Mary C Donn, SRN, DN
Theatre nurses meet changing social needs It was Florence Night,ingale who said “For us who nurse, our nursing is a thing which, unless in it we are making progress, every year, every month, every week, take my word for it, we are going back.”’ The winds of change are blowing in Britain, a t times reaching gale force, but whether Florence Nightingale would think the changes all represent progress in terms of the safe care of the surgical patient is open to some doubt. The function of nurses is continually changing because their role must always be closely related to the changing needs of the public they serve. Those needs vary according to individuals, patients, medical and technological ad-
Mary C Donn, SRN, DN. is a nursing officer in
the operating departments at Bromley Hospital, Kent, England Chairman of the National Association of Theatre Nurses, Donn received a diploma of nursing from London University She presented this paper at the 1978 Congress session, International OR Nursing
vances, and demographic profiles. Expansion of primary care services is the top priority of Great Britain’s Government Health Department in planning for the future. Such expansion means looking after more people in the community to help relieve the pressure on hospital and residential services. Acute services a r e continually reviewed, thus releasing resources for priority groups such a s the elderly, mentally ill, mentally handicapped, and children. I n view of t h e s e t r e n d s , radical changes in Britain’s system of nurse education, combined with younger entry and a common basic training for all nurses and midwives, have been proposed by the Committee on Nursing, chaired by Professor Asa Briggs. The committee’s findings, known a s t h e Briggs Report, will go to Parliament to become a Bill of Law. Britain’s entry into t h e European Economic Community has also affected nursing. Directives have been formulated by nursing and medical representatives appointed by their countries t o provide common training so that qualified nurses can work in any of the eight member countries-Britain, France, West Germany, Holland, Italy, Belgium, Ireland, and Luxembourg. At present, there are three forms of basic nurse training in Britain: a twoyear course to become a state enrolled nurse, a three-year course t o become a
AORN Journul. September 1978. Vol 28. No 3
41 1
state registered nurse, and a five-year program to qualify as a state registered nurse with a bachelor of science degree. The five-year course is carried out in a university. During basic training, the student spends some time in the operating room and is usually supervised by a clinical instructor. Presently, 7 5 4 of the students spend eight weeks in the OR, the other 25‘4 a mere two weeks. As the statutory body for nursing education, the General Nursing Council suggests minimal periods for each specialty, but each school of nursing can form its own policy, Since this two-week period in the operating room is not adequate for students or instructors, the National Association of Theatre Nurses (NATN) has been instrumental in obtaining a n extra weeks experience for these students to be spent caring for the postoperative patient in the recovery area. As OR nurses, we are convinced that the eight-week course is essential so that students can participate with real understanding in the total care of surgical patients, including preoperative, intraoperative, and postoperative periods. The objectives of NATN’s recommended syllabus for the eight weeks in the OR are ( 1)to train the student to assist with the preparation of the anesthetic room and to care for the patient while he is there; (2) to assist with the preparation of the operating room and to apply aseptic techniques; (3) to move the patient within the operating theatre and participate, under the supervision of a clinical instructor or qualified, experienced theatre nurse, as a member of the surgical team, fulfilling the duties of the circulating nurse and the scrub nurse; (4) to apply safety measures in the OR; (5)t o communicate and to take care of specimens; and finally, ( 6 )to care for the patient in the immediate postoperative period. We hope that during this rotation in
412
the OR, the student will gain a greater understanding of the treatment of surgical patients, thereby resulting in improved patient care and the development of the nurse’s professional ability. We also hope that the student will appreciate the role of the OR nurse and we believe t h e i r rotation through t h e operating room can be a good method of nurse recruitment. Postbasic courses are available if the student, once qualified as either a state registered nurse or as a state enrolled nurse, wishes to specialize in OR nursing. These are organized by our Joint Board of Clinical Nursing Studies, an official body established in 1973 to review all postbasic education and that is now responsible for the approval of all postbasic courses. There a r e presently 46 courses throughout Britain to accommodate nurses wishing to specialize in OR nursing. This is the largest number of any of the special postbasic courses offered by the Joint Board. Periodically reviewed by t h e OR Panel of the Joint Board of Clinical Nursing Studies, these one-year courses are designed to enable the OR nurse to function in all areas of the operating department. They follow a standard syllabus, and each nurse must gain experience in the anesthetic and recovery rooms. The nurse must also spend time in the preparation of supplies and instruments, in special units such as the central sterile supply department or theatre sterile supply unit. Experience in surgery m u s t include all major branches of surgery for both adults and children. Another postbasic course offered to nurses is the six-month Joint Board Course in anesthetic room nursing. The anesthetic room is attached to OR. Patients are induced in the anesthetic room before being moved to the OR. This course is designed to prepare anes-
AORN Journal, September 1978,Vol28, No 3
W
e are concerned about changes in basic nursing training.
thetic room nurses to work with the anesthetist in any setting where anesthetics are administered-either in the hospital or the community. Anesthetic room nurses are not nurse anesthetists, however. A Joint Board Short Course for experienced OR nurses will soon be set up. I believe this is a great step forward in the area of continuing education for operating room nurses, and it will be an even greater advance if participation in these short courses becomes compulsory, which it may in the future. Operating rooms in Britain are predominately staffed by nurses, and postbasic courses in theatre nursing and anesthetic room nursing ensure that OR staffs are qualified to meet a national standard. It is not expected that any changes in the system of basic nurse training will affect postbasic education. (The Joint Board of Clinical Nursing Studies will continue, however, under the new name of Advisory Clinical Nursing Studies Committee.) We are currently most concerned about the changes taking place in basic nurse training. The Committee of Nursing has recommended that there should be one basic 18-month course t h a t would lead to a basic statutory qualification-the certificate in nursing practice. In this program, OR nursing experience would be limited to the student accompanying a patient to the OR to observe surgery as a concept of
total patient care. For those holding the certificate in nursing practice, a n additional 18-month course would lead to a second statutory qualificationregistration-which is the same a s the present state registered nurse qualification. Nurses who complete this additional course will be able to work in all countries belonging to the European Economic Community. Both courses would be planned on a modular basis, and it is hoped that a n optional module in OR nursing would be included in the second 18 months. Modules of training are already available in obstetric nursing, and they are compulsory for geriatric nursing, psychiatric nursing, and all aspects of community nursing. Britain’s primary care services a r e to be expanded for social and economic reasons, and nursing education is being designed to reflect this expansion. The recommendations of the Committee on Nursing are in line with the directives on nurse training drawn up by Britain and the other countries in the European Economic Community. Here again, the main emphasis is on community nursing. Changes in the patterns of health and illness and society’s expectations for health care must affect the training of the nurse. To prepare us for the changes in education, the official education policy document of the General Nursing Council (which is responsible for student training) states, “There is no doubt
AORN Journal, September 1978, V o l 2 8 , N o 3
413
t h a t t h e inclusion of obstetrics, psychiatry, and geriatric and community nursing for all nurses will affect the number of learners available for general acute nursing experience.”‘ General acute nursing training includes operating room experience, and if t h i s p a r t of n u r s e t r a i n i n g i s shortened, OR experience for the student w i l l be reduced. NATN feels strongly t h a t if OR experience is excluded from the nurses’ curriculum, then nurses’ training in the care of the acutely ill patient will be incomplete. This view is shared by our colleagues in anesthesia and surgery. It is difficult to discuss the situation of OR nursing in Britain without mentioning the controversial and emotional subject of technicians. A committee, chaired by Walpole Lewin; a Fellow of the Royal College of Surgeons, set up to study the organization and staffing of operating theatres, published the Lewin Report in April 1971.3 At that time, there was such an acute shortage of OR nurses that operating rooms were being closed. The Lewin Report gave official recognition to the technician for the first time. It recommended that two grades of technicians be set up with the titles of operating department assistant (ODA)and senior operating department assistant (SODA). To train the technicians, a fully organized program of teaching and inservice training was established. The program lasts two years for the trainee operating department assistant. Promotion to senior grade takes place after t h r e e more years’ experience as a n operating department assistant. Today, to become an operating department assistant, the trainee must follow a national syllabus and pass a national examination after completing t h e two years of training. Thanks to the Joint Board Courses, we now have enough nurses holding na-
414
tional certificates in theatre technique, and I do not expect ORs in Britain ever to be staffed without nurses. However, 1 believe that OR nurses will always need a back-up service from well-trained staff. Whether they are called operating department assistants or technicians is not important, but it is important that we recognize the need for these trained assistants. We must recognize the reasonable aspirations of the technicians, but we must not allow technicians to assume responsibilities for which they have not been trained. In Britain, our medical colleagues are in complete agreement with this, and we have received government support as well. A Department ofHealth report on the promotion ofthis new technician grade states that the nurse is in charge of the operating department a t all times and that nonnurses a r e responsible t o the nurse a s the person qualified in all aspects of patient care. During the past ten years, nursing in Britain h a s achieved a professional maturity not before known. We now control our own affairs, take a n active interest in research, and influence decision making. We have learned to anticipate and adapt to change. The isolationist policy of which OR nurses were once accused has disappeared. The operating department staff h a s opened its doors to increased communication with the wards and with other departments by participation in ward rounds and by preoperative and postoperative visits. This has resulted in a n improvement in both the physical and psychological care of the patient. We have reasons to be optimistic about the future. Research into many aspects of OR nursing is increasing. This includes care of the unconscious patient on the operating table, staffing norms, sterilization of fiberoptic equipment, budgeting in the OR, and
AORN Journal. September 1978. V o l 2 8 . N o 3
t h e m a n a g e m e n t o f one-day s u r g e r y , w h i c h h a s increased d r a m a t i c a l l y . Researchers a r e v i s i t i n g c o u n t r i e s s u c h as t h e U n i t e d States, Russia, N e w Zeal a n d , a n d C a n a d a t o c o m p a r e proced u r e s a n d s e e k n e w i d e a s . T h e OR nurse's r o l e as teacher h a s developed by p a r t i c i p a t i n g in " A r t - o f - T e a c h i n g courses." w h i c h a r e run by t e c h n i c a l colleges, w h i l e a l l qualified OR staff a r e n o w t r a i n e d in t h e m a n a g e m e n t of t h e
OR. This is a challenging time for theatre n u r s e s in Britain, but t h e n w e a r e u s e d
t o challenges. I b e l i e v e o u r challenges a r e m u c h t h e same as yours, a n d I am h o p e f u l that t h e y w i l l r e s u l t in h i g h e r s t a n d a r d s and b e t t e r , safer c a r e for o u r 0 patients. Notes 1 Address to student nurses at St Thomass Hospital School of Nursing, London 1914 2 "General nursing council policy document ISsued by the General Nursing Council of England and Wales, August 1977. 3. "The organisation and staffing of operating departments." Central Health Services Council. London: Her Majesty's Stationery Office. 1970.
Nursing groups support ERA Three nursing organizations have taken stands on the Equal Rights Amendment (ERA). At the American Nurses' Association (ANA) Convention, the House of Delegates voted that "ANA encourage members not to attend national meetings held in states that have not ratified the Equal Rights Amendment." The delegates also supported the ANA Board of Directors' decision not to hold ANA meetings in states that have not ratified the amendment. Officials of the Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG) and the National Student Nurses' Association (NSNA). also recently issued statements in support of equal rights for women. The NSNA Board of Directors has voted to support an extension of the deadline for ratification of the ERA. The NSNA House of Delegates voted in 1974 to support the ERA and reaffirmed its position at its convention in April 1978. The Executive Board of NAACOG has unanimously endorsed the concept and definition of equal rights for women as expressed in the statement "equality of rights under the law shall not be denied or abridged by the United States or by any state on account of sex." "As the major nursing specialty organization concerned primarily with providing health care for women and
infants, we wish to express publicly our support for equal rights for women said NAACOG President Sallye P Brown RN Because NAACOG is not a political organization and recognizes that its membership comprises a wide range of views, we cannot insist that our members become involved in political action but we encourage them to support ERA legislation in their individual states
NLN to continue as test service agency The National League for Nursing (NLN) has agreed to continue as the test service agency for the newly independent National Council of State Boards of Nursing The Council is recqonsible for the State Board Test Pool Exdminations for registered and practical nurse licensure The Council of State Boards of Nursing had been a component of the American Nurses Association since 1950. with individuals as members At a June 1978 meeting, a new National Council was established as an independent entity, with the State Boards of Nursing as members
AORN Journal. September 1978, Vol 2 8 , N o 3
415
Theatre nurses meet changing social needs It was Florence Night,ingale who said “For us who nurse, our nursing is a thing which, unless in it we are making progress, every year, every month, every week, take my word for it, we are going back.”’ The winds of change are blowing in Britain, a t times reaching gale force, but whether Florence Nightingale would think the changes all represent progress in terms of the safe care of the surgical patient is open to some doubt. The function of nurses is continually changing because their role must always be closely related to the changing needs of the public they serve. Those needs vary according to individuals, patients, medical and technological ad-
Mary C Donn, SRN, DN. is a nursing officer in
the operating departments at Bromley Hospital, Kent, England Chairman of the National Association of Theatre Nurses, Donn received a diploma of nursing from London University She presented this paper at the 1978 Congress session, International OR Nursing
vances, and demographic profiles. Expansion of primary care services is the top priority of Great Britain’s Government Health Department in planning for the future. Such expansion means looking after more people in the community to help relieve the pressure on hospital and residential services. Acute services a r e continually reviewed, thus releasing resources for priority groups such a s the elderly, mentally ill, mentally handicapped, and children. I n view of t h e s e t r e n d s , radical changes in Britain’s system of nurse education, combined with younger entry and a common basic training for all nurses and midwives, have been proposed by the Committee on Nursing, chaired by Professor Asa Briggs. The committee’s findings, known a s t h e Briggs Report, will go to Parliament to become a Bill of Law. Britain’s entry into t h e European Economic Community has also affected nursing. Directives have been formulated by nursing and medical representatives appointed by their countries t o provide common training so that qualified nurses can work in any of the eight member countries-Britain, France, West Germany, Holland, Italy, Belgium, Ireland, and Luxembourg. At present, there are three forms of basic nurse training in Britain: a twoyear course to become a state enrolled nurse, a three-year course t o become a
AORN Journul. September 1978. Vol 28. No 3
41 1
state registered nurse, and a five-year program to qualify as a state registered nurse with a bachelor of science degree. The five-year course is carried out in a university. During basic training, the student spends some time in the operating room and is usually supervised by a clinical instructor. Presently, 7 5 4 of the students spend eight weeks in the OR, the other 25‘4 a mere two weeks. As the statutory body for nursing education, the General Nursing Council suggests minimal periods for each specialty, but each school of nursing can form its own policy, Since this two-week period in the operating room is not adequate for students or instructors, the National Association of Theatre Nurses (NATN) has been instrumental in obtaining a n extra weeks experience for these students to be spent caring for the postoperative patient in the recovery area. As OR nurses, we are convinced that the eight-week course is essential so that students can participate with real understanding in the total care of surgical patients, including preoperative, intraoperative, and postoperative periods. The objectives of NATN’s recommended syllabus for the eight weeks in the OR are ( 1)to train the student to assist with the preparation of the anesthetic room and to care for the patient while he is there; (2) to assist with the preparation of the operating room and to apply aseptic techniques; (3) to move the patient within the operating theatre and participate, under the supervision of a clinical instructor or qualified, experienced theatre nurse, as a member of the surgical team, fulfilling the duties of the circulating nurse and the scrub nurse; (4) to apply safety measures in the OR; (5)t o communicate and to take care of specimens; and finally, ( 6 )to care for the patient in the immediate postoperative period. We hope that during this rotation in
412
the OR, the student will gain a greater understanding of the treatment of surgical patients, thereby resulting in improved patient care and the development of the nurse’s professional ability. We also hope that the student will appreciate the role of the OR nurse and we believe t h e i r rotation through t h e operating room can be a good method of nurse recruitment. Postbasic courses are available if the student, once qualified as either a state registered nurse or as a state enrolled nurse, wishes to specialize in OR nursing. These are organized by our Joint Board of Clinical Nursing Studies, an official body established in 1973 to review all postbasic education and that is now responsible for the approval of all postbasic courses. There a r e presently 46 courses throughout Britain to accommodate nurses wishing to specialize in OR nursing. This is the largest number of any of the special postbasic courses offered by the Joint Board. Periodically reviewed by t h e OR Panel of the Joint Board of Clinical Nursing Studies, these one-year courses are designed to enable the OR nurse to function in all areas of the operating department. They follow a standard syllabus, and each nurse must gain experience in the anesthetic and recovery rooms. The nurse must also spend time in the preparation of supplies and instruments, in special units such as the central sterile supply department or theatre sterile supply unit. Experience in surgery m u s t include all major branches of surgery for both adults and children. Another postbasic course offered to nurses is the six-month Joint Board Course in anesthetic room nursing. The anesthetic room is attached to OR. Patients are induced in the anesthetic room before being moved to the OR. This course is designed to prepare anes-
AORN Journal, September 1978,Vol28, No 3
W
e are concerned about changes in basic nursing training.
thetic room nurses to work with the anesthetist in any setting where anesthetics are administered-either in the hospital or the community. Anesthetic room nurses are not nurse anesthetists, however. A Joint Board Short Course for experienced OR nurses will soon be set up. I believe this is a great step forward in the area of continuing education for operating room nurses, and it will be an even greater advance if participation in these short courses becomes compulsory, which it may in the future. Operating rooms in Britain are predominately staffed by nurses, and postbasic courses in theatre nursing and anesthetic room nursing ensure that OR staffs are qualified to meet a national standard. It is not expected that any changes in the system of basic nurse training will affect postbasic education. (The Joint Board of Clinical Nursing Studies will continue, however, under the new name of Advisory Clinical Nursing Studies Committee.) We are currently most concerned about the changes taking place in basic nurse training. The Committee of Nursing has recommended that there should be one basic 18-month course t h a t would lead to a basic statutory qualification-the certificate in nursing practice. In this program, OR nursing experience would be limited to the student accompanying a patient to the OR to observe surgery as a concept of
total patient care. For those holding the certificate in nursing practice, a n additional 18-month course would lead to a second statutory qualificationregistration-which is the same a s the present state registered nurse qualification. Nurses who complete this additional course will be able to work in all countries belonging to the European Economic Community. Both courses would be planned on a modular basis, and it is hoped that a n optional module in OR nursing would be included in the second 18 months. Modules of training are already available in obstetric nursing, and they are compulsory for geriatric nursing, psychiatric nursing, and all aspects of community nursing. Britain’s primary care services a r e to be expanded for social and economic reasons, and nursing education is being designed to reflect this expansion. The recommendations of the Committee on Nursing are in line with the directives on nurse training drawn up by Britain and the other countries in the European Economic Community. Here again, the main emphasis is on community nursing. Changes in the patterns of health and illness and society’s expectations for health care must affect the training of the nurse. To prepare us for the changes in education, the official education policy document of the General Nursing Council (which is responsible for student training) states, “There is no doubt
AORN Journal, September 1978, V o l 2 8 , N o 3
413
t h a t t h e inclusion of obstetrics, psychiatry, and geriatric and community nursing for all nurses will affect the number of learners available for general acute nursing experience.”‘ General acute nursing training includes operating room experience, and if t h i s p a r t of n u r s e t r a i n i n g i s shortened, OR experience for the student w i l l be reduced. NATN feels strongly t h a t if OR experience is excluded from the nurses’ curriculum, then nurses’ training in the care of the acutely ill patient will be incomplete. This view is shared by our colleagues in anesthesia and surgery. It is difficult to discuss the situation of OR nursing in Britain without mentioning the controversial and emotional subject of technicians. A committee, chaired by Walpole Lewin; a Fellow of the Royal College of Surgeons, set up to study the organization and staffing of operating theatres, published the Lewin Report in April 1971.3 At that time, there was such an acute shortage of OR nurses that operating rooms were being closed. The Lewin Report gave official recognition to the technician for the first time. It recommended that two grades of technicians be set up with the titles of operating department assistant (ODA)and senior operating department assistant (SODA). To train the technicians, a fully organized program of teaching and inservice training was established. The program lasts two years for the trainee operating department assistant. Promotion to senior grade takes place after t h r e e more years’ experience as a n operating department assistant. Today, to become an operating department assistant, the trainee must follow a national syllabus and pass a national examination after completing t h e two years of training. Thanks to the Joint Board Courses, we now have enough nurses holding na-
414
tional certificates in theatre technique, and I do not expect ORs in Britain ever to be staffed without nurses. However, 1 believe that OR nurses will always need a back-up service from well-trained staff. Whether they are called operating department assistants or technicians is not important, but it is important that we recognize the need for these trained assistants. We must recognize the reasonable aspirations of the technicians, but we must not allow technicians to assume responsibilities for which they have not been trained. In Britain, our medical colleagues are in complete agreement with this, and we have received government support as well. A Department ofHealth report on the promotion ofthis new technician grade states that the nurse is in charge of the operating department a t all times and that nonnurses a r e responsible t o the nurse a s the person qualified in all aspects of patient care. During the past ten years, nursing in Britain h a s achieved a professional maturity not before known. We now control our own affairs, take a n active interest in research, and influence decision making. We have learned to anticipate and adapt to change. The isolationist policy of which OR nurses were once accused has disappeared. The operating department staff h a s opened its doors to increased communication with the wards and with other departments by participation in ward rounds and by preoperative and postoperative visits. This has resulted in a n improvement in both the physical and psychological care of the patient. We have reasons to be optimistic about the future. Research into many aspects of OR nursing is increasing. This includes care of the unconscious patient on the operating table, staffing norms, sterilization of fiberoptic equipment, budgeting in the OR, and
AORN Journal. September 1978. V o l 2 8 . N o 3
t h e m a n a g e m e n t o f one-day s u r g e r y , w h i c h h a s increased d r a m a t i c a l l y . Researchers a r e v i s i t i n g c o u n t r i e s s u c h as t h e U n i t e d States, Russia, N e w Zeal a n d , a n d C a n a d a t o c o m p a r e proced u r e s a n d s e e k n e w i d e a s . T h e OR nurse's r o l e as teacher h a s developed by p a r t i c i p a t i n g in " A r t - o f - T e a c h i n g courses." w h i c h a r e run by t e c h n i c a l colleges, w h i l e a l l qualified OR staff a r e n o w t r a i n e d in t h e m a n a g e m e n t of t h e
OR. This is a challenging time for theatre n u r s e s in Britain, but t h e n w e a r e u s e d
t o challenges. I b e l i e v e o u r challenges a r e m u c h t h e same as yours, a n d I am h o p e f u l that t h e y w i l l r e s u l t in h i g h e r s t a n d a r d s and b e t t e r , safer c a r e for o u r 0 patients. Notes 1 Address to student nurses at St Thomass Hospital School of Nursing, London 1914 2 "General nursing council policy document ISsued by the General Nursing Council of England and Wales, August 1977. 3. "The organisation and staffing of operating departments." Central Health Services Council. London: Her Majesty's Stationery Office. 1970.
Nursing groups support ERA Three nursing organizations have taken stands on the Equal Rights Amendment (ERA). At the American Nurses' Association (ANA) Convention, the House of Delegates voted that "ANA encourage members not to attend national meetings held in states that have not ratified the Equal Rights Amendment." The delegates also supported the ANA Board of Directors' decision not to hold ANA meetings in states that have not ratified the amendment. Officials of the Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG) and the National Student Nurses' Association (NSNA). also recently issued statements in support of equal rights for women. The NSNA Board of Directors has voted to support an extension of the deadline for ratification of the ERA. The NSNA House of Delegates voted in 1974 to support the ERA and reaffirmed its position at its convention in April 1978. The Executive Board of NAACOG has unanimously endorsed the concept and definition of equal rights for women as expressed in the statement "equality of rights under the law shall not be denied or abridged by the United States or by any state on account of sex." "As the major nursing specialty organization concerned primarily with providing health care for women and
infants, we wish to express publicly our support for equal rights for women said NAACOG President Sallye P Brown RN Because NAACOG is not a political organization and recognizes that its membership comprises a wide range of views, we cannot insist that our members become involved in political action but we encourage them to support ERA legislation in their individual states
NLN to continue as test service agency The National League for Nursing (NLN) has agreed to continue as the test service agency for the newly independent National Council of State Boards of Nursing The Council is recqonsible for the State Board Test Pool Exdminations for registered and practical nurse licensure The Council of State Boards of Nursing had been a component of the American Nurses Association since 1950. with individuals as members At a June 1978 meeting, a new National Council was established as an independent entity, with the State Boards of Nursing as members
AORN Journal. September 1978, Vol 2 8 , N o 3
415
