperative Nurse Internship DESIGNING, IMPLEMENTING A COLLABORATIVE PROGRAM Cynthia A. Bray, RN; Joan E. Enz, RN; Jane C. Rothrock, RN t Hahnemann University Hospital, Phila- delphia, a 616-bed tertiary care medical of the nursing staff. Major weaknesses existed in the operating system such as A center, the situation was grim. In 1987, the surgical service division had a staff vacancy rate of almost 42%, with a turnover rate near 50%. The staff was composed of 49% RNs and 51% technicians. More than half of the nursing staff had less than two years OR experience, and unfortunately, there was no clinical nurse specialist/educator to help new nurses. Staff frustration and low morale contributed to daily occurrences of friction and confrontation poor management of patient information and scheduling, poor use of block time that required staff overtime, delays in surgery, frequent lack of inventory, and lack of accountability with instrument processing, which lead to shortages of high- use items and incomplete surgical instrument trays. with surgeons who had lost faith in the quality We had two major projects on the horizon: Cynthia A. Bray Joan E. Enz Jane C. Rothrock Cynthia A. Bray, RN, MSEd, CNOR, is clinical specialist/education director of perioperative nursing at Hahnemann Universiv, Philadelphia. She received her diploma in nursing from Hahnemann Medical College and Hospital School of Nursing, Philadelphia, her bachelor of arts degree in liberal arts from the University of Pennsylvania, Philadelphia, and her master of science degree in health education from St Joseph 3 Universiv, Philadelphia. Joan E. Enz, IW MSN CNA, is vice president of patient care services, chief nursing officer, and clinical assistant professor, School of Allied Health 790

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Page 1: Perioperative Nurse Internship: Designing, Implementing a Collaborative Program

Perioperative Nurse Internship DESIGNING, IMPLEMENTING A COLLABORATIVE PROGRAM

Cynthia A. Bray, RN; Joan E. Enz, RN; Jane C. Rothrock, RN

t Hahnemann University Hospital, Phila- delphia, a 616-bed tertiary care medical

of the nursing staff. Major weaknesses existed in the operating system such as A center, the situation was grim. In 1987,

the surgical service division had a staff vacancy rate of almost 42%, with a turnover rate near 50%. The staff was composed of 49% RNs and 51% technicians. More than half of the nursing staff had less than two years OR experience, and unfortunately, there was no clinical nurse specialist/educator to help new nurses.

Staff frustration and low morale contributed to daily occurrences of friction and confrontation

poor management of patient information and scheduling, poor use of block time that required staff overtime, delays in surgery, frequent lack of inventory, and lack of accountability with instrument processing, which lead to shortages of high- use items and incomplete surgical instrument trays.

with surgeons who had lost faith in the quality We had two major projects on the horizon:

Cynthia A. Bray Joan E. Enz Jane C. Rothrock

Cynthia A. Bray, RN, MSEd, CNOR, is clinical specialist/education director of perioperative nursing at Hahnemann Universiv, Philadelphia. She received her diploma in nursing from Hahnemann Medical College and Hospital School of Nursing, Philadelphia, her bachelor of arts degree in liberal arts from the University of

Pennsylvania, Philadelphia, and her master of science degree in health education from St Joseph 3 Universiv, Philadelphia.

Joan E. Enz, IW MSN CNA, is vice president of patient care services, chief nursing officer, and clinical assistant professor, School of Allied Health

790

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____ A O R N J O U R N A L OCTOBER 1990, VOL. 52, N O 4

a commitment to become a level I trauma center equipped with a helipad and a complete revamping of our cardiothoracic surgical service. Where to start was the only question. More staff had to be recruited, trained, and retained as soon as possible.

During a major revamping of operating systems, the primary focus was on personnel issues. Whenever possible, technical positions were converted to registered nurse positions to achieve increased staff flexibility. A perioperative clinical nurse specialist was recruited to direct and manage all educational and clinical development programs. We investigated the cost, structure, and organiza- tional benefits of the six-month critical care nursing internship, which was tied to a two-year work commitment. With that information, we developed a model for perioperative nursing. To make the program more attractive, a faculty member from a local community college joined us. She made arrangements for six college credits to be given at the completion of the internship, and she planned and developed a preceptor course for selected nurses. The primary initiative and leadership necessary to carry out this newly proposed program now rested with these two educators.

Professions at Hahnemann University Hospital, Philadelphia. She received her diploma in nursing from the Hartford (Conn) Hospital School of Nursing, her bachelor of arts degree in sociology from the University of Hartford, (Conn), her muster of science degree in nursing from the Hartford (Conn) Graduate Center, and her master of business administration degree from the Rensselaer Polytechnic Institute, Troy, NI:

Jane C. Rothrock, RN, DNSc, CNOR, is professor and curriculum director of perioperative nursing, Delaware County Community College, Media, Pa She received her diploma in nursing from the Bryn Mawr (Pa) Hospital School of Nursing, both her bachelor of science and master of science degrees in nursing from the University of Pennsylvania, Philadelphia, and her doctorate of nursing science from Widener Universiq. Chester, Pa.

Planning

erioperative internships assist the new nurse in making the transition from school or P another practice setting to novice practi-

tioner of perioperative nursing. They replace the less desirable method of orientation that uses a hit-or-miss approach. An internship introduces perioperative nursing practice to the new nurse over a longer period of time than traditional orientation. A more highly structured method of orientation, the formal internship recognizes the need for organized instruction, clinical practice, and supervision by a clinical nurse preceptor.

Internship programs that are developed collaboratively with educational institutions and health care facilities can be innovative, creative, resourceful, and reality-centered. They can be based on professional scientific knowledge and offer college credits. These attributes can be obtained only when the educational institution and the health care facility work together to identify external and internal influences that will affect the success of a collaborative program.

Before developing such a program, the health care facility should conduct a needs assessment. That assessment should explore external influences in the environment such as

the adequacy of local nursing curricula in preparing graduates for perioperative nursing, the impact of the nursing shortage, competition for new graduates or nurses in the geographic locale, and recruitment and retention efforts and problems.

Internal influences include 0 perioperative staffing needs, 0 institutional resources available to support

an internship program, administrative support, and anticipated costs and benefits.

Internship Design

he internship program designed jointly by Delaware County Community College, T Media, Pa, and Hahnemann University

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Table 1 Knowledge and Skill Competencies

Knowledge The nurse intern will

describe the psychosocial influences affecting the patient’s response to surgical intervention, demonstrate knowledge necessary to implement the perioperative nursing role, discuss principles of asepsis used in providing patient care during the periop- erative period, define the theoretical basis of role function as an interdisciplinary team member in the delivery of care to the perioperative patient, plan nursing interventions that reflect the nursing process in providing care to the perioperative patient, and relate nursing, legal, and ethical boundaries

in the practice of professional perioperative nursing.

Skills The nurse intern will

assess the pathophysiological and psycho- social influences affecting the patient’s response to surgical intervention, demonstrate the knowledge and skills needed to implement the perioperative role, apply principles of asepsis in providing patient care during the perioperative period, function as a member of the interdisciplin- ary perioperative team, and demonstrate application of the nursing process to perioperative patient care.

Hospital, Philadelphia, is competency based. The competencies include knowledge as well as clinical skill.

Competencies that relate to knowledge are considered empowering for the new nurse; they enable the novice practitioner to base practice on what is known about perioperative nursing. They obviate practice based on ritual, tradition, or “I don’t know why I’m doing it; I only know that’s how I was taught to do it.”

Clinical skill competencies emphasize the provision of safe patient care. All of the competencies have objectives, which are either met through structured educational sessions or during clinical rotations (Table 1). Competencies are measured by course examinations, classroom assignments and projects, as well as self- evaluations and preceptor evaluations.

Based on the AORN National Committee on Education’s Preceptor Guides for Perioperative Nursing Practice, all preceptors must meet the following guidelines1

haveaBSN, have at least one and one half years clinical experience,

demonstrate clinical competence, be willing to participate in the overall development of the new perioperative nurse, and be willing to spend several hours preparing for their roles (classroom, reading assign- ments, discussions).

Assigning students to the same preceptor for this time period allows for continuity of instruction and prevents sensory overload. When a preceptor is ill or off work, the program director and/or the clinical instructor assumes the preceptor role.

Recruitment, Admission to the Program

nurse internship program’s ultimate purpose is recruitment and retention, A therefore, decisions about advertising and

application methods, as well as maximum number of nurses accepted into the program should be made early. Future policies and procedures will depend on these decisions.

Recruitment into the program can be accomp- lished by

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Individualized instruction between the student and instructor is common.

internal transfer mechanisms for qualified, interested nurses, internal advertising through job posting and hospital newsletter, and/or advertising in local newspapers to recruit nurses from other hospitals and care centers.

Student nurses often are overlooked; they have been an untapped resource for years. Students can be reached with brochures distributed to schools of nursing or at job fairs, career days, or student nurse conventions. Why not tap this resource and develop a structured, intensive internship that will address their needs? With the proper guidance, skills labs and theoretical approach, new graduate nurses can be developed into excellent perioper- ative nurses.

The Program

n our program, as soon as a nurse or student applies for admission the director schedules I an interview with the applicant. Two people,

one of whom is the director of the program, conduct interviews in a relaxed, casual manner.

We hope to reduce biases with two interviewers. Each interviewer has a preassigned portion of the interview to cover.

Some specific questions asked are: “Tell us about yourself.” (Look for lead- ership, management potential, likes, dislikes, and self-concept.) “Why do you want to become a periop- erative nurse?” (Look for areas to explore further.) “What does perioperative nursing mean to you?’ (Evaluate the applicant’s knowledge base. This is the time to correct false assumptions.) “What aspect of perioperative nursing causes or would cause you the most stress?’ (This could give some insight into the person’s ability to handle daily pressure and the fast pace of an operating room.) “What aspect of nursing gives you the most satisfaction ?” (This gives insight into the person’s strengths as well as character.)

Role playing is an effective and fun method to learn about the applicant. It also serves to inform

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the nurse of the many roles assumed in the operating room. Regardless of the interview structure, it is important to convey all of the pertinent information involving course content, internship structure, responsibilities, clinical rotations, educational opportunities, contract, and postinternship expectations. Enough time is allocated so that the applicant does not feel rushed. At the conclusion of the interview, we give the applicant a brief written summary of the program which can be reviewed at home.

Once the formal interview is completed, the applicant is taken for a tour of the operating rooms. One half day is spent in the operating room observing perioperative nurses. Most people really have no idea what happens behind “the magic doors” and seeing this, as well as spending time with a staff nurse, is an important activity for the applicant.

Course Requirements

A I1 nurse interns must purchase the assigned books, Alexander’s Care of the Patient .in Surgery,2 and the current AORN

Standards and Recommended Practices for Perioperative N ~ r s i n g . ~ Three written care plans are required: one emphasizes intraoperative positioning; the second emphasizes a specific patient’s anesthetic experience; and the third is a complete nursing care plan of the student’s choice. Participants keep a daily log that becomes a feedback mechanism for both instructor and student. The instructor encourages comments and monitors the progress of students.

Special assignments involve presentations that relate the nurse intern’s previous experiences to perioperative nursing practice. For example, new graduates can discuss their previous medical- surgical experiences; surgical unit nurses can relate preoperative and postoperative care given to a specific patient population; critical care nurses can discuss pulmonary artery lines. The options are as open as one’s imagination.

Each student must master both the theoretical and the clinical components of perioperative nursing. The preceptor/instructor validates the clinical skills checklists as soon as the student

performs the activities satisfactorily. The student must master 85% of the clinical skills to remain in the program.

Each nurse admitted to the program signs a contract. The contract specifies that the student is responsible for giving 24 months of continuous employment in surgical services starting the day after the internship ends.

New graduate nurses are hired into the system several weeks before the start of the official internship program. This preinternship enables them to adjust to their new status and environment and gives them time to learn about the hospital and its personnel. New nurses rotate through the peripheral areas of surgical services and gain knowledge about preoperative patient admission and assessment, postoperative patient care, and postoperative patient evaluation.

Once the internship begins, the new graduate nurses have increased confidence and validated practice skills that correspond to the patient care setting. This is especially helpful when combining new graduates and nurses with established practices; it also reduces intimidation significantly for new graduates.

Experienced graduate nurses in the internship also are rotated through the following areas: postanesthesia care unit, endoscopy, patient holding, admission/discharge for surgical patients, preadmission testing, and instrument processing.

Course Design

he internship program has three phases, each increasing in length from the three T week first phase to the final 17-week phase.

Combined, the three phases make up a 28-week commitment.

Phase one. The first phase lasts three weeks and consists of classroom lectures and demon- strations. Theoretical as well as technical components of perioperative nursing are taught. Practice does make perfect, and these sessions often are conducted in an operating room without a patient. Participants review and read assigned topics before each class and during class a videotape reinforces the readings. When approp- riate, demonstrations and/or a lecture from the

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instructor follow the videotape. Students are encouraged to practice what they have seen and then listen to an audiocassette for reinforcement.

Phase two. This phase lasts eight weeks, and is a combination of classroom and clinical practice. Mondays, and initially some Tuesdays, are spent in the classroom, where other personnel are invited to give supplemental lectures and demonstrations. (See “Examples of Lectures/Demonstrations.”) Participants simulate, and then perform preoper- ative and postoperative patient assessments and evaluations. To further reinforce the importance of proper care and handling of instruments, the group visits a local instrument manufacturing company for a tour.

Students spend the remaining weekdays during the second phase with an assigned preceptor. Participants use this time to concentrate on technical and patient care skills. They practice how to

gown and glove themselves and team

pass instruments and open supplies, and assess and evaluate patients preoperatively

Preceptors follow adult learning methodologies, and students are encouraged to share past experiences. We encourage students to become independent early and to discover what they have mastered and what assistance they need before they are sent to work on their own.

Phase three. At the end of the eight-week classroom/preceptor phase, the third phase, or clinical rotation begins. The intern is assigned to a different preceptor for each specialty rotation. It is now time for exposure to multiple methods of instruction and information exchange. The intern continues to keep a daily log, which is reviewed with the instructor during a weekly conference. Before the final clinical rotation, participants are not scheduled for weekends or off-shifts. When the nurse intern completes all specialty rotations, a week of 11:OO PM to 7:OO AM and one week of 11:OO AM to 7:OO PM shifts are scheduled. Call is not assigned to participants until the end of the program. Students working off-shift rotations gain insight into the activities encountered during these times and begin

members quickly,

and postoperatively.

AORN JOURNAL __

Examples of Lectures/Demonstrations

Organ harvesting lnternal stapling Hemostasis Wound closures Risk management Cardiopulmonary

Trauma perfusion

Anesthetic mo- dalities

Malignant hyper- thermia

Stress management Renal dialysis Instrument manu-

facturing

to grasp the meaning of organizing and prioritizing in the operating room.

The students spend a week reviewing trauma policies, protocol, and instrument sets. If a trauma code is called, the intern accompanies the primary perioperative nurse on trauma duty to the emergency department to assess the patient and provide surgical assistance if needed. Participants also spend time with the head nurse learning the responsibilities of the charge role.

The nurse internship concludes with a gradua- tion and luncheon. These nurses have now completed the formal program, but they still have much to learn; for this reason they do not specialize. They spend three months or longer, if necessary, rotating through each specialty area. They also assume weekend and call duties. To lessen the stress of being on call for the first time, new nurses are scheduled with experienced perioperative nurses.

Summary

he perioperative nurse internship program has become a valuable retention and T recruitment method for the operating

room. The major contributions are evidenced by the following:

registered nurse vacancies have been filled, a waiting list of applicants exists, the staff has shifted to a high concentration of RNs, turnover has decreased to less than 8%, O R utilization is high; 18 rooms are open

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Operating rooms that are not in use become classrooms.

and staffed, and

fully operational. the trauma and cardiothoracic programs are

The effects of the internship program are being further evaluated through nursing research on the development of professional self-concept. Prelimi- nary work has indicated that students in the internship program statistically improve their professional self-concepts ~ignificantly.~ Nurse researchers are using early data in determining the effectiveness of the internship program on recruitment and retention. Measures of desirable employee behaviors are being collected to determine if the internship nurses show differences in the amount of sick time, absences and lateness, involvement in institutional projects and commit- tees, and job satisfaction. These measures will be used, in part, to determine if the initial growth in professional self-concept is sustained and translated into professional behaviors.

Future research considerations include the dynamics of the new nurse-preceptor relationship, the impact of the intern group as a social unit,

the intern’s means and ability to deal with feelings of inadequacy, frustration, and stressors, the group process and how it works, and the influence the group has during its internship and in its institutional tenure.

This program continues to demonstrate success for two major reasons. First, the operating systems were greatly improved by a new preoperative holding area, implementation of an exchange cart system, better management and processing of supplies, and installation of an OR computer system. Second, we gained important organizational and administrative support; a second clinical instructor was hired, as well as an exceptional director of nursing for surgical services. All job descriptions, criteria-based performance evaluations, policies, and procedures and protocols were put into place; therefore, the staff knew what was expected of them and how to do it. As the educational process began to produce competent nursing practitioners, we saw clear evidence of improved communications and working relationships among nurses, surgeons, and anesthesiologists.

More than three years have passed since the

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start of the first perioperative nurse internship. The accumulated salary costs for 36 interns during their training is more than $500,000, (ie, about $15,000 each). Compared to a nationwide average of $20,000 to $25,000 in training cost per periop- erative nurse, this program continues to demon- strate significant savings, especially in light of our two-year work commitment.

It will be interesting to analyze the program data and outcomes to determine the right mix of new nurses and experienced nurses, appropriate length of the internship and curriculum, and the costs of the program. The data will allow us to address issues of academic differentiation in learning and practice, and the role of academic and service education in stress, burnout, and job satisfaction. This endeavor remains open to

OCTOBER 1990, VOL. 52, NO?

change, renewal, adventure, and experimentation. It is a part of a new frontier at our hospital and will play a role in shaping our future.

Notes 1. AORN National Committee on Education,

Preceptor Guide for Perioperative Nursing Practice (Denver: Association of Operating Room Nurses, Inc, 1988).

2. B J Gruendemann, B Huth Meeker, eds Alex- ander’s Care of the Patient in Surgery, eighth ed (St Louis: The C V Mosby Co, 1987).

3. AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1990).

4. J C Rothrock, “Professional self-image: A research study of perioperative nursing students,” AORN Journal 49 (May 1989) 1419-1425.

Spontaneous Abortion Increases With Age Women are waiting longer to start their families. With advancing maternal age comes several dis- advantages; an increased risk of fetal abnormali- ties and, according to a study published in the July 7, 1990, issue of The Lancet, an increased risk of spontaneous abortion.

A study of 384 women aged 36 to 49 years showed that there was an age-dependent rise in fetal loss rates between nine and 16 weeks of ges- tation, and after age 36 there was a sharp rise in the loss of genetically normal fetuses.

The good news is this study showed that cho- rionic villi sampling for genetic abnormalities does not adversely affect the spontaneous abor- tion rate for this age group if performed in the latter part of the first trimester. The rate of spon- taneous abortion was in fact higher before the procedure than after it.

It was suggested that these findings justify the use of late first-trimester chorionic villi sampling in women 36 years of age and older because the rate of spontaneous abortion and procedure related risks do not exceed the risk of fetal abnormalities.

A New Approach to Seizure Control Fifteen centers across the United States will begin expanded clinical trials on approximately 100 patients to see if implanting a small, electrical, anti-epilepsy device will reduce seizures in patients who do not respond well to drug therapy or surgery.

An article published in the May 14, 1990, issue of Medical World News describes the device as similar in size to a pocket watch. It is implanted in the subcutaneous tissue below the left clavicle and transmits electrical stimulation to the brain via the vagal nerve. This stimulation desensitizes the brain to stimuli that trigger seizures. It can be activated through an automatic program or by the patient when he or she senses that a seizure is about to occur.

The device manufacturer says initial trials on patients showed a reduction in seizure activity or a reduction in the length and intensity of seizures.

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