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Department: LEARNING CURVE

Growing specialty area exposure with an undergraduate perioperative nursing course

Ruth-Sahd, Lisa A. EdD, RN, CEN, CCRN

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doi: 10.1097/01.NURSE.0000526902.45745.04
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NURSING STUDENTS are exposed to many different specialty areas during their undergraduate education, but many are minimally or never exposed to perioperative nursing.1 Exposure is often not enough for the student to gain a full understanding of the nurse's role in scrubbing, circulating, or first assisting. Graduate nurses who aren't aware of the perioperative nurse's role will likely not apply for available positions in the field upon graduation.1,2

Currently, there's a severe worldwide shortage of perioperative nurses. Many of these practicing clinicians are age 60 or more, and research indicates that up to 64% of perioperative nurses are planning to retire by 2022.3-5 Additionally, the demand for perioperative nurses in the United States is growing steadily by 1% to 2% each year as the result of increased surgical caseloads.6-10 So, a critical shortage of perioperative nurse leaders can be expected.4

Educators concerned about the perioperative nursing shortage may want to consider offering a related course to their students. By taking a perioperative nursing course, undergraduate nursing students will gain more in-depth exposure to this highly specialized area of nursing. An appreciation for perioperative nursing will help inform and shape their future career choices.6-8,11,12

Curriculum challenges

Undergraduate nursing curricula provide minimal exposure to the perioperative specialty area despite the fact that many students are very interested in this area of nursing.1,2,11 Both the Association of Perioperative Registered Nurses (AORN) and American Society of PeriAnesthesia Nurses recommend exposing undergraduate nursing students to multiple perioperative learning experiences, including active participation in the care of perioperative patients, rather than a single passive observation.9,10,13

The American Association of Colleges of Nursing states that interdisciplinary education is an essential component of baccalaureate nursing education.14 The National Academies of Science, Engineering, and Medicine's Health and Medicine Division has called for a smoother transition to practice, and the Institute of Medicine supports experiential types of clinical experiences in its Future of Nursing report.3,15 Reasons noted in the literature for a lack of exposure to perioperative information are the lack of specialty professors to teach the subject, lack of time in the already overloaded nursing curriculum, and minimal elective opportunities.6,7,11,12

Perioperative specialty course

York College of Pennsylvania collaborated with Wellspan Health-York Hospital to provide a 3-week perioperative nursing elective to meet the hospital's needs as well as pique the interest of their student body. As a faculty member at York College who also attended a perioperative course there as an undergraduate, I recognized and valued this experience and wanted to offer the course again. I polled the student body to gauge interest. Next, I met with the perioperative clinical nurse educator at the hospital, who was very supportive and saw this as a way to help ease the hospital's staffing shortage.

The course objectives were developed in collaboration with the perioperative nurse educator using the AORN Periop 101: A Core Curriculum learning modules as well as the text “Alexander's Care of the Patient in Surgery” and AORN's Perioperative Standards and Recommended Practices: For Inpatient and Ambulatory Settings.16

The skillsets of the students were taken into consideration when we formulated the following student learning outcomes:

  • Describe basic perioperative nursing concepts as they relate to patient and environmental safety.
  • Identify introductory principles of anesthesia, including types, indications, and complications.
  • Administer care to the perioperative patient and significant others, including assessment and teaching.
  • Observe care for the intraoperative patient, including instrument identification, safe patient positioning, patient preparation, assessment, identification of surgical team roles, and proper handling of specimens and implants.
  • Provide care to the postoperative patient.
  • Describe surgical specialties, including general/vascular, open heart, orthopedic, neurologic, urologic, ear nose and throat, plastic surgery, and obstetric/gynecologic.
  • Recognize special needs patients (for example, bariatric, pediatric, and geriatric patients) in the perioperative environment.
  • Identify complications of surgery (for example, malignant hyperthermia, infection, and bleeding).
  • Determine legal/ethical issues surrounding perioperative nursing.

Eligibility considerations

Prerequisites included all science courses (Chemistry, Biology, Microbiology, Human Anatomy and Physiology I and II) and the first clinical fundamentals nursing course. Completing these courses prepares the junior or senior nursing student to apply course principles in the perioperative environment. Additionally, taking the perioperative course right after Anatomy and Physiology lets students witness the course subject matter right before their eyes. By taking the course before the medical-surgical clinical experience, the nursing students gain the opportunity to identify why patients experience degrees of postoperative pain and treat them in a more holistic manner. For example, one student observed a laparoscopic colon resection in a patient with a volvulus. She then understood why the patient was experiencing bilateral shoulder pain postoperatively and could relate this to phrenic nerve irritation secondary to carbon dioxide trapping that occurred during the procedure.8,16 The student recognized that patient ambulation would be more beneficial than analgesia for pain.

Course structure and requirements

This course is a three-credit (one credit for theory; two credits for clinical), 3-week, elective course. Much of the theoretical content is frontloaded in the first few days to provide a basic foundation of knowledge to apply once the experiential learning portion in the perioperative arenas begins. The first full week of the course is conducted in the classroom and simulation lab and the last 2 weeks in the perioperative setting.

Students completed a patient follow-through experience where they met the patient in the holding area, followed the patient through the surgery, went with the patient to the postanesthesia care unit, and then followed the patient to discharge or admission to a nursing unit. Students also completed a daily journal explaining how they met the course objectives, and participated in clinical postconferences. They also completed an anesthesia drug card, wrote a follow-through paper, and gave a presentation on their clinical experience. The course included two exams, one in the middle of the course and the final exam on the last day.

Outcomes

After the experiential learning component, students made the following comments:

  • “I'm so grateful I got to see open heart surgery (OHS). My grandfather just had OHS, and now I know what he went through.”
  • “I understand sterile technique so much better.”
  • “I appreciate why patients have so much postop pain and why encouraging coughing and deep breathing postoperatively is essential in preventing pneumonia.”
  • “Wow this was awesome! I have a much better appreciation for postoperative patient care, which will help me in my senior year when I'm in the intensive care setting.”
  • “I recognize how preoperative patient teaching reduces the risk of postoperative complications.”
  • “I most definitely want to pursue a career in perioperative nursing after graduation.”

All of the 41 students to date thoroughly enjoyed the course and appreciated the hands-on approach to patient care and working collaboratively with excellent RN role models in the perioperative setting. Course evaluations noted that students liked the 3-week intensive immersion, where they entered the course knowing very little about this specialty area of nursing and finished the course feeling better prepared to care for the surgical patient. Although they recognized this was only an introduction, they stated that actually “scrubbing in” and “circulating” made them feel like a “real member” of the surgical team.

Of the 41 students, 16 (40%) chose to work in a surgical environment after graduation. Seven of the 16 students (44%) chose perioperative nursing as a stepping stone into nurse anesthesia programs. Two of the 16 (12%) worked for up to 1 year in perioperative services.

Recent York College graduates report that they couldn't get a job in perioperative nursing due to a lack of perioperative experience. York Hospital now hires students who've successfully completed the perioperative course. Research is presently under way to determine the impact of the perioperative course on new hire orientation to the surgical service line. Additionally, York Hospital has started an innovative perioperative nursing extern program for students who've completed this course. This is a paid position where students work in the OR, postanesthesia care unit, or the short stay unit during their senior year of nursing school and then may be hired into the perioperative specialty area.

Another option for students who've completed this course is to work as unlicensed assistive personnel or an anesthesia technologist in the OR during their final year of nursing school. Then, with the successful completion of school and the NCLEX-RN, students may apply and be interviewed for an RN position.

Students in this course were introduced to the AORN 40 under 40 Campaign, in which the AORN recognizes 40 nurses under age 40 who've demonstrated the ability to apply evidence-based practice and to mentor other members of the perioperative team.10 These nurses, who are recognized with a shooting star on their name tag, will be our next generation of perioperative leaders. It's a way to thank them for their passion and commitment and to continue to support and cultivate their creativity and success.

Overcoming barriers

Educators should consider several barriers or challenges when implementing a course such as this.

  • The first challenge is creating a safe learning environment for the students and perioperative patients. Students are “guests” in the OR, and factors such as space, the need for new staff members to observe cases, surgeon preferences, and the acuity of patients all need to be considered when assigning students to cases.
  • A second challenge is that the perioperative cultural environment is a bit different from other clinical environments where students had practiced. Students were quick to learn about the unique personalities and various roles of the surgical team members.
  • A third challenge involves working with the surgeons and perioperative team members. While some embraced teaching students, others didn't. The lack of teaching, or student neglect, happened on a very limited basis. Overall, the perioperative team welcomed the students and were willing to teach.
  • Other challenges involved OHS and orthopedic cases where students had very limited access due to patient safety factors, such as infection risk, and staff issues, such as the need to orient new staff members.

It can also be a challenge to find a qualified faculty member to teach perioperative nursing. I developed the course and offered to teach, but I wasn't a perioperative nurse. Therefore, in preparing to teach this course, I spent many hours in the OR watching, learning, and working with the OR team and staff educators. I attended conferences to learn the latest perioperative information; read textbooks and journal articles; and watched many select videos.

Another issue to consider when teaching this kind of course is the size of the class and the additional workload demands on the staff, particularly at a time when new hires would be onboarding and experienced staff mentors would be taking vacations. After discussions with the OR nurse educator, we mutually decided that 10 students would be reasonable for all involved.

Staff and educators in the perioperative environment voiced many positive comments and felt that this course was very much worth their effort. They stated they hope to see many of these students in the upcoming year after graduation and look forward to calling them colleagues. Institutions are always striving to meet the needs of their community, and this course was one way we've endeavored to meet the needs of ours.

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