The Meaning of Being a Perioperative Nurse

AORN Journal, August, 2001 by Hrafn Oli Sigurdsson

The purpose of this study is to decipher the meaning of being a perioperative nurse within the contexts of the sociopolitical, economic, and cultural forces that influence perioperative practice. Understanding this meaning will sensitize nurses and administrators to the struggles inherent in perioperative nursing and the value of professional nurses' presence in the OR.

This study employed critical hermeneutics, a research approach that attempts to gain understanding of social phenomena from within rather than from the viewpoint of an objective outside observer. To understand social phenomena from within, the researcher must have knowledge of the traditions and historical processes that form the context of the phenomenon.(1) Many sociopolitical, economic, and cultural processes have had an impact on perioperative nursing.

SOCIOPOLITICAL AND ECONOMIC CONTEXTS OF NURSING IN THE OR

Several factors have influenced perioperative nursing throughout the years. Some examples include World War II and the health care restructuring of the 1990s.

Historical perspective of nursing in the OR. One author traced the history of perioperative nursing in the United States to 1873 when nursing schools were being established.(2) Perioperative nursing was recognized as a nursing specialty by 1889. During the last decades of the nineteenth century, medical knowledge advanced greatly as causes of infections were discovered. The importance of asepsis and sterilization of instruments and supplies for invasive procedures became widely accepted. These advances called for nurses who had the interests and skills to assume responsibility for the many tasks associated with surgery, including preparing the patient, preparing all supplies and instruments for sterilization, and assisting with surgery. Perioperative nursing, with a clinical rotation for students in the OR, became a legitimate portion of the basic professional nursing curriculum.(3)

During the first decade of the twentieth century, two traditional perioperative nursing roles emerged. The scrub person washed his or her hands aseptically, donned a sterile gown and gloves, and assisted during surgery by organizing the instruments and passing them to the surgeon. The circulator remained outside the sterile surgical field, managed the OR, and maintained contact with those outside the OR.(4)

Until World War II, only RNs and nursing students were considered to have the required knowledge and skills necessary to work in the OR.(5) During World War II, there was a dramatic demand for nurses to care for the wounded in military hospitals, both on the battlefield and at home. At the same time, civilian hospitals were understaffed as nurses joined the armed forces. Despite efforts to provide sufficient numbers of nurses through initiatives, such as the shortened training program of the Cadet Nurse Corps,(6) there were not enough nurses to fill the needs of either military or civilian hospitals.

In response to this nursing shortage, the armed forces created the role of OR technologist, a corpsman trained in all aspects of OR work. Similarly, with fewer nurses available to work, orderlies in civilian ORs were trained to assume some RN responsibilities. Thus, a precedent was set--nonprofessional technical staff members could replace professional nurses. After the war, nonprofessional staff members remained in both military and civilian ORs, and many civilian hospitals hired OR technologists who were leaving the armed forces. The trend of reducing the number of RNs in the OR that began during World War II has continued to the present.(7)

Cost concerns: Influences on staff skill mix and workload. The health care restructuring of the 1990s and the concomitant impact on personnel budgets and cost containment have contributed to the changing work environment of the OR, as it has other areas of nursing. Early in the decade, budget cuts and staff mix restructuring resulted in fewer RNs and more assistive personnel in the OR. These changes called for the same quality service at a lower cost.(8)

Administrators, who could no longer afford the higher salaries of professional nurses, continued the attempt to replace them with assistive personnel. Perceived cost savings has been a factor in the pressure to change staff skill mix because surgical technologists (STs) cost only 60% of an RN's salary.(9) The actual cost benefit of substituting STs for RNs as circulators is questionable, because STs still require RN supervision.(10)

The influence of cost concerns on perioperative nursing practice is illustrated further by changes in personnel budgets and the number of surgical procedures being performed. From 1992 to 1997, with a reduction in the number of clinical and nonclinical staff members, the average OR personnel budget was reduced from $2.16 million to $1.6 million. During the same five-year period, the number of procedures performed monthly increased dramatically.(11) Increased productivity has taken place despite a reduction in full-time employees in the average OR. It is apparent that perioperative nurses are expected to work harder now than ever.