About Baccalaureate Curriculum
Implementing a perioperative nursing: elective in a Baccalaureate Curriculum
PERIOPERATIVE NURSING UNITS are experiencing a critical shortage of trained RNs, and new nursing school graduates are unlikely to enter this specialty
The United States is experiencing a nursing shortage that is expected to worsen significantly during the next two decades. Specialty units that require additional and unique training for nurses, including perioperative nursing units, already are reporting critical shortages. (1,2) The current perioperative nursing shortage is the result of several trends:
* an aging nursing workforce,
* an aging population that requires more health care services,
* technological innovations that create a constantly changing work environment, and
* the lack of exposure of nursing students to perioperative clinical experiences. (3)
The majority of future specialty nurses are new graduates from nursing programs; however, if new graduates have had little or no experience in perioperative clinical areas, it is unlikely that they will choose to work in these units. (4 )After graduation, nurses generally choose to work in areas in which they had the most clinical experience as students. (1)
The most aggressively recruited specialists today are perioperative nurses, clinical nurse specialists, medical/surgical specialists, critical care nurses, emergency services nurses, and obstetric nurses. (5) Insufficient numbers of trained perioperative nurses may lead to the hiring of staff members who are not nurses but who can be trained in technical tasks. Patients are most vulnerable when they are sedated or anesthetized, however, and one of a perioperative nurse's major responsibilities is to be the patient's advocate in the OR. (6) If there is no professional nurse to speak for the patient, patient care may suffer.
THE CURRENT STATE OF NURSING EDUCATION
Nursing education must take on the responsibility of preparing future practitioners to meet the needs of surgical patients in efficient and cost-effective ways without neglecting the need for increased patient advocacy in today's health care environment. Most undergraduate nursing programs offer few, if any, courses or experiences specific to the specialty of perioperative nursing. During the past 40 years, rotations in perioperative areas have been eliminated from most baccalaureate nursing curricula, even as the demand for nurses in this specialty has increased. There also has been a move away from the medical model to a more generalist preparation for nursing students. (6) Focused content and even brief clinical experiences in specialty areas within nursing have been reduced drastically in most baccalaureate nursing programs.
The nursing shortage is not restricted to staff nurses but extends to nursing faculty members as well. There are fewer qualified faculty members available to teach an already full curriculum. It is difficult to develop experiences in perioperative nursing within the curriculum when faculty positions are vacant and faculty members are overwhelmed with existing coursework. The impetus to add new content to the classroom and clinical area simply does not exist in this environment. Faculty members also are not willing to give up hours dedicated to already developed content to facilitate new and different experiences.
SHORTCOMINGS OF TRADITIONAL NURSING SCHOOL CURRICULA
In many traditional nursing school curricula, several factors may limit or prohibit students' observation of surgical procedures. A patient who is assigned to a student for a clinical rotation may not undergo surgery during that clinical rotation. Surgery also may be scheduled on an emergency basis, and the short notice may not allow time for necessary permissions to be obtained so that the student can observe in the OR. Furthermore, students should have the time to review surgical asepsis and principles of care of an anesthetized patient before observing procedures so that they can think critically about what occurs from preoperative preparation through postanesthesia care.
Other factors that may prevent students from observing in perioperative areas include short staffing, a heavy surgical case load, restrictions on the number of individuals allowed in the OR for certain procedures, lack of extra scrub clothing for student use, and the number of new employees being oriented in the unit on a given day. As a result, many nursing students receive minimal exposure to perioperative nursing, and this limited exposure does not allow them to develop an understanding of or appreciation for the specialty.
Some educators report that they encounter resistance to placing students in the OR for clinical rotations. Issues include nurses and physicians who are not interested in having students in the OR and OR staff members who feel that working with students is an intrusion on their work time rather than an opportunity to foster an appreciation for the specialty. (9)
Some nursing programs, however, report having developed unique and individualized perioperative nursing electives. Credit for these electives vary from one to four credit hours. The amount of didactic and clinical time allotted also varies. All electives were developed in collaboration with clinical agencies with whom the schools of nursing held clinical affiliation agreements.
DEVELOPING A PERIOPERATIVE NURSING ELECTIVE
Nursing programs that have developed elective courses for perioperative nursing experiences usually have a faculty member who has experience in this area and who is willing to undertake the challenge of developing the course. The AORN position statement "Inclusion of perioperative nursing learning activities in undergraduate nursing curricula" affirms that perioperative nursing content and clinical skills should be taught by faculty members and cooperating agency staff members who are both academically qualified and clinically experienced in perioperative nursing. (7)
At the Auburn University School of Nursing, Auburn, Ala, several facts became clear to faculty members who were teaching clinical courses and sending students to observe surgery on a space-available basis.
* Students were excited to be able to go to surgery with a patient and felt privileged to have an opportunity most of their peers would not have.
* Students consistently reported that staff members in the surgical suites were helpful and willing to teach them.
* Students gained a more thorough understanding of postanesthesia care.
* Students exhibited a greater understanding of and empathy with their patients who had undergone surgical interventions. This behavior extended to other patients they worked with during the clinical rotation and not just to the patient they had observed in the OR. As a result of these observations, a clinical instructor at the university undertook development of a perioperative nursing elective.
All electives in the curriculum at the Auburn University School of Nursing are offered to senior students in the fall semester of the final year of the professional program and provide three semester hours of academic credit. Before the development of the perioperative elective, none of the electives offered included a clinical component. Faculty members continued to receive a large number of student requests for new and different electives, which prompted a request from the assistant dean that faculty members consider topics in their own areas of expertise that might be offered as electives.
The proposal for development of a perioperative elective was presented to and accepted by the curriculum committee in the spring of 2001, with the course to be offered in the fall semester of that year. The course syllabus and supporting materials were developed by the clinical instructor and presented to the curriculum committee for approval. After approval was secured, a course number was assigned, the perioperative elective was listed in the course catalog, and enrollment was opened to students.
Developing a perioperative nursing elective requires a commitment from both academic faculty members in the school of nursing and clinical and administrative leaders in the practice setting. The quality of the affiliating perioperative nursing department and the expertise of nurse educators in the specialty have been found to influence the success of these electives significantly. Clinicians who mentor students can foster interest in the perioperative nursing specialty by investing their personal time and effort and by providing an honest and clear representation of perioperative nursing practice. Nursing programs need hospitals to provide the clinical components of nursing education, and opportunities exist to extend these collaborative relationships and provide quality experiences in a comprehensive perioperative elective. (2)
During the initial planning for the course, the director of perioperative services at a local hospital met with the course leader for the elective. They discussed the elective and details of the anticipated didactic and clinical content. The director was enthusiastic about the opportunity to participate in student education. She made several suggestions concerning the perioperative units (ie, preoperative preparation, OR, cardiovascular surgery, postanesthesia care unit [PACU]) and ancillary units (ie, chronic pain clinic, endoscopy unit, outpatient surgery) that could be used for student clinical experiences and identified individuals who might be willing to precept students for the elective. The director assisted in coordinating planning meetings with the physician director for anesthesia services to secure an agreement to host students and to garner any suggestions he might have about appropriate preclinical instruction and procedures for the anesthesia rotations. The perioperative elective was discussed with OR staff members and with many of the surgeons who would encounter students in the surgical suites during the students' clinical rotations.
A meeting was held with the unit managers of both the OR and PACU to discuss experiences to be provided for students and anticipated course outcomes. It was agreed that hospital staff members would provide part of the course orientation, with a focus on confidentiality for patients and the procedures performed.
THE PERIOPERATIVE ELECTIVE
Course enrollment was limited to 18 students so clinical placement could be secured without difficulty, but there were many more requests from students than could be accommodated. The first offering of the course, in fall 2001, included six class days with three hours per session. At the end of this portion of the course, the students took a written examination. They were required to pass the examination with a minimum of 80% to progress into clinical rotations for the course. If a student did not pass the examination, remediation was to be offered; however, the lowest score achieved was 86%, so no remediation was necessary.
Students then were scheduled for clinical rotations in a variety of areas within the scope of perioperative nursing practice, including the outpatient pain clinic, preoperative unit, OR, endoscopy unit, day surgery center for outpatients, and the PACU. Sixty clinical hours were divided among these areas.
After all clinical rotations were completed, a final class meeting was held with students to obtain their objective comments on all facets of the course. Students were enthusiastic about the experiences they had gained, but they had several suggestions for revising the didactic and clinical content. After final written course evaluations were received, adjustments were made in both course content and clinical areas used for student rotations.
The perioperative nursing elective continues to include both didactic content and clinical rotations, but the clinical component is extensive, requiring a total of 90 hours in addition to the regularly scheduled class and clinical hours for the senior level course that runs concurrently and which focuses on critical care and community health. Students are asked to provide calendars to the course leader that show the dates and times they are available for clinical rotations for the perioperative elective. Unless there is an emergency, students are not allowed to change their schedules after the schedules are given to the course leader.
After completing the didactic part of the course, students still must undertake a comprehensive examination and receive a score of 80% to progress to clinical rotations. Changes that have been made since the initial course was designed allow students to take the examination more than once, but with each successive attempt, the maximum achievable score decreases by five percent (ie, a student taking the examination a second time can earn a maximum score of only 95%). The examination assesses the student's knowledge of
* environmental safety in the OR,
* infection control issues,
* principles of asepsis,
* responsibilities and training of perioperative personnel,
* phases of wound healing,
* positioning of patients for specific surgical procedures, * instrumentation, and
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* general procedures seen in the perioperative units.
The examination consists of multiple-choice and short-answer questions.
Clinical hours for the course are broken down by unit of experience, as presented in Table 1. The heaviest clinical-hour component focuses on the surgical suites. The total number of hours in each trait is based on the variety of experiences provided in the specific unit, previous student evaluations, and suggestions from host hospital staff members. The director of perioperative services works with the unit managers and the department educator to determine the most appropriate staff members to serve as clinical preceptors for students. This experience may be used as part of a clinical enhancement program for staff members and may contribute to their receiving additional or bonus pay for their participation.
Students may not schedule daily blocks of fewer than four hours for clinical rotations. They are strongly encouraged to spend full eight-hour days in the surgical suites whenever possible to achieve the optimum experience. During the cardiovascular surgery experience, for example, the student arrives before the scheduled procedure and observes the preoperative phase, beginning with the arrival of the patient at the hospital. The student accompanies the patient to surgery, and after surgery, he or she stays with the patient in the cardiovascular intensive care unit for approximately two hours to observe the immediate postoperative care.
Students must complete a written assignment during the semester that focuses on the types of surgical procedures they will see most often in the surgical suites. Table 2 includes the types of surgeries reviewed as well as the required information for each procedure. Of the total course grade, written assignments comprise 25%, the course examination is 40%, class attendance and participation is 5%, and the clinical component is 30%.
Enrollment for the perioperative nursing elective currently is limited to 20 students because of the lack of available surgical facilities for clinical rotations. Students initiate enrollment requests in the spring for electives in the following fall semester. The course leaders for the electives send e-mails to students containing the details of each elective and the expectations required for each course. Students who express interest in the perioperative elective are advised of the clinical hour requirement before they enroll in the class and reminded that these hours are in addition to the regular clinical hours to be accrued for the critical care/community health course. The course leader is available to discuss expectations for the elective, and interested students are encouraged to talk with graduating seniors who have taken the class to clarify course expectations. There continue to be more student requests for the course than can be accommodated.
FUTURE PLANS
The perioperative nursing elective has been offered for three successive years and has received consistently strong, positive evaluations from the students. The course will continue to be taught and revised based on input from students and staff and faculty members involved. Senior students who have taken the course have recommended the perioperative course to junior-level students as a great learning experience, and most believe the additional clinical hours were well worth their time and effort. Many have said that the perioperative experiences they gained gave them insight into working more effectively with postoperative patients who experience complications, as well as a better understanding of some of the principles of critical care nursing, particularly airway management.
Staff members who have participated in precepting students in the perioperative nursing elective have contacted the course leader to ask to participate again. The course leader also has had requests from two other hospitals in the region that would like to participate in hosting students for the elective in perioperative nursing. Discussions with these facilities are ongoing and may allow many more students to participate in the elective in the future.
The local hospital has added a long-anticipated, separate outpatient surgery wing that includes three OR suites and a second PACU. The center opened in 2003, and procedures performed there include pediatric surgeries that do not require overnight hospital stays, most ocular surgeries, laparoscopic procedures that do not require overnight hospital stays, and arthroscopic procedures. The addition of this center should expand the possibilities for student placement and provide additional clinical experiences. The maximum number of students who can enroll in the perioperative elective will increase to 25 in the fall of 2005.
CAREER PROSPECTS
Many of the students who are interested in perioperative nursing as a career have asked if hospitals other than the one where the perioperative nursing experience took place are willing to hire new graduates into the OR or other perioperative units. An informal telephone survey was conducted with directors and unit educators of perioperative departments of eight hospitals within a 200-mile radius of the program. Each of the individuals contacted agreed that new graduates would be considered for hire in the OR or other perioperative units.
The perioperative nursing elective was described to each of the individuals surveyed, and they were asked if taking this elective would make a new graduate more attractive as a new hire. All respondents said that the experience gained through this elective would be the strongest recommendation for hiring a new graduate. Approximately 25% of students who have taken the perioperative nursing elective currently are working in an OR or PACU. Another 20% currently are enrolled in programs that prepare nurse anesthetists. Two 2004 graduates who participated in the perioperative nursing elective took positions in an OR immediately after graduation, one in a cardiovascular surgical suite in a large teaching hospital and one in a surgical suite in a regional pediatric referral facility.
AN AFFIRMATION
A surgeon who initially had strong negative opinions about students in the OR had the opportunity to observe a student from the perioperative elective during an emergency procedure. The surgeon assumed that the student was a new nurse being oriented to the OR. The surgeon complimented the student on his knowledge and understanding of the specific surgical problems encountered. Several days later, the surgeon realized the student was not a new employee when he saw the student in a school of nursing uniform on the postoperative floor during a clinical rotation. The surgeon took time to encourage the student to pursue perioperative nursing as a career after graduation. This encounter demonstrates another positive outcome of the perioperative nursing elective.
SUPPORT FOR THE PROGRAM
Although the perioperative nursing elective is a time- and labor-intensive experience for students, faculty members, and hospital staff members, it receives strong support from each of these groups. The experience is recognized by hospital staff members as a way to acquire enthusiastic staff members when students graduate from the nursing program. Students believe they have greatly enriched their clinical experiences through participation in the elective, and faculty members recognize the unique specialty of perioperative nursing as a vital, interesting, and exciting part of nursing.
TABLE 1
Clinical Rotations for the
Perioperative Nursing Elective
Clinical hours
Unit of experience for rotation
Preoperative unit 4
Surgical suites 40
Postanesthesia care unit 24
Cardiovascular surgery 6
Experience with certified
RN anesthetist 8
Pain clinic 4
Endoscopy 4
Total clinical hours 90
TABLE 2
Procedure Analysis and Nursing
Concerns--Written Assignment
Surgical procedures for analysis
Breast reduction or augmentation--student's choice
Colonoscopy
Coronary artery bypass grafting
Esophagastroduodenoscopy
Laminectomy and disectomy
Partial colectomy
Thoracotomy
Total abdominal hysterectomy
Items to be included in the analysis
* The 3 most common reasons for performing the
procedure
* Preoperative instructions given to the patient that
are specific to this procedure
* Anatomical patient position during the surgical
procedure
* Specific diagnostic procedures done before this procedure
(eg, dye studies)
* Areas of the body to be prepared and antiseptic
solutions that would be preferred for this procedure
* A brief description of how the procedure is
performed
* Postoperative care that is most important for
patients having this procedure
* Specific types of dressing used for this procedure
* The 3 most common complications seen immediately
after and within postoperative days 1 and 2 of
this procedure
* At least 3 nursing diagnoses appropriate for this
specific procedure. May include 1 for the immediate
postoperative period and 2 others for the first 24 to
48 postoperative hours
NOTES
(1.) B Happell, "Student interest in perioperative nursing practice as a career," AORN Journal 71 (March 2000) 600-605.
(2.) L Mitchell et al, "Establishing a collaborative relationship with a college of nursing," AORN Journal 76 (November 2002) 842-850.
(3.) R P Ward, C Saylor, "Nursing school curricula and hospital-based training programs," AORN Journal 76 (December 2002) 1022-1031.
(4.) L L McCausland, "A precepted perioperative elective for baccalaureate nursing students," AORN Journal 76 (December 2002) 1032-1040.
(5.) "AONE sends message on shortage," OR Manager 17 (January 2001) 5.
(6.) S C Kurtz, L W Eichelberger, "Developing a perioperative nursing elective," AORN Journal 70 (November 1999) 879-886.
(7.) "Inclusion of perioperative nursing learning activities in undergraduate nursing curricula," Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 159-161.
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(8.) J M Beitz, P M Houck, "Advanced perioperative nursing elective for baccalaureate students," AORN Journal 66 (July 1997) 119-128.
(9.) K E Schulz, K DiSanto, "Investing in the future--An OR orientation program for nursing students," AORN Journal 69 (March 1999) 635-638.
(10.) K K Lunday, W K Winer, A Batchelor, Developing clinical Learning sites for undergraduate nursing students," AORN Journal 70 (July 1999) 64-71.
(11.) A T Onstott, "Hospital explores winning balance in perioperative education," AORN Journal 68 (September 1998) 395-399.
Susan P. Holmes, RN, MSN, CRNP, is a clinical instructor, Auburn University School of Nursing, Auburn, Ala.
COPYRIGHT 2004 Association of Operating Room Nurses, Inc.
COPYRIGHT 2004 Gale Group
