Angie Tesla, RN

Training our own replacements

The effect of the omission of operating room experience in student nursing programs is now being felt in the lack of OR nurses. We hope schools of nursing and hospitals will eventually acknowledge the need for the basic operating room skills, will take another look at their training programs, and will attempt to meet the needs of the patient, the nurse, and the hospital. But what of the interim? Where else does the student nurse learn and practice the basic principles of aseptic technique, which can be applied to other duties such as changing a pa-

Angie Tesla, RN, is OR assistant supervisor at Children’s Hospital of Pittsburgh, Pittsburgh. She is a graduate of Pittsburgh Hospital School of Nursing. 302

tient’s dressings, assisting the emergency room surgeon with cleansing wounds and suturing lacerations, and in the care and handling of sterile supplies? A recent editorial in the AORN Journal described the fears of one senior student nurse who wished to pursue a career in the operating room but felt she would not find a job because of her lack of OR experience.’ While such a predicament may be real for this nurse, the experience requirement is not unique for nurses. One may have a major in economics but without experience may not even be hired as a bank teller. Employers want capable, productive, and satisfied employees but are unwilling to train the inexperienced. Although there may be a shortage of nurses in some communities, many cities and towns do not suffer from this problem. As in many other instances, one must be in the right place at the right time. If there is a demand for nurses in the operating room, one might “get lucky,” be hired, trained on the job, and be a good OR professional. But, what if the nurse does not get lucky? Schrader states that “specialty nursing courses should be affiliated with a college or university rather than bur-

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dening the hospital.”2 While I might agree with this, it is somewhat expensive to set up a curriculum, furnish an OR practice laboratory, and purchase necessary equipment. There may not even be enough interested nurses at the time to make the pursuit profitable. Also, if there are sufficient nurses to train, there may not be OR positions available when they complete the program. Six years ago I answered a want ad for OR nurses: “No experience needed; will train.” I was in the right place at the right time, and I was hired at Children’s Hospital of Pittsburgh. Since then, many other inexperienced nurses have been hired because trained OR nurses were not available. Some of those I now consider our best OR nurses came without OR experience. We have tried different teaching techniques and have found no one program is best for all nurses. Some learn technical skills more quickly than others; some have natural talents for the OR; some are simply not OR professionals and never will be. I believe, if a hospital is not able to affiliate its operating room training program with a university or college, it is possible to hire the inexperienced and to teach them at their own pace using on-the-job training and a “buddy system.” The first requisite for a program of this type, however, is a cooperative hospital administration, which recognizes that OR nurses do not grow like weeds-adequate “growing” time and nurturing are essential. At our hospital, we have asked our nurses to notify us as soon as possible when they decide to terminate. Their sincerity allows us to recruit in advance and to start training a replacement, sometimes before the nurse leaves.

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All our nurses learn to scrub and to circulate because we feel a nurse can be more perceptive as a circulator if she is also a scrub nurse, and our nurses are not satisfied performing only circulating duties. During my learning experiences, my “buddy” taught me to think logically-think in sequence, in steps: “First the surgeon cuts, then clamps-give him a hemostat; next he dissects-give him the scissors and a forcep; after suturing-give him scissors to cut. To insert a bone screw, the orthopedist needs a drill bit, depth gauge, proper bone screw, screwdriver.” My first two weeks in the OR had not been going as well as I thought they should, and I considered resigning until my buddy patiently advised me to “think in sequence and lay out your instruments in the order of usage.” At the present time, our general surgical specialty nurse introduces new nurses to the OR’S physical layout, the policy book, the procedure book, and the skills, such as aseptic technique, scrubbing hands and arms, and gowning and gloving themselves and the surgeon. The specialist teaches the nurse to drape the prep table and the Mayo stand and to identify Kelly and Kocher forceps, needle holders, and army-navy and Deaver retractors. The specialist also demonstrates how to pick surgical sets of instruments. The general specialist has the important responsibility to provide the basic skills. She is the gourmet who brings all of the ingredients together to provide a special, unique flavor. However, the most important function of the general specialist is in the role of confidant, adviser, and resource person for each new OR nurse. About the third or fourth day of

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orientation, the nurse is assigned to scrub with a buddy for herniorrhaphies, cyst removal, and other minor cases, practicing until he/she becomes proficient enough to scrub alone. Then the nurse scrubs, again with a buddy, for laparotomies and thoracotomies until comfortable in major surgery. After scrubbing for general surgery, we concentrate on the circulating duties for the same service. The next specialty to learn may be plastics or ENT. In each, the nurse first learns to scrub with the specialty nurse and then learns to circulate. We follow through with orthopedic surgery, neurosurgery, genitourinary surgery, and finally cardiovascular surgery where the nurse scrubs first on closed heart cases and then in open heart. In neurosurgery and cardiac surgery, however, the nurse does not scrub first and then circulate. We feel the first days in these two services are best spent with the specialty nurses, observing the surgery, operating the equipment, and learning procedures. Whether the new nurse scrubs or circulates initially depends on the surgical procedure for the day. If the surgery is a closed-heart procedure such as a ligation of a patent-ductus arteriosus or an excision of a coarctation, the nurse would scrub with the specialty nurse. If the procedure is t o close an atrial or ventricular septa1 defect on bypass, the nurse would circulate with the specialty nurse. After rotating through all services, the new nurse has finished her OR orientation. We do not set deadlines. The orientation, an undetermined period, is over only when the nurse has completed a rotation of all the surgical services. This may take three months, four months, or longer if more than one nurse is being oriented. The new nurses are usually anxious

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to be rid of the preliminaries and get into the sterile field. It is selfsatisfying for those who teach to sit back and observe “inexperienced” nurses complete a first solo herniorrhaphy, craniotomy, or mitral valve replacement and to share their excitement and good feelings. Each knows if the job has been well done, and there is much satisfaction in suddenly realizing, “I can stand alone.” Before this triumph however, there can be confusion, frustration, and many obstacles. It is not easy for a former head nurse or even a new graduate to return to a situation that I regarded as worse than any “probie” period. The new OR nurse is suddenly in a strange world. There is so much to learn, and it might be considered an impossible feat if thought of only in short-range terms. The new nurse must keep the long-range goals in mind. Scrubbing and circulating with different persons in the beginning of the orientation might cause confusion and frustration; therefore, the new employee should share initial experiences with as few staff members as possible. It must be kept in mind, however, that each senior staff member has his or her own little trick-of-the-trade, which he or she might be willing to share. If junior staff members are patient and receptive, they will eventually be free to choose from a smorgasbord of styles, skills, and techniques. In our operating room, reorientation continues daily for all nurses and technicians as they rotate through orthopedic, ENT, neuro, general, or cardiovascular surgeries. Also, all the staff nurses are given an opportunity to “run the schedule.” If possible, each nurse is assigned as the charge nurse a week a t a time. During this period, the nurses learn to keep the schedule

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moving by using empty surgical suites and by keeping the n u r s i n g and anesthesia staffs notified o f changes, additions, and cancellations; t o handle maintenance problems-whom t o contact for autoclave breakdowns or equipment failure; how t o retrieve a lost “security blanket” or a magnetic m a t from central l i n e n service; and how to manipulate the cases t o prepare for a neonatal emergency or a ruptured spleen. In “What future for nursing” in t h e AORN Journal, Hoffman states each OR nurse must replace herself, r e c r u i t

for the specialty, and campaign for a “continuing supply of ably trained and committed registered nurses in t h e surgical suites of tomorrow . . . .3

Mixed report on vitamin C effects

High school students use multiple drugs

Vitamin C can help young girls and is also of some value to young boys in combating the common cold, but according to a research report in the Journal of the American Medical Association, the vitamin shows “no significant overall treatment effect on cold symptoms.” Judy Miller, Indiana University School of Medicine, Indianapolis, and colleagues used 44 school-age twins to test the theory that vitamin C reduces the frequency and severity of colds. Sets of twins were selected to rule out the possibility of differences in inborn hereditary resistance to colds. One twin from each set of twins received daily doses of vitamin C and the other twin received an inert substance. Their mothers were not told which their children were receiving. As the five-month project progressed, mothers reported on the number and severity of colds their children had. Girls treated with vitamin C in the youngest two age groups had significantly shorter, less severe illnesses. The youngest group of boys treated with vitamin C reported somewhat less severe illnesses as well. Surprisingly, however, the seven treated twins in the youngest group of boys grew an average of about one-half inch more than their untreated cotwins. Miller reports that this effect on growth must be confirmed before it can be accepted as established fact.

High school students using mind-altering drugs are likely to be using several different drugs at the same time, according to a 1972-to-1973 study of more than 1,000 high school students in the New Haven, Conn, area. The study is published in Archives of General Psychiatry. Most students follow a “stepping-stone” pattern of drug usebeginning with alcohol and moving on to marijuana, hashish, barbiturates, amphetamines, LSD, mescaline, cocaine, and heroin, according to Leroy C Gould, PhD, and colleagues at Yale University, New Haven.

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If our OR training programs cannot affiliate w i t h a university or college, t h e n we must immediately accept t h e responsibility to train our o w n nurses.

0 Notes 1. Elinor S Schrader, ”A growing need for specialty OR nursing courses,” AORN Journal 24 (November 1976) 845. 2. lbid, 846. 3. Martha Hoffman, et at, “What future for nursing,”AORN Journal 24 (August 1976) 231.

Three-fourths of the students used alcohol outside the home with friends. Over half had at least tried marijuana, and one-third reported they were currently using it. One-third had tried hashish, with 18% currently using it. Approximately 18% had used barbiturates, 18% had used amphetamines, 12% had tried LSD, 10% had used mescaline, 9% had sniffed glue, 6% had used cocaine, and 2% had used heroin, Gould said. Multiple-drug use was prevalent; 58% of the students reported they had used more than one drug, and 44% said they had used three drugs or more. Of the study population, 43% reported they were still multiple-drug users at the time of the survey.

AORN Journal, August 1977, Vol26, No 2

Training our own replacements.

Angie Tesla, RN Training our own replacements The effect of the omission of operating room experience in student nursing programs is now being felt...
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