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Perioperative Nursing Education: Rejuvenating a Vanishing Curriculum

By Kathy Dix

Training nurses in the perioperative arena has been a dying mission since the ‘60s. Penny Boone, who graduated nursing school in 1968, wrote a senior paper on the changes occurring in operating room (OR) nursing — and her conclusions still apply today. “OR nurses today face vast challenges, the largest problem of which is the shortage of well-trained, educated nursing personnel,” Boone wrote. “The OR experience was or is being eliminated from many nursing programs. The role of the OR nurse in patient care extends outside of the operating suite. However, the trend in collegiate nursing education today is toward the elimination of the OR experience as part of the basic clinical preparation of nurses. Those responsible for directing collegiate programs have assumed that operating room nursing is not patient-centered and that only conscious patients can receive such care.”

Boone received a call to arms last summer, when she was asked to assist with perioperative education in Arizona. The Arizona Hospital and Healthcare Association (AzHHA) sponsored a Day of Dialogue during which the local Association of periOperative Registered Nurses (AORN) chapter addressed the nursing shortage. Boone had also become associated with the national chapter on this subject, and the association provided funding and a speaker for the dialogue, Debra Fawcett, an expert on the topic. Local hospitals are now offering clinical experience to basic nursing students.

“We OR nurses have shot ourselves in the foot, because historically, the OR has been a very closed and unwelcoming place to new people,” says Boone. “In the old days, the concept was that you had to have at least three years of experience on the fl oor before you could work in the OR. I’m here to tell you that it’s critical patient care. Being under a general anesthetic — what could be more critical than that? The nurse is the advocate for the patient.”

But there are now many programs to educate nurses in perioperative work.

“Since 1999 we have had a six-month registered nurse OR internship,” says Alice Speers MEd, RN, BC, an education specialist in surgical services at William Beaumont Hospital in Royal Oak, Mich. “Since there were inadequate numbers of available experienced OR nurses, the hospital decided that an internship would help to meet this need. At the beginning of the program, only nurses with at least two years’ clinical experience as a registered nurse were considered for the program. However, in 2002, the program was extended to include new graduates.

“In preparation for our expansion and addition of 16 ORs and four procedure suites, there was a need for continued preceptor development and enrichment,” Speers says. “Basic preceptor classes are held four times per year and an advanced preceptor class was developed and is offered with the same frequency. And in addition to the internship, we provide orientation programs for experienced OR nurses new to our hospital.”

When asked how he attracts nurses to his OR, “I would make them aware of our fellowship of $7,000 per year to become an RN,” says Alan Beatty, Shore Memorial Hospital’s vice president of human resources. The onsite perioperative training program at Shore Memorial began in 1999; its first four graduates were all RNs, but in 2002, the program was opened to licensed practical nurses (LPNs).

“The first four graduates in May 2000 were all registered nurses, but in 2002 the program was opened to LPNs,” adds Maggie Sterling, LPN, CST, CRCST, MA, educational coordinator of the OR at the hospital. “Being an OR nurse is not for everyone. A good OR nurse needs a personality that enables them to work in a very regulated, often stressful environment and as part of a team.”

“The Northeastern University Perioperative Nursing Certificate Program is an intensive continuing education program that prepares RNs to transition into the perioperative nursing role,” says Lea Johnson, MSN, MS, MS, RN, ANP, perioperative program director and director for the Institute for Healthcare Leadership and Professional Development at Northeastern University in Boston. “This program is unique in that it uses a collaborative approach to the educational process we call the ‘Boston Model.’ Our program is guided by an advisory board with members representing the perioperative clinical leadership from a dozen area hospitals. Advisory board members provide input regarding curriculum, recommend faculty, and also provide closed OR settings that are used as learning labs at the beginning of the program.”

The program is currently not for credit, but is a 500-hour CEU program. Nurses come to campus for their didactic one evening per week for the duration of the program. “In the future, we hope to offer a distance education component to meet the needs of outlying areas within the region,” Johnson says. “Ideally, perioperative nursing should be included in the undergraduate nursing curriculum; however, until perioperative undergraduate education becomes a national reality, continuing education opportunities like the Boston Model serve an important role in educating tomorrow’s perioperative nurses and nursing leadership.”

“The fellowship I teach is nine months in length, and we take an RN, a graduate or with experience, and teach them how to be an OR nurse from the bottom up,” says Belinda Alt, RN, a nurse at St. John’s Mercy Medical Center in St. Louis, which teaches the AORN module, Perioperative Nursing 101. This course covers only the role of circulating nurse. Alt has therefore created her own course for the role of surgical scrub nurse. On one day of the course, a registered nurse first assistant (RNFA) takes trainees for an entire day, during which they set up an OR and tear it down multiple times. On another day, a charge nurse has them choose a card from basket that lists a procedure; the students must then pull every item appropriate for the case within a set time.

This is an entirely different kind of nursing, she adds. “We get our ‘attaboys’ [in a different way] — we are the patient’s advocate in [the OR]. You make sure everything is sterile when it goes on that fi eld so they won’t get an infection. You’re the one making sure there’s a safety strap so their foot won’t fall off the bed when they’re asleep and cause a pressure sore, or edema. You’re the one positioning the patient properly so they won’t have problems later on with a muscle or nerve entrapment. It’s like having a baby, because babies are helpless. These people are helpless; you have to take care of them.”

George Washington University Hospital has recently made its informal program formal; what used to be one-on-one precepting has now evolved to classroom lectures and clinical experience with multiple students.

“We try to get them to scrub first, because then they can learn to anticipate what a surgeon needs,” says Mary Ellen Hutchins, at George Washington University Hospital in Washington, D.C. “They also are able to experience the actual procedure.” And technology has changed how they train as well. “You’re doing more than nursing, you have to understand [technology],” she adds.

The facility is a teaching hospital, which makes training nurses easier; “The surgeons are teaching residents, so the nurse can learn at the same time. The surgeons are a little more patient also,” Hutchins quips.

There may be a shortage of nurses for the OR, but a more pressing need is that of educators, she points out. “The problem is that universities don’t pay as well. Therefore, the colleges don’t have enough faculty to teach; they have to limit class size.”

“When I went to nursing school back in the late ‘60s, it was really all about the instruments. Today it’s all about the patient,” says Christine Smith, RN, MSN, CNOR, clinical nurse specialist of perioperative services at Fox Chase Cancer Center in Philadelphia.

Smith also teaches at Delaware County Community College, which “has been somewhat the Mecca of perioperative education in this perspective. AORN offers a preceptor course for nurses who want to be clinical preceptors. There are still some hospitals that have enough staff and enough seasoned staff that they can take on new graduate nurses or nurses without OR experience. They educate them in the theoretical knowledge, but primarily in the skill sets.”

Smith sat on an educational summit earlier this year that looked at nursing education across the country. “Many of the people on the panel were nursing educators and deans from across the country,” she says. “We looked at ways we could reintegrate perioperative nursing and interventional procedural nursing into basic nursing education. When I speak of interventional procedural nursing, I’m also including under that umbrella, nurses in endoscopy, interventional radiology, interventional cardiology. Those are areas that, like perioperative nursing, are not typically included in primary nursing education.

“We were looking at a module system, where, say, perioperative and interventional procedural nursing could be a separate module taken as a senior elective. The nurse would get fundamental skills in the basic program. We looked at options for courses given online, where the nursing student would take the theoretical knowledge piece as an online course, and then would be assigned to the clinical area under the direct guidance of clinical preceptors. We’re very concerned, because we know between 2010 and 2020, we’re going to lose a significant number of our perioperative nursing population to retirement. At this point, we are not appreciating the entry into this particular realm.

“We’re also looking at ergonomic strategies, staffing and scheduling strategies to try to keep these older nurses in the perioperative setting, for their wisdom, their critical decision-making skills, and to be here to precept the younger nurses. There are hours of standing, lifting, pushing and shoving of heavy equipment, long hours, night call, and many older nurses are leaving because they find it difficult to withstand the demands, and there are other areas in nursing that are more forgiving for older nurses. Some older nurses would like to not have to take call, or work a late shift, or they’d like to work half days, do lunch and coffee relief and go home at 3,” she says.

Smith agrees that nursing faculty are in short supply, adding, “We’re trying to encourage more young nurses to become engaged in formal teaching, either as a teacher, or a mentor, or teaching part-time. We’re trying to encourage more nurses to consider working part time in their clinical specialty in nursing education, rather than having academic faculty, who have doctoral degrees or no field experience. If somebody’s going to teach me how to be a PACU nurse, I’d rather learn that from a PACU nurse than from an academic faculty person who hasn’t worn scrubs in four years,” she says.

Mount Sinai Hospital in Chicago is running all its current experienced OR nurses through the AORN course as a refresher, “so people will understand about cutting corners,” says Val Campbell, human resources nurse recruiter at the hospital.

They’ve hired nurses who do not have a med/surg background, and those nurses have been put through a rotation of each perioperative area, including PACU, preadmission testing, outpatient surgery and then the OR. “Once we get our existing nurses through Perioperative Services 101, [our goal is to] hire new grads. To be honest, we have not taken new grads in the OR; we’ve taken them into those areas that have an impact on the OR. They first learn those areas, then slowly integrate into the OR,” she explains.

“At the national level, there are several things [to help nurses transfer to the OR],” says Pauline Robitaille, vice president and chief nursing officer of AORN. “When I was president of my local chapter, we gave students scholarships to local chapter meetings, to our workshops, a couple times a year. On the national level, there is a student nurse membership at a reduced cost, and at our annual meeting, there is a student nurse program for them.”

Programs are available to members as well as non-members, she points out, ideal for those just getting into the specialty. For more information, visit www.aorn.org.