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Operating Room Etiquette

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Operating Room Etiquette: Preparing for Perfection

Operating Room Etiquette: Preparing for Perfection
Patient safety plays an intricate role in the nursing profession. It is through the foundation of a germ free environment in which protocols are set in an effort to decrease patient morbidity and mortality. The operating room (OR) is a major sector of hospitals in which its core is maintaining an environment of sterility in an effort to reduce hospital acquired infections or surgical wound infections (Duncan & Mayo, 2004). The OR is a fast paced nursing specialty requiring expert training and mentorship for perspective candidates. According to Burnette (2007), nursing students felt like they were not adequately trained for the complexity of the OR during nursing school. As an effort to combat this, The Methodist Hospital began the Methodist Advancement into Professional Practice Program (MAPP). MAPP students are senior professional nursing school students with an interest of pursuing a career as an OR nurse. The internship is an aggressive two month program focusing on the skills required to function as a highly trained OR nurse. In an effort to uphold recommended standards and practices, the core curriculum is based on the fundamental elements of the Association of PeriOperative Nurses (AORN). During the first two weeks students began their training in a classroom setting where were introduced to the basic concepts of the OR. The next six weeks students will be engage in simulations labs of what was taught in the classroom setting. They will demonstrate mastery through return demonstration prior to orienting through the OR suites. Once on the unit, MAPP students are assigned a preceptor for the remainder of their training and are allowed to function independently through direct supervision by their preceptor. Philosophy
Philosophies are essential to nursing organizations as it defines values and expectations of an institution. According to Chou & Lee (2007), the formation of nursing philosophies involves knowledge acquisition and the reflection on the value of nursing. The Methodist Hospital Philosophy of Nursing is as followed: “The Methodist philosophy is that professional nursing is the practice of Leadership, Art and Science. The belief is that all nurses have leadership potential and can actualize this potential through daily patient decisions as well as through the shared governance model. Education is encouraged as well as evidence-based practice. And the art of nursing revolves around Relationship Centered Care.” Organizing Framework: Concepts and Sub-concepts
Operating Room (OR) nursing is a complex and highly efficient environment focusing on the surgical patient and their families. Compromising a plan of care and looking at the patient with holistic approach aides in formulating a clean safe surgical suite. While a holistic approach is taken into consideration for the surgical patient’s plan of care, the practice itself is focused. It is focused because the main goal is reducing contributing environmental factors that have the potential in causing a negative effect on the patient’s health. One of the theories of Florence Nightingale was Environmental Theory which contributed environmental factors to affecting patient’s health. Nightingale believed the concepts of pure fresh air, pure water, sufficient supplies, cleanliness, and direct sunlight contribute to optimal patient health (Woods, 2003). These same principles and concepts can be applied to the OR environment. Without adequate clean water at the appropriate temperatures needed to sterilize instrumentations, soiled instrumentations would be used on patients. This practice would expose patients to dangers causing a decline in their overall health status. The concept of focus is sterility with the sub-concepts of aseptic technique, instrument sterilization, integrity of sterile supply packaging, and maintaining a surgical conscience. These sub-concepts ultimately focus around the framework and concept of sterility. Without adequate sterility the end result is patient harm.
Course Program/Outcome The course outcome criteria of the program is for MAPP students to display knowledge of aseptic technique in the surgical environment, function independently in the circulating role under direct supervision of OR nurse, and uphold the fundamental principles of developing a surgical conscience and remembering patient safety first. Manias & Riley (2002), defines a surgical conscience as a protocol in maintaining a sterile field during surgical procedures and encourages individuals of the scrubbed team to perform a self-examination of their sterile technique through an internal examination of the conscience. The evidence of return demonstration in the simulation labs regarding maintaining aseptic technique is a course requirement and outcome which ultimately determines the success of the MAPP student’s professional career as an OR nurse. Curriculum Plan Curriculum planning and development is essential to the success or failure of any program. The OR is a complex and highly skilled nursing specialty. The need for OR education is highly needed for individuals entering into the OR without prior knowledge of the environment. In an effort to produce proficient OR nurses, the MAPP curriculum is tailored to fit the needs of the students. According to Cullen & Joyce (2010), it is important to revise curriculum plans in an effort to the specified needs of the student and environment of choice. Research has shown that nursing students often feel they were not adequately trained to care for the complex surgical patient. (Burnette, 2011). The curriculum plan was carefully devised and focuses on the core components and basic fundamental elements of the OR environment. It is important to develop a step by step approach in curriculum development. (Windish, 2011). The core components are comprised of OR attire, sterile/sub-sterile core, OR furniture, open/closed gloving, donning sterile gown, and basic OR positioning, aseptic technique, and the surgical scrub. At the conclusion of the two months, students should be able to accurately identify basic OR furniture, differentiate between sterile/sub-sterile core, proficiently perform the surgical scrub, independently open/closed gloving, donning of the sterile gown, and most important be able to identify breaks in aseptic technique.
Course Description The course description for the MAPP program is composed of two days of classroom time focusing on an introduction of the intended curriculum. The remainder of the two weeks will be dedicated to the stimulation lab where the students will have hands-on and return demonstration of the core components. Over the next four weeks the students will be assigned to an OR suite of the educators choosing. The students will be carefully paired experienced OR preceptors in an effort to be mentored throughout the remainder of the program. According to Straughair (2011), it is important for student nurses to have a compassionate role model in the clinical environment. Nurse educators must be mindful when implementing appropriate curriculum designs, taking into account the moral codes and values of nursing today. (Straughair, 2011). MAPP students will shadow their selected preceptor for 24 per week from 0700-1500. Upon completion of the course description, MAPP students will earn a 8.4 CEU’s and a certificate of completion in OR preparation. This can ultimately be used as a great advantage over other candidates applying for the OR residency program once they become an RN.
Curriculum Program/Evaluation Curriculum Evaluation is an important factor when devising any curriculum plan. The overall assessment of the agencies philosophy can be identified through the evaluation process. According to Keating (2006), the formative portion of the evaluation process consists of the student’s evaluation of the curricula. It is important for students to be honest in the evaluation process, as it aides in re-structuring process of the curricula. Before the re-structuring of the curricula occurs, it is important for educators to learn how the curricula changes will affect future students. (Farrell, Nanda, & Shield, 2011). Upon completing the course, MAPP students will gain the basic knowledge and skills needed to function in the OR. Upon Completion of the program, MAPP students will be able to: 1. Identify basic OR furniture 2. Identify the difference in sterile/sub-sterile areas 3. Proficiently perform the surgical hand scrub 4. Independently don sterile gown and gloves 5. Proficiently identify breaks in aseptic technique
Facility Description The facility of choice for the stimulation is the Methodist Institute for Technology , Innovation, and Education (MITIE) lab. The MITIE lab is a 35,000 square foot stimulation lab created for the continuing education and research. It is a virtual lab cultivated to mimic the OR’s. It is in the MITIE lab that students will began to develop a surgical conscience applying aseptic technique. There are different stations specified for different areas of OR. Two rooms are set up as an OR suite stimulation of patient positioning and patient safety. Within those two stimulation rooms are basic OR furniture stations. Prior to entering those stimulation rooms, MAPP students must enter the department through a corridor similar to the sterile/sub-sterile core of the OR. Outside of the stimulation OR suites are the scrub sinks where MAPP students will began the art of the surgical scrub and donning a sterile gown and gloves. The students will repeat these steps for the remainder of the two weeks until they master each skill independently.

Summary Educational curriculum is a vital part in any teaching/learning experience. It is important to incorporate frameworks and evidenced based practices (EBP) as a foundation for the intended curricula. According to Titler (2008), EBP is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions. As an effort to combat nursing students not being well prepared for the transition of nursing school to the working force (Burnette, 2011), The Methodist Hospital has created a MAPP program which addresses the issue. MAPP students are allowed the opportunity to do an internship in the OR in preparation as a professional OR nurse. Through a curriculum based on frameworks, philosophies, and simulation return demonstration MAPP students are mentored into OR nurses. Education is an ongoing necessity vital to the future of nursing.

Personal framework figure 1.


Framework Concept: Sub-concepts: Link between concepts: Concept/subcon.

Framework Model The framework model identifies the concept of sterility as the core or foundation of the framework. The sub-concepts of aseptic technique, integrity of sterile packaging, instrument sterilization, and maintaining a surgical conscience are linked to the core of sterility through the bolded arrows. This indicates the sub-concepts are linked back to the core. The arrowed lines intertwine all concepts as they are correlated to one process forming the concept of sterility.


Burnette, M. (2011). Advancing education in a changing health care environment. AORN

Connection, 93(2) C1, C8-C9
Chou, M., H, Lee, L, C. (2007). Initial formation of nursing philosophies following fundamental clinical practice: The experience of the male nursing student. Journal of Nursing Research, 15(2)127-136
Cullen, B., Joyce, B. (2010). Essentials of baccalaureate nursing education for entry-level community public health nursing. Public Health Cursing, 27(4) 371-382. Doi:10:1111/j.1525-1446.00867.x
Duncan, G. H., Mayo, R. S. (2004). Patient and family centered care: A multiple approach in patient safety. American Journal of Nursing, 35(7), 78-86.
Farrell, T. W., Nanda, A., Shield, R. R., Wetle, T. (2011). Integrating geriatrics into medical schools: student journaling as an innovative strategy for evaluating curriculum. The Gerontologist, 52(1) 98-100. doi:10.1093/geront/gnr079
Manias, E., Riley, R. (2002). Philosophical and ethical issues: Foucault could have been an operating room nurse. Journal of Advanced Nursing, 39(4) 316-324
Straughair, C. (2011). Exploring compassion: implications for contemporary nursing. Part 2. British Journal of Nursing, 21(4) 239-243
Titler, M. G. (2008). Patient safety and quality: An evidenced based practice handbook for nurses. Rockville:MD
Windish, D. M. (2011). Brief curriculum to teach residents study design and biostatistics. Evidence Based Medicine, 16(4) 100-104. doi:10.1136/ebm.2011.04.0011
Woods, M. R. (2003). Clean care is safer care: Patient safety challenge. International Journal of Infection Control, 7(2), 109-129.



Aseptic Technique

Instrument sterilization Sterile Packaging Integrity

Maintaining a surgical conscience

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