The invisible nurse—behind the scenes in an Australian OR

AORN Journal, April, 2004 by Rosalind M. Bull, Mary Fitzgerald

Perioperative nursing is facing a watershed. Currently, the average age of nurses, including perioperative nurses, is in the mid 40s. (1) Attracting a younger workforce during a period of widespread nursing shortages can be difficult. Furthermore, the value of nurses in the OR is being questioned. Perioperative nurses argue that as a specialty nursing group, they ensure safety, efficiency, and sterility in the OR, as well as provide an ethic of holistic and humanistic care in an otherwise highly technological area. One author describes the typical role assigned to nurses and suggests, that within this view, the nurse is

   ... client focused and possesses multidisciplinary
   skills; manages the care
   environment; delivers all but the most
   highly specialized services to the client;
   humanizes the system at the point of
   contact; and acts therapeutically as the
   experience is lived by the client. (2) (p626)

Notwithstanding these beliefs about general and perioperative nurses, both types of nurses experience similar difficulty defending their roles. In both areas, unlicensed health care workers (ie, anesthetic and theatre technicians) increasingly are performing activities that previously were within the purview of nurses alone. This is occurring in part because nurses are expanding their scope of practice to meet demands triggered by changing health care needs and budgetary constraints. Advanced practice roles are developing in response to higher acuity patients, shortages of medical personnel, and changing medical technology. It is reasonable, however, to question whether to expand nursing's scope of practice rather than refine it.

THE PERIOPERATIVE NURSING ROLE

Perioperative nurses recognize their vulnerability and have felt compelled to itemize their activities to define their practice territory, explain how they contribute to the work of the OR, and describe their role as patient advocate. Fiscal agendas, which often appear to drive managerial workforce decisions, emphasize the urgent need for nurses to refine their practice roles before non-nursing imperatives take priority over holistic and humanistic nursing perspectives.

The long list of skills performed by RNs in the OR cannot hope to capture the rich complexity of the work that they perform. In fact, when managers rely on these lists to make staffing decisions with little or no appreciation of the fullness of the nursing scope of practice, such lists may weaken rather than strengthen nurses' positions. These function-focused lists can give the impression that anyone can perform the tasks. Consequently, managers have an excuse to consider alternatives to the traditional workforce. This has resulted in a substantial increase in the number of unlicensed health care workers employed. Although surgical technicians are not common in Australian theatres yet, the role of anesthetic technician is more established. Non-nursing personnel, such as theatre attendants, now are assuming many of the roles previously performed by perioperative nurses, (3-5) including direct patient care. (6)

Attracting nurses to the OR and keeping them there also is becoming more difficult. Concerns about the shortage of theatre nurses are reflected in both national and international literature, and several key contributing themes are evident. For example, there is widespread recognition that although the OR captures the interest of undergraduate students, (7) lack of exposure to the perioperative area during undergraduate preparation means students are less likely to pursue a career there upon graduation. (7-13) The lack of available postgraduate courses that enable RNs to specialize in perioperative nursing also may contribute to the downturn of nurses applying for positions in the OR.

Central to these issues is the hidden nature of perioperative nurses' work. The isolation of the operating department from the rest of the hospital means that few outside people are able to observe perioperative nurses at work. Entry into the OR is restricted by the rules governing traffic flow and dress code. The documentation performed in the OR inevitably reflects anesthetic and surgical interventions rather than nursing activities. These differences have contributed to the mystique that still surrounds operating departments and the relatively invisible nature of perioperative nurses' work.

ETHNOGRAPHY

This article describes a doctoral level ethnographic study conducted in an Australian OR department between 1998 and 2002 that sought to generate substantial insights into the day-to-day working lives of perioperative nurses. (14) Ethnographic research explores the taken-for-granted values, beliefs, and activities in a particular culture and presents it in such a way that outsiders can gain some insight into that particular world. For this reason, ethnography was useful in illuminating the contribution of nurses to the perioperative arena. By writing about perioperative nurses' daily working lives, the researcher hoped to contribute to the available information people use to make important decisions about the future of nurses in the OR. The fieldwork generated through an intensive nine-month period of observation and interviews emphasized nursing knowledge and actions and used them to construct strong, nurse-generated arguments regarding the contribution nurses make to the work of the OR. Excerpts from interviews with perioperative RNs and the field notes generated during the study are used as illustrations.