Introduction
Now-a-days nursing has developed its all functional activities in accordance with technological, political or socio-economical rapid change. Perioperative practitioners are the part of this all nursing activities. Most importantly, in the operating theatre the role of the perioperative nurses vary for several reasons. For example, the different rules and regulation defines the role of perioperative nurses within the operating theatre and generated differently.
Furthermore, from the legal, ethical or professional perspective nursing within the perioperative environment has become in new challenges. The changing boundaries of professional responsibility and its influence on their scope of practice have been emerged. This paper is to find out all these roles that the nurses do inside the operating theatre. It has to be mentioned how clinical experience and practice has influenced personal, academic and professional development (Christina, Kettis, & Patricia, 2007). The paper also enhances professional practice expertise through the application of skills, research and knowledge.
The nature of perioperative practice
Perioperative practice is to be said the nursing activities done in the operation theatre or in the perioperative environment. Perioperative nursing is in growing status as a profession and it is improving in regarding standards and applicants. The nurse practitioners in a teaching method are the want of current situation at every aspect. It is because the lack of understanding about the nurse practitioners may lead to a negative outcome of the healthcare professional. The perioperative practitioners are obligated to respect the dignity and worth of individual patients.
The innovative framework in regard to perioperative nursing profession provides the opportunity to the health and social care which is related with the theatre practitioners. The perioperative practitioners generally wish to extend their professional role through achieving skills and experience. It should be stated that the reflecting of any critical incident in most of the cases helps to recognize the knowledge & experience and also motivations which guide the practitioners during the incident. It provides the personal and professional development through connecting similar incidents. With the help of this method the perioperative nursing practice and knowledge gaps can be exposed.
Nursing around the world needs to feel the confident and the essential and significant contribution to the provision of safe, quality patient care. It is known that the nursing workforce is the largest group within the health care system. The theoretical and practical knowledge not only guide the theatre practitioners, but also the beliefs, values and personal thinking help them to emerging advance scope of practice.
Though perioperative practice is manipulated by a number of factors, but it is also needed to state that the total outcome of these challenges is in favor of mankind. Therefore, in every practice the reflection provides a professional development of knowledge and skills. “The process of reflecting on practice to develop and maintain a professional portfolio is a time consuming but rewarding process.”(Hilliard, 2006 & Leinonen, et. al., 1996).
However, Nurses have the potential to continue integrated interventions from the perspective of health care setting. The needs of the patients vary with the change of health care setting and the function of theatre practitioners as well. So, theatre practitioners need to clarify their roles and functions in relation to both the setting where they work and the patients to whom they deal with. The healthcare professionals need to demonstrate the effectiveness of what they are used to do and how they do to maintain the quality of patient care.
Traditionally, the surgeons are assisted primarily by the nurses. It is known that the scrub nurses do their daily job mostly with the surgeon in the sterile field. They provide the surgeon the required equipment with their skilled assistance. Consequently, the nurses become responsible for handling and selecting over the appropriate instrument, swabs and supplies which are required in the operation theatre at the time of surgical procedure. They scrubbed their hands and arms with special disinfecting soap and wear surgical gowns, shoe covers, gloves or so many other things. By doing this the safety surgical experience by the patient is ensured. In addition, the nurses help and assist the surgical team in creating and maintaining a safe surgical environment.
The nurses are the link between the sterile team and the rest of the environment and are liable for the nursing activities outside the sterile field. After the operating theatre the nurse becomes responsible about the safety and monitoring the patient until he or she recovers.
Now whatever they do, the factor is that what are the legal issues and accountability on what the theatre nurse do in theatre. Are they covered by the trust to do that?
Another type of nurse in operating theatre is nurse anaesthetist (Roemer, 1991). They are advanced registered nurses trained specially both in the art and science of anaesthesia. They provide a lot of activities such as administering anaesthesia and related care to the patients, monitoring every significant function of the patient’s body, regulating the anaesthesia as necessary. They also analysis how and when the patient is responding, then they make swift decision in appropriate manner. According to Joyce (18 May 2008), “[t]he nurse anaesthetists play their role by:-
- Takes care of the patient’s anaesthesia needs before, during and after surgery.
- Performs physical assessment.
- Participates in pre-operation teaching.
- Prepares for anaesthetic management
- Administers anaesthesia to keep patient pain free.
- Oversees recovery from anaesthesia.
- Follows the patient’s post-operation recovery to the recovery room and beyond.
- Provides services in conjunction with other health-care professionals such as surgeons, anaesthesiologists, dentists, etc.”
So, without any doubt these all activities are to be done by someone who are expert and used to. When the practitioner will deal with such thing then it is expected that it would not be easy for them at all. During the operating theatre the perioperative nurses have to act as the registered nurses. The theatre nurse is individually responsible for his or her practice. They must do their work in a two-way and cooperative manner with health and care profession. The other nurses are involved in providing care and recognize what would be their contribution to the care team.
For the effective care the nurses must all work together toward a common goal to meet the needs and serving the interest of the patient. According to the UKCC code of professional contact, clause 4 states that in the exercise of professional accountability, the registered nurse must, “Acknowledge any limitations in your knowledge and competence and decline any duties or responsibilities unless able to perform them in a safe and skilled manner” (Mark, n.d.)
The role of the nurses at the time of surgery is an interested factor for the health service mangers keen to know what actually happens behind the closed doors of the operation theatre. What is the exact role is important to identify and clarify from the perspective of legal issue. The role of all healthcare professionals has changed over the last several years and particularly the nurses have been affected.
The theatre practitioners sometimes have to play the role as a professional one. Sometimes the surgeon do wrong thing in regarding to very crucial issues. In this case what the practitioners can do? Do they have the qualification to retract these wrong steps?
The practitioners are to be said expert when they no longer rely on the rules and guidelines to link their thinking and understanding the situation to take the appropriate action. So it should not be the problem for the practitioners if they operate from a deep and intuitive understanding of the whole situation. As a result an expert practitioner should be professionally qualified and the activities show no difference with the other.
“[A]ccountability refers to obligation and liability which come from professional regulations arising from the NMC, the law on civil wrongs to patients and employment law covering the relationship between employers and their employees. Dowling et al (1996) state that the NMC is required by statute to regulate the standards of practice of nurses and advise nurses on issues such as accountability. Negligence and battery are the two areas of civil law which may involve nurses.” (Al-Hashemi, Feb 2007)
If the performance of the practitioner becomes usually a role performed by a doctor then it is assume that the standard of the care is same. It is also true that the patient has the right to know who assists in performing his or her treatment. So it is required to introduce them by the doctor from the accountability and legal perspective. Then it only can become ethical and the accountability of the practitioners is accepted.
The responsibility and roles of the nurse changes with the surgical techniques advance. These nurses are known as perioperative nurse who reflect the range of their duties, whether it is in hospital or in day surgery unit. They do it immediately before surgery, during the surgery and also after the surgery while patients are recovering. Their do maintain their responsibility by monitoring every patient’s physical and mental well being before, during and after surgery. Besides this, they focus on creating a better and safety environment and manage patient care throughout the surgical care period (Oud, et. al., 2007).
During the surgery procedure the doctors get helps from the perioperative nurse; such as passing instruments, sponges and other items (Foti, 2002). Actually the perioperative nurses act as both scrub nurse and circulating nurse. The above activities are the result of scrub nurse. As a circulating nurse, they do their work outside the field and handle the nursing care in theatre (Hoffman, 3 June 2004).
They monitor the surgical team; assist in creating and ensuring a secure and comfortable environment for the patient. Most importantly, until the patient are transferred to a ward or discharged home, the perioperative nurse do their duty by observing and caring the patient.
An example of wrong dealing
It is very much imperative to give the workers guidance to improve health and safety. How the misunderstanding in the communication of shift handover may create a serious problem. As for example, a man was seriously injured while he was getting the treatment in high pressure line to repair a valve. The accident occurred because of the fault by the workers while they isolated the valve.
“They knew the isolating valves were not operating, so they shut down the drain-line again. They left a message for the next shift to re-open first to blow line down. …. Somehow, during the shift handover, the message was not passed on.” (OTO, June 1996)
So, in such case who will take the responsibility that occurs due to the inefficiency and inexperience? In the operating theatre the practitioner’s activities needs to be legal as it is very sensitive issue. Moreover, if the question rose, then to face it the practitioners need to be more accurate and reliable.
Nurses normally meet legal issues in their place of work. However, many of them are either unaware of their significance or unable to face these issues. Since the findings of the study identify that learning at workplace has been valuable to gain knowledge about law, it is needed to identify legal issues in their workplace. Perioperative practice is influenced by legal issues. For this reason theatre practitioner needs to know about the law or legal issues of nursing. This will help them to increase their efficiency because knowledge about legal issues upgrades their sense about their tasks. These issues provide direction that what needs to do or not to do.
Some factors that define the function of perioperative practice
In the operating theatre the perioperative nurses often find some ethical decisions difficult to make. But it is also necessary to care for surgical patients in practice. The perioperative nurses require being able to identify the ethical dilemmas and take proper action in accordance with necessity. The perioperative nurses in the operating theatre are responsible for nursing decision. These decisions “are not only clinically and technically sound but also morally appropriate and suitable for the specific problems of the particular patient being treated” (Seifert, August, 2002). The question arises what can be done or what ought to be done for the patient in practitioners mind.
The kinds of practice in operating theatre vary from country to country. The type of perioperative practice is different from the U.S.A or Australia. The Indian perioperative practice is totally different from these countries. The rapid change and develop of technology is an important factor that defines the different practice. It largely affects the function of nursing in operating theatre. The outcomes of surgical experience is strongly depends on the most up-to-date and better technology. The improve technology makes the differences and easier for the perioperative practitioners.
The western countries are good at using the innovative technology. Hence, the country wise rules and regulation keep a major role in the theatre practice. For example, in Iraq the perioperative nurses have to be busy and deal with the wounded patient most of the time.
So their experience is certainly different from the others countries nurses. In the operation theatre they face extremely hard and complex situation. “Nurse Practice acts and nursing practice standards provide the foundation for perioperative nurses’ accountability and responsibility. Core activities for perioperative nursing care include assessment, diagnosis, outcome identification, planning, implementation, and evaluation. When these activities are incorporated into daily practice, perioperative nurses are empowered to provide safe and competent care” (Mamaril, 2003).
In addition, nurses demonstrate accountability to the nursing profession and to the public by maintaining licensure and continually gaining knowledge about new treatments and technology. In many states, nursing license renewal requires verification of continuing education. Perioperative nursing practice also includes teaching, delegation, administration, and research. Accountability applies to these aspects, as well. Perioperative nurses are accountable to their employers, their profession, and the public. They demonstrate independence in accountability as they make decisions and accept responsibility for their decisions”. (Berlandi, 2002).
Debate and Accountability
Accountability with responsibility is one of the functions of theatre practitioner in perioperative environment. It is because the perioperative nurses are liable for the outcomes of patients before, during and after the surgical experience. Accountability means the quality of being answerable. From the accountability point of view it is found that perioperative nurses are responsible for their decision and the outcomes of these decisions.
As a result, it defines the boundary of loyalty and duty of nurses and provides the rights of patients regarding competent care. The knowledge, skills and experience in nurse’s daily practice support accountability and responsibility.
In every job there is the presence of responsibility and accountability and nursing is not out of this rule. The patient has the right to know who will take care of them immediately before, during and after his or her surgical experience. From the customer perspective it is expected. The patients always feel to be served by the professional or registered practitioners. There are some delegations by which these activities are performed in the operating theatre.
Whatever, in the operating theatre the question may raise about the inexperience of the practitioners whether they are capable to handle the hard situation as it is very controversial issue from the ethical, legal and professional perspective. In addition, there is the argument in favor of registered nurses and also in favor of the practitioners. Some say that such type of ethical issue should be handled by the registered nurse, because they are experienced in knowledge and skills. On the other hand, some give their logic in favor to the practitioners. Their argument is that if the practitioners don’t get knowledge about what are happening outside the door, then how they will become experienced.
In addition, sometimes in emerge situation the practitioners have to deal with what they are not used to or have not done before. Generally, only the registered nurses are familiar and have the authority to involve in such type of activities. So, simply it becomes the questionable issue from the legal perspective.
The trust that covers what the theatre practitioners do in the perioperative environment is very much sophisticated. Assistant theatre practitioners are known as non-medical practitioners who do their activities as a member of an extended surgical team, who provides perioperative intervention under the direction and supervision of the consultant.
The assistant theatre practitioner get employed as a member of the consultant and become responsible to the named consultant surgeon. They do their activities beyond an advanced scrub practitioner. The assistant theatre practitioners push a major impact on the registered nurses. The assistant theatre practitioner (ATP) has the overall responsibility to the care received by the patient. The registered nurses are used to perform their activities independently. So they simply would not like to interfere in their activities from the others. In recent year, the healthcare organizations have found a better result in regarding to the assistant theatre practitioners. Independent Healthcare Advisory Services (February 2006) sets the rules of the assistant theatre practitioners, which are mentioned below:-
- To ensure that patient safety is not compromised by the maintenance of high Standards of care and safety
- To facilitate IHAS Member Hospitals in assessing the competencies of SCP’s.
- To assist the IHAS Member Hospitals in endorsing the role of the SCP.
- To assist the IHAS Member Hospitals in formulating policies for the SCP role
- To satisfy the regulatory bodies (HCC) in the employment of this group of Staff
- To aid and protect the staff working within the Theatre environment in
- Clarifying the boundaries of extended roles in theatre.
- To ensure that there is a clear demarcation between
- the extended role ofindividual members of the Theatre Team, (particularly when such an individual is working as a Advanced Scrub Practitioner (formerly first assistant) and
- the role of the SCP.
To work on all phases of a job, professional issues to practitioners can be compared with blood to the body. Day by day the standard of nursing care is developing. The health care leaders are very supportive of nursing and they recommend this profession is the key of health care. The meaningful relationship with either families or patient is the strength of the nursing profession. The need within the profession comprises continuity of education and training in regard to various kinds of general issues and technology. The major benefit of nursing education is in the link between the nursing school and the clinical practice area.
Recommendations
In operating theatre the practitioners have to maintain some principles which are concerned with the ethical issues. To provide patients serving interest, holistic care, build up professional skills and knowledge and being responsible for the individual actions.
Nursing care generally provided to patients in a perioperative environment but in addition the nurses have to deal with instrumentation and other technical equipment. However, there has been always a question about the presence of practitioners in the operating theatre from the ethical and legal point of view. Before going to that discussion, it would be better to understand the concept of emotional labor. Emotional labor is very vital both for the nurses and for the patients. It has been established as a crucial factor in nursing work. Though there are insufficient studies in regarding emotional labor in an operating theatre context, but the looking after the surgeons is to be said as a “hostess role”.
In operating theatre the nurses has to consider two major areas of their activities. One is ‘keeping the surgeons happy’ and another is ‘not upsetting the surgeons’. If the first one is analyzed then it can found that the surgeons are always in need for a number of assistance. The second one reminds that if the nurses can make the surgeons happy, then they also have to ensure not to upset the surgeons. It is strongly recommended to maintain the emotional labor performed by the theatre nurses with coworkers rather than patients. The following activities done by the theatre nurses to enhance their professionalism that comes from in believing the holistic approach to the perioperative care to the patients:-
- To promote the standard of patient care and service provided by the theatre practitioners.
- To involve and influence the exchange of technical and professional information.
“Perioperative nurses are obligated morally to respect the dignity and worth of individual patients. Perioperative nursing care must be provided in a manner that preserves and protects patient autonomy and human fights. Nurses have an obligation to be knowledgeable about the moral and legal rights of their patients and to protect and support those rights. Health care does not occur in a vacuum, so perioperative nurses must take into account both individual rights and interdependence in decision making.
By doing so, nurses can recognize situations in which individual rights to self-determination in health care temporarily should be overridden to preserve the life of the human community. For example, during a bioterrorism attack, victims infected with transmissible organisms (e g, small pox) require infection control measures to prevent transmission to others”. (Kathryn, 2002)
So, a lot of functional activities have to be done through the theatre practitioners. These activities are generally done by the registered nurses. So their activities are becoming limited in such case. But it also be noted that the political violence or stability can change the nature of the theatre practitioners.
The scrub practitioner, nurse anaesthetist, assistant theatre practitioner or the registered practitioners all are liable for their decision and the result of those decisions. Though they are different from each other from the rank point of view, but their activities are same in most of the cases. Human rights cannot be avoided in regarding the theatre practitioner as it is very sentimental issue. Furthermore, for the rapid change in the technology or in the politics or in the socioeconomic condition the practice usually would be affected. But it does not indicate the any type of bad direction.
Conclusions
So, therefore in the operating theatre the practitioners do their job in systematic way. However, these activities face some challenges which are also affected by some existing factor. Some of these challenges are controllable and some are uncontrollable. It is strongly recommended that the theatre practitioners needs to ensure the overcome of these controllable challenges. As clinical experience and practice has a strong role in regarding to the personal, academic and professional development, these challenges are to be handled in effective way.
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