Perioperative education

Chapter 1


Perioperative education



Chapter objectives


After studying this chapter, the learner will be able to:


• Compare and contrast the art and science of surgery.


• Identify three characteristics of adult learners.


• Name five educational resources available for the learner.


• Define the difference between andragogy and pedagogy.


• Describe how adult learning principles apply to patient teaching.


• Discuss the problems associated with disruptive behavior in the perioperative environment.



Key terms and definitions



Andragogy 


Teaching and learning processes for mature adult populations.


Behavior 


Actions or conduct indicative of a mental state or predisposition influenced by emotions, feelings, beliefs, values, morals, and ethics.


Cognition 


Process of knowing or perceiving, such as learning scientific principles and observing their application.


Competency 


Creative application of knowledge, skills, and interpersonal abilities in fulfilling functions to provide safe, individualized patient care.


Critical thinking 


The mental process by which an individual solves problems.


Disease 


Failure of the body to counteract stimuli or stresses adequately, resulting in a disturbance in function or structure of any part, organ, or system of the body.


Knowledge 


Organized body of factual information.


Learning style 


Individualized methods used by the learner to understand and retain new information. These may be visual, auditory, tactile, sensory, or performance-oriented behaviors.


Mentoring 


A nurturing, flexible relationship between a more experienced person and a lesser experienced person that involves trust, coaching, advice, guidance, and support. A sharing relationship guided by the needs of the less experienced person.


Objectives 


Written in behavioral terms, statements that determine the expected outcomes of a behavior or process.


Pedagogy 


Teaching and learning processes for immature and/or pediatric populations. A very directed style is used.


Perioperative 


Total surgical experience that encompasses preoperative, intraoperative, and postoperative phases of patient care.


Preceptor 


A person who observes, teaches, and evaluates a learner according to a prescribed format of training or orientation.


Psychomotor 


Pertaining to physical demonstration of mental processes (i.e., applying cognitive learning).


Role model 


A person who is admired and emulated for good practices in the clinical environment. The relationship between a role model and a learner can be strictly professional without personalized mentoring.


Skill 


Application of knowledge into observable, measurable, and quantifiable performance.


Surgery 


Branch of medicine that encompasses preoperative, intraoperative, and postoperative care of patients. The discipline of surgery is both an art and a science.


Surgical conscience 


Awareness that develops from a knowledge base of the importance of strict adherence to principles of aseptic and sterile techniques.


Surgical procedure 


Invasive incision into body tissues or a minimally invasive entrance into a body cavity for either therapeutic or diagnostic purposes during which protective reflexes or self-care abilities are potentially compromised.



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The main focus of this chapter is to establish the baseline or framework for an in-depth study of perioperative patient care and support the educational process of the learner. Consideration is given to the perioperative educator, who may not have had a formal education in the teaching of adult learners. Both learners and educators should understand that the same learning and teaching principles apply to patient education. The key terms are commonly used terms that the learner should understand as the basis for learning about and participating in the science and art of surgery.



The art and science of surgery


Health is both a personal and an economic asset. Optimal health is the best physiologic and psychologic condition an individual can experience. Disease is the inability to adequately counteract physiologic stressors that cause disruption of the body’s homeostasis. Additional influences, such as congenital anomalies, infection, or trauma, interfere with optimal human health and quality of life. As both a science and an art, surgery is the branch of medicine that comprises perioperative patient care encompassing such activities as preoperative preparation, intraoperative judgment and management, and postoperative care of patients. As a discipline, surgery combines physiologic management with an interventional aspect of treatment. The common indications for surgical intervention include correction of defects, alteration of form, restoration of function, diagnosis and/or treatment of diseases, and palliation. Table 1-1 describes some of the most common indications for surgery.



In the 1930s the English physician Lord Berkeley George Moynihan (1865-1936) said, “Surgery has been made safe for the patient; we must now make the patient safe for surgery.” Surgical intervention is becoming a safer method of treating physiologic conditions. Most of the former contraindications to surgery that were related to patient age or condition have been eliminated because of better diagnostic methodologies and drug therapies. More individuals are now considered better candidates for surgery; however, each patient and each procedure are unique. Perioperative caregivers should not become complacent with routines but should always be prepared for the unexpected. Surgery cannot be considered completely safe all the time, and patient outcomes are not always predictable.


A surgical procedure may be invasive, minimally invasive, minimal access, or noninvasive. Any invasive or minimal access procedure enters the body either through an opening in the tissues or by a natural body orifice. Noninvasive procedures are frequently diagnostic and do not enter the body. Technology has elevated the practice of surgery to a more precise science that minimizes the “invasiveness” and enhances the functional aspects of the procedure. Recovery or postprocedure time decreases, and the patient is restored to functional capacity faster. Improvements in perioperative patient care technology are attributed to the following:



Surgical procedures are performed in hospitals, in surgeons’ offices, or in freestanding surgical facilities. Many patients can safely have a surgical procedure as an outpatient and do not require an overnight stay at the facility. The types of surgical procedures performed on an outpatient basis are determined by the complexity of the procedure and the general health of the individual. Procedures performed on patients who remain overnight in the hospital vary according to the expertise of the surgeons, the health of the patient, and the availability of the equipment.


The purpose of this text is to provide a baseline for learning the professional and technical patient care knowledge and skill required to provide safe and efficient care for patients in the perioperative environment.



Perioperative learner


The learner in the perioperative environment may be a medical, nursing, or surgical technology student enrolled in a formal educational program, or the learner may be a newly hired orientee. Medical students have a surgical rotation that includes participation in surgical procedures. They learn some of the basic principles of surgical technology and sterile technique to ensure the safety and welfare of patients.


Some nursing schools offer basic exposure to perioperative nursing, as a short observation period, part of the core curriculum, or an elective. After graduating from nursing school, the nurse needs further education before functioning as a perioperative professional. This education may take place in a postbasic/postgraduate perioperative nursing course offered by a community college or a hospital orientation program. Entry-level education for perioperative practice prepares nurses to be generalists. Basic perioperative nursing elective programs focus on the role of the perioperative nurse as both generalist circulator and scrub person. Specialization can follow a period in professional practice in a specific service. The perioperative nurse’s role encompasses supervision of unlicensed personnel who scrub in surgery, such as surgical technologists, and requires knowledge of practices and procedures performed under this title.


Surgical technology programs focus primarily on scrubbing in to prepare and maintain the sterile surgical field and handle instruments. Some surgical technology programs offer circulating experiences under the supervision of a registered nurse; however, the role of the circulator requires knowledge and skill not commonly covered in significant depth in shorter training programs. Most surgical technology programs provide scrub experiences in many specialties. After satisfactory completion of the program, many technologists are capable of functioning in the scrub role as a generalist or in some circumstances, a specialist. Advancing technology indicates the need for specialized competencies for all disciplines of perioperative patient care. Surgeons, perioperative nurses, and surgical technologists should continually strive to learn new procedures and technologies in a team-oriented environment.


Perioperative caregivers new to a particular practice setting should learn the specific performance standards and expectations of that institution. All personnel go through an orientation process to familiarize themselves with the philosophy, goals, policies, procedures, role expectations, and physical facilities specific to their institution. Departmental orientation is specific to the area in which the caregiver is employed.


Many graduates seek employment in the institutions in which they performed clinical rotations. This is usually beneficial to the facility and the employee. Some students are hired into apprenticeships before graduation enabling them to work in the OR in a limited capacity in anticipation of a permanent position. Schools that permit students to work while still in the education process should have a policy in place to delineate the student role from the employee role. The policy should be made known in writing to all clinical facilities hosting students and students performing clinical rotations where apprenticeships are offered. The following are considerations in developing a policy for working students:



All learners in the perioperative environment are adults and do not want to be treated as children. This concept applies whether the caregiver is experienced or a novice. Treating an adult learner in a pedagogic manner, as a child is treated, is counterproductive and becomes a barrier to learning. The learner can become resentful and unable to separate feelings of inexperience from feelings of inadequacy. Regardless of the level of learning required, the general characteristics of the adult learner (andragogic) as compared with the child learner (pedagogic) apply (Table 1-2). These concepts also should be applied to patient education programs.



Not everyone learns at the same speed or assimilates information in the same manner. Theoretic knowledge or a skill learned quickly by one individual may be difficult for another. Cognition is premised on the ability to process and retain information. Learning styles vary among individuals and are influenced by internal and external factors. Examples of learning style influences are listed in Box 1-1. Learning styles were described in the early 1990s by Howard Gardner at Harvard University. Understanding the differences in individual learners is the first step to imparting knowledge and skill. Seven learning skills identified by Gardner are summarized as follows with application of teaching methods for perioperative learners:



BOX 1-1   Learning Style Influences





1. Visual-spatial: Very environmentally aware. Learns well by observation, puzzles, graphics, and modeling.



2. Bodily kinesthetic: Keen sense of motion and hands-on sense. Communicates well by physical practice.



3. Musical: Learns well by listening and use of multimedia. Frequently learns better with music in the background.



4. Interpersonal: Group dynamics and study sessions work well for this learner.



5. Intrapersonal: Learns well through self-study and independence. Highly self-motivated and disciplined.



6. Linguistic: Very good with language and auditory skill. Learns effectively through lectures and explanation.



7. Logical-mathematical: Prefers to investigate and solve problems. Conceptual thinking precedes detailing with these learners.



Each facility should clearly define the role of the perioperative learner of each discipline. Activities of new perioperative nurses and surgical technology students are not the same. The perioperative nurse is involved with more direct patient care and decision making through physical assessment. The student surgical technologist is concerned primarily with preparing and maintaining the sterile field. Both disciplines of learners help prepare for, assist a qualified preceptor during, and clean up after surgical procedures, but they are not considered members of the staff complement. Instructional staff should observe for and guard against laziness in the preceptor group. Some preceptors may want to sit back in the pretense of “letting the student take over.” In essence, this is not an improper approach to precepting, but can be abused if the preceptor continually leaves the student to flounder or delay the progress of the procedure.


Some preceptors may “bully” the students and become impatient because of the students’ inexperience. Students should be taught to respect the preceptors, but not fear them. Students should know basic standards and protocol before entering the OR for a clinical rotation. Preceptors may have developed shortcuts with questionable technique not understood by students who are new to the OR environment. Students should not blindly perform tasks directed by preceptors that cause question as to technique or safety without fully understanding what resultant outcome is expected. Educators should discuss the potential for these questionable events and give the student a vehicle for professionally or assertively deferring or opting out of doing something that is nonstandard by the level of education they have experienced in the classroom. This process can be particularly uncomfortable if the student does not feel supported by the educator in doing what has been ingrained as the standard of care. Some examples of this activity include but are not limited to the following (these examples actually happened at a clinical site):



1. Event: Preceptor insists on gowning and gloving from the primary sterile field and instructs the student to do so as well. Student deferral vehicle: “My clinical instructor will give me a deficiency grade if I gown and glove from the back table. I am required to gown and glove from a separate surface other than the main field.”


2. Event: Preceptor is impatient and goes to sit on a stool in the corner because part of the procedure is taking a long period of time. Student deferral vehicle: “My clinical instructor will give me a deficiency grade if I sit and change the level of sterility of the front of my gown.”


3. Event: Preceptor instructs the student to offer a towel from the open and biologically contaminated back table to a person who plans to enter the working sterile field. Student deferral vehicle: “My clinical instructor will give me a deficiency grade if I offer a towel from my working back table.”

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  4. Urologic surgery

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Apr 6, 2017 | Posted by in GENERAL SURGERY | Comments Off on Perioperative education

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