What does "the circulator is in charge of the room" mean in your OR?

  1. "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?
    Last edit by stevierae on Aug 17, '03
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    About stevierae

    Joined: Mar '02; Posts: 1,888; Likes: 117


  3. by   spineCNOR
    Do your surgeons respect your opinions and gut feelings about why it might compomise patient care to proceed with certain situations as they stand?
    Stevierae, you're killing me! But seriously, I work in a for-profit facility where most of the surgeons (IMHO) see the patients primarily as a source of revenue, and aren't accepting of anything that will interfere with their "billable hours". The managers' jobs are dependent on keeping the surgeons happy, and as such, aren't interested in having nurses think independently if this might result in case delays. Sadly, I don't see that managers where I work have much respect for the staff in the rooms getting the cases done, and do not treat staff nurses as fellow professionals.
    A few surgeons are receptive to nurses' concern about patient care, but sadly, these are the exception, not the rule.
    "The circulator is in charge of the room" rule only applies when the surgeon or managers are looking for a scapegoat--THEN it's the circulating nurse's fault!
    Under no circumstances would a nurse be involved in the decision whether or not to cancel a case.
  4. by   stevierae
    Originally posted by spineCNOR
    "The circulator is in charge of the room" rule only applies when the surgeon or managers are looking for a scapegoat--THEN it's the circulating nurse's fault!
    Isn't that the truth in far too many facilities!!
  5. by   Pam RN
    I've worked in two different OR's and in the first, a community hospital the manager felt strongly that the "circulating RN is in charge". He made many enemies out of some of the surgeons for this. We also had an educator that followed sterile technique and practices to the letter of the law and required us to follow it and expected us to make sure the doctors followed it as well. She also had a long list of MD enemies. I felt fairly empowered there and felt that the docs on the service it was in charge of went along with the rules pretty well. There are always some MD's that make trouble to push their weight around, but we did have our times of being over ridden by the desk to push cases in and sending for patients when we weren't ready but we felt we could reasonably complain. As a smaller hospital with 10 OR's plus 2 cysto room and an endo room we had constant communication with the desk. The manager was a "micro manager" so nothing seemed to get by him and thus they could anticipate delays such as tardy reps better.

    The second OR I worked for was a specialty women's OR at a huge university hospital and I had never felt so disrespected. The MD's were a-holes to the max. The word "team" had no meaning and I might as well have been wearing a Richard Nixon mask for how well they didn't get to know me or the others. I could not correct any break in technique, make any suggestions or use my brain in any capacity except for involuntary respiratory function. At the community hospital the docs expected me to help them, took suggestions and wanted my help in trouble shooting. 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.

    I hope the working environment from my last experience at the university is more the exception than the norm. I miss the OR but I'm so afraid I'd end up in the same situation. If that's the normal treatment of OR nurses then no wonder there is a shortage.
  6. by   stevierae
    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
  7. by   Pam RN
    We do some office-based surgery like vasectomies once in a while and lots of I&D's of thrombosed hemorrhoids, abscesses. It's no bowel resection but it keeps my package-opening and sterile techniques skills from getting too rusty.

    I used to be in charge of a surgical service at my first job and I have this hope that one day someone will want my experience on their team. Like maybe get a call from a past coworker that knows I'd fit in on the team. I know jobs don't come by that way but one of my old bosses got her current job that way, so anythings possible!

    I'm planning on attending AORN meetings starting this fall to keep up with the educational stuff and to make some connections.

    I do like my job now and the hours are great but their is no advancement of any kind. I'm learning tons about post op care, pre op diagnosis', phone triage and joy, insurance. Not my cup of tea. I think the manager knows I'm really an OR nurse at heart and has make comments about my "loving gadgets".

    I left that first job at the homey community hospital for numerous reasons, one being low census and a slow OR. I felt restless and wanted to learn other things about nursing. I felt I was missing out and this current job offers me the opportunity to learn those things. I had a pretty good gig but the cart sort of came before the horse in my career timeline. It sure would be nice to find another situation like that again, but I guess we all have to go with the flow. I'll find out in due time.

    I agree about management being unsupportive. The manager at the university hospital I was at was more concerned about wearing street clothes and attending meetings with the "big-wigs" than really interacting with the staff and making sure the place was successful. The staff basically ran it themselves. When I started I picked up rather quickly that the staff had been unhappy with her for quite some time. Then they demanded a meeting with her boss to complain and that woman's attitude was "talk to the hand." So, after that unsuccessful meeting people were dropping like flies. I was about the sixth person to quit in a two month period. If I hadn't been so burned out I may have stayed and tried to make an opportunity for myself, but I just had to get out. That manager eventually quit.

    Management needs to really wake up and get a clue about what it's going to take to get and retain nurses. If the conditions were better nurses would come back. We love to do it but not under these conditions.
  8. 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
  9. by   Ferret
    Hi All,

    In Australia, it means absolutely nothing. Our scrub nurses are the room bosses, and junior and Enrolled Nurses take the scout(circulating nurse) role. It is nice to see that in some countries that role is given the recognition it deserves. It is frusruating the amount of time that I, as an enrolled circulating nurse, had to explain to some junior RN with a bit of plastics experience how to do their draping, put together the scopes, and do the case, when I know that I could do it faster and easier myself. Now I'm an RN Scrub/Scout, I still appreciate the role of the circulating nurse, and pay attention in a way that few scrubs did me the courtesy. I've seen many agency nurses who can scrub for any case, but without the local scouting knowledge of where everything is, they can ONLY scrub.
  10. by   BarbPick
    Stevie Rae,

    In Florida the circulator is an agent of the state and the legal witness. I have no idea how it is in any other state.
  11. by   shodobe
    So, what your saying is your an employee of the state as well as a "spy"? I am an agent for no one and an advocate only for the patient. I think I know what you are saying but it sounds a little silly. Please tell us more.Mike
  12. by   stevierae
    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
  13. by   BarbPick
    It isn't a big deal. When I worked in the OR for a year, The Circlulator is the one who doccuments everything, has to be responsible for the count, and a case can't go on leagally without an RN present.

    I don't want to get into a dissertation here. It just is what it is.

    There are still ranting raving lunatic surgeons, who think they are God, but the RN has the final word on the case. Until the count is accepted by the RN, nobody leaves.
  14. by   stevierae
    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