"They" (AORN et al) always tell us "The circulator is in charge of the room."
I agree that that is the way it should be.
I believe that the circulator is first and foremost the advocate for the patient, and should have the power to say to the surgical team, if they feel a patient care environment or situation is suboptimal or dangerous:
"I will not proceed with this case until we get (fill in the blank) the proper monitoring equipment, better informed consent, an interpreter, more experienced personnel, the proper instrumentation, etc. This is dangerous patient care. I will not compromise patient care."
I think we have all been in a situation such as this:
Specialty hardware has not arrived yet for a case. Or, even better scenario: Frozen bone graft has not arrived from bone bank.
The desk says, despite your objections, "Just put the patient on the table; the rep called and says he is on his way." (The desk RN is probably under pressure, either from management or other surgeons, to keep the schedule moving.)
Then the case is well underway, you are ready for the hardware or allograft, and guess what: the rep or bone bank person is stuck in traffic across town.
Or, how about this one: You are scheduled to do an extremely dangerous and/or complicated case; one which you and the surgeon and your scrub have done many, many times before, and feel comfortable with.
However, on this particular day, an anesthesia provider is assigned whom you know has very little experience with this procedure, or, even worse, is one that you have seen get into trouble on a procedure such as this one before.
I feel that you, as the circulator and in your role as patient advocate, have not just the right but the responsibility to speak up to the surgical team as to your gut feelings, your rationale for them, and your suggestion as to who might be a better choice for this case, even if it means delaying the case until that more experienced person is available.
You should be able to suggest a remedy as simple as a room trade between the two anesthesia providers.
Yet, usually "the desk" or management somehow gets involved; either voicing their disapproval as to how you dared to make a patient care decision without consulting them, or, worse, overriding your decision.
I would really like to get a clear cut position statement from AORN as to just HOW empowered (legally) we are in asserting our patient advocacy roles and taking charge of our rooms, as we should be able to.
Guidelines are worthless, in my opinion-- OR mangement tends to interpret them to suit their own agendas. Even "circulator in charge of the room" is interpreted differently by different managers in the same OR.
It seems that the circulator is frequently discouraged or even prohibited from making independent decisions in his or her own room. What is with this lack of autonomy? Don't they trust our critical thinking skills and experience?
Sadly, I think this is a control tactic on the part of management; I think some nurse managers simply don't value independent thinkers, even if it means compromising quality patient care. They want to be the only ones doing any decision making in "their" ORs.
In theory, and when writing policies they espouse the "circulator in charge of the room" theory, but in practice they always seem to want to override the decision of the circulator who wants to delay the case over issues like these--even if the case is elective, and even if another case could be put in the room in its place, so that the schedule would proceed uninterrupted.
What is really bad is the situation where, instead of supporting the nurse who says "It is my opinion that we should not proceed with this case until conditions X, Y and Z are satisfied, and I will not do so until they are," management instead assigns ANOTHER nurse to the room who has no objection to proceeding--usually a nurse who is less experienced or is new on staff and is afraid of "making waves."
Generally, if there is a patient safety issue, or if I feel, in talking to the patient or his family that he or they have not had all their questions or concerns addressed adequately by the surgeon, I hold off on taking the patient to the room until I am satisified that those questions have been addressed.
The surgeons I have worked with respect the nurses who speak up to them and make their concerns known; we are a team, after all.
I would love to hear from all OR nurses as to your opinions and experiences in this matter.
To what degree are you in charge of your rooms?
Do you have the support of management when you want to hold off doing a case because of patient safety or ethical concerns?
Do your surgeons respect your opinions and gut feelings about why it might compomise patient care to proceed with certain situations as they stand?
Do they respect and support your role as patient advocate and nurse in charge of room, and validate the fact that you can and should be able to decide whether a case should be cancelled or postponed?
Do they even know that you, as the circulating RN, are the one in charge of the room?
Originally posted by Pam RN
The second OR I worked for was a specialty women's OR at a huge university hospital and I had never felt so disrespected. This place was the worst. I couldn't take it anymore and after sinking into depression I quit after 7 months. It was a huge mistake to work there. I left feeling like a shell of my old self. As the circulator I had to just sit there and basically shut up. I left the OR and am working in the office of a group of general surgeons who are really cool.
Oh, Pam, that is so sad! What a miserable hellhole that must have been!
Do you get to go first assist the sugeons in your office, or at least do outpatient office procedures? It's nice that the new docs are cool.
University hospitals can certainly be that way.
Some residents are really cool--most, in fact--but boy, there are some who really need to be put in their places and told that, while they may be doctors, they are not board certified surgeons yet--and there is a huge difference.
I can't believe how some can get to be such cocky know-it-alls with so little experience behind them--and how some of the attendings allow them so much autonomy too early in the game.
I have been lucky enough to work at places such as the first OR you described--we were truly a team; everybody knew not only each other's names but their kids'names, husbands' and wives' names, etc.
Anesthesia and the surgeons had no problem asking "What do YOU think?" of the nurses; they truly valued our input and knew that sometimes we might be seeing part of the picture that they might have missed.
They knew that a lot of us came from interesting clinical backgrounds and were always interested in hearing about another institution's or doctor's way of doing things.
They respected our various clinical skills and encouraged us to make use of them (i.e, starting IVs, etc. in the O.R.) so that we could keep them up.
Back then, more than one case would cancel or be postponed simply because the circulating RN discovered some critical lab info that the anesthesiologist had overlooked, or because the patient would share a bit of personal info with the RN (i.e., "I did some meth last night") that they were embarrased to confide to anesthesia.
Even our saying, "There's something about this patient that just doesn't feel right; I can feel it in my gut" could prompt a case to get postponed or cancelled; no questions asked. They always were appreciative of gut instinct!
However, I, too, have worked at places where the circulating RNs aren't even trusted to assist during intubation--something we were doing before some of these anesthesiolgists were born! What, exactly, do they think we are there for?
Needless to say, these guys don't bother to get to know our names, or even acknowledge us in the hallway. We are non-entities. It doesn't bother me. To me, THEY are non-entities.
These types don't even seem to form any kind of connection with their patients, either; they seem incapable of empathy in some of the most tragic situations.
What does bother me, however, is lack of respect from nursing management. That seems to be the epidemic these days.
I hope you give some other OR a chance. Try a travel assignment when you get the opportunity; you just might find a place you like so much that you will want to stay. Hint: California ORs are my favoite, hands down!
Last edit by stevierae on Aug 17, '03
Aug 20, '03
by Janet E Groll
I've been practicing for 16 long years in various diverse instituions and I feel that as time goes on we as professionals are getting more and more disrespect, irregardless of the years of experience and the lengths we go to , to please all involved(ie: management, the surgeons our peers and mostly the patients.) We work long hours with mandatory overtime, and when we press the issue as patient advocate, as we were all trained to be first and foremost, we are hit with such resistance. I know in the instances where I spoke up as the circulator in charge, I'm glad that I did. You see more and more wrong site surgeries occuring, and I just don't care if "the team" gets miffed if I call a time out until I see the attending in the room and varify with the team and that includes everyone from the scrub to the anesthesiologist to the resident, that we are doing the procedure as stated on the permit and that we are all in agreement that the site is the correct site. Management will always try to treat us as cattle from this day forward, but it is still my license and I will do whatever to protect that license and firstly the patient. You know that healthcare has changed so drastically since 1980 when I started as a student nurse in the hospital after 1 semester under my belt. It really was so much fun back then but now with all the changes going on you really have to be not only be an advocate for the patient but for yourself as well. Diplomatically speaking I've gained more respect from the surgeons when I've spoken up and prevented an occurance, than not,sure there was annoyance at first but I'm good and I studied hard ,learning their preferences, and playing the game, per say, but you all know we as OR nurses tend to eat our young, and I really hate my back side getting chewed on. So I say be the best that you can be and learn to get your message across in such a way that management and even the surgeons feel like whatever you are saying was their idea. It really works, when all you really want to do is get through your day and continue to practice nursing the way you were taught. I've conducted an attitude like the fellow in Shawshank Redemption, I whistle while I work and do my job to the best of my ability, never letting anybody ever say anything about my skills and knowlede, or work, and so what if you make waves ,some people just can't take life without beefing on someone throughout the day. Walk around with a stupid smile if you have to, knowing you graced their day with your presence. Continue to do all you can also to protect the patient and your license, because management doesn't care how they get their cases done so long as they do.:chuckle
Last edit by Janet E Groll on Aug 21, '03
Yes, please do expound on this, Barbara, as it's not the first time I've heard it with regards to Florida--that Florida is one of the few states that still clings to the "surgeon as the captain of the ship" and the nurses as his "borrowed servants."
Is this really to be interpreted--or is it interpreted--that Florida RNs, at least in the operating room, are not accountable for their own actions and do not feel that they must, first and foremost, advocate for the patient--they are merely there to follow "captain's orders? Even when they are not in the best interest of the patient?
Mike and I will both be anxiously awaiting your reply--this practice seems so contrary to our philosophy of how to deliever optimal patient care--and to AORN's, our governing body, and ANA's as well! If it is that way--WHY? Why have nurses allowed this archaic practice to continue?
Last edit by stevierae on Jan 30, '04
Oh, OK, that makes sense, Barbara. Thanks for explanation--I think Mike and I both interpreted it to mean that, as agents of the state, they (circulating RNs) are powerless.
But, now that the subject has been opened--as a Florida RN, can you tell us a little bit about your understanding of the "nurses as borrowed servants" rule, or law--as I said, I have come across this in more than one Florida case--where the defense tried to excuse the part the circulating nurse played in not advocating for the patient and essentially allowing surgical errors to occur--because, after all, she was only there as the surgeon's "borrowed servant" and was therefore powerless in taking any steps to control or prevent a tragic outcome--
Last edit by stevierae on Jan 30, '04