Working as a Perioperative Team
By Ruth A. LeTexier, RN, BASN, PHN
IF ONE COULD CHOOSE A BUZZWORD for the operating room it would be change. Within the context of any given day, a healthcare worker (HCW) can be certain of one stable influence in the work environment--change will occur. The OR is truly a theater of sorts, with everyone gathered under the spotlight, focused on a single purpose, players in an unfolding drama. The outcome hangs in the balance, as the patient responds to the surgical intervention. The surgeon provides direction as he or she seeks to accomplish the best outcome. Anesthesia maintains a homeostatic balance for the patient as he or she lies in an anesthetized state. The technologists respond to visual and auditory cues in order to hone technical competencies, and the circulator keeps pace with the events as he or she seeks to respond to and plan for change. All of this occurs day in and day out as the perioperative team works cohesively to build perfection.
The common goal of the perioperative team within the operating room, is the effective delivery of care in a safe, efficient, timely manner. Teamwork requires the commitment and effort of all team members to increase productivity, ensure quality performance, and participate in problem solving by communicating and cooperating with one another.1 In the operating suites today, all of this occurs at the speed of thought. Technology has enabled us to decrease the time a patient spends in the operating room, while significantly increasing the technical skills required to be proficient, and the people skills required to maintain strong working relationships.
Historically, the operating team was comprised of the surgeon, registered and licensed practical nurses, nonphysician and nonnursing assistants in various roles, and anesthesia personnel. The advent of World War II, created a nursing shortage and a need for persons specifically trained to work in the operating theaters. The surgeon was undeniably recognized as "captain of the ship" in the operating room. Under this doctrine, the surgeon is likened to the captain of a ship, and it is his or her duty to control everything that is going on in the operating room.2
The Pennsylvania Supreme Court first used the phrase in 1949 in McConnell vs. Williams. In that case, an intern at a charity hospital was responsible for blinding a newborn by improperly applying silver nitrate drops to her eyes. The physician was found to be legally liable for the harm caused to the infant in that he had given the order to the intern and the actions of the intern resulted in the injury to the patient. The phrase "captain of the ship" became a catch-all term in the provision of healthcare, and was applied to a variety of different circumstances and events beyond the origination of the phrase until its demise in 1972, when it was challenged and rejected by the Oregon Supreme Court.
Today the organization of professionals involved in providing patient care has evolved from that of a hierarchy, with the surgeon as the sole command, to that of a multidisciplinary team, interacting with many professionals and paraprofessionals. Working together as a team, professionals must balance responsibilities, values, knowledge, skills, and even goals about patient care with their role as a team member.3
In the OR, the nursing role has evolved from the role of handmaiden to the physician, to an independent professional with practices grounded in research and science. The evolution of specialist roles in perioperative nursing has been explosive. The RN first assistant, the perioperative nurse practitioner, and the perioperative clinical nurse specialist (CNS) have developed to provide leadership, expert clinical knowledge and skills, and patient centered care.4
The activities of registered nurses are supplemented and complemented by the services of allied healthcare personnel or the paraprofessional.5 The "scrub person" role has evolved from nurses trained on the job, military trained nonnurses, and nursing assistants to the present day paraprofessional expert surgical technologist (ST). The surgical technologist functions as a member of the direct patient care team and works as an integral member of the perioperative team. Surgical technologists are uniquely trained with a knowledge base grounded in science, research, and technical expertise.
Since the 1950s the perioperative team has remained somewhat constant in that the team traditionally is composed of the surgeon, circulating nurse, surgical technologist or scrub person, and anesthesia personnel. Interspersed within the team on any given procedure are the new learners to the OR, a myriad of specialty students: nursing and surgical technology, orientees, surgical residents, medical students, physical therapy, anesthesia, and biomedical engineering students. Within the confines of the operating room itself, a designated team gathers to collaborate in their efforts to reach a single goal: a positive patient outcome. Excellence within the operating room is a matter of habit or standard course of delivery during any and all procedures.
Changes in Industry
The technology explosion of the 1970s created a new environment in the operating room, one in which standard modes of operating were pushed aside to accommodate new tools and approaches which decreased hospital stay and patient recovery time. The number and length of inpatient stays have decreased as healthcare delivery trends have increased treatment in ambulatory settings.
The changes in industry caused a ripple effect within the operating room. Experienced or seasoned veterans in the OR learned new techniques as the surgeon learned the application of the technology. The advanced technology gave rise to a greater complexity of surgical procedures to be performed in a reduced time frame. Perioperative teams evolved into specialty teams geared toward mastery of the tools and technology required for each medical specialty. As the 1970s merged into the 1980s, perioperative teams learned the cost of technology and all that it allowed them to do.6 The technology that allowed the teams to improve care and decrease length of stay sent costs spiraling out of control, giving way to the birth of diagnostic-related groups.
Today's healthcare climate of managed care is forcing us once again to try to halt burgeoning costs. Nursing is being forced to work differently. Efficiency, cost effectiveness, new technology, and procedures and multiple shifts in job responsibilities are permeating our environments during a time when teams are strained and sometimes broken.7
Working together as a team, professionals must balance responsibilities, values, knowledge, skills, and goals about patient care against their role as a team member. Ethically, every member of the operating room team has separate obligations or duties toward patients, which are based on the provider's profession, scope of practice, and individual skills. Team members also have ethical obligations to treat each other in a respectful and professional manner.8
Mutual respect can be nonexistent when one enters into what one author terms the "blame game." Dawes describes the blame game, where everyone else is at fault. Perioperative nurses defined problems in the OR as incorrect scheduling of procedures, improperly selected supplies for procedures, team members working in isolation, or personnel packaging instruments incorrectly. These few everyday examples cited that resulted in negative attitudes and assumptions. In turn, physicians described problems or situations that were the fault of nurses.
The original intent of identifying a problem in the operating room and then working backwards from the problem to the originator is one of prevention. If a HCW could determine causation, he or she could prevent future problems; although, many problems can be resolved or avoided, it also begins the blame game. According to Dawes, "As problems continue and the cycle of blame perseveres, not only do individuals get a bad rap, but professional suffering and lack of respect for each other becomes more difficult to overcome."
The perioperative team experiences strained interaction as stressors of the work environment create tension. Tension is a necessary ingredient in the operating room, as it spurs teams to respond to the changes in the environment or patient condition. Technology has enabled surgeons to perform procedures less invasively, while increasing the technical competency required for assembling equipment and executing intricate procedures. Each team member has different knowledge, experience, values, and perspectives on which decisions are based. Thus, communication is demonstrated.
One nurse described a frustrating scenario: it is a typical day in OR 12. The patient delayed in admissions, enters the room, accompanied by anesthesia personnel and is greeted by the circulator. The permit is verified, and the patient anesthetized, all while the scrub person is setting up the sterile field in preparation for a laparoscopic cholecystectomy procedure. The circulator has performed the standard check of equipment prior to the patient entering the room: the insufflator is set to the proper pressure setting. The CO2 tank is full, the monitors are positioned, the video recorder is properly set up, and the light source is working. The skin prep is performed as the circulator and scrub person count sponges, needles, and blades. The patient is draped and all await the entry of the surgeon. He arrives and immediately begins by relaying to everyone his displeasure at the amount of time between cases, also known as the "turnover time." In his mind, turnover time has been excessively long and he berates the team, until he focuses his remarks solely on the circulator for failing to move things along. "Have you been sitting on your hands?" was one of his remarks. The nurse described her feelings of anger, because the unfair remark was directed toward her. She also was frustrated because the delay in the patient's admission process lengthened the turnover time. She felt underappreciated and defensive.
The scenario described can either escalate or be defused by the next actions of the team. The surgeon has personalized his comments and directed his frustration toward the circulator. All who are familiar with working in an operating room understand there is a time and a place for discussion. In this scenario, the nurse opted to relay to the surgeon the fact that admission was delayed and then to discuss the problem later outside of the OR so as not to escalate the situation or to enter into the blame game mentality.
Respectful behavior begins with both listening to and considering the input of other professionals. Respect is demonstrated through language, gestures, and actions. When conflict occurs within the operating room, positive human connection must occur in order to manage the situation. Objective observations about the situation prevent the interaction from becoming personalized. Maun9 believes that as professionals in healthcare, our conflict management skills can be improved and developed on an ongoing basis. Interpersonal skills need to be sharpened in order for an organization to be healthy. Interpersonal conflict can best be remedied when it is addressed directly and teaming practices are used to require individuals to come up with solutions themselves. When conflict occurs within an organization, the appropriate management steps include:
- Require the two individuals involved in the conflict to meet face-to-face.
- Provide appropriate support for the meeting.
- Make a strong statement that this will not go to higher levels of involvement (no taking sides).
- Require individuals to work toward a solution rather than blaming or pointing fingers.
- Give positive praise when meetings produce success, and the solution works.
The perioperative team can become dysfunctional in that, as the team develops as a single unit, individual members can assume roles that can decrease the human connection. If one team member assumes the role of victim or blamer, he or she can be relied upon to assume the negative role when something goes awry during a procedure and thereby decrease connectivity with the his/her teammates. If a team member assumes the role of power, he or she can be certain to try to control the entire team's dynamics. Maun identified "problem finders" as the person who has a doctorate in problem finding and a second-grade education in problem solving. He calls the person a BMG--a bellyacher, moaner, and groaner. The negative aspects of a dysfunctional team lead to a hardened group of people unwilling and unable to collaborate for the success of the team.
Thriving perioperative teams seek to improve the human connection. The team interaction is professional and respectful. One nurse described working on such a team as a member of a cardiovascular team. "You know when things start to go wrong with the patient, our surgeon maintains his cool, no yelling and screaming at the rest of us, just quiet control, and that helps me to remain calm and work under pressure to resolve the problem." The nurse's words speak volumes about human collaboration and connectivity on that perioperative team.
Every day in every operating suite, perioperative teams gather for the sole purpose of providing excellent care to patients in crisis or need. Changes that occur in the operating room which relate to the patient, the environment, equipment, instrumentation, or personnel all have an effect on the perioperative team. Good perioperative teams recognize that the patient is the most important person in the room--the focus of all effort and duty. The secondary obligation of the perioperative team members is to the team itself. The duty of the perioperative team is to work toward collaboration in order to cement the commitment to each member and to the overall mission and goal of human connection.
Ruth A. LeTexier, RN, BASN, PHN, is the director of surgical technology at Northwest Technical College in East Grand Forks, Minn.
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