UNIT ONE Lesson 1 Fundamentals of Perioperative Nursingrnpdc.nshealth.ca/images/pdf/Unit 1 Lesson 1...

Unit One: Lesson 1 Fundamentals _________________________________________________________________________

_________________________________________________________________________ September 2015 © RN Professional Development Centre & Nova Scotia DOH, Halifax, NS 1

UNIT ONE

Lesson 1 Fundamentals of Perioperative Nursing

Introduction This lesson will provide an overview of the three components that come together to provide for a competent, compassionate, and safe surgical experience: perioperative patient factors, perioperative nursing factors, and perioperative environmental factors. The level to which these three components are considered by the perioperative nurse and the collaborative team will determine the difference between a poor surgical experience and an optimal surgical experience. This lesson will provide the foundation for the remaining lessons in the perioperative nursing program. Learning Outcomes 1. Identify patient factors that the perioperative nurse needs to consider when

promoting a safe surgical experience.

2. Define perioperative nursing.

3. Differentiate between preoperative, intraoperative, and postoperative phases of the surgical continuum.

4. Describe the two different perioperative nursing roles. 5. Discuss what is meant by Standards of Perioperative Practice and relate ORNAC’s

role in it.

6. Discuss the benefits of teamwork, collaboration, and effective communication in the perioperative setting.

7. Examine the role of professionalism in perioperative nursing.

8. Identify some basic conflict management strategies that may be used in the

resolving conflict with health care team members.

9. Discuss patient safety and importance in the perioperative environment.

10. Recognize the value of quality improvement in the perioperative environment.



11. Discuss the importance of being knowledgeable regarding legal issues in the perioperative environment.

Required Readings Operating Room Nurses Association of Canada. (2015). ORNAC Standards for

Perioperative Registered Nurses (12th ed.). Canada: Author. • Foreward, page 11 • Section 1, page 19-21, 32

Required Video AORN. (2014). Perioperative Environment of Care. [39 mins]. AORN: Denver, CO. AORN. (1998). Effective Team Building in the OR. [15 mins]. AORN: Denver, CO.



Perioperative Patient Factors Before we can explore the various perioperative patient factors that perioperative nurses must consider when promoting a safe surgical experience, let’s first explore a case study and the patient’s health journey that is requiring surgical intervention.

Case Study Jack Murphy is a 64 year old retired carpenter who is booked for an elective right below the knee amputation. He is married to his wife, Marilyn, and has two grown sons who both live in his home community of Bridgewater, all of whom are with him today. Jack has a grade twelve education. He is Catholic and attends mass regularly. He still enjoys working in the workshop making wooden pieces for Marilyn’s toile painting projects. Jack smokes a pack of cigarettes per week but denies drinking any alcohol. Jack retired at the age of 60 and had since decreased his activity and put on extra weight. Jack weighs 200 lbs or 91 kgs (height is 5’10” or 178 cm). He has NIDDM but does not take any medication for his diabetes. Marilyn checks his blood glucose every couple of days at home and has kept him on a strict diet for the past year and he had lost a total of 30 pounds. He takes no medications other than multivitamins, and ibuprofen for occasional headaches. His lab values are all within normal ranges, including his blood glucose. His only previous surgery was for a torn rotator cuff repair to his right shoulder 10 years ago. He stated having decreased range of motion to this shoulder with some arthritis in this shoulder and both knees. Jack had a sore on his right heel for the past 3 months that would not heal properly. The right heel and foot became severely infected over the past number of weeks. Jack’s GP placed him on antibiotics and narcotics (Tylenol#3) for pain for his infected foot, and referred him to the surgeon for a below knee amputation. Jack just saw the surgeon in the preoperative area and Jack did not voice any concerns or questions regarding the surgery itself. However, Jack seemed upset with the outcome of the surgery and how he will function with everyday life without his foot. After consultation with the anesthetist, Jack has elected for a general anesthetic. Case Analysis To achieve an optimal surgical experience, the perioperative registered nurse must first explore Jack’s health journey, which is requiring surgical intervention. From the perspective of a perioperative nurse, we must consider the unique attributes and resources that Jack brings to his surgical experience: his physiologic condition, psychosocial needs, complexity of care needs, predictability of care outcomes, and risk for negative outcomes from care. So let’s look more in-depth at the patient factors, and consider how these factors influence the patient’s surgical experience.



In exploring a patient’s health journey, it is important to get an understanding of where the patient is on the health-illness continuum and how this has led to the requirement of a surgical intervention. The overall goal is to identify as many positive health factors that the patient is presenting with, and to also identify the negative health factors that are impacting the patient’s health and could pose risk and complications during the surgical experience. Both positive and negative health (risk) factors need to be identified in promoting an individualized plan of care and a safe surgical experience. • Physiologic condition (body systems, nutrition, weight/height, age, mobility, pain,

medications, allergies, developmental stage, etc.)

• Psychosocial needs (health literacy, coping, anxiety, support, culture, values, spiritual needs, etc.)

• Complexity of the patient’s care needs (e.g., co-morbidities, chronicity, etc.)

o Complexity of the patient’s needs is hard to define. The current literature debates putting a specific definition to complexity but for the purposes of the program, we will define complexity as patients with multiple chronic conditions, frequent hospitalizations, and limitations on their ability to perform basic daily functions due to physical, mental and psychosocial challenges (Hickman et al, 2013).

• Predictability of outcomes of patient care (e.g., geriatric or pediatric, length/extent

of surgery, etc.) o Predictability of outcomes of patient care refers to how well the patient

ends or fairs in the expected condition, at the expected time, and using the expected resources at the end of the surgical continuum. Hence, it is about anticipating the possible variations in the surgical continuum that may happen to the patient.

• Risk of negative outcomes in response to care (e.g., risk for unanticipated events -

elective versus emergency case, trauma patients, etc.) o Risk of negative outcomes in response to care refers to how well we can

predict a patient’s response to care. A negative outcome is an unanticipated, unexpected, or unplanned response to treatment or intervention (CRNNS & CLPNNS, 2012).

Every attempt is made to identify and stabilize those conditions that could potentially hinder a smooth surgical experience. When negative patient factors dominate, it places the patient and surgical team at risk for unexpected events (ORNAC, 2015). Hence, identification of these patient factors helps reveal both the professional and the perioperative environment factors/resources that need to be considered if optimal results are to be achieved for the surgical experience (Woodhead & Wicker, 2005).



The above patient factors will be explored in further detail throughout the program and how the perioperative registered nurse incorporates these patient factors into achieving an optimal surgical experience.

Case Analysis In reviewing what we know about Jack Murphy, let’s explore what patient factors would be relevant to the perioperative nurse. • Physiologic condition – Jack is in relative good overall health except for his NIDDM

and his right gangrenous foot. He does have limitation in his mobility due to the arthritis and previous shoulder surgery.

• Psychosocial needs – Jack’s family is present and seems to be a good support. Jack

understands his surgery and what will happen during it. Jack will need support postoperative for ADLs and for the loss of a limb, included in a rehabilitation program.

• Complexity of the patient’s care needs –Jack does not present as a patient who is

overly complex. He has NIDDM and a he is a smoker. He has had one previous shoulder surgery and this left him with decreased ROM.

• Predictability of outcomes of patient care – Jack is 64 which put him more at risk for

anesthetic complication due to his age, especially because he is a smoker. The surgery would last approximately 45-60 minutes; therefore, it is not a long surgery.

• Risk of negative outcomes in response to care- This is an elective case and the

surgical procedure is fairly routine. The gangrenous foot may increase his risk if the infection is more widespread than anticipated.



Perioperative Nurse Factors We will now move onto the perioperative nurse factors that help us in preparing for an optimal surgical experience for our patients. Let’s go back to our case study involving Jack Murphy.

Case Study Susan, RN, has been assigned the role of the circulating nurse for the first scheduled surgery of the day. When she checks the OR list for her assigned vascular surgery room, she notes it says Jack Murphy, 64, is scheduled for a right below the knee amputation at 0730. Susan feels confident in circulating for this case as she had previous experience in the circulating role for these types of cases since coming to the OR 5 years ago after completing her post graduate perioperative program. She has worked on a rotating basis through general surgery, vascular surgery, and plastic surgery since completing her program. She also acquired her Canadian Nurses Association (CNA) certification in perioperative nursing. She notes that she is also assigned in the room with George, a perioperative LPN, who has 6 months experience since completing his perioperative LPN program. Susan knows that there will be another RN assigned to the room at 0900 to help with breaks and lunches. Susan completes her work in setting up her scrub nurse George and completes her set up for a circulating nurse’s role in the operating room. Susan moves now down to the preoperative area where Dr. Allan, the anesthetist, and Dr. Wong, the vascular surgeon, are speaking with Jack Murphy and his wife Marilyn regarding the surgery. Dr. Wong was getting the patient to sign the consent for the below knee amputation to the right knee and marked the right leg as the appropriate surgical site with his initials. Dr. Wong and Dr. Allan agreed upon a preoperative course of antibiotics and then Dr. Allan reviewed the anesthetic options with Jack and Marilyn. Susan then proceeds with her assessment of the patient asking such things as allergies, previous medical history, last time something to eat/drink, mobility issues, etc. In completing her assessment, Susan was asked by Jack and Marilyn if it would be possible to have Jack take his rosary beads in the OR with him as he goes to sleep. Susan agrees and proceeds with Jack Murphy to the operating room to get started with the surgical procedure. Case Analysis To provide safe, competent, ethical, and compassionate care for Jack Murphy during the surgical experience, Susan requires specific knowledge and skills. Susan needs to understand what perioperative nursing entails- perioperative phases, roles of the perioperative nurses, standards of perioperative nursing practice, and her scope of practice.



What is Perioperative Nursing? Perioperative nursing was formerly referred to as “operating room nursing”. This term historically referred to patient care provided in the intraoperative period and administered within the operating room itself. However, as the responsibilities of the operating room nurse expanded to include care in the preoperative and postoperative periods, the term “perioperative” was recognized as a more appropriate term (Phillips, 2013). Perioperative nursing focuses on the surgical experience and the meaning this has for patients, families, nurses, and other members of the health care team. Working collaboratively with an interdisciplinary team including surgeons, anesthesiologists and other health care team members, the perioperative registered nurse continually advocates for the needs and dignity of the patient. Overseeing every step, from pre-surgical preparation to post-surgical care, the role demands methodical preparation, technical knowledge, sound situational judgment, critical thinking, as well as sensitivity and compassion (Phillips, 2013). Perioperative nurses integrate a broad range of knowledge and skills in perioperative nursing by:

• Preparing, managing and monitoring the work environment to minimize risks and provide comfort for diverse patient populations

• Working efficiently, effectively and collaboratively as a member of a interprofessional perioperative team

• Assessing the needs and personalizing the care of individuals throughout the various phases of their perioperative experiences

• Managing complex technology and competently performing diverse perioperative care activities

• Relating competently in a diverse range of interpersonal interactions with individuals and groups

• Managing change in a fast-paced, highly technical work setting (AORN, 2013a). Perioperative Phases Perioperative nursing is a comprehensive practice supporting the patient’s surgical experience from the preoperative, through the intraoperative, and into the postoperative period. According to ORNAC (2015), perioperative nursing practice is categorized in three distinct phases: preoperative, intraoperative, and postoperative. However, for the purposes of this program, we will also include the immediate preoperative and immediate postoperative phases, which are more descriptive of the surgical continuum.



Preoperative: begins when the decision for surgical intervention is made and ends with the transfer of the patient to the operating room bed (ORNAC, 2015). Immediate preoperative: period where the OR nurse receives the patient to the placement of the patient on the OR table (ORNAC, 2015). Intraoperative: begins when the patient is transferred to the operating room bed and ends when the patient is admitted to the post anesthesia care unit (PACU) (ORNAC, 2015).

Immediate postoperative: period in which there is emergence from anesthesia and transfer of patient care to the appropriate health care provider (ORNAC, 2015). Postoperative: begins with the admission to the PACU and ends with a resolution of the surgical condition (ORNAC, 2015). These phases will be continuously referred to throughout the program. Each phase will be explored in further detail and how the perioperative nurse’s role changes with each phase on the surgical continuum. Perioperative Nursing Roles There are two main perioperative nursing roles in the operating room, circulating nurse and scrub nurse that you will be learning while in this perioperative nursing program. A circulating nurse is a perioperative nurse that manages the plan of care for the patient during surgery. The circulator is not scrubbed in the case, but rather coordinates the needs of the surgical patient, the surgical team and the management of the perioperative environment during the surgical experience. A scrub nurse is a perioperative nurse that works directly with the surgeon and the scrubbed surgical team (e.g., surgeons, assistants, residents, etc.) within the sterile field. The scrub nurse remains “sterile” and is responsible for directly assisting the surgical team by anticipating and providing the necessary instruments and supplies during the procedure. The roles and responsibilities of the scrub and circulating nurse roles will be outlined in further detail in future lessons.



Standards of Perioperative Nursing Practice Perioperative nurses must be able to cope with a variety of situations and provide patients with the best possible care. Written policies, procedures, guidelines and standards developed by experts in the field are ways to ensure that all perioperative personnel are following recommended perioperative practices (Phillips, 2013). In Canada, we use the Operating Room Nurses Association of Canada’s (ORNAC) Standards for Perioperative Registered Nursing Practice to guide perioperative nursing practice in attaining and maintaining competence in the performance of quality patient care (ORNAC, 2015). In the United States, the Association of periOperative Registered Nurses (AORN) publishes the Perioperative Standards and Recommended Practices which help guide perioperative practice in an effort to promote optimal patient care (AORN, 2013b). Operating Room Nurses Association of Canada ORNAC is a non-profit volunteer organization comprised of expert perioperative Registered Nurses from across Canada (ORNAC, 2015). ORNAC has a membership of over 3500 members and it is an associate member of the Canadian Nursing Association (CNA). The organization is completely managed by volunteers who give of their time to promote educational programs and high standards of operating room nursing practice. ORNAC serves as a spokesperson for perioperative registered nurses on issues affecting registered nurses, nursing practice, patient care, and societal needs/expectations. ORNAC produces the ORNAC Standards which assist nurses and health care facilities in applying national standards in the perioperative setting. These standards of practice provide standards, guidelines, and positioning statements that ensure patient safety and quality patient care in the perioperative environment in all Canadian operating rooms (ORNAC, 2015). Please refer to your required readings in ORNAC (2015) for further explanation of the ORNAC Standards and their role in perioperative nursing. This perioperative nursing program will be using the ORNAC Standards in most classes, labs, and clinical, and will remain a constant throughout your future perioperative nursing careers. Scope of Practice In health care, all health professionals are expected to work collaboratively with each other and in partnership with the person receiving care. This is also true with the profession of nursing, where we have Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) working together in caring for patients receiving care.



RNs, LPNs, and managers are responsible to ensure that the patient is matched with the nurse whose scope of practice best meets their health care needs (CRNNS & CLPNNS, 2012). The scope of practice (outer limits of practice) of an individual RN or LPN may be constrained by education, experience, and the authority given to that particular nurse to perform all of the functions outlined within the definition of the practice of nursing (RN Act) and the practice of practical nursing (LPN Act) (CRNNS & CLPNNS, 2012). RNs, LPNs, and managers must be aware that effective decisions to match patient needs with either a RN or a LPN focus on three factors of equal importance – the patient, the scope of practice of the nurse, and the environment. The more complex the client situation and the more dynamic the environment, the greater the need for a registered nurse to coordinate, and if necessary, provide the full range of nursing care, assess changes, re-establish priorities and determine the need for additional resources. When the licensed practical nurse requires consultation on an increasing basis such that it interferes with efficient care delivery, it is most likely that the client requires care provided by a registered nurse (CRNNS & CLPNNS, 2012). This intra-professional collaboration occurs in the clinical setting and requires both time and resources for efficient and effective consultation, as often as necessary, to meet patient needs (CRNNS & CLPNNS, 2012). This is also very true in the operating room as well. In the perioperative setting, both RNs and LPNs function in similar but different roles depending on their own education, experience, and authority given to that particular nurse to perform certain functions in their own health care facility (scope of employment). The complexity of surgical patients, the nurse’s competence, and resources available in the perioperative setting, influence the amount of consultation required, and in turn, which perioperative nurse is the right provider of care to best meet the patient surgical outcomes (Department of Health and Wellness, 2013). This important discussion on scope of practice and how it affects the perioperative nurse’s role and the general functioning of the surgical suite will be further explained in future lessons.

Case Analysis In looking at the surgical experience of Jack Murphy, Susan must consider a variety of perioperative nurse factors when planning for the optimal surgical experience. • Perioperative phase- Susan and her patient Jack are currently in the immediate

preoperative phase. There is a lot of coordination with the interprofessional team during this time to make sure everyone knows their roles and responsibilities prior to the start of surgery.



• Roles of the perioperative nurse- Susan takes the lead in the circulating role as she is paired with a junior perioperative LPN. There is no other relief from another RN until 0900 so the patient care is best served with the RN as the circulating nurse for this case and the LPN George in the scrub role.

• Standards of perioperative nursing practice and scope of practice- Susan would be

considered an expert in the field of perioperative nursing with her education and nursing experience. In Susan’s health care facility, her facility permits a perioperative LPN to function in the scrub role only when there are 2 staff (1 RN and 1 LPN) per operating room.

Perioperative Environment Factors The perioperative setting is a consistently fast-paced, unpredictable, and multifaceted environment. In this environment, perioperative nurses are expected to work with a variety of perioperative services, team members, and equipment, to coordinate and deliver safe, compassionate and competent care to their patients.

Case Study Susan has brought Jack Murphy in the operating room and gets Jack settled on the OR table and connected to patient monitors (e.g., ECG, blood pressure, and pulse oximetry). Dr. Wong reviews the surgical safety checklist with the surgical team, including Jack Murphy in correctly identifying the operative procedure and correct operative site. Susan assists Dr. Allan in administering the general anesthetic to the patient and the patient goes off to sleep without incident. Susan and Dr. Wong begin to position the patient for the below the knee amputation. Susan asks both the anesthestist and surgeon of possibility keeping the patient’s right arm tucked at the side due to his previous surgery and limited range of motion. The entire surgical team agrees and the patient is prepped, draped, and surgical incision is made at 0742. Case Analysis Susan must take into consideration the following perioperative environment factors when planning Jack Murphy’s care: collaboration with an interprofessional team, communication/conflict management, safety, legal issues, and available resources.



Team Work and Collaboration

Successful surgery depends upon the coordinated activity of a well-prepared surgical team whose members work synchronously with one another to meet the needs of the patient. The patient’s comfort, health, and well-being depend upon every member of this team doing his or her job well. Team members, committed to the premise that the patient is at the centre of all we do, recognize that it is only through continued aseptic vigilance, communication of information, and coordination of expertise that optimal surgical outcomes can be achieved. Interprofessional Collaborative Teams Many health professionals would claim that they presently work on teams. Often these teams are coordinated teams in which there is distinct professional roles, designated team leadership, nonconsensual decision making and little emphasis on group process. This type of team functioning is very different from the interprofessional collaborative team where individuals integrate their efforts, competence, and skills to work on a common goal of positive patient outcomes. The key determinants for collaborative practice involve the team members sharing: • Knowledge of each other’s roles • Good communication, including negotiation skills • A willingness to work together • Trust related to self-competence and competence in other’s abilities • Mutual respect, which implies knowing other health professionals and their

contribution to patient care.

For effective interprofessional collaborative practice, it is important that team members share a common patient-oriented vision and goal. Saying that the patient/family is at the center of the collaborative patient-centered team is not just a courtesy so that the patient/family feels involved. In collaborative practice, the patient is the reason the team exists. Most professional fields recognize the importance of effective collaboration. Complex work environments, like the perioperative environment, require individuals to perform together in order to efficiently and effectively provide services, while preventing costly inefficiencies and mistakes. Interprofessional collaborative practice involves a group of individuals from different health professions working together towards a common goal, the advantage being that each professional brings different perspectives to the team caring for the patient. In the perioperative environment, the interprofessional team consists primarily of surgeons, anesthetists, and nurses.



Communication and Professionalism With increased use of interprofessional health care teams, it is becoming more important for all health professionals to understand how health care teams work and communicate with the team (Smith & Jones, 2009). Individuals within the team, including perioperative registered nurses, occupy different roles and need to coordinate/collaborate with one another through communication (Smith & Jones, 2009). As we explore how the surgical team communicates with one another to get a case completed, it becomes apparent that effective communication is not only necessary, but imperative for a successful outcome. The entire surgical team, including the perioperative registered nurse, must work together in the perioperative environment to prevent undesired outcomes resulting from ineffective or incomplete communication and develop communication strategies that are timely and effective vehicles for transmission of valuable patient information. In promoting effective communication strategies to ensure quality care and cooperation of the team, there must be respect and appreciation for each team members’ unique skills and contribution. In demonstrating this respect for other team members, it is important to understand that each team member has their own professional behaviors and characteristics that distinguish one team member from another. How these behaviors and characteristics get portrayed is known as professionalism. Professionalism is the use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the patient and the community being served (Epstein & Hundert, 2002). Professionals maintain their autonomy through self-regulation, serving as an advocate for the public and being accountable to the public. Perioperative nursing is a professional branch of nursing that combines standardized and individualized care to its patients in the perioperative environment (Phillips, 2013). The perioperative registered nurse is a health care professional who is responsible and accountable for the nursing care of the surgical patient during the surgical experience (ORNAC, 2015). The remaining members of the interprofessional team, such as the surgeons and anesthetists, are responsible and accountable for the surgical and anesthetic care, respectfully. Other members of the surgical team such as technicians (anesthesia, surgical, etc.), housekeeping, porters, patient attendants, sterile processing staff, support staff (clerks) are non-regulated personnel whose responsibilities are clearly defined by each heath care facility’s job description. All members, both regulated and non-regulated, must work together in communicating the needs of the surgical patient throughout the surgical experience.



Conflict Management The OR is a challenging environment where people work closely together for extended periods of time, therefore, it is inevitable that differences may arise (Phillips 2013). Differences that are handled properly can result in richer, more effective, and collaborative interactions. When disagreements are handled poorly the outcome can be contention and conflict. It is therefore, very important for perioperative nurses to have the skills to resolve conflicts that occur in the perioperative environment. Conflicts should be addressed professionally, in a timely manner and in an appropriate place (Phillips 2013). A few common strategies that may be useful when communicating professionally would be to avoid blame, remain objective, and to maintain respectful language (Phillips 2013). Here are more basic strategies to help you in resolving conflict.

• Acknowledge that the problem exists. Ignoring the issue will not make it go

away. However, taking some time to think the problem over may help in resolving it, but do not let too long a time lapse between the situation and when you deal with it.

• Focus on the issue, not the person. Focus on one issue at a time, if there is more than one involved.

• Discuss matters privately. The charge nurse’s station is not the place to discuss a conflict. Choose a private place, preferably on neutral ground. If at all possible, keep the conflict as quiet as possible.

• Choose your words carefully. Use “I” statements: I feel, I wanted, I think. Avoid placing blame on the other party. This can only cause resentment and anger in the other person. Be positive; try to stay away from negative statements and criticisms. Keep to the facts.

• Be direct. State what you want to say in a clear and direct manner. Do not be ambiguous. Clearly communicate your wants and needs so that the other person(s) know where you are coming from. Back up your statements with reasons why you feel the way you do. Try not to argue. You are there to solve a problem, not prove that the other person is wrong.

• Keep your emotions in check. Expressing your anger or frustration may prevent you from communicating your views in a logical manner. Anger is a negative emotion and can cause the conversation to be non-constructive.

• Listen to what the other person is saying to you. This includes making an effort at understanding the person’s point of view. Ask questions and pay attention to nonverbal clues. If you both have an understanding of the other’s perspective, then you have a better chance of agreeing on a solution.

• Be prepared. Sounds like the Boy Scouts, but come to the meeting with not only a Plan A on how to solve the problem, but also a Plan B. If you can anticipate possible objections to your plan, you can come up with alternatives. You will stand a better chance at resolution if you come prepared.



• Put your heads together. See if you can collaborate with the other person to agree to a solution to your problem. Agree to work together to resolve the problem.

• Be willing to compromise. Find a way to compromise. Compromise is most effective when each individual feels they are in a winning situation to some degree. Before agreeing on a compromise, make clear which issues are negotiable and which ones are not.

• Push the ego aside. A win-win situation is the ideal; however, this may not be possible in all situations. Be prepared to accept compromise.

• Accept personality differences. Personality differences are bound to happen in working relationships, especially in the operating room with a variety of professionals comprising the surgical team. You cannot like everyone. You have little control over a team member’s behavior(s) and opinion(s). Focus your energies on your own thoughts and actions to prevent an unpleasant situation.

• Seek help. Seeking help from a third party (e.g., preceptor, mentor, charge nurse, manager, etc.) may help if the problem is too large or you just cannot come to a solution.

• Take action. Follow through on an agreed course of action. Follow up to ensure that lines of communication remain open.

• Keep things in perspective. Is the problem something you can live with? Will it matter to you in 3 hours, 3 days, or 3 weeks? If the answer is no, think again before confronting a person with a situation. Direct your energy elsewhere.

Let’s return to our case study to see how George, the perioperative LPN, manages conflict when it arises during the amputation for Jack Murphy.

Case Study The surgery is well underway and without complications until Dr. Wong encounters an increase in bleeding while performing the amputation. He asks for a particular suture and more sponges. A moment later he repeats his request for the particular suture in a very stern voice. George fumbles looking for the appropriate needle driver in his string of instruments and drops the needle driver on the floor. Dr. Wong snaps, “Are you incompetent?” Susan quickly moves over to the back table and directs George with her finger to another appropriate needle driver. George loads the suture and passes it to the surgeon. Dr. Wong is able to control the bleeding and the surgery proceeds along uneventfully after this. Dr Wong completes the amputation and the patient is transferred to PACU. George transports the case cart to dirty utility room and on his way back to the room he sees Dr. Wong finishing up a phone call in the hall. George asks to speak with Dr. Wong



in an empty OR. George communicates with Dr. Wong that he felt upset by Dr. Wong’s comment. George stated that he recognized that the period of bleeding was very tense for both Dr. Wong and himself, but felt that he was not deserving of that comment. Dr. Wong agreed and apologized to George, stating that he had not meant that comment and had been stressed by the complication of the bleeding. Case Analysis By addressing the conflict in a timely manner and in an appropriate manner, George was able to convey how Dr. Wong’s comment made him feel. He also was able to communicate to Dr. Wong that he did recognize that the patient’s condition was a contributing factor but that the comment did not promote collaborative teamwork, especially during a stressful phase of the surgery. George was able to conduct himself professionally by remaining objective, respectful, and avoiding blame.

Safety and Quality Improvement One of the most important environmental factors that perioperative nurses must take into account when planning the care for their surgical patients is the concept of safety. This focus on safety drives practice and unifies the interprofessional team to work toward the common goal of personal, professional, and patient safety (Watson, 2011). Patient safety is a concern for all health team members. According to the Canadian Nurses Association (2008), patient safety is an important issue for nurses who are committed through their code of ethics to providing “safe, competent and ethical care”. It is essential to admit when errors occur, learn from the errors, and develop a preventative approach by studying and improving all the components that impact on safety. The new vision of patient safety moves health care providers from the nonproductive practice of placing blame to a proactive approach which focuses on protecting patients from harm (either real or potential), and promoting safer patient care practices and environments. Two initiatives currently underway to promote safer patient care include the Safer Healthcare Now campaign and the focus by Health Canada to promote collaborative patient-centered practice. The operating room is no different when it comes to striving to produce a safe environment for patients and staff. The operating room is a unique environment that includes many challenging variables: complex clinical care performed by interprofessional teams, sophisticated technologies, and a large array of supplies,



instruments, and equipment that are difficult to manage. These variables create an environment of massive complexity and, unfortunately, are a source of a significant risk for patient and surgical team safety during the surgical continuum. Perioperative nurses must use their specialized knowledge, skills, and attitudes to provide a safe perioperative environment for themselves, their team members, and for their patients. Improving quality is about making healthcare safer, more effective, efficient, and patient-centered. It is about identification and adoption of strategies that promote improvement in the delivery and outcomes of patient care using our evidence-based practices. In the perioperative environment, perioperative nurse can strive to improve the care provided to patients in the operating room setting promoting such things as efficient room turn-over times, tracking delay times, participating in safety checklist, etc. Each and every lesson in this perioperative nursing program will bring out the importance of safety in the perioperative environment, and the perioperative registered nurses role and responsibility in promoting and improving safety. Legal Issues A rapidly changing healthcare system, development of new information technologies and interventional technologies, and deeper emphasis on professional scope of practice are creating legal issues in nursing practice. Providing patient centered care mandates the public become better informed about adequate health care and it is an expectation that they are involved in making decisions that affect their plan of care. Patients undergoing surgical interventions are unable to protect themselves and must rely on the surgical team for their well-being. To effectively meet the challenges of delivering quality care to patients, the perioperative nurse must be knowledgeable about and adhere to legal and professional nursing standards and incorporate them into their daily practice. Legal issues such as consents, confidentiality, and surgical counts will all be discussed later in the program and their application to the perioperative environment. Resources The perioperative nurse considers factors related to safety, effectiveness, efficiency, and environmental concerns, in planning and delivering quality and safe patient care. The perioperative registered nurse needs to be aware of the environmental resources required in the perioperative setting such as:



• Surgical team members and ancillary staff’s knowledge, skill, and expertise (e.g., extra staff in case of emergency-for example nursing or anesthesia, dayshift staff resources versus on-call staff resources, etc.).

• Equipment and supplies availability and complexity (e.g., additional equipment for malfunctions, additional supplies, portable oxygen, extra instruments if contaminated, knowledgeable staff available for complex equipment, etc.).

• Technology requirements (e.g., clinical equipment, informatics, electronic health

record, etc.).

• Linkages with other units/departments (e.g., blood bank, radiology, medical records, ICUs, etc.).

Case Analysis In preparing Jack Murphy for a safe surgical experience, Susan must consider the following perioperative environment factors: • Collaboration/Communication within an interprofessional team- Susan, Dr. Wong,

and Dr. Allan were in constant communication regarding the surgical plan for Jack Murphy and his family in his surgical experience. Each surgical team member was aware of each other’s roles. Susan advocated for her patient by bringing forth his previous surgery to his right shoulder and collaborating with the surgical team a possible option to the standardized positioning that would take into account this potential risk for additional injury (negative outcome).

• Safety- The surgical team performed the surgical safety checklist, making sure to

include the patient to make sure the correct operative site was reviewed. • Legal issues- In the preoperative area, Susan identified the correct consent on the

chart. • Resources- Susan and George would have reviewed the case at beginning of the

shift to make sure they had all the equipment and supplies they needed. Equipment would have been checked for safety issues prior to patient use. Susan made sure that the surgical team was present and ready to proceed prior to taking patient to the operating room.

Although the above perioperative case scenario demonstrates a very simple and basic surgical experience for the patient Jack Murphy, it outlined the perioperative lens



that was used by the perioperative nurse Susan in which to view the patient during the surgical experience. It demonstrates the importance of how the three components of patient factors, nursing factors, and environmental factors come together to promote an optimal and safe surgical experience. Summary Perioperative nursing is a highly skilled specialty that aims to provide competent, individualized patient care. This nursing specialty promotes comfort, safety and stability for individuals undergoing surgery and anesthesia, by collaboratively managing and coordinating all phases of individuals' perioperative experiences, advocating for their rights and needs and providing the "human touch" in a predominantly technical environment. Internet Links Operating Room Association of Canada (ORNAC) http://www.ornac.ca/ Association of periOperative Registered Nurses (AORN) https://www.aorn.org/

http://www.ornac.ca/

https://www.aorn.org/



References AORN (2013a). Orientation of the Registered Nurse and Certified

Surgical Technologist to the Perioperative Setting. Retrieved Sept 13, 2013 from http://www.aorn.org/TwoColumnInsert.aspx?id=21939&terms=position%20statements

AORN (2013b). Perioperative Standards and Recommended Practices. Denver,

Colorado: Author. Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa:

Author. College of Registered Nurses of Nova Scotia and College of Licensed Practical Nurses of

Nova Scotia (2012). Guidelines Effective Utilization of RNs and LPNs in a Collaborative Practice Environment. Halifax, Nova Scotia: Author.

Department of Health and Wellness (2013). Collaborative Care Guidelines for

Perioperative Nurses, RN & LPN. Halifax, Nova Scotia: Government of Nova Scotia.

Epstein, R. M., and Hundert, E.M. (2002). Defining and assessing professional competence. Journal of the American Medical Association, Jan 9;287(2):226-35.

Giddens, J.F. (2013). Concepts for nursing practice. St. Louis. MO: Elsevier. Hickam, D.H., Weiss, J.W., Guise, J.M., et al. (2013). Outpatient Case Management for

Adults With Medical Illness and Complex Care Needs . Retrieved Sept 13, 2013 from http://www.ncbi.nlm.nih.gov/books/NBK116491/

Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the

21st century. Washinton, D.C.: National Academies Press. Retrieved Sept 23, 2013 from http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

Operating Room Nurses Association of Canada. (2015). ORNAC Standards for

Perioperative Registered Nurses (12th ed.). Canada: Author. Phillips, N. (2013). Berry & Kohn’s Operating Room Technique. (12th ed.). Toronto:

Mosby. Rothrock, J.C. (2015). Alexander’s Care of the Patient in Surgery (15th ed.).Toronto:

Mosby. Smith, B. & Jones, C. (2009). Perioperative communication. Journal of Perioperative

Practice, 19(8), 248-253.

http://www.aorn.org/TwoColumnInsert.aspx?id=21939&terms=position%20statements

http://www.aorn.org/TwoColumnInsert.aspx?id=21939&terms=position%20statements

http://www.ncbi.nlm.nih.gov/books/NBK116491/

http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx



Watson, D.S. (2011). Perioperative safety. Toronto: Mosby. Woodhead, K., and Wicker, P. (2005). A textbook of perioperative care. Toronto:

Mosby. World Health Organization (WHO). (2013). Determinants of health. Retrieved on Sept 2,

2013 from http://www.who.int/hia/evidence/doh/en/

http://www.who.int/hia/evidence/doh/en/

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