The influence of context on role behaviors of perioperative nurses

AORN Journal,  Dec, 2004  by Helen E. McGarvey,  Mary G.A. Chambers,  Jennifer R.P. Boore

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Medical staff members had the power to control the extent to which preoperative visits took place. One surgeon, for instance, prevented nurses from visiting his patients at all. Medical staff members ultimately were in control of the procedure, and the nurses did not want to give patients information that may not have been accurate; thus, nurses in the study tended to focus on a small but very general collection of questions and statements about care that would not mislead patients.

The nurses cited both ward organization and the organization of the operating list as inhibitors to making preoperative visits. Wards were reported to be busy, and bed shortages meant patients often were sitting in corridors. These conditions were perceived to be unsuitable circumstances for visits to occur. The nurses also reported having time limits within which to undertake visits, perhaps 20 minutes to see all the patients on the morning's schedule.

There were days when staff members spoke of being exhausted and under stress. There also were days, however, when this was not the case, and on these occasions, staff members still perceived preoperative visits as problematic. Low motivation clearly was an issue.

The overall picture of preoperative visits was one in which nurses were torn between the expectation that they carry out visits and the personal realization that visits were difficult and, sometimes, impossible. At the one site where visits occurred most frequently, staff members had the support of a senior clinical nurse who had influence in motivating staff members, generating ideas, and setting practice standards. The value of clinically-based specialist nurses thus appears to be important in role enactment.

PATIENT RESPONSIBILITY--NAMED NURSING. The idea of "named nursing" (ie, primary nursing) was endorsed at all sites. One nurse--the named nurse--was allocated to be responsible for a patient's care while the patient was in the operating department. This nurse was expected to visit a patient preoperatively, assess his or her needs, and plan the care that would be provided to this patient on his or her arrival in the operating department. In the absence of the named nurse, an associate would be appointed to continue the care.

This concept was fundamentally problematic in each of the study sites for two reasons. First, the boundary within which the named nurse was expected to perform was unclear, and there were varying interpretations about where the role should end. There was general agreement that the role began with the first nurse-patient interaction, whether that was on the ward during a preoperative visit, in the holding area, or in the anesthetic room. The point at which the relationship terminated, however, was a matter of some ambiguity. Opinions differed about whether it ended when the patient was transferred to the OR bed, when he or she was attached to the anesthesia machine, or when he or she was draped for surgery. There was a period of time, therefore, when no single person had responsibility for the patient. This was a time when patients' bodies most frequently were exposed, sometimes for up to 20 minutes. Not only did this have implications for the patient's dignity but also for the maintenance of his or her body temperature. The named nurse did not appear to have any responsibility for the patient during surgery, and a key caregiver with ultimate responsibility was not evident. The nurses said everyone was responsible, but in reality, observations showed that no one assumed overall care.