JANUARY 1990, VOL 51, NO I
Opinion Is professional nursing in the operating room ?
o speculate credibly about the future of operating room nursing, nurse leaders must confront their stereotypical beliefs about operating room nurses. They must balance biases with an objective appraisal of the operating room nurse’s true presence in the larger nursing community. In this respect, it is helpful to reflect on health care issues that are important to nursing in general before concentrating on operating room nursing as a specialty. Four issues are having a profound effect on nursing and should capture the attention of operating room nurses. Those issues are: the levels and scope of nursing practice, a changing health care culture that is more consumer-oriented, the education and supply of health practitioners, and increasing emphasis on cost containment. One issue that poses a threat to the future viability of operating room nursing is the professional/technical debate. Arguments over boundaries and levels of practice are not isolated in operating room nursing; they are germane to the entire nursing community. Technical practice in any discipline is narrow in scope, but has varying degrees of depth.l The scope of operating room nursing might be described as narrow-involving support of the sterile environment and facilitation of surgical procedures. The variety and complexity of those procedures and the technology related to them, however, is great. People might ask if operating room nursing is really professional nursing. Nursing: A Social Policy Statement, published by the American
Nurses’ Association, defines professional nursing as “the diagnosis and treatment of human responses to actual or potential health problems.”* That document also specifies that nurses share boundaries with other professionals. Nurses have some dependent medical functions, such as implementing physician prescriptions. Yet, the essence of nursing involves independent judgment and activity initiated by the nurse. The functions performed by an operating room nurse seem to be a direct extension of physician practice. Many activities performed by circulating and scrub nurses support the surgeon in performing a surgical procedure. Thus, it is somewhat ambiguous whether operating room nursing is a
Sandra R. Shelley, RN,DNSc, is vice president, nursing services, St Louis Children’sHospitaL She earned her bachelor of science degree in nursing from the University of Missouri, Columbia, her master of science degree in psychiatric nursing from Boston University, and her doctorate of nursing science from Rush University, Chicago.
AORN J O U R N A L
JANUARY 1990, VOL. 51, NO 1
The perioperative role allows OR nurses to extend their influence beyond the technical duties of the operating room. technical extension of the surgeon’s practice, or truly nursing practice as defined by the American Nurses’ Association. Another issue that affects the future of operating room nurses is their low visibility to patients. In most situations, patients have limited personal contact with operating room nurses. Thus, they have little or no opportunity to observe directly activities that operating room nurses perform. This lack of public visibility makes it particularly difficult for operating room nurses to define their unique role and services to consumers. It also makes it difficult for the public to appreciate the nurse’s role as essential to the operating room experience. Thus, it is difficult for the public to determine whether operating room nurses provide direct service to patients or to physicians, who in turn provide service to patients. The emergence of the perioperative role over the past several decades has been an interesting phenomenon in the evolution of operating room nursing. In concept, the perioperative role involves the operating room nurse in the immediate preoperative assessment of the patient, from the perspective of both physiological and psychosocial readiness for surgery. In addition to the traditional intraoperative responsibilities, the operating room nurse also is involved in postoperative assessment and interventions related to the patient’s postsurgical ~tabilization.~ Clearly, the perioperative role affords the operating room nurse an opportunity to extend his or her influence beyond the technical duties that are pervasive in the operating room. The perioperative role also engages the operating room nurse in more direct interaction with patients and their support networks. If the perioperative role enhances the visibility of operating room nurses and the sophistication and significance of their contributions to patients, why then, are nurses reluctant to fulfill this role? It would behoove operating room nurses to study 288
advantages and disadvantages of the perioperative role in reference to its impact on recruitment, retention, and distribution of services. A third issue confronting operating room nurses is the education and supply of practitioners. If one analyzes the situation from the perspective of the general systems theory, operating room nursing may be considered in a state of entropy. The needs of the system are met by greater use of existing resources rather than reliance on new sources of energy. The end result is system exhaustion-a state of entropy! For all practical purposes, nurses are not educated to be operating room nurses, at least not in schools of nursing. We are thus calling on existing pools of operating room nurses to meet an ever-increasing demand for their services. Considering the theory of entropy, the current system may be approaching exhaustion. It is paradoxical that education for general and specialized nurses has moved toward formal academic settings, while preparation of operating room nurses has shifted to on-the-job training. Presently, little or no content in operating room nursing can be found in contemporary nursing curricula. One might question if what nurses do in the operating room is generic to nursing practice, or idiosyncratic to a particular surgeon, piece of technology, or institution. If operating room nursing is specific to a setting, perhaps it is an occupational trade acquired by apprenticeship, rather than a professional discipline learned by scholarly pursuit and scientific inquiry. Or perhaps, the knowledge base of operating room nursing is so specialized that it is beyond the scope of generalist education and should occur at the post-baccalaureate level. Finally, the overwhelming majority of operating room nurses are hospital employees. The popular form of reimbursement for their services is a fixed hourly rate plus a system of differentials and bonuses. At best, this practice is cumbersome for
JANUARY 1990, VOL. 51, NO 1
the payroll department, human resources staff, and nursing personnel. It creates a piecemeal approach to the work at hand and supports a nonprofessional attitude, which in turn, makes it ultimately difficult to retain and recruit nurses. Rather than accepting hourly reimbursement, operating room nurses could explore independent contracts with institutions, and accept reimbursement on a capitative, per-case, or per-diem method. Although these methods of reimbursement involve more risk to the nurse, they provide more autonomy and greater potential for increased earning power. Professional groups that comprise today’s dynamic health care environment are constantly faced with opportunities and threats to their survival. It is easy to avoid issues that are controversial or conflict laden; however, the debate of such matters often reveals windows of opportunity. In that sense, the issues presenteb in this article are intended as a springboard for discussion. By being sensitive to, and proactive on, events that currently affect health care, operating room nurses can consolidate their future position in the health care industry. SANDRA R. SHELLEY. RN Notes 1. M L Montag, “Looking back Associate degree education in perspective,” Nursing Outlook 28 (April 1980) 248-250. 2. American Nurses’ Association, Nursing: A Social Policy Statement (Kansas City, Mo: American Nurses’ Association, 1980) 9. 3. AORN Standards and Recommended Practicesfor Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1989). 4. A M Putt, General Systems Theory Applied to Nursing, (Boston: Little, Brown, and Co, 1978).
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