how do new nurses survive in the OR?

Editorial Team / Admin · May 21, 2011

Take a deep breath and relax! If things are starting to make sense after one month, then you should pretty much be right on pace with where you should be. It's been said that it takes a good year to get truly comfortable in the OR- and for most of the new OR nurses I've met, that has been the truth.

Things that I found helped me: if you have some down time when the schedule isn't busy, see if you can get your hands on some of the instrument trays. This can help you get familiar with what is in each set, and the names of the instruments. Study surgeon preference cards- some surgeons use the same trays for the same procedure, but some may have their own special trays- we have trays known as Dr X ortho trauma specials, Dr Y back specials, Dr Z vascular specials. This can help with knowing what trays will always be needed for a certain case (ie, we need a laparoscopic general set for every lap chole, dx lap, or lap appy) and also if a surgeon likes a certain instrument (ie, a fan retractor for the liver, which is not in the lap general set).

canesdukegirl, BSN, RN · May 21, 2011

Shuubie-WOW! You are a superstar if you are already getting the hang of things after only a month in the OR! Good for you!

It sounds like you are doing all of the right things. Asking questions is SO important. Sometimes (in my experience, MOST of the time) the pref cards are not exactly up to date. Keep a small notebook with you and divide into specialties like Neuro, General, Ortho, Vascular, GYN, Peds and then further subdivide into each doc on the service. I use the little stick on tabs-you can get them at Target or Staples. I write the most common surgical procedures at the top of the page and then list out what is needed. Example:

Under the General Tab, Under Dr. K:

Dr. K

Pager # xxx-xxxx

MD ID # xxxxxxx

Gloves 8.5 Biogel/8.0 Micro

Uses only XL LP gown

Only uses OSI flat top bed for lap chole cases. Page X-ray at beginning of case.

*likes classical music

Lap Chole

Instruments to open:

Major set

ABD extras set

Lab Chole set

Endolock clip appliers

HD camera

10-30 scope

5-30 scope

Instruments to have available only:

Liver/panc set

Dr. K extras

Supplies:

Lap chole pack

L-hook

Endocatch bag

Endoscissors

Endokitners

1 5mm bladeless trocar

2 5mm sleeves

1 Hassan

Pneumoneedle

Endo irrigation set

Cholangiogram set available only

0 Vicryl on a UR-6 needle

2-0 Vicryl SH x2

4-0 Monocryl PS-2

Dermabond

Positioning:

Supine

OSI flat top with full length gel pad

SCDs

Pillow under knees

Foam at heels

Tuck arms

Pharmacy:

0.25% Bupivicaine plain for trocar sites

Ancef 1 or 2mg prior to incision

NACL for irrigation

Omnipaque available only

Additional notes:

Always uses a foley

Bovie at 30/30

Will always send specimen to path for gross only

Page him as soon as the pt arrives in the room

Call for next patient as soon as specimen is out

This is just an example of what I typically write for each surgeon. I will write additional notes for surgeons who are picky so that I don't have to ask them over and over again what kind of positioning they want before a case. There are a few surgeons that want weird positioning equipment (like a Kerlix suspended from an IV pole to prep a shoulder), and it helps me to remember when I write it in my book.

I am happy that you are finding your niche in the OR. It really is a great place to work. If you find that you are behind the 8-ball for big cases, try to see if you can get to work a little early to set up. Keep asking questions!

Good luck to you!

lockheart678 · May 21, 2011

I found it really helpful to make a checklist of everything that needs to be done when first setting up the room in the morning and also from the time the patient gets to the room until the procedure has started. When you have the basics for every procedure down, it can be easier to focus on the things that are different about every case. Also, when you are in the more confusing surgeries, take the preference cards home where you can spend more time looking over them without any distractions.

You sound like you're doing great. I remember when I was just starting, I thought my preceptor was going to kill me because I felt like I was so stupid. It turns out though that she and everyone else I worked with saw my potential way before I did, and things really weren't as bad as I felt they were. Remember, there's a reason why orientation is so long in the OR. It can be very overwhelming at times, but keep asking those questions when something doesn't make sense and don't give up. Like it was said before, it probably does take around a year before you really feel comfortable with what you're doing. Stick with it and it'll get better and better every day.

canesdukegirl, BSN, RN · May 21, 2011

I found it really helpful to make a checklist of everything that needs to be done when first setting up the room in the morning and also from the time the patient gets to the room until the procedure has started. When you have the basics for every procedure down, it can be easier to focus on the things that are different about every case. Also, when you are in the more confusing surgeries, take the preference cards home where you can spend more time looking over them without any distractions.
You sound like you're doing great. I remember when I was just starting, I thought my preceptor was going to kill me because I felt like I was so stupid. It turns out though that she and everyone else I worked with saw my potential way before I did, and things really weren't as bad as I felt they were. Remember, there's a reason why orientation is so long in the OR. It can be very overwhelming at times, but keep asking those questions when something doesn't make sense and don't give up. Like it was said before, it probably does take around a year before you really feel comfortable with what you're doing. Stick with it and it'll get better and better every day.

This is awesome advice. It DOES take quite a while to learn everything there is to know about the OR, and just when you think you are pretty comfortable with everything, you learn even MORE! It is non-stop learning, which is why I love the OR so much.

It is easy to feel overwhelmed at first. When I see my students start to prioritize their care within the first month without freaking over the small stuff, I know that they will be wonderfully efficient OR nurses. I remember one nurse intern in particular that was very concerned about doing everything perfectly her first few days with me. When I ran through my expectations at the beginning of the day with her and then asked her what her learning needs were for the day, we agreed upon the things that we would focus on together. It is very important to break things down into small pieces when learning the OR. They will eventually merge together and make sense.

If you will allow me to rant about a few pet peeves of mine when teaching students, hopefully you can avoid some pitfalls:

I understand that the OR is scary. I will never leave a student to flounder around. I have witnessed some nurses that actually enjoy seeing students flounder and fall. It is disgusting. If your preceptor does not set expectations for you, then you must be assertive and ask them what their expectations are. I expect students to ask questions and I will provide as complete an answer as I can. If further clarification is needed, I will take extra time to go over the confusing parts. I HATE it when students believe that they know something, do not ask, but rather bulldoze through something that leads to a mistake in which an inordinate amount of time is then needed to fix the mistake. For example, I was showing a student how to open a pack on the backtable. He said, "Jesus, I know how to open a pack! You open the tab away from you like this, then the side tabs like this and then the one closest to you goes down like this," as he promptly bent down and hit his mask on the edge of the sterile table in his fervor to show me "how easy it is". Needless to say, we had to break the entire table down and start over, much to the displeasure of the impatient surgeon.

Along those same lines, I also expect a student to deliver when they tell me that they know what their priorities are. We review these together at the beginning of the day. When I was teaching a new staff member that she should never leave the pt's side during induction and emergence, her response was, "I know that!". Well, guess what she was doing during induction? Charting. Yes, CHARTING!

If I can see that my students are terrified, I will prompt them as to concerns that they have. Some are willing to talk about their fears, others believe that they should put on their "game face" and not vocalize concerns regarding their abilities. WRONG! When you are just starting out in the OR, you must be able to trust either your preceptor or your nurse educator and discuss fears before they get out of control. I had one nurse intern look at me one day misty eyed. I thought she was doing a great job, but she was being entirely too hard on herself. I took her into the locker room and she UNLOADED. She said that she felt like Rainman and that she would never learn all of the stuff she needed to learn. She told me that she was debating about quitting the internship. I told her that she was doing all the right things, and provided factual examples of such. Only 6 months later, she was a primary preceptor.

Shuubie, I think that you will do fine. You are asking the right questions and you are getting some great advice here. Write down specific questions that you have during a case and research the answer. If you need further help, don't hesitate to ask your nurse educator or come back to this forum and ask us.

I am proud of you!

RNOTODAY, BSN, RN · May 22, 2011

I know this is going to be a simplistic explanation and might not seem like it is of any help. But beleive me, I have been where you are, asking the same questions, wondering the same things. The answer is : just show up. It just takes time time time. after doing a case 5 times, you will remember it. Time is the key. dont expect to know every preference of every doctor right now , etc... just know the basics... suction bovie prep, blood availability......really.... the OR takes time. dont be afraid to ask questions, you are expected to. soon it will all just click. be patient. I have been there. honest. good luck!!!

LuvScrubs2, BSN, RN · May 22, 2011

Great info to use..... I hope I land a nursing position in the OR soon. I did apply to the Gateway Program @ HUP

shuubie · Jul 11, 2011

Thanks for everyone's advice! It's so helpful. I'm eventually going to be in orthopedics. Does anyone have any advice regarding ortho surgeries? I've been reading about total hips/knees, fractures so far and find it confusing.

NurseSnarky · Jul 13, 2011

Thanks for everyone's advice! It's so helpful. I'm eventually going to be in orthopedics. Does anyone have any advice regarding ortho surgeries? I've been reading about total hips/knees, fractures so far and find it confusing.

And that's why I think Ortho Reps are a godsend. Yes it seems like the doc brings a freakin' entourage, but they help when the room is moving fast, the doc needs a burr or implant two seconds ago and at the same time. Ortho is messy so keep it as clean as you can along the way. If you have devices that will suction the floor when the bag on the drape isn't cuttin' it (and honestly when does it? EVER?)...you are one step up on the game. Learn from your scrub tech what the instruments are if you can. Many are happy to teach you since if you know, you can find it faster than if you didn't. :) I've worked in heavy ortho cases in the past, but now just do scopes, shoulders, carpal tunnels, small ORIFs. So used to it now that I had a cyst excision today and thought it was way too easy...surely I must be missing SOMETHING! It went way too fast and seamless...lol! Oh ortho...one of my favs next to plastics. :)