Clifford A Jordan, RN
Accountability for nursing practice
In the keynote address I delivered a t the 1977 AORN Congress, I focused on nurse control of nursing practice. I took the position then, as I do now, that nursing is an independent health care profession and that professional nurses are accountable to their patients for the care they give. Accountability, a t the root of control and autonomy in decisions about nursing, is a requirement for the independent practice of nursing in any setting, including the operating room.
Clifford H Jordan, RN, EdD, is associate professor and director,graduate program in nursing service administration, University of Pennsylvania, Philadelphia.A graduate of the Pennsylvania Hospital School of Nursing for Men, Philadelphia, he received his BS and E d D degrees from Temple University, Philadelphia,and his MS degree from the University of Pennsylvania. This article was originally presented as a speech to the Michigan Association of Operating Room Supervisors in Oakland, Mich.
1076
Nurses who have chosen to pursue careers in the operating room have a strong and abiding conviction about the worth of the field. The responses of those at that Congress t o what I said and my work in 1977 with AORN as a member of the Project 25 Task Force have convinced me of the commitment of OR nurses to their field of practice. I am also convinced that OR nurses believe it is right and appropriate to continue t o reexamine their role in order t o stay current and responsive t o the nursing needs of those undergoing surgical intervention. As stated by Barba Edwards, past AORN president, “It is essential that nurses working in the operating room have knowledge and are able to practice nursing as defined by themselues and their professional organization.” This means t h a t a s nurses you have the privileges that society bestows upon its professionals, and those privileges include the right to define your practice and the right to practice your profession responsibly. It also means that for these privileges you will accept responsibility for what you do as nurses. “Accountability” is currently a fashionable term because consumers are demanding return on their investment in health care. Emphasis on cost containment and cost effectiveness are further indicators that those entrusted with t h e h e a l t h of society will be accountable for their actions. We must
AORN Journal, M a y 1978, V o l 2 7 , No 6
show that what we do is unique and needed and that sound results of our actions are evident and in the public interest. As nurses, we have not yet demonstrated readiness and willingness to accept fully the consequences of our actions. Our history, which has cast us in a subservient, subordinate role, is at the bottom of this problem. We have been seen as an appendage of medicine; our identity as full-fledged professionals has been obscured; and it has been expected, even required, that we manifest obedience and outright dependence on physicians and employers. Certainly, these attitudes do not make clear the need for accountability for our own actions. However, there is another side to this argument. Also recorded in our history is our acceptance ofa dependent position-we have not been credited with knowing much, we have not been acknowledged as vital to patient care, we have certainly not been rewarded psychologically or monetarily for what we do, and we have been either apathetic or satisfied with this state of affairs. Most disturbing, our educational preparation for nursing and the skills we have developed have never been fully tapped. Equally disturbing is the fact that we may have enjoyed and gained security in seeking and finding anonymity, content that someone else was responsible and accountable for what we did. We know, however, that under the laws that govern our practice, we are accountable and answerable for our actions, and we are liable for our own negligence. We have known these things, even if our past behavior has not suggested it. Now, the major thrust of our profession is t o gain identity as fullfledged professionals. We are proclaiming our right to autonomy, and we have signaled the public and other health care professionals that we are ready to
be accountable for our o w n acts. We are all concerned about the credibility of the role of the professional nurse in the operating room. However, if you know who you are and what your unique role is, then no other group can pose an effective threat to your role or its credibility. I believe your presence in the operating room is essential. Do you believe that? Do you demonstrate that essentialness? Does your presence in the OR make a difference to the patient? What is t h a t difference, how is it unique, and is it nursing? There are, of course, many questions related to your role that must be examined. For example, there is not full agreement about the professional nurse acting as first assistant, and it is crucial that you reach consensus on that issue. If it is to be your role, then it must be a standard of your practice and you must be prepared for it and accountable for your actions as you perform that task. If it is not, then say so, refuse to do it, and make it very clear why it is not nursing and leave it to others to decide how the surgeon will be assisted with that surgical task. Neither is there consensus among OR nurses about the perioperative role, which, according to the Project 25 definition, includes “those behaviors assumed by the nurse in the preoperative, intraoperative, and postoperative phases of the patient’s surgical procedure.” Rather, many OR nurses are content with circulating or scrubbing during the intraoperative phase of surgical intervention. What about the preoperative and postoperative care surgical patients receive that play a large part in successful surgery and full recovery? I believe the nurses in the operating room are most expert with preoperative and postoperative management. You must decide collectively what your role should be, and if it is to be the perioperative role (and I hope this is what it will
AORN Journal, May 1978, V o l 2 7 , N o 6
1077
f nurses allow others to speak for them, they will lose their credibility.
I
be), then that must be widely publicized and you must insist that it is your role. Remember that you are better prepared to teach, counsel, and support patients before, after, and during the surgery than any other nurse, OR technician, and perhaps even surgeon. It is absolutely necessary also that you evaluate your practice. If you are practicing nursing in the operating room, then no one else is competent to evaluate your practice but yourself and other OR nurses-not surgeons or hospital administrators. Nursing has made many advances in accountability already. Nursing has defined and implemented its standards for entry into nursing practice and has established a national examining system to assure safe practice in the public interest. Nursing has defined its practice in each state, and nurses act according to the laws that regulate that practice. The same laws fix penalties for infractions or violations, including revocation of the license where incompetence or gross negligence can be proved. Essentially, this means that it is becoming clearer what nursing is and what nurses are accountable for, ethically and legally, a n d primarily t h i s i s accountability to the consumers. However, most nurses in practice are also employees, and we may also be accountable to employers for certain organizational policies and regulations. However, when those policies and regu1078
lations extend to defining our role and responsibility, they are not legitimate and we must collectively reject such constraint and domination. Arrangements must be made with hospitals to include such things as cooperative and collaborative relationships with administration and other health care professionals, but only as equal partners, with as much investment in the successful achievement of goals as any other grOUP. As we move toward a model of shared governance, a s we gain parity with physicians, the kind of collaboration necessary for optimum care for patients will result. Collaboration among disciplines in the business of health care is becoming more and more important; each health care discipline, while independent in its practice, is interdependent as well. Each must rely on the other if we are to achieve our goals. If we as nurses continue to allow others to speak for us, to keep us out of the decision-making arena, then we will lose our credibility. Through my work with the Project 25 Task Force, I have had much contact with OR nurses. While I do not presume to speak for OR nurses, I do believe that your continued viability and credibility as well as increased job satisfaction and self-fulfillment will come as you accept and carry out the perioperative role. Your sphere of influence and your expertise must extend to the patient be-
AORN Journal, M a y 1978, Vol27, No 6
fore and after as well as during surgical intervention. No other nurse knows better t h a n you what goes on during surgery, so no other nurse can better anticipate the patient’s preoperative and postoperative needs than you can. To those of you who may he thinking, “Impossible,” or, “I went into the OR to get away from all that other stuff,” or, “The first assistant role is an alternative,” I hope you will think about what I’ve said. Furthermore, I take the position that the role offirst assistant is not a nursing role. Although more and more of what was once considered solely medical treatment is being incorporated into nursing, I do not see how the first assistant’s tasks fit into nursing practice. This question must be decided by the profession, not by individual nurses, but with OR nurses discussing and coming to a decision together. You can reclaim nursing practice in the OK if you want to, and asserting yourself in deciding whether you will or will not function in the first assistant role is a way to begin. The question of first assistant brings home another point-that the nursing profession is very diverse. With almost 1million nurses in active practice, titles and positions are as varied as can be. Small groups unite and move in different directions with different goals, causing divisiveness and making us all vulnerable. Educationally, we are also diverse-we are the only profession in this country that prepares its members in three ways. As nurses, we are a t different points in our education and experience and specialization. We are not all capable of doing the same things, and within specialties we have differing levels of competency. We are different from each other, each with something of value to offer, but in different ways and a t different levels. Individuals and groups must be clear about what they do, present i t well, and accept
accountability for it. Despite our diversity, I believe there is a role for every nurse in the health care system and that each must know what he or she is ready for while also being ready to learn more. We cannot permit nurses to remain complacent in the belief that they know all they need to and that things as they are and have been are still acceptable. Instead, we must provide and make accessible continuing education, either through pursuit of an advanced degree or by less formal means. To stop learning is not consistent with professionalism and accountability. If we insist on no change and continue to define our roles narrowly, we will have no future. To be accountable requires that we increase our knowledge and skills so that our practice will reflect current thinking and accountability. As mentioned above, evaluation of nursing practice is a crucial element in accountability, but who should do the evaluating and what is the basis for evaluation? Are you a good OR nurse because you serve the surgeon well, are loyal t o the institution, and have had long tenure in the same job, or are you a good OR nurse because your peers review your practice and the results of your nursing intervention and judge you competent? Peer review is, of course, the method of choice in evaluating nursing practice. It is just beginning to replace the old, ineffective performance evaluation done by superiors in the hierarchy who may not have the slightest notion of what we do. Peer review centers on practice, actual care given, and the outcome of that care, and it can be used to demonstrate that OR nurses are needed because they are essential to the patient’s welfare and recovery. It will not necessarily be easy to stand up and be counted as health care professionals. It never is. We must deal with
AORN Journal, M a y 1978, V o l 2 7 , No 6
1079
the constraints that nurses impose o n their own freedom. We m u s t face the facts t h a t many nurses seem content with things as they are; t h a t nurses feel threatened, as a l l persons do, w i t h being evaluated; that advanced and continuing education a r e not seen as required by many; and t h a t dependence o n others outside n u r s i n g to some is a desirable posture. It i s tempting t o r e m a i n dependent o n others, and it is comforting t o take orders a n d blame others i f something goes wrong. However, that i s the p a t h to professional disintegration. I believe that OR nurses have the resources to grow and t o establish firmly t h e continued credibility of the role of the professional nurse in the operating
room. AORN, a n acknowledged leader among specialty organizations, is committed t o that role. AORNs Standards of Nursing Practice: Operating Room, though n o t new, are yet to be fully implemented. The standards provide the framework for putting the nursing process i n t o action for the surgical patient, and each OR nurse has the knowledge a n d s k i l l t o implement these standards. AORN, t h e standards, and the role of t h e perioperative nurse described by Project 25 together will give y o u the tools you need t o demonstrate your abili t y t o change, inaugurate peer review, evaluate the outcome o f your care, and signal your acceptance of accountability for the care you give. 0
Elastic bandages source of nosocomial infection
Sample bandages for fungal culturing were taken from four different areas of the hospital-a patient’s room, a bone marrow laboratory, an orthopedic dressing cart, and an OR store room. All cultures grew Rhizopus species, and the cultures were confirmed by similar tests done by the US Food and Drug Administration and the manufacturer.The bandages were subsequently removed from use on patients pending further investigation. Related to fungi in the Mucoraeae family, species of Rhizopus most commonly produce infection in patients with “severe host deficiencies such as leukemia in relapse, diabetic ketoacidosis, or severe malnutrition.” According to the CDC, spread of infection by R oryzae was unique because the microorganism is “ubiquitous in the hospital environment and patients are presumably exposed to this and related microorganisms commonly without developing disease. The fact that 6 patients, including 3 without serious serious underlying host disorders, acquired Rhizopus infection after exposure to contaminated (elastic) dressings suggests that the dressings may have been heavily contaminated.”
A nosocomial outbreak of Rhizopus oryzae related to elastic adhesive bandages was reported among six patients in a Minnesota hospital between July 19 and Sept 15, 1977. According to a report published in the Center for Disease Control’s (CDC) Morbidity and Mortality Weekly Report, the infection occurred in three surgical patients who had had Harrington rod insertions, two children with lymphocytic leukemia, and a premature infant with respiratory distress syndrome and additional complications. Elastic bandages were used to secure sterile dressings over the Harrington rod patients’ surgical wounds and over abscesses the leukemic patients had developed. A nasogastric feeding tube was held in place by an elastic bandage on the infant. An epidemiologic investigation revealed that the elastic bandages were kept in a stockroom in boxes until used. Because they are generally used to secure already sterile dressings, the bandages were sorted and distributed in an unsterile state. The hospital had no system for recording lot numbers of the bandages, and distribution of the bandages was difficult to trace.
1080
AORN Journal, May 1978, Val 27, No 6
Accountability for nursing practice
In the keynote address I delivered a t the 1977 AORN Congress, I focused on nurse control of nursing practice. I took the position then, as I do now, that nursing is an independent health care profession and that professional nurses are accountable to their patients for the care they give. Accountability, a t the root of control and autonomy in decisions about nursing, is a requirement for the independent practice of nursing in any setting, including the operating room.
Clifford H Jordan, RN, EdD, is associate professor and director,graduate program in nursing service administration, University of Pennsylvania, Philadelphia.A graduate of the Pennsylvania Hospital School of Nursing for Men, Philadelphia, he received his BS and E d D degrees from Temple University, Philadelphia,and his MS degree from the University of Pennsylvania. This article was originally presented as a speech to the Michigan Association of Operating Room Supervisors in Oakland, Mich.
1076
Nurses who have chosen to pursue careers in the operating room have a strong and abiding conviction about the worth of the field. The responses of those at that Congress t o what I said and my work in 1977 with AORN as a member of the Project 25 Task Force have convinced me of the commitment of OR nurses to their field of practice. I am also convinced that OR nurses believe it is right and appropriate to continue t o reexamine their role in order t o stay current and responsive t o the nursing needs of those undergoing surgical intervention. As stated by Barba Edwards, past AORN president, “It is essential that nurses working in the operating room have knowledge and are able to practice nursing as defined by themselues and their professional organization.” This means t h a t a s nurses you have the privileges that society bestows upon its professionals, and those privileges include the right to define your practice and the right to practice your profession responsibly. It also means that for these privileges you will accept responsibility for what you do as nurses. “Accountability” is currently a fashionable term because consumers are demanding return on their investment in health care. Emphasis on cost containment and cost effectiveness are further indicators that those entrusted with t h e h e a l t h of society will be accountable for their actions. We must
AORN Journal, M a y 1978, V o l 2 7 , No 6
show that what we do is unique and needed and that sound results of our actions are evident and in the public interest. As nurses, we have not yet demonstrated readiness and willingness to accept fully the consequences of our actions. Our history, which has cast us in a subservient, subordinate role, is at the bottom of this problem. We have been seen as an appendage of medicine; our identity as full-fledged professionals has been obscured; and it has been expected, even required, that we manifest obedience and outright dependence on physicians and employers. Certainly, these attitudes do not make clear the need for accountability for our own actions. However, there is another side to this argument. Also recorded in our history is our acceptance ofa dependent position-we have not been credited with knowing much, we have not been acknowledged as vital to patient care, we have certainly not been rewarded psychologically or monetarily for what we do, and we have been either apathetic or satisfied with this state of affairs. Most disturbing, our educational preparation for nursing and the skills we have developed have never been fully tapped. Equally disturbing is the fact that we may have enjoyed and gained security in seeking and finding anonymity, content that someone else was responsible and accountable for what we did. We know, however, that under the laws that govern our practice, we are accountable and answerable for our actions, and we are liable for our own negligence. We have known these things, even if our past behavior has not suggested it. Now, the major thrust of our profession is t o gain identity as fullfledged professionals. We are proclaiming our right to autonomy, and we have signaled the public and other health care professionals that we are ready to
be accountable for our o w n acts. We are all concerned about the credibility of the role of the professional nurse in the operating room. However, if you know who you are and what your unique role is, then no other group can pose an effective threat to your role or its credibility. I believe your presence in the operating room is essential. Do you believe that? Do you demonstrate that essentialness? Does your presence in the OR make a difference to the patient? What is t h a t difference, how is it unique, and is it nursing? There are, of course, many questions related to your role that must be examined. For example, there is not full agreement about the professional nurse acting as first assistant, and it is crucial that you reach consensus on that issue. If it is to be your role, then it must be a standard of your practice and you must be prepared for it and accountable for your actions as you perform that task. If it is not, then say so, refuse to do it, and make it very clear why it is not nursing and leave it to others to decide how the surgeon will be assisted with that surgical task. Neither is there consensus among OR nurses about the perioperative role, which, according to the Project 25 definition, includes “those behaviors assumed by the nurse in the preoperative, intraoperative, and postoperative phases of the patient’s surgical procedure.” Rather, many OR nurses are content with circulating or scrubbing during the intraoperative phase of surgical intervention. What about the preoperative and postoperative care surgical patients receive that play a large part in successful surgery and full recovery? I believe the nurses in the operating room are most expert with preoperative and postoperative management. You must decide collectively what your role should be, and if it is to be the perioperative role (and I hope this is what it will
AORN Journal, May 1978, V o l 2 7 , N o 6
1077
f nurses allow others to speak for them, they will lose their credibility.
I
be), then that must be widely publicized and you must insist that it is your role. Remember that you are better prepared to teach, counsel, and support patients before, after, and during the surgery than any other nurse, OR technician, and perhaps even surgeon. It is absolutely necessary also that you evaluate your practice. If you are practicing nursing in the operating room, then no one else is competent to evaluate your practice but yourself and other OR nurses-not surgeons or hospital administrators. Nursing has made many advances in accountability already. Nursing has defined and implemented its standards for entry into nursing practice and has established a national examining system to assure safe practice in the public interest. Nursing has defined its practice in each state, and nurses act according to the laws that regulate that practice. The same laws fix penalties for infractions or violations, including revocation of the license where incompetence or gross negligence can be proved. Essentially, this means that it is becoming clearer what nursing is and what nurses are accountable for, ethically and legally, a n d primarily t h i s i s accountability to the consumers. However, most nurses in practice are also employees, and we may also be accountable to employers for certain organizational policies and regulations. However, when those policies and regu1078
lations extend to defining our role and responsibility, they are not legitimate and we must collectively reject such constraint and domination. Arrangements must be made with hospitals to include such things as cooperative and collaborative relationships with administration and other health care professionals, but only as equal partners, with as much investment in the successful achievement of goals as any other grOUP. As we move toward a model of shared governance, a s we gain parity with physicians, the kind of collaboration necessary for optimum care for patients will result. Collaboration among disciplines in the business of health care is becoming more and more important; each health care discipline, while independent in its practice, is interdependent as well. Each must rely on the other if we are to achieve our goals. If we as nurses continue to allow others to speak for us, to keep us out of the decision-making arena, then we will lose our credibility. Through my work with the Project 25 Task Force, I have had much contact with OR nurses. While I do not presume to speak for OR nurses, I do believe that your continued viability and credibility as well as increased job satisfaction and self-fulfillment will come as you accept and carry out the perioperative role. Your sphere of influence and your expertise must extend to the patient be-
AORN Journal, M a y 1978, Vol27, No 6
fore and after as well as during surgical intervention. No other nurse knows better t h a n you what goes on during surgery, so no other nurse can better anticipate the patient’s preoperative and postoperative needs than you can. To those of you who may he thinking, “Impossible,” or, “I went into the OR to get away from all that other stuff,” or, “The first assistant role is an alternative,” I hope you will think about what I’ve said. Furthermore, I take the position that the role offirst assistant is not a nursing role. Although more and more of what was once considered solely medical treatment is being incorporated into nursing, I do not see how the first assistant’s tasks fit into nursing practice. This question must be decided by the profession, not by individual nurses, but with OR nurses discussing and coming to a decision together. You can reclaim nursing practice in the OK if you want to, and asserting yourself in deciding whether you will or will not function in the first assistant role is a way to begin. The question of first assistant brings home another point-that the nursing profession is very diverse. With almost 1million nurses in active practice, titles and positions are as varied as can be. Small groups unite and move in different directions with different goals, causing divisiveness and making us all vulnerable. Educationally, we are also diverse-we are the only profession in this country that prepares its members in three ways. As nurses, we are a t different points in our education and experience and specialization. We are not all capable of doing the same things, and within specialties we have differing levels of competency. We are different from each other, each with something of value to offer, but in different ways and a t different levels. Individuals and groups must be clear about what they do, present i t well, and accept
accountability for it. Despite our diversity, I believe there is a role for every nurse in the health care system and that each must know what he or she is ready for while also being ready to learn more. We cannot permit nurses to remain complacent in the belief that they know all they need to and that things as they are and have been are still acceptable. Instead, we must provide and make accessible continuing education, either through pursuit of an advanced degree or by less formal means. To stop learning is not consistent with professionalism and accountability. If we insist on no change and continue to define our roles narrowly, we will have no future. To be accountable requires that we increase our knowledge and skills so that our practice will reflect current thinking and accountability. As mentioned above, evaluation of nursing practice is a crucial element in accountability, but who should do the evaluating and what is the basis for evaluation? Are you a good OR nurse because you serve the surgeon well, are loyal t o the institution, and have had long tenure in the same job, or are you a good OR nurse because your peers review your practice and the results of your nursing intervention and judge you competent? Peer review is, of course, the method of choice in evaluating nursing practice. It is just beginning to replace the old, ineffective performance evaluation done by superiors in the hierarchy who may not have the slightest notion of what we do. Peer review centers on practice, actual care given, and the outcome of that care, and it can be used to demonstrate that OR nurses are needed because they are essential to the patient’s welfare and recovery. It will not necessarily be easy to stand up and be counted as health care professionals. It never is. We must deal with
AORN Journal, M a y 1978, V o l 2 7 , No 6
1079
the constraints that nurses impose o n their own freedom. We m u s t face the facts t h a t many nurses seem content with things as they are; t h a t nurses feel threatened, as a l l persons do, w i t h being evaluated; that advanced and continuing education a r e not seen as required by many; and t h a t dependence o n others outside n u r s i n g to some is a desirable posture. It i s tempting t o r e m a i n dependent o n others, and it is comforting t o take orders a n d blame others i f something goes wrong. However, that i s the p a t h to professional disintegration. I believe that OR nurses have the resources to grow and t o establish firmly t h e continued credibility of the role of the professional nurse in the operating
room. AORN, a n acknowledged leader among specialty organizations, is committed t o that role. AORNs Standards of Nursing Practice: Operating Room, though n o t new, are yet to be fully implemented. The standards provide the framework for putting the nursing process i n t o action for the surgical patient, and each OR nurse has the knowledge a n d s k i l l t o implement these standards. AORN, t h e standards, and the role of t h e perioperative nurse described by Project 25 together will give y o u the tools you need t o demonstrate your abili t y t o change, inaugurate peer review, evaluate the outcome o f your care, and signal your acceptance of accountability for the care you give. 0
Elastic bandages source of nosocomial infection
Sample bandages for fungal culturing were taken from four different areas of the hospital-a patient’s room, a bone marrow laboratory, an orthopedic dressing cart, and an OR store room. All cultures grew Rhizopus species, and the cultures were confirmed by similar tests done by the US Food and Drug Administration and the manufacturer.The bandages were subsequently removed from use on patients pending further investigation. Related to fungi in the Mucoraeae family, species of Rhizopus most commonly produce infection in patients with “severe host deficiencies such as leukemia in relapse, diabetic ketoacidosis, or severe malnutrition.” According to the CDC, spread of infection by R oryzae was unique because the microorganism is “ubiquitous in the hospital environment and patients are presumably exposed to this and related microorganisms commonly without developing disease. The fact that 6 patients, including 3 without serious serious underlying host disorders, acquired Rhizopus infection after exposure to contaminated (elastic) dressings suggests that the dressings may have been heavily contaminated.”
A nosocomial outbreak of Rhizopus oryzae related to elastic adhesive bandages was reported among six patients in a Minnesota hospital between July 19 and Sept 15, 1977. According to a report published in the Center for Disease Control’s (CDC) Morbidity and Mortality Weekly Report, the infection occurred in three surgical patients who had had Harrington rod insertions, two children with lymphocytic leukemia, and a premature infant with respiratory distress syndrome and additional complications. Elastic bandages were used to secure sterile dressings over the Harrington rod patients’ surgical wounds and over abscesses the leukemic patients had developed. A nasogastric feeding tube was held in place by an elastic bandage on the infant. An epidemiologic investigation revealed that the elastic bandages were kept in a stockroom in boxes until used. Because they are generally used to secure already sterile dressings, the bandages were sorted and distributed in an unsterile state. The hospital had no system for recording lot numbers of the bandages, and distribution of the bandages was difficult to trace.
1080
AORN Journal, May 1978, Val 27, No 6
