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Canadian Operating Room Nursing Journal, Sep 2007 by Downey, Chris
ABSTRACT:
Perioperative nurses have developed specific expert nursing care practices. "Counting as caring" is certainly an approach in keeping with the perioperative nurse's guiding principle of beneficence (to do no harm). This article takes a retrospective look, from the first half of the last century through into the late 1960s, at the practice of counting and the influences that have changed it.
RÉSUMÉ :
Les infirmières et infirmiers périopératoires ont développé des pratiques en soins infirmiers de pointe très spécifiques. La pratique de compter tous les instruments et matériaux en est une découlant directement du principe directeur des soins périopératoires de ne jamais faire de tort. Cet article s'agit d'une analyse rétrospective de cette pratique et des influences l'ayant changée de la première moitié du 19e siècle jusqu'aux années 60.
INTRODUCTION
Perioperative nursing is a specialty devoted to the ethical principle of beneficence (to do no harm). In order to maintain the safety of a patient undergoing surgical intervention perioperative nurses have developed expert nursing care practices regarding aseptic technique, patient positioning, and counting of sponges and instruments. This article takes a retrospective look, from the first half of last century through to the late 1960s, at the practice of counting and the influences that have changed it.
The operating room has traditionally been the domain of surgeons. Perioperative nurses took direction, regarding patient care, from the surgeon.1 Like their sisters on the wards, however, these nurses took these directions, turned them in to rituals, and made them their own:
"...the specific rituals of their practice empowered nurses to define for themselves what constituted good nursing."2
The practice of counting was, and is, one such ritual. This practice has evolved from counting only sponges (1900 through the 1950s), to counting sponges and all of the instruments (by the 1960s).
A review of the literature proves challenging as there are large gaps in the body of historical evidence regarding perioperative nursing. Some of the secondary sources used in this article are based on actions and happenings in the United States. These sources are felt to be valid, and their use to be justified, as the medical changes in the United States very often set the precedents for what happens in Canada.
COUNTING IN THE OPERATING ROOM
Perioperative nurses have counted surgical sponges since the early 1900s when sea sponges began to be used to clear blood from the surgical site.3 Counting was of utmost importance to surgeons who also practiced the principle of beneficence and therefore did not wish to leave any sponges in the wound.
Surgeons and nurses alike were well versed in the complications, such as pain and infection, associated with retained sponges.
By the post World War II era counting had become part of the perioperative nurse's surgical repertoire. The ritual itself, was taught by the demonstration and return demonstration method as described in the following,
"It wasn't a written procedure but I was taught by the nurse who taught me that the scrub nurse was the person who must count the sponges with another Registered Nurse, and she was the person who would count the sponges and relay the final count to the surgeon..."4
Counting was done at the beginning of the case, before a cavity was opened, again when layers, such as the peritoneum, were closed, and finally when the skin was closed. The most important aspect of an uneventful surgical intervention remained the sponge count. As a perioperative nurse in 1953, OR/Perioperative Consultant Teresa Rodgers, RN, pointed out,
"...when you would give them [surgeons] their count they would stop talking and listen very carefully to what you had to say."5
COUNTING IN THE 1950s
By 1957, Canada had moved to insurance-based payment for hospitalization. The availability of these programmes made medical and nursing services affordable to a greater segment of the public and, thereby, increased the demand.6 Third party payments also meant that the insurance companies could dictate terms regarding practices to both doctors and hospitals. This was seen to be a shift in power as the public began to recognize the authority of the insurance company. The insurance company could pick and choose physicians and hospitals depending on whether or not they conformed to accepted practices. The practice of counting was outlined, by such a company, in 1956:
"to ensure the patient's safety in the operating room, the Insurance Council of the California Hospital Association strongly recommends the use of sponges containing radio-opaque materials, and an accurate sponge count. The council's research indicates that three sponge counts are being taken routinely in most of the hospitals studied..."7
The insurance companies now became involved in setting hospital policy and nurses were required to follow these policies in order to ensure patient safety and fiscal responsibility on the public's behalf.
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