Using Adult Learning Principles for Perioperative Orientation Programs

Using Adult Learning Principles for Perioperative Orientation Programs – surgical nursing

Fraulein S. Nelson

There has been a continuous decline in the number of nursing schools offering perioperative clinical experience since the 1950s.(1) One survey showed that 67% of more than 1,000 schools that confer diplomas, associate degrees, and bachelor of science degrees in nursing had no perioperative content.(2) Recruiting nurses is difficult for health care institutions because new graduates lack necessary knowledge and skills. Shrinking budgets, increased costs, and the reduced availability of staff members qualified as educators affect the development and implementation of perioperative nursing orientation programs.(3) Perioperative nursing is a specialty, and new nurses require a comprehensive orientation program to perform their jobs.

Perioperative nursing is flexible and diverse. It encompasses the behavioral and technical components of professional nursing.(4) Perioperative nurses use their technical abilities to use surgical equipment and instruments while exercising sound judgment and problem-solving skills to ensure that each patient experiences a safe and effective surgical procedure. Perioperative nurses also provide patient support, comfort, and safety, and they advocate for the patient and his or her family members.

Perioperative nursing comprises roles with scrub, circulator, manager, educator, and first assistant responsibilities. New nurses usually focus on the scrub person and/or circulating nurse positions. New nurses frequently do not have perioperative clinical experience in these positions. Developing and implementing a structured and comprehensive orientation or training program for these nurses is one method to promote quality patient care. Regulatory agencies also mandate that staff members competently perform their daily work activities and that employers develop strategies to assess each individual’s ability to achieve job expectations.(5) Consumers demand competent professionals, as well.

One survey of perioperative nurses shows that more than 70% of respondents were between 31 and 50 years of age. This suggests a potential perioperative nursing shortage.(6) What is the future of perioperative nursing? How will perioperative nurses be trained when nursing schools offer limited perioperative experience? Health care agencies must provide the necessary and proper training for new perioperative nurses. Orientation programs are expensive, time-consuming, and use human resources. A high turnover of newly trained nurses wastes time and money. Comprehensive orientation programs provide opportunities for nurses to develop job competence and confidence and to increase their job satisfaction, which may improve the perioperative nursing retention rate.

LITERATURE REVIEW

A review of the relevant literature shows that the principles of adult learning should be included in a quality perioperative orientation program. The review suggests a framework that staff developers and nurse managers can use to create or revise a perioperative nurse orientation program.

According to AORN’s Standards, Recommended Practices, and Guidelines, perioperative orientation programs are established and required for all personnel to help them adjust to their organization, environment, and duties.(7) The program should be based on individualized learning needs.

As nurses acquire and develop skills, they experience five levels of proficiency:

* novice,

* advanced beginner,

* competent,

* proficient, and

* expert.(8)

Nurses need adequate training to function in the OR. To perform their jobs beyond the novice level, nurses with no clinical experience should know the goals and tools of patient care of that specialty.(9)

ADULT LEARNING PRINCIPLES

The basic components of orientation are the people learning (ie, new employees), the orientation process, and the outcomes of the training program.(10) Orientation is the attempt to familiarize new employees with the institution’s policies, procedures, philosophies, purposes, personnel benefits, and position requirements.(11) Orientation also may include skills training and leadership skills instruction. Depending on each learner, orientation may be modified. A less experienced nurse may require a longer orientation than a more experienced nurse. Educators need to be aware of each person’s differences.

The purpose of adult learning is to improve one’s competency.(12) An orientation program that uses adult learning principles helps new employees adjust to working in the OR.(13) Adult learners are responsible for their education, and each person comes with his or her own styles and pace for learning. Teaching plans and strategies, therefore, must be highly individualized.

Assumptions about adults as learners and the learning process are as follows.

* Adult learners have a self-concept of being an adult. They take responsibility for planning and managing their learning with help from others.

* Adult learners offer a background of experience that is a valuable resource for all learners.

* Adult learners are ready to learn what they believe contributes to an effective performance and higher level of achievement.

* Adult learners recognize the uniqueness of self. They recognize that each person has his or her own style, learning pace, outside commitments, pressures, goals, and motivation.(14)

SELF-DIRECTED LEARNING

As people mature, their self-concepts move from being dependent personalities toward being people who are capable of making their own decisions.(15) Adults often resist learning when conditions are incompatible with their self-concept. Adults want to be treated with respect and to learn in a safe, non-threatening environment.(16) It is important that the physical and psychological environments are conducive to learning so that people feel comfortable. An orientation program should allow each person to learn in the best environment for them, if possible. Adults learn and pursue educational opportunities when the experiences are individualized and flexible.(17) Self-instructional methods are used when lessons are repeated, when adults are allowed to set their own pace, or when education is needed and an educator is unavailable.(18) Methods and techniques involving self-directed study produce the greatest learning.(19) Self-study or self-directed learning is one strategy used to orient new nurses, and it allows them to learn at their own pace and take responsibility for their education.(20)

The learners’ and organization’s needs are assessed when developing a self-learning module.(21) The type of institution and the type of surgical procedures performed in the OR dictate the orientation requirements. For example, if orthopedic procedures are performed primarily in an OR, new perioperative nurses need orientation about those procedures. Learning objectives must be specific to the content and to the outcome behaviors expected in the clinical setting.(22) Objectives provide guidelines for the nature and purpose of the educational activity.(23) A training manual for new employees can contain these goals. For example, the goals can state that “on completion of the training program, new nurses will be able to use basic instruments, sutures, and sterilization techniques.”

Educators need to determine if the self-learning module is an effective education tool for individuals.(24) Self-study is one method to teach institutional policies, standards, and recommended practices. Demonstrations and return demonstrations are effective methods to explain surgical equipment and scrubbing, gowning, and gloving techniques.

Appropriate media selection for learning is important.(25) Textbooks provide the conceptual framework, standards, and principles of perioperative practice, and they are a resource for information that learners can use for self-study. One textbook provides perioperative nursing considerations with the nursing process as a framework.(26) This book includes general and specialty surgical interventions with detailed steps for various procedures. The book can be used as a reference for surgical instrumentation and procedures and for patient care practices and standards. Another textbook includes the historical development of perioperative nursing, physiology, anatomy, the nursing process, patient care management, and nursing practice standards.(27) This textbook provides self-assessment exercises in each chapter, and review questions that can be used as self-learning standards or assignments that each person can finish at his or her own pace.

Another educational tool is videotape.(28) Videotapes provide visual details of surgical procedures, proper use of equipment and instruments, and surgical practices and interventions.

Finally, evaluations determine the effectiveness of the training method.(29) Educators’ assignments, worksheets, skills checklists, and written or verbal evaluations assess nurses’ competencies according to the program’s objectives and identify further education needs.

RESOURCES FOR LEARNING

The richest learning resource comes from each person’s background. It is assumed that each individual’s experience differs from others and the combined experience of people in the program provides a rich learning resource.(30) Sharing experiences is a significant form of adult learning.

Preceptors are another valuable resource to facilitate adult learning. By using the knowledge, skills, and expertise of these experienced staff nurses, the recruitment and retention rates of nurses improve. Orientation can be cost-effective when resources are used efficiently, and nurse retention rates improve.(31) The use of preceptors is well documented in nursing literature.(32)

Preceptors help new employees adjust to the workplace and new clinical experiences by helping them in their transition from being the “new person” to being accepted by their colleagues.(33) Preceptors act as role models, educators, nurturers, and resource people, and they help new employees feel accepted, respected, and supported.(34) Learning is an internal process that is controlled by the learner, but this process can be facilitated by others.(35)

Preceptors are knowledgeable about the technical aspects of nursing, and they apply the nursing process to clinical practice.(36) These educators help set appropriate priorities and goals for new nurses. Preceptors understand and apply adult learning principles and use these principles to explore, discuss, and modify their teaching styles to meet each person’s needs. New employees and preceptors share responsibility for assessing learning needs, planning and implementing appropriate clinical experiences, and evaluating and documenting clinical performance and progress.

To individualize learning, preceptors evaluate each person’s knowledge and skills and modify training according to the individual’s needs. The preceptor is a resource person for self-directed learners.(37) To facilitate learning, educators remove or reduce learning obstacles (eg, time constraints, anxiety about work and learning responsibilities).(38) By allowing adults to learn at their own pace and helping them focus on learning instead of obligations, educators reduce learners’ anxieties. It is suggested that experienced nurses in each service specialty (eg, general, orthopedic, neurosurgery) serve as preceptors for new nurses as they rotate through the different specialties.

To help measure the outcomes of new nurses’ learning experiences, it is necessary to continuously evaluate learners’ performance and knowledge. Adult learning principles dictate a process for self-evaluation of learning needs in which preceptors assist new nurses in assessing their progress toward the educational goals and their present level of competency.(39) Evaluation is a mutual undertaking. Immediate feedback from preceptors concerning each nurse’s performance is vital to a positive learning experience.(40) With continuous assessment of competencies, the preceptors and learners identify learning difficulties or learning gaps, address them immediately, and plan more experiences to produce the desired outcome.

A competency skills list measures the learners’ progress objectively.(41) The skills list may include new nurses’ behaviors, patient care attitudes, skills, and competencies necessary for quality patient care and safe practice in the OR. Examples of objectives for nurses are listed in Table 1.

Table 1

* Practices aseptic technique

* Sets up the back table properly

* Assists in the safe transfer of patient

* Effectively communicates with team members

* Asks appropriate questions

It is critical that the strengths, weaknesses, and experiences of each new employee are communicated by the preceptor to other preceptors, the nurse educator, the nurse manager, and the employee. This strategy maintains continuity in the learning process and builds on each person’s experience and knowledge.

Using techniques that share the experience of the learners is useful to train new perioperative nurses. Participatory techniques that build on experience may include group discussion, demonstrations, simulation exercises, problem-solving activities, case study methods, laboratory methods, and skill exercises.(42) Self-diagnosis of the learning progress and immediate feedback are important.

READINESS TO LEARN

Adults become ready to learn when they experience a need to know or a need to do something to cope effectively with real-life situations.(43) Adults experience phases of growth and resulting developmental tasks, readiness to learn, and teachable moments.(44) During these phases, adults’ developmental tasks change. These changes trigger their readiness to learn. For example, when an adult wants to work, his or her first developmental task is to acquire a job. At this stage, adults are ready to learn what is required to obtain their desired job. After they are hired, adults must become competent about their chosen profession. New nurses are ready to learn what they need to know to be competent to perform their job. They are ready to learn what they believe contributes to effectively functioning in their career.

It is important to capture adults’ teachable moments through sequential learning experiences. This principle becomes a guide for arranging the orientation schedule (eg, becoming familiar with new surroundings, understanding what is expected of each nurse during the first week). It is advised that new nurses start their surgical rotations with simple and nonintimidating procedures before learning specialized procedures. This builds self-esteem and decreases anxiety.

There also are techniques to motivate readiness. Using effective role models (eg, preceptors) and simulation exercises (eg, demonstration of skills and return demonstration) can induce readiness.(45)

APPROACHES TO LEARNING

Adults are motivated to learn if they perceive that it will help them perform tasks or deal with problems that they confront. People acquire knowledge, skills, values, and attitudes most effectively when they are presented in a real-life context.(46) Competency-based education and competency-based orientation programs are based on the premise that individuals must demonstrate their ability to perform skills and activities.(47) This idea requires that learners apply knowledge and skills to real-world situations. Competence involves the individual’s capacity to perform job functions (ie, having the knowledge, skills, behaviors, and personal characteristics necessary to function well in a situation). In a competency-based framework, learners assume an active role and are responsible for their learning.(48) Educators facilitate and guide people to achieve specific outcomes or competencies; learners select the best teaching methods. Successful learning depends on a variety of methods. New employees can use observation, demonstration, return demonstration, discussion, participation in skill laboratories, lectures, reading, and videotapes to facilitate their learning. It is important that learners play an active role in their education.

One difficulty institutions face with their orientation programs is how to define and measure new employees’ performances. Nurses’ competency levels have been measured by their knowledge, technical skills, achieved objectives, and time management skills.(49) Institutions that implement a competency-based orientation can develop their own competency-based checklist to evaluate their new employees.(50)

SUMMARY

Perioperative nursing is in jeopardy because of the lack of new graduates’ experience in the OR.(51) Beginning a career in this specialty is difficult without having experience in the OR. To provide optimal patient care, institutions need to employ competent nurses who are a part of the health care team. New perioperative nurses need comprehensive training to perform their jobs effectively.

It is possible to develop or revise perioperative nursing orientation programs based on adult learning principles. Staff developers and nurse managers must recognize that nurses interested in this specialty are self-directed adults who are ready to learn and possess their own experiences. Adults also have their own style of learning. It is important for new nurses to be responsible for their learning and collaborate with teachers to provide education activities that motivate them.

The strategies presented serve as guidelines in orienting perioperative nurses. Applying adult learning principles to the perioperative orientation program may lead to increased job satisfaction and improved retention rates. New staff members’ job performances dictate the program’s strength. With an effective orientation program and retention of competent nurses, the institution benefits financially and provides quality patient care.

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* phrases such as “scientific breakthrough,” “miraculous cure,” “exclusive product,” “secret formula,” and “ancient ingredient”;

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Virtual “Treatments’ Can Be Real-world Deceptions (consumer alert, Washington, DC: US Federal Trade Commission, June 1999) 1.

NOTES

(1.) V D Wagner, C C Kee, D P Gray, “A historical decline of educational perioperative clinical experiences,” AORN Journal 62 (November 1995) 771-780.

(2.) Ibid.

(3.) A T Speers, K M Gilberg, F A Koch, “Competency-based orientation for registered perioperative nurses,” AORN Journal 62 (October 1995) 567-574, 577-578.

(4.) “Standards of perioperative professional performance,” in Standards, Recommended Practices, and Guidelines (Denver: Association of Operating Room Nurses, Inc, 1999) 152.

(5.) Joint Commission on Accreditation of Healthcare Organizations, Hospital Accreditation Standards (Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, 1998).

(6.) E A McConnell, “1991 salary survey: Examining the results,” Today’s OR Nurse 13 (March 1991) 23, 25.

(7.) “Standards of perioperative administrative practice,” in Standards, Recommended Practices, and Guidelines (Denver: Association of Operating Room Nurses, Inc, 1999) 148.

(8.) P E Benner, From Novice to Expert: Excellence and Power in Clinical Nursing Practice (Menlo Park, Calif: Addison-Wesley Publishing Co, 1984) 20-34.

(9.) Ibid.

(10.) P A Heizenroth, “Key components of perioperative orientation,” AORN Journal 63 (January 1996) 183-190.

(11.) H M Tobin, The Process of Staff Development: Components for Change, second ed (St Louis: C V Mosby, 1979).

(12.) Ibid.

(13.) K B Ammon-Gaberson, “Adult learning principles: Applications for preceptor programs,” AORN Journal 45 (April 1987) 961-963.

(14.) M S Knowles, Using Learning Contracts: Approaches to Individualized and Structuring Learning (San Francisco: Jossey-Bass Publishers, 1986).

(15.) M S Knowles, The Modern Practice of Adult Education.’ Andragogy Versus Pedagogy (New York: Association Press, 1970).

(16.) Ammon-Gaberson, “Adult learning principles: Applications for preceptor programs,” 961-963; Knowles, The Modern Practice of Adult Education: Andragogy Versus Pedagogy; M S Knowles, The Adult Learner: A Neglected Species, fourth ed (Houston: Gulf Publishing Co, 1990).

(17.) B Brunt, A L Scott, “Factors to consider in the development of self-instructional materials,” The Journal of Continuing Education in Nursing 17 (May/June 1986) 87-93.

(18.) S L Phelps, “Off to a successful start! The use of self-study for hospital-wide nursing orientation,” Journal of Nursing Staff Development 12 (January/February 1996) 712; K L Rufo, “Effectiveness of self-instructional packages in staff development activities,” Journal of Continuing Education in Nursing 16 (May/June 1985) 80-84; Tobin, The Process of Staff Development: Components for Change.

(19.) Knowles, The Modern Practice of Adult Education: Andragogy Versus Pedagogy, second ed.

(20.) Brunt, Scott, “Factors to consider in the development of self-instructional materials,” 87-93; P Grant, “Formative evaluation of a nursing orientation program: Self-paced vs lecture-discussion,” The Journal of Continuing Education in Nursing 24 (November/December 1993) 245-248; L A James, “Orientation through self-study,” Journal of Nursing Staff Development 9 (March/April 1993) 85-87; Phelps, “Off to a successful start! The use of self-study for hospital-wide nursing orientation,” 7-12; J L Prociuk, “Self-directed learning and nursing orientation programs: Are they compatible?” The Journal of Continuing Education in Nursing 21 (November/December 1990) 252-256; K L Schmidt, J C Fisher, “Effective development and utilization of self-learning modules,” The Journal of Continuing Education in Nursing 23 (March/April 1992) 54-59.

(21.) Schmidt, Fisher, “Effective development and utilization of self-learning modules,” 54-59.

(22.) Ibid.

(23.) Brunt, Scott, “Factors to consider in the development of self-instructional materials,” 87-93.

(24.) Schmidt, Fisher, “Effective development and utilization of self-learning modules,” 54-59.

(25.) Ibid.

(26.) M H Meeker, J C Rothrock, Alexander’s Care of the Patient in Surgery, 11th ed (St Louis: Mosby, 1999).

(27.) S S Fairchild, Perioperative Nursing: Principles and Practice, second ed (Boston: Little, Brown, and Co, 1996).

(28.) Schmidt, Fisher, “Effective development and utilization of self-learning modules,” 54-59; Tobin, The Process of Staff Development: Components for Change, second ed.

(29.) Schmidt, Fisher, “Effective development and utilization of self-learning modules,” 54-59.

(30.) Knowles, The Modern Practice of Adult Education: Andragogy Versus Pedagogy; Knowles, Using Learning Contracts: Approaches to Individualizing and Structuring Learning; Knowles, The Adult Learner: A Neglected Species, fourth ed.

(31.) H L Craven, J G Broyles, “Professional development through preceptorship,” Journal of Nursing Staff Development 12 (November/December 1996) 294-299; P F Giles, V Moran, “Preceptor program evaluation demonstrates improved orientation,” Journal of Nursing Staff Development 5 (January/February 1989) 17-24; Heizenroth, “Key components of perioperative orientation,” 183-190; V A Mooney, B Diver, A A Schnackel, “Developing a cost-effective clinical preceptorship program,” Journal of Nursing Administration 18 (January 1988) 31-36.

(32.) Ammon-Gaberson, “Adult learning principles: Applications for preceptor programs,” 961-963; Craven, Broyles, “Professional development through preceptorship,” 294-299; J L Davis, “Orientation made easy: Using preceptors and skills checklist,” AORN Journal 45 (April 1987) 951-959; L Friesen, B J Conahan, “A clinical preceptor program: Strategy for new graduate orientation,” Journal of Nursing Administration 10 (April 1980) 18-23; Giles, Moran, “Preceptor program evaluation demonstrates improved orientation,” 17-24; Mooney, Diver, Schnackel, “Developing a cost-effective clinical preceptorship program,” 31-36; K M Radziewicz; P M Houck; B J Moore, “Perioperative education: Transforming preceptor program into perioperative elective,” AORN Journal 55 (April 1992) 1060-1071.

(33.) Davis, “Orientation made easy: Using preceptors and skills checklist,” 951-959.

(34.) Ammon-Gaberson, “Adult learning principles: Applications for preceptor programs,” 961-963; Craven, Broyles, “Professional development through preceptorship,” 294-299; Mooney, Diver, Schnackel, “Developing a cost-effective clinical preceptorship program,” 31-36.

(35.) Knowles, Using Learning Contracts: Approaches to Individualizing and Structuring Learning.

(36.) Davis, “Orientation made easy: Using preceptors and skills checklist,” 951-959.

(37.) Knowles, Using Learning Contracts: Approaches to Individualizing and Structuring Learning.

(38.) Ammon-Gaberson, “Adult learning principles: Applications for preceptor programs,” 961-963.

(39.) Knowles, The Modern Practice of Adult Education: Andragogy Versus Pedagogy.

(40.) Ammon-Gaberson, “Adult learning principles: Applications for preceptor programs,” 961-963; Knowles, The Modern Practice of Adult Education: Andragogy Versus Pedagogy.

(41.) Davis, “Orientation made easy: Using preceptors and skills checklist,” 951-959; J A Faulhaber, J A Coleman, R L Cardwell, “Orthopedic orientation: A guide for new nurses,” AORN Journal 46 (October 1987) 706-717; Mooney, Diver, Schnackel, “Developing a cost-effective clinical preceptorship program,” 31-36.

(42.) Knowles, The Modern Practice of Adult Education: Andragogy Versus Pedagogy; Knowles, The Adult Learner: A Neglected Species fourth ed.

(43.) Knowles, The Adult Learner: A Neglected Species, fourth ed; M S Knowles and Associates, Andragogy in Action: Applying Modern Principles of Adult Learning (San Francisco: Jossey-Bass Publishers, 1984).

(44.) Knowles, The Modern Practice of Adult Education.’ Andragogy Versus Pedagogy.

(45.) Knowles, The Adult Learner: A Neglected Species, fourth ed; Knowles and Associates, Andragogy in Action: Applying Modern Principles of Adult Learning.

(46.) Knowles, The Adult Learner: A Neglected Species, fourth ed.

(47.) Speers, Gilberg, Koch, “Competency-based orientation for registered perioperative nurses,” 567-574, 577-578.

(48.) Speers, Gilberg, Koch, “Competency-based orientation for registered perioperative nurses,” 567-574, 577-578; J Strauss, “Perioperative nursing orientation: A primer for designing your own program,” AORN Journal 59 (June 1994) 1293-1301.

(49.) M Voorhees, “Using competency-based education in the perioperative setting,” Nursing Management 27 (August 1996) 35-38.

(50.) Speers, Gilberg, Koch, “Competency-based orientation for registered perioperative nurses,” 567-574, 577-578; Strauss, “Perioperative nursing orientation: A primer for designing your own program,” 1293-1301.

(51.) Wagner, Kee, Gray, “A historical decline of educational perioperative clinical experiences,” 771-780.

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