The OR- ivory tower or patient care area

Joun Miller, R N

For years, operating rooms have been referred to as “ivory towers,” and for years, the connotation of this label has stirred my soul to rebel- lion. Physically isolated we must be! Restricted from the routine traffic of other hospital areas (shades of Joseph Lister) I most certainly hope so! But out of touch with the reality of patient care and not a real, vital part of the hospital ‘family’ and pa- tient care team most assuredly not!

You as an operating room nurse agree, of course. But, how about the rest of your nursing staff? How can we reach them with our message? How can we convince them that we do give nursing care in the operating room? How can we let them know that we can and should contribute to

Joan Mi l ler , RN. i s operating room inservice in- structor at Leila Y. Port Moatgomery Hospi ta l i n Battle Creek, Michigan. She i s a graduate of Mercy Col lege of Nursing i n Detroi t , and i s a member of the Western Michigan chapter of AORN.

the planning of the patient’s total care? By lowering the drawbridge that’s how! Let the nursing staff meet the “princesses” in their tower. Let them see the operating room nurses planning, preparing for and implemented patient care during this critical period of illness. Let them see the special kind of communica- tion and cooperation of the OR team as they cope with tense and stressful situations.

“Impossible,” many of you will say. “Possible,” I say. Here’s how it can be done, and how we did it at our 200 bed hospital in the Midwest:

Each day brought a list of neg- ative comments and complaints to the nursing service office from the physicians and surgeons about care of the operative patient. Some of these comments were justified. Most pointed to a lack of understanding of the nursing staff concerning surgical aspects of the patient’s illness. At the same time, each day brought a rash

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of problems between the operating room and the patient units over im- proper or incomplete preparation of the patient coming to the operating room. While many of these prob- lems were not critical, they were ir- ritating and time consuming.

Our diagnosis: many of the staff nurses from the patient care units had very little real understanding of the operative procedures, the operat- ing room and the anesthesia tech- niques being used. For the older nurse, many changes had transpired since her operating room experience as a student. The recent graduates had very little or no exposure to the operating room during their educa- tional preparation.

Our treatment for this malady was to update the knowledge of these nurses, to give them firsthand in- formation and observational oppor- tunities and to bring them into the operating and recovery rooms. The idea came from a progressive and foresighted director of nursing serv- ice. The necessary tools for imple- mentation were an instructor with the time and facilities for classes, a cooperative operating room team, recovery room staff and surgical staff; and patience and persistance on the part of all of the persons in- volved.

An educational experience involv- ing three working days was estab- lished. The first day is a full eight hour seminar with lectures on the operative patient and the various surgical procedures. All information is slanted towards the implications involved in care on the patient unit. Groups of five to ten members of the nursing staff are assigned to this mandatory session. Included are reg- istered nurses and licensed practical

nurses. (Nurse aides are given a spe- cial session.) Operating room and re- covery room nurses are also required to attend a lecture session. Follow- ing attendance at the lecture session, the nursing staff is assigned, one or two at a time, to spend two days in the 0 R and recovery room areas. The staffing coordinator makes the as- signments, taking care not to create staff shortages on the units. Nurses with transportation, and child care problems, are given choices of alter- nate dates as it often means a change in tour hours for these three days.

The format is kept very informal with open discussion and participa- tion by all encouraged. Since vary- ing tours of duty and nursing units are represented, we open each ses- sion by getting to know one another. This mingling of staff has been an added dividend as it has fostered a better rapport. between the units, and between nurses on different shifts on the same units. The purpose of the session is explained, and the ob- jectives reviewed, with an invitation for additional objectives from the staff participants. Our objectives are:

1. To develop a better understand- ing of the operative patient.

2. To open avenues of communica- tion for better understanding and cooperation between the operating room, recovery room and patient care units.

3. To give the nursing staff an ap- preciation of all phases of patient care. 4. To increase knowledge of drains,

tubes and prosthetic devices used in our patients.

5. To update general information about anesthetic methods and agents.

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6. To learn and review the care of the anesthetized and reacting pa- tient.

A review of the recent progress in the field of surgery, with a brief dis- cussion of some of the technical im- provements, helps to give an under- standing of the new procedures. We review the criteria that constitutes a surgical patient and the classifica- tions of major and minor procedures. The physical and psychological needs of the patient in all instances is stressed.

Filmstrips showing the basic pre- operative and postoperative care are viewed with discussion on specific areas. The consequences of the fail- ure to carry out the preparatory measures are explained, both from the view of the operating room and the possible complications to the pa- tient in surgery and convalescence.

Various tubes, drains and implants are used for a ‘show and tell’ seg- ment with emphasis placed on the proper postoperative care of these items. The special or ‘pet’ appliances of the various surgeons are ex- plained, along with the rationale for his preference, so that a greater un- derstanding of his plan for the pa- tient’s care is realized.

During the two days of observa- tional experience that follow, the head nurse in the recovery room gives a lecture on the patient during the immediate post-operative period. She also shows a film: “Principles of suctioning to maintain an oper airway”. The staff nurse is then dressed in operating room attire, given a tour of the surgical suite and is allowed to select a procedure to observe. She usually chooses a pa- tient from the unit that she normally works. Unless there are extenuating

circumstances, there are no restric- tions as to what cases may be viewed. The only rule that we emphasize is that they follow a t least one patient from entry into the surgical suite, through anesthesia induction, stay for the entire operative procedure, go with the patient to the recovery room and finish with assisting in the transport of the patient back to his own bed. During the time that the nurses are observing surgery, the operating room instructor avails her- self to act as guide, make introduc- tions and answer questions. This helps allay the insecurity of the vis- itor in strange surroundings, and re- lieves the circulating nurse of the full responsibility of a n extra person in the room.

One of the most gratifying aspects of the project has been the way that the OR staff have accepted the visit- ors, and have offered support and information. The visiting nurses are really welcomed as guests and treated most cordially. The surgeons have supported the program and vol- unteer lectures during the cases to assist in the learning experience. Their comments on the program have been very favorable and they have made suggestions of items to be added to the program content.

At the end of each individual’s three days, we give them an evalua- tion form to be returned to the nurs- ing office anonymously. We felt that this would give us their reaction to the experience and give the staff an opportunity to suggest future pro- grams. While the percentage of eval- uations returned is very low, the romments have been positive, and requests for more such continuing education have been made. The greatest feedback that we get is

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through the hospital grapevine. “I think we should do this every couple of years.” “Now I know why pa- tients complain of pain.” “The OR nurses really do worry about the pa- tient’s needs.” These are some of the remarks heard in the coffee lounges in the halls.

Although this project is barely a year old and has not been com- pleted, we feel that there have been some very positive results. The atti- tude of the staff towards this un- usual assignment has changed from suspicion (we were going to make OR nurses out of all of them) and hostility (I never did like the OR and want no part of it) to eager an- ticipation of their turn. Some of the staff, not yet scheduled, have called to insure that they have not been overlooked. Resistance from the nurses, who were concerned about lack of staff on their unit during the sessions, has improved, although some still exists.

One area of misunderstanding and fear in the beginning was that the nursing staff from the patient units would be expected to function as re- covery room nurses. As this is strictly an educational adventure, we do not depend on them to staff, but let them function a t whatever level they choose and can handle with comfort and security. The un-

- Experience i s whaf you‘ve got pleniy of when you‘re too old to get the job.

derstanding between the patient units and the operating and recov- ery rooms has improved, and the nurses are calling the OR for infor- mation about procedures that are un- familiar to them. We hope that soon the operating room staff will be in- volved as resource agents for the nursing care conferences. Because of their observation and exposure to the anesthetized patient during the recovery room assignment, some of the nurses have stated that they are more secure when a patient is re- turned to their unit immediately postoperatively, during the hours when the recovery room is not open.

There has been a noticeable drop in the complaints received by nurs- ing service. The surgical staff seems appreciative of the fact that an all out effort is being made to solve problems dealing with the care of their patients. But best of all, the en- tire nursing staff has discovered that new learning experiences are not a drudge, and are beginning to mine that ‘mother lode’ of information and experience - the operating room nurse.

To further establish the concept of total patient care, and to widen the horizons of the operating room nurs- ing staff, our next step will be to re- verse the drawbridge and give the OR nurses a similar experience on the postoperative units.

A 0 R N Jot1 rnir 1