AORN education
How can we do audits when we're so harried? The operating room staff in my hospital is so busy trying to survive the day-to-day activities that they resent the mention of doing such things as preoperative visits. peer review, and patient care audit. The supervisors lament usually ends in questions such as, How will I convince them? Where do we find time? Why are they so resistant? Is all this really necessary? As a staff member at AORN, I understand these statements and questions. They are valid and have been of great concern to me. I realize from my own experience as a staff nurse and supervisor that in many situations, it takes all our time to do the routine, wellestablished duties and functions that require expertise in aseptic technique. This cannot be negated because it is an important component of our work in terms of patient safety. An added burden is created when demands are put on us to implement pre and postoperative visits, formulate OR nursing care plans, develop standards of practice, initiate peer review, and evaluate patient care. These components of patient care also cannot be negated, and outside pressures cause us to become anxious and exasperated. As an operating room supervisor, I have experienced the typical day in your life. It starts with one or two of the staff calling in ill. Personnel are rescheduled and sometimes
@
you schedule yourself to cover. Then, the C-section that can't wait disrupts the schedule and fouls up lunch relief. The cranial drill shorts out in the middle of a craniotomy. The maintenance man comes roaring into the department in his street clothes to fix the autoclave. The students' instructor needs to coordinate the activities of the new students. Finally, a patient in recovery room goes into shock. Your response may be, "That supervisor isn't a very good manager," or you may be more honest and add another hundred things that happen in a typical day. The day ends and somehow we manage to survive, but I would wager that it is only by luck. For a staff nurse, a typical day in the operating room is scrubbing or circulating. In many operating rooms, this encompasses pulling instruments, supplies, and equipment. The emergency C-section necessitates pulling additional instruments, packs and supplies, calling of preops, and notifying personnel of changes in schedule. After the cases are completed, the room must be cleaned and stocked. Teaching and orienting new personnel takes time. Other assigned duties may include such things as inventotying stock, pulling cases for tomorrow, ordering routine supplies, refilling solutions, doing pharmacy requisitions and, finally, trying to be nice to teammates and help them. Suddenly, the day is gone. Then someone comes along and says, "Wouldn't you like to start doing preoperative visits?" "No way," respond the harried staff nurses. Is it realistic to expect nurses to be
873
interested or even motivated to do preoperative visits or anything else when the time is taken up doing tasks? If we expect OR nurses to do preoperative visits and nursing audit, we are going to have to plan these functions into the work day. Nurses should not be expected to do these on their own time. I sometimes wonder, “Are registered nurses in the operating room allowed to function as professional nurses? Do they want to? Given the opportunity, will they?” It is time operating room nurses think and act like nurse practitioners who work in the operating room setting. Do we believe that only the world about us changes and not our little world inside the OR? The practice of nursing is undergoing changes that present each of us with a challenge. Can we cope? Or are we ignoring it? It is time for us to discover that the old must be laid aside and the new tried and its validity tested. One of the newest developments in the health care field that has been forced on the operating room nurse is the patient care audit. Demands for evaluating care to determine quality have been imposed by the consumer. Courts increasingly are calling for accountability. Federal legislation has been enacted because of the billions of dollars spent on health care. Finally the profession’s own inherent need for self-regulation is a factor. An operating room nurse may ask herself, “How do I cope with this one change that I see as beneficial to patients but difficult to implement?” First, let us look at what nurses are doing and how we can delegate nonnursing functions to the paraprofessional. This may mean updating job descriptions, changes in philosophy, and writing new policies. It will have an impact on the budget in terms of numbers of professional and nonprofessional staff. This may even create problems in terms of cost control versus quality. Let’s take a look at some of the pros and cons of evaluating patient care. Auditing may assist in identifying strengths and weaknesses in the areas of aseptic technique, patient safety, and the ecosystem. It will force the staff to focus on the patient, which in turn may provide an incentive for more consistent care. You will be able to identify roles and
814
functions of different levels of personnel. Teaching needs will be identified and team work promoted. Communication will be improved both intra and interdepartmentally. Opposition to audit patient care may be the time it will take not only to implement the audit, but also to prepare staff through inservice and staff development programs. There is resistance to change because it is threatening when we are not sure how it will affect us. For example, we may find that persons other than registered nurses can provide the care we think only we can give. Recently, I heard a comment that auditing caused operating room nurses to have “nervous paranoia.” Auditing will also challenge our nursing knowledge and technique. To evaluate the care given in the operating room, it is essential to provide that care. Therefore, it will be imperative to utilize the nursing process and formulate a plan of care for each patient. This includes seeing the patient preoperatively. It has been found that the more we know about the patient before he comes to surgery, the more efficient and effective we are in providing care. By preplanning, we could eliminate some of the disorganization arising from the long delay because transportation of a 350-pound patient was not anticipated and planned, instruments of proper size and length were not sterilized, and the genitourinary surgeon comes unexpectedly to insert ureteral catheters. Other factors the OR nurse learns during a preoperative visit that are important to patient care in the OR are allergies, limitations in mobility, and the emotional state of the patient before preoperative medication. Nurse practitioners in the operating room, as other nurses, are the patient’s advocate. We have an obligation to the surgical patient who is removed from the personal contact of his family and friends and put into one of the most alien environments he has ever known. We must accept the fact that change is inevitable and that in the health care field professionals are being forced to reexamine their roles and reassess their contributions to patient care. Are you and I exceptions?
Julie Kneedler, RN, MS Assistant director of education
AORN Journal, Decemher 1975, Vol 22, N o 6
How can we do audits when we're so harried? The operating room staff in my hospital is so busy trying to survive the day-to-day activities that they resent the mention of doing such things as preoperative visits. peer review, and patient care audit. The supervisors lament usually ends in questions such as, How will I convince them? Where do we find time? Why are they so resistant? Is all this really necessary? As a staff member at AORN, I understand these statements and questions. They are valid and have been of great concern to me. I realize from my own experience as a staff nurse and supervisor that in many situations, it takes all our time to do the routine, wellestablished duties and functions that require expertise in aseptic technique. This cannot be negated because it is an important component of our work in terms of patient safety. An added burden is created when demands are put on us to implement pre and postoperative visits, formulate OR nursing care plans, develop standards of practice, initiate peer review, and evaluate patient care. These components of patient care also cannot be negated, and outside pressures cause us to become anxious and exasperated. As an operating room supervisor, I have experienced the typical day in your life. It starts with one or two of the staff calling in ill. Personnel are rescheduled and sometimes
@
you schedule yourself to cover. Then, the C-section that can't wait disrupts the schedule and fouls up lunch relief. The cranial drill shorts out in the middle of a craniotomy. The maintenance man comes roaring into the department in his street clothes to fix the autoclave. The students' instructor needs to coordinate the activities of the new students. Finally, a patient in recovery room goes into shock. Your response may be, "That supervisor isn't a very good manager," or you may be more honest and add another hundred things that happen in a typical day. The day ends and somehow we manage to survive, but I would wager that it is only by luck. For a staff nurse, a typical day in the operating room is scrubbing or circulating. In many operating rooms, this encompasses pulling instruments, supplies, and equipment. The emergency C-section necessitates pulling additional instruments, packs and supplies, calling of preops, and notifying personnel of changes in schedule. After the cases are completed, the room must be cleaned and stocked. Teaching and orienting new personnel takes time. Other assigned duties may include such things as inventotying stock, pulling cases for tomorrow, ordering routine supplies, refilling solutions, doing pharmacy requisitions and, finally, trying to be nice to teammates and help them. Suddenly, the day is gone. Then someone comes along and says, "Wouldn't you like to start doing preoperative visits?" "No way," respond the harried staff nurses. Is it realistic to expect nurses to be
873
interested or even motivated to do preoperative visits or anything else when the time is taken up doing tasks? If we expect OR nurses to do preoperative visits and nursing audit, we are going to have to plan these functions into the work day. Nurses should not be expected to do these on their own time. I sometimes wonder, “Are registered nurses in the operating room allowed to function as professional nurses? Do they want to? Given the opportunity, will they?” It is time operating room nurses think and act like nurse practitioners who work in the operating room setting. Do we believe that only the world about us changes and not our little world inside the OR? The practice of nursing is undergoing changes that present each of us with a challenge. Can we cope? Or are we ignoring it? It is time for us to discover that the old must be laid aside and the new tried and its validity tested. One of the newest developments in the health care field that has been forced on the operating room nurse is the patient care audit. Demands for evaluating care to determine quality have been imposed by the consumer. Courts increasingly are calling for accountability. Federal legislation has been enacted because of the billions of dollars spent on health care. Finally the profession’s own inherent need for self-regulation is a factor. An operating room nurse may ask herself, “How do I cope with this one change that I see as beneficial to patients but difficult to implement?” First, let us look at what nurses are doing and how we can delegate nonnursing functions to the paraprofessional. This may mean updating job descriptions, changes in philosophy, and writing new policies. It will have an impact on the budget in terms of numbers of professional and nonprofessional staff. This may even create problems in terms of cost control versus quality. Let’s take a look at some of the pros and cons of evaluating patient care. Auditing may assist in identifying strengths and weaknesses in the areas of aseptic technique, patient safety, and the ecosystem. It will force the staff to focus on the patient, which in turn may provide an incentive for more consistent care. You will be able to identify roles and
814
functions of different levels of personnel. Teaching needs will be identified and team work promoted. Communication will be improved both intra and interdepartmentally. Opposition to audit patient care may be the time it will take not only to implement the audit, but also to prepare staff through inservice and staff development programs. There is resistance to change because it is threatening when we are not sure how it will affect us. For example, we may find that persons other than registered nurses can provide the care we think only we can give. Recently, I heard a comment that auditing caused operating room nurses to have “nervous paranoia.” Auditing will also challenge our nursing knowledge and technique. To evaluate the care given in the operating room, it is essential to provide that care. Therefore, it will be imperative to utilize the nursing process and formulate a plan of care for each patient. This includes seeing the patient preoperatively. It has been found that the more we know about the patient before he comes to surgery, the more efficient and effective we are in providing care. By preplanning, we could eliminate some of the disorganization arising from the long delay because transportation of a 350-pound patient was not anticipated and planned, instruments of proper size and length were not sterilized, and the genitourinary surgeon comes unexpectedly to insert ureteral catheters. Other factors the OR nurse learns during a preoperative visit that are important to patient care in the OR are allergies, limitations in mobility, and the emotional state of the patient before preoperative medication. Nurse practitioners in the operating room, as other nurses, are the patient’s advocate. We have an obligation to the surgical patient who is removed from the personal contact of his family and friends and put into one of the most alien environments he has ever known. We must accept the fact that change is inevitable and that in the health care field professionals are being forced to reexamine their roles and reassess their contributions to patient care. Are you and I exceptions?
Julie Kneedler, RN, MS Assistant director of education
AORN Journal, Decemher 1975, Vol 22, N o 6
