The Labor and Delivery (L&D) department at the University of Chicago Medical Center is staffed 24/7 with a mix of RNs and surgical technicians. There are a limited number of surgical technicians available to scrub for all emergency cesarean sections (C-sections). The patient population sometimes includes high-risk patients, necessitating the availability of highly-skilled nursing staff particularly trained to perform emergency C-sections. Therefore, a decision was made to train all RNs in the role of the scrub nurse.
Many of these nurses had some prior training for the role of the circulating nurse during a C-section procedure. The scrub role's training develops a unique skill set that requires additional knowledge. Reserach has shown that scrub nurses go on to become better circulating nurses.1 The nurse becomes more efficient in the OR by increasing his or her ability to anticipate and assess the potential needs of the surgical team.1 A verbal assessment was completed to determine the staff nurses' skills. Because there was no historical documentation, verbal assessment criteria included the following:
* aseptic setup of a sterile field
* proper surgical hand scrub
* ability to aseptically gown and glove
* identifies the names and uses of the surgical instruments in a C-section procedure.
To prepare the L&D staff nurses to function at different skills levels, an educational program was designed to cover the novice to advanced beginner levels.
Circulating versus scrubbing in the L&D
An extensive literature review revealed limited articles and evidence-based research regarding the instruction of L&D nurses in the role of a scrub nurse. Most of the articles from the Association of periOperative Registered Nurses (AORN) standards were adopted in practice communally.2 AORN's Perioperative Standards and Recommended Practices provides direction for the L&D scrub nurse regarding prevention of retained surgical items (sponges, sharps, and instruments), electrosurgery safety, and maintaining a sterile field.2 These standards provided direction for the development of the educational program.
Assessment. The first step of designing and planning the educational program was to assess the skills and levels of training needs for the L&D staff nurses. Benner's stages of clinical competence were used to assess the overall skill of the staff nurses and to design the training program. The levels of nursing experience defined in Benner's theory are novice, advanced beginner, competent, proficient, and expert. These levels are defined as follows3,4:
* Novice: Unable to function in the role of the scrub nurse during a C-section surgical procedure.3
* Advanced beginner: Able to function in the scrub nurse role independently but limited to routine C-section procedures.3
* Competent: Able to function independently without a preceptor for routine and emergency C-section procedures.3
* Proficient: Able to function independently without a preceptor for routine and emergency C-section procedures. Anticipates and applies critical thinking skills to the procedure.3
* Expert: Able to function independently without a preceptor for routine and emergency C-section procedures. Effectively applies critical thinking skills while in the role of a preceptor.3
These levels are fluid and may change depending on skill and experience. A nurse may be an expert in one specialty, but when placed in an unfamiliar specialty (for example, scrubbing for a C-section case), will revert to a novice skill level.3,4
Many L&D nurses had no experience in the scrub role, or their experience level wasn't recent. The competency needs assessment findings indicated that the majority of nurses were at the novice or advanced beginner level. These needs assessment findings were used to develop the scrub course content. For example, a nurse who had experience as a scrub nurse for C-sections within the last 5 years may have less hands-on case experience versus the non-experienced L&D nurse.
Adult Learners. Special attention was given to the adult learner with circulating experience. Engaging into the scrub role offers the advantage of making the nurse a better circulating nurse. The experience of the circulating nurse was beneficial to the staff nurse in the new role of scrub nurse. A disadvantage of an adult learner with experience is that the staff member may be resistant to changes with practices that haven't traditionally been expected of his or her role.
The scrub course provided an environment for blended adult learning concepts. It provided the opportunity to use life experiences, and with the transference of new knowledge, it offered enhanced career experiences.5 The course uses a blended approach of learning-centered and teacher-centered styles.5 Because the staff didn't have experience in the scrub role, the course used PowerPoint presentations (overview of instrument classification), video training content (sterile technique, hand washing), and policies and standards for review.5 The goal of a comprehensive course is to increase the confidence level of the staff nurse, expand knowledge, and increase the scope of practice.1
The scrub course was designed for the L&D staff over a 2-day period. Day one began with the fundamentals of the OR, including hand washing, sterile technique, surgical hand scrub (both waterless [alcohol-based surgical hand rub] and wet surgical hand scrubs), gowning and gloving, and maintaining a sterile field. Basic items were reviewed, including OR dress code, personal protective equipment (PPE), and recommended vaccinations (for example, hepatitis B vaccine [HBV]).
The scrub course was designed in two parts: the classroom didactic and hands-on simulation lab sessions. The classroom didactic was the first half of day one, which included many different types of teaching methods, such as lecture, videotapes, discussion, and hands-on items (instruments).6 The didactic content was taught by the same group of instructors to maintain consistency. When not instructing a segment, the other instructors assisted in setting up the simulation lab sessions. The simulation lab sessions were developed into a small group size. The small size (6 to 8) allowed the 1-to-4 ratio of instructor to students so that the simulation lab session could be maintained. The simulation lab sessions are prepared in an OR suite that has back tables, mayo stands, and a patient bed. The OR suite provides a realistic setting for the staff members and provides the correct OR environment for the low level of simulation training.
In the past, the scrub nurse would have learned the art of passing instruments and preparing a sterile field in real time—during an actual surgical procedure. The use of the simulation lab provides participant realism without the possibility of harm to a patient. The simulation lab also provides instant feedback for the participant.7 Simulation learning can be low- or high-fidelity. Fidelity refers to what extent the simulation lab promotes reality.8 Low fidelity usually relates to psychomotor (hands-on) training, while high fidelity refers to development of high-risk training, such as airway management, advanced cardiovascular life support, or treatment of malignant hyperthermia.8,9
Scrub course content
The goal of the scrub course was to provide the staff member with knowledge related to the scrub role, and the expectation was to apply the knowledge that was received in the didactic content.10 The staff was also given additional instrument props to provide increased recognition of the instruments during the lecture (see Educational program content).
The use of flash cards was implemented to help the staff nurses learn the different instruments they'd be using during a C-section. The perioperative educator created flash cards for each instrument in the C-section tray. Surgical reference textbooks were used as resources to develop the flash cards.11,12 Each instrument was photographed using a digital camera and placed in a format to create flash cards. One side had the instrument picture and the other with the name and classification of the instrument. The flash card was designed to assist the nurse in the continual process of learning to identify the instruments when they scrubbed.
The staff was given the opportunity to review the flash cards and use them to prepare for their upcoming case. Other tools that were developed included a practice tray list and an instrument tray. They also provided another avenue of practice for the staff nurse (loading of needle holders with needles, opening and closing clamps, and correctly passing of instruments).
Hands-on laboratory sessions
The hands-on simulation lab sessions were developed to provide a sense of realism for the staff nurse. The first half of the simulation lab session was to provide the staff nurses with the basics of surgical hand scrubbing, gowning, and gloving. Emphasis was placed on sterile technique. The second part of the simulation lab sessions provided the staff nurse the experience of learning the instruments, sterile field set up, and draping. The staff nurses were given time to set up their sterile field. The other staff members were used as observers of the sterile field setup and sterile technique. The instructors of the hands-on simulation lab sessions provided instruction and addressed any break in technique while providing insight into any other issues that came up during the session.6
During the last part of the simulation lab sessions, the staff nurses participated in a simulation of a C-section surgery. The simulation provided realism in a safe setting, and the instructor played the role of the surgeon to provide realism of a surgical experience.6 The simulation provided them a chance to practice the skills and reinforced the knowledge and skills that had been taught (see Example of validation skills for a hands-on simulation lab session).
The program evaluation was completed at the end of the 2-day course. The overall class evaluation scores showed that the L&D staff nurses were satisfied with their training experiences.
During the designing and planning stages of the hands-on training session, a competency validation tool was developed to validate the nurse's skills in sterile technique, draping a sterile field, surgical hand scrub, gowning, gloving, and maintaining a sterile field. During the planning stages of this training program, it was determined that the nurses would have five experiences. This would depend on the level of learning (novice versus advanced beginners). Each staff nurse was given a log to maintain a record of their experiences.1 The log was turned into the Obstetrics/L&D educator. The log gave the staff nurse a current record of C-sections they participated in and the skills performed during the procedure.
The staff nurses were required to complete a scrub goal sheet for each procedure. This provided the educator a record of their strengths and weakness. The scrub goal sheet provided documentation of their independence during their scrub role experience. The staff nurse was given a final validation of skill by one of the educators or a “superuser” clinician to observe their case and skills.
Outcomes and lessons learned
During the 2-day course program for L&D staff nurses, over 40 nurses were trained in the scrub role within 6 months. After the successful completion of the 2-day course, each nurse was given a certificate of completion. The practicum experiences in the OR with a preceptor are still in the process of completion. Currently, only small numbers of staff nurses have fully completed their experiences and have been fully validated.
The staff nurses will need to continue the process of professional development and increase their knowledge in the role of a scrub nurse. According to Marzlin, continuing education is one component of professional development.13 Each nurse has the professional responsibility to acquire knowledge and skills that reflect current practice.13
Additional options for training include the use of a video recorder during the simulation lab training sessions.7 Once the session is completed, the staff nurses are able to view the video of their training session. The video is a tool that allows participants to self-evaluate their overall performance during the training.14
Educational program content
* Introduction of educators
* Review of objectives
* View the following videos:
- Sterile technique
- Wet surgical hand scrub, gowning, and gloving
- Waterless surgical hand scrub
* Dress code review:
- Discuss hospital infection control policy: dress code section
- Acquiring scrub attire
- No jewelry, clothing, fanny packs, dedicated shoes
- No artificial nails
* PPE – eyewear must be worn by all scrubbed personnel
* HBV – recommended for all staff entering the OR
* Distribute competency validation tools:
- Waterless surgical hand scrub
- Wet surgical hand scrub
- Gowning and gloving
- Sterile technique
- Sterile set up
* Review instrumentation and suture PowerPoint presentations
* Applying the principles of sterile technique in the surgical clinical setting
* Review the fundamental traits of a “surgical conscience”
* Review basic operative skills including:
- Aseptically opening sterile supplies onto a sterile field without contamination
- Proper surgical hand scrub and aseptic gowning and gloving
- Gowning and gloving other surgical personnel without contamination
- Moving in and around a sterile field without contamination in both the scrubbed and circulating roles
* Practice mock C-section set ups
- Opening sterile supplies onto a sterile field without contamination
- Apply the principles of sterile technique in the surgical clinical setting
* Demonstrate the fundamental traits of a “surgical conscience” while maintaining a sterile field (identify any breaks in sterile technique)
* Demonstrate competency in performing basic operative skills including:
- The ability to demonstrate a surgical hand scrub and aseptically gown and glove without contamination
- The ability to move in and around a sterile field without contamination in both the scrubbed and circulating roles
- The ability to demonstrate the draping technique for a C-section procedure
- The ability to name and handle surgical instruments (such as universal and bladder retractors, placenta ring, parker retractor)
- The ability to select and open supplies and sutures without contamination in the scrub role, specifically for C-sections
Example of validation skills for a hands-on simulation lab session
1. Sterile persons must stay within sterile field
2. Sterile scrub nurse must keep hands at or above the waist level
3. Scrub nurse must avoid changing levels unless the surgical procedure is at this level
Waterless surgical hand scrub:
1. Dispense approximately 2 ml of antiseptic skin prep into hand using foot pump
2. Spread skin prep from wrist to elbow
3. Repeat steps 1-2 on opposite hand
4. Dispense a final 2 ml of antiseptic skin prep into hand and rub both hands together
Wet surgical hand scrub:
1. Follow manufacturer's instructions
Sterile field set-up:
1. Open sterile OR pack
2. Open sterile gown and glove; scrub, gown, and glove aseptically
3. Aseptically drape the mayo stand
Draping the sterile field:
1. Place the drapes on a dry sterile field
2. Do not reach across the OR bed to drape but walk around to apply the drape
3. Ensure sterile gown doesn't touch unsterile bed or patient while applying the drapes
4. Hold the drapes to avoid touching the floor and OR lights
5. Do not shake or fan drapes while applying
1. Phillips N. Operating Technique. 11th ed. St. Louis, MO: Mosby Elsevier; 2007.
2. 3M Avagard. Application Instructions for Surgical hand Antisepsis. St. Paul, MN: 3M; 2003.
© 2014 by Lippincott Williams & Wilkins, Inc.