MAY 1987, VOL. 45, NO 5 AORN JOURNAL

Teaching Perioperative Nursing A PROPOSED DESIGN FOR A CURRICULUM

Jo Ann Lierman, RN

he continual rapid increase in medical knowledge, the changing role of the nurse T in professional practice, and the rising costs

of health care make it necessary for colleges to offer courses that will teach nurses the necessary skills and knowledge to meet new trends. Through an effective curriculum, a perioperative nursing course for registered nurses could provide multiple learning outcomes and have advantages for nurses, faculty, and hospitals.

Graduates of such a course could transfer to the OR when openings occur or function with moderate supervision in emergency O R staffing situations. It would also acquaint more nurses with the perioperative role and demonstrate the importance of professional nurses, rather than technicians, in the OR.

By basing this course in a collegiate setting, hospital costs would be decreased because less in-service instructor time would be needed. It also provides increased opportunity for role models, well-qualified clinical leadership, and a spirit of ongoing learning and inquiry. It could provide an opportunity for educators and practicing perioperative nurses to work together. Viewpoints and knowledge could be exchanged, personal skills increased, and communications improved, thus nurturing enthusiasm and understanding of perioperative nursing and its importance in professional practice.

A collegiate-based course would provide an incentive for the registered nurse to learn about perioperative nursing while receiving college credit. By providing a general overview of all aspects of perioperative nursing, this course can

1 Is(,

help those working toward a CNOR certificate. Nurses interested in perioperative nursing but

practicing in other areas can apply the course concepts to their specific areas of patient care. Perioperative nursing is an excellent nursing specialty to use for teaching holistic care and continuity of care because it helps ensure a nursing commitment to the whole person.

Curriculum Design

he following is a proposed curriculum for a course in perioperative nursing that could T be used for staff development or as an

elective for registered nurses. (See “Course

Jo Ann Lierman, RN, MN, is a surgical instructor, School of Nursing, University of Kansas, Kansas City. She earned her bachelor of science degree in nursing from Graceland College, Lamoni, Iowa, and her master’s degree in nursing from the University of Kansas, Lawrence.

AORN JOURNAL MAY 1987, VOL. 45, NO 5

Objectives.”) The content is divided into five units-the history and philosophy of perioperative nursing, the surgical environment, preoperative care, intraoperative care, and postoperative care. An outline of the curriculum is presented in Table 1. Theoretical aspects are stressed in the first two units, and clinical practice is stressed in the last three.

The units are divided into classroom time, laboratory time, and clinical practice time. During clinical practice time, the emphasis is on applying new and previously learned concepts to periop- erative nursing. During laboratory time, practical experience is simulated in a classroom setting. Students can practice skills and techniques on mannequins and on each other. Equipment comparable to that found in the clinical setting can be used to simulate practical situations in the laboratory.

Unit I. As designed, this unit begins with a historical review of OR nursing and surgery. It then provides an overview of OR personnel with an emphasis on the perioperative nurse’s role and responsibilities. In this unit, nurses examine the concept of team management and collaboration as applied to the operating room, along with the aspects of group dynamics, effective communi- cation, and interpersonal relationships. This will provide a foundation for clinical practice later in the course.

Because the OR is a highly technical critical care area and surgical intervention causes stress in the patient, the topic of stress adaptation for both the patient and nurse is addressed. The effects of stress on interpersonal relationships, team management, and clinical practice are examined. The concept of stress is developed further in units dealing more specifically with patient care.

Unit II. In this unit, students would learn about the surgical environment. The objective of this unit is to provide a foundation of knowledge for skills used in later units.

To provide perioperative nursing care that ensures patient safety, adequate patient prepara- tion, and quality care during surgery, the nurse must be familiar with the environment and the equipment used. In this unit, the nurse is taught the principles of asepsis, sterilization, and safety;

Course Objectives

After completing the course, the nurse will be able to do the following:

a

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understand the role and responsibilities of the perioperative nurse, use the nursing process to develop nursing care plans for patients and their families during all perioperative phases, function as a member of an interdiscipli- nary surgical team with an emphasis on collaborative efforts conducive to positive patient outcomes, demonstrate competency in basic perioper- ative nursing skills, apply the principles of asepsis in a surgical clinical setting, understand the effects of stress upon self, team members, and the patient, comprehend the interrelationships among biological-psychological-social factors that affect the patient’s adaptation to the surgi- cal experience, understand the effects of the surgical envir- onment on the patient and personnel, understand the ethical and medical-legal responsibilities of the perioperative nurse, apply management skills to a controlled OR environment, use principles of teaching-learning theories to conduct patient teaching sessions for selected patients and their families, comprehend the interrelationships among surgical pharmacological agents and their effects on the patient, and understand the principles of wound healing.

the role of the central supply department; and the use and care of basic instruments and equipment. Standards of OR nursing practice, legal, moral, and ethical issues are also examined.

Unit III. With the knowledge learned in the previous units, the nurse will be able to understand the rationale for direct patient care activities. For example, the concepts of stress and its management taught in unit I are applied to direct preoperative patient care in this unit. As relationships are made

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Table 1 Perioperative Nursing Curriculum

Unit I Unit I1 Perioperative nursing Surgical environment

Historical aspects Organization and structure of surgery and OR nursing

Roles and responsibilities circulating nurse scrub nurse other team members

Team management and collaboration

Stress adaptation

Unit I11 Preoperative care

Nursing process phases assessment, planning intervention, evaluation

Psychosocial aspects health care practices age, gender spiritual/religious practices language, socioeconomic status family organization emotional reaction of family

Preoperative teaching objectives implementation methods

Cultural and ethnic responses transcultural components of health care related to surgery ethnic values and responses

Stress management Pathophysiological components fluids and electrolytes oxygen saturation levels changes in body temperature nutritional state stress adaptation hormonal alterations neurological, musculoskeletal disturbances

Preoperative medication actions, side effects monitoring

OR suite basic equipment basic instruments and use

Electrical safety Central supply identification, care, and cleaning of instruments cart system

Aseptic technique sterilization disinfection microbiological principles spread of infection sterile field

Jurisprudence legal, moral, ethical aspects OR permits practice acts of state standards of practice

Room preparation

Unit IV Intraoperative care

Nursing process application Pharmacology anesthesia, actions side effects, monitoring

Basic positioning principles Suture and needles Medical-legal, ethical responsibilities

Interdisciplinary surgical team management

Self-awareness Personal stress control Pathophysiological responses expected

Patient monitoring implications for postoperative care

Potential complications

Units 111-V Skilldtechnology

Aseptic preparations hands and patient skin

Sterile field setup gowning, gloving, draping

Instruments cleaning and sterilizing Mayo and back table setup passing instruments

Counts sponges, instruments needles, sharps

Suture and needle preparation Specimen care and handling Blood loss estimates intake and output

Wound dressings Transfer positioning

Documentation team reports

Safety practices Teaching project Medication and fluid administration

Patient care plan development

Unit V Postoperative care

Nursing process phases Pharmacology, pain medication actions, side effects monitoring

Expected pathophysiological and psychosocial responses

Wound closure principles of healing process of infections

Postoperative monitoring Potential complications Body image changes, affect on patient family

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By being aware of expected nursing care and the required patient monitoring, the nurse

can anticipate postoperative care.

between new information and concepts learned in units I and 11, students should begin to become aware of a logical sequence of events in perioperative care.

In unit 111, students review the nursing process, the vehicle for providing patient care. Nurses discuss physical and psychological preparations of a patient before surgery. In a clinical setting, students would be given an opportunity to apply the nursing process. During the preoperative interview, for example, the students would assess the patient’s psychosocial aspects such as age, gender, religion, language, and socioeconomic status as well as his or her physiological status including electrolyte balance, body temperature, nutritional state, and oxygen saturation level. To develop a patient care plan, students would, during the preoperative interview, incorporate knowledge of stress management and document which preoperative medications their patient will receive.

Preoperative preparation of the patient provides the rationale for future direct patient care. Knowing the OR environment and patient preparation techniques will help the nurse to anticipate problems that might arise and to provide thorough, safe care that will meet the patient’s needs.

Unit I K Continuity of care is a theme throughout units IV and V. In these units, nurses will continue to make relationships between previous learning and new information to support continuity of care. Throughout the unit, the nursing process is used to develop a care plan. By being aware of expected nursing care and the required patient monitoring, the nurse can anticipate needed postoperative care.

In unit IV, students are introduced to intraop- erative care. Topics such as patient positioning are related to pathophysiological problems and the type of surgical intervention. Instructors relate anesthesia and typical intravenous agents to expected patient responses, pathophysiological

conditions, type of surgical intervention, required nursing care, and anticipated postoperative care. The importance of nursing care and patient monitoring in preventing patient complications becomes apparent when considering the interre- lationship of pathophysiology, surgical interven- tion, drugs, and the environment.

Principles of wound healing are related to physiology and asepsis taught in previous units. Knowledge of wound healing becomes important when considering wound closure, suture material, physical condition of the patient, type of dressing applied, anticipated nursing care, and preventing potential complications. Pathophysiological alterations occurring in surgery and their complications will be related to nursing care in unit V.

Nurses also learn skills that apply to intraop- erative care, such as gowning and gloving; scrubbing; patient positioning and draping; counting sponges, instruments, and sharps; specimen and instrument handling; wound dressings; suture and needle preparation and handling; and sterile field setup. In learning these skills, the importance of the principles of asepsis taught in unit I1 becomes apparent when applied to procedures requiring sterile technique. By reviewing the evolution of sutures, needles, and sharps, and instruments from unit I, the nurse would be better able to appreciate advances in medical science.

During this unit, nurses would participate in patient care by assuming various perioperative nursing roles, functioning as a team member, practicing team collaborative techniques, and having the opportunity to apply management skills under supervision.

Legal aspects regarding frequently encountered cases would be presented and related to anticipated postoperative care in unit V.

Unit F! This unit deals with immediate postoperative care and with returning the patient

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Table 2 Course Timetable

in Hours

Classroom Laboratory

Unit I 12 8 Unit I1 16 8 Unit 111 28 6 Unit IV 21 14 Unit V 13 2 Written exams 8 0 Total 98 38

Clinical

0 48 56 40 40 0

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to the surgical unit. By this time, the nurse has been presented with

enough knowledge relating to the surgical experience to realize the full extent of the physical and psychological trauma to which the patient must adapt. This knowledge base should enable the nurse to anticipate postoperative problems and plan the needed nursing care. The nursing process is used to ensure continuity of care through all surgical phases.

During this unit, the nurse would be exposed to clinical settings with patients in altered states of consciousness, at risk for psychological trauma due to body image changes, and in altered physiological states.

By knowing drugs and their interactions with anesthesia, the nurse can provide pharmacological comfort measures for the patient. By knowing patient positioning, factors that affect wound healing, and the effects of surgical interventions, the nurse can provide physical comfort measures during the postoperative phase. Providing patient comfort and assessing complications are prime nursing concerns in the immediate postoperative period. Clinical practice is also used in this unit to help apply knowledge to direct patient care.

Course Applications

his course could be used several ways. Originally, it was designed to be offered T during an eight-week summer session. But

it is possible to adapt the course to fit into a regular 12-week semester.

This course could be used as an elective for the registered nurse student in a BSN program, or it could be used as a vehicle for hospital in- service education and orientation of inexperienced OR personnel.

If the course has an enrollment of 20 nurses, four instructors would be needed to make a recommended 5 1 ratio in laboratory and clinical settings. A small instructor-student ratio provides more individualized attention and enhances learning. Using staff preceptors in the clinical area could provide each student with a 1:l or 1:2 ratio. With a class of 20 students, four clinical locations would be recommended to prevent an overload of students in any one location and to ensure optimum learning experiences for each student.

A timetable for the course is provided in Table 2. Students could earn eight to 10 college credit hours for completing the course, depending on the college ratio of clinical hours to classroom hours.

During the course, instructors can evaluate a student’s knowledge through written examina- tions, case studies, written care plans, laboratory demonstrations, and performance in the clinical area. As the course progresses, the student would be required to demonstrate and display an increasing depth of knowledge and application of the nursing process.

I believe this course offers a strong theoretical

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base for a professional nurse beginning periop- erative nursing practice. A comprehensive understanding of theory will provide the nurse with an easier application of concepts and skills in the clinical setting. 0

Suggested reading Fitzpatrick, C Y; DiMattia, N D; Fennessey, N T. “A

regional course in OR nursing.” AORN Journal 35 (March 1982) 735-742.

Fletcher, J; Tighe, S M; Vorderstrasse, P. “Perioperative nursing: A survey of schools.” AORN Journal 42 (October 1985) 548-564.

Cough, F A. “The perioperative elective: A baccalau- reate program.” AORN Journal 39 (May 1984)

Kramer, M. “Philosophical foundations of baccalaureate nursing education.” Nursing Outlook 29 (April

Rothrock, J C. “Perioperative nursing goes to college.” AORN Journal 40 (December 1984) 873-877.

1009-1024.

1981) 224-228.

Physicians Dispensing Prescription Drugs Despite criticism from professional pharmacy associations, more physicians are dispensing prescription drugs from their offices, according to the Jan 23 issue of American Medical News.

Professional pharmacy associations have criticized the new physician business venture. They contend that by eliminating the traditional system of checks and balances between pharma- cists and physicians, patients could be adversely affected.

Physician drug dispensing has the support of the American Medical Association and the Fed- eral Trade Commission. Several states have rec- ognized physician drug dispensing as a legitimate business and have passed laws regulating require- ments. Florida, for example, mandates strict drug labeling requirements and six hours of continuing pharmaceutical education for physicians who dis- pense drugs, according to the article. Four states, however, have prohibited physicians from dis- pensing drugs.

Many physicians obtain their drugs from drug repackaging companies. These companies buy drugs in bulk, repackage them into varying dos- ages that last between five and 10 days, and sell them to physicians. Most companies furnish phy- sicians with a cabinet (with a lock and key) and a computer system for patient record-keeping (for a fee). The physicians are responsible for labeling and setting their own prices. Usually, their prices are lower than those set by pharma- cists because of the low overhead, according to the article.

Film Review: A Laser Safe Environment This film was one of three AORN and Davis + Geck films to premiere at the 1987 AORN Con- gress. I t is an excellent film that demonstrates the perioperative nurse’s role in providing a safe environment when working with laser equip- ment. The film explains the classifications and applications of lasers in practical terminology, and identifies laser characteristics unique to each system (carbon dioxide, ne0dymium:yttrium aluminum garnet [Nd:YAG], and argon).

nurse educator, and nursing students with an important tool in preventing patient and staff injuries during laser applications. Information is presented in a manner easily understood by both professional and novice laser personnel.

Guidelines presented in the film are reinforced in the learner’s guide, which is distributed with the film. The guide provides reference material to help the perioperative nurse formulate standards of patient care and to develop documentation forms. This film and study guide could be an asset to every hospital or ambulatory surgery set- ting that uses lasers in patient care.

A Laser Safe Environment is available on 16- mm film or videotape from Surgical Film/Video Library, American Cyanamid Co, I Casper St, Danbury, CT 06810. The film costs $17.50 to rent, $125 to purchase.

This film provides the perioperative nurse, the

SANDY MOOREHEAD, RN, CNOR AUDIOVISUAL COMMITTEE

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