Orientation "Cardiac Catheterization"


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

The patient may be very sick and require the full attention of the staff. This makes it even more important to have expectations for new hires set from the start. Prioritization of tasks needs to be discussed so the new team member does not feel slighted, snubbed or inadequate. Ensure that all the players understand the rules, level the field and ensure comfort for all parties.

As with any new experience, transition leaves new employees, preceptors, and physicians with mixed feelings. Lack of comfort can leave the new hire feeling totally overwhelmed. Often feelings of ineptitude follow a stressful case. These issues typically occur when expectations have not been set in such a fast-paced work environment. We are continually working with new people, learning procedures and dealing with idiosyncrasies of physicians and coworkers, all of which make it even more critical for preceptors to be clear and concise on prioritization. These issues should be discussed up-front with the physicians, trainees, and coworkers to ensure comfort by all parties. This will create a team atmosphere that will help the trainee feel more accepted and comfortable.

The Effects of Personality and Personal Attributes

Cath labs are filled with personality. Berry & Kohn’s Operating Room Technique is an invaluable resource that discusses issues in the surgical environment, many of which are applicable to the cath lab. The opening chapter discusses the personal attributes required of patient care providers. A firm understanding of attributes and personality traits by the preceptor can make a world of difference when trying to orient a new hire. I frequently refer to these attributes when I am called on to evaluate an employee’s progress since they provide proper descriptors that compliment individual skill performance.

How will the new hire measure up? Personal attributes are reflected in the manner in which an individual performs his or her duties. Having a template that lays out attributes so the new hire can see what he or she is being measured against will improve the outcome. In other words, show the new player where you are setting the basket. Some of the characteristics will be innate; others will take a lot of work to attain. This should be expected by both the preceptor and the trainee.

Work Ethics Carries out job responsibilities in a timely and efficient manner, communicating a positive attitude about these responsibilities to patient, customers, and coworkers.

Performance Improvement Constantly strives to meet or exceed the expectations of the persons we serve.

Collaboration & Cooperation Coordinating efforts toward a common goal while demonstrating a responsibility to the system, the persons we serve, and to each other.

Honesty & Integrity Exemplifying conscientiousness, reliability, and trustworthiness.

Ethical Conduct Actions that maintain the highest principles and values for our patients, customers, and coworkers.

Accountability Uses the authority one has been delegated to make decisions consistent with the system’s missions and values.

Innovation & Flexibility Has an understanding of the principles of one’s work. With the resources available, is creative and efficient at solving problems without sacrificing quality.

Job Knowledge Has a comprehensive knowledge of instrumentation, equipment, procedures, and the care required for many diverse patients. Approaches each procedure as unique and individualized, while maintaining acceptable performance standards.

Efficiency & Good Organization Develops organized work habits, anticipates the needs of patients and team members to save time and energy. Prepared for the unexpected.

Initiative Aptitude displayed in the initiation of action.

Ability to Take Instruction Pays attention, listens to details of instruction and reacts appropriately.

Manual & Intellectual Dexterity Has quick hands, sharp minds, and keen eyes. Manual dexterity is perfected with experience.

Intellectual Eagerness & Curiosity The team has a legal responsibility to remain current in their knowledge. 2

Use the Attitude You Choose

Every member of the cath lab team’s role is to provide exceptional customer service that supports patients, families, physicians, and support staff. Is the customer always right? To put it bluntly YES! Communicate that feeling to everyone with whom you come in contact. I call that presence. Some people say they can’t or don’t play that way. I say, if you do anything to compromise patients’ trust in your institution, and do not support the physician or coworkers, that’s equivalent to treason. You’re a team, so act like one. Never lose sight of the patient, and always view them as the customer. After all, they can always go to another facility if you don’t meet their needs.

Self-confidence and happiness are elusive. Most people don’t have the satisfaction of saving a life or taking 10/10 chest pain to 0/10 in a matter of minutes. Most people receive satisfaction as a side product of an accomplishment. We are the lucky ones because we have the opportunity to relish the satisfaction of changing lives each and every day. It may sound corny, but if you honestly measure the trainee and yourself against a structured set of personal attributes, you will learn and succeed in whatever endeavor you choose. Teaching this attitude from day one will change the atmosphere of your cath lab. Not only will you influence the way a new hire views the lab, but soon you will get buy-in from the existing team as well.

Love the One You’re With

The world is made up of diverse personalities. Often conflict arises because of individuality and variations in personalities. Frequently we don’t pay attention to these differences or allow for individual perspective. We operate in our own silo and don’t pay attention to the types of people with whom we are working. The Treasure Tree is a wonderful book written for children to provide insight about different personality types. I find it both helpful and humorous to apply to numerous situations at work and at home. It gives another view to nurture growth and development of staff, and has real-life application.

Lion. This personality likes to lead. The lion is good at making decisions and is very goal-oriented. They enjoy challenges, difficult assignments, and opportunity for advancement. Because lions are thinking of the goal, they can step on people to reach it. Lions can be very aggressive and competitive. Lions must learn not to be too bossy or to take charge of others’ affairs.

Beaver. Organized. Beavers think that there is a right way to do everything and they want to do it exactly that way. Beaver personalities are very creative. They desire to solve everything, but take their time and do it right. Beavers do not like sudden changes. They need reassurance.

Otter. Otters are very social creatures and love people. They enjoy being popular, and influencing and motivating others. Otter can sometimes be hurt when people do not like them. Otter personalities usually have lots of friends, but not deep relationships. They love to goof off. (They are notorious for messy rooms.) Otters like to hurry and finish jobs. (Jobs are not often done well.)

Golden Retriever. Good at making friends. Very loyal. Retriever personalities do not like big changes. They look for security. Can be very sensitive and are very caring. Have deep relationships, but usually only a couple of close friends. Wants to be loved by everyone. Looks for appreciation. Works best in a limited situation with a steady work pattern.

Take the time to accurately place a new hire with a preceptor that will be able to deal with their personality type. You want to foster a trusting relationship, and you can’t do that without knowing your partner. The preceptor will be intimately involved with the preceptee for months. Ensure you have personalities and learning styles that mesh, and this will make life easier on all involved. The personality types listed above are one sample tool, but you can find a tool that works for your facility to identify your preceptor personality types and pair them appropriately with new hires.

Lion personalities are feelings-oriented. They value people and harmony within the group. Lions want lots of details. To connect with a lion personality, be sure you are correct and have all the facts and details to back up what you say, then give this person time to analyze what you have said. Beaver personalities want you to be bright, brief, and gone. They crave stability and order, and are accomplishment-oriented. They value dependability and hard work. Beavers can become frustrated when others do not show the same level of organization or attention to detail that they feel is appropriate to the task. Golden retriever personalities are idea-oriented. They value rational thought and curiosity, and find joy in discovering and understanding things. These personalities are particularly hurt when their competence is questioned. Otter personalities are action-oriented. They want to be involved in everything. Otters value taking risks and competition. They find joy in trying new activities and competing. Otters will react negatively when confronted with rigid structures or a lack of activity.


It is important to understand and accept that not everyone will be your best friend. While friendship is not a critical element of successful teams, respect is. Respect is earned through the actions and attitudes displayed daily.

Love the one you’re with may sound naive, but you can bring the best out in people when you bring your best to the table. It is impossible for a negative mind to attract positive things. If you are worried about the staff you’re working with today or that Dr. So-and-So intimidates you, you will not have a positive outlook. When negativity and pessimism replace positive thoughts, your fears will become the obstacle. Focus on the job and advancing your contribution to patient care.

My mentoring, supervisory, and education role in the cath lab has required me to counsel numerous individuals. The psychological carnage of conflict is complex. Try to avoid as much conflict as humanly possible. In training the new hire, prepare them for the stress of the lab. Be proactive by preparing them to face people who may not always be calm, rational, or reasonable. If awareness is instilled ahead of time, issues will not cut as deeply. Teach new staff to remain calm and reasonable themselves, and always be sympathetic. Never let them forget to be professional.

You can’t build a reputation on what you’re going to do.
“ Henry Ford


I would like to thank Adam Chavez RN, MSN, and my co-workers for assistance with this article.

Doug Langager graduated from the Navy’s cardiopulmonary program in Bethesda, Maryland, in 1975. From 1983-1988, the cardiac catheterization program at Brooke Army Medical Center, Fort Sam Houston, Texas, was under his care. After retiring from the Army, he worked as both a supervisor and staff educator at Providence Hospital in Portland, Oregon and University Hospital in Augusta, Georgia. Currently, Mr. Langager is employed by Winchester Medical Center in Winchester, Virginia. He can be contacted at potetehode@yahoo.com

1.Reardon M and Derner S. Strategies for Great Teaching — Maximize Learning Moments. Chicago, Ill.: Zephyr Press; 2004.<p>2.Phillips, N. Berry & Kohn's Operating Room Technique. 10th Ed. St. Louis, Missouri: Mosby; 2000.<p>3.Trent J, Trent C, Smalley G, Smalley N. The Treasure Tree. Nashville, Tenn.: W Publishing Group; 1992.

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