Orientation "Cardiac Catheterization"

Author(s): 

Doug Langager, RCIS, Winchester Medical Center, Winchester, Virginia

Webster’s Dictionary defines orientation as familiarization with and adaptation to a situation or environment.

Over the past 20 years, I have been involved in training cath lab techs and nurses in some capacity or another. Throughout my total 30 years of cardiac catheterization experience, I have found one of the greatest deficiencies across labs to be the variation and disjointedness of the new hires orientation process. The orientation models currently in use typically leave new hires feeling overwhelmed. Many labs have adopted a sink-or-swim orientation process where definitive, didactic training plans are frequently thrown aside in favor of lab time. Physician demand for laboratory time and the patient load require efficiency, job knowledge, and manual and intellectual dexterity. Given current working conditions and employee expectations, new employees are required to develop quickly, since time is muscle in emergency cardiac medicine. In many cases, time spent on training is viewed as an annoyance that slows things down. Preceptors have limited time to develop skills required for independent (on-call level) work. Many excellent nurses or technologists are rendered ineffective as preceptors because they are not given the skills or tools to teach, guide, and evaluate a new team member. The transition from new employee into an accepted cath lab team member should be easier than it is. Our goal should be to make the new employee’s first impression a positive one. This article will discuss some concepts and experiences that may help preceptor and trainee alike have a more positive learning and training period.

In my experience, an interview for a position in a cardiac catheterization laboratory is similar to a casting call or signing up for a tryout. When you come on board for orientation, you are still trying to make the team. During the orientation process, the employee receives specialized training that helps them adapt and become familiar with the cath lab environment. Upon conclusion of orientation, it is expected that each individual will be a contributing member of an amazing medical team.

As a youngster, I dabbled in sports, with basketball being my favorite. Watching the beauty of a fast break the synchronized movement of the players, the exacting execution of a well-run play was always something to behold. To the inexperienced observer, basketball may look chaotic. It takes time and experience to play at the feverish pace of a basketball game and switch from zone defense to a man-on-man. Basketball is a wonderful analogy for the cath lab team, since many basketball themes hold true when you look at how nurses and technologists perform their jobs. Players on a team execute plays, rehearse, practice on the court and most importantly, function as a well-oiled machine. On a successful team, teammates know the skills, weaknesses, and personal attributes of themselves and every other player, and they use this knowledge to succeed. New employees will not be able to focus on their jobs until they feel familiar with their surroundings, routines and understand the flow of the game.

Each employee, or player, has had a preceptor, or coach, to guide them through the challenges of being a new cath lab member. We all started out as rookies, became experienced players, and strive to refine skills as we become seasoned veterans. In order for a new employee to start out on the right foot, it’s important that the preceptor understand the levels of skill development through which their rookie will transition.

Levels of Skill Development

Each employee progresses through five basic skill levels:

Novice: Focused on concrete, objective assessment data, the employee relies on rules and procedures.

Advanced Beginner: Begins to think in terms of guidelines rather than strict rules.

Competent: Nurse/tech able to manage and organize much of the clinical aspects, but may miss some subtleties.

Proficient: Sees the situation as a whole, has the ability to recognize patterns based on experience and an aggregate of knowledge, and responds to subtle cues.

Expert: Has the ability to go beyond the rules. Maintains awareness through integration of theory and intuition. Able to zero in on the essence of the clinical situation. Fully engaged and involved, allowing this individual to feel one with the experience.

As the new hire progresses through the five skill levels, it is imperative that the preceptor understand that a transition in knowledge will also occur. Every employee starts out working on the basics. Just as a basketball player must first learn to dribble before they can play, a cath lab member must first be grounded in the basic knowledge of anatomy, physiology, patient care and critical thinking. Once the basic knowledge has been established, the employee will move away from reliance on abstract principles and toward the use of past experience to solve problems. Next, a change in perception occurs as the employee moves from seeing bits and pieces of information to seeing a complete whole and at the same time, understanding which parts may be relevant. Last, a move occurs from detached observer to involved participant.

If preceptors are familiar with the concepts of how basic knowledge is acquired and skills progress, they will be better able to adequately support their preceptee. Along with these concepts, the use of a basic clinical evaluation criterion may be useful for both the preceptor and preceptee. Table 1 provides a structured evaluation method that enables new hires to set standards for performance and improvement. In the event of a deficiency, criteria may be reviewed and improved upon. Just as it is much easier to hit a stationary basket in basketball, it is our job as preceptors to provide a stable, structured environment that allows growth and development for new hires.

Strategies for Great Teaching: Five Methods

Chunking: organizing information in meaningful units

Rote rehearsal: repeating information or a skill many times

Elaborative rehearsal: immersing information in meaning or highlighting its relevance

Pattern recognition: identifying familiar patterns

Emotional involvement: embedding information with feelings or emotions.1

Training Methods

The following concepts are taken from Strategies for Great Teaching, by Mark Reardon and Seth Derner, which discusses several valuable approaches to teaching.

The Hole-in-One Moment couples mental imaging with a few practice swings to increase success. Learners mentally prepare to perform a new skill. First, they visualize the step or process. Next, they take a few practice swings. Finally, they take a shot (i.e., perform the step or process). Another helpful method is called The Fred Astaire. Mr. Astaire worked out, rehearsed and put together his dance routine increment by increment. The secret to creating his routines was fitting together the step sequences, initially broken down into manageable parts. Individual tasks must be learned in pieces. Once learned, each of the steps, now strung together, become magic on the screen. In the cardiac cath lab, individuals learn tasks that support the cardiac catheterization procedure. We organize a learning pathway, setting a course that typically takes three months to complete. Below are some examples of learning situations for new employees.

Sterile Technique. When I scrub, I first become aware of the steps and standards of surgical scrub. Donning a gown and gloves, and draping the patient both pose high risk of an inadvertent break in sterile technique. I exaggerate my actions, keeping my distance from potential sources of contamination. I frequently challenge new employees on this process. I will tell them they contaminated themselves. If the new employee was focused on what he or she was doing, they will know their technique was flawless. If they have doubt or hesitation, they will head back to the sink and start over. Once they become confident in their processes and procedures, they will look me in the eye and know with confidence that I am pulling their proverbial chain.

Seldinger Technique. New trainees also focus on learning the Seldinger technique. I have them write the sequence of the steps many times.

1. Obtain arterial or venous access

2. Physician protocol: Introducing a JL4 catheter. Take pictures.

3. Catheter exchange to a JR4, more pictures

4. Catheter exchange for a pigtail catheter

This process is universal. These simple activities by the scrub tech and physician provide unique markers in time during a procedure. The circulator and the monitoring person can anticipate and queue their tasks off these steps.

Organizing for Speed. Setting up the procedure table has its own training demands. The preparation sequence focus moves from table organization to developing on-call speed. Emergency cases place demand on safety and efficiency. If all the steps are done correctly, there is no wasted motion. Prioritization is crucial as you work against time to open a closed artery. Important tasks include immediate draping of the patient, drawing up of lidocaine, and having the 18-gauge thin-walled needle with flush available for the physician. Then, flushing the guide wire, place up on the field do the same to the introducer set. As you are watching through the eyes in the back of your head, the manifold and transducer are flushed. Maybe the physician has gotten arterial access, and your assistance must be directed back to those Seldinger steps. When you are there, it is like watching a well-rehearsed dance.

Three important things to remember:

1. A good team has a script and everyone is on the same page. New employees focus on each element of the procedure, but with their preceptor, should take it from the beginning and perfect the steps so that eventually each step can be performed at on-call speed. After a procedure, ask trainees to critique themselves and answer any questions that they may have. Reassure them of the process. Get them back into another procedure; they will improve.

2 It is very common that when training new employees in other areas of the job, their focus is on the newest task and they lose much that was learned earlier. A very little falling off of trained skill and information occurs.

3. As a team, ALL our activity is support. Anticipating the next move keeps the team focused on patient care. Just remember, as a preceptor, you need to help others get to this same point. Keep focused on the priorities. Let’s break the sink-or-swim orientation trend. As a physician at our facility once said, If you don’t fix the problem, you still have a problem.

Create a Fair Playing Field

The new team member’s first impressions set the stage for success; even the fundamentals need a proper setup. The entire orientation process is about safety, efficiency and effectiveness. Whether you are operating as a preceptor or a new employee in the process of developing skills, orientation has numerous requirements that need to be appropriately prioritized. Training of the new hire typically falls third on the list of priorities in the lab. The list goes as follows:

1. Patient needs

2. Physician needs

3. Needs of the trainee

References: 

1.Reardon M and Derner S. Strategies for Great Teaching — Maximize Learning Moments. Chicago, Ill.: Zephyr Press; 2004.

2.Phillips, N. Berry & Kohn's Operating Room Technique. 10th Ed. St. Louis, Missouri: Mosby; 2000.

3.Trent J, Trent C, Smalley G, Smalley N. The Treasure Tree. Nashville, Tenn.: W Publishing Group; 1992.


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