By Ruth A. LeTexier, RN, BASN, PHN
IFONE COULD CHOOSE A BUZZWORD for the operating room it would be change. Withinthe context of any given day, a healthcare worker (HCW) can be certain of onestable influence in the work environment--change will occur. The OR is truly atheater of sorts, with everyone gathered under the spotlight, focused on asingle purpose, players in an unfolding drama. The outcome hangs in the balance,as the patient responds to the surgical intervention. The surgeon providesdirection as he or she seeks to accomplish the best outcome. Anesthesiamaintains a homeostatic balance for the patient as he or she lies in ananesthetized state. The technologists respond to visual and auditory cues inorder to hone technical competencies, and the circulator keeps pace with theevents as he or she seeks to respond to and plan for change. All of this occursday in and day out as the perioperative team works cohesively to buildperfection.
The common goal of the perioperative team within the operating room, is theeffective delivery of care in a safe, efficient, timely manner. Teamworkrequires the commitment and effort of all team members to increase productivity,ensure quality performance, and participate in problem solving by communicatingand cooperating with one another.1 In the operating suites today, allof this occurs at the speed of thought. Technology has enabled us to decreasethe time a patient spends in the operating room, while significantly increasingthe technical skills required to be proficient, and the people skills requiredto maintain strong working relationships.
Historically, the operating team was comprised of the surgeon, registered andlicensed practical nurses, nonphysician and nonnursing assistants in variousroles, and anesthesia personnel. The advent of World War II, created a nursingshortage and a need for persons specifically trained to work in the operatingtheaters. The surgeon was undeniably recognized as "captain of theship" in the operating room. Under this doctrine, the surgeon is likened tothe captain of a ship, and it is his or her duty to control everything that isgoing 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 forblinding a newborn by improperly applying silver nitrate drops to her eyes. Thephysician was found to be legally liable for the harm caused to the infant inthat he had given the order to the intern and the actions of the intern resultedin the injury to the patient. The phrase "captain of the ship" becamea catch-all term in the provision of healthcare, and was applied to a variety ofdifferent circumstances and events beyond the origination of the phrase untilits demise in 1972, when it was challenged and rejected by the Oregon SupremeCourt.
Today the organization of professionals involved in providing patient carehas evolved from that of a hierarchy, with the surgeon as the sole command, tothat of a multidisciplinary team, interacting with many professionals andparaprofessionals. Working together as a team, professionals must balanceresponsibilities, values, knowledge, skills, and even goals about patient carewith their role as a team member.3
In the OR, the nursing role has evolved from the role of handmaiden to thephysician, to an independent professional with practices grounded in researchand science. The evolution of specialist roles in perioperative nursing has beenexplosive. The RN first assistant, the perioperative nurse practitioner, and theperioperative clinical nurse specialist (CNS) have developed to provideleadership, expert clinical knowledge and skills, and patient centered care.4
The activities of registered nurses are supplemented and complemented by theservices 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 dayparaprofessional expert surgical technologist (ST). The surgical technologistfunctions as a member of the direct patient care team and works as an integralmember of the perioperative team. Surgical technologists are uniquely trainedwith a knowledge base grounded in science, research, and technical expertise.
Since the 1950s the perioperative team has remained somewhat constant in thatthe team traditionally is composed of the surgeon, circulating nurse, surgicaltechnologist or scrub person, and anesthesia personnel. Interspersed within theteam on any given procedure are the new learners to the OR, a myriad ofspecialty students: nursing and surgical technology, orientees, surgicalresidents, medical students, physical therapy, anesthesia, and biomedicalengineering students. Within the confines of the operating room itself, adesignated team gathers to collaborate in their efforts to reach a single goal:a positive patient outcome. Excellence within the operating room is a matter ofhabit or standard course of delivery during any and all procedures.
Changes in Industry
The technology explosion of the 1970s created a new environment in theoperating room, one in which standard modes of operating were pushed aside toaccommodate new tools and approaches which decreased hospital stay and patientrecovery time. The number and length of inpatient stays have decreased ashealthcare 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 surgeonlearned the application of the technology. The advanced technology gave rise toa greater complexity of surgical procedures to be performed in a reduced timeframe. Perioperative teams evolved into specialty teams geared toward mastery ofthe tools and technology required for each medical specialty. As the 1970smerged into the 1980s, perioperative teams learned the cost of technology andall that it allowed them to do.6 The technology that allowed theteams to improve care and decrease length of stay sent costs spiraling out ofcontrol, giving way to the birth of diagnostic-related groups.
Today's healthcare climate of managed care is forcing us once again to try tohalt burgeoning costs. Nursing is being forced to work differently. Efficiency,cost effectiveness, new technology, and procedures and multiple shifts in jobresponsibilities are permeating our environments during a time when teams arestrained 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 ateam member. Ethically, every member of the operating room team has separateobligations or duties toward patients, which are based on the provider'sprofession, scope of practice, and individual skills. Team members also haveethical obligations to treat each other in a respectful and professional manner.8
Mutual respect can be nonexistent when one enters into what one author termsthe "blame game." Dawes describes the blame game, where everyone elseis at fault. Perioperative nurses defined problems in the OR as incorrectscheduling of procedures, improperly selected supplies for procedures, teammembers working in isolation, or personnel packaging instruments incorrectly.These few everyday examples cited that resulted in negative attitudes andassumptions. In turn, physicians described problems or situations that were thefault of nurses.
The original intent of identifying a problem in the operating room and thenworking backwards from the problem to the originator is one of prevention. If aHCW could determine causation, he or she could prevent future problems;although, many problems can be resolved or avoided, it also begins the blamegame. According to Dawes, "As problems continue and the cycle of blameperseveres, not only do individuals get a bad rap, but professional sufferingand lack of respect for each other becomes more difficult to overcome."
The perioperative team experiences strained interaction as stressors of thework environment create tension. Tension is a necessary ingredient in theoperating room, as it spurs teams to respond to the changes in the environmentor patient condition. Technology has enabled surgeons to perform procedures lessinvasively, while increasing the technical competency required for assemblingequipment and executing intricate procedures. Each team member has differentknowledge, 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. Thepatient delayed in admissions, enters the room, accompanied by anesthesiapersonnel and is greeted by the circulator. The permit is verified, and thepatient anesthetized, all while the scrub person is setting up the sterile fieldin preparation for a laparoscopic cholecystectomy procedure. The circulator hasperformed the standard check of equipment prior to the patient entering theroom: the insufflator is set to the proper pressure setting. The CO2tank is full, the monitors are positioned, the video recorder is properly setup, and the light source is working. The skin prep is performed as thecirculator and scrub person count sponges, needles, and blades. The patient isdraped and all await the entry of the surgeon. He arrives and immediately beginsby relaying to everyone his displeasure at the amount of time between cases,also known as the "turnover time." In his mind, turnover time has beenexcessively long and he berates the team, until he focuses his remarks solely onthe circulator for failing to move things along. "Have you been sitting onyour hands?" was one of his remarks. The nurse described her feelings ofanger, because the unfair remark was directed toward her. She also wasfrustrated because the delay in the patient's admission process lengthened theturnover time. She felt underappreciated and defensive.
The scenario described can either escalate or be defused by the next actionsof the team. The surgeon has personalized his comments and directed hisfrustration toward the circulator. All who are familiar with working in anoperating room understand there is a time and a place for discussion. In thisscenario, the nurse opted to relay to the surgeon the fact that admission wasdelayed and then to discuss the problem later outside of the OR so as not toescalate the situation or to enter into the blame game mentality.
Respectful behavior begins with both listening to and considering the inputof other professionals. Respect is demonstrated through language, gestures, andactions. When conflict occurs within the operating room, positive humanconnection must occur in order to manage the situation. Objective observationsabout the situation prevent the interaction from becoming personalized. Maun9believes that as professionals in healthcare, our conflict management skills canbe improved and developed on an ongoing basis. Interpersonal skills need to besharpened in order for an organization to be healthy. Interpersonal conflict canbest be remedied when it is addressed directly and teaming practices are used torequire individuals to come up with solutions themselves. When conflict occurswithin an organization, the appropriate management steps include:
The perioperative team can become dysfunctional in that, as the team developsas a single unit, individual members can assume roles that can decrease thehuman connection. If one team member assumes the role of victim or blamer, he orshe can be relied upon to assume the negative role when something goes awryduring 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 tocontrol the entire team's dynamics. Maun identified "problem finders"as the person who has a doctorate in problem finding and a second-gradeeducation in problem solving. He calls the person a BMG--a bellyacher, moaner,and groaner. The negative aspects of a dysfunctional team lead to a hardenedgroup of people unwilling and unable to collaborate for the success of the team.
Thriving perioperative teams seek to improve the human connection. The teaminteraction is professional and respectful. One nurse described working on sucha team as a member of a cardiovascular team. "You know when things start togo wrong with the patient, our surgeon maintains his cool, no yelling andscreaming at the rest of us, just quiet control, and that helps me to remaincalm and work under pressure to resolve the problem." The nurse's wordsspeak volumes about human collaboration and connectivity on that perioperativeteam.
Every day in every operating suite, perioperative teams gather for the solepurpose of providing excellent care to patients in crisis or need. Changes thatoccur in the operating room which relate to the patient, the environment,equipment, instrumentation, or personnel all have an effect on the perioperativeteam. Good perioperative teams recognize that the patient is the most importantperson in the room--the focus of all effort and duty. The secondary obligationof the perioperative team members is to the team itself. The duty of theperioperative team is to work toward collaboration in order to cement thecommitment to each member and to the overall mission and goal of humanconnection.
Ruth A. LeTexier, RN, BASN, PHN, is the director of surgical technologyat Northwest Technical College in East Grand Forks, Minn.
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