Performing in the operating theater

AORN Journal, Sept, 2006 by Margaret Miller

As nurses, we perform our duties throughout the hospital and other health care venues, but nowhere does our role so closely mimic a theatrical production as in an OR. It is no accident that surgical suites are called theaters in much of the world, and although that originally had to do with the audience who gathered to watch, (1) thinking of a surgical procedure as a stage performance provides a way of understanding what makes this area of nursing distinctive.

Most hospitals require nurses to gain experience in another area before they begin to work in the OR, and most nursing programs do not offer perioperative courses in their curricula. Nurses who are new to the OR, therefore, not only need to learn new technical skills but also must learn new communication patterns, forms of patient advocacy, and ways of relating to coworkers. Although the welfare of the patient remains at the heart of all that happens in the OR, the personal relationship a nurse has learned to forge with his or her patient--the role of listener, teacher, and comforter--becomes a "bit part." In the OR, the interactions among nurses, surgical technologists, and physicians predominate. The metaphor of a theatrical production provides a way for new nurses to understand the concept of the team in the success of a surgical procedure.

THE ROLE

In a subtle way, we assume a new "character" as soon as we shed our clothes in the locker room and put on our scrubs. The homogenous style of our dress diminishes our individual differences and circumscribes us to our professional roles. As in a play, the costume helps us assume an identity that is prescribed by the nature of the production. That we all dress the same bolsters the notion that we are part of a whole, but it does not mean we are the same. Whatever the strengths of the other actors, there is no doubt that the surgeon is the "star." Surgeons, like actors, wear their star power differently, but no one knows better than the star the importance of the supporting cast. The surgeon knows that a misstep by any member of the cast may have profound significance for the success of his or her own performance.

THE STAGE

The physical design of an operating theater also supports this metaphor, with the sterile field as "front stage" and the surrounding area as "backstage." The backstage crew consists of the circulating nurse as stage manager and the anesthesia care provider and other supporting members as the technical crew who prepare the stage while the members of the scrub team wait for their entrance.

Each procedure, like a play, requires its own props and set design. After the scrub team members take their places, they are confined, just as actors are confined to the stage. The offstage crew must anticipate the needs of the actors and provide what is necessary for the success of the production.

THE SCRIPT

The three acts of a play (ie, the exposition, the complication, the resolution) find counterparts in a surgical procedure. Act I (ie, the exposition) correlates with the incision and exposure phase of a procedure. During Act II (ie, the complication) the problem is identified and repaired. As in a play, this typically is the longest act. Act III (ie, the resolution) correlates with the closing phase of a procedure.

The circulating nurse must learn to recognize this structure as well as the transitions from act to act. Each act tends to have its own identity and produce its own mood. Acts I and III are relatively routine and often are characterized by conversation that flows between onstage and offstage team members. Some surgeons even prefer livelier music during these two phases. Act II, however, usually is characterized by less conversation and a greater concentration on the task. Problems that arise most likely will occur during this act. Most nurses who work in the OR will have experienced the discomfort of asking a question or making a statement that is met with silence during this phase of the procedure. An inexperienced circulating nurse also may have difficulty differentiating statements that he or she must respond to from those directed at others.

Another difficulty encountered when a nurse is unfamiliar with the OR culture is interpreting priorities. When I moved from the intensive care unit to the OR, one of the most disconcerting cues was the urgency with which a surgeon demanded another instrument or another suture. To me, that urgency signified an impending crisis for the patient. I would rush off to find the instrument, acutely aware of the seconds ticking by, believing that the patient's survival was in jeopardy. Often, I was confused because nothing obvious appeared to be wrong. I learned, however, that I was working from the wrong script. In the OR, the urgency is not necessarily based on the status of the patient but rather on the status of the procedure itself. Even though a patient might not be at risk for harm, a missing instrument or an inadequate instrument (ie, the wrong instrument or a defective one) provided during a procedure is like a dropped line or a missed entrance in a play--it causes a glitch in the perfection of the performance.