key: cord-0930138-udsv2fv9
authors: Peneza, Daphny; White‐Edwards, Karen Y.; Bricker, Crystal; Mahabee‐Betts, Mary; Wagner, V. Doreen
title: Perioperative Nurse Educators: Rapid Response to the COVID‐19 Pandemic
date: 2021-02-03
journal: AORN J
DOI: 10.1002/aorn.13305
sha: c8816eba8f6c8385e83ead63aba757c1e9e9289b
doc_id: 930138
cord_uid: udsv2fv9

During the initial response to the coronavirus disease 2019 (COVID‐19) pandemic, hospital leaders limited or halted the scheduling of elective surgical procedures. Perioperative nurse educators participated in a rapid response to develop innovative strategies and use a variety of modalities to provide information and education activities for staff members who were reassigned to different hospital areas. Residency program educators used alternative teaching methods to accommodate the lack of clinical rotations and allow orienting nurses to progress in an OR nurse residency program. Limited access to ORs and social distancing rules prevented nursing students from completing clinical rotations in health care settings, and academic educators developed flexible solutions to meet the students’ needs. Perioperative educators can use guidance from national and international organizations to assist leaders and staff members with managing patient care during the pandemic. This article presents specific information on perioperative nurse educator roles and responses during the pandemic.

protect the community and keep the workforce informed, health system administrators launched communication strategies to relay COVID-19-related topics across the system in early March. Hospital administrators immediately suspended all student affiliates (eg, nursing student clinical rotations) and prohibited group education meetings with guest speakers from outside the facility. An additional component of the immediate response to ensure clinical safety included the implementation of a travel ban for all health care workers (HCWs) and visitor screening throughout the health system. Service line educators assisted perioperative services leaders with selecting essential industry partners who would be allowed in the facility for surgical support.

The service line educators developed an education plan for staff members to facilitate safe surgery and perioperative team member well-being. In partnership with the clinical managers, the service line educators implemented a back-to-basics focus during morning huddles and service line meetings that included education on handwashing, standard precautions, and aseptic technique. To avoid the spread of COVID-19 in clinical settings, hospital administrators required strict adherence by all HCWs to practice social distancing and wear masks. The service line educators initially scheduled education sessions in larger venues (eg, large conference rooms), offered sessions several times a day, and limited attendance to 10 team members. Because guest speakers were not permitted in the facility, any surgical services education activities involving guests transitioned from face-to-face meetings to video teleconferencing.

To avoid the spread of COVID-19 in clinical settings, hospital administrators required strict adherence by all health care workers to practice social distancing and wear masks.

Systemwide, all staff members completed the required online education module and competency assessment on COVID-19 concepts. System information technology personnel created an intranet web page for surgical services education so leaders and educators could provide the timely distribution of unit-specific information and immediate education in various formats (eg, frequently asked questions, videos, process maps). Clinical leaders and educators encouraged staff members to access the health system's social media site for urgent COVID-19 alerts. System leaders only approved an in-person tabletop presentation for critical education on the use of smoke evacuators during procedures involving patients with COVID-19.

The Collaborative Systemwide COVID-19 Taskforce created a process for interdisciplinary perioperative teams to use when managing patients under investigation for or diagnosed with COVID-19. Perioperative educators collaborated with physicians to disseminate information on perioperative COVID-19 processes rapidly and safely. Hospital educator team members created, edited, and quickly distributed a video that provided the implementation steps of the process. Perioperative leaders provided time for staff members to view the video and easy access to review the process before caring for patients. Perioperative leaders also maintained a printed copy of the process and process map for staff members to use in the OR. Staff members could access the documents virtually using the health system's intranet site.

As the number of patients with COVID-19 continued to increase in Harris County, Texas, perioperative educators supported multiple task forces focused on safety. First, the chief nursing officer directed educators to serve as shift educators at screening stations and provide triage at hospital entry sites. Second, as partners with the facility's infection prevention team, educators assisted with providing staff members with information on proper methods for donning and doffing personal protective equipment (PPE). In March 2020, the chief nursing officer requested D.P. to lead the Surgical Services' PPE Quality Task Force that deployed perioperative staff members to five nursing units dedicated to the care of patients with COVID-19 to assist in PPE selection, donning, doffing, product inventory management, and recycling.

The hospital education team at Memorial Hermann Hospital-Texas Medical Center, Houston, shortened the time frame for employee orientation from four days to two and a half days. The onboarding employees reviewed the required policies and completed initial competencies online. In mid-March, it became difficult for educators to place perioperative orientees because the procedure schedule only comprised urgent and emergent cases. The clinical educator created a revised orientation matrix and converted staff member orientation schedules from five 8-hour shifts to three 12-hour shifts so onboarding staff members could learn tasks and processes specific to the evening shift. Service line educators collaborated with the evening shift charge nurse to plan orientee experiences and met routinely with orienting staff members to assess their progress and assist with their learning needs.

In April 2020, the American College of Surgeons, the American Society of Anesthesiologists, AORN, and the American Hospital Association released the Joint Statement: Roadmap for Resuming Elective Surgery After COVID-19 Pandemic. 3 Perioperative leaders and hospital administrators reviewed the statement and released a phased approach to resume elective surgical procedures safely and address the current and ongoing health care needs of the community (Figure 1 ). 4 As an additional safety measure that began when the facility entered phase 2 on April 27, 2020, patients undergo testing for COVID-19 before surgeries.

The service line educator's three most essential skills (ie, communication, focus on safety, supporting staff members) were necessary to provide multifaceted COVID-19 education. Initially, service line educators found changes to communication approaches difficult because of enforced limitations (eg, virtual rather than face-to-face). However, communication became easier as the health care system leaders continued to use internal communication mechanisms such as leader tool kits, a system-wide news app, COVID-19 daily updates, weekly virtual town halls with the health care system's chief executive officer, and weekly newsletters from the chief nursing officer. These methods provided simple, clear, frequent, and effective information for HCWs.

Service line educators focused on safety when they verified that staff members used appropriate and adequate PPE and created expedited N95 respirator-fitting processes for staff members who were working on the COVID-19 front lines and requested reassessment. In addition, service line educators participated on interdisciplinary teams that created or updated several clinical processes focused on safety, including postmortem care in the OR, protected code blue (ie, HCWs don PPE when responding to a cardiorespiratory arrest) for patients with COVID-19, and transport of patients with COVID-19. The service line educators also assisted staff members with maintaining awareness of support resources, including around-the-clock access to the occupational health support line, child and older adult care resources, voluntary COVID-19 testing for active infection and antibody testing to assess if HCWs had the disease, access to leaders for support, psychological support via chaplain services, and campus-wide celebrations for National Nurses Week in May. 

At the Carle BroMenn Medical Center in Normal, Illinois, the abrupt transition to performing only urgent and emergent procedures meant that there were staff members who were not needed in the perioperative department. As a result, perioperative and hospital leaders asked staff members who were used to only working in the OR to step outside their department and support other areas in need. However, reassigning staff members required more preparation than simply assigning them to a different department, and hospital leaders needed to develop a plan to provide reassigned personnel with the necessary knowledge and skills to perform tasks safely. The perioperative educator (C.B.) collaborated with hospital leaders and other department educators to identify locations in which OR staff members could provide care and address educational needs. The educator provided staff members with information related to identified knowledge gaps that included navigating inpatient nursing documentation, the medication administration process, and policies or procedures for nonperioperative areas in which the OR staff members would be working.

The perioperative staff members were instrumental in supporting visitor and patient screening stations and other departments (eg, employee health, emergency department [ED]) that were experiencing increased workloads because of the crisis. The staff members required information on policies and procedures specific to their reassigned areas; and because the processes, policies, and procedures continued to change, the reassigned staff members also required notification of the changes and information on how the changes affected them in their temporary roles.

Perioperative staff members also were able to support the increased workload in the employee health department. During the initial months of the crisis, the reassigned perioperative staff members assisted with phone triage and support, N95 respirator fit testing, and employee illness tracking and follow-up phone calls. They also learned how to collect specimens for onsite COVID-19 testing and assisted in staffing a drive-up testing site for any hospital staff members who required testing as determined by employee health nurses. The process that perioperative staff members helped to streamline was the foundation of the COVID-19 drive-up testing process used later to schedule and test all patients arriving at the facility for elective procedures.

During the initial months of the crisis, the reassigned perioperative staff members assisted with phone triage and support, N95 respirator fit testing, and employee illness tracking and follow-up phone calls.

Hospital leaders also assigned perioperative staff members to assist in the ED during the pandemic. Preparations for a possible patient surge required additional staff members to assist at screening checkpoints and in the ED triage area, and perioperative staff members became part of that plan. Although there was not as great a surge as leaders anticipated, the staff members were prepared.

Perioperative staff members also provided support at the entrance screening stations for patients, visitors, and staff members. When hospital leaders implemented universal screening for entrance to the facility, it was important to provide staff members at all check-in points who were competent in performing the screening. The staff members also required information on troubleshooting situations that involved individuals who should not be allowed to enter the building, the process for issuing identification for individuals who have completed the screening process, proper PPE, and current patient visitation policies.

Response to the COVID-19 pandemic has required many changes in a short amount of time, and changes continue to occur as health care experts gain knowledge on the disease and its transmission. An important role of the perioperative educator includes providing information to staff members on changes as they occur. When staff members work outside the perioperative department, they still require updated information on PPE requirements, symptoms and screening tools, and process and procedure changes. Perioperative educators continue to work to remain abreast of the many changes, a process that requires flexibility and a willingness to venture outside the doors of the OR. The collaborative efforts of the perioperative educator working in conjunction with other department educators and hospital leaders has been vital to support reassigned staff members who transitioned from regular perioperative tasks to nonperioperative tasks or departments.

The unexpected COVID-19 crisis affected the normal progression of nurses in the Houston-Methodist Hospital Health Care System's six-month OR nurse residency program, which has been in existence since the 1980s. The OR nurse residency program is offered twice a year, with cohorts usually beginning in January and July. This health care system consists of the Houston Methodist Hospital and seven community hospitals; the main hospital has 85 ORs and each community hospital has a perioperative department with 10 to 24 ORs that support seven surgical specialties. There were 25 residents in the January 2020 cohort.

The residency program includes a combination of classroom didactic work, simulation skills labs, and precepted education for the RN circulator role. Because of the pandemic, two months into the January cohort's program, the OR residency program coordinator, a perioperative administration professional development leader, experienced a sudden change in the way that she was able to present the program. On Monday, March 9, 2020, the hospital administrators initiated rules that allowed no more than 15 people in a room; four days later, the administrators decreased that number to 10 (including the instructor). Therefore, the OR residency program coordinator's main goal was to decrease in-person meetings and maintain the program for this cohort. The OR nurse residency program coordinator identified methods of teaching and learning and modified work schedules so all cohort participants could continue a 40-hour work week. She also collaborated with perioperative leaders and OR clinical educators to minimize direct interpersonal contact and streamline the hiring process for the June 2020 cohort.

When the changes that affected the January cohort began, the participants had completed all the required education activities in the simulation laboratory; the remaining portions of the program were classroom didactic work, skills in the clinical environment, and AORN video assignments. To address alternative methods for teaching, the OR residency program coordinator implemented video conferences for distance learning. Initially, she moved the class from a large practical task area that could host the 25 residents to a conference room that could comfortably accommodate 16 people. Because of the revised personal space directive, she separated the resident cohort into two groups and classrooms. Additional OR residents from Houston-Methodist Hospital Health Care System's community hospitals remained at their facilities and attended the video conference education session using a designated computer. After overcoming initial technical challenges, the video conferencing platform worked well, and most presenters were able to present virtually.

To address alternative methods for teaching, the OR residency program coordinator implemented video conferences for distance learning.

Another beneficial resource was AORN's Online Perioperative Nursing Video Library, 5 which contains 43 videos with study guides and a posttest at the end of each video that requires participants to attain a score of at least 80% to receive a certificate of completion. The OR residency program coordinator scheduled the residents to work from home and complete video assignments on Wednesdays. As the administrator of the online account for the residency, the OR nurse residency program coordinator assigned the videos to the residents and accessed the online video library record-keeping spreadsheet to monitor residents' completion of the assignments. The use of the online video library and accompanying resources replaced the program's final two scheduled exams.

Additionally, the OR nurse residency program coordinator developed a detailed outline for each day that included time to review the study guides for each topic, watch the video, and complete the posttest. The residency program incorporates use of a clinical evaluation tool at 7, 11, 16, 20, and 24 weeks to validate the learning of the OR nurse residents. After elective surgery resumed on May 4, 2020, the OR nurse residency program coordinator placed the evaluations on a revised timeline and adjusted the completion date of the January cohort to allow additional time to make up the lost clinical experiences. She used e-mail, video conferences, text messages, and phone calls to communicate with residents, perioperative leaders, and OR clinical educators; distribute information; and maintain interpersonal connections during the COVID-19 pandemic.

The OR residency program coordinator and educators found it difficult to identify alternate work solutions for the orienting residents. The abrupt cessation of surgical procedures and uncertainty regarding their resumption added to the challenge of providing work hours for the residents. The health system's labor pool became an important resource for the educators and residents because they could use it to obtain work hours. Some of the residents worked in the laboratory or medical intensive care unit or on units designated for patients with COVID-19, and some residents provided support to respiratory care services or at screening stations. In addition to maintaining the OR nurse residency program, the coordinator participated in hospital-wide education and competency verification for RNs in the labor pool regarding their ability to complete a head-to-toe patient assessment.

The January cohort completed all the video-conference classes and video assignments. The OR nurse residency program coordinator modified the clinical orientation calendar for the January cohort into three groups based on the return of the residents to the clinical setting. The OR residency program coordinator, clinical educators, perioperative leaders, and human resources staff members decided to move the planned June cohort to begin at the end of July to allow the January cohort time to complete an additional three or four weeks of clinical experience. The two remaining OR nurse residents from the January cohort completed their orientation on October 15, 2020.

The OR residency program coordinator and human resources staff members helped perioperative leaders and OR clinical educators determine and implement alternative methods for hiring nurses into the planned July 2020 resident cohort in a manner that maintained social distancing and provided a positive experience for applicants and existing team members. Before the pandemic, the hiring process included phone screening and onsite observations with interviews that included staff members, an educator, and the manager. The combination of visitor restrictions, efforts to conserve essential PPE for existing staff members, and lack of elective procedures prevented prospective perioperative nurses from participating in the normal OR tour and interview process. As a result of the restrictions, leaders and educators transitioned the interview process to the video-conference format. After revising the interview and hiring plan, the OR residency program coordinator completed the remaining phone screening interviews and worked with the clerical professionals to schedule video-conference interviews and with human resources team members to fill the July cohort positions.

Beginning in mid-March 2020, faculty members at Kennesaw State University in Georgia initiated remote learning for general education courses throughout the university. However, academic educators for specialty courses (eg, education, social work, nursing) needed to transition hands-on work experiences to remote approaches. For nursing clinical courses, academic educators used virtual clinical situations, evolving case studies, and critical thinking application exercises. AORN has offered remote education for many years, and early in the pandemic, it provided a tool kit for COVID-19 that continues to be updated as new information becomes available. 6 In addition, numerous nursing organizations have offered free online workshops and webinars during the pandemic that address topics such as COVID-19 care approaches, epidemiology basics, and self-care activities.

For nursing clinical courses, academic educators used virtual clinical situations, evolving case studies, and critical thinking application exercises.

In 2005, a large local health system formally partnered with the Wellstar School of Nursing at Kennesaw State University to share resources and learn from one another. One faculty member has perioperative nursing experience, and she developed and teaches an elective perioperative course with assistance from perioperative practice partners. This perioperative course provides nursing students with 90 clinical hours of learning with a staff perioperative nurse instructor. When the hospital visitor restrictions began in mid-March, the students had completed 40 clinical hours of the perioperative course that included orientation, a sterile processing department experience, scrub role participation for a day, and observing the surgical continuum of care with several patients. As a result, the academic educator and one staff perioperative nurse instructor provided the remaining 50 hours of circulating experiences using two evolving perioperative case studies with associated videos and reading assignments. The two scenarios included perioperative care of a patient experiencing a below-the-knee amputation and another patient experiencing a traumatic brain injury requiring a hemicraniectomy. During each of the case studies, the nursing students used a variety of assessment skills, communication processes for patient hand overs (eg, SBAR [situation, background, assessment, and recommendation]) and time outs, and addressed wide-ranging changes in each patient's surgical situation (eg, family communication, preoperative assessments, intraoperative procedure preparation, medication needs). Faculty members and students were aware that the lack of clinical time may affect outcomes, specifically regarding meeting state board licensing requirements.

The American Organization for Nursing Leadership (AONL) provides important recommendations for partnerships between academic prelicensure nursing programs and practice facilities to assist students, faculty members, and clinical staff members and leaders during the pandemic. 7 The AONL encourages nursing education programs and health care facilities to partner and allow nursing students to supplement and support nursing services in health care settings. Numerous nursing leadership organizations involved with nursing education (eg, the American Nurses Association, the National League for Nursing, the Commission on Collegiate Nursing Education) endorse the AONL workforce recommendations.

An internet search for COVID-19 resources provides approximately five billion results, which makes it difficult for users to identify pertinent information. Key organizations such as the World Health Organization, 8 the US Department of Health and Human Services, 9 the Centers for Disease Control and Prevention (CDC), 10 and AORN 6 provide up-to-date information on addressing health care-related workforce issues instigated by COVID-19 (Sidebar 1). These organizations offer a variety of information such as daily updated statistics; online training; and frequently updated tools, resources, and guidance to assist health professionals working on the front lines and those who support them.

The mission of the US Department of Health and Human Services is to safeguard the health and welfare of all Americans through the provision of medicine, public health, and social services. 11 This federal department provides updates and guidance to health care professionals on topics related to COVID-19 (eg, clinical care, testing, telehealth) and provides guidance to state and local government officials, public health officials, researchers, and members of the public on pandemic response. 9 The CDC assists state and local public health agencies with preparing for COVID-19 outbreaks 12 and provides more than 100 evidence-based practice guidance statements on a variety of topics, including infection control principles and practices, hospital and supply preparedness, conservation strategies, and direction on the use of telehealth Key Takeaways  As the coronavirus disease 2019 (COVID-19) spread through the United States, health care leaders and staff members responded with swift actions and preparation to protect patients and staff members in surgical settings. One of these actions was limiting or halting elective surgical procedures.

 Perioperative educators focused on educating staff members using alternative methods such as virtual morning huddles, video teleconferencing, e-mail, and the hospital's intranet. The educators also supported staff members at screening stations, in employee health departments, and when scheduling orientee onboarding.

 Residency program educators modified program schedules and resident experiences to meet hospital and department needs and assisted leaders with revised hiring processes to maintain social distancing among applicants. Academic perioperative educators also modified curricula to maintain social distancing and meet course requirements.

 Perioperative educators can use resources from organizations such as AORN to assist leaders with developing an organizational perioperative protocol for patients who are suspected or confirmed to have COVID-19.

tools. 13 The CDC supports communities, businesses, and schools by developing planning and response guides on outbreaks in these areas. 14 The COVID-19 (Coronavirus) AORN Tool Kit 6 provides resources for perioperative practice decision making related to COVID-19 and addresses a variety of topics, including nursing skills, leadership skills, PPE selection and use, supply shortages, infection prevention and control, perioperative guidance, and self-care strategies. To support organizational leaders as they continue to resume and maintain elective surgery, the American College of Surgeons, the American Society of Anesthesiologists, AORN, and the American Hospital Association issued an updated roadmap in August 2020 that focused on maintaining essential surgery during the pandemic. 15 The roadmap addresses readiness, prioritization, scheduling, supply chain, PPE, and COVID-19 issues during perioperative care.

Perioperative educators can use resources from governmental agencies and other organizations to assist leaders with developing an organizational perioperative protocol for patients who are suspected or confirmed to have COVID-19. The educators should consider required PPE, preprocedure preparation (ie, virtual versus face-to-face), intraoperative care (ie, staff member presence during intubation and extubation), OR cleaning and adequate time to complete required air exchanges, and protocols for surgical procedures after normal business hours and on weekends. 15 For contact tracing of a possible exposure to a patient with COVID-19, perioperative nurses should document the names of all personnel who enter the OR in the patient's medical record. An additional staff member should be stationed outside the room to retrieve supplies as needed. Perioperative team members should use effective communication and planning before the procedure to verify all essential equipment and supplies are present and minimize OR traffic.

The COVID-19 pandemic challenged educators across all areas of perioperative nursing, and its effects likely will continue for quite some time. Regardless of the work setting, perioperative educators are adjusting to provide the needed information and resources to support staff members, leaders, and students. Flexibility and resilience allow perioperative educators to use their expertise to address the rapid and constant changes in procedures and processes necessitated by the pandemic. As perioperative educators continue to navigate changes affecting health care practice settings, they should remember that they are not alone in their struggles and that they can use a variety of resources to support leaders, staff members, and students with providing safe and high-quality patient care.

COVID-19: elective case triage guidelines for surgical care. American College of Surgeons

CMS releases recommendations on adult elective surgeries, non-essential medical, surgical, and dental procedures during covid-19 response

American College of Surgeons

Memorial Hermann launches phased approach to safely resume services

COVID-19 (Coronavirus) AORN Tool Kit

Policy Brief: US Nursing Leadership Supports Practice/ Academic Partnerships to Assist the Nursing Workforce During the COVID-19 Crisis

COVID-19) pandemic. World Health Organization. www.who.int/emerg encie s/dis ea ses/novel -coron aviru s-2019

US Department of Health and Human Services

Healthcare facilities: managing operations during the COVID-19 pandemic

US Department of Health and Human Services

COVID-19)

Guidance documents

COVID-19). Community, work, and school

American Hospital Association. Roadmap for Maintaining Essential Surgery during COVID-19 Pandemic

is an education resource specialist III at Memorial Hermann Hospital-Texas Medical Center

is a professional development leader at Houston Methodist Hospital, TX. Ms White-Edwards has no declared affiliation that could be perceived as posing a potential conflict of inter