5
Donna Kirschenrnann, RN, tells her discussiongroup about how the AORN audit tool is used in her operating room. Patricia Patterson Nurses and surgeons talk over concerns A surgeon insists you fit him into the schedule. He says the case is an emergency, but you wonder. This has happened too many times recently. You are trying to enforce aseptic technique with the nursing staff, but residents and sur- geons appear in the OR with no shoe covers, gold chains, and Rolex watches. You believe in instrument counts, but the surgeons argue there are no data to prove their worth. How often have you felt these OR problems could be solved if you could talk them over with surgeons away from the hectic OR suite? More than 100 teams of OR nurses and surgeons had that opportunity at the second Symposium on the Operating Room Environment May 4 to 6 in Chicago. The two and one-half day con- ference was jointly sponsored by AORN and the American College of Surgeons (ACS) to improve dialogue between the two profes- sions. Participantswere required to register in pairs from the same hospital. The approach was different than that of the first symposium two years ago, when experts lectured, and the audience listened. This time topics were selected from issues submitted by the registrants. After introductory panel pre- sentations, participants broke into ten groups for discussion of three key issues-quality as- surance, OR management, and the OR envi- ronment. Leadershipof the groups was evenly 86 AORN Journal, July 1981, Vol34, No 1

Nurses and surgeons talk over concerns

Embed Size (px)

Citation preview

Page 1: Nurses and surgeons talk over concerns

Donna Kirschenrnann, RN, tells her discussion group about how the AORN audit tool is used in her operating room.

Patricia Patterson

Nurses and surgeons talk over concerns

A surgeon insists you fit him into the schedule. He says the case is an emergency, but you wonder. This has happened too many times recently.

You are trying to enforce aseptic technique with the nursing staff, but residents and sur- geons appear in the OR with no shoe covers, gold chains, and Rolex watches.

You believe in instrument counts, but the surgeons argue there are no data to prove their worth.

How often have you felt these OR problems could be solved if you could talk them over with surgeons away from the hectic OR suite? More than 100 teams of OR nurses and surgeons had that opportunity at the second Symposium

on the Operating Room Environment May 4 to 6 in Chicago. The two and one-half day con- ference was jointly sponsored by AORN and the American College of Surgeons (ACS) to improve dialogue between the two profes- sions. Participants were required to register in pairs from the same hospital.

The approach was different than that of the first symposium two years ago, when experts lectured, and the audience listened. This time topics were selected from issues submitted by the registrants. After introductory panel pre- sentations, participants broke into ten groups for discussion of three key issues-quality as- surance, OR management, and the OR envi- ronment. Leadership of the groups was evenly

86 AORN Journal, July 1981, Vol34, No 1

Page 2: Nurses and surgeons talk over concerns

divided between nurses and surgeons. Later each group reported to the entire audience. Two open forums provided a chance for the total group to talk about these topics and regu- lations governing the operating room.

Leading off discussion in his group, Los Angeles surgeon Stephen L Michel, MD, FACS, said, “This is not the kind of workshop where we sit back and let somebody show us slides.” He encouraged the group to look be- yond specific technical problems such as “the kind of scrub solution to use or the color of the OR walls.” He is associate director of surgery at Cedars-Sinai Medical Center.

On Monday morning, the focus was on qual- ity assurance. Symposium coordinator Paul F Nora, MD, FACS, introduced the panel. Nancy L Mehaffy, RN, AORN president, described quality assurance in nursing. The surgeon’s perspective was offered by Peter Dineen, MD, FACS, professor of surgery at Cornell Univer- sity Medical College, New York City. Frank L Murphy, Jr, MD, spoke for the anes- thesiologists. He is assistant professor of anesthesia at the Hospital of the University of Pennsylvania, Philadelphia.

In small groups, surgeons were concerned about privileges. The most knotty questions centered on how to handle the older surgeon whose technique is slipping. “Strict documen- tation, collecting accurate data, and working closely with the executive committee” are im- portant for enforcement of physician creden- tialing, one group agreed.

Problems with the older surgeon are “hard to document unless there’s a dramatic break in technique,” Frederic G Inglis, MD, FRCS, of University Hospital, Saskatoon, Saskatche- wan, said in his group’s report. “Retrospective review of records frequently doesn’t help be- cause they look pretty good. We felt that in most cases the surgeon would respond if talked to quietly. But there’s always the one in ten who will threaten legal action, and we didn’t have a final solution to that problem.”

“I’m curious about nursing,” a physician in one group said. “How do you credential?”

Orientation was described. One surgeon mentioned hearing about AORN’s certification program. Heather McGuire, RN, said the Uni- versity Hospital of the State University of New York at Stony Brook is trying to establish self- governance for nurses based on the medical

AORN President Nancy Mehaffy, RN, describes how operating room nurses participate in quality assurance.

model. Nurses would handle their own creden- tialing. Another nurse talked about a system of clinical levels for nurses with evaluation by peer review. This allows nurses to advance in rank and salary through their clinical achievements. They do not have to leave clini- cal nursing to progress in their careers.

How many were practicing the perioperative role? Several nurses in one group raised their hands. How is it working?

“The patients love it, and the nurses love it,” commented Mary L Peterson, RN, of Commu- nity Memorial General Hospital, l a Grange, 111. What about the surgeons? I think it’s good,” added surgeon William B Frymark, MD, FACS.

Some surgeons were skeptical. How can they be sure a nurse is not giving the patient information they consider inadvisable?

“I submitted the proposal to our surgeons, and they approved it,” Peterson emphasized. “We don’t discuss surgery with patients. We discuss the operating room environment.”

Acknowledging that not all nurses are pre-

AORN Journal, July 1981, Vol34, N o 1 a7

Page 3: Nurses and surgeons talk over concerns

pared or qualified for going to the patient units, Carol Evans, RN, from St Francis Memorial Hospital, San Francisco, said preoperative as- sessments are done by a core group of nurses who are prepared.

Everyone had questions about audit and the new quality assurance standard from the Joint Commission on Accreditation of Hospitals (JCAH), which went into effect Jan 1 . Hospitals are to have a coordinated quality assurance program for the whole institution, using a problem-focused approach. The standard calls for integrating audit, credentialing, and other kinds of reviews.

Some discussion groups pointed out the merits of having a multidisciplinary committee in the OR to set quality assurance policy. Prob- lems seen were making sure audits were more than busy work and integrating the operating room’s quality assurance effort with those of the rest of the hospital.

Attention turned to operating room man- agement. AORN Executive Director Jerry Peers, RN, moderated a panel including Cynthia C Hayes, RN, CNOR, director of the operating room and ancillary services at Emory University Hospital, Atlanta; John S Hattox, Jr, MD, San Diego, Calif, anes- thesiologist and immediate past-president of the American Society of Anesthesiologists; and George F Sheldon, MD, FACS, professor of surgery at the University of California, San

Barbara Wibberly, RN, leads a discussion of

how to solve OR management problems. John E McAllister, MD, FACS, chief of surgery

at Winchester (Va) Memorial Hospital,

accompanied her to the symposium.

Francisco, General Hospital. Small group discussion revolved around

scheduling and utilization, counts, turnover time, and stress.

“Scheduling is a serious problem all over,” Terry Litterst, RN, of Swedish Medical Center, Englewood, Colo, commented, speaking for her group. ” 1 thought I had come for solutions, but I only heard about more problems.” Block scheduling combined with some open rooms available on afirst come, first served basiswas the most common system. It was agreed that no one system would work for everyone due to hospital sizes and types and the specialties involved. Some institutions were finding com- puter profiles more accurate than the surgeon himself in estimating how much time he was likely to take in performing a procedure.

Count policies varied widely. On counting instruments, one surgeon remarked, “No one has data, and I think it’s a waste of money.” Kay Lange, RN, supervisor at Saint Joseph Hospital, Denver, countered that her institution has been counting instruments successfully for nine years.

Loss of instruments to the laundry prompted a surgeon to suggest that airport x-ray devices be set up to screen the baskets of soiled linen. A plus for instrument counts was that those who did them were often able to reduce the number of small instruments in a set-up, sav- ing both staff time and money.

90 AORN Journal, July 1981, Vol34, No 1

Page 4: Nurses and surgeons talk over concerns

member than an outsider. I’ve also found that the nurses who suffer the most stress are the least interested and least involved in the pro- cedure. I’d like some ideas on how to encour- age more involvement.”

Technical and environmental issues were next on the agenda. On the lead-off panel, Charles E Whitcher, MD, an expert in waste anesthetic gases, advised “deciding on your own control program” since there are as yet no national guidelines. He is professor of clinical anesthesia at the Stanford (Calif) University School of Medicine. Harold Laufman, MD, FACS, reviewed the elements of hazard con- trol, and Rosemary Roth, RN, CNOR, intro- duced nursing concerns. Dr Laufman, an ex- pert on the OR environment, is professor emeritus in the Department of Surgery at Al- bert Einstein College of Medicine of Yeshiva University, New York City. A member of the AORN Board of Directors, Roth is chairman of the Technical Practices Coordinating Commit- tee.

Discussion groups reached consensus on one issue-laminar air flow in operating rooms was not worth the money, and few institutions were using it.

“This has taught us how a popular idea can take over without our really understanding the reasons behind it,” Dr Laufman observed, seconding the opinion that it was unnecessary.

Favorable remarks were made about dis- posable linens and the practice of using the same sanitation techniques for clean and dirty cases. There was no agreement on lights but an acknowledgment that track systems cause cleaning problems.

People, as always, were the major prob- lems. One operating room director remarked, “You try to get your nurses in line with aseptic practice. Then the residents and surgeons come in an break all the rules. I don’t know what to do.”

A colleague said she tells her staff that even if they cannot change the physicians’ behavior, they do not have to contribute to bad tech- nique.

What does a chief of surgery tell his staff when they challenge him by saying their prac- tices don’t affect the infection rate? “I say that just because an airline hasn’t had a crash in ten years doesn’t mean they should let up on their maintenance program,” said R H Hay-

The perioperative role is working at University Hospital, Stony Brook, MY. Heather McGuire, RN, and W G Abel, MD, FACS, talk about the program.

Surgeon’s behavior received a frank and open aiiiny. “We do1i.t allow atiybody to be throwing things around the room. That makes it harder for everyone,” Philip J Ferris, MD, FACS, said. He believes his staff is tolerant “when you’re under pressure, and they take it into account.“ He is chairman of the Depart- ment of Surgery at Franklin Square Hospital, Baltimore.

Another surgeon observed that he does not believe intimidation is fostered in surgeon’s training programs anymore. “Now the Denton Cooley manner has taken over-he‘s a cool guy under fire.”

Terry Litterst told the group she had worked on being more assertive. It seemed to help when she told one surgeon she worked with, “I thought you were inconsiderate to me today.” His behavior changed.

Forming specialty teams helps counteract both stress and rude behavior, suggested Thomas E Topper, MD, from Montgomery County Culver Union Hospital, Crawfordsville, Ind. “You’re less likely to jump on a team

AORN Journal, July 1981, Vol34, No 1 91

Page 5: Nurses and surgeons talk over concerns

ward, MD, of Scott and White Memorial Hospi- tal, Temple, Tex.

Whatever disagreements they had among themselves, the group was unified in challeng- ing overregulation in the operating room. Ap- pearing on the final panel were George W Graham, MD, vice president for external affairs of the JCAH; Edward J Bertz, director of the Division of Health Facilities and Standards of the American Hospital Association; and Pat- ricia McGuire, RN, assistant director in the American Medical Association’s (AMA) Wash- ington office.

Dr Graham explained how standards are developed and surveyors chosen. As panel moderator, Dr Nora got a round of applause when he called for a separate operating room section in the JCAH accreditation manual. Currently, standards applying to the OR are scattered throughout the volume.

During the open forum after the panel’s pre- sentations, nurses had questions and com- ments about their role in the health system. Janett Propst, RN, AORN Board member, asked Dr Graham for nursing representation on the JCAH governing body. Patricia McGuire commented that no one would listen to nurses if they are not involved. She pointed out that many physicians volunteer on committees after putting in a long day.

“Everyone is concerned about rent-a-nurse,

Joining in a discussion of the perioperative role were Carol Evans, RN, and Hugh Vincent, MD, an anesthesiologist from St Francis Memorial Hospi, 31, San Francisco.

yet President Reagan has proposed cutting back education funds for nurses,” said Heather McGuire from Stony Brook, comment- ing on the use of agency personnel to alleviate shortages. She asked for support from AMA and ACS.

“But when we train them, where do they go?” countered Patricia McGuire. “They don’t stay in nursing. They’re being tapped by other professions.”

Jerry Peers responded that what nurses want more than money is “direction of their own destiny.” She observed that many hospi- tal administrators were too likely to dictate pol- icy rather than listen to nurses.

In the end, it seemed that the goal of “im- proving dialogue” had been met. No decision was made about future symposiums, although there were suggestions to expand the nurse- surgeon team to include anesthesiologists and hospital administrators.

Reports from the group discussions showed that teams from all over the country had the same problems. Participants began complain- ing there were more questions than answers. They began asking for solutions. That in itself was a positive sign. Nurses and surgeons had started talking to each other. They had laid their concerns on the table honestly. Now they were ready to look for the answers.

94 AORN Journal, July 1981, Vol34, No 1