Chapter 1 Perioperative nursing
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The purpose of this chapter is to introduce the beginning perioperative nurse to the key concepts used in perioperative nursing. It examines issues that are fundamental to understanding the context and culture that frames the perioperative nurses’ professional roles. Specifically, this chapter addresses issues related to the history and philosophy of perioperative nursing, the concept of cultural safety, and the multifaceted aspects of workplace culture. Chronic skills shortages in perioperative nursing mean that retention and recruitment of nurses to this specialty remains a crucial imperative for the profession if it is to advance in the current healthcare climate. Additionally, the nursing workforce is ageing. Addressing crucial issues associated with these concerns are key aspects of perioperative nursing knowledge.
Perioperative nursing in Australia is one of the oldest nursing specialties and has existed as a distinct entity for almost a hundred years, dating back to 1910 (Richardson-Tench, 2002). Operating room nursing underwent considerable change throughout the 20th century. The advent of sophisticated anaesthesia with its associated complexity of surgical procedures and the increased use of technology required the operating room nurse to develop commensurate knowledge and skills. In the 1970s, the term “perioperative nursing” gained acceptance with a shift in emphasis away from the traditional geographic boundaries inside the operating suite to the temporal boundaries of preoperative patient assessment, intraoperative care and postoperative evaluation. The advancing technology and changes in the healthcare system has impacted upon perioperative nursing practice, providing the professional nurse with a variety of roles to practice. Perioperative nursing practice is flexible, with the scope of practice inclusive of all aspects of care of the surgical patient (Richardson, 2000).
Historically, surgical interventions have taken place in the traditional environment of the hospital operating suite. Advances in surgical technology and procedures, improvements in anaesthetic techniques and changes in the healthcare environment have altered where and how surgery is performed.
The perioperative nurse is a professional who provides complex care for patients in a high-dependency situation. The care encompasses safe and effective management in collaboration with other health team members; the nurse also safeguards the patient’s integrity by acting as an advocate for patients during their perioperative experience. Furthermore, the perioperative nurse explores strategies for the enhancement of practice through continuing education, research and habits of lifelong learning.
Professional nursing in the operating room has been defined in the United States as:
the identification of the physiological, psychological and sociological needs of the patient, and the implementation of an individualised program of nursing care that co-ordinates the nursing interventions, based on a knowledge of the natural and behavioural sciences, in order to restore, or maintain, the health and welfare of the patient before, during, and after surgery (Atkinson & Fortunato, 2000, p 22).
Even though the literature is replete with descriptions of the role of Australian perioperative nursing, there does not appear to be an explicit definition. Richardson-Tench (2002) describes the role of the perioperative nurse as follows:
The perioperative nurse is in a unique and privileged position as s/he assists with the surgical procedure. S/he is the consciousness of the unconscious patient. The perioperative nurse maintains the personhood of the patient by the provision of psychological care and by making ordinary the extraordinary event of surgery. S/he designs, co-ordinates and delivers care comprised of nursing knowledge and psychomotor skills which are a blend of thinking and doing, to meet the needs of the surgical patient. While scientific nursing techniques underpin perioperative nursing practice, competent fulfilment of the role is based on the knowledge and critical application of the biological, physiological, behavioural and social sciences (p 37).
Perioperative nursing is a highly skilled specialty with subspecialties, and a clearly defined role in terms of the surgical team and the patient. It requires nurses to be educated in nursing theory and the health sciences and to have attained appropriate interpersonal communication skills. The delivery of perioperative patient care requires complex knowledge and skills to effect safe outcomes for the surgical patient (Richardson-Tench, 2002).
Ideally, perioperative nursing practice is based on a written stated philosophy, which blends with the hospital’s mission statement and describes values and beliefs that pertain to professional nursing practice. Perioperative nurses’ primary professional responsibility is to the patients for whom they care. In the perioperative setting, healthcare personnel from different professional disciplines work together for a common objective: to provide competent, skilled and appropriate patient care. The philosophy of perioperative nursing encompasses a holistic, multidisciplinary approach that is concerned with:
Thus, perioperative nurses possess unique knowledge and skills. They provide holistic care and are particularly aware of the fears and anxieties of the patient, as well as their physical needs (e.g. warmth and comfort), spiritual needs (e.g. support from staff) and sociological needs (e.g. acquaintance with staff and environment). Perioperative nurses constantly analyse, reflect and evaluate their performance. In other words, how they deliver patient care reflects their professionalism.
The technical dominance that defines perioperative culture inevitably links the evolution of nurses’ roles to the development of technology. Technology can be best understood in terms of knowledge, skills, techniques, artefacts and resources (Barnard, 2007). Of necessity, perioperative nurses need to have technical aplomb for the wide array of machinery and equipment used in the provision of patient care. Moreover, some research suggests that there is still theoretical distancing of perioperative nursing from mainstream nursing based on conventional notions of the nurse–patient relationship that develops between people (Yamaguchi, 2004). Defining nursing care in the perioperative setting within this narrowly conceived traditional model has contributed to stereotypical perceptions that cast nurses as “handmaidens” to the surgeons (Gruendemann, 1970), and positions the specialty as task-orientated and technical (Sandelowski, 1999). These descriptions imply that nurses’ interpersonal relationship with patients in the perioperative setting is restricted; and that the nature of “caring” is considerably diminished because of the differences in role orientation. There is continuing debate about whether perioperative nursing can even be considered nursing (Sandelowski, 1999), or even if nurses need to be present in the operating suite (Bull & FitzGerald, 2006).
For example, one field study found that perioperative nurses experienced role confusion as they were socialised to perform exclusively as technicians and assistants to the surgeons, not as nurses (Yamaguchi, 2004). This study demonstrated that nurses’ roles in the perioperative environment were more technically focused and task-orientated, and substantiates the struggle that many perioperative nurses have working within a non-traditional area of nursing. The apparent conflict between caring and technical roles as the level of technology increases in the perioperative context has the potential to distance nurses from their patients, and erode the quality of care that patients receive (Bull & FitzGerald, 2006). Likewise, technical competence is often recognised and rewarded in the perioperative setting, and nurses with these attributes are held in high esteem—they are trusted and consulted (Bull & FitzGerald, 2006; Gillespie et al., 2008b). Consequently, perioperative nurses may find themselves faced with something of a predicament because of the dual nature of their perioperative role. The caring aspect of their role is what makes them “real nurses” and yet the technological component is what earns perioperative nurses professional respect (Bull & FitzGerald, 2006). An example of the conflict that nurses experience between the technical and caring roles is emphasised in research conducted by Richardson-Tench (2007), presented in Box 1-1.
Box 1-1 Dialectic between caring and technical roles
Findings from Richardson-Tench’s (2007) field study illustrate the tensions that perioperative nurses experience in their dual roles as carers and technicians. It appeared that for some of the lesser experienced nurses, the caring role was subsumed in the technical imperative that was associated with learning the surgical procedure. Consequently, for the novice, ‘humanistic caring’ could not take place until there was mastery of the psychomotor skills that defined the technical aspect of the perioperative role.
Patient care presents many challenges as perioperative nurses often have minimal time to establish rapport or provide reassurance, as well as obtain important clinical and/or psychosocial information. Perioperative nurses must have the ability to assess the patient quickly and become attuned to the patient’s verbal and non-verbal cues. In many instances, the nurse is the last person that patients see before they are anaesthetised (Sigurdsson, 2001). For perioperative nurses, the central purpose of the patient–nurse relationship is to ensure the safe passage of patients during the perioperative period (Bull & FitzGerald, 2006). Perioperative nurses are in a unique position, as they must ensure a safe therapeutic environment for patients by maintaining practice standards (Richardson-Tench, 2007). Patients are at their most vulnerable when they enter the operating suite and are profoundly reliant on the skills and expertise of the nurses who care for them. In combining the technical and caring aspects of their perioperative role, nurses are the human conduits that provide the physical link between the patient and the machine (Glaze, 1999; Sandelowski, 1999).
Nursing roles in the perioperative setting are based on both behavioural and technical components of clinical competence. The perioperative nurse plans and directs nursing care for patients undergoing operative and other invasive procedures. The scope of practice may include (but is not limited to) preadmission nurse, anaesthetic nurse, circulating nurse, instrument nurse, postanaesthetic recovery unit (PARU) nurse, perioperative nurse surgeon’s assistant (PNSA), manager, educator and researcher. The roles of anaesthetic nurse and PARU nurse are usually exclusively designated—that is, nurses working in these roles do not routinely undertake other perioperative roles—but this may be dependent on staffing levels and skills. However, the traditional intraoperative roles of circulating nurse and instrument nurse are undertaken interchangeably throughout the day’s operating list. Importantly, perioperative and surgical outcomes are influenced by the standard of care delivered by the nurse working within each of these roles (ACORN, 2006; PNCNZNO, 2005).
The preadmission nurse plays an important role in the preparation of the patient for surgery by functioning in a screening role, detecting medical or physical conditions that may generate a referral to the surgeon or anaesthetist.
The presence of an appropriately educated anaesthetic nurse/assistant is integral for the safe and efficient administration of anaesthesia (ACORN 2006; ANZCA 2003; PNCNZNO 2005). Specifically, the role of the anaesthetic nurse is to collaborate with the anaesthetist to provide patient care and procedural support (ANZCA, 2003). If an anaesthetic technician is required to fulfil this role briefly, then they require the appropriate professional education.
A registered nurse (RN) or enrolled nurse (EN) (Division 2 Registered Nurse, Victoria/Western Australia) may perform the anaesthetic nurse role. Perioperative nurses who work in this role have an option to obtain specialty education through an accredited postgraduate program. The Australian and New Zealand College of Anaesthetists recommends 150 contact hours (ANZCA, 2003). Enrolled nurses must work within their defined scope of practice as determined by the relevant state registration board authority (ACORN 2006; PNCNZNO 2005). Some of the role responsibilities of the anaesthetic nurse are outlined in Box 1-2.
Perioperative nurses’ primary role in the operating room is that of the circulating nurse. This is a complex role encompassing management of nursing care of the patient within the operating room and coordination of the needs of the surgical team and other care providers necessary for the completion of surgery (Matson, 2001). The circulating nurse’s duties are performed outside the sterile area. Using critical thinking skills, the circulating nurse observes the surgery and the surgical team from a broad perspective and assists the team to create and maintain a safe and comfortable environment for the patient. The circulating nurse assesses the patient’s condition before, during and after the operation to ensure an optimal outcome for the patient. Most patients undergoing surgery are anaesthetised or sedated and are powerless to make decisions on their own behalf during the intraoperative phase.
The critical importance of the circulating nurse cannot be understated (Matson, 2001). The circulating nurse serves as patient advocate while patients are least able to care for themselves. However, they have limited time to establish a bond with the patient before the procedure in order to be an effective advocate. Some of the role responsibilities of the circulating nurse are summarised in Box 1-3.
The instrument nurse works directly with the surgeon within the sterile field, passing instruments, packs and other items needed during the procedure. Both the circulating and instrument nurses have a dual role in checking to ensure that all appropriate sterile instrumentation and surgical supplies are available and functional before the start of the list (ACORN, 2006; PNCNZNO, 2005). During surgery, the instrument nurse’s role should be distinct from, and not overlap with, the role of the first surgical assistant, that is, the person assisting the surgeon. While there may be situations where there is a transient overlap of these roles (e.g. patient haemorrhage, difficult access), this situation should not occur routinely. Knowledge in relation to standards of perioperative practice (e.g. standards for cleaning and practice, aseptic technique, infection control, medicolegal requirements, anatomy/physiology, surgical procedures) is essential to perform these roles safely and effectively. To assist nurses to develop a broad knowledge base, specialty perioperative education through an accredited program is recommended (ACORN, 2006; PNCNZNO, 2005). Depending on the policy of the particular hospital, the instrument nurse may be an RN or an EN. ENs must work within their defined scope of practice as determined by the relevant state regulation authorities and must be under the supervision of an RN (ACORN, 2006). The role responsibilities of circulating/instrument nurse(s) may overlap a little with that of the anaesthetic nurse, depending on the policy of the relevant operating room department, scope of practice of individual nurses within the team and the structure of the surgical team. For instance, in some operating suites, it is the role of the anaesthetic nurse to check the patient’s details (i.e. correct identity/surgical site, consent, allergies, etc.) when they arrive, whereas this duty may be incorporated in the role of the circulating nurse in other departments. Box 1-4 highlights some of the responsibilities associated with the instrument nurse role.
It has been recognised for many years that nurses have acted as assistants to surgeons in the capacity of first assistant, where the nurse provides skilled assistance but not surgery (McGarvey et al., 2000). However, more recently, changes in health care delivery have precipitated the emergence and recognition of an extended practice role for RNs in the perioperative setting (ACORN, 2006). The PNSA role in Australia incorporates the preoperative, intraoperative and postoperative phases of care. Within its most limited scope of practice, the PNSA role may be restricted to the intraoperative phase (Riley & Peters, 2000). The Australian College of Operating Room Nurses endorses the ongoing development and expansion of the PNSA as a Nurse Practitioner role (ACORN, 2006), which would require educational preparation to a Masters degree. Essentially, the scope of practice within the PNSA role is determined by state and federal legislation. Box 1-5 details some of the role responsibilities undertaken by the PNSA.
Box 1-5 Role responsibilities of the PNSA
The PARU nurse is an important member of the perioperative team and provides patient care immediately following an anaesthetic, surgical or other procedure (ACORN, 2006; PNCNZNO, 2005). The role of the PARU nurse is to ensure patient safety through a trajectory of unconsciousness and instability to consciousness and stability, following the transfer of the patient from the operating room to the PARU. Vigilance is crucial in achieving the intended outcome as the patient is at increased risk during this trajectory.
In some health care facilities, the PARU and anaesthetic nurse roles are interchangeable, with nurses working across both subspecialties. Where direct patient care is given by an EN, an RN must supervise it. ENs must work within their scope of practice as determined by the relevant state registration authority and departmental policy. Specialty education through an accredited postgraduate program is recommended. Box 1-6 features some of the role responsibilities performed by the PARU nurse.
Cultural safety is a concept that arose in the context of post-colonial countries, such as Australia, Canada and New Zealand. It emerged in health care as a means of engendering a critical understanding of colonial structures and their impact on contemporary Indigenous populations (Dyck & Kearns, 1995). The concept of cultural safety emphasises that health care is not merely provided for individuals but for members of minority ethnic groups whose care is inevitably defined and influenced by social disadvantage. The Nursing Council of New Zealand (NCNZ) (2002, p 7) defines cultural safety as:
The effective nursing practice of a person or family from another culture, and is determined by that person or family. Culture includes, but is not restricted to age or generation, gender, sexual orientation, occupation and socioeconomic status, ethnic origin or migrant experience, religious or spiritual belief, and disability.
Therefore, cultural safety encompasses a person’s socioeconomic status, age, gender, sexual orientation, ethnic origin, migrant/refugee status, religious belief or disability to enable the delivery of safe, appropriate and acceptable nursing care. Cultural safety relates to the experience of patients as recipients of nursing care, and extends beyond cultural awareness and cultural sensitivity. While the terms “cultural awareness” and “cultural sensitivity” are used synonymously with “cultural safety”, they are not interchangeable with cultural safety (Ramsden, 2002). These are separate concepts that are positioned on a continuum that ultimately leads to cultural safety.
It is important that health care professionals involved in patient care consider the cultural implications of their practice on others. Within the literature, cultural safety may also be referred to as cultural competence. Cultural competence is a way of being sensitive to the differences in culture and acting in a way that is respectful of the values and traditions of the patient while performing those activities or procedures necessary for the patients well-being (de Chesnay, 2005).
As a result of the fundamental differences in the personal characteristics and backgrounds of the patient and the nurse, cultural safety provides care within a framework that affirms and respects these individual differences (Milnes et al., 2007). It is the nurses’ responsibility to engender trust; and the patient determines whether sufficient trust has been established for cultural safety. Accordingly, a culturally safe nurse does not need to be culturally similar to patients; however, it is considered culturally safe because patients believe that their own values are accepted rather than discounted. For instance, in Māori culture, all body parts are highly revered and are either disposed of according to tikanga practices and/or returned to patients and their whanau (extended family) (Waikato District Health Board, 2006). Tikanga refers to the customs and traditions that have been passed down through generations and guides general behaviour. Box 1-7 describes a practice example where observance of this cultural belief has implications for the disposal of resected organs or tissues postoperatively.
Box 1-7 Respect for traditional values and religious beliefs
Huatare, a 53-year-old Māori man, has been scheduled to have a left lower leg amputation. Prior to the surgery, at the request of his whanau, two members from the perioperative team met to discuss the possibility of returning the amputated limb back to Huatare. Explicit consent and informed acceptance was obtained from Huatare and his whanau regarding their intentions for removal, retention and return of Huatare’s amputated limb. The family wanted the amputated limb so they could ‘return to the earth what has come from the earth’. A notation of the discussion and its outcome was documented in Huatare’s chart.
During surgery, handling of the amputated limb reflected tikanga practices. The perioperative team made the necessary arrangements regarding the appropriate handling and prompt return of the amputated limb to family members.
Cultural safety is also concerned with recognising the inherent power imbalances that exist between the health care provider and the people who use the service. Within the hospital setting, the use, control and language of clinical information have contributed to a disproportionate power base in favour of health care professionals (Ramsden, 2002). Nurses’ clinical, biological and technical knowledge and their access to resources have clearly created and maintained inequities within the nurse–patient relationship (Milnes et al., 2007). The potential for disparity in power relations between nurses and their patients is acutely evident in the perioperative context as patients enter the alien environs of the operating suite. Not only are patients stripped of the vestiges of their personal and social identities through the donning of operating room attire, they have been relocated to an environment where medical technology is an omnipresent feature, and the esoteric language of surgery is fluently spoken. In this context, cultural safety recognises that perioperative nurses have greater access to power because of their professional and technical knowledge. Box 1-8 presents a practice example to illustrate this.
Box 1-8 Recognising powerlessness and power
A 19-year-old Indigenous woman from the Tjapukai mob, north of Cairns, arrived at the operating suite reception area and was scheduled to have surgery for an excision and drainage of a Bartholin’s cyst. The anaesthetic nurse greeted the young woman and briefly explained the ‘checking-in’ process, and then proceeded to ask the woman questions based on the preoperative checklist. The nurse noticed that the young woman was not accompanied by a relative and was very reluctant to speak. Upon completion of the check-in process, the nurse asked the young woman to verify the procedure to which she had given written consent. The young woman’s reticent and incomplete responses indicated that her understanding of the surgery and the perioperative process was very limited. At that moment, the anaesthetist and operating orderly arrived and introduced themselves as they began to wheel the young woman into the operating room.
Unfortunately, there was no family member or interpreter to intervene and assist the young Indigenous woman to negotiate through the maze of these dilemmas during this crucial time.
Ramsden (2002) suggests that cultural safety is about the nurse rather than the patient, meaning the enactment of cultural safety is about the nurse, while for the patient it is a mechanism that allows the recipient of care to say whether the service is safe for them to approach and use. The Nursing Council of New Zealand (2005) asserts that cultural safety may provide consumers of nursing services with the power to comment on practices and contribute to the achievement of positive health outcomes and experiences. Mistakenly, when questioned about cultural safety, health professionals may answer that they treat all their patients equally. In terms of cultural safety, the response of equal treatment is not appropriate as this does not allow for the unique needs of each patient. Unsafe cultural practice may lead to the disempowerment of the cultural identity or well-being of an individual (NCNZ, 2005).
Within the preoperative phase of a patient’s journey, cultural safety may be demonstrated in numerous ways. Examples may include ensuring that the patient has the appropriate support person or family with them during the consultation period, or that the patient has the services of a medical interpreter if required. Aspects of the physical examination may also require gaining permission from the patient to touch their head, as in some cultures the head area is deemed sacred. When unsure of a patient’s beliefs, the best approach is to ask the patient if the care they are receiving is appropriate to their beliefs. While obtaining surgical consent, consideration may be required by the patient as to whether they would like their body parts/tissue returned to them postoperatively, regardless of whether laboratory investigations are required. The wishes of the patient are to be clearly documented on the surgical consent/agreement to treatment form. Individual hospital guidelines and policy are required to guide practice with any such request.
The concept of cultural safety has had a powerful ideological influence on health education and practice. The “cultural safety” model was developed by Māori nurse leader, Irihapeti Ramsden (NCNZ, 2002). The tenets of this model are outlined in Box 1-9.
Box 1-9 Tenets of the cultural safety model
Ramsden (2002)
The relevance of culture to workplaces is becoming increasingly important because of its psychosocial impact on group dynamics. Culture has been symbolically described as the universal “glue” that binds the members of a workplace together through mutual patterns of meaning, conveyed through language (Chao et al., 1994). Professional socialisation involves developing the necessary skills, attitudes and behaviours that are expected and reinforced by the collective. Research conducted in Australia and overseas indicates that the extent to which new staff members are accepted into complex work environments, such as the perioperative setting, generally depends on: (a) their ability to acclimatise to the contextual subtleties of the workplace; and (b) the level of professional (e.g. education/preceptorship) and social support (e.g. included in the team) given as new staff members acquire the required specialty knowledge and develop their clinical skills (Bull & FitzGerald, 2006; Gillespie et al., 2008b; Richardson-Tench, 2007; Silēn-Lipponen et al., 2004).
Based on research conducted in Australia, North America and the United Kingdom, pertinent aspects of perioperative culture have been identified: specialty knowledge; social organisation; teamwork and communication; and the caring versus the technical role. The following sections present a discussion on each of these aspects.
Recent Australian research has indicated that specialty knowledge is a critical attribute of perioperative culture (Gillespie et al., 2008b). Operating suites are characteristically fast-paced clinical environments where specialty knowledge and clinical judgement are highly valued. Nursing practice in this unique setting includes specialty knowledge related to standards of perioperative practice, principles related to infection control and aseptic technique, and the management of instruments and equipment. For example, the way that instruments should be laid out on the sterile trolley for efficient use, how instruments should be passed in a dextrous manner so that the surgeon does not have to reposition the instrument before it is used, and the timely and intuitive response given to the surgeon’s request is underpinned by specialty knowledge. Therefore, for nurses to develop the knowledge and skills to assume the role of instrument nurse, they are “double-scrubbed” with a more experienced member of the nursing staff to provide physical and psychological support, and to enable close observation and appraisal of the novice’s skills (Riley & Peters, 2000). Additionally, perioperative nurses need specialty knowledge in relation to the wide array of machinery and equipment used to provide patient care.
However, more implicit forms of specialty knowledge are also developed as a function of experience, familiarity and time. Perioperative nurses necessarily develop an intimate knowledge of the requirements of the surgeons and anaesthetists with whom they work closely (Riley & Manias, 2007). Perioperative nurses possess detailed knowledge relating to the minute aspects of clinical practice; for instance, surgeons’ habits and preferences, such as which way to load a needle on the needle holder or how abdominal packs are to be folded. The importance of technical instrumentation knowledge and knowing the surgeon’s preferences is an important aspect of specialist knowledge for the perioperative nurse (Richardson-Tench, 2002). As well as a knowledge of surgeons’ technical preferences, perioperative nurses also develop knowledge of whether surgeons are fast or slow during surgery, the time they usually take to perform a specific procedure, whether they are punctual or habitually late, and their degree of flexibility during surgery (Riley & Manias, 2007). Having such knowledge informs the organisation of the nurses’ work activities in the operating rooms, such as when to commence the instrument setup, who would be best placed in the role of the circulating and instrument nurse, and when to send for the next patient (Riley & Manias, 2007).
Language is another salient feature of workplace culture and influences the ways in which individuals are socialised. As a form of knowledge, language frames the clinician’s technical dialogue, which consists of acronyms, nomenclature and vernacular that are unique to the health care setting (Chao et al., 1994). When perioperative nurses are conversant in the specialty language, they are more likely to communicate effectively with other members of the team (Gillespie et al., 2006). When nurses were unable to understand and use this language effectively to converse, other members frequently became frustrated and this increases tensions within the team. Recent research conducted by Gillespie et al. (2008b) illustrated the difficulties perioperative nurses had when they were not familiar with the specialty language. The potential consequences this presented are highlighted in Box 1-10. Other researchers suggest that specialty language also determines professional and social boundaries (Lingard et al., 2002b; Tanner & Timmons, 2000). Therefore, the perioperative nurse’s sense of professional identity, which is constructed through language, is forged during the early socialisation period.
In a recent Australian field study that examined perioperative culture, Gillespie et al. (2008b) identified that nurses’ ability to understand and use the specialty language associated with perioperative practice was influenced by their level of knowledge and clinical experience. Effective communication depended on nurses’ ability to interpret and act on subtle verbal and non-verbal messages given by other team members who assumed, to some degree, that all team members would have this form of knowledge. When participants were unable to use this specialty language proficiently, they felt that they were not able to contribute to the team, and some even reported feelings of social isolation.
The impact of socialisation is particularly evident in operating room culture, where the traditional hierarchical model has historically defined social organisation (Richardson-Tench, 2007). Seminal research described the traditional, medically dominated social structure that has dictated the direction of authority in the perioperative environment (Goffman, 1972). Subsequent research has identified that power and culture were reflected in the conversations between medical and nursing staff in the operating suite (Tanner & Timmons, 2000). Conversation among doctors was often serious and intellectual, whereas conversation with the nursing staff was jocular and superficial. However, this research also indicated that the professional identities, and therefore the social status of members, were concealed through the uniformity of dress, enabling hierarchy to be suspended.
More recent research conducted in Australia and North America has challenged the prevailing myth of a “pecking order”, historically captained by the surgeon (Gillespie et al., 2008b; Lingard et al., 2002a). For instance, Gillespie et al.’s (2008b) Australian field study noted that while traditional authority gradients do exist in the perioperative context, they are momentarily manipulated to fit the needs of the situation. There are instances when the situation dictates that the person who is ultimately responsible for a specific patient treatment—the anaesthetist or surgeon—carries out coordination of a particular activity. Alternatively, the most qualified person who is not easily distinguishable by professional status may be more appropriate than the attending doctors on specific aspects of patient care in a particular situation. An example of this in the operating room is during the positioning of the patient prior to surgery. It is usually the operating room technician who is designated as being responsible for retrieving and using equipment required to position the patient (e.g. hip joint replacement surgery). In this instance, the operating room technician is recognised by other members of the surgical team as being the most informed and should therefore coordinate this activity. Clinical practice in the perioperative setting tends to encourage a certain amount of flexibility of authority, which is determined by the situation and the people involved.
Workplace bullying and harassment have been described in the literature as prevalent features that have influenced social organisation in the perioperative context (Dunn, 2003; Gillespie et al., 2008c; Gilmour & Hamlin, 2003). It is also contended that regressive behaviours, such as sabotage, social exclusion and withholding of vital information, limits the extent to which individuals can participate as team members. These types of behaviours have historically constrained the development of perioperative nursing and, in doing so, have reinforced nursing’s subordination to medicine (Dunn, 2003). It has also been suggested that workplace bullying and harassment in the perioperative setting reinforces the “pecking order” of the culture (Gillespie et al., 2008c).
Bullying appears to flourish in environments where there is a strict hierarchical order and where there is a high value placed on the skills required to perform work roles competently (Hughes, 2003). Some authors have attributed the prevalence of bullying in the perioperative setting to its geographic isolation, the high stress associated with the nature of the work, the familiarity and the bonding that develops between staff, and the dated belief that nurses are “handmaidens” to surgeons and anaesthetists (Dunn, 2003; Gilmour & Hamlin, 2003). Bullying has been described in relation to decreased job satisfaction, diminished work performance, low staff morale, burn-out and attrition (Dunn, 2003; Hughes, 2003).
Emphasis is placed on preventing workplace bullying and, in many health care institutions, primary prevention is underpinned by education and training of staff. The Australian College of Operating Room Nurses (ACORN) has published a position statement that details the obligations of individuals and organisations in relation to the prevention and management of workplace bullying, and the imperative to promote “a culture of zero tolerance” in perioperative environments (ACORN, 2006, PS3).
Embedded in perioperative culture is the notion of teamwork. Teamwork is defined as a group of individuals who share common goals, work together interdependently to perform tasks, and who manage their relationships and clinical roles across professional boundaries (DiPalma, 2004). Teamwork is underpinned by factors related to effective communication, team formation, leadership, resource management, workload prioritisation and distribution, and coping with stress (Aggarwal et al., 2004).
In the perioperative setting, a number of professionals with differing clinical back-grounds and expertise perform a variety of activities directed towards a common goal—the well-being of the patient (Schaefer et al., 1995). Every team member has a specialised role: the anaesthetist’s focus is to maintain life-support measures during surgery; the surgeon’s role is to perform surgery to improve the patient’s physical status in some way; the technician’s role is to support the anaesthestist; and the nurse’s role centres on providing safe patient care by ensuring that all team members adhere to professional standards and practices that are circumscribed by the context. Within this team culture, optimal patient outcomes are dependent on the performance of individuals.
The perspective for measuring a team’s performance in the perioperative setting has traditionally focused on assessing the skill of the surgeon alone (Aggarwal et al., 2004), with little acknowledgement given to the role of the perioperative nurse. However, the increasing reliance on complex surgical technologies in perioperative nursing has led to nurses being recognised as valued members of the multidisciplinary team since they must possess a comprehensive knowledge of how the equipment is prepared, used and maintained (ACORN, 2006).
There is growing evidence that supports the need for better communication among surgical teams. The role of effective communication in maintaining patient safety is increasingly being recognised as essential in high-risk environments, such as the perioperative setting (Undre et al., 2006). Surgical teamwork involves complex interpersonal dynamics among highly specialised professionals—specifically, nurses, anaesthetists, surgeons and technicians.
There is much evidence to suggest that communication failures can have devastating results, leading to the potential for human error (Reason, 2005; Schaefer et al., 1995). Recent data from the Australian Institute of Health and Welfare suggests that up to 50% of adverse events in Australian hospitals occur as a result of communication failures between health care professionals, in particular, nurses and doctors (AIHW, 2007). In the operating room specifically, communication failures have been identified as the primary cause in 80% of perioperative sentinel events (JACHO, 2004). Retained sponges, wrong-site surgery, and mismatched blood transfusions and organ transplants can be the result of interpersonal dynamics, where communication failures occur among members of the perioperative team (Giles et al., 2006). Therefore, the performance of the collective is the key to good surgical care and a predictor of optimal surgical outcome (Flin et al., 2003; Giles et al., 2006). Box 1-11 illustrates the dynamics needed for effective communication during surgery.
Box 1-11 Dynamics of communication in surgery
During surgery, effective communication between the surgeon and the perioperative nurse depends on:
A communication breakdown between the nurse and the surgeon has the potential to adversely affect the care of the patient during these critical intraoperative moments.
Communication is not standardised in the perioperative setting and will vary depending on the rapport among team members (Gillespie et al., 2008a; Healey et al., 2006). Communications among the multidisciplinary team may be based on previous professional and social relationships, and may have the potential to hinder team effectiveness (Lingard et al., 2002b). This is particularly true when team members are transitory and there is a significant reliance on casual or agency staff. Additionally, nurses and doctors have been socialised into different communities of practice and, therefore, have different foci and communication styles. For example, doctors tend to approach a clinical situation using a diagnosis-and-treatment model, whereas nurses operate from a different contextual frame, using a provision-of-care model (Dayton & Henriksen, 2007). Accordingly, there is the potential for communications to derail, resulting in communication breakdowns (Gillespie et al., 2008a; Leonard et al., 2004; Lingard et al., 2006). The potential for the loss of vital information as a result of poor communication among team members is highlighted in research conducted by Lingard and colleagues, presented in Box 1-12.
Box 1-12 Communication failures
In a series of Canadian observational studies, Lingard et al. (2004; 2005; 2006) identified problematic issues in relation to team communication in the perioperative setting. Communication was often too late to be effective, the content was inconsistent or incomplete, issues were left unresolved until the point of urgency and key personnel were excluded from discussions. Consequently, up to 30% of procedurally relevant information exchanges were obscured or lost as a result of communication failures among members of the surgical team.
The authors wish to acknowledge Prue Hames RN MN (Hons), Unit Manager, Short Stay Surgical Unit, Greenlane Clinical Centre, Auckland, and Leigh Anderson RN MN (Hons), Nurse Educator, Adult and Emergency Operating Rooms, Auckland City Hospital, for their contribution on cultural safety to this chapter.
The operating list is an artefact that represents a structured means of communication. The list indicates the sequencing and priority of surgical procedures used by members of the surgical team (Riley & Manias, 2007). It communicates the surgical procedures undertaken in each operating room and the subsequent nursing actions that maintain it. The list may be typewritten, and the information is arranged to correspond to the numbered operating rooms, beginning with the morning sessions, followed by the afternoon sessions. All work in the operating room revolves around the written operating list. Further, members of the team frequently refer to it as “the list”, acknowledging its iconic role in the communication of essential information. Nevertheless, situations frequently arise that necessitate a change in the order of the list based on the availability of particular instruments or unplanned surgical emergencies. Consequently, negotiating the flow and priority of the operating list is based on a complex set of interactions among various key team members.
Unplanned (urgent or semi-urgent) surgery presents the surgical team with competing individual and organisational challenges, especially when there is an increasing queue of patients requiring surgery (Lum & Fitzgerald, 2007). Prioritisation involves clinical assessment and a process for deciding the order of patients and competing teams. Negotiations surrounding these clinical issues may be inherently problematic as surgical emergencies present contemporaneously. Often, determining surgical priority ultimately rests with the surgeon, who liaises with the anaesthetist. However, there may be occasions when disagreement arises between these two professional groups based on competing priorities. Barriers to communication occur when there is an absence of, or ineffective, communication, differing perceptions about the same event, or when there is a lack of leadership. Collectively, this situation is problematic not only for those team members from different disciplines, but also for those from the same discipline.
This chapter introduced the beginning perioperative nurse to the key concepts used in perioperative nursing. The chapter addressed issues related to the history and philosophy of perioperative nursing, and the concept of cultural safety, which guides appropriate and sensitive patient care. A discussion of nursing roles within the perioperative specialty was presented. Additionally, issues that are fundamental to understanding the context and culture that frames the perioperative nurses’ socialisation into professional roles were identified and explored. Specifically, specialty knowledge, social organisation, teamwork and the caring versus technical role have defined operating room culture. Moreover, safe patient care depends on the ways in which team members communicate with each other.
The perioperative role allows operating room nurses to extend their influence beyond the technical duties of the operating room.
The operating room represents the epitome of teamwork. When members become part of the perioperative team, many dimensions of group dynamics come into play and members’ behaviours are often influenced by the situation and the ways in which information is exchanged.
You are a new graduate working in the orthopaedic trauma operating room. You have been asked to scrub for a right knee washout and debridement. During the procedure, the surgeon asks you to take a “sprinkler system” onto your set-up. You are feeling a little out of your depth because you are unfamiliar with this term of speech.
It is 10.30 pm and Dr Smith, an orthopaedic surgeon, has been waiting in the operating room department to perform an open reduction and internal fixation of a fractured hip. Unfortunately, there are three other patients requiring emergency surgery who are considered by the anaesthetist as “more urgent” by the anaesthetist. Dr Smith approaches you—he is angry at being kept waiting and insists that another operating room be opened to allow him to perform the procedure.
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