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December 1, 2007 | American Society of Registered Nurses

Teaching Nurses to Stand Up to Surgeons in the OR

The Operating Room Nurses The Operating Room nurses have worked alongside surgeons in the operating room (OR) throughout the history of Medical Science. The role of operating room nurses has evolved from performance of mere vocational functions like sterilization of instruments to that of professional functions (Judith Brumm, 2004). Today, the Operating Room nurse enjoys professional autonomy making reasonably independent and self-governing decisions in practice dealing specifically with the human response to life threatening conditions. Any lack of coordination between the nurses and the surgeons in a theatre results in poor patient care with serious consequences. Thus, it is important to teach nurses to stand up to surgeons in the operating room. This process includes teaching supply chain management, communication, error prevention, aseptic techniques and core concepts. Teaching Supply Chain Management The operating room nurse team usually consists of a scrub nurse who handles all the required instruments for the operation, a circulating nurse to help and trainee nurses apart from highly trained specialty nurses. Supply chain is the lifeline of nurse care in operating rooms. Poor management of supply chain always leads to complications in patients, wasteful expenditure of energy in terms of repeat procedures and time, which is a vital factor in theatres. This also causes delays in interventions, cancellation of surgeries and other lapses. It should be noted that much time is usually lost waiting for the sterilized instruments, cotton and other petty consumables at the table rather than waiting for an oxygen cylinder or ECG monitor. This is especially true when several

health care organizations have adapted the one surgeon working on multiple tables with the support staff taking all other responsibilities like administration of anesthesia and oxygen. Teaching Communication Communication in the operating room among the health care team often pertains to discussions about patient cancellations, sending for the next patient, preparation of the theatre resources, equipments, responsibilities, safety, sterility temperature regulation, and recording data. Although fundamental communication skills have been identified for effective practice in the operating theatre, there are significant barriers to their use because of confusion over clarity of roles and the implications for teamwork (Nestel and Kidd, 2006). Thus, there is a need for educating nurses in the areas of verbal and nonverbal communication, on active listening and the effective use of these communication skills with due attention to the environment in which the communication is taking place. Studies have shown that ineffective team communication causes frequent medical errors in the operating room. A recent study to describe the characteristics of communication failures in the operating room and to classify their effects has elucidated that communication failures in the operating room is composed of a common set of problems that occur in team exchanges pertaining to the content, audience, purpose, and occasion of a communication exchange (Lingard et.al,2004). Teaching Error Prevention Nursing profession is legally and morally accountable. Hence, teaching error prevention is vital. A study to describe the potential sources of errors and error prevention in operating room nurse team by qualitative content analysis has shown that there is a need for teamwork practice, shared responsibility in teams and organized teamwork among operating room nurses (Lipponen et.al, 2005). The study has identified fear of errors, turnover in teams, overtime work and emotional distress as potential factors leading to errors in operating room team. The study has also highlighted how shared responsibility among the familiar teams, safety control and formal documentation of

errors prevent medical errors. The study stresses on the need to educate operating room nurses that will help them learn from errors and teach them more effective ways of reporting incidents. (Lipponen et.al, 2005). Teaching Aseptic Techniques The spread of infection via hands is well established (Larson, 1955). Hand washing is one of the most important procedures for preventing the spread of infection and disease. Hand hygiene is an infection control practice with a clearly demonstrated efficacy and remains the cornerstone of efforts to reduce the spread of infections. Hands play a significant role in breaking the chain of infection, the transmission of infection between patients. Factors that influence hand hygiene compliance include workload and staff shortage, poor facilities and lack of understanding (Taylor, 1978). Therefore, every individual involved in surgical procedures should receive appropriate training in surgical hand hygiene. A recent study (Shelly et.al, 2001) has shown that strains of Pseudomonas aeruginosa isolated from 16 post surgical patients in a health care center were from a single nurse who had an infected thumbnail. A study to define the risk factors of blood contamination and injury to operating room nurses has shown at least fifty percent of the operations resulted in an adverse event where at least one person was contaminated with patient blood (Quebbeman et.al, 1991). Teaching core concepts The operating room nurse has to be taught core concepts to effectively manage emotionally stressful situations. Factors such as strained relationships within surgical teams, concerns about the dignity of the patient and the well-being of the family, exposure to death, trauma and procedures like surgical removal of organs for transplantation add up to emotional distress (Cheryl Regehr, 2004). Recommendations A recent study on the need for advanced training for the operating room team (Aggarwal et.al, 2004) strategies has shown that a simulated operating theatre similar

to the simulated laboratory used in aviation industry will enable assessment and improvement of technical and non-technical performance of the staff in the operating room. The study recommends an assessment by experts situated in a control room adjacent to the simulated theatre where the effect of distractions, equipments and patient crisis situations is defined towards reducing the number of adverse events arising in the real operating room. Riley and Manias (2003) have shown that photography can be used as a means of data generation in clinical nursing settings by taking 'snap-shots' of operating room events. Analysis of these snap shots reveals the outcomes in the operating room and paves way for remedial measures. Douglas et.al (2000), have elucidated the use of video recoding as a means to monitor the surgical procedures and team performance to improve outcomes. To improve the nurse output and the quality of patient care, it is also recommended to make a Time Activity Analysis. A Time Activity Analysis helps to lists out all the daily activities and the time spent on them in a theatre (Baylis et.al, 2006). Conclusion Any adverse medical event in an operating room can lead nurses to serious legal consequences and affect their professional future. Hence, it is absolutely important to teach operating room nurses to stand up to surgeons on all the vital aspects discussed. Further, it is also essential to educate nurses to adapt an evidence based approach with the ingredients of critical thinking and emotional intelligence in their practice. References Aggarwal, S Undre, K Moorthy, C Vincent, A Darzi. (2004). The simulated operating theatre: comprehensive training for surgical teams. Qual Saf Health Care; 13:27-32. Baylis, Wendy E Adams, David Allenand, Scott G Fraser. (2006). Do Variations in the Theatre Team Have an Impact on the Incidence of Complications? BMC Ophthalmology 6:13.