NOVEMBER 1992, VOL 56, NO 5 AORN JOURNAL

Opinion

A letter to my colleagues

appy OR Nurse Week to my former col- H l e a g u e s ! Enjoy the week and use it to reflect on the elements that make perioperative nursing special. Be proud of your nursing skills and your technical skills. Appreciate your coworkers and the relationships you have with them. Accept the satisfaction that comes at the end of a case that has gone well. Look inward and rediscover those elements that make OR nursing important to you. Then look for me, because I am hoping to be an OR nurse like you again soon.

I was an OR nurse for 10 years, but I do not currently work in the OR. Changing family commitments led me to seek a job with shifts that would fit my personal needs better. After a year away from the surgical suite, I would like to share some of my insights about periopera- tive nursing, critical care nursing, and myself.

Making A Change

ere do OR nurses look when they need w professional change? Which unit will serve their needs best? I quickly learned in nursing school that my organizational skills allowed me to deal easily with the multiple problems of one patient. The single problems of multiple patients, however, confused me. In short, floor nursing was not an option. A situa- tion where I could practice one-on-one patient care would be most appropriate for me. This narrowed my choices to working in the OR, the intensive care unit (ICU), or the labor and delivery (L and D) department.

Ten years ago, my first job interview was with an OR supervisor who hired me and pro- vided the necessary on-the-job training. Because the OR was no longer meeting my needs, however, and because my hospital did not have an L and D department, I decided to apply for a job in the surgical intensive care unit (SICU).

The Interview

was nervous during the interview for the I SICU job, but I tried to hide it. The head nurse was a very knowledgeable, effective, and friendly manager who made me feel comfort- able within a few minutes. We discussed my personal reasons for leaving the OR and choos- ing the SICU. Then we talked about the specifics of my nursing abilities. The conversa- tion went like this.

Head nurse: So, you’ve been a nurse for 10 years?

Me: Yes. Head nurse: All the time in the OR? Me: Yes. Head nurse: So you have no critical care

The silence hung in the room, but the noise experience then.

Sheila Thompson, RN, BSN, CNOR, is a staff nurse on the step-clown unit a t Tucson Veterans Affuirs Medical Center. She earned her bachelor of science degree in nursing from the University of Arizona, Tucson.

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It was an excellent review that increased my confidence and validated my beliefs that

OR nurses are critical care nurses.

in my head was deafening. There it was again, I thought, the prejudiced perception that OR nurses are simply technicians. Disregard the fact that we care for patients who are totally dependent on us. Ignore the fact that we are the nurses who care for surgical patients right up to the minute they arrive at the ICU doors. Then consider the fact that a surgeon is present in the OR with us, which seems to negate our intelli- gence and skills as nurses in the eyes of non- perioperative nurses.

“No! No! That is not correct,” I said to myself. “I do have critical care experience. I am familiar with all the cardiotonic drugs, the hemodynamic monitors, and the decision-mak- ing criteria used in determining care. While it is true that I have never been solely responsible for any of these, it would not be hard for me to learn.” I told the SICU head nurse what I was thmking. My sound arguments must have con- vinced her because I was hired to fill a position in the step-down unit (SDU).

Critical Care Course

efore working in any of our hospital’s criti- B cal care areas (ie, SICU, SDU, medical intensive care unit [MICU], renal transplant unit, life-support unit), nurses must complete a critical care course. Each week of the month- long course includes three days of didactic instruction and two days of internship in either the SICU or MICU. The intense course includes daily written homework assignments and weekly performance criteria.

During the first day, we reviewed cardiac anatomy. In the following days, we discussed numbers, numbers, and more numbers, includ- ing hemodynamic values, normal versus abnor- mal values, monitors and catheters for measur- ing values, and cardiotonic drugs for manipu- lating values. It was an excellent review that

truly increased my knowledge, but the best effect it had on me was to increase my confi- dence. All that reviewing validated my beliefs that OR nurses are critical care nurses.

The SICU internship was my favorite part of the course. The nurses knew I had cardiotho- racic OR experience, so I usually was teamed with the nurse who would be accepting that day’s heart patient. Following the care of a patient through the four to eight hours immedi- ately after surgery really fascinated me. My preceptor and I continuously assessed the patient for stability or change; intervened with ventilatory, cardiotonic, or fluid support when necessary; and reassessed the patient as needed.

My preceptors were very experienced, and I was impressed by their nursing knowledge and skills. I found ways to share my perioperative experience with them as well. When patients were stable, I would describe surgical proce- dures to the SICU nurses or answer their ques- tions. I made a lot of friends that month, and by the end of my internship, we respected each other as colleagues.

Step-Down Unit

he SDU was created along with the cardio- T thoracic surgery program as a unit where postsurgical open-heart patients stay after release from the SICU and before their transfer to the nursing unit. The SDU is a six-bed unit with bedside monitoring and a central monitor at the nurses’ station. Patients are monitored for dysrhythmias, stability of vital signs, mainte- nance of adequate ventilation, decreased chest tube drainage, and ability to urinate. We help patients regain their ability to complete activi- ties of daily living while easing their physical pain and emotional fears.

When all the beds are not needed for cardio- thoracic patients, we receive other patients who

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require intensive nursing care and cardiac mon- itoring. The SDU provides all the nursing care aspects of an ICU except ventilator support and titratable cardiotonic drips. Helping patients through the postoperative course is a new expe- rience for me, and I find the unit a fascinating place to work. It has broadened my nursing knowledge base immeasurably.

I enjoy postoperative teaching as well. The SDU patients often have many questions about what happened to them in surgery and what they can expect before their discharge. I believe the best teaching is done during caregiving. I would often educate a patient about his or her drains during dressing changes, which would lead the patient to ask other questions. The nurse/patient relationship is totally different from the doctodpatient relationship. Nurses spend the day with patients, which provides many opportunities to interact with patients, assess needs, provide intervention, and educate. I work at a teaching institution where the doc- tors complete rounds in mass. The physicians have only a few minutes to question patients about how they are feeling, which leaves little time for patients to ask their own questions. Nurses could have an awesome power to influ- ence and educate the public if only we had the time to use it.

New Routine

y nurse colleagues on the unit were experi- M enced RNs who had a variety of specialty backgrounds and licensed practical nurses who had completed advanced assessment classes. Some nurses had critical care experience and surgical orthopedic backgrounds. One had exten- sive oncology training. The nurse preceptors taught me their own nuances of providing care until I finally developed a routine of my own.

My routine incorporated a great deal of my OR training. Our nurse aide was the first to notice this. One evening as the aide helped me turn a stroke patient, we discovered that the patient had soiled himself. The aide offered to get a wash cloth and sheet, but I already had them at the bedside. I knew that with an incon-

tinent patient, a situation like this was always possible. During the linen change, the patient’s external urinary catheter was removed. The aide offered to go to the supply cart for a new one, but I had already stocked an extra one in the patient’s bedside table for just such an event. We also had trouble untying a soft restraint. Before the aide could straighten up and go to the desk for a scissors, I had placed my hot pink bandage scissors, which I got at Congress, in his hand. When we finished treat- ing the patient, the aide looked me straight in the eye and said, “I’ve never seen such organi- zation.” This was a fitting compliment for an OR nurse.

Another part of my routine includes joining physician rounds. As an OR nurse, I always have felt like an equal member of the surgical team, so I feel comfortable not only listening to physicians on rounds but also questioning, qualifying, and suggesting patient care. I have been known to follow doctors right out the door of our unit, questioning them until I fully understand the goal of their orders or make them understand a patient problem.

I know these physicians because I have worked with them for many years in the OR. My interactions with them are much different than the interactions they have with the other nurses. I find the physicians are more patient with me than they are with the other nurses. They are more accepting of my questions and assessments and more responsive to my requests. We OR nurses may have earned more respect than we know.

The’ Future

ne thing I have learned during my experi- 0 ences is that working in critical care is not the same as working in the OR. I believed that if I met my personal need for one-on-one patient care, I would enjoy any nursing experi- ence. While critical care nursing is fascinating and I enjoy my work right now, I am planning to return to the OR someday.

I need to return to the OR because I have two remaining needs that are not being met by

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working in the SDU. I discovered the first missing element while I was completing a change-of-shift report. I hate reporting to the nurse coming on duty, because i t means that the nursing job is not finished. I do not like being at the hospital for 12 hours and not curing, edu- cating. or discharging a patient. In the OR, we prepare for a procedure, conduct the procedure, and complete the procedure. I miss that fre- quent feeling of a job well done.

I also am not experiencing the satisfying sense of teamwork in the critical care area. I discovered this problem when I completed ori- entation and was on my own, After we start our shift and receive our assignments. we pretty much go our own way. Critical care nurses are autonomous. They like their autonomy and are very proud of it. Of course, if a patient becomes

unstable, we all pull together and help. After the crisis is over, however, we split up again.

I miss the teamwork that is typical in the OR. The members of a surgical team include the scrub nurse and circulating nurse. Anesthesia staff members join the nurses to prepare their equipment and collaborate. The patient is added, and finally, the surgeons arrive to com- plete a team that works together toward the goal of quality patient care. I miss my OR team terribly.

For these reasons, I am looking forward to the day when I can return to perioperative nurs- ing. Although my experience as a critical care nurse is valuable, I look forward to again expe- riencing the pride, appreciation, and satisfac- tion of being an OR nurse.

SHEILA THOMPSON, RN

lnexpensive Laser Program Promotion Because the first item cut from budgets is advertising, hospitals that want to promote their laser programs to the public must devise inex- pensive ways to educate their consumers about the benefits of laser surgery. According to an article in the Spring I992 issue of Laser Nursing. the elements of promoting hospital programs (eg, staff and patient education, informing the community, working with the media) can be fulfilled inexpensively.

Informed staff members can promote the institution’s laser program to family and friends. When educating staff members, the promoter must decide which departments will benefit from laser procedures and schedule in- service programs to educate staff members about new procedures and to promote other laser activities in the hospital, the article states. The promoter also should publish laser-related articles in hospital publications.

To educate the public, the promoter can pre- sent laser information to existing hospital- based patient education programs and patient support groups. These presentations can be opened to the public and can include health 882

screenings as a way to entice people to partici- pate. Inviting school groups to attend is anoth- er way to educate the public inexpensively, according to the article. Additionally, press releases are an excellent way to inform the mass media of hospital programs.

Brochures serve as educational and rein- forcement tools, and, although they do require some expenditure, they are a relatively inex- pensive way to reach many people. When pro- moting a laser program, the article states, the promoter should include information on how lasers work, the benefits versus the risks of laser surgery, the treatment modalities avail- able at the institution, and emphasis on treat- ments unique to the institution.