The Association of periOperative Registered Nurses (AORN) recently issued a position statement about orientation that emphasizes teamwork, safety, and competency assessments in orienting perioperative RNs and surgical technologists (ST).
Titled “Orientation of the Registered Nurse and Surgical Technologist to the Perioperative Setting,” the position statement suggests teamwork is an essential element in a successful orientation program. (Editor’s Note: This statement is available for download at: http://bit.ly/2FXkrZZ under the heading “Education & Orientation.”)
“Teamwork is essential in all facets of healthcare,” says Jan Davidson, MSN, RN, CNOR(E), CASC, director of the ambulatory surgery division for AORN. “In the perioperative environment, it is essential that the entire surgical team function as a true team during a surgical procedure.”
For instance, the ST role is extremely important and respected, although STs might believe they are at a lower status than other professionals in the surgical suite. This impression can make them reluctant to speak up, even when they have something critical to contribute, Davidson observes.
“There should be no hierarchy in the operating room,” she says. “Encouraging the entire team to call each other by first names, including physicians, tends to level the playing field. That may be one way to encourage open and honest communication.”
AORN says in its position statement that orientation for a novice perioperative RN may be six to 12 months, and the orientation for a novice ST is up to six months. Orientation and training take time when conducted well.
“There is so much to learn when first going to work in the OR. Unfortunately, nursing students are typically not introduced to the OR during their clinical rotations in school,” Davidson laments. “That is likely why it is so hard to find young nurses who have an interest in surgery.”
The perioperative RN needs to understand anatomy, physiology, and the pathophysiology of patients’ surgical conditions. They should understand normal lab values, different surgical modalities, proper positioning, instrumentation specific to the surgical procedure, other equipment used in the OR, and any operating suite risks.
“They should know how to troubleshoot if equipment malfunctions in the middle of the case,” Davidson adds. “They must understand radiation safety, tourniquet safety, and laser safety.”
A year is ideal for orientation; less than six months would be a mistake, Davidson suggests. “It would not be safe for the patient, nor would it be fair to the new perioperative registered nurse if they were turned loose in less than six months,” she explains.
Training new nurses is challenging and costly, but necessary. “They cannot really be counted as a productive employee yet. That will show as a negative on your payroll for the period of time they are training,” Davidson explains. “Be sure your physician owners are aware of that before you begin a new Periop 101 program.”
Surgery center leaders also should understand productivity and its effect on patient satisfaction and the bottom line, Davidson adds. “Another critical piece of training for a new nurse or surgical technologist is making sure they understand the facility’s supply costs and utilization of block scheduling,” she says.
AORN’s position statement lists nearly 60 topics of education for STs and RNs. These fall under the categories of safety, physiological responses, infection prevention and control, behavioral responses, and health systems.
For instance, under the category of health systems, there is information about certification, career advancement, code of conduct, communication, and critical thinking. The behavioral responses category includes information about advance directives, advocacy, age-specific policies, cultural/population-specific policies, and others.
“There are many different cultures and religious beliefs that are critical for a perioperative nurse to understand,” Davidson says. “For example, a patient who is a Jehovah’s Witness generally will not accept blood or blood products. That is an important piece of information for everyone on the surgical team to know before the surgery.”
Patients’ cultural identification also can affect how they answer questions about pain and discomfort. For instance, people of Irish descent, as a group, tend to minimize their expressions of pain, according to Davidson.
“It is also true of many cultures ... that the patient’s family must be the first to be told of a poor prognosis. The family then decides how much the patient should know,” she says. “That would be important information for the surgical team to know and to allow the surgeon and patient an opportunity to have that conversation before surgery ever begins.”
Body language differs by culture, too. “Some may see lack of the patient making eye contact as a lack of respect, embarrassment, or depression,” Davidson says, while others may view that as showing respect.
Likewise, some healthcare providers believe a light touch might demonstrate empathy to patients. But for patients who are Orthodox Jews, touching (outside of hands-on care) is prohibited.
STs and RNs also should learn about working with elderly patients. “Age-specific policies, procedures, and competencies are an extremely important part of operating room training,” Davidson stresses. “There are age-related physiologic changes that occur during surgery that the perioperative nurse should know.” One example is the assessment of an elderly patient for the risk of developing a pressure ulcer, using the Braden scale.
Informed consent also requires specific training. “The perioperative registered nurse must follow the policy and procedure of their facility and their accreditation organization’s standard with regard to informed consent,” Davidson says. “Some facilities do allow anyone on the surgical team to obtain the signature on the informed consent. Ultimately, the surgeon is responsible for knowing the patient’s questions have been answered and the patient is capable of making an informed decision.”
The AORN position statement also advocates for surgery centers to use a preceptor system when orienting new RNs. This practice is ideal for training purposes, Davidson notes.
“Have the new RN or ST partner with one particular person who will provide them with their orientation, training, and mentoring,” she offers. “Most of us who work in the OR have a system we use consistently on all of our patients. It is generally methodical and deliberate so that no steps are left out.”
A mentoring system that is not consistent can cause confusion. “If the new RN or ST has to work with someone different either daily or weekly, it can become confusing and may even promote some bad habits,” Davidson warns.