A O R N J O U R N A L J U N E 1986. VOL. 43, NO 6

Skill Acquisition STUDENTS IN THE OR

Michelle Byme, RN

perating rooms are clinical sites for medical, nursing, and paramedic students. 0 Although those students have designated

instructors, frequently much of the teaching falls on the staff nurse. Many times the staff nurse experiences frustration and stress when a novice student is assigned to him/her, and this may impede the student’s learning. A better understand- ing of the student’s behavior may decrease this frustration.

This article describes the use of the Dreyfus model in identifying novices’ and advanced beginners’ behaviors in OR clinical experiences. This information may be beneficial to staff and teachers who plan, manage, and evaluate student behaviors in the OR. In my personal experience with teaching baccalaureate nursing students, the Dreyfus model of skill acquisition has been useful. This article addresses areas such as clinical environment, student behaviors, and teaching techniques that influence the skill development of the nursing students.

Dreyfus Model

he obvious reason for a student’s novice behavior is the lack of experience. Expe- T rience allows the student and/or nurse to

test and retest previously held beliefs in clinical situations. A student’s experience occurs in the clinical setting; however, the previously held beliefs are learned in the classroom.

To better understand the nursing knowledge gained through experience, Patricia Benner and associates, University of California, San Francisco,

interviewed pairs of beginner/expert nurses, nurse clinicians, new graduates, and senior nursing students.l Each of the nurses described a “critical incident,” which was then interpreted and analyzed regarding content and common meanings. Based on the analysis, Benner was able to describe the performance characteristics at each level of development within the Dreyfus model of skill acquisition.

The Dreyfus model identifies five levels of proficiency in the acquisition of skill and knowledge development. The five levels-novice, advanced beginner, competent, proficient, and expert-are based on the levels of chess players and airline pilots. After study, Benner found she was able to apply this model to nursing.

Michelle Byrne, RN, MSN, was a part-time teaching assistant at the University of Wisconsin-Madison when this article was written. She received both her MSN degree in medical-surgical nursing and her BSN degree from the Universily of Wisconsin-Madison.

7fic author thanks Nancy Diekelmann, RN. PhD, FAAN, ursociate profe.nor, Univtwiy of Wisconsin- Madisoti j i x her msimnce with this manuxript

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An individual’s behavior may vary in the clinical setting

because of circumstances.

Although the characteristics and behaviors of nursing skills may be generalized, those levels cannot be used as concrete labels. An individual’s behavior may vary in the clinical setting because of circumstances. For example, an expert cardiac intensive care unit (ICU) nurse, if put in a neonatal ICU, may practice at a novice or an advanced beginner level.

The following describes characteristics of the five stages of the Drevfus model as they apply to the nursing practice.

Novice. This nurse has no previous experience on which to base decisions. Traditional rules have been engrained in the novice; therefore, he/she develops anxiety if the rules need to be broken or adjusted to fit a particular situation. The clinical situation could, and often does, differ from the textbook version. Nursing often has gray areas, and the novice’s adherence to the textbook rules may inhibit optimal clinical performance.

Advanced beginner. This nurse has some previous experience and is able to discern aspects of real-life situations. Experience allows the advanced beginner to acquire some guidelines on which to base hidher actions. However, the nurse is still unable to differentiate subtleties in situations or prioritize actions.

Competent. This nurse has worked two to three years in the same clinical area and is able to see the effect of nursing actions on long-range goals. He/she frequently follows a conscious, deliberate plan to organize the working environment.

Proficient. This clinician has had sufficient experience to see situations as a whole rather than just certain aspects. He/she supports decisions on nuances of the situation based on past experiences that were similar or dissimilar. This nurse can guide hidher performance on descriptions of past skilled performances and can determine the relevance of each action.

Expert. This nurse’s experience has more depth, and that allows for an intuitive approach to

problem-solving. As a result, this nurse is able to give quality nursing care by assessing and evaluating patient needs.

Those levels of skill development reflect three trends in a nurse’s career. The first is to rely less on abstract principles and more on past experience; the second is to view a situation as a whole; and the third is an ability to be actively involved as opposed to being a passive observer.’

For example, a novice nurse may observe increased pulse, decreased blood pressure, and cyanotic nail beds and realize that the patient is in shock. With more experience, this same nurse could recognize when shock is developing and react more quickly to the situation.

The fact that nursing skills increase with experience holds strong implications for nursing education. Most students in an OR clinical are practicing at a novice or advanced-beginner level.

OR Clinical Experience

t the University of Wisconsin-Madison, the 20-hour clinical experience is a

.required one-credit course divided into four five-hour periods. The majority of students are seniors although a few second semester juniors do take the class; the student-teacher ratio is 5: 1 . All the students have had basic sciences, nursing process theory, prior hospital experience, and a physical assessment course.

Course objectives require the student to demonstrate psychomotor skills such as scrubbing, gowning. gloving. instrumentation, OR environ- ment, and to understand the role of the OR nurse. Students are required to observe those techniques in audiovisual tapes before coming to the clinical area. The clinical experience includes ambulatory surgery and postanesthesia recovery room nursing care.

The perioperative period is an ideal time for students to refine. confirm, or reject the rules and

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principles learned in the classroom. Too often the students’ education is fragmented. Physical assessment is taught in one class, legal issues in another, and pharmacology in a third. The clinical experience can help the students pull those issues together and apply them to real-life situations.

During day one, students are oriented to the OR. First, students complete a learning assessment survey that asks them to list concerns, apprehen- sions, fears, and things they dread in relation to this course. Some of the responses include:

“doing something wrong and delaying

“fear over breaking sterile technique,” “handing the wrong instrument,” “being in the way,” “fainting,” and “throwing up.”

Only one response in 26 was “patient safety.” Those responses show that novice/advanced

beginners are more concerned with technology and want those fears relieved before discussing patient implications. Therefore, the remainder of day one is spent discussing technical aspects and learning procedures for scrubbing, gowning, and gloving.

The other sessions focus on patient care. Students are assigned to a staff nurse and may function either as a scrub nurse, a circulator, a recovery room nurse, or incorporate all those roles while in ambulatory surgery. During a one-hour postconference, students work through the theoretical and practical diametrical viewpoints. The instructor can apply theory to practical situations by identifying aspects of the environment that affect the patient. Many novices are unable to do that because the OR may seem foreign.

surgery,”

Student Behaviors

he following examples are student behav- iors observed during an OR clinical T experience, and are interpreted according

to the Dreyfus model of skill acquisition. One example is the novice’s adherence to the

rules. The novice knows the textbook rules for asepsis, but has never considered those cases in which strict asepsis is impossible (eg, tonsillec-

tomies). The instructor can stimulate discussion by identifying variations in asepsis, and the student can adjust hidher behavior accordingly.

Another typical novice behavior shows that novices have a narrow perspective of the environment. For example, a student assigned to help circulate was seen in the hallway outside the operating room immediately after surgery. Although the surgeon had finished, the circulating nurse was still taking care of the patient experiencing airway problems after extubation. The student failed to see that the circulating nurse’s role was patient centered.

The novice also has difficulty acknowledging that different techniques may serve the same purpose. Four students observed another student prepare the urethral meatus for insertion of a Foley catheter with instructions to start at the meatus and work outward. That proved to be different than their previous instructor’s technique. When told either technique would work, the students became defensive and demanded to know which procedure was the correct one. After a long discussion, some students were able to accept the explanation that either way was correct as long as one followed the clean to dirty principle.

Student Assessment

t the end of the third day, students write a patient assessment. They are encouraged A to write a preoperative or postoperative

assessment of a patient population they are familiar with. The assignment is used to evaluate the students’ ability to apply clinical knowledge and to incorporate assessment skills for a surgical patient; it also provides insight into the students’ skill level.

Two student assessments, one novice and one advanced beginner. are described to show the differences in learning levels. The following assessment was written by a novice.

28 y o Asian male to OR per protocol. A wuke and alert. Skin warm, dry and intact. Moved to OR table bv sey Sajev belt in place over thighs. Right arm out on arm board. Leji arm on arm table. Surgeon presenl.

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Sometimes, an expert and a novice are at such extremes that working together can be

a stressful experience for both.

This student failed to document that this patient was unable to speak English, a significant finding regardless of the area in which the student practices. The student also failed to assess the patient’s left hand, which had evidence of noticeable trauma. The novice assessment illustrates how the student was unable to discern relevant aspects of this situation.

The following nursing assessment illustrates a student’s ability to integrate theory and practice. This student is beyond the novice stage and is practicing as an advanced beginner.

58 y o white male admiited to the OR per protocol. Patient orienled x 3, cooper- aiive, and responding appropriately, although sleepy, Is informed about fhe surgical procedure and reports feeling somewhat anxious. Skin without breakdown. Transferred self to OR table. Turned fo lefl lateral position after intubation. AxilIary roll placed, pillow between legs. Arms on padded armboards and secured. Patieni placed in supine posiiion after ihoracotomy compleied. Patient reprepped from nipple to groin and redraped. X-ruy following closure. Truns- ferred to bed. Breathing via ventilator. Responds to verbal stimulation by opening eyes. This assessment incorporates many aspects of

this patient’s care and after reading it, one is able to picture the patient’s condition.

Teaching Implications

’ot all students are ready to relinquish their dependence on textbook rules, and it would be wrong to push a student before

he/she is ready for this cognitive change. When is a student ready to move from novice to advanced beginner? Additional research is necessary in the area of student learning to answer that question.

It is important, however, for an instructor to

encourage students to participate in the OR because of the wealth of knowledge available to them. Communication, multiteam decision- making, patient advocacy, stress, infection control, positioning, and airway maintenance are issues that have been discussed in the classroom; however, the OR clinical may be the first time the students can apply their knowledge in a nursing practice setting.

To promote students’ acquisition of clinical skills, the instructor should assign students to a patient population that they already know. Matching the patients undergoing surgical procedures with the type of patients the students cared for preoperatively increases the students’ confidence. Also, increased exposure to a certain type of patient population allows students to see many aspects of patient care.

The instructor should also match students with appropriate staff nurses. The assignment is very subjective with many variables influencing it. A student who is dependent upon set rules for practice has less anxiety when assigned to a staff nurse who is able to verbalize and give textbook rationale for every nursing action.

Sometimes, an expert nurse and a novice are at such extremes that working together can be a stressful experience for both. On the other hand, many students enjoy the experience of working with an expert. To prevent the students from feeling intimidated and the expert feeling frustrated, usually the expert/novice assignment, if made. is on the third or fourth clinical day.

Because student behaviors vary during the clinical experience, the instructor needs to be flexible and demonstrate leadership and listening skills. Many times anger and resistance to change appear in a student’s behavior upon relinquishing the novice perspective. However, all of the students in the course generally evaluate the experience positively when asked in a course evaluation if there were skills or theory learned in the OR that

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could not have been attained elsewhere. In addition to the expected responses of learning

sterile technique, gowning, and gloving, students have made positive responses that reflect that they learn far more than the general course objectives of the OR clinical. Some of the responses were:

“Even if I never work in an OR, it has given me a very good idea of what my patients will have experienced.” “Good exposure to areas we’ve never encountered before.” “1 feel more comfortable with preoperative and postoperative teaching of patients.” “_ . . opportunity to be part of a team.” “A great place to observe human interaction

One student’s comment, “It gives you a broader horizon.” summarizes most students’ evaluation of the OR clinical experience.

in a stressful situation.”

Conclusion

he Dreyfus model provides the instructor with insight into the student’s level of T functioning. The OR clinical provides a site

for hands-on learning that allows students to confirm or reject previously held rules, theories, or beliefs.

Instructors and staff nurses must constantly strive to improve education, and be open to new ideas, theories, and models. The senior-level nursing instructor must begin to dissipate the “which way is the correct way” attitude of students.

Although there needs to be more research at the novice/advanced beginner level of skill acquisition. the Dreyfus model provides under- standing and meaning to student behaviors. Benner’s research of nursing knowledge gives the educator, student. and staff nurse direction and hope for the future of the nursing profession. 0

Notes 1 . P Benner, From Noviw 10 E.xperf: trct4ltwcc~ and

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