Running head: TEACHING PROJECT SUMMARY 1

Teaching Project Summary

Mary Davidson
UIN#00934875










NUR 402
Old Dominion University
Spring 2013
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Teaching Project Summary
Ive been working as an O.R. nurse for the past 4 years, and am employed a small
community hospital with 9 O.R suites. A for-profit corporation acquired our facility two years
ago, and many financial cuts were made that have impacted our department. Weve been
without a Nurse Educator for the past 18 months, and consequently staff education has suffered.
I discussed educational needs of the staff with my department manager, clinical leaders, and co-
workers. I gathered information about what topics staff was interested in through conversations,
as well as an education questionnaire, which I tailored to the O.R. setting. The most common
topic requested was surgical site infection prevention and how it relates to what we do in the
O.R. One of the major contributing factors to infection is the use and application of an
antimicrobial agent before incision is made. These are called surgical skin prep agents and are
critical to skin asepsis. There are many different skin prep agents and indications for them, and
the staff in my work environment doesnt generally utilize each one on a daily or even monthly
basis. My goal was to assess our staffs current understanding and ability to use the various prep
agents our facility uses in the O.R
Nature and Scope of Problem
Surgical site infections affect thousands of patients each year and greatly impact not only
patient outcomes, but also overall health care costs. These infections can result in more than
$50,000 in additional health care costs per patient (Barnett, 2007). In retrospect, it wouldve
been helpful to see actual data from my hospital on the number and costs of actual post-op
infections. Due to confidentiality, I was unable to access any current statistics. Intraoperative
skin prep agents are one factor examined when surgical site infections occur post-operatively.
There are several different skin prep agents currently on the market today, and each has a
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specific mechanism of action and indication. Factors to consider when choosing an appropriate
intraoperative skin prep agent include contraindications, environmental risks, the patients
allergies and skin condition, the surgical site, the manufacturer recommendations for the prep
agent, and surgeon preference (Zinn, 2010). Its imperative that Operating Room staff has the
most up-to-date information on how and when to use them.
Target Audience
My audience was a professional group of O.R. staff who are responsible for surgical skin
asepsis. Since correct selection and application of antimicrobial agents is one of the first lines of
defense in preventing infections, I focused on the staff that routinely performs that task. In the
operative setting, its typically the circulating nurse who applies the surgical skin prep agent.
Occasionally the Surgical Technician (Surg. Tech.) will apply it. For that reason, the target
audience for assessment purposes included both groups of staff members. Our staff circulators
are RNs, where Surg. Techs. are trained and certified by non-degree programs. Our RNs have an
average of 12 years of O.R. experience, and the Surg. Techs have an average of 17 years of
experience. There are 15 women and 8 men who were the learners. The average age of the
group was 41. There were 2 members of staff that have hearing difficulties. All staff members
spoke English as their primary language. There were two Hispanics, one Asian, and 21
Caucasians in the group of learners. The RNs and Surg. Techs. are trained in the entire specialty
areas of surgery at our facility, but are typically assigned to a surgical service (i.e., orthopedics,
neuro, general, plastics, ENT, etc.) in their daily O.R. work assignments. The implications of
this are that the orthopedic service RNs and Surg. Techs. may have not worked in the other
services in several months. Each specialty may utilize prep agents that are new, or are being
used in a new way, which poses problems for staff that arent routinely assigned to that service.
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In addition, our RNs and Surg. Techs. take night and weekend call, and may do cases in any of
the surgical specialties, therefore need to have a working knowledge of all the agents that may be
used. The selection of FDA approved skin prep agents for a surgical specialty is typically
driven by surgeon preference, recommendations by his specialtys governing board, or AORN
standards. Nonetheless, RNs are responsible for determining if an agent is safe and appropriate
for their patient.
Standards of Practice
The Association of perioperative Registered Nurses (AORN) is the national association and
premier source for perioperative nurses. Our O.R. standards, practice, and policies are based on
AORNs current recommendations. AORN is committed to improving patient safety in the
surgical setting (AORN Standards, 2013). My teaching project was based on the following:
Recommended Practices for Preoperative Patient Skin Asepsis, Recommendation III: The
antiseptic agent used should be selected based on the patient assessment. Recommendation
VII: The antiseptic agent should be applied to the skin over the surgical site and surrounding
area in a manner to minimize contamination, preserve skin integrity, and prevent tissue damage.
Recommendation XIII: Policies and procedures on the skin preparation of patients should be
written, reviewed annually, and readily available within the practice setting. (AORN Standards,
2013). Although I couldve presented more recommendations on skin asepsis, it was not
possible due to time constraints. In my opinion, the standards give a foundation of theory; the
why we practice a particular way. The other equally important aspect of my teaching project
was the mechanical application and skill of using the skin prep agents. Because the prep agents
are applied in different ways, I thought it was important to leave enough time for the
demonstration/ return demonstration portion of my presentation. The majority of staff preferred
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to learn hands-on based on my questionnaire results, so it was my priority to allow enough time
in the presentation for this to occur.
Needs Assessment
The needs assessment portion of my project began with an in-service suggestion sign-up
sheet, which I posted in the staff break room. I also met with my department manager as well as
clinical leaders to find out what topics they felt was important for staff education. Many topics
were suggested, and based on those results, I devised a survey asking more specifics about what
staff wanted, including topics, preferred learning style, and preferred time/setting for learning. I
distributed the questionnaires at a staff meeting, and 12 of the 23 target audience members
completed and returned them to me. The most requested topic requested was surgical site
Infections related to surgical prep solutions, and all of the responders preferred hands-on
learning.
Since the survey results represented only half of my target audience, I had many informal
conversations with staff members. I asked about their familiarity of AORN standards regarding
prep agents, and stated what the current guidelines were. I inquired about their knowledge and
comfort level utilizing various prep agents, and asked for examples of situations in which they
were unsure of indications and correct application. I asked what type of learning environment
they preferred; lecture, hands-on, group discussions, computer modules, individual study. We
also discussed that type of learners they were- visual, auditory, tactile.
I also did an observation assessment, and randomly selected staff RNs and Surg. Techs. to
watch apply prep agents. I chose to observe staff that was working in the usual surgical service
as well as those who were assigned to different services.
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The results of the questionnaire survey were clear in that the learners wanted to learn more
about surgical prep solutions related to surgical site infections, and how to correctly apply them.
I was disappointed that more staff didnt respond to the survey, but in retrospect I got a more
comprehensive picture of what and how the staff wanted to learn from my conversations with
them. I found that the most experienced staff (men and women) were familiar with AORN
standards, more comfortable with the older prep solutions, and are generally learners who prefer
hands-on practice in addition to lecture formats. Theyre the generation of staff who were
trained with watch one, do one, teach one mentality of years ago, so theyre accustomed to
learning by practicing the skill. The least experienced staff (men and women) was also familiar
with AORN standards and more comfortable using the newer prep agents that are more
commonly used today. They expressed an interest in group discussions to hear from the more
experienced staff. Overall, the staffs assessment of their learning styles were varied. Some
reported visual learning preferences, while others felt they were auditory learners. Every staff
member reported they needed hands-on learning with prep agents in order to learn and master
proper application techniques.
Teaching Plan
My purpose was to provide instruction on correct selection and application of surgical skin
prep agents for patients and types of procedures to O.R. RNs and Surg. Techs. I based this
choice of topics on its relevance to surgical site infections, and feedback from my manager,
clinical leaders, and co-workers. The bottom line for a for-profit hospital, well, is the bottom
line. Our department has gone through many changes due to the financial awareness of our
employer. Although our department is one of the more profitable areas of the hospitals, revenue
from a single surgery can turn into a loss if the patient develops a post-op infection. Hospitals
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generally do not receive full reimbursement from costs associated with surgical site infections
(Barnett, 2007).
I determined the teaching plan based on AORN guidelines and manufacturers
recommendations for their prep agent. I also determined the framework of the teaching plan by
researching other teaching plans on this subject. (Merrill, 1982). Although the content was
outdated, I was able to get ideas on how to structure my presentation. The cognitive objectives
of the plan included AORN standards and a review of the prep agents. I utilized information
from a table grid of the various prep solutions including chemical makeup, how they worked,
and indications/contraindications. (AORN Standards, 2013) I also reviewed patient assessment
and how it affected selection and application of an agent, also based on AORN Standards
(AORN Standards, 2013). This information was presented in a power point format, as well as
printed materials. My original teaching plan called for 20 minutes to cover this material,
however, in practicing my presentation beforehand, I discovered I only needed 12 minutes to get
through the power point presentation. During my actual presentation, I completed it in 10
minutes. This proved to be helpful, since I realized I needed more time for the psychomotor
objective of my project. My plan included having staff members demonstrate how to correctly
apply the prep solutions to a mannequin body part after the lecture. I planned 15 min, but this
was clearly not enough time for everyone to demonstrate all the preps. In actuality this portion
took 25 minutes.
The affective objective of my teaching plan was designed to be a group discussion about
communication and surgical conscience as it relates to skin asepsis. Surgical conscience refers
to exhibiting ethical behavior in order to promote patient safety. It involves an awareness of the
entire surgical team, and empowers staff to halt the surgery if a break in sterile technique is
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observed, without fear of repercussions. Perioperative staff members are taught sterile
technique and surgical conscience at the beginning of their training. However, over time, staff
members may become complacent and stop correcting each others practices (Roesler, 2010).
The purpose of this part of my presentation was to have an open dialog amongst staff to discuss
their feelings regarding communication with all members of the O.R. team when a break occurs
in skin asepsis. I had allotted 10 minutes for this part in my teaching plan. In actuality, this
portion could have gone on longer, but staff members had to start their cases for the day. Many
times in the O.R., this exchange of information and ideas is one of the most effective ways to
learn about how each member confronts their own ethical dilemmas and surgical conscience. At
the conclusion of the group discussion I handed out a post-test for the learners to complete. My
presentation ended up being longer than our usual staff in-services.
Instructional Strategies
For the cognitive objectives, I chose a lecture format and created a power point presentation
utilizing prep solution information found in the AORN Standards 2013. I extrapolated
information from a chart and arranged it in an organized and simple bullet point format. My goal
was to not inundate the learners with too many details, so I kept the format fairly basic. This was
keeping with the gestalt principle of Cognitive Learning Theory, in that psychological
organization is directed toward simplicity, equilibrium and regularity. (Bastable, 2008, p. 61).
In general, cognitive psychologists note that memory processing and the retrieval of
information are enhanced by organizing information and making it meaningful (Bastable, 2008,
p. 61). The purpose of utilizing a lecture format for this objective was to convey clear, succinct
differences with the prep solutions. Each prep agent has a specific mechanism of action along
with specific advantages and disadvantages. (Zinn, 2010). The learners were going to need to
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know how to differentiate between the choices in order to select an appropriate agent for their
patient. I then utilized information from AORN Standards 2013 to address choosing skin prep
agents based on patient assessment. I listed patient considerations when choosing an agent
according to AORN recommendations. Overall, lecture format seemed appropriate for the size
of the group of learners. I used a large projection screen so it was easily visible to everyone in
the room, and made room in the front for staff that have difficulty hearing.
For the psychomotor objective, I had prepared an area in the room for demonstration/return
demonstration of 6 different types of skin prep solutions. I arranged each workstation with the
skin preps and supplies needed for return demonstration. I first explained to the learners the
purpose of the procedure, essential supplies needed (sterile gloves, prep), step-by-step process of
applying the prep and what was expected of them. I then demonstrated how each prep is
correctly applied. Staff worked with partners for the return demonstration, and each learner
demonstrated how to apply each prep to the mannequin. I circulated the room and observed the
learners as they demonstrated how to apply the each of the 6 prep agents. This choice of
instruction is supported by the Behaviorist Learning Theory, where by the focus is on the learned
behavior and its directly observable. (Bastable, 2008, p. 54). Correct performance of the
surgical site skin prep is essential to maintain the patients skin integrity, thereby reducing the
possibility of infection(Barnett, 2007).
For the affective objective of my teaching plan, I chose to use group discussion. I had
presented an ethical dilemma as an example to initiate discussion in order to keep the learners
focused on the topic of surgical conscience related to skin prep. I believed it was important for
the staff to exchange feelings and opinions regarding observation of another staff member
breaking sterile technique when prepping the skin. I acted as a facilitator to keep the learners
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focused on the topic. Although group discussion with this many learners could be difficult, I felt
it was important for staff to engage in open and honest discussion about their own experiences.
This type of learning is supported by the Social Learning Theory, specifically role modeling.
(Bastable, 2008, p. 67). My goal in using this type of instructional strategy, was to have the
more experienced staff discuss their own surgical conscience and to give perspective and a point
of reference to the less experienced staff.
Evaluation
The three evaluation models I utilized were Process (formative) Evaluation, Content
Evaluation, and Outcome (summative) Evaluation. I utilized formative and content evaluation to
address the psychomotor objective of my teaching, and content evaluation for the cognitive
objectives.
For evaluation of the cognitive objectives outcomes, I created a written post-test for the
learners. The test was based on the information contained in my power point presentation. It
included questions pertaining to the characteristics of the skin prep agents, appropriate selection
and application on patients, and patient assessment criteria. The test had true/false and multiple-
choice questions. I administered the test at the end of the teaching session.
For evaluation of the psychomotor objective outcomes, I utilized a performance checklist.
Each staff member was evaluated based on my observation during the return demonstration.
Evaluation of the affective objective outcomes was more difficult, and I was unable to
determine what evaluation model it would encompass. I essentially tallied the number, gender,
and years of experience of the staff that participated in the group discussion.
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Results of the post-test were as follows: 18 out of 23 learners scored 85% or higher on the
test. 5 learners were unable to complete the test due to time constraints. All 5 of those learners
achieved a score on 85% or higher on the questions they did answer.
Results of the performance checklist: 16 of the 23 learners were able to perform all items on
the checklist the first time I observed them demonstrate the skin prep application skills. 7
learners had to perform the return demonstration more than once to complete the skills checklist.
Results of the group discussion: 3 men and 8 women spoke during the group discussion. Of
those who spoke, the average number of years of experience was 16.
My overall evaluation of the teaching session is somewhat mixed. I think the topic was
relevant, and tailored to what the learners wanted to learn more about. When asked, only 50% of
the learners were aware of the financial impact of surgical site infections. It was helpful to
present the big picture of why skin asepsis is so important and how we play a significant role in
the well being of our patients post-operatively. However, I feel there was not enough time to
do the demonstration/return demonstration portion of the presentation. Even though I had set up
the workstations ahead of time, it was difficult for the learners to practice the application of all
the prep agents without being rushed. I also believe it wouldve been beneficial to spend more
time in group discussion about surgical conscience. Although the in-service was scheduled for
45 minutes, I think an hour would have been more appropriate. I thought the results of the post-
test were positive, in that the majority of the learners were able to recall the information during
the power point presentation. I was a bit surprised there were so many learners who had to
repeat the return demonstration in order to successfully complete the checklist. I think this could
be partially due to lack of time, size of the group, and the difficulty in observing me demonstrate
correct application. This was a large group to be performing return demonstration at the same
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time; it may have been more effective to split the group and do two separate teaching sessions.
Unfortunately that approach isnt possible in my work environment, as we have very limited
time for in-services.
Summary
My experience in doing this teaching project was very enlightening! Good educators make
teaching look very simple, which Ive found isnt. Theres so much more thought, planning and
evaluating that goes into teaching that I never knew. I have no formal training in teaching, and
although I do act as a preceptor to new RNs at work, I have never presented a teaching session
like this before. I struggled with estimating time for each segment of my teaching, but in the end
I feel I was able to enhance my co-workers knowledge and skill in skin asepsis.
Initially the process of needs assessment was confusing to me. I had spoken with my
manager, and she had created a list of topics she felt the staff needed for continuing education. It
didnt occur to me that the staff (learners) might feel otherwise as far as their learning needs. In
conducting the needs assessment, I realized that what I thought was important, wasnt
necessarily important to the learners. My educational needs survey and conversations with staff
really assisted me in focusing the topic and tailoring the presentation to the learners. I also
underestimated how the AORN Standards would form the foundation of my teaching. Ive
developed quite an appreciation for this O.R. bible, and now understand how our department
policies and practices are developed by these standards. In many ways, I feel the O.R. work
environment is so specialized, and unless you have experience in that area, its difficult to
understand perioperative nursing practice. It was a challenge for me to communicate (i.e.,
discussion boards) and translate how my nursing practice is different in that teaching is almost
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entirely among co-workers. Ive realized its a skill Ill have to continually practice and improve
upon.
So much of the textbook is geared toward patient teaching, that I found it was challenging to
translate some concepts for staff education. There is not a lot of patient teaching that occurs in
my daily tasks; its almost always teaching to and learning from my co-workers. I found the
teaching plan to be an excellent way of organizing the content and it was helpful to focus in on
teaching objectives. In actuality, I thought that was the most beneficial assignment in preparing
the teaching project. I realized during the process how important it is to have a framework for
the teaching session, and have clear objectives with goals and outcomes. My initial agenda was
to disseminate the information, without regard to how it was received. I learned that the
learners understanding of the information is truly the only way to measure the success of the
teaching session. It seems like such a simple concept, however, in the beginning I was focused
on what I wanted to teach, not what the learners should learn! The teaching plan assignment
really helped me conceptualize this. The online video lecture about the teaching plan was
extremely helpful.
The evaluation process was unfamiliar to me as well. The text and lecture topics were helpful
in creating tools to measure outcomes. I had planned to have a post-test for the cognitive
objectives, but didnt give much thought to measuring the return demonstration besides my
observation. The checklist tool was an excellent way to standardize how I was evaluating the
learners skills. Ive been a learner in many return demonstration in-services, and Ive never
seen a checklist used by the evaluator. Perhaps they had a mental checklist, but I had too many
learners to evaluate to do it that way!
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Overall I found this teaching project one of the most challenging assignments Ive done in the
ODU nursing curriculum, although Ive only taken 4 courses. It was very eye opening to see the
process from beginning to end, and I think Ive acquired a better understanding and skills in
teaching. Im already seeing some of these concepts transfer to my preceptor role at work. The
process has broadened my perspective on teaching, and Im hoping Ill have more opportunities
to practice and improve upon my new set of skills.

















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References
AORN Perioperative Standards and Recommended Practices For Inpatient and Ambulatory
Settings. 2013 Edition. 75-89.
Barnett, T. (2007, August). The Not-So-Hidden Costs of Surgical Site Infections. AORN
Journal, 86(2), 249-258.
Bastable, S. B. (2008). Nurse as Educator Principles of Teaching and Learning for Nursing
Practice (3 ed.). Sudbury, MA: Jones and Bartlett Publishers.
Merrill, S. (1982, June). A Teaching Plan for Surgical Skin Preparation. AORN Journal, 35(7),
1372-1378.
Roesler, R., Hallowell, C., Elias, G., Peters, J. (2010, February). Chasing Zero: Our Journey to
Preventing Surgical Site Infection. AORN Journal, 91(2), 224-235.
Zinn, J., Jenkins, J., Swofford, V., Harrelson, B., McCarter, S. (2010, December).
Intraoperative Patient Skin Prep Agents. AORN Journal, 92(6), 662-674.






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Appendix A



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Appendix B
O.R. Staff Educational Needs Survey


Please respond to the following educational topics with a V (very interested), S (somewhat
interested), or N (not interested)
Procedures:
___Craniotomy ___Spinal Fusions ___Corneal Transplant
___Anterior total hip ___VATS ___AAA

Clinical:
___Sponge/instrument counts ___Intraop Hypothermia ___Code Cart
___Patient Positioning ___SSI/Prep solutions ___O.R. Equipment
___Malignant Hypothermia ___Anesthesia Review ___Implants
___Flash Sterilization

Interpersonal:
___Teamwork ___Communication ___Call/Vacation Schedule
___Ethical Issues ___Managing Stress


Please rank the educational formats which you prefer with 1 being the most and 6 being the least
preferred.
____Lecture ___Seminars ___Group Discussions
___ Hands-on ___Computer simulation ___Independent Study

Is it important that educational offering include CME?
___Yes ___No

Please rank what time you prefer to attend educational presentations with 1 being the most and 4
being the least.
___Before Shift ___Morning Mtg. during work ___After shift
___Weekend/non-work days


*Please return to Mary Davidson





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Appendix C
Surgical Skin Prep Post-Test

True or False

1. ___Surgical Site Infections can cost upwards of $50,000 per patient
2. ___Skin prep agents do not affect the rate of Surgical Site Infections
3. ___AORN recommends all skin preps can be used for all patients
4. ___Patient assessment should be made before choosing skin prep
5. ___None of the skin preps are flammable
6. ___5% ophthalmic betadine is ototoxic
7. ___Chloraprep contains a high concentration of alcohol
8. ___Betadine may be used on a patient with iodine allergies
9. ___All skin preps may cause skin irritation
10. ___ All preps should be removed from skin at the end of case

Multiple-Choice

1. Which of the following prep agents are broad spectrum?
A. Betadine C. Duraprep E. All of them
B. Chloraprep D. 4% Chlorhexidine

2. Which prep agents are flammable?
A. Betadine C. Duraprep E. All of them
B. Chloraprep D. 4% Chlorhexidine

3. Which preps must dry for 3 minutes before draping?
A. Betadine C. Duraprep E. None of them
B. Chloraprep D. 4% Chlorhexidine

4. Which agents can be used on mucous membranes?
A. Betadine C. Duraprep E. All of them
B. Chloraprep D. 4% Chlorhexidine

5. Which agents are FDA approved?
A. Betadine C. Duraprep E. All of them
B. Chloraprep D. 4% Chlorhexidine
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Appendix D

Return Demonstration Checklist


____Opens outside of prep maintaining sterility inside
____Dons gloves in sterile fashion
____Correctly prepares prep solution
____Chooses correct site to initiate application
____Applies betadine scrub/ paint at incision & works out
____Applies 5% opthalmic betadine to eye & ear correctly
____Applies betadine solution at incision site & outward
____Applies Duraprep scrubbing over incision site
____Applies Chloraprep scrubbing 30 sec. over incision
site and allows to dry for 3 min. before draping
____Applies 4% chlorhexidine over incision site
____Removes towels underneath prepped area without
contaminating surgical site
____Disposes of used skin prep in appropriate container


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Honor Pledge:
I have neither given nor received unauthorized aid on this
examination (or other material turned in for credit) nor do I
have reason to believe anyone else has. Mary P.
Davidson







































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