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| ORIGINAL ARTICLE |
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| Year : 2016 | Volume
: 14
| Issue : 4 | Page : 107-112 |
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How to train your surgical assistant? Assessment of "in-service training" program for orthopedic surgical assistants in a rural mission hospital
Deeptiman James, Nirmal Kurian
Department of Orthopedics, Christian Hospital, Mungeli, Chhattisgarh, India
| Date of Web Publication | 22-Nov-2016 |
Correspondence Address:
Dr. Deeptiman James
Department of Orthopedics, Christian Hospital, Mungeli, Chhattisgarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0973-4651.194475
Context: While lack of physicians and surgeons in rural India has received wide publicity, minimal attention has been spared for lack of ancillary personnel, such as surgical assistants. Personnel with no formal training often play the role of surgical assistant. This study evaluates the efficacy of "In-service training" of orthopedic surgical assistants in a rural mission hospital. Methodology: A retrospective, one group pre- and post-test experimental study was designed to evaluate the effectiveness of the "In-service training" program for surgical assistants who participated in orthopedic procedures conducted over a 5-year period (2011-2016), at a rural mission hospital. Data were collected from the hospital's Orthopedic Department database from July 2011 to March 2016. All orthopedic surgical assistants included in the study were classified according to their highest educational qualification and duration of "In-service training" program. Initial and final level of competence of each orthopedic surgical assistant after "In-service training" was evaluated. Paired t-test was used for statistical assessment. Results: A total of 1156 orthopedic procedures were carried out from 2011 to 2016. Twenty-eight personnel including nine General Nursing and Midwifery nurses, two Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homoeopathy doctors, one dentist, one physiotherapist, one MBBS doctor, 12 medical student volunteers and two college graduates participated in "In-service training" program as orthopedic surgical assistants in the rural mission hospital. The participants had no prior training in operation theater technique or orthopedic procedure. Mean initial competence score was 1.00357 (standard deviation [SD] = 0.1889) and mean final competence score was 3.3928 (SD = 0.9165). This difference was statistically significant with P < 0.00001. Conclusions: "In-service training" program at the rural mission hospital increased the competence level of orthopedic surgical assistants. This is a novel method to overcome the human resource deficit in rural health-care sector.
Keywords: In-service training, orthopedic surgical assistant, rural orthopedics
How to cite this article:
James D, Kurian N. How to train your surgical assistant? Assessment of "in-service training" program for orthopedic surgical assistants in a rural mission hospital. Curr Med Issues 2016;14:107-12 |
How to cite this URL:
James D, Kurian N. How to train your surgical assistant? Assessment of "in-service training" program for orthopedic surgical assistants in a rural mission hospital. Curr Med Issues [serial online] 2016 [cited 2023 Jun 8];14:107-12. Available from: https://www.cmijournal.org/text.asp?2016/14/4/107/194475 |
| Introduction | |  |
Mission hospitals continue to confront the existing urban-rural divide in healthcare. [1],[2],[3] Unlike the bygone era where basic healthcare was the ultimate aim, now mission hospitals must provide quality multi-specialty care to remain relevant in the health-care sector. [1] Given the current trend of compulsory rural posting for fresh medical graduates and postgraduates, one must not neglect to acknowledge the lack of modern equipment and qualified human resource necessary for quality healthcare in resource-limited areas of the country. [4],[5],[6],[7] Government initiatives, evolving corporate social responsibility policies and independent philanthropic activities have enabled acquisition of equipment. [8],[9],[10],[11] However, the same is not true about qualified human resource. Lack of doctors in rural area has generated wide media publicity, but the lack of ancillary personnel has hardly made it to a footnote. [4],[12],[13] With gradual shift of rural, especially mission hospitals functioning in rural areas, toward surgical specialties, the urgency for trained surgical assistants is ominous. [14],[15],[16] Despite existing network of orthopedic and trauma care facilities in several rural mission hospitals across India, training program for orthopedic surgical assistants continues to be ambiguous. The aim of this study is to assess the effectiveness of an "In-service training" program for orthopedic surgical assistants at a mission hospital in rural central India.
| Methodology | | |
All orthopedic procedures carried out at the rural mission hospital were included in the study. Data were collected from Orthopedic Department database of the hospital from July 2011 to March 2016 [Table 1] and [Table 2]. Personnel who participated as orthopedic surgical assistants were classified according to their highest educational qualification and duration of participation in the "In-service training" program at the mission hospital [Figure 1] and [Figure 2]. None of the orthopedic surgical assistants had any prior training in either operation theater (OT) technique or orthopedic surgery. All surgical assistants underwent "In-service training" program at the mission hospital [Figure 3] and [Figure 4]. | Figure 1: Distribution of orthopedic surgical assistants in major orthopedic procedures
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 | Figure 2: Distribution of orthopedic surgical assistants in minor orthopedic procedures
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 | Figure 3: Dental surgeon and Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homoeopathy doctor participating as orthopedic surgical assistants
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 | Figure 4: Medical student volunteer participating in "In-service training" program for orthopedic surgical assistant
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 | Table 1: Educational qualifications of personnel who participated in the 'In-service training' programme
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 | Table 2: Duration of training as orthopaedic surgical assistant in the 'In-service training' programme
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"In-service training" was carried out through classroom lectures, seminars conducted by the trainees, interactive focused group discussions and live sessions in the central sterile services department (CSSD) and operating room with an emphasis on "hands on" training concept [Figure 5]. All trainees participated in interactive sessions on basic life support, universal precautions, and minimizing radiation hazards with scenario-based learning (inspired by Early Management of Trauma Course modules). Orthopedic surgical assistants underwent "In-service training" in universal precautions, identification of orthopedic instruments and implants, cleaning and sterilization, maintenance of equipment, tourniquet application, and fracture table assembly, OT procedures such as fumigation, surface decontamination, biohazard protocol, scrubbing technique, and radiation protection as well as safe patient positioning, plaster technique, and wound care [Table 3]. Training was tailored to individual candidates based on their education level as well as their aptitude. All instructions were carried out in English as well as Hindi. Powerpoint presentations with diagrams, pictures, and videos were used for various sessions. Soft copies, as well as printed booklets, were accessible in the operating room. Diagrams, flash cards, and notices were placed in the CSSD, plaster room, and operating room to facilitate easy access to all "In-service program-" related information. | Table 3: Components of 'In-service training' module for orthopaedic surgical assistants
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A retrospective, one group pre- and post-test experimental study was designed to assess the effectiveness of the "In-service training" program. A 5-point scale [Table 4] was used to evaluate the initial and final level of competence of each surgical assistant at 1 year after "In-service training" or at the time of discontinuation of service, whichever was earlier. One point was considered as very poor and incompetent to participate in orthopedic procedures. Five points were awarded to candidates with excellent results considered capable of training others. All candidates were graded on twelve separate parameters [Table 3]. The evaluation was carried out based on their performance and participation during the operative procedures. Each participant was assigned a mode value derived from grades earned in all twelve parameters. A null hypothesis stating "no change in the quality of surgical assistants irrespective of the In-service training program" was postulated. Paired t-test was applied for evaluating the null hypothesis in this study.
| Results | | |
Twenty-eight personnel including nine General Nursing and Midwifery (GNM) nurses, two Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homoeopathy (AYUSH) doctors, one dentist, one physiotherapist, one MBBS doctor, twelve visiting medical students and two college graduates participated as surgical assistant in orthopedic procedures during this period. The average duration of "In-service training" for orthopedic surgical assistants was 7.67 months (from 3 months to 12 months).
A total of 1156 orthopedic procedures were carried out from July 2011 to March 2016 [Table 1]. Three hundred and forty-three were major orthopedic procedures and 813 were minor orthopedic procedures. Orthopedic surgical assistants in major orthopedic procedures were AYUSH doctors (38%), GNM nurses (20%), dentist (15%), visiting medical students (14%), MBBS doctor (6%), physiotherapist (4%), and others (3%) [Figure 1]. Orthopedic surgical assistants in minor orthopedic procedures included GNM nurses (48%), visiting medical students (11%), dentist (6%), MBBS doctor (5%), physiotherapist (5%), AYUSH doctors (2%), and others (23%) [Figure 2].
Mean initial competence score was 1.00357 (standard deviation [SD] = 0.1889) and mean final competence score was 3.3928 (SD = 0.9165). This difference was statistically significant with P < 0.00001.
| Discussion | | |
An efficient and effective surgical team is vital for success of any surgical specialty, irrespective of the level of healthcare. [17] A basic surgical team is led by a qualified surgeon and constitutes surgical assistants, scrub nurses, floor manager, and anesthetic team. [17] The current format of training and posting of doctors and ancillary staff in rural India as well as in mission hospitals is noncomplementary. [2],[5] This leads to surgeons being posted in resource-limited areas of rural India with minimal or no support staff to carry out quality surgical work. [4],[6],[18] Complaints from doctors posted in rural centers about lack of qualified assistants and ancillary staff is commonly considered as a case of "sour grapes" and is generally ignored. Instead, under qualified and inexperienced staff often fill in the shoes of surgical assistant for a surgeon who himself is coming to terms with rural practice in a resource-limited scenario. [12],[18],[19] Postgraduate courses do not teach adapting to the constraints of rural surgical practice. Our experience involved twenty eight different orthopedic surgical assistants, none of whom had any prior training in OT technique or exposure to orthopedic surgery. All participants were fresh graduates or trainees doing 1 st year of their service obligation period or were medical students on elective posting from Danish and American medical universities. Some personnel was fresh out of colleges doing an apprenticeship in the hospital.
Formal education for surgical assistants is primarily available only at tertiary centers. [20] There is a few distance education options available for training surgical assistants or OT technician, but they are expensive. [21] Unlike nursing and allied health science schools mushrooming across the rural health sector, formal training course for OT technician and surgical assistant has not garnered much attention. Hence, innovative methods are necessary to overcome this resource crunch. Training available staff to perform role of skilled workers have been utilized to overcome resource crunch in resource-limited areas. [7],[12],[19],[22] Drawing inspiration from such reports, we developed a novel "In-service training" program to train orthopedic surgical assistants. To the best of our knowledge, this is the first study that objectively evaluates the efficacy of an "In-service training" program for orthopedic surgical assistants in a rural mission hospital in India. The "In-service training" program included classroom seminars, interactive discussion, teaching during rounds as well as "on the job" training session. The teaching sessions covered universal precautions, identification of orthopedic instruments and implants, basic surgical techniques, cleaning and sterilization, maintenance of equipment, tourniquet application and fracture table assembly, OT protocols for fumigation, surface decontamination, biohazard protocol, scrubbing technique and radiation protection as well as safe patient positioning, plaster technique, and wound care.
The duration of "In-service training" program varied for different participants. Twelve orthopedic surgical assistants completed 12 months of "In-service training." Eleven 4 th year medical students from University of Copenhagen, Denmark, participated in the "In-service training" program as part of their 3 month elective Praktikant i Troperne program, under aegis of International Medical Cooperation Committee, at the rural mission hospital. One medical student from Elon University, North Carolina, USA participated in the "In-service training" as orthopedic surgical assistant for 6 months, at the rural mission hospital. One dentist, one physiotherapist and an MBBS doctors working at the hospital underwent 12 months of "In-service training" as orthopedic surgical assistants. Two college graduates employed by the hospital for apprenticeship in the operation room and plaster room underwent "In-service training" program. The second author participated in the "In-service training" program, initially as a trainee and subsequently as a co-instructor.
Orthopedic surgery is essentially based on the tenets of team play. An effective and efficient team directly affects the outcome and results reflect on the department. A good assistant is one who anticipates what the surgeon needs next and stays alert to avoid complications. The single doctor orthopedic department, actively supported by the physiotherapy unit catered to more than 15,000 outpatients, at the rural mission hospital from July 2011 to March 2016. Orthopedic procedures carried out at the rural mission hospital varied from closed reduction, plaster cast application and intra-articular steroid injections to polytrauma care, hip hemiarthroplasty, diagnostic arthroscopy, hand and flap reconstructive surgery, and pediatric deformity corrections. Hence, it is essential to have efficient and trained personnel to ensure smooth functioning of the department and quality care to the patient. Given the varied type and numbers of orthopedic surgical assistants at the rural mission hospital, we wanted to assess whether the "In-service training" program was effective in improving the competence of orthopedic surgical assistants. All orthopedic surgical assistants were evaluated by the first author. Entry and exit level competence evaluation was done using a competence score guide. The statistical evaluation proved that "In-service training" program improved competence level of orthopedic surgical assistants.
Certain limitations of the study must be highlighted. A single doctor department essentially meant that the evaluation was done by the instructor himself. Hence, ascertainment bias cannot be ruled out. Varied educational qualifications, duration of participation in "In-service training" program and nationality and language of orthopedic surgical assistants could have influenced the outcome. "In-service training" program was tailored for individual orthopedic surgical assistants; hence a universal training program was not be administered to all participants. No predetermined syllabus was used for the "In-service training" program. No objective evaluation test was administered to the orthopedic surgical assistants.
| Conclusions | | |
"In-service training" program is an effective and novel means to overcome the deficit of trained and qualified orthopedic surgical assistants in rural mission hospitals.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]
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