RN in the OR?

jeckrn, BSN, RN · Oct 22, 2011

With your line of thinking why do you need surgeon to do the surgery when PA or FA can do it. Just as you think about the whole body process so do nurses on how positioning, medications, etc. will effect the patient. Yes you are right a large part of our job could be done by anyone but it is other mental parts that can not. Next time you need a medication from the back table ask your tech what it is used for and why you need it.

TakeTwoAspirin, MSN, RN, APRN · Oct 22, 2011

This topic has been done to death on this board. Look through some of the posts and you will see the pros and cons. As someone who went from CST to BSN I can tell you that you don't know what you don't know until you have seen this from both sides.

ruralgirl08 · Oct 22, 2011

I have to admit, I was curious about this too, being an RN interested in working in the OR. But now that I have had some OR experience, I can tell you why RNs are very useful to the OR.

1)The main reason is the RN is there to assist both the surgical team and the anesthesia provider. Before a patient "goes to sleep" and "awakes" are both critical points in the OR experience. When things get "hairy," an RN is there to assist anesthesia, usually before RT even gets there (if there is RT). Someone who understands the ACLS protocol, managing Airway/Breathing/Circulation, who can anticipate (without being asked the meds & equipment needed) who can read ECGs, ect, is better equipped to circulate a code situation. Many nurses in the OR came from floors, where they had more autonomy in a code situations. An RN scope is to function in critical situations, and surgery is risky business. When the surgical team is scrubbed in, they need to stay sterile for the patient. You need high functioning nonsterile members in the room.

2) Just like medical school, which starts out as a 4 year basic program before branching out into specialty areas. Nursing is now becoming a 4 yrs basic program, before specializing. Having a broad knowledge base, makes a nurse more versatile, in case they ever want to work outside the OR, and that broad knowledge base is useful on an everyday basis to the OR.

3) Where I work RNs scrub and circulate. We also use LPNs/Scrub techs (and they are great). But being a multifunctional OR nurse does make it easier to relieve each other, or for jumping in to lend a hand.

I guess from an outsiders point of view, its easy to just focusing on the "tasks" in the OR, but its the thought & understanding of why we do those "tasks" is what makes the RN very functional. Our education, experience, and scope is larger. We can be the "glue" between the surgical and anesthesia teams. With the importance of surgery, the expense, and the critical nature, why wouldn't you want the most qualified circulating the room?

canesdukegirl, BSN, RN · Oct 22, 2011

Are you a surgeon? Just curious.

You have posed a great question. Many times when I spend 20 minutes of turnover time in search of an all-elusive gel pad, I ask myself, "Did I REALLY go to school for 4 years to be a sterile waitress, a gopher dressed in scrubs, or an IT tech when the computer/arthroscopy machine/laparoscopy machine needs fixing?" It can get frustrating sometimes.

However, when I catch errors or notice that an order was not written, I am thankful for my nursing education and experience.

A few examples:

A CRNA announced to the surgeon that he was going to go ahead and give Toradol. The surgeon was busy teaching a resident how to ream the femur for a Gamma Nail placement, and either didn't hear the CRNA or his statement didn't compute. I immediately spoke up and told the CRNA that the pt was allergic to Toradol, and pointed to the whiteboard where the allergy was listed in big red letters.

I always review my pt's H&P thoroughly prior to a procedure. I read the e-chart the night before and make notes with questions, should I have anything to clarify with the surgeon. If I notice that my pt's HCT is in the toilet, and an order for PRBCs was not written, I ask the surgeon if he would like some blood ready before we go back to the OR. If I notice that my pt's K+ is 6.5, I alert both the anesthesia care provider and the surgeon. If I see that my pt's INR is 3.5, I ask the surgeon if he wants to delay the surgery so that the pt can receive some FFP.

When we are positioning a pt for surgery, I know which nerves are being compromised by a particular position, and take steps to protect those nerves.

I know because of my education and experience, that induction and emergence are the most dangerous times of any surgical procedure. I am trained to recognize MH and know how to reconstitute and deliver the appropriate medications. I also know how to interpret VS on the monitor and recognize when a pt is becoming unstable. Thankfully, the anesthesia attendings are never far, but in the mean time I can offer assistance to a new anesthesia resident when they are floundering.

An RN knows how to delegate, and must implement critical thinking skills during a crisis.

When a procedure is unexpectedly extended for a period of time, and I know that there is not a bair hugger on the pt, I ask the anesthesia care provider for a temp reading. You wouldn't believe how many times this gets overlooked, and the anesthesiologist gets this look of surprise, and then we put on the bair hugger. I get the dubious honor of showing everyone my backside as I crawl under the drapes to put it on! An RN understands the importance of normothermia both in the intraoperative setting and in the post op phase.

Inevitably, if a pt goes down fighting, they emerge fighting. Because I learned soothing techniques AND because I understand various drugs used intraoperatively exaggerate sensitivity to light, temperature and sound, I know that I should have the OR warmed, the lights dimmed and the room QUIET. This is especially important in the peds population.

There have been plenty of times that I feel like nothing but a gopher. But the examples offered above are a testament to why we need RNs in the OR. Most of the time, the circulators are the ones that notice things FIRST, because it is our job to do so.

Patient safety is absolutely front and center in the mind of a circulator. RNs have the education, experience and critical thinking skills to ensure every aspect of patient safety by implementing appropriate and efficient patient care during the intraoperative phase.

2bDocOc · Oct 22, 2011

This topic has been done to death on this board. Look through some of the posts and you will see the pros and cons.

I did look through the forum, back to back in fact, but all it came down to was being a patient advocate. And I don't think advocacy is something only a RN can do.

To ruralgirl08 and canesdukegirl:

Thank you for your honest answers. No I'm not a surgeon. I'm a BSN turned MS, so I only know the basics of nursing, and have no real experience whatsoever. I just had my first observation in the OR, hence all the questions. The circulator wasn't exactly the most approachable, and my surgeon wondered the same thing as I did. But your answers cleared it up for me a little bit, so I appreciate it.

Ilovethe80s · Oct 22, 2011

I graduated from an RN program in Dec and went straight into a Circulator position in the OR. I can tell you that there are certainly plenty of things that could be done by an LPN, but I do believe that an RN's education (A&P, Pharm, Micro) is more in-depth and needed when in the OR. I am not trying to be rude, but I think one day of observation in the OR is not an adequate amount of time to truly understand what a Circulator does.

GadgetRN71, ASN, RN · Oct 23, 2011

I was a surgical technologist before I was an RN. A surg tech's education is very specific to the OR where as an RN receives a wider scope in their education. In our OR, we put in IVs, a good amount of foleys, and we do give meds.here and there. We also do conscious sedation monitoring. My nursing school education is used everyday at work.

canesdukegirl, BSN, RN · Oct 23, 2011

I agree with Collen. Your username was a bit misleading for me, because as 'DocOc', I assumed that you were a surgeon and just wanted to know more about the duties of a circulating RN.

Observing what a circulating nurse does in the OR for one day is like watching one game of football. You get the gist of it, but don't really understand what goes on behind the scenes. You see the QB throw a couple of interceptions, get sacked, and have an awful game. However, when the next game is played, you see so much improvement from the team as a whole, and wonder if you are watching the same team you did last week.

Circulators work in pairs with scrub techs. If a tech is not pulling their weight and does not open the needed supplies for the case, the circulator is then left to play 'sterile waitress' and must constantly be interrupted to fetch supplies that should have been opened from the start.

Example:

Oftentimes, I work with the same tech. We have gotten so used to each other that I don't feel the need to ask him if he has pulled and opened all of the necessary items for the case. He knows that I have to concentrate on my pt when they enter the OR, and is well prepared to start the case.

Occasionally, I work with a scrub tech that is not so well prepared. She knows that she should pull 0 Vicryl, 2 hemovacs and an extra suction tip. She also knows that if she doesn't, then I MUST. When the pt arrives, I am focused on making them as comfortable as I can, assisting anesthesia with induction, inserting a foley after intubation, positioning the pt with the surgeon, and ensuring that the case gets started smoothly. I don't have the time to make sure that my tech has opened supplies that are routinely needed. I rely on her to do so.

It makes my blood boil when she asks me for items that she KNOWS she should already have on the backtable. I must then stop what I am doing, (charting, looking up labs, finding an ICU bed or floor bed, updating family members, answering pages, running blood gasses, arranging for PRBCs to be delivered to the room, etc.) to find and open supplies because the tech didn't feel the need to do so.

THIS is what makes an observer believe that RNs are just gophers. It takes a team working in collaboration to get the job done. Communication and clear expression of expectations are key in the positive outcome of any surgical procedure. The bulk of this responsibility falls on the RN in the room.

2bDocOc · Oct 24, 2011

Thank you canesdukegirl for your detailed reply.

I know one day in the OR is hardly enough time for me get get a full understanding. I'll probably know what a circulator does way better when I being my clerkship. I really only just had questions, I didn't mean to offend anybody.

Does the circulator ever perform a head-to-toe assessment? I mean, we learned that quite intensively in nursing school, and the degree of coverage we learned in obtaining HPI and physical assessment is I think what separates RNs from other health workers. I didn't see one circulator with a stethoscope when I was in the OR (which is very little time, I will admit again)?

kids · Oct 24, 2011

I graduated from an RN program in Dec and went straight into a Circulator position in the OR. I can tell you that there are certainly plenty of things that could be done by an LPN, but I do believe that an RN's education (A&P, Pharm, Micro) is more in-depth and needed when in the OR. I am not trying to be rude, but I think one day of observation in the OR is not an adequate amount of time to truly understand what a Circulator does.

I think that is going to depend on the program. In the community college program I attended not only were the pre-reqs exactly the same for LPN & RN, we attended the exact same nursing classes, together, the entire first year.

jeckrn, BSN, RN · Oct 25, 2011

I think that is going to depend on the program. In the community college program I attended not only were the pre-reqs exactly the same for LPN & RN, we attended the exact same nursing classes, together, the entire first year.

As you state "first year" not any education beyond that.