William B Long 111, MD
Can OR nurses reverse role erosion?
There are disturbing trends in surgical education in this country. Perhaps in response to an alleged plethora of surgeons, many medical schools have devalued the surgical experience by making surgery and its subspecialties elective subjects in the medical school curriculum. Today, medical schools are producing a generation of physicians unfamiliar with and unknowledgeable in many basic principles and current advances in surgery. Medical postgraduate education does little to correct these deficits, and many patients suffer needlessly for want of an informed opinion from a nonsurgeon about the risks and benefits of surgical intervention. Specialization too early in life often leads to an ignorance of related fields of study. Nursing education is following a similar but slightly different pattern.
William B Long 111, MD, is director of emergency medical service, Fallston General Hospital, Baltimore, and a general surgeon, Baltimore. He is a graduate of Brown University, Providence, RI, and the University of Maryland Medical School, Baltimore. He presented this paper at the 1977 AORN Congress program, “Film, ‘Update-OR nursing .’” 390
The focus of nursing has shifted from task orientation of the diploma school toward university training in psychological support and concern for the patient’s social as well as physical needs. Emphasis is now on the nursepatient relationship rather than on nursing skills. In fact, nursing technical skills have been deemphasized. Nowhere has this been more obvious than in operating room nursing. Since the late 1940s, the trend has been toward complete elimination of the operating room experience from the nursing school curriculum. The shortage of OR nurses during and immediately after World War I1 and the return of well-trained corpsmen from the war theaters perhaps demonstrated that nonprofessionals perform adequately in the operating room setting. This observation led some nursing educators to conclude that operating room nursing is technically oriented,’ lacks a nurse-patient relationship,* and is nona~ademic.~ Although technicians in the operating room have been increasingly accepted by the surgical and nursing professions, many technicians are not properly trained to assume a wider re~ponsibility.~ While there are exceptions to the rule, the evolution of surgery to a highly specialized science
AORN Journal, August 1977, Vol26, No 2
has caused such specialization that many OR nurses and technicians are unable or unwilling to perform outside their narrow experience. In some ways, the rigidity of the job description for nonprofessional paramedical personnel seems to have permeated the thinking of OR nursing, and few operating room nurses are willing to exceed or expand their nursing horizons. What is happening to nursing in general? As the pendulum of nursing educational goals has swung from task orientation to the psychosocial nursepatient relationship, a horde of paramedics has rushed in t o fill the vacuum of specialized hospital care involving highly technical skills disdained and abandoned by nurses. With ever-increasing frequency, these paramedical personnel are performing traditional nursing and other skills that could have been acquired by nursing had it been more interested and more willing. Community colleges are producing graduates of health care technology with associate of arts or associate of science degrees who are saturating hospital staffs and demanding a bigger role in health care. Trained by physicians and paraprofessionals, they are hired by the hospital and supervised by physicians. Nursing has had very little input into their development, education, training, and hospital duties. What is nursing and what is the nurse’s role in this rapidly changing hospital setting? What will be left for the nurse to do? She is losing the role of team leader and is becoming a patient coordinator directing the secretaries, nurse’s aides, and technicians as they perform specialized skills at the bedside. As a surgeon, I am saddened to see
392
How little has changed Specialism in Society, then, is, we think, one cause of our present state. Specialism in study is another. We doubt whether this has ever been a good thing since the world began; but we are sure it is much worse now than it was. Formerly, when a man became a specialist, it was out of affection for his subject. . . . Nowadays it is quite different. Our pendantry wants even the saving clause of Enthusiasm . . . . Knowledge is now too broad a field for your Jack-Of-All-Trades; and, from beautifully utilitarian reasons, he (the student) makes his choice, draws his pen through a dozen branches of study, and beholbJohn the Specialist. That this is the way to be wealthy we shall not deny; but we hold that it is not the way to be healthy or wise. The whole mind becomes narrowed and circumscribed to one punctual spot of knowledge. A rank unhealthy soil breeds a harvest of prejudices. Feeling himself above others in his one little branch-in the classification of toadstools, or Carthaginian history-he waxes great in his own eyes and looks down on others. Having all his sympathies educated in one way, they die out in every other; and h e is apt to remain a peevish, narrow, and intolerant bigot . . . . We wish our students to abandon no subject until they have seen and felt its merit-to act under a general interest in all branches of knowledge, not a commercial eagerness to excel in one. From “The modern student considered generally,”an essay by Robert Louis Stevenson, printed in 1879 this trend develop. The patientphysician relationship is intimate yet objective, oriented toward the better welfare of the patient, and enhanced by the laying on of hands, ie, doing something for the patient with your own hands. That physical contact and the human concern that goes with it relieve patient anxiety and establish a
AORN Journal, August 1977, Vol26, No 2
rapport that helps carry many critically ill patients to recovery. As a rule, the more people acting as intermediaries between the patient and his physician and the patient and his nurse, the less rewarding the relationship for the patient. It is, therefore, with a sense of bewilderment that I see nursing allowing paraprofessionals to interpose themselves between the patient and the nurse. Only in the coronary care units are nurses learning and applying the technical skills that are a necessary part of nursing care. Three basic problems confront OR nursing today: 0 the devaluation of the OR experience in nursing education 0 the specter of the paramedictechnician and its implications on nursing care 0 the operating room nurse’s future role in health care. If not corrected, the first two problems will sound the death knell for OR nursing-to the detriment of medicine and nursing alike. The last problem depends on you, your pride, and your ambitions for your profession. If the OR experience is not returned in full to the nursing school curriculum, future recruiting efforts for high-quality nursing school graduates for operating rooms will be compromised by a lack of student exposure. More ominously, future nursing colleagues outside the operating room will be ignorant of the operating room milieu. While many technicians perform their jobs well, I question the depth of education and training by many technical programs across the country. I feel technicians are severely limited and inflexible outside their narrow range of expertise. Like other paraprofessionals, they will become unionized and act as a force in hospital care 394
policy for which neither nursing nor medicine is prepared. If the current trend of medical and nursing education is directed toward primary care, then the pendulum may swing away from super and overspecialization to plumb center, ie, comprehensive care by well-educated physicians and well-educated nurses. Operating room nursing demands more knowledge and more skills than any other branch of nursing. An operating room is the ultimate intensive care unit. If one believes the adage that no patient is too ill to receive a n anesthetic, then any patient in any ICU is a potential surgical patient. The operating room nurse not only is responsible for arranging the operating room for the planned surgery, but must plan for recreating the intensive care unit environment from which the patient may come. This requires a preoperative visit to assess the patient’s physical and psychological needs, the metabolic and hemodynamic status of the patient, and what monitoring will be required. This involves reading and understanding the chart and interviewing the nurse in charge of the patient. Anticipation of and adequate preparation for a patient’s arrival in the operating room should be hallmarks of preoperative nursing care. Troubleshooting a monitor or a respirator should be a part of the operating room nurse’s repertoire. Too often, OR nurses rely on physicians for preparing anesthesia and monitoring equipment in the operating room. If nursing is concerned about patient welfare and feels responsible for the operating room, every piece of equipment in that room should be checked prior to the patient’s arrival. If not, technicians will be assigned those tasks.
AORN Journal, August 1977. Val 26. N o 2
Intraoperative nursing care demands a vigilant eye on the surgeons as well as the anesthesiologists. Nurses in teaching institutions must be particularly alert because many physicians are not unfamiliar with the equipment. No postoperative nursing care plan is complete without a detailed discussion with the recovery room nurse on the operative problems and special needs of the patient. The film, "Update-OR nursing," stresses the need for the operating room nurse to venture beyond the OR doors preoperatively to provide better intraoperative nursing care. The operating room nurse must be knowledgeable about the patient's preoperative physical and mental status to provide the proper environment in the operating room when the patient is anesthetized and totally dependent on the OR medical and nursng staff. Postoperatively, nursing colleagues outside the operating room need to know what the surgical team has done for the patient. With this knowledge, they can take better care of the patient. The problems exist, the threats are there, the trends are apparent. It is up to nurses, especially operating room nurses, to decide whether the nurse will stand with the physician at the bedside and the operating room table or look over the shoulders of the crowd 0 rushing in to take her place. Notes 1. Barbara J Gruendemann, "Operating room in the basic curriculum: An opinion," Nursing Outlook 18 (January 1970) 44; Jerry G Peers, "The frightening gap in the operating room," AORN Journal 17 (April 1973) 192-196. 2. Frances Ginsberg, "The attitudes of nursing educators contribute to OR nurse shortage," Modern Hospitel 108 (January 1967) 102. 3. Jeanne Riddle, "Baccalaureate education of nurses vs OR experience," AORN Journal 3 (September-October 1965) 79. 4. Janet Fitzwater, "It's time for a return to OR experience," RN 36 (March 1973) 45.
396
Pediatric nurse practitioners certified The National Board of Pediatric Nurse Practitioners and Associates has certified 823 pediatric nurse practitioners and associates. The National Qualification Examination for Pediatric Nurse Practitioners and Associates was given for the first time in February to 958 pediatric nurse practitioners and associates at 27 sites in the United States, Europe, and Central America. The voluntary, one-day written examination evaluated the entry level competency of those taking the test. The examination was developed with the assistance of the National Board of Medical Examiners. The next examination will be offered in April 1978. Inquiries should be directed to Mary Kaye Willian, executive director, National Board of Pediatric Nurse Practitioners and Associates, PO Box 1034, Evanston, 111 60204.
ANA division head on Carter commission Martha Louise Mitchell, RN, MSN, chairperson of the American Nurses' Association Division of Psychiatric and Mental Health Nursing Practice, has been named to President Carter's Commission on Mental Health. She is the only nurse to serve on the new commission. Mitchell is assistant professor of psychiatric nursing at Yale University School of Nursing, New Haven, Conn, and associate director of nursing at the Connecticut Mental Health Center in New Haven. The 20-member commission, composed of psychiatric specialists and lay persons, is charged with researching and identifying the nation's mental health needs and estimating the costs for implementing them. First Lady Rosalynn Carter is honorary chairperson. The President has asked the commission for a preliminary report of its recommendations by Sept 1 and a final report on April 1, 1978.
AORN Journal, August 1977, V o l 2 6 , No 2
Can OR nurses reverse role erosion?
There are disturbing trends in surgical education in this country. Perhaps in response to an alleged plethora of surgeons, many medical schools have devalued the surgical experience by making surgery and its subspecialties elective subjects in the medical school curriculum. Today, medical schools are producing a generation of physicians unfamiliar with and unknowledgeable in many basic principles and current advances in surgery. Medical postgraduate education does little to correct these deficits, and many patients suffer needlessly for want of an informed opinion from a nonsurgeon about the risks and benefits of surgical intervention. Specialization too early in life often leads to an ignorance of related fields of study. Nursing education is following a similar but slightly different pattern.
William B Long 111, MD, is director of emergency medical service, Fallston General Hospital, Baltimore, and a general surgeon, Baltimore. He is a graduate of Brown University, Providence, RI, and the University of Maryland Medical School, Baltimore. He presented this paper at the 1977 AORN Congress program, “Film, ‘Update-OR nursing .’” 390
The focus of nursing has shifted from task orientation of the diploma school toward university training in psychological support and concern for the patient’s social as well as physical needs. Emphasis is now on the nursepatient relationship rather than on nursing skills. In fact, nursing technical skills have been deemphasized. Nowhere has this been more obvious than in operating room nursing. Since the late 1940s, the trend has been toward complete elimination of the operating room experience from the nursing school curriculum. The shortage of OR nurses during and immediately after World War I1 and the return of well-trained corpsmen from the war theaters perhaps demonstrated that nonprofessionals perform adequately in the operating room setting. This observation led some nursing educators to conclude that operating room nursing is technically oriented,’ lacks a nurse-patient relationship,* and is nona~ademic.~ Although technicians in the operating room have been increasingly accepted by the surgical and nursing professions, many technicians are not properly trained to assume a wider re~ponsibility.~ While there are exceptions to the rule, the evolution of surgery to a highly specialized science
AORN Journal, August 1977, Vol26, No 2
has caused such specialization that many OR nurses and technicians are unable or unwilling to perform outside their narrow experience. In some ways, the rigidity of the job description for nonprofessional paramedical personnel seems to have permeated the thinking of OR nursing, and few operating room nurses are willing to exceed or expand their nursing horizons. What is happening to nursing in general? As the pendulum of nursing educational goals has swung from task orientation to the psychosocial nursepatient relationship, a horde of paramedics has rushed in t o fill the vacuum of specialized hospital care involving highly technical skills disdained and abandoned by nurses. With ever-increasing frequency, these paramedical personnel are performing traditional nursing and other skills that could have been acquired by nursing had it been more interested and more willing. Community colleges are producing graduates of health care technology with associate of arts or associate of science degrees who are saturating hospital staffs and demanding a bigger role in health care. Trained by physicians and paraprofessionals, they are hired by the hospital and supervised by physicians. Nursing has had very little input into their development, education, training, and hospital duties. What is nursing and what is the nurse’s role in this rapidly changing hospital setting? What will be left for the nurse to do? She is losing the role of team leader and is becoming a patient coordinator directing the secretaries, nurse’s aides, and technicians as they perform specialized skills at the bedside. As a surgeon, I am saddened to see
392
How little has changed Specialism in Society, then, is, we think, one cause of our present state. Specialism in study is another. We doubt whether this has ever been a good thing since the world began; but we are sure it is much worse now than it was. Formerly, when a man became a specialist, it was out of affection for his subject. . . . Nowadays it is quite different. Our pendantry wants even the saving clause of Enthusiasm . . . . Knowledge is now too broad a field for your Jack-Of-All-Trades; and, from beautifully utilitarian reasons, he (the student) makes his choice, draws his pen through a dozen branches of study, and beholbJohn the Specialist. That this is the way to be wealthy we shall not deny; but we hold that it is not the way to be healthy or wise. The whole mind becomes narrowed and circumscribed to one punctual spot of knowledge. A rank unhealthy soil breeds a harvest of prejudices. Feeling himself above others in his one little branch-in the classification of toadstools, or Carthaginian history-he waxes great in his own eyes and looks down on others. Having all his sympathies educated in one way, they die out in every other; and h e is apt to remain a peevish, narrow, and intolerant bigot . . . . We wish our students to abandon no subject until they have seen and felt its merit-to act under a general interest in all branches of knowledge, not a commercial eagerness to excel in one. From “The modern student considered generally,”an essay by Robert Louis Stevenson, printed in 1879 this trend develop. The patientphysician relationship is intimate yet objective, oriented toward the better welfare of the patient, and enhanced by the laying on of hands, ie, doing something for the patient with your own hands. That physical contact and the human concern that goes with it relieve patient anxiety and establish a
AORN Journal, August 1977, Vol26, No 2
rapport that helps carry many critically ill patients to recovery. As a rule, the more people acting as intermediaries between the patient and his physician and the patient and his nurse, the less rewarding the relationship for the patient. It is, therefore, with a sense of bewilderment that I see nursing allowing paraprofessionals to interpose themselves between the patient and the nurse. Only in the coronary care units are nurses learning and applying the technical skills that are a necessary part of nursing care. Three basic problems confront OR nursing today: 0 the devaluation of the OR experience in nursing education 0 the specter of the paramedictechnician and its implications on nursing care 0 the operating room nurse’s future role in health care. If not corrected, the first two problems will sound the death knell for OR nursing-to the detriment of medicine and nursing alike. The last problem depends on you, your pride, and your ambitions for your profession. If the OR experience is not returned in full to the nursing school curriculum, future recruiting efforts for high-quality nursing school graduates for operating rooms will be compromised by a lack of student exposure. More ominously, future nursing colleagues outside the operating room will be ignorant of the operating room milieu. While many technicians perform their jobs well, I question the depth of education and training by many technical programs across the country. I feel technicians are severely limited and inflexible outside their narrow range of expertise. Like other paraprofessionals, they will become unionized and act as a force in hospital care 394
policy for which neither nursing nor medicine is prepared. If the current trend of medical and nursing education is directed toward primary care, then the pendulum may swing away from super and overspecialization to plumb center, ie, comprehensive care by well-educated physicians and well-educated nurses. Operating room nursing demands more knowledge and more skills than any other branch of nursing. An operating room is the ultimate intensive care unit. If one believes the adage that no patient is too ill to receive a n anesthetic, then any patient in any ICU is a potential surgical patient. The operating room nurse not only is responsible for arranging the operating room for the planned surgery, but must plan for recreating the intensive care unit environment from which the patient may come. This requires a preoperative visit to assess the patient’s physical and psychological needs, the metabolic and hemodynamic status of the patient, and what monitoring will be required. This involves reading and understanding the chart and interviewing the nurse in charge of the patient. Anticipation of and adequate preparation for a patient’s arrival in the operating room should be hallmarks of preoperative nursing care. Troubleshooting a monitor or a respirator should be a part of the operating room nurse’s repertoire. Too often, OR nurses rely on physicians for preparing anesthesia and monitoring equipment in the operating room. If nursing is concerned about patient welfare and feels responsible for the operating room, every piece of equipment in that room should be checked prior to the patient’s arrival. If not, technicians will be assigned those tasks.
AORN Journal, August 1977. Val 26. N o 2
Intraoperative nursing care demands a vigilant eye on the surgeons as well as the anesthesiologists. Nurses in teaching institutions must be particularly alert because many physicians are not unfamiliar with the equipment. No postoperative nursing care plan is complete without a detailed discussion with the recovery room nurse on the operative problems and special needs of the patient. The film, "Update-OR nursing," stresses the need for the operating room nurse to venture beyond the OR doors preoperatively to provide better intraoperative nursing care. The operating room nurse must be knowledgeable about the patient's preoperative physical and mental status to provide the proper environment in the operating room when the patient is anesthetized and totally dependent on the OR medical and nursng staff. Postoperatively, nursing colleagues outside the operating room need to know what the surgical team has done for the patient. With this knowledge, they can take better care of the patient. The problems exist, the threats are there, the trends are apparent. It is up to nurses, especially operating room nurses, to decide whether the nurse will stand with the physician at the bedside and the operating room table or look over the shoulders of the crowd 0 rushing in to take her place. Notes 1. Barbara J Gruendemann, "Operating room in the basic curriculum: An opinion," Nursing Outlook 18 (January 1970) 44; Jerry G Peers, "The frightening gap in the operating room," AORN Journal 17 (April 1973) 192-196. 2. Frances Ginsberg, "The attitudes of nursing educators contribute to OR nurse shortage," Modern Hospitel 108 (January 1967) 102. 3. Jeanne Riddle, "Baccalaureate education of nurses vs OR experience," AORN Journal 3 (September-October 1965) 79. 4. Janet Fitzwater, "It's time for a return to OR experience," RN 36 (March 1973) 45.
396
Pediatric nurse practitioners certified The National Board of Pediatric Nurse Practitioners and Associates has certified 823 pediatric nurse practitioners and associates. The National Qualification Examination for Pediatric Nurse Practitioners and Associates was given for the first time in February to 958 pediatric nurse practitioners and associates at 27 sites in the United States, Europe, and Central America. The voluntary, one-day written examination evaluated the entry level competency of those taking the test. The examination was developed with the assistance of the National Board of Medical Examiners. The next examination will be offered in April 1978. Inquiries should be directed to Mary Kaye Willian, executive director, National Board of Pediatric Nurse Practitioners and Associates, PO Box 1034, Evanston, 111 60204.
ANA division head on Carter commission Martha Louise Mitchell, RN, MSN, chairperson of the American Nurses' Association Division of Psychiatric and Mental Health Nursing Practice, has been named to President Carter's Commission on Mental Health. She is the only nurse to serve on the new commission. Mitchell is assistant professor of psychiatric nursing at Yale University School of Nursing, New Haven, Conn, and associate director of nursing at the Connecticut Mental Health Center in New Haven. The 20-member commission, composed of psychiatric specialists and lay persons, is charged with researching and identifying the nation's mental health needs and estimating the costs for implementing them. First Lady Rosalynn Carter is honorary chairperson. The President has asked the commission for a preliminary report of its recommendations by Sept 1 and a final report on April 1, 1978.
AORN Journal, August 1977, V o l 2 6 , No 2
