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Teaching Affective Competencies to Surgical Technologists

urgical technologists (STs) are trained to assist licensed (ie, registered) nurses in providing patient care as delegated. The role of STs essentially is limited to technical tasks that

egate.’ Nurses traditionally have focused on teach- ing the cognitive and psychomotor competencies that support training for technical roles. Teaching these competencies requires specific teaching strate- gies (eg, lecture and return demonstration, pro- grammed modules of instruction, viewing of video- tapes) that nurses typically understand and use with- out difficulty.

The notion of teaching affective competencies, however, is surrounded with mythology and confu- sion, reflecting a lack of understanding of the nature of the affective domain and its relationship to per- sonhood and the profession.’ Some nurses believe that affective learning concerns only staff members’ attitudes or behaviors and that dealing with compe- tencies in the affective domain is the responsibility of management. The affective domain emphasizes feelings and emotions, such as

and methods of adjustment.’ A B S T R A C T The first step in developing Categories within the affective Learning in the affective any curriculum is selecting a con- domain are domain encompasses behaviors ceptual framework. This is per-

receiving, and beliefs concerned with Val- haps the most critical decision that responding, ues, morals, and caring, and sur- a nurse educator can make when valuing, gical technologists have not been developing a curriculum.” The organization, and well trained in affective compe- conceptual framework serves as development of a value system.‘ tencies. This article describes the basis for selecting and organiz-

Practical strategies exist that will the development of a curricular ing what will be taught in the cur- help nurse educators teach affec- model based on Martha Rogers‘ riculum. Each conceptual frame- tive competencies, and they can be Science of Unitary Human Beings work has a unifying theme or con- used in the course of routine pen- and on humanistic learning theo- cept; for example, self-care,’ adap- operative activities. ry. AORN J 70 (NOV 1999) 776- tation,’” or caring.” The conceptu-

The ST functions in the ster- 781. a1 framework selected will assist

ile or “scrubbed” role, and the primary responsibili- ty of the ST is the establishment and maintenance of an aseptic environment in which a patient will undergo a surgical procedure.’ The ST role was cre- S nurses traditionally perform but can safely del- ated during World War I1 as a result of the shortage of RNs available to render intraoperative care to a large number of wounded soldiers.fi Before this, care of surgical patients was the almost exclusive domain of the RN. As the ST necessarily functions under the direct supervision of the RN in the OR, STs are expected to defer to the judgment and direction of RNs.’

GOALS OF THE EDUCATIONAL PROGRAM The goal for educational efforts with STs is that

they are able to translate all of their cognitive, psy- chomotor, and affective knowledge to behavior that supports the well-being of perioperative patients. Additionally, goals include development of a focus on perioperative patients, a positive attitude, dedica- tion to teamwork, and improved communication skills.

interests, attitudes, appreciation, DEVELOPMENT OF CURRICULUM

C H R I S M . P A T T Y , K N

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the educator in developing specific interventions based on the needs of the population to be educated. In the case of STs, a conceptual framework is needed that will facilitate development of a curriculum designed to meet the educator’s goals. Such a frame- work can be found in Martha Rogers’ Science of Unitary Human Beings.”

If a unifying theme can be identified in Rogers’ conceptual model, it may be one of Rogers’ founda- tional assumptions that the practice of nursing is the use of knowledge in human service. Rogers empha- sizes that practice must be flexible and creative, indi- vidualized and socially oriented, compassionate and skillful. Other important Rogerian concepts hold that broad principles to guide practice must replace the rule of thumb, and that educators should stress teach- ing students how to learn rather than just what to learn, how to think critically, and how to find mean- ings and patterns.” Rogers said that “In the educa- tional process, we do not need to teach students how to do everything. Rather, we need to teach them how to find out how to do everything.”“

Rogers’ model is well suited to the teaching and learning of affective competencies and strongly emphasizes that students have the opportunity to translate theory into practice. It stresses that laborato- ry (ie, clinical) study is a necessary adjunct to didac- tic content. As the clinical (ie, perioperative) setting contains many opportunities for teaching affective skills, the inherent flexibility and creativity of the Rogerian framework will assist educators in making the most of scarce time, human, and economic resources. Certainly the practice of the ST encom- passes many cognitive and psychomotor competen- cies, but even superior knowledge and technical skills will not compensate for lack of patient focus. A cur- ricular design based on Rogers’ conceptual model

should meet the goals that the educator has estab- lished for this population; namely, the translation of all cognitive, psychomotor, and affective knowledge to behavior that supports the well-being of periopera- tive patients.

DISCUSSION OF LEARNING THEORY UTILIZATION How we propose to teach depends to some

extent on how we believe people learn. Various theo- ries of learning have evolved over time to provide a framework for teaching and learning activities. Insofar as the science of nursing is dedicated to improving the health of human beings, and that Rogers’ concept of nursing is as a humanistic and humanitarian science, the utilization of a humanistic learning theory is appropriate. In humanistic theory, the motivation for developing one’s full learning potential is inherent in each of us.‘ The role of the educator involves facilitating learner growth through active interpersonal participation, and it is important that the educator’s behaviors and attitudes reflect honesty, empathy, and respect for self and others. The impact of the educator as a positive role model is par- ticularly well explained if viewed from a humanistic perspective.

LEARNING OBJECTIVES FOR TEACHING AFFECTIVE COMPETENCIES

Affective objectives focus on instilling attitudes, feelings, and beliefs in learners. Learning in the affec- tive domain encompasses behaviors concerned with values, morals, and caring. Learning objectives should address each category within the affective domain and be both specific and measurable. Table 1 depicts sample learning objectives for teaching com- munication skills to a population of STs. They corre- spond to the five categories within the affective

Table 1 SAMPLE LEARNING OBJECTIVES

The ST will listen to others before making decisions about the performance of his or her duties and will consider the effect of his or her actions on the well-being of patients, family members, and coworkers.

The ST will respond willingly in meeting information needs of patients, family members, and coworkers.

The ST will demonstrate responsibility for informing patients, family members, and coworkers on matters pertinent to decisions involving them.

The ST will demonstrate a manner of acting that ensures advocacy of the rights of patients, family members, and coworkers to be knowledgeable in making decisions relative to their needs. The ST will demonstrate a philosophy of life and of patient care that is manifested by practice as a consistent advocate for patients and family members and by respect for the values and rights of coworkers.

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domain and are presented respectively; they are based on objectives explicated in a taxonomy of the affec- tive domain.’”

CONTENT OF THE EDUCATIONAL PROGRAM Specific content that is taught should follow the

sequence of these learning objectives. To support the first objective, content should include discussion of listening skills. For the second objective, content should include therapeutic communication tech- niques and instruction on confidentiality and appro- priate transfer of information. Content related to the third objective should include discussion of the con- cepts of empathy and self-determination. The fourth objective’s content should include instruction about patient rights and organizational ethics, the ST’s role in patient advocacy, and ethical concepts such as end-of-life issues. Last, instruction should be given on the mission, values, and nursing philosophy of the organization, and the role of the ST in support of the organizational mission and values should be explored.

TEACHING STRATEGIES Strategies specific for teaching affective compe-

tencies include analysis and confrontation, clinical assignment, hands-on care, examination of verbal expressions, and model learning.” Additional strate- gies that may facilitate affective learning include role play, lecture and discussion, textbooks and other reading assignments, self-directed learning modules, and assigned projects and learning contracts.’“ Strategies for teaching toward the fulfillment of objectives should be presented respectively, and strengths and weaknesses of each strategy should be discussed.

First objective. Role modeling is a good strategy for the first learning objective. The educator can share with the ST that he or she took action based on specific information learned from talking with the patient. For example, if a patient expresses anxiety about being exposed during a procedure, the educator can explain to the ST that his or her extra attention to the patient’s privacy is in response to the conversation with the patient. Patient care itself is demanding enough, and sharing verbally while performing care can be exhausting. Advantages of this strategy include the potential for highly interactive learning and immediate feedback. The main disadvantage is that this requires energy and time from the role model.

Examining verbal expressions

gives immediate feedback

and requires no additional

time investment,

Second objective. A good strategy for the second learning objective is examining the ST’s verbal expressions. By carefully listening to the ST interact with a patient and talking with him or her about the interaction, judgments can be made concerning both the quality of information given and the willingness with which it is presented. For example, many patients are concerned that they may be incontinent while they are under the effects of anesthesia. If the ST’s response to a patient’s concern is “Don’t worry, you’ll be asleep,” the ST’s level of knowledge should be examined further. If the ST refers to certain patients as “the gallbladder” or a “basket case,” it can be inferred that the ST may have certain prejudices and a negative attitude. Examination of verbal expressions gives immediate feedback and requires no additional time investment. Interpreting what has been heard, however, requires special training, and discussing what has been heard will require excellent therapeutic communication skills to avoid making the learner feel defensive.

Third objective. The third learning objective might best be taught by using a role-playing exercise. The nurse educator can play the role of the patient and ask the ST, for example, for permission to read his or her medical records. Suppose that this elicits unexpected questions from the patient regarding the plan of treatment immediately before he or she is being transported to the OR. The ability and willing- ness of the ST to provide answers for the patient, or to find someone who can, may be demonstrated by using this strategy.

Fourth objective. For the fourth learning objec- tive, a dual strategy of a programmed model of instruction and observation of patient interaction can be used. The programmed model is a good strat- egy for teaching patients’ and coworkers’ rights. As

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Patient care activities have

been perceived by surgical

technologists to be the

responsibility of RNs.

the preceptor observes interaction with the patient or coworker, he or she can understand better whether the ST needs more cognitive or affective instruction. This type of instruction has many advantages: it facilitates mastery learning, is clear and easily repeatable, and allows the learner to progress at his or her own pace. A disadvantage to this strategy is that it allows learner procrastination and requires good reading skills.

Fifth objective. The last learning objective requires a strategy of analysis and confrontation. What is to be examined and changed here are values and beliefs. Confrontation is an important strategy; without challenge to one’s beliefs, no growth will occur.” The confrontation of the learner’s values represents a climax in the teaching-learning rela- tionship-it is a moment of truth. One must not be afraid to look his or her learner in the eye and ask how the learner’s behavior demonstrates advocacy and caring. Careful analysis and confrontation can provide the ultimate benefit; the learner can be led to examine and change his or her values and beliefs.

BARRIERS TO AFFECTIVE LEARNING Constraints on and obstructions to the teaching

of affective competencies to the ST population can be considered in terms of subject, student, and set- ting. Some of nurses’ reluctance to educate in the affective domain has been discussed, and further study will help demystify the concepts of affective learning. Some constraints to learning are inherent in and to the lifestyle of the learner. For example, if your facility employs a significant percentage of STs who are the primary economic providers for their families and who work irregular hours cover- ing emergency call-back shifts to earn overtime pay,

the greatest part of their education will need to occur in the clinical setting.

Perhaps the greatest barrier to learning in the clinical setting is inherent in the clinical setting itself. The nature of work in the OR is not particularly sup- portive of learning, especially in the affective domain. There are several reasons for this.

First, the OR is a setting where communication is difficult, particularly for STs. They must be atten- tive to the needs of the surgical team members throughout the surgical procedure and are not encour- aged to communicate verbally. Indeed, a system of hand signals has been developed to facilitate nonver- bal communication among scrubbed people.”’ The fact that OR staff members usually wear face masks causes a further impediment to communication.

Second, although R N s often have the opportuni- ty to collaborate in intraoperative practice, STs sel- dom do. For example, it is not highly unusual for two circulating nurses to work together during a surgical procedure. In very task-intensive situations (eg, car- ing for a patient undergoing intracranial surgery), one RN might concentrate on assisting the anesthesia care provider, while another concentrates on assisting the surgical team members. In contrast, STs almost always work alone after they have achieved basic cognitive and psychomotor competencies. This arrangement offers minimal opportunity for peer (ie, intradisciplinary) collaboration.

Third, patient care activities typically have been perceived by STs to be the exclusive responsibility of RNs. It also seems that many nurses in the periopera- tive setting do little to encourage STs to participate in patient care activities. Another common perception among perioperative RNs is that STs illegitimately occupy positions that should belong to RNs. This atti- tude among RNs is another barrier to the education of the ST population.

CONCLUSION The correct approach to educating a population

is the one that produces the best outcome. The notion of teaching affective competencies can be demysti- fied and facilitated if educators treat teaching in the affective domain with the same rigor and preparation as the cognitive and psychomotor domains. The ST population brings a unique set of educational needs and challenges to the clinical setting. These staff members are part of a team, and yet they are isolated in many ways. Their educational preparation has not been uniform and has emphasized cognitive and

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psychomotor skills to the exclusion of skills in the affective domain.

The ST population must be taught affective com- petencies so that STs can develop a clear patient focus

Rogerian model may be ideal, as it stresses the unique- ness and humanity of the patient and emphasizes learn- ing how to learn rather than what to learn. A

and then concentrate on cognitive and psychomotor learning. The goal of their training is that they be able to translate all their learning to skilled performance that will benefit surgical patients.

To this end, the use of a curricular framework that emphasizes learning skills in the affective domain is essential. Additionally, this framework should incor- porate elements of humanistic learning theory. The

NOTES 1. R Moss, “Managing the chal-

lenge: Strategies for effective use of unlicensed assistive personnel,” Surgical Services Management 1 (October 1995) 21-24; J Wurstner, F Koch, “Role redesign in periopera- tive settings,” AORN Journal 61 (May 1995) 834-844; M L Phippen, C Applegeet, “Unlicensed assistive personnel in the perioperative set- ting,” AORN Journal 60 (September

“Intraoperative nursing activities per- formed by surgical technologists,” AORN Jourrzal60 (September 1994)

2. D R Reilly, M H Oermann, Clinical Teaching in Nursing Education, second ed (New York: National League for Nursing, 1992) 291.

Process: Theory and Practice in Nursing (Kalona, Iowa: Kalona Graphics, 1994) 21-22.

4. Reilly, Oermann, Clinical Teaching in Nursing Education, sec- ond ed, 291.

1994) 455-458; C Abbott,

382-393.

3. H L Van Hoozer, The Teaching

5. J R Fuller, L K Groah, Surgical Technology: Principles and Practices, third ed (Philadelphia: W B Saunders Co, 1994) 23.

6. V D Wagner, C C Kee, D P Gray, “A historical decline of educa- tional perioperative clinical experi- ences,” AORN Journal 62 (November 1995) 77 1-782.

7. California Code of Regulations, Title 22, Section 70225, Surgical Service Staff (South San Francisco, Calif: Barclays Law Publishers, 1990) 768.

to a conceptual base curriculum,” International Nursing Review 38

8. A Orb, D E Reilly, “Changing

(Mar~NApril 1991) 56-60. 9. D E Orem et al, Nursing:

Concepts of Practice, fourth ed (St Louis: Mosby-Year Book, 1991).

10. C Roy, Introduction to Nursing: An Adaptation Model (Englewood Cliffs, NJ: Prentice- Hall, 1976).

11. J Watson, Nursing: The Philosophy and Science of Caring (Boston: Little, Brown and Co, 1979).

Chris M . Patty, RN, BS, CNOR, is clinical educator, perioperative serv- ices, Kaweah Delta Health Care District, Visalia, Calif.

12. M Rogers, “Science of unitary human beings,” in Explorations on Martha Rogers’ Science of Unitary Human Beings, ed V M Malinski (Norwalk, COM: Appleton-Century- Crofts, 1986).

13. M Rogers, “Nursing: A sci- ence of unitary man,” in Conceptual Models for Nursing Practice, second ed, J Riehl-Sisca, C Roy, eds (New York: Appleton-Century-Crofts, 1980) 111.

14. Ibid. 15. Van Hoozer, The Teaching

Process: Theory and Practice in Nursing, 8.

16. Ibid, 21-22. 17. Reilly, Oermann, Clinical

Teaching in Nursing Education, second ed, 352-327.

18. Van Hoozer, The Teaching Process: Theory and Practice in Nursing, 145-155.

19. Reilly, Oermann, Clinical Teaching in Nursing Education, second ed, 326.

20. Fuller, Groah, Surgical Technology: Principles and Practices, 2 15-2 16.

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