Opinions
Should OR nurses act as first assistant? This is a new feature to stimulate members’ opinions on issues relating to nursing and health care. Each month we will ask several membersto respondto a specific question. This month’s question is: Should operating room nurses act as first assistants?At the 1977 Congress, the House of Delegates approved a study to consider the concept of including the function of the first assistant in the role of the nurse practitioner in the operating room. An AORN committee on Nursing Practice in the OR, chaired by Board member Claire Plourde, is conducting this study. What is your opinion? The Journal will welcome further comments on these subjects from readers.
“The OR nurse is the logical and most qualified professional to be first assistant.”
890
In the absence of a physician, the operating room registered nurse is the logical and most qualified professional to be first assistant to the surgeon. More and more OR personnelat all levels of training are serving with varying degrees of participation as first assistant to the surgeon. My concern at this point is that, with few exceptions, properly established, documented, and adequate education, training, and clinical preparation for this position are almost nonexistent. By refusing to assume the function of first assistant, we encourage the assignment of first assistant to personnel with lesser qualifications. Are OR registered nurses giving ultimateconsiderationto the welfare and safety of patients if, by relinquishing the task, they permit those with less preparation to become first assistants? Ideally, the first assistant should be a qualified surgeon or resident in an approved surgical training program. However, I am aware that regardless of any statutes and policies registered nurses, licensed practical nurses, operating room technicians, former military servicemen without documented training and OR experience, and others without any health care education are performing procedures at the operating table formerly assigned to the graduate physician, whose competency is considered second to that of the surgeon. Operating room registered nurses are on the brink of a decision that will not only have a far-reaching effect on
AORN Journal, November 1977, Vol26, No 5
“Our decision will have a far-reaching effect on intraoperative patient care.
”
“Taking a blood pressure reading was at one time the privileged duty of the physician.
”
intraoperative patient care but also will determine whether or not additional categories in the OR will once again fragment operating room personnel. Those of us already in this dilemma or under powerful pressures to provide first assistants lack the facilities and time to research the issue effectively,to develop standards, and to design a program for the preparation of the registered nurse as first assistant. As was apparent during delegate and general meetings at the 1977 AORN Congress, resistance to having the OR registered nurse function as first assistant came primarily from OR leaders and staff members involved in teaching institutions where surgical residents filled the role of first assistants. These people theorized that actions of the first assistant were not nursing. If we had always followed this premise, nursing would never have progressedbeyondthe patient’s morning bath and would never have included taking a blood pressure reading, which at one time was the hallowed and privileged duty of the physician. The decrease in the number of surgical residencies already is precluding attainment of the ideal first assistant, a qualified surgeon or resident in an approved surgical training program. James F Glenn, MD, and Kenneth M Endicott, MD, in a presentation to the panel on Health Planning in the UnitedStates at the October 1976 meeting of the American College of Surgeons, cited the Study on Surgical Services for the United States (SOSSUS), which proposed an optimal number of surgeons to be 50,000 to 60,000, plus 10,000 to 12,000 interns and residents. There would be a projected need for 1,600to 2,000new students each year. An American Medical Association survey indicates that there are now 93,000 surgeons. This suggests that there are perhaps too many surgeons. The current number of first-year residents in surgery is 5,899-three times more than the need calculated by SOSSUS. The recommended increase in primary care residencies will correspondingly decrease the number of surgeons, increasing the pressure on nurses to act as first assistants. If personnel other than the traditional, qualifiedphysician or surgical resident are to become first assistants, the obvious candidate is the operating room registered nurse. However, this should happen only following completion of established requirements for formal education, training, and experience under qualified supervision. Their growth and accomplishmentsshould be rewarded by appropriate, additional compensation. Those of us who are confronted by this problem urgently
Cb AORN Journal, November 1977, Vol26, No 5
891
“We urgently need the need the guidance of national AORN. My plea is for guidance of AORN. prompt, in-depth action relating to the diverse questions J J
that must be answered. Not only must the intraoperative care of patients be considered in the AORN study, but the difficult questions on behalf of the nurse must be answered and acted upon by AORN as soon as possible.
Anne S Hoffman, RN OR supervisor Waterbury Hospital Health Center Waterbury, Conn
If there are no available residents or interns, who should be first assistant-the registered professional nurse with several years of experience, or the operating room technician who, under the nurse practice act of that state, is not licensed to perform the duties? Many small hospitals and communities not connected with medical schools must make this decision every day. The registered professional nurse for too many years has let nursing care be delegated to paramedical personnel. Now that the question of first assistant faces OR nurses, do we sit back and let this again go to Ruth E Vaiden, RN paramedical personnel? Definitely not! We must assume the role as a continuation of good nursing care. One of the ultimate goals of OR nursing should be the best nursing care possible preoperatively, intraoperatively, and postoperatively. Just as scrub and circulating nurses provide good nursingcare when they assist the surgeon by anticipating his needs and by applying their skills and knowledge of surgery and surgical practice, the registered nurse as first assistant can give quality nursing care. Assuming the function of first assistant creates many new concerns. Consequently, we need to develop appropriate criteria. These could be developed by AORN, by individual states, or by hospitals and surgeons. There should be policies included in each hospital’s policy book concerning this role for nurses. Since many individuals have expressedconcern that the nurse is acting out of the realm of nursing practice, I quote from the Nurse Practice Act of Virginia to support my stand: Professional nursing means the performance for compensation of any act in the observation, care, and counsel of persons who are ill, injured or experiencing changes in normal health processes or the maintenance of health or prevention of illness of others; or in the couldbe developedby supervision and teaching of others who are or will be A 0 RN. ” involved in nursing care; or the administration of
894
AORN Journal, November 1977,Vol26, No 5
medicationsand treatments as prescribed by a licensed “Those of us in this role medical practitioner. Professional nursing requires should not be labeled specialized education, judgment and skill and is based ‘cheap labor’ or upon knowledge and application of principles from the ‘frustrated would-be biological, social and physical sciences. surgeons.’ Thus, the registered professionalnurse functioning as first ”
assistant is acting under the auspicesof the nurse practice act and is covered by her malpractice insurance as long as she is practicing within the realm of the act of her state. Since we owe our patients continuation of quality care, I believe we must assume the role of first assistant before it is delegated to others by default. All operating room nurses may not be suited or want to fill the role. However, those of us who are in this role and have been there for years should not be labeled “cheap labor” or “frustrated would-be surgeons” simply because we have accepted the challenge and responsibility of providing continuation of good nursing care for our surgical patients. We do not have a choice of whether or not to accept the role of first assistant. It is a must for us to accept the challenge and to expound on it. In this “Year of the Nurse,” we must start the uphill fight of giving operating room nursing back to the registered professional nurse. Ruth E Vaiden, RN Private neurosurgical nurse Richmond, Va
“I question if this is Nurses should not function as first assistant in the what nursing care is operating room. At first glance the idea of being first really all about. assistant seems to be role expansion and development, ”
but I feel this is an erroneous assumption. As first assistants, it is true that we would be able to see direct results of our intervention-a dry wound, a secure anastomosis. We would also be receiving primary feedback for a good job, not just a quick “thanks for your help” as the surgeon leaves or a yelp if something malfunctions.Our technical skills would be sharpened, our knowledge of anatomy reaffirmed, and our manual dexterity would increase. However, I question if this is what nursing care and function is really all about. To me, nursing involves more than technical skills and manual dexterity-it is the promotion to wellness. By this I mean the level of wellness the patient can obtain through physical care, emotional support, and sociological understanding. Wellness is promoted by the operating room nurse. This involves care of the surgical patient, not the surgical
& AORN Journal, November 1977,Vol26, No 5
895
“Role expansion for nurses should not be based On a physician-extender model-”
wound. Carrying out this intervention involves preoperative assessments and teaching, intraoperative advocacy, and postoperative evaluations. What nurse feels that he or she has enough time for all the components of nursing? In the rush to finish the schedule, does not nursing,even now, get skimmed over? Care is given to the patient, but is it complete and individualized? Is it the best care available? Physicians have a problem with the new regulations concerning surgical residencies. Nurses will also have a problem caused by this, but it is not our problem. We may feel that patients will suffer because of the physician’s problem, but they will suffer more if we neglect our own role. The patient will then be faced with a physician problem and a nurse problem. Role expansion for nurses should not be based on a physician-extender model. It should come only from nursing research and nursing care audits.
Mary E Hanson, RN North Carolina Memorial Hospital Durham, NC
In my opinion, good, experienced operating room nurses should act as first assistants. However, I feel they should undertake this task only after introductory training in assisting and that they work as an apprentice for a specific period of time. To be a first assistant takes time and experience. It is not just a matter of taking agood OR nurse and expecting him or her to do the job. The nurse as first assistant should know anatomy, understand the operative technique, know how to handle delicate tissue, and know the instruments and how to use them. He or she should know how to suture all tissue and Bonnie J Keegan, RN have practice suturing (under supervision). The nurse must learn to work with the surgeon in a rhythm that will enhance his skills, and he or she should be able to remain calm and in control during difficult situations. It is not a task that can be undertaken lightly and not everyonewill qualify for the position. The operating room nurse who has masteredthe roles of scrub nurse and circulating nurse will be able to meet the necessary criteria. The legal responsibility will need investigating and will probably depend on geographic area, hospital, and/or surgeon. As first assistants, nurses will have to be careful to remain within the boundaries of the job description. A qualify for the procedure should be established in the event a surgeon is position. ’’ unable to continue an operation.
898
AORN Journal, November 1977, Vol26, No 5
“lt takes not only mental strength but sometimes a great Of physical strength. ”
The graduate nurse is probably the only member of the present operative team (with the exception of another surgeon) who is qualified and has the appropriate skill and knowledge to be first assistant. The patient has a right to the best and that is a topnotch operating room nurse. I have been an assistant to a specialty surgeon for about five years (two years part time and three years full time), and I’m still learning. I have found it necessary to draw on my experience as an operating room nurse to handle some situations. I’mcareful not to overstep my job boundariesas a nurse assistant. I can suture and do other technical tasks but try hard to keep them within the described boundaries. I’m learning the art of handling tissue and must continually study anatomy. I find it necessary to do researchand study before many cases. I have found it takes not only mental strength but also sometimes a great deal of physical strength. I have not found it difficult working with other personnel (nurses and physicians), but this could be a problem. Bonnie J Keegan, RN Neurosurgical assistant Kankakee, Ill
’’
‘‘we have not a’ways accepted Our challenges With an open mind. ”
As operating room nurses, we are faced with another challenge to our role in the operating room-that of registered nurse as first assistant. In the past, we have not always accepted our challenges with an open mind, nor have we had concern for how our decisions may affect us nationally. The OR nurse’s role requires participation in the care of the surgical patient before, during, and after surgical intervention. This is done through preoperative visits, preparation of the operating room suite, functioning as the circulating nurse or scrub nurse, and visiting the patient postoperatively.Functioningin all of these areas allows the OR registered nurse the opportunity to properly evaluate and prepare a care plan for the patient undergoing a surgical procedure. The nurse learns to anticipate needs and makes care plans accordingly. He or she is alert to the possibility of complications and is prepared to meet these knowledgeably and with assurance. The OR nurse is a professional who recognizes his or her capabilities and limitations. It is because of these qualifications that I support the preparationof the registered nurse to function in an expanded role as first assistant in surgery. Another possibility is that a nurse practitioner fill the position of first assistant. In Virginia, for example, the role
d+ AORN Journal, November 1977,Vol26, No 5
899
“First assistant is viewed as an expanded role for RNs rather than a nurse practitioner’s function. ”
“We will need to prepare guidelines that encompass the necessary educational preparation.
”
of nurse practitioner, as described by the Joint Board of Medicine and Nursing, is specific as to educational preparation, range of responsibility, qualifications for certification, and standards for approval of nurse practitioner programs. A certified nurse practitioner is a registered nurse fully licensed in Virginia who has been certified by the State Boards of Medicine and Nursing to deliver primary health care in a particular clinical specialty in collaboration with and under the direction of a licensed physician. These persons are authorized to engage in activities that constitute the practice of medicine under specific described conditions. However, committees of the Joint Board have adopted the position that the registered nurse, not necessarily nurse practitioner, may serve as first assistant in surgery. This statement implies that the function of first assistant is viewed as an expanded role for registered nurses rather than a nurse practitioner’s function. In each state, much consideration should be given to whether the function of first assistant should be included with the role of nurse practitioner. I would advise OR nurses to review their state’s regulations governing the certification of nurse practitioners and then consider how placing the first assistant functions in this category would affect their own hospital’s working situations. In considering whether the first assistant should be a nurse practitioner, one should also consider how many OR nurses would have access to formal nurse practitioner programs if they wished to gain the necessary credentials. If you examine the needs of your particular hospital, Iam sure you will discover that the OR registered nurse is the logical individualto preparefor the role of the first assistant. There is no need to encourage the enlistment of yet another paramedical group in the operating room. As we enter into this new role, we will need to prepare guidelines that encompass the necessary educational preparation, to describe the actual functions and limitations, and to present documentation that the registered nurses who are assisting have been properly prepared. Until this role is endorsed by the state Board of Nursing, it is my opinion that each hospital that employs registered nurses as first assistants should prepare written policies under which the registered nurse may function safely and effectively. Throughout the history of nursing, we have been faced with challenges to our role as nurses. We have survived! We will only continue to grow if we are willing to accept
AORN Journal, November 1977, Vol26, No 5
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growth and development with eagerness and prepare ourselves accordingly. It is my hope that we all work together through proper communication and educational endeavors to reach the goal of another expanded role in operating room nursing, the first assistant.
Rita M Bishop, RN Director of Surgical Services Community Hospital of Roanoke Valley Roanoke, Va
“There is need
for a
postgraduate course and/or program for on-the-job training. ”
I believe nurses functioning as first assistants can not only meet the standards of nursing care for the surgical patient but perhaps even improve those standards. The reasons are several: 1. Because of the decreasing number of surgical residents, there is a growing need for nonphysicians to function as first assistants. Nurses are best qualified to fill this void by virtue of their basic nursing education. Nurses are professionals-that is, they govern themselves; this allows for the creation of controls and requirements specific for nurses functioning in this capacity. Not all nurses should function as first assistant anymore than all physicians should be surgeons. Therefore, it need not deplete the number of OR nurses. In addition, it may provide incentivefor those who wish more job challenge. 4. Nurses who wish to act as first assistant should do so only if they are willing to incorporate it into the total nursing process. This would include preoperative interviews and assessments, implementation of intraoperative nursing plans, and postoperative interviewswith evaluation of the nursingcare plan. At the present time a BS or higher degree should not be required because this might place unfair limits on those who have achieved specific skills and expertise conducive to proficient OR nursing, including first assistant to the surgeon. At the same time, there is a need to formulate a postgraduate course and/or program for on-the-job training, the latter especially for rural areas. AORN could meet this need. I recognize the inherent risks for nurse practitioners functioning as first assistants-especially malpractice-and I also recognize that the community must accept this new role and risk and appropriately recompense the nurse practitioner. Currently, some nurse
d-. 904
AORN Journal, November 1977, Vol26, No 5
“The result could be a more sophisticated approach to ‘he nursing process*
practitionersare employed by private surgeonsto function as first assistants and are thus covered by the surgeon’s malpractice insurance. Many nurses are afraid of this new role. They feel threatened when role structures are changed. However, nurse first assistants will not necessarily assume a “greater” role than the circulating or instrument nurse, but rather can become an integral part of the nursing process for the benefit of the patient. Of course there will be problems, but the end result could be a more sophisticated approach to the nursing process of the surgical patient by increasing the level of nursing care. In this question of first assistant, I support AORN President Nancy Ertl’s statement: “If we are not moving forward, we are not standing still but going backwards.” We can meet the challenge, and we can handle the responsibility involved.
Joan Koehler, RN Surgical nurse practitioner Phoenix. Ariz
We as nurses in the surgical suite should seek the role of first assistant. By taking charge of this new role, by molding and shaping it into nursingterms, we take full advantage of an opportunity to guide and control the future of our profession. In making this decision, we should lead rather than be ordered by the law and consumer into a role in which we have neither autonomy nor input. As nursing practitioners,we must respondwith the force of our convictions to opportunities that can improve the health care system of this country. We cannot let our profession continue to be buffeted and drawn hither and yon by outside forces. So far, we have been contented with less than our true Stephen F Husher, RN place among professional health care providers. The actual limitation of the law, which has been dictated by physicians,is severe in itself; but the most recent disgrace has been perpetrated by our peers. This is because we have refused to accept the challenge of the role of physician’sassistant.We now are placed in the position of debating the validity of orders written by questionably trained paraprofessionals whose performance lacks “we should take full formal regulation and certification. We must accept the challenge of this new role now; advantage Of an define it in nursing terms and knowledge requirements; opportunity to guide then implement it fully. We should act with the and control the future wholehearted commitment of true professionals and the of our profession. steely eyed determination of our forebearers. 908
AORN Journal, November 1977, Vol26, No 5
"We shall become total care providers and patient advocates perioperative """e practitioners.
We are called professionals,but can anyone define us in professional terms? I think not, for we remain salaried employees, relying on the beneficenceof both the hospital and physician. Our services are not contracted by the consumer as is true for physicians or lawyers. We talk of binding arbitration, unionization, right to strike for changes; yet in doing so we are furthering the employer-employee relationship that currently exists. The opportunity to be first assistant will, when developed beyond the initial technical phase, permit the nurse to provide additional professional care to clients before and after surgery. In providing nursing care on a client-practitioner basis, dealing directly with each person, nursing in the surgical suite will then no longer be locked into a primarily technical role. Instead, we shall become total care providers and patient advocates-perioperative nurse practitioners. The ideas presented in this article are those solely of the author and in no way reflect Air Force policy.
Stephen F Husher, RN Head nurse, Surgical Hand Service US Air Force San Antonio, Tex
Wi//iamsl
RN
Let's get back to the best possible patient care in the OR: an MD assistant, an RN scrub nurse, and an RN circulator! I believe there is a need to reemphasize the importance of quality care to the surgery patient in nursing education. There is no place for the less educated and trained personnel now being allowed to enter the surgical area. It seems to me we operating room nurses are concentrating more on what other groups such as OR technicians and physician'sassistants are doing or trying to do and less on giving the best care possible to the surgical patient by maintaining a staff of predominantly or all registered nurses. Although I support the mandate of a registered nurse as circulator, I believe she is less and less in the surgical field. Can you imagine the number of registered nurses who have never scrubbed? Should they become first assistants? If the registered nurse functions as first assistant, it will mean we are vulnerable to lawsuits and high insurance rates. Can you afford the premiums? Granted, there are some registered nurses who are technically as capable as some physicians, and perhaps even some after many years of experience have capabilities of judgment as good
d. AORN Journal, November 1977, Vol26, No 5
909
“ w e need to leave as some physicians. However, we are not legally licensed medical judgment to as physicians. Can you honestly say a registered nurse is capable of
surgeons‘” making a medical judgment as to whether to dissect four more inches of colon for a malignancy? Should she be put in a position of completing a cholecystectomy or a hip nailing should the surgeon have a coronary? Do you want to be operated on by a registered nurse? I feel we need to leave medical judgment to qualified surgeons. Put them in the position of policing their peers. Do not put an OR technician, who is not yet licensed and does not have the educational background, in this position. Do not put the physician’s assistant, who is not even recognized in some states, in this position. Let’s remain legal, concentrate on giving good patient care, cause no controversy that the attorneys will have to deal with, leave the responsibilities of medical judgment to the physicians, and get back to the ultimate-the best care possible for the patient!
Josie Williams, RN OR supervisor Campbell General Hospital Chattanooga, Tenn
INCREASE YOUR CHAPTER MEMBERSHIP Encourage other nurses to join AORN, to share experiences and to promote growth and achievement of every operating room nurse. Complete and return to: Membership Dept, AORN Headquarters, 10170 E Mississippi Ave, Denver, Colo 80231. The following nurses are qualified to join AORN and may be interested to know of the advantages of AORN membership.. Name
312
Address
City, State & Zip
AORN Journal, Nooernber 1977,V o l 2 6 , No 5
Should OR nurses act as first assistant? This is a new feature to stimulate members’ opinions on issues relating to nursing and health care. Each month we will ask several membersto respondto a specific question. This month’s question is: Should operating room nurses act as first assistants?At the 1977 Congress, the House of Delegates approved a study to consider the concept of including the function of the first assistant in the role of the nurse practitioner in the operating room. An AORN committee on Nursing Practice in the OR, chaired by Board member Claire Plourde, is conducting this study. What is your opinion? The Journal will welcome further comments on these subjects from readers.
“The OR nurse is the logical and most qualified professional to be first assistant.”
890
In the absence of a physician, the operating room registered nurse is the logical and most qualified professional to be first assistant to the surgeon. More and more OR personnelat all levels of training are serving with varying degrees of participation as first assistant to the surgeon. My concern at this point is that, with few exceptions, properly established, documented, and adequate education, training, and clinical preparation for this position are almost nonexistent. By refusing to assume the function of first assistant, we encourage the assignment of first assistant to personnel with lesser qualifications. Are OR registered nurses giving ultimateconsiderationto the welfare and safety of patients if, by relinquishing the task, they permit those with less preparation to become first assistants? Ideally, the first assistant should be a qualified surgeon or resident in an approved surgical training program. However, I am aware that regardless of any statutes and policies registered nurses, licensed practical nurses, operating room technicians, former military servicemen without documented training and OR experience, and others without any health care education are performing procedures at the operating table formerly assigned to the graduate physician, whose competency is considered second to that of the surgeon. Operating room registered nurses are on the brink of a decision that will not only have a far-reaching effect on
AORN Journal, November 1977, Vol26, No 5
“Our decision will have a far-reaching effect on intraoperative patient care.
”
“Taking a blood pressure reading was at one time the privileged duty of the physician.
”
intraoperative patient care but also will determine whether or not additional categories in the OR will once again fragment operating room personnel. Those of us already in this dilemma or under powerful pressures to provide first assistants lack the facilities and time to research the issue effectively,to develop standards, and to design a program for the preparation of the registered nurse as first assistant. As was apparent during delegate and general meetings at the 1977 AORN Congress, resistance to having the OR registered nurse function as first assistant came primarily from OR leaders and staff members involved in teaching institutions where surgical residents filled the role of first assistants. These people theorized that actions of the first assistant were not nursing. If we had always followed this premise, nursing would never have progressedbeyondthe patient’s morning bath and would never have included taking a blood pressure reading, which at one time was the hallowed and privileged duty of the physician. The decrease in the number of surgical residencies already is precluding attainment of the ideal first assistant, a qualified surgeon or resident in an approved surgical training program. James F Glenn, MD, and Kenneth M Endicott, MD, in a presentation to the panel on Health Planning in the UnitedStates at the October 1976 meeting of the American College of Surgeons, cited the Study on Surgical Services for the United States (SOSSUS), which proposed an optimal number of surgeons to be 50,000 to 60,000, plus 10,000 to 12,000 interns and residents. There would be a projected need for 1,600to 2,000new students each year. An American Medical Association survey indicates that there are now 93,000 surgeons. This suggests that there are perhaps too many surgeons. The current number of first-year residents in surgery is 5,899-three times more than the need calculated by SOSSUS. The recommended increase in primary care residencies will correspondingly decrease the number of surgeons, increasing the pressure on nurses to act as first assistants. If personnel other than the traditional, qualifiedphysician or surgical resident are to become first assistants, the obvious candidate is the operating room registered nurse. However, this should happen only following completion of established requirements for formal education, training, and experience under qualified supervision. Their growth and accomplishmentsshould be rewarded by appropriate, additional compensation. Those of us who are confronted by this problem urgently
Cb AORN Journal, November 1977, Vol26, No 5
891
“We urgently need the need the guidance of national AORN. My plea is for guidance of AORN. prompt, in-depth action relating to the diverse questions J J
that must be answered. Not only must the intraoperative care of patients be considered in the AORN study, but the difficult questions on behalf of the nurse must be answered and acted upon by AORN as soon as possible.
Anne S Hoffman, RN OR supervisor Waterbury Hospital Health Center Waterbury, Conn
If there are no available residents or interns, who should be first assistant-the registered professional nurse with several years of experience, or the operating room technician who, under the nurse practice act of that state, is not licensed to perform the duties? Many small hospitals and communities not connected with medical schools must make this decision every day. The registered professional nurse for too many years has let nursing care be delegated to paramedical personnel. Now that the question of first assistant faces OR nurses, do we sit back and let this again go to Ruth E Vaiden, RN paramedical personnel? Definitely not! We must assume the role as a continuation of good nursing care. One of the ultimate goals of OR nursing should be the best nursing care possible preoperatively, intraoperatively, and postoperatively. Just as scrub and circulating nurses provide good nursingcare when they assist the surgeon by anticipating his needs and by applying their skills and knowledge of surgery and surgical practice, the registered nurse as first assistant can give quality nursing care. Assuming the function of first assistant creates many new concerns. Consequently, we need to develop appropriate criteria. These could be developed by AORN, by individual states, or by hospitals and surgeons. There should be policies included in each hospital’s policy book concerning this role for nurses. Since many individuals have expressedconcern that the nurse is acting out of the realm of nursing practice, I quote from the Nurse Practice Act of Virginia to support my stand: Professional nursing means the performance for compensation of any act in the observation, care, and counsel of persons who are ill, injured or experiencing changes in normal health processes or the maintenance of health or prevention of illness of others; or in the couldbe developedby supervision and teaching of others who are or will be A 0 RN. ” involved in nursing care; or the administration of
894
AORN Journal, November 1977,Vol26, No 5
medicationsand treatments as prescribed by a licensed “Those of us in this role medical practitioner. Professional nursing requires should not be labeled specialized education, judgment and skill and is based ‘cheap labor’ or upon knowledge and application of principles from the ‘frustrated would-be biological, social and physical sciences. surgeons.’ Thus, the registered professionalnurse functioning as first ”
assistant is acting under the auspicesof the nurse practice act and is covered by her malpractice insurance as long as she is practicing within the realm of the act of her state. Since we owe our patients continuation of quality care, I believe we must assume the role of first assistant before it is delegated to others by default. All operating room nurses may not be suited or want to fill the role. However, those of us who are in this role and have been there for years should not be labeled “cheap labor” or “frustrated would-be surgeons” simply because we have accepted the challenge and responsibility of providing continuation of good nursing care for our surgical patients. We do not have a choice of whether or not to accept the role of first assistant. It is a must for us to accept the challenge and to expound on it. In this “Year of the Nurse,” we must start the uphill fight of giving operating room nursing back to the registered professional nurse. Ruth E Vaiden, RN Private neurosurgical nurse Richmond, Va
“I question if this is Nurses should not function as first assistant in the what nursing care is operating room. At first glance the idea of being first really all about. assistant seems to be role expansion and development, ”
but I feel this is an erroneous assumption. As first assistants, it is true that we would be able to see direct results of our intervention-a dry wound, a secure anastomosis. We would also be receiving primary feedback for a good job, not just a quick “thanks for your help” as the surgeon leaves or a yelp if something malfunctions.Our technical skills would be sharpened, our knowledge of anatomy reaffirmed, and our manual dexterity would increase. However, I question if this is what nursing care and function is really all about. To me, nursing involves more than technical skills and manual dexterity-it is the promotion to wellness. By this I mean the level of wellness the patient can obtain through physical care, emotional support, and sociological understanding. Wellness is promoted by the operating room nurse. This involves care of the surgical patient, not the surgical
& AORN Journal, November 1977,Vol26, No 5
895
“Role expansion for nurses should not be based On a physician-extender model-”
wound. Carrying out this intervention involves preoperative assessments and teaching, intraoperative advocacy, and postoperative evaluations. What nurse feels that he or she has enough time for all the components of nursing? In the rush to finish the schedule, does not nursing,even now, get skimmed over? Care is given to the patient, but is it complete and individualized? Is it the best care available? Physicians have a problem with the new regulations concerning surgical residencies. Nurses will also have a problem caused by this, but it is not our problem. We may feel that patients will suffer because of the physician’s problem, but they will suffer more if we neglect our own role. The patient will then be faced with a physician problem and a nurse problem. Role expansion for nurses should not be based on a physician-extender model. It should come only from nursing research and nursing care audits.
Mary E Hanson, RN North Carolina Memorial Hospital Durham, NC
In my opinion, good, experienced operating room nurses should act as first assistants. However, I feel they should undertake this task only after introductory training in assisting and that they work as an apprentice for a specific period of time. To be a first assistant takes time and experience. It is not just a matter of taking agood OR nurse and expecting him or her to do the job. The nurse as first assistant should know anatomy, understand the operative technique, know how to handle delicate tissue, and know the instruments and how to use them. He or she should know how to suture all tissue and Bonnie J Keegan, RN have practice suturing (under supervision). The nurse must learn to work with the surgeon in a rhythm that will enhance his skills, and he or she should be able to remain calm and in control during difficult situations. It is not a task that can be undertaken lightly and not everyonewill qualify for the position. The operating room nurse who has masteredthe roles of scrub nurse and circulating nurse will be able to meet the necessary criteria. The legal responsibility will need investigating and will probably depend on geographic area, hospital, and/or surgeon. As first assistants, nurses will have to be careful to remain within the boundaries of the job description. A qualify for the procedure should be established in the event a surgeon is position. ’’ unable to continue an operation.
898
AORN Journal, November 1977, Vol26, No 5
“lt takes not only mental strength but sometimes a great Of physical strength. ”
The graduate nurse is probably the only member of the present operative team (with the exception of another surgeon) who is qualified and has the appropriate skill and knowledge to be first assistant. The patient has a right to the best and that is a topnotch operating room nurse. I have been an assistant to a specialty surgeon for about five years (two years part time and three years full time), and I’m still learning. I have found it necessary to draw on my experience as an operating room nurse to handle some situations. I’mcareful not to overstep my job boundariesas a nurse assistant. I can suture and do other technical tasks but try hard to keep them within the described boundaries. I’m learning the art of handling tissue and must continually study anatomy. I find it necessary to do researchand study before many cases. I have found it takes not only mental strength but also sometimes a great deal of physical strength. I have not found it difficult working with other personnel (nurses and physicians), but this could be a problem. Bonnie J Keegan, RN Neurosurgical assistant Kankakee, Ill
’’
‘‘we have not a’ways accepted Our challenges With an open mind. ”
As operating room nurses, we are faced with another challenge to our role in the operating room-that of registered nurse as first assistant. In the past, we have not always accepted our challenges with an open mind, nor have we had concern for how our decisions may affect us nationally. The OR nurse’s role requires participation in the care of the surgical patient before, during, and after surgical intervention. This is done through preoperative visits, preparation of the operating room suite, functioning as the circulating nurse or scrub nurse, and visiting the patient postoperatively.Functioningin all of these areas allows the OR registered nurse the opportunity to properly evaluate and prepare a care plan for the patient undergoing a surgical procedure. The nurse learns to anticipate needs and makes care plans accordingly. He or she is alert to the possibility of complications and is prepared to meet these knowledgeably and with assurance. The OR nurse is a professional who recognizes his or her capabilities and limitations. It is because of these qualifications that I support the preparationof the registered nurse to function in an expanded role as first assistant in surgery. Another possibility is that a nurse practitioner fill the position of first assistant. In Virginia, for example, the role
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“First assistant is viewed as an expanded role for RNs rather than a nurse practitioner’s function. ”
“We will need to prepare guidelines that encompass the necessary educational preparation.
”
of nurse practitioner, as described by the Joint Board of Medicine and Nursing, is specific as to educational preparation, range of responsibility, qualifications for certification, and standards for approval of nurse practitioner programs. A certified nurse practitioner is a registered nurse fully licensed in Virginia who has been certified by the State Boards of Medicine and Nursing to deliver primary health care in a particular clinical specialty in collaboration with and under the direction of a licensed physician. These persons are authorized to engage in activities that constitute the practice of medicine under specific described conditions. However, committees of the Joint Board have adopted the position that the registered nurse, not necessarily nurse practitioner, may serve as first assistant in surgery. This statement implies that the function of first assistant is viewed as an expanded role for registered nurses rather than a nurse practitioner’s function. In each state, much consideration should be given to whether the function of first assistant should be included with the role of nurse practitioner. I would advise OR nurses to review their state’s regulations governing the certification of nurse practitioners and then consider how placing the first assistant functions in this category would affect their own hospital’s working situations. In considering whether the first assistant should be a nurse practitioner, one should also consider how many OR nurses would have access to formal nurse practitioner programs if they wished to gain the necessary credentials. If you examine the needs of your particular hospital, Iam sure you will discover that the OR registered nurse is the logical individualto preparefor the role of the first assistant. There is no need to encourage the enlistment of yet another paramedical group in the operating room. As we enter into this new role, we will need to prepare guidelines that encompass the necessary educational preparation, to describe the actual functions and limitations, and to present documentation that the registered nurses who are assisting have been properly prepared. Until this role is endorsed by the state Board of Nursing, it is my opinion that each hospital that employs registered nurses as first assistants should prepare written policies under which the registered nurse may function safely and effectively. Throughout the history of nursing, we have been faced with challenges to our role as nurses. We have survived! We will only continue to grow if we are willing to accept
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growth and development with eagerness and prepare ourselves accordingly. It is my hope that we all work together through proper communication and educational endeavors to reach the goal of another expanded role in operating room nursing, the first assistant.
Rita M Bishop, RN Director of Surgical Services Community Hospital of Roanoke Valley Roanoke, Va
“There is need
for a
postgraduate course and/or program for on-the-job training. ”
I believe nurses functioning as first assistants can not only meet the standards of nursing care for the surgical patient but perhaps even improve those standards. The reasons are several: 1. Because of the decreasing number of surgical residents, there is a growing need for nonphysicians to function as first assistants. Nurses are best qualified to fill this void by virtue of their basic nursing education. Nurses are professionals-that is, they govern themselves; this allows for the creation of controls and requirements specific for nurses functioning in this capacity. Not all nurses should function as first assistant anymore than all physicians should be surgeons. Therefore, it need not deplete the number of OR nurses. In addition, it may provide incentivefor those who wish more job challenge. 4. Nurses who wish to act as first assistant should do so only if they are willing to incorporate it into the total nursing process. This would include preoperative interviews and assessments, implementation of intraoperative nursing plans, and postoperative interviewswith evaluation of the nursingcare plan. At the present time a BS or higher degree should not be required because this might place unfair limits on those who have achieved specific skills and expertise conducive to proficient OR nursing, including first assistant to the surgeon. At the same time, there is a need to formulate a postgraduate course and/or program for on-the-job training, the latter especially for rural areas. AORN could meet this need. I recognize the inherent risks for nurse practitioners functioning as first assistants-especially malpractice-and I also recognize that the community must accept this new role and risk and appropriately recompense the nurse practitioner. Currently, some nurse
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“The result could be a more sophisticated approach to ‘he nursing process*
practitionersare employed by private surgeonsto function as first assistants and are thus covered by the surgeon’s malpractice insurance. Many nurses are afraid of this new role. They feel threatened when role structures are changed. However, nurse first assistants will not necessarily assume a “greater” role than the circulating or instrument nurse, but rather can become an integral part of the nursing process for the benefit of the patient. Of course there will be problems, but the end result could be a more sophisticated approach to the nursing process of the surgical patient by increasing the level of nursing care. In this question of first assistant, I support AORN President Nancy Ertl’s statement: “If we are not moving forward, we are not standing still but going backwards.” We can meet the challenge, and we can handle the responsibility involved.
Joan Koehler, RN Surgical nurse practitioner Phoenix. Ariz
We as nurses in the surgical suite should seek the role of first assistant. By taking charge of this new role, by molding and shaping it into nursingterms, we take full advantage of an opportunity to guide and control the future of our profession. In making this decision, we should lead rather than be ordered by the law and consumer into a role in which we have neither autonomy nor input. As nursing practitioners,we must respondwith the force of our convictions to opportunities that can improve the health care system of this country. We cannot let our profession continue to be buffeted and drawn hither and yon by outside forces. So far, we have been contented with less than our true Stephen F Husher, RN place among professional health care providers. The actual limitation of the law, which has been dictated by physicians,is severe in itself; but the most recent disgrace has been perpetrated by our peers. This is because we have refused to accept the challenge of the role of physician’sassistant.We now are placed in the position of debating the validity of orders written by questionably trained paraprofessionals whose performance lacks “we should take full formal regulation and certification. We must accept the challenge of this new role now; advantage Of an define it in nursing terms and knowledge requirements; opportunity to guide then implement it fully. We should act with the and control the future wholehearted commitment of true professionals and the of our profession. steely eyed determination of our forebearers. 908
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"We shall become total care providers and patient advocates perioperative """e practitioners.
We are called professionals,but can anyone define us in professional terms? I think not, for we remain salaried employees, relying on the beneficenceof both the hospital and physician. Our services are not contracted by the consumer as is true for physicians or lawyers. We talk of binding arbitration, unionization, right to strike for changes; yet in doing so we are furthering the employer-employee relationship that currently exists. The opportunity to be first assistant will, when developed beyond the initial technical phase, permit the nurse to provide additional professional care to clients before and after surgery. In providing nursing care on a client-practitioner basis, dealing directly with each person, nursing in the surgical suite will then no longer be locked into a primarily technical role. Instead, we shall become total care providers and patient advocates-perioperative nurse practitioners. The ideas presented in this article are those solely of the author and in no way reflect Air Force policy.
Stephen F Husher, RN Head nurse, Surgical Hand Service US Air Force San Antonio, Tex
Wi//iamsl
RN
Let's get back to the best possible patient care in the OR: an MD assistant, an RN scrub nurse, and an RN circulator! I believe there is a need to reemphasize the importance of quality care to the surgery patient in nursing education. There is no place for the less educated and trained personnel now being allowed to enter the surgical area. It seems to me we operating room nurses are concentrating more on what other groups such as OR technicians and physician'sassistants are doing or trying to do and less on giving the best care possible to the surgical patient by maintaining a staff of predominantly or all registered nurses. Although I support the mandate of a registered nurse as circulator, I believe she is less and less in the surgical field. Can you imagine the number of registered nurses who have never scrubbed? Should they become first assistants? If the registered nurse functions as first assistant, it will mean we are vulnerable to lawsuits and high insurance rates. Can you afford the premiums? Granted, there are some registered nurses who are technically as capable as some physicians, and perhaps even some after many years of experience have capabilities of judgment as good
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“ w e need to leave as some physicians. However, we are not legally licensed medical judgment to as physicians. Can you honestly say a registered nurse is capable of
surgeons‘” making a medical judgment as to whether to dissect four more inches of colon for a malignancy? Should she be put in a position of completing a cholecystectomy or a hip nailing should the surgeon have a coronary? Do you want to be operated on by a registered nurse? I feel we need to leave medical judgment to qualified surgeons. Put them in the position of policing their peers. Do not put an OR technician, who is not yet licensed and does not have the educational background, in this position. Do not put the physician’s assistant, who is not even recognized in some states, in this position. Let’s remain legal, concentrate on giving good patient care, cause no controversy that the attorneys will have to deal with, leave the responsibilities of medical judgment to the physicians, and get back to the ultimate-the best care possible for the patient!
Josie Williams, RN OR supervisor Campbell General Hospital Chattanooga, Tenn
INCREASE YOUR CHAPTER MEMBERSHIP Encourage other nurses to join AORN, to share experiences and to promote growth and achievement of every operating room nurse. Complete and return to: Membership Dept, AORN Headquarters, 10170 E Mississippi Ave, Denver, Colo 80231. The following nurses are qualified to join AORN and may be interested to know of the advantages of AORN membership.. Name
312
Address
City, State & Zip
AORN Journal, Nooernber 1977,V o l 2 6 , No 5
