RN in the OR?

[2bDocOc]

Question for the OR nurses. Keep in mind I'm not trying to start a flame war, I'm genuinely curious about this:

Why do we need a RN in the operating room? Most of the tasks (fetching for supplies, time-outs, advocating for patients) can be done by a LPN/Surg Tech. What makes the RN education applicable to the OR? Pre-op interviews comprise mostly of making sure documents are signed and whether the pt is NPO. I don't know any circulator that actually does a head-to-toe assessment during pre-op interview. As for med-passing, the anesthetist does that mostly. A lot of OR nurses I know are quite clueless regarding pharamcology.

I think nurses are fantastic and are much needed in health care, but I don't see why one has to go through 4 years of school to be an efficient OR nurse. Being a patient advocate requires compassion and common sense, and that's not specific to RNs.

Enlighten me. And again, I'm not trying to insult anybody. I may just be painfully ignorant as to what a circulator does. In that case, please convince me that what you learned in nursing school is actually useful in the OR?

[cdsga]

Wow: I appreciate your candor. I have been an ICU nurse, PACU nurse and OR nurse as well as home health and office nurse over my 35 year career. The OR is a place for a vast number of potentially fatal situations to occur. I can tell you as as a nurse not immediately trained in the OR, the other nursing skills, such as assessment are done by me every time I see the patient in the pre-op area or arriving immediately from the ER or ICU. You don't need a stethoscope to do the assessment that OR nurses need to do. Lord knows you have several other folks listening to their heart and lungs. OR nursing has a different skill set which includes, listening, touching, feeling, seeing, preparing-teaching, assessing fear, family dynamics, lack of friends and sig. others. Oh and the big thing, having your supplies ready, your equipment in good working order before the patient enters the room, and documenting properly. It takes a strong nurse to orchestrate all these things. You must think in a sequential way, expedite, limit steps, streamline, organize, to anticipate needs of your particular procedure. When crap hits the fan, it's the nurse that coordinates and reports all the information and corrective action. While I am sure that LPN's and ST's or robots could do the nurses job, they don't have that ability now. I'm glad, because I have seen over the years, it's the nurse who keeps people following policy and procedure. If the RN was not there, then doctors and anesthesia would rule the OR and cut many corners, and cause multiple injuries to the patient. Infections would soar and you would have all kinds of problems. One other thing, making the patient advocate role such a small thing, really tells me you don't know much about nursing and the true enormity of that two word explanation.

[Robbone]

You bring up a good point. I have been in the OR for almost 30 yrs. I started as a scrub tech but I felt I always THOUGHT like a nurse. So, I became one. As a tech, I didn't just focus on the sterile field, I would challenge myself by also thinking of the equipment, positioning devices, meds (back in those days you could just pull them off of the shelf) and even the paperwork (yes, we had paper back then). The less my nurse had to "fetch" the better I felt my performance was. However, NOTHING prepared me for the day I was the RN in the room and realized the buck stopped with me. All of a sudden I was accountable for everything and to everybody! While the rest of team was bantering back and forth, I had to FOCUS because the buck stopped here. Oh, I knew the nuts and bolts of preparing for a case, the procedures and even some of the staff but what about when there was a nick in the femoral artery during the case or a difficult intubation? My best answer to you is this: it's all fun and games 'till someone gets their eye poked out. By that I mean 99% of the time things go the way they are planned in surgery (with a few variables) BUT that 1% of the time when things go South and it gets......crazy where everybody is freaking out someone has to be the voice in the wilderness. That takes drawing on everything you've learned in college, your identity as a professional and as a patient advocate. As an RN you have a scope of practice independent of what the surgeon, scrub tech or anesthesia provider thinks your role is. That's how the law, as the nurse practice act in your state, views the RN role. It is no longer a legislative matter that the circulator in the OR be an RN but it has become the standard of care. If you have ever had to front-off a surgeon or an anesthesiologist to advocate for your patient, then you know first hand that you have to be secure in your professionalism and clear about your role. Am I as much fun in the room and popular as I used to be? Probably not but my patients are safe and get the best nursing care possible no matter what happens or who else is there. I sleep soundly at night!

[2bDocOc]

One other thing, making the patient advocate role such a small thing, really tells me you don't know much about nursing and the true enormity of that two word explanation.

I never downplayed patient advocacy. It's important, no doubt, but let's not oversell it either. It's not something specific to RNs. LPNs/Surg Techs/RCAs, whoever really, can be just as good patient advocates as RNs. Advocacy is about being caring and ethical, not what kind of degree you hold. Honestly I think it's quite arrogant of RNs to think that they're the only effective patient advocates out there.

[FlyOR]

You've been given a lot of good answers, but as someone who is still relatively new to healthcare I see the circulating nurse in the OR as the minimum. Surgery is the cutting open of the human body. The patient has no defenses except those that the team provides. That requires knowledge and expertise. Being a patient advocate is not just caring, it's knowing your stuff so you can see danger coming. I know plenty of nurses that I don't exactly like, or think are kind people, but I would have my family member with them in the OR, because they are hell on wheels for their patient. Expertise = safety.

The OR is a team, there's a surgeon, anesthesiologist, a scrub tech and the circulating nurse, at minimum. The surgeon and the anesthesiologist have their responsibilites and often they are very much in their own head. Knowingly or not, they rely on me to catch what may be outside their present view. That's why I am there. Effective safety protocols have layers and I am the last layer. Without my education, how would I know what often simple dips and rises mean?

Everyday I tell myself that my goal is to be THE nurse that I would want my family member with. I want someone who will assess, observe and check all throughout the case and sorry, but I want them licensed and responisible. At the end of the day healthcare is very elitist at heart, especially amongst doctors. Whether or not you are listened to and respected rests on your expertise and that requires education and experience and THOSE allow you to call STOP and be effective.

[Robbone]

Couldn't have said it better myself, canesdukegirl! It is the critical thinking process using all the eclectic knowledge you have gained and the responsibility you have accepted that sets the OR RN apart. No, you don't HAVE to be an RN to be a patient advocate but let's be honest, out of the 4 people that comprise an OR team, who do you think has the agenda where the patient and patient safety is at the top of their list? Hint: Probably the one that is not getting paid on a case by case basis. This topic may have been overdone here but the question is STILL asked and those of us who are CLEAR about our role will continue to answer.

[cdsga]

I don't think you can oversell patient advocacy as the core of nursing practice. In it's vernacular it is oversimplified. A lot of good OR team members advocate for the patient no doubt, but the rubber meets the road with the nurse. If you think that is not true then talk with nurses who are called into legal briefings when the nurse did not uphold the policy and procedure and was reminded of the patient advocacy role. The nurse is held accountable for it all, and by all I mean the demeanor of the OR, the order, the policy adherence and the enactment of the chain of command. The surgeon and those not employed by the healthcare institution are held accountable on their own. It's not arrogant it's a fact and I'll gladly defend any nurse who has to defend their role in the OR.

[LuvScrubs2, BSN, RN]

WoW you'll give such great info....

[Do-over, ASN, RN]

I never downplayed patient advocacy. It's important, no doubt, but let's not oversell it either. It's not something specific to RNs. LPNs/Surg Techs/RCAs, whoever really, can be just as good patient advocates as RNs. Advocacy is about being caring and ethical, not what kind of degree you hold. Honestly I think it's quite arrogant of RNs to think that they're the only effective patient advocates out there.

My opinion - Being a patient advocate is not about "caring" or "ethics" only. In the case of the OR, or any situation where the patients are helpless - it is about speaking for, protecting and defending the patients - who CANNOT speak for or defend themselves. It isnt about tasks, it is about the big picture. My mom cares about me and is an ethical person, but she isn't the one I want in the OR with me. I had emergency surgery 7 years ago and I still remember the face and demeanor of the nurse in that OR with me. I knew I was safe with her.

I do not believe it is possible to oversell patient advocacy.

[coconutzz]

DocOc, you asked if an OR nurse does a head to toe assessment earlier. When I started in the OR I wondered why they didn't either. The reason is that an OR nurse performs a focused assessment. The OR nurse is concerned about positioning, metal in the body, NPO status, allergies, possibly labs depending on the type of surgery the patient will have, SCDs/TEDs, any lines in place, if the patient is to be admitted or discharged postop, need for blood (along with appropriate samples taken to expedite getting blood), etc. It's like when you were in nursing school. If you had a test on the diseases of the lungs, you didn't go home and study labor and delivery. You focused on what you needed to know and used your ability to gather pertinent information and even some past experiences (maybe your own weakness or mistakes you made before) to prepare for the task at hand. While it is nice to know as much as possible, it is best to know the information that will most likely affect your patient during surgery.

When you mention patient advocate, you are right, anyone could be one. I have worked will OR RNs who make me embarrassed to share the same title and have worked with ORAs and STs who I can't learn enough from not only because of their skill but their ability to work as a team, allowing their experience to lend itself to ensuring that the surgery at hand is the best it can be. The same can be said for surgeons/doctors though. Each individual decides who they are going to be and how they are going to perform, their title does not do that for them. Having an RN in the room, I believe, is to ensure that another trained person is there to catch mistakes, to critically think when a situation occurs, and has the licensure needed to perform certain tasks. Mistakes and events occurred routinely enough to make an RN in the room required for surgery.

[flipflopsRN]

I've been circulating for 9 months and have wondered the same thing. I went to nursing school and now I spend my day pushing heavy things (stretchers, equipment, patients), opening things, plugging things in, taking things out, and putting things away. Most days I feel more like a technician. There have been moments that others mentioned in earlier posts where I see why it's good to have an RN helping out in a room. It's a unique specialty, that's for sure.

One MDA i work with has joked that each room doesn't need it's own circulator- a circulator could go between 2 rooms.

[2bDocOc]

I've been circulating for 9 months and have wondered the same thing. I went to nursing school and now I spend my day pushing heavy things (stretchers, equipment, patients), opening things, plugging things in, taking things out, and putting things away. Most days I feel more like a technician. There have been moments that others mentioned in earlier posts where I see why it's good to have an RN helping out in a room. It's a unique specialty, that's for sure.

One MDA i work with has joked that each room doesn't need it's own circulator- a circulator could go between 2 rooms.

That's probably what I'm getting at, that you don't really need an RN for each room. I know the general concesus here is that you need a registered nurse for each operating room, but only when things get hairy; other times you're doing pretty much something anyone without a nursing degree can do. I wonder if in the future they'll decrease the numbers of RNs working in the OR department, assigning 1 RN to say 2 or 3 rooms.

[Rose_Queen, BSN, MSN, RN]

That's probably what I'm getting at, that you don't really need an RN for each room. I know the general concesus here is that you need a registered nurse for each operating room, but only when things get hairy; other times you're doing pretty much something anyone without a nursing degree can do. I wonder if in the future they'll decrease the numbers of RNs working in the OR department, assigning 1 RN to say 2 or 3 rooms.

Actually, the opposite is true. More and more states are passing legislation that the circulator must be an RN. Currently, 23 states require an RN circulator. On this page, http://www.aorn.org/PublicPolicy/CurrentLaws/RNCirculator/ there are PDF files that specify requirements by state.

As for waiting until things "get hairy" before bringing an RN into the room, things can go bad very quickly and in multiple rooms at once. I was once charge nurse where we had three codes called at the same time (one geriatric, one middle aged, and one poor little kiddo). Had those three rooms been supervised by 1-2 RNs, who would have been the odd one out? STs also are trained in technical aspects, hence the "technologist" title. They are not taught the assessment skills and critical thinking that nurses are. Patients in the OR are a vulnerable population- they deserve the assessment skills and critical thinking abilities of an RN.