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?

[jjjoy, LPN]

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 don't think it's overkill to say it's important to have an experienced acute care nurse in the OR. Just having an RN license in no way reflects a person's ability to respond to such "hairy" situations. Nursing school doesn't really teach those things and even many experienced nurses have never really had to take charge of that type of emergency. That is what nurses learn on-the-job, not in school.

Ideally, the OR nurse brings those emergency skills to the OR. Is a nurse who doesn't have that kind of relevant experience and skills and has to learn that along with all of the OR specific responsibilities to the OR still better than an experienced surg tech or paramedic who receives rigorous training in all of the responsibilities of OR non-physician staff (eg positioning, assisting with emergency medications, etc)? It's an honest question of mine as someone who has completed nursing school and does hold an RN license.

[cdsga]

Doc Oc: I respectfully hope that you are not in an OR without an experienced OR RN in the room with you. I think you are seriously misinformed and as the tip of the iceberg of this new healthcare climate change emerges-more patients not seeing doctors on a routine basis due to lack of insurance- we will need more experienced RN's available to anticipate the unexpected complications of undiagnosed problems in our patient population. You have the right to your own opinion, I just hope it does not become the majority opinion because people who share your opinion are somewhat ignorant and naive.

[2bDocOc]

I have received a lot of good answers, some of them I even agree with.

Thank you for your answers. Obviously I know very little about the OR. Just from reading though, I still feel like a lot of the tasks are procedural/skills based, and a bit less critical thinking involved than say if you were in ICU. But I guess OR nursing is something that you need to experience and not read about to fully grasp the significance.

[2bDocOc]

Is a nurse who doesn't have that kind of relevant experience and skills and has to learn that along with all of the OR specific responsibilities to the OR still better than an experienced surg tech or paramedic who receives rigorous training in all of the responsibilities of OR non-physician staff (eg positioning, assisting with emergency medications, etc)? It's an honest question of mine as someone who has completed nursing school and does hold an RN license.

That's a great question. Any takers?

[cdsga]

Yes-let's state it this way. In the field you are instructed on life-saving maneuvers limited by your standards of practice. A surgical tech also has to maintain their practice within their limited scope of practice. In the hospital arena-an inexperienced nurse must take an internship course specific to the OR, and should not be left alone in the OR if not supervised or at least have a proper preceptor and mentor in place to assist the novice nurse. While surgical techs and paramedics can learn on the job by observation or if allowed to participate with a surgeon or ED MD who supervises their practice skills, they are not solo players, and therefore add a limited scope of practice to the team. The one thing about nursing is that the basic nursing education is completed and licensure obtained and when you work in an OR, ICU, L&D, or any other specialty area-additional training must be obtained, and in the event that surgical technician jobs or paramedics became less available or jobs were cut, then it would be the nurse that steps in and fills the void. That reciprocal cannot be said for the other two jobs mentioned above.

[jjjoy, LPN]

in the event that surgical technician jobs or paramedics became less available or jobs were cut, then it would be the nurse that steps in and fills the void. That reciprocal cannot be said for the other two jobs mentioned above.

Thanks for your response. I think you make some good points!

Still, isn't the above issue more of a legal technicality than an issue of qualification and competency? Advance practice nurses have fought for the right to prescribe drugs without physician supervision instead of going with the status quo which said that prescribing was not the scope of practice of nurses.

[cdsga]

What I have learned and witnessed is that changes in scope of practice have to do with many variables. If you look at the history of Surgical Techs-it came from the doctors lobbying to have that technically trained scrub in the OR due to nursing shortages etc. That also was the driving force for PA's as well. Nurses have not always had a good centralized lobbying force until recent times. But I remember a time when only nurses were in the OR-they were trained to scrub and circulate. CNM's and CNA's have practiced independently with support from remote doctors in rural areas for many years. Especially in places where doctors were in short supply. When you think about the number of nurses comparative to the number of doctors you can see why these two advanced practice branches of nursing have been so valuable. We are just now seeing a surge of advanced practice nurses in all areas due to the Healthcare reform, shortages in professors in nursing programs, etc. But still the ST position remains unlicensed, and that is due in part to political/legal issues. PA's are still not 50 state wide. So there are alot of variables at this time that control the outcome of these jobs/professions. I personally like the 100% nursing staff (don't get me wrong, I respect and love my ST's) because it allows for more flexibility in staffing cases. But there are very few places where this happens. Nurses leave and return, leave for promotion and stay gone, or stay-but get promoted leaving voids that must be filled. That has been the reason for the introduction of these new physician driven jobs.

[jjjoy, LPN]

To me, this comes back to a key issue.... what *is* nursing? Nurses can *do* many things... from emptying trash cans, to intubating in an emergency. From giving injections, to taking a health history, to identifying medication errors, to assessing hemodyamic status, to teaching safer sex. From circulating, to scrubbing, to 'first assist'.

But what is it that nurses offer that is actual *nursing care* as opposed to care/service that a nurse happens to be well-positioned/well-qualified to learn and to perform but is not necessarily *nursing care*? What is the *nursing* knowledge/skills that logically would be at the heart of nursing education to make for the safe and competent practice of *nursing*?

For example, patient education is an important responsibility of many nursing roles but I don't see it as "nursing care" per se. A good dietician will also provide education during their dietary consult. A good physical therapist will also provide education while going through exercises with the patient.

While not not all nurses provide personal hygiene assistance for someone incapacitated in some manner, such care is generally considered "nursing care", is it not?

And while some non-nurse personnel do participate in activities such as on-going monitoring, & treatment provision (such as med aides, pt care techs), it, too, is generally considered "nursing care", is it not?

Activities to prevent deterioration and complications (early ambulation, position changes, bandage changes, etc) generally are considered "nursing care", whether or not a professional nurse is providing the service (eg 'nursing' one's family member).

I've gone away from the specific issue of RNs in the OR, but I see it all as interrelated. My 2.5 cents!

[cdsga]

This is what a competent OR RN provides to patients, families/sig. others/physicians/coworkers/facility.

1. Provide proper brief assessment of the patient-knowledge deficits included, medications patient is currently taking and to be continued in timely manner prior to surgery which would include DVT prophylaxis, beta blockers, antibiotics and others-reports any discrepancies and corrects those discrepancies to appropriate personnel-physicians

2. Provide proper assessment of completed documentation complete with team related activities regarding universal protocol, consents, room readiness, equipment-implants-diagnostics and reports any discrepancies found prior to surgery

3. Prepare OR by:

Setting up and maintaining sterile environment, pre-procedure equipment troubleshooting, ensuring equipment and ancillary staff availability, medication administration, implant or tissue bank, or blood availability

Corrects any discrepancies or reports those discrepancies to appropriate personnel

4. Provides good customer service to patients families physicians involved with the procedure by communicating, providing name, professional affiliation, and care to be provided, education concerning procedure, approximate time of procedure, reporting any delays and delivering confidence in personal knowledge or OR procedures to the patient and family in ways of understanding---Allays fear and anxiety, reports to anesthesia or surgeon/MD patient concerns and addresses those concerns prior to entering the OR.

5. Ensures proper safety procedures in the OR-Proper time out, patient transfers, proper safe positioning and use of proper positioning devices, fire safety procedures

6. Reports to pre-and post op units regarding the patient's experience during the procedure-provides necessary information for safe transport to post op unit-O2, monitoring, set up of vents, pressure monitoring devices, blood, etc.

7. Safeguards patient's assistive devices, eyeglasses, hearing aids, dentures, etc and may provide those assistive devices to the post op unit for the optimal delivery of patient care based on pre-op patient assessment interview and observation

8. Maintains a neat and organized OR by keeping clutter away/contained, dusted daily, monitoring infection control practices in the OR including but not limited to knowing the amount of air exchanges/hour, humidity settings, what to do when environmental issues contaminate all sterile supplies, Keeping cords and other items off the floor to safeguard co-workers from trips and falls.

9. Provides data and ideas for process improvements in the OR-case flow, efficiency, storage organization, proper surgical attire, drug security processes, and medication practices. Provides support in flexibility in schedule changes. Reports any unsafe or potentially unsafe or inefficient practices based on AORN Standards of Recommended Practices, Joint Commission, CDC, MSDS information on cleaning supplies, toxic materials handling.

10. Provides accurate processing of specimens, pathology and lab with proper fixative, completing documentation, labeling and transport of those specimens to the proper diagnostic unit.

11. Know principles of sterilization of all forms-process and demonstrate that knowledge, understand how to operate autoclaves, semi-critical item disinfection, decontamination and be able to monitor and address any discrepancies and provide documentation of sterilization practices.

12. Overall organizes, maintains continuous readiness for regulatory inspections, reports findings, maintains education on most current procedural guidelines, facility policy and procedure, etc. And educates others. also provide basic nursing care to the patient, inserting catheters, IV's. perform CPR-ACLS, assist anesthesia during patient procedure-intubation, extubation, obtaining labs, or blood products. Basically be prepared to act on a moment's notice.

13. Infection control practices concerning proper skin preparation, knowledge of all the different prep solutions, efficacy, guidelines for proper use, hair removal, monitoring and reporting any breaks in that process. Also proper documentation of patient classification related to potential for surgical infection post op.

A super OR nurse would be certified in their area of specialty, be active in their professional organization, maintain continuing education, provide support to co-workers, and be involved in nursing activities within the facility not just the OR.Provide confident and competent care consistently. Can communicate appropriately, delegate when necessary, and follow up on delegated tasks.

Patient advocacy is Number 1- which performing these steps above is involved with patient advocacy even though many things look technical.

While it may look like many nurses don't do these things, I can guarantee you a nurse may make it look easy, or they may have to be reminded. But at some point in time everything listed above must be provided. Maybe not in one case, maybe not all in one day, but they must be prepared to do these things and many more.

[jjjoy, LPN]

Wow, what a great detailed description of all that OR nurses do! I certainly get that they do a lot!

My question is which of those activities are *nursing* activities (regardless of whether or not a nurse is doing it) and which are not necessarily *nursing* activities that the nurse is responsible for. For example, the role of scrub nurse. Is prepping and anticipating surgical supplies *nursing*? Or is it a skill/role that nurses learned and performed but still is not necessarily, or uniquely, *nursing*?

When there wasn't so much demand for certain roles, if you needed someone to fill that role, it would make sense to recruit a nurse to fill the role. The nurse clearly already had some medical background and they could also fill multiple roles. But when the demand for that role increases such that it can support training programs and full-time employees just for that role, then why 'borrow' a nurse for that role anymore? Respiratory techs and surgery techs are examples.

Thoughts?

[cdsga]

What I have tried to explain, many times over has eluded you. I give up-I suppose you can quote what doctor's have told me many many times, "You can train a monkey to do your job!" So I guess my above list of some of the things that nurses are doing in the OR are going above your head. Bring in the monkeys! I have observed surgeon's doing procedures many many times and could probably diagnose, treat and perform technical procedures just like them, but I don't have the credentials or the ability to perform outside my scope of practice, so they have very expensive robots and all nurses can get is monkeys.

[jjjoy, LPN]

I don't think you're saying that health care techs function at the level of a trained monkey, are you? If techs are lacking in any needed skills/competencies, then can't they be taught? Can only nursing programs teach patient advocacy? Delegation skills? Infection control practices? Can only nurses perform these skills?

I know I got very little training in delegation at my school. And one elective through the public health school covered at least as much about infection control as was covered in nursing school. Process improvement? We didn't cover anything that any business major wouldn't have covered and probably a LOT less.

I'm not saying OR RNs are unnecessary or superfluous, not at all!!! That's someone else's argument. As an RN myself, I just wonder at where nursing stops and starts amonst the many different needs/roles in health care. And I realize that it's fluid and ever-changing. : )