Surgical conscience: still pertinent

AORN Journal,  July, 2007  by Nancy J. Girard

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Somewhere in their curricula, schools of nursing and institutions that teach perioperative nursing usually address the concept of "surgical conscience." Course competency statements and learning outcomes often include criteria mandating that the student will demonstrate surgical conscience as evidenced by consistently exhibiting ethical behavior, promoting patient safety, and doing the right thing even when no external monitors are present (although it is unclear how it could be determined that surgical conscience was being exercised without someone watching). The importance of listening to one's surgical conscience may or may not be drilled into students, depending on the institution and the instructor.

One of the first editorials published on this topic was written for surgeons in 1950. The article proposed that "conscience is the light that guides men's steps...." (1 p315) and warned that without it, irresponsible and unsafe actions could occur. Many would argue, however, that moral decay in today's society has crept into all professions, including perioperative nursing, and that surgical conscience is no longer a working concept in today's world of "any means to an end."

We need to ask ourselves the following questions: Is moral and ethical behavior still taught and valued in nursing school? Is surgical conscience still guiding perioperative care today? Do perioperative nurses always exercise their surgical conscience for the good of the patient?

DEFINITIONS

There are many definitions of surgical conscience, most of which reflect use of aseptic technique and maintenance of infection control measures. These definitions are limited, however, because the concept is much broader than simply using good technique. Acting on personal surgical conscience involves knowledge, self-awareness, intelligence, and the courage to make ethical and moral decisions that benefit the patient.

H. L. Mencken stated that "Conscience is the inner voice which warns us that someone may be looking," (2) but exercising surgical conscience does not involve having someone else notice an infraction. A nurse with a surgical conscience knows that wearing earrings outside a surgical cap is wrong because it could endanger that patient if the earring back comes off and a piece falls into the wound (yes, dear readers, this has happened). The nurse knows that long, false, or painted fingernails can potentially harm a patient. The nurse knows that a cap should cover all head and facial hair. Having this awareness and taking the appropriate actions to protect the patient will lead to practice that is internally directed by intellect and the desire to do no harm.

Collective surgical conscience involves the awareness of the entire surgical team, such as is demonstrated by participation in the surgical "time out" that is mandated by the Joint Commission and fostered by AORN and its collaborating partners. Perioperative nurses who serve as managers and preceptors are vital to the conduct of surgical conscience and promote it by providing an environment of safety for the surgical team. In such an environment, collective surgical conscience gives each individual the power to halt a surgery if the informed consent is incorrect, to delay closure of the surgical site if a sponge or needle is missing, to help prevent wrong site surgery, and to stop unsafe techniques and practices, with support from the other team members and no fear of repercussions.

BARRIERS

The external forces and powers that control health care practices today (eg, insurance company demands, mandates from large corporations, legislative requirements) may interfere with personal surgical conscience and make it very difficult to uphold. These influences force decisions on care, such as dictating unrealistically short turnaround times, that may lead to the omission of some necessary activities and result in negative outcomes. Individuals may be pushed to practice in ways they know to be unsafe (eg, performing an incomplete skin prep because the surgeon is in a hurry) or to fear retaliation for adhering to standards that they know should be maintained.

In addition, surgical conscience should prompt practitioners to admit to committing an error, if need be, and to correct the situation. When a culture is punitive, however, it impedes one's willingness to admit an error. We all know that living by a good conscience is very hard and is not for the weak of heart. Erich Fromm observed that "the paradoxical--and tragic--situation of man is that his conscience is weakest when he needs it most." (3)

PROMOTING SURGICAL CONSCIENCE

Teachers of perioperative nursing are vital in the promotion of surgical conscience. Excellent teaching encompasses strategies that allow students to think, discover, and seek knowledge. Teaching without considering the impact of surgical conscience on students and patients can lead to stereotypical and authoritarian learning and hinder motivation for further learning.