What exactly is a nurses role in the OR?

Editorial Team / Admin · Sep 14, 2011

The role of the OR nurse may vary from facility to facility. In my hospital, it is rare that nurses scrub unless they are on the heart team, were former STs, or we are extremely short on STs and they have prior scrub experience. While it may seem to an outsider that the OR nurse stands and documents all day, that really isn't the case either. They are responsible for ensuring that the patient is there for the right procedure for the right surgeon, they are positioned properly in a way that will not cause any harm (think brachial plexus injuries or compartment syndrome from improper arm positioning), making sure that all of the proper equipment/implants are available (nothing makes a surgeon angry like getting the patient off to sleep and prepped to find out that the specially ordered implant didn't arrive- actually happened, and the surgeon had already made incision before the staff found out), and many other things. Yes, primarily during the surgery itself is when the documentation part comes into play, but the beginning and end of the patient's time in the OR can be quite hectic with everything the OR nurse must do.

If you want to see what an OR nurse does, shadow one for the day. Most people concentrate on watching the surgery itself, but make sure you also watch what the nurse is doing when, and don't be afraid to ask questions.

jmokeefe · Sep 14, 2011

Thank you! I did do a share day years ago but like you stated, I was more focused on the actual surgery at the time...I put a call in to the OR nurse educator also to find out specifically what RN roles we have in our OR. What about RNFA's? Are they utilized in most major hospitals?? Do RN's have opportunity for advancement? I am getting some smack from the other RN's on my current floor about my decision to apply for the OR internship at my hospital...they are saying that I will lose my skills and such, and that the OR is 'boring' because you stand and observe/document. One RN stated that the most a friend of hers ever did was insert a foley. I am still a 'young' RN...I don't want to throw my skills and such totally down the drain...

Editorial Team / Admin · Sep 15, 2011

RNFAs: I couldn't tell you if most hospitals use RNFAs or not. Mine has only one, in the robotics program. Most of our surgeons have PAs or NPs who assist them in surgery.

Boredom: Those who tell you that the OR is boring more than likely never were OR nurses. I'm not going to say every day is a thrill ride; doing hernia after hernia after hernia can get a little repetitive. But working in a trauma center, I can really get those adrenaline rushes when a bad one comes screaming up from the ER. I do things to keep myself occupied if it's a particularly long case, such as making up a list of supplies in the room that need to be restocked. But if a patient goes south, they usually go quickly and very badly. I did a case that was supposed to be a laparoscopic cholecystectomy or appendectomy (not sure which, but I want to say lap appy) where when the surgeon inserted the trocar, he hit the iliac artery. That was not a pretty sight.

Advancement: Well, there's the opportunity to become a charge nurse, specialty line coordinator (where you're in charge of maintaining preference cards, inventory, dealing with unhappy surgeons, etc), nurse manager, and other higher management positions.

Losing skills: You will probably lose some skills, but you will also learn so many more. To be honest, I haven't started an IV since nursing school. I've had patients who needed them, but because I didn't go through my hospital's mandatory 6 week course, I am not allowed. However, I've also gotten really good assessment skills. We only have 5-15 minutes to get to know our patients before we bring them to the OR. In that time, we have to assess their knowledge of the procedure, whether they are in need of meds (Versed is your friend), whether the ordered antibiotic is appropriate (Ancef ordered but anaphylactic reaction to PCN), what their vitals are, what their lines look like and are they patent, and what their skin looks like (the patient got this pressure ulcer in the OR! But the OR nurse's documentation shows that it was there before the surgery). And then there's the new skills: technology is big in the OR and we have to know how to troubleshoot a laparoscopic monitor that suddenly isn't showing us what the camera sees, why the electrocautery unit isn't working, things like that. And yes, you will insert lots of foleys, but it's so much more than that.

lockheart678 · Sep 15, 2011

RNFAs:
Boredom: Those who tell you that the OR is boring more than likely never were OR nurses. I'm not going to say every day is a thrill ride; doing hernia after hernia after hernia can get a little repetitive. But working in a trauma center, I can really get those adrenaline rushes when a bad one comes screaming up from the ER. I do things to keep myself occupied if it's a particularly long case, such as making up a list of supplies in the room that need to be restocked. But if a patient goes south, they usually go quickly and very badly. I did a case that was supposed to be a laparoscopic cholecystectomy or appendectomy (not sure which, but I want to say lap appy) where when the surgeon inserted the trocar, he hit the iliac artery. That was not a pretty sight.

I swear you were reading my mind with that, even down to the laparoscopic case where the surgeon hits the iliac artery. That was not a fun experience for me either. Half of the time when I see patients go south, it is on a routine procedure like that too. I've seen too many people who just don't have enough experience in the OR complain about some of the routine cases being boring as well. Chances are, if anyone in the OR says that, they've never been there long enough either. The OR is such a critical area, even the simplest of procedures could go south in a second. As OR nurses, we have to be prepared for anything.

One thing you need to keep in mind about your skill set is that nursing school doesn't prepare you for the OR. What we do is totally different, and we are so specialized that not just anyone can walk into an OR and do our job. I can pretty much guarantee that I couldn't start an IV if my life depended on it, but I'm not about to back down if my surgeon is trying to demand that I take a liver resection patient back without a type and cross.

Like it was stated before, your best bet would be to spend a day or two shadowing a circulator. If you do that, you really should make sure to focus more on what the circulator is doing rather than what the surgeon is doing. If you do end up doing the internship, it will be a huge benefit to you if the OR is where you want to be. Keep in mind, there's a reason that so many OR nurses never leave the OR.

ChristineAdrianaRN, BSN, RN · Sep 16, 2011

*rubs hands together* Ah! I feel like I can have some authority on this! I, too, came from a med/surg-but-mostly-post-op floor, which was my first job out of school for a year, and now am in the OR.

Whether you are circulating or both scrubbing and circulating depends on the facility. Where I work, we are trained to both circulate and scrub (or "scrubulate" as they like to call it!). We have OR techs who scrub, and while the RNs mostly circulate, it's helpful to be flexibile enough to scrub if needed. Also, they work with you on your preferences; there are some RNs where I work that primarily scrub.

Scrubbing is more than just handing instruments. You are responsible, with the help of the circulator, to make sure your case cart has everything you need for the cases for the day. Sometimes you are running around gathering supplies and making trips down to CPD (central processing department, where everything is sterilized). You make sure all the equipment in the room is in working order. You set everything up, which for some big cases like in neuro, can involve two mayo stands, two back tables, and a million instruments and pieces of equipment, and is just a major to-do. The scrub, along with the RN, is responsible for the count. Counting instruments and keeping track of everything can be quite the task (I did a plastics case with 97 needles last week! Talk about exercising organization skills!) Scrubs become well-versed in individual doctors preferences, and are great multitaskers; I've seen experienced scrubs pass instruments, cut grafts, ask for suture, and start a count all at the same time. :lol2: You are an advocate for the patient in that you are keeping an eye out that sterile technique is maintained. When clueless med students are in the room, you have to be extra vigilant.

The ciruclator definitely does more than document. You are running the show. When you first come in, you, along with the scrub, check equipment in the room, and help make sure they have everything they need to set-up. You are the contact person for everyone else involved in the patient's care- they are in touch with the nurse caring for them from where they are coming and to where they are going, with the doctor, with anesthesia, with sales reps, and making sure everything is in order for the cases you have. You go get the patient, speak with them and the family, verify name, birthday, procedure, right/left and is it marked?, NPO status, allergies. Discuss what to expect and where the family is to go. Take the patient back. Then this is busy time. Not only are you keeping track of all your important time notations (time you came in the room, time patient was induced, time the time-out was done, time surgery started, etc) and making sure it lines up with anesthesia's times, but you are calling the anesthesiologist, sometimes paging the surgeon, helping transfer the patient, initiating a time-out (and exercising your confidence and assertiveness as most physicians don't want to listen *cough*), standing by during induction, helping with positioning (which, depending on the procedure can be a hell of a job) and securing the patient, placing padding to prevent ulcers, doing a look-over assessment on the patient as you do so, setting up for caudal if necessary (though I think that might just be peds), placing the Bovie pad, inserting a foley, doing a count, doing another time-out because God knows its a miracle if the anesthesiologist and the surgeon are in the room at the same time, prepping the surgical field, helping secure draping, plugging things in, turning on equipment and adjusting settings, putting local and maybe additional prep on the field, fetching whatever the scrub needs, AND THEN documenting. Whew!

And even then, depending on the case, you're still running around for a lot of it. Think about it - besides the anesthesia team who has their own stuff to worry about, you're the only non-sterile person in the room. That means anything like answering phones, making calls, getting report and making sure your next patient is set up and ready to go, fetching what is needed during the surgery, handling any specimens, handling any labwork, keeping the room clean and organized (like the dirty sponges that seem to get tossed around), monitoring who is in the room and what times they are in/out (time notation seems to be big in the OR), updating the count, getting an oxygen tank and monitor ready for when the patient wakes up, contacting PACU, etc etc...you stay busy! All the while, keeping an eye and ear out for your patient (if you hear that monitor change, you better be over there!) because you are their ultimate advocate.

So I agree that anyone that says OR is boring has never been an OR nurse!

I found that a lot of people gave me crap about "losing my skills" and "being bored" but I actually found out that apparently, many people were pretty jealous I was leaving the floor for the OR. I will never go back. I love it here.

Also, there is a particular anesthesiologist who encourages me to do the IVs sometimes so I don't lose that skill. If you end up working with nice ones, ask! I'm sure they'd be okay with it!

As far as other skills, yeah, you're not going to be putting in an NG or anything, but you gain a whole new invaluable knowledge and skill set.

If you can both scrub and circulate and get trained in different services, I don't see how it can be boring - it's something new every day!

As far as advancement, at my particular hospital, we don't use RNFAs, but that is an option. I personally plan on getting CNOR certification to better myself. There is an opportunity for advancement where I work (and I imagine most places) of a "team leader" role, which means you are basically the charge nurse of your service (cardiothoracic, neuro, general, etc) and you have a little more responsibility and authority. And of course, OR charge nurse, clinical nurse specialist, educator, manager, etc. If you are at all interested in being a CRNA, then the OR is where you need to be.

It's been interesting because a girl who is my age and has similar experience as I do started at the same time as me, and I love it and she hates it. She says that she doesn't like working as a team - she enjoyed having her own load of patients and doing her own thing and not working so much with other staff - and doesn't like that the patients are asleep for most of the time. If these are things that you think would bother you, then I would reconsider. Personally, I thought floor nursing was hard. 7 patients at a time (I worked nights), lots of pain management, lots of complaining, lots of trying to make everyone happy at once....the dynamic is different in the OR. You DO see the patient awake, even if it's only for a half an hour total. You are still a very important figure to them and their family, and you are there calming them up until the moment they go to sleep. That's enough "patient contact" for me. Though I hear this is the biggest issue when people get to the OR and realize they don't like it. OR nursing is challenging, but I think it's much easier than floor nursing, and not as exhausting.

Like I said, I love it. I'm really happy I made the decision to go to the OR. Good luck with your decision!

ICU, RN, BSN, B.S. · Sep 17, 2011

Great posts everyone! My sister lisa, is an OR nurse (both scrub and circulator), also does Endoscopy and PACU....she too has encountered jealous older nurses wondering how she got into the OR after 1.5 years of being an RN....and a lot of people saying "oh, all you must do is hand the surgeon sponges." and other people saying " i would never do OR, that seems so boring."

She replies "good, more cases for me to do ." :)