Meeting the Challenge

THE PERIOPERATIVE EDUCATOR has a challenge common to all teachers making information fresh when its been heard a hundred times before. Repetition can only do so much. It becomes the educators responsibility to make data exciting or interesting to the healthcare provider.


I think there are such new and evolving national patient safety standards that are set forth through the surgical care improvement project (SCIP) program, and through the 100,000 Lives campaign, says Alecia Cooper, RN, BS, MBA, CNOR, vice president of clinical services at Medline Industries. There is so much coming at the nurse now from a different perspective. Safety has always been important, because its a high risk area. There is so much coming at them at once that the knowledge deficit is related to What does this mean to me, and what is my responsibility?

The second deficit, Cooper adds, is that technology advances occur daily in surgical services with equipment and instrumentation, as well as in the development of new types of procedures and refinement of existing procedures, such as transitioning from an open procedure to a minimally invasive procedure.

You have to depend on the industry and manufacturers [to offer education], because whoever youre buying or obtaining equipment from, those folks have to step up to the plate and help provide training and education, she says.

Some of the biggest problems are that the nurses get caught in the middle. They know what to do, and how to do it, for infection control, says D.J. Flournoy, PhD, director of microbiology at the Veterans Affairs Medical Center in Oklahoma City. Often they know what the right thing to do is, but they are subject to this double standard because physicians can bypass some of the written rules, and sometimes the physicians who bypass are in the right. There are occasions when a sign that tells you how to do something when you come in the room is not appropriate, like if a patients crashing. In that case, forget it you have to keep the patients alive first and worry about infection control second. The nurses try to do what they have time to do; theyve got to take care of the patient, to please the provider, to do all the bureaucratic minutiae thats thrown at them.

Nurses, he adds, do an excellent job in general, but their time is precious, and there is rarely enough of it. I dont envy the operating room (OR) nurses; theyre working with people who are aimed at a different thing. The surgeons their job as they see it is often to do the surgery right and then its over for them. Not always some of them are more conscientious than others but for many of them, once the surgery is done, their job is done. The nurses and other people have to pick it up from there.

Im in the microbiology lab, and when we deal with the OR, the biggest problem at the end of the day is when we get specimens that arent identified properly. The order numbers arent correct, or the patient names might be mixed up. Its because the staff members get a lot of work late in the day, but the surgeons are gone. The surgeon does this surgery, gets these pieces of tissue, and wants them sent to the lab for a culture, but they dont seem to even want to be involved in the rest of it. Its not going to get done if the sample is not in the right container, or if its not labeled properly, or if we dont know what they want done on it, and if we cant find them, Flournoy adds.

He recalls a recent experience with a specimen of what was officially pleural fluid. However, the specimen could have been mistaken for urine it was colored brown, and slightly foamy. I thought, Im just going to call up there and find out if it really is pleural fluid. One of the nurses gave me the physician who aspirated the pleural fluid. He was upset. He said, Dont bother me; talk to the nurse. The nurse verified that it was really pleural fluid, but I was just doing my job. We need to check out things that are questionable, because it could be the wrong thing. And if it were urine, they could be totally different organisms; it could mess up the reports.

A year ago, additional problems presented themselves not due to deliberate mistakes on the part of the OR nurses, but due to their lack of knowledge of additional resources. Flournoy set up a meeting with the OR nurse manager and had a fruitful discussion with the nursing staff. Good communication was essential, he recounts. You must go into it with no hard feelings, trying to determine how to help each other.

First of all, the nurses didnt have the right transport media, and they didnt know that there was anything else out there. We found a transport media that would accept tissue, so they could submit anaerobic cultures, because they would cram a piece of tissue the size of your index finger in a culturette tube, and if you try to get it out of there, its almost impossible.

But they didnt have anything else, and didnt know anything else was available. We ended up finding a vendor and purchasing a more appropriate container.

Oftentimes, its just a simple problem with a simple solution. After that incident with the possible urine that was actually pleural fluid, I asked the nurses if it was possible to write down on the specimen tube/media what it was, in their own handwriting, so we would have a double-check that way. When we look up the orders in the computer, if it says the same thing on the specimen, it reinforces that its the correct specimen. It could save them a call and having to bother somebody later on. Previously, nothing was written on the tube there was an order number and the patients name. If you go to all the trouble of obtaining a sample, if youre the patient, and somebody cuts on you, you dont want that to be labeled as the wrong thing. We go to all this trouble to do these surgeries theyre very invasive and hard on the patients, and theyre costly and time consuming, but the specimen may not be labeled properly and not ordered properly.

Janie Thomas, RN, BSN, MA, clinical consultant for Ansell Healthcare, provides education and clinical training in ORs and lectures both regionally and nationally. She observes that one deficit in education is emerging diseases and antibiotic resistance, which are constantly evolving and must be dealt with almost on a daily basis. Theres always something around the corner that we have to learn about, she comments.

Where were finding enormous deficits that we werent aware existed is actually how to do sterilization and disinfection according to the Spaulding method, says Frank Myers, III, MA, CIC, CPHQ, a clinical infectious disease epidemiologist at Scripps Mercy Hospital in San Diego.

By that, we mean what equipment gets high-level disinfected. Oftentimes, a hospital will train individuals on how to clean scopes in the OR, and validate the competencies of a large number of people, but that individual may encounter only one scope a year, and not the scope they were trained on, so they may not know about all the channels on that scope. They may think that all scopes are high-level disinfected, and not know that arthroscopes need to be sterilized because theyre going into sterile tissues. There had been the assumption that you train them how to do high-level disinfection with product A, and they understand the entire process, but they dont necessarily know that. Youre creating what we call high-risk, low-frequency events, and its difficult to train staff for those events. If you train somebody on how to do fl ash sterilization, and they work on the weekends and only do fl ash sterilization twice a year, the possibility theyre getting something wrong is quite high.

Its possible, Myers says, that the staff member could forget a step, or not remember if they should use a biological indicator with it or not. That depends on the hospital policy. And if the staff member works at multiple hospitals, there could be differences in each facilitys policy for biological indicators. The chances theyll remember that, if they only do one or two fl ash sterilizations a year, is pretty remote, he adds.

Whenever youre training staff, you have to consider the question, Is this something theyre going to be doing regularly? If not, then you shouldnt be training large numbers of people, but rather a few people. If youre limiting the number of people, the frequency of their doing that job increases, so they are more competent. Dont train a hundred people for something theyll do once a year. Instead, train ten people who will do it ten times a year.

Innovative Presentation Techniques

Making the information fresh remains a challenge. But technological advances make it much easier to give the staff member multiple means of access to the same information. You need to look at flexible options to do present the information, such as online training, web-casts or v-cast, even CDs. Its no longer possible to take someone out of staffing for an entire day or an entire week for training. Companies have to come on-site to the facilities and provide the necessary training in an easy format, and be flexible enough to work around the clock, on all shifts, Cooper says.

Video, teleconferencing, and magazines or journals that are presented in a more easy-read format are an effective means of conveying information, she continues. The way I look at it is that at the bottom line, they need to know what they need to know quickly, so we are looking at ways to do that through CDROMs, video-casts, magazines, training guides, application guides, even having an application specialist on-site.

Medline is also considering the idea of a kiosk, setting up multiple stations in strategic locations throughout the facility. They also offer a magazine, OR Connection, which offers current articles related to the national patient safety initiative, as well as the new procedures and projects going on within perioperative services, and accompanying continuing education credits, three times a year.

Theres no one set method of getting education to the staff members, Cooper continues. There are seminars you can go to, but hospitals are cutting back on those, so the staff member is on her own to pay for that. Sometimes it works, but not always, so they have to have a method they can continue in their off-time. With Medline University, you can start a training and education session, and if you get called back to work, you can later pick up where you left off; its the same thing if you were doing it at home or on a weekend. Flexible methods that will work 24/7, no matter where you are, are the key whether its a CD they can take home or an online training program or a booklet they can use. We have clinical specialists who will travel on-site and do a Saturday program or a half-day or full-day educational program. Some topics are hard to do a video-type or CD-type course on. They need to be live applications, or handson training, so you have to provide all the different mediums. Its one thing to read about it, but another thing to actually perform the task.

Nurses seem to learn very well from self-study modules, says Thomas. Self-study modules have become a very effective way to give nurses the information, she continues. As busy as they are every day trying to get the cases done, sometimes its difficult to get people out for a seminar or to hear a session. So self-study guides or a self-contained module on the information with a pretest and posttest can be a beneficial way of getting new information out there to them. If you can tie that into whats going on in their individual facilities with statistics on surgical site infections (SSI), for example, I think that can be a good means of getting the information out to them. The nurses come to us asking for this, so its something they find valuable. Right now, we have nine different programs that we offer, including latex allergies, radiation safety in the OR, and bioterrorism and appropriate barrier protection. I think that for OR nurses since theyre so extremely busy it is a good means for them to learn at their own pace. They can take it home or study it on breaks, and they can get the information when they have the time to do it.

I think providing online or at-their-fingertips answers to problems they may encounter during the actual event is a good way to reinforce the learning, Myers observes. People may not remember 20 steps in a process. Since policies vary by instrument, and the steps are going to be complex, come up with a book to use for that case, so they can see that for product A, instructions are on this particular page all of the steps are laid out for them.

Even with new technology, it can still be difficult to convey the information in a fresh, captivating manner. One of the ways were working at is videotaping the individual performing the necessary task, then providing feedback. Its pretty rare for the facilities to all have that ability, but if you have it in-house, its very effective. If you walk somebody through a particular task, pointing out what they did wrong and what they did right, if you film them doing the same task a few times, it can be extremely useful. You can see those mistakes, and have more ownership over the process. Anytime somebody is inserviced because somebody else made a mistake, theres this assumption that I would never make that mistake myself, but showing the film is another effective way to do that.

A few companies also work with fl ash technology, Myers adds. This is computer animation, in which you can program demonstrations on how to do something correctly. For example, I just consulted with a company on how to clean up a fecally incontinent patient without causing cross-contamination, which is pretty hard to do if you think of all the steps we do with wiping down the patient, etc. There are sprays we use on the patient to prevent skin breakdown, etc. With all of those events, it is pretty easy to cross-contaminate, so to be able to go to a company and say, I want you to have computer animation of how to clean this patient correctly, is pretty effective because you can get those animations out there quickly."

Industry Associations Involvement

The Association of periOperative Registered Nurses (AORN) certainly provides e-mail broadcasts, Cooper adds. Im a member and receive weekly e-mail broadcasts from them. The associations all have Web sites, as we do, which offer at-your-fi ngertips information and search engines that allow you to get the latest, greatest information. Theyve always had telephone access, journals, periodicals, and papers that they publish occasionally, as well.

The industry associations have made it much easier to find the standards to which healthcare providers must adhere, Myers points out. The Association for Professionals in Infection Control and Epidemiology (APIC) and the Association for the Advancement of Medical Instrumentation (AAMI) have done a good job of moving resources online so theyre readily available, he says. They are on the Web or in a PDF format, so you are able to perform a search on particular keywords. In years past, you would receive big tomes that were diffi cult to go through on a quick basis to find an answer to what the standard was, but now with a PDF, you can do a search on one word.


So much more would be possible if funding were increased for education. Myers suggests the possibility of virtual trainings a luxury only afforded by big budgets for education. We could put people in situations in which there werent patients actually present, he offers. We could walk them through simulations of what was going to happen. For instance, whenever it comes to things like antibiotic dosing, you could run a simulation to find out, Does it make sense to do that at the time-out, or is that not going to work? Youd be able to problem-solve a lot of the performance improvement efforts weve put into place, without first having done a dry run on it. I think those would be fairly useful in cases of preps; youd be able to test whether people were prepping the site correctly.

Consider space travel, he proposes. Think about how often an astronaut goes through a dry-run practice on what the space flight is going to be like. They experience hundreds of simulations in artificial capsules before they ever take one flight, and the reason we do that is because their lives are on the line. But at the same time, well put a nurse in a situation in the OR for the first time [without adequate training or education], with the patients life on the line, and that doesnt make a whole lot of sense.

Increasing the funding available for education may be a pipe dream, but is certainly an ideal to strive for, Thomas observes. If we had more funding, we could have more research and more studies performed. We could obtain more answers and more direction for where e need to go. That would be a wonderful thing, but whos going to do that? she queries.

Education is not exactly an afterthought, but when dollars get tight, she says, its one of the categories that suffers, especially in hospitals. Any nurse will tell you that, she adds. In the hospital setting, when things get tight, the educational budgets get cut. That is one of the reasons why it is so important that industry has a strong education and clinical component, to support and educate the nurses and techs and other people in the hospital, because the hospital hasnt been able to keep up with that, due to budget cuts.

In years past, hospitals had a lot of money to spend on education, and on sending nurses to seminars and conventions, and I think that has been cut back tremendously. Even their own internal budgets as far as educational programs they put on within the facility have been cut, so I think that is one reason that industry has found it so necessary to keep their educational budgets going, to offer this service to hospitals.

The manufacturer gets something back from offering this education to the facilities. If youre educating on what you do know, youre going to get feedback from the staff on what types of cases theyre doing and whats new and what theyd like to see in the future, Thomas says. Its also an altruistic thing, because its the right thing to do. Every company wants to be doing the right thing. I think its important for companies to keep that education component, and I think most of them realize that. Nurses have started looking to [manufacturers] to continue to support them in their educational endeavors, and we dont want to let them down."

The techniques for presenting information to the OR staff often depend on funding, points out Cathy Halterbaum, an instructional design manager for AORN. Were all restrained by budgets, she observes. There are real intricate and expensive ways to present material. There are also less expensive means of presentation. The cheapest would be to write a paper with the information and post it on the Web, or send it out through an Internet or Intranet for nurses to read. Thats not very interactive, and its not very fun, actually, she adds. You can also use the same distribution method, but with a PowerPoint presentation that has audio, animation, or graphics. Then you get a look at something that is more fun visually, but with the same information. If you add audio, then you get a higher level of not interactivity, but you feel like you are listening to the speaker live, even though youre not.

AORN offers CDs, or puts the information on the Internet. Here, we do four short presentations, Web seminars, and live sessions that are recorded to be posted for viewing at a later date, she says. If the speaker is only available on a limited basis, we can record it and later post the recorded session. In this case, however, you dont get the advantage of a question-and-answer session.

Of course, there are more expensive online programs, in that if you have the information already prepared, you need a designer to make it presentable for online delivery, she adds. Its a little different for online than if it were presented in a document or in a PowerPoint format. There are more design aspects to it, as well as graphics. The nice thing about offering an online program is that you can add questions and get immediate feedback whether your question right or not utilizing multiple choice, fillin-the-blank, or free text. You can have links that go to Web sites, and add audio, video, get as fancy as you want and as expensive as you want.

AORN utilizes a vendor called BlueSky. This vendor takes the PowerPoint of a presentation and then records the presenter, and then offers accompanying audio. The PowerPoint is then made downloadable or streamed off the Web. It plays in a common format, Windows Media Player, and the healthcare worker is able to listen at his or her convenience. The association also has the opportunity to set up a discussion board, which will allow the viewers to post questions in the setting of a threaded discussion group or bulletin board, and immediately see if the instructor or speaker has answered their question.

We havent put a Webcam into our Webinars, because our nurses arent ready for that technology, Halterbaum comments. They wouldnt have the bandwidth for webcam capability. Many of them dont have high-speed Internet. Presentation is everything, she adds, but the information and the style of its production can be customized to the speakers style. People do like seeing a picture of the speaker, but if you have a dynamic speaker, sometimes not even that is necessary. If the speaker is so compelling that you are riveted, you dont have to see him or her; you just listen. Their PowerPoint presentations are appealing and speak directly to what theyre saying, and that keeps you engaged.

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