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An all-RN OR staff
Luther Christman, RN, PhD
An all-RN OR staff When one reflects upon and analyzes the major variables that influence the quality and work effectiveness ratio in the operating room, the issues are reduced to one pervasive variable-the competency of the staff. If better preparation and training advances the ~~
Luther Christman, R N , P D, is professor of nursing and dean o f the College of Nursing at Rush University, Chicago, and vice-president for nursing affairs, Rush-Presbyterian-St Luke’s Medical Center, Chicago. He is a graduate of the Pennsylvania Hospital School of Nursing for Men, Philadelphia. He received his B S degree from Temple University, Philadelphia; his EdM degree in clinical psychology from Temple University, and his PhD in sociology and anthropology from Michigan State University, East Lansing. Dr Christman presented this paper at the 23rd annual A O R N Congress in Miami Beach.
1194
competency of workers in other fields, this should also be true for nurses. Hospitals with nursing staffs composed entirely of registered nurses indicate that the broader range of skills of registered nurses, the reduction in costly supervision, the elimination of expensive training, and the lessening of ideological conflicts have improved the quality of patient care without increasing c0sts.l However, strong action to defend the status quo can be identified in almost any type of organization. As long as people behave within the stated norms, what they do becomes correct by definition rather than by an explanation based on the canons of science. This set of attitudes becomes the first line of defense in resistance to change. Those who raise questions about the status quo frequently are accused of asserting that workers are ineffective and, perhaps, incompetent. Thus, their suggestions for change, no matter how sound and wise, are lost in a wave of overwrought responses. Frenzied thinking replaces logical considerations. In the conceptualizing of work effort, certain principles need consideration: (1) there must be a high degree of predictability that the work flow will remain constant in quality and quantity, (2) the cost-effective ratio must move in the direction of the most desirable, (3) quality assurance must
AORN Journal, June 1976, Vol23, No 7
A
physician-nurse check and balance system is of utmost importance.
have built-in controls, (4) workers in a particular organizational assignment must share perceptions about the work effort with a high degree of agreement about the process and goals of the work objective, and ( 5 ) management of turnover replacement must be accomplished with the least effort. Research on all kinds of organizations shows that the greater the number of task specialists, the greater the intraorganizational strain.* Research also has demonstrated that workers tend to interpret the job process according to their specific background of training and experience.3 Thus, the more diverse the difference in training and experience, the less accord among workers. Covert and overt discords in carrying on work to be done are more likely to occur. The work objectives of the operating room may make these abstractions more concrete. First, the premise in attaining high level OR patient quality care is to have a well-developed clinical process rooted in the methods of science. Staff members should have sharply honed scientific insights that they use in assessing, planning, anticipating issues, and managing each patient undergoing a surgical procedure. There is a remarkable difference in the quality of care that stems from the utilization of knowledge and skills in a scientific process compared to the unimaginative care that generally is the outcome of the task-specific, au-
tomatic behavior one might call reflex practice. How well the scientific process will be developed depends on the education and training of members of the operating room staff. The larger and more embracing the cognitive map of science possessed by members of the staff, the less likely are errors of commission and omission and the more probable are innovations and advances in practice. The cognitive areas include crucial knowledge systems such as anatomy, physiology, microbiology, biochemistry, and behavioral science. In addition, excessively refined psychomotor skills are the means of transforming a great deal of knowledge into empirical action. Psychomotor skills should be based on the need to help transform the application of science into reality, not the need to know how to do a task. Persons cannot use knowledge they do not have; hence, the care process tends to settle out at the level of the poorest prepared workers in the care unit. The corollary to this principle is that the better prepared are all the workers, the greater the chance that care will be high quality. Second, a major requirement in the operating room is that nursing personnel serve as patient advocates. Nurses have an ethical responsibility to serve as legal watchdogs for patients, because patients lack the power and information to protect themselves.
AORN Journal, June 1976, Vol23, No 7
1196
A physician-nurse check and balance system is of utmost importance. Nurses must ascertain that the patient has been properly assessed and that all the precautions and requirements for surgery have been met, that infection control procedures are being observed, that accepted techniques are not being violated, and that nursing staff members caring for each patient are fully informed about the patient’s clinical condition and the surgical procedure at hand. Teaching the patient about his illness, the surgical steps being planned to help intervene in that illness, and possible outcomes are all part of patient advocacy as well as clinical practice. In addition, nurses should teach the patient how to assist in his own care and how to evaluate the outcome of his hospitalization. By doing this, nurses can enable their patients to cope more adequately with illness. Third, a relevant issue is the establishment of standards of nursing care. The patient should be the focus of concern of the standards. The closer the staff mix approaches a completely registered nurse composition, the higher the standards can be in actual practice. When the work is performed by persons with less than professional preparation, there is more likelihood of standards falling short of professional expectation. Work in the operating room is completely dependent on persons with appropriate backgrounds of education. Fourth, a prerequisite that demands attention for the orderly functioning of the operating room is the management of “people” problems. Diverse opinions about the nature of the work adds to the possibility of interpersonal problems. Social structure is a prime cue to expressed behavior. Part of the social structure is the nature of the education and training of the participants in the organization As this education and 1196
background grows more homogeneous, the probability of disagreement about the professional effort lessens. Thus, uniformity in preparation may reduce intraorganizational strain to personality issues. This problem is a lower order of management and can be handled by coaching, inservice education, and counseling. Fifih, an important function is the management of supply purchasing to facilitate the maintenance of high standards. Nurses should be aware of the subtleties of product evaluation. The best outcomes for patients will take place when a reliable system of product evaluation is part of the professional responsibility of nursing personnel. Sixth, a critical need for the induction of students into the professional role is the presence of appropriate behavior models of expert practice for students to observe and copy. Too varied a mixture of professional and nonprofessional behaviors in the work arena may cause the students to get mixed messages about the desired behaviors. Seventh, a highly desirable consideration for operating room nurses is the development of a clinical graduate degree with a major in operating room practice at both the master’s and doctoral levels. Nurses with this form of preparation are needed to lead the advances in practice as have leaders in other professions. The conceptualization of new uses of knowledge and the investigation of clinical problems demand persons with this depth of education. Advances in operating room practice will be pedestrian in pace until there is a liberal sprinkling of nurses with advanced preparation on the OR staffs. All the principles stated in this paper could be more easily achieved and managed with all registered nurse staffs. It is plausible to speculate that
AORN Journal,June 1976, Vol23, No 7
these outcomes for an all registered nurse staff would come t o pass in t h e operating room. To demonstrate this, the nursing staffs of some operating rooms must take it upon themselves t o attempt to implement these principles and to document their The
benefit to patients is riding o n t h i s challenging endeavor.
Notea 1. Private communication from other directors of nursing. 2. Basil Georgopoulos, ed. Organization Research on Health Institutions, lnstwe for social Research (Ann Arbor, Mich: The University of Michigan, 1972) Chapter 2. 3. E Chance, J Arnold, “The effect of professional training, experience, and preference for a theoretical system upon clinical case description.” Human Relations 13 (1960) 195-213.
Possible relief for hypercalcemia Nonsteroid antiinflammatory drugs such as aspirin and indomethacin may relieve the hypercalcemiathat causes physical debilitation and mental disorientation in 10% to 20% of cancer patients. This was reported in an article by Hannsjorg W Seyberth, MD, of the Vanderbilt School of Medicine, Nashville, Tenn, in the spring issue of Prostaglandins & Therapeutics. Dr Seyberth writes that this possibility has been raised by the finding that this hypercalcemia may result from production of abnormally large amounts of certain prostaglandins (PGs) by body tissues. If further research identifies the tumor types likely to produce such hypercalcemia and if benefits are found to outweigh the risks, then drugs such as aspirin and indomethacin-known inhibitors of PG synthesis-may be valuable supplements to cancer therapy, he concludes. Prostaglandins are a family of hormone-like fatty acids, approximately 20 of which have been found to occur naturally in humans. Synthesized normally by tissues throughout the body, PGs are potent regulators of such life functions as inflammation, gastric secretion, fat metabolism, reproduction, nerve impulse transmission, and blood clotting. Hypercalcemiacauses dehydration, weight loss, and grave physical weakness due to patients’ loss of appetite and failure to drink enough liquids. Because calcium is involved in nerve and brain chemistry, hypercalcemia also causes mental disorientation to the point of hallucinations. Physical effects of
hypercalcemia ultimately may be fatal. These symptoms have been found to disappear when normal calcium levels are restored with diuretics, steroids, or mithramycin. Research suggests that calcium is liberated into the blood by PR-medicated action on bone. “The site of the increased prostaglandin production is not known,” Dr Seyberth writes. “Certain prostaglandins might be synthesized in bone in response to a circulating stimulus from the tumor, or a prostaglandin synthesized by the tumor itself could be transported to the bone via the circulation. The Vanderbilt physician analyzed cancer patients’ urine and that of other patients as well for a metabolite of the prostaglandins PGE, and PGEI which he calls PGE-M. “The levels of this prostaglandin metabolite were 10.3-fold elevated when compared with age-matched, hospitalized, control patients,” he reports. Some normocalcemic cancer patients excrete PGE-M in amounts within the control range, and some excrete larger amounts, but in no instance was excretion greater than twice the normal range. “There seems to be a unique association between increased PGE production and hypercalcemia associated with solid tumors, because PGE-M excretion was not elevated in hypercalcemia patients with other hematologic malignancies (multiple myeloma, lymphosarcoma, reticulum cell sarcoma, and malignant lymphoma) or primary hyperparathyroidism.”
AORN Journal, June 1976, Vol23, No 7
1197
An all-RN OR staff When one reflects upon and analyzes the major variables that influence the quality and work effectiveness ratio in the operating room, the issues are reduced to one pervasive variable-the competency of the staff. If better preparation and training advances the ~~
Luther Christman, R N , P D, is professor of nursing and dean o f the College of Nursing at Rush University, Chicago, and vice-president for nursing affairs, Rush-Presbyterian-St Luke’s Medical Center, Chicago. He is a graduate of the Pennsylvania Hospital School of Nursing for Men, Philadelphia. He received his B S degree from Temple University, Philadelphia; his EdM degree in clinical psychology from Temple University, and his PhD in sociology and anthropology from Michigan State University, East Lansing. Dr Christman presented this paper at the 23rd annual A O R N Congress in Miami Beach.
1194
competency of workers in other fields, this should also be true for nurses. Hospitals with nursing staffs composed entirely of registered nurses indicate that the broader range of skills of registered nurses, the reduction in costly supervision, the elimination of expensive training, and the lessening of ideological conflicts have improved the quality of patient care without increasing c0sts.l However, strong action to defend the status quo can be identified in almost any type of organization. As long as people behave within the stated norms, what they do becomes correct by definition rather than by an explanation based on the canons of science. This set of attitudes becomes the first line of defense in resistance to change. Those who raise questions about the status quo frequently are accused of asserting that workers are ineffective and, perhaps, incompetent. Thus, their suggestions for change, no matter how sound and wise, are lost in a wave of overwrought responses. Frenzied thinking replaces logical considerations. In the conceptualizing of work effort, certain principles need consideration: (1) there must be a high degree of predictability that the work flow will remain constant in quality and quantity, (2) the cost-effective ratio must move in the direction of the most desirable, (3) quality assurance must
AORN Journal, June 1976, Vol23, No 7
A
physician-nurse check and balance system is of utmost importance.
have built-in controls, (4) workers in a particular organizational assignment must share perceptions about the work effort with a high degree of agreement about the process and goals of the work objective, and ( 5 ) management of turnover replacement must be accomplished with the least effort. Research on all kinds of organizations shows that the greater the number of task specialists, the greater the intraorganizational strain.* Research also has demonstrated that workers tend to interpret the job process according to their specific background of training and experience.3 Thus, the more diverse the difference in training and experience, the less accord among workers. Covert and overt discords in carrying on work to be done are more likely to occur. The work objectives of the operating room may make these abstractions more concrete. First, the premise in attaining high level OR patient quality care is to have a well-developed clinical process rooted in the methods of science. Staff members should have sharply honed scientific insights that they use in assessing, planning, anticipating issues, and managing each patient undergoing a surgical procedure. There is a remarkable difference in the quality of care that stems from the utilization of knowledge and skills in a scientific process compared to the unimaginative care that generally is the outcome of the task-specific, au-
tomatic behavior one might call reflex practice. How well the scientific process will be developed depends on the education and training of members of the operating room staff. The larger and more embracing the cognitive map of science possessed by members of the staff, the less likely are errors of commission and omission and the more probable are innovations and advances in practice. The cognitive areas include crucial knowledge systems such as anatomy, physiology, microbiology, biochemistry, and behavioral science. In addition, excessively refined psychomotor skills are the means of transforming a great deal of knowledge into empirical action. Psychomotor skills should be based on the need to help transform the application of science into reality, not the need to know how to do a task. Persons cannot use knowledge they do not have; hence, the care process tends to settle out at the level of the poorest prepared workers in the care unit. The corollary to this principle is that the better prepared are all the workers, the greater the chance that care will be high quality. Second, a major requirement in the operating room is that nursing personnel serve as patient advocates. Nurses have an ethical responsibility to serve as legal watchdogs for patients, because patients lack the power and information to protect themselves.
AORN Journal, June 1976, Vol23, No 7
1196
A physician-nurse check and balance system is of utmost importance. Nurses must ascertain that the patient has been properly assessed and that all the precautions and requirements for surgery have been met, that infection control procedures are being observed, that accepted techniques are not being violated, and that nursing staff members caring for each patient are fully informed about the patient’s clinical condition and the surgical procedure at hand. Teaching the patient about his illness, the surgical steps being planned to help intervene in that illness, and possible outcomes are all part of patient advocacy as well as clinical practice. In addition, nurses should teach the patient how to assist in his own care and how to evaluate the outcome of his hospitalization. By doing this, nurses can enable their patients to cope more adequately with illness. Third, a relevant issue is the establishment of standards of nursing care. The patient should be the focus of concern of the standards. The closer the staff mix approaches a completely registered nurse composition, the higher the standards can be in actual practice. When the work is performed by persons with less than professional preparation, there is more likelihood of standards falling short of professional expectation. Work in the operating room is completely dependent on persons with appropriate backgrounds of education. Fourth, a prerequisite that demands attention for the orderly functioning of the operating room is the management of “people” problems. Diverse opinions about the nature of the work adds to the possibility of interpersonal problems. Social structure is a prime cue to expressed behavior. Part of the social structure is the nature of the education and training of the participants in the organization As this education and 1196
background grows more homogeneous, the probability of disagreement about the professional effort lessens. Thus, uniformity in preparation may reduce intraorganizational strain to personality issues. This problem is a lower order of management and can be handled by coaching, inservice education, and counseling. Fifih, an important function is the management of supply purchasing to facilitate the maintenance of high standards. Nurses should be aware of the subtleties of product evaluation. The best outcomes for patients will take place when a reliable system of product evaluation is part of the professional responsibility of nursing personnel. Sixth, a critical need for the induction of students into the professional role is the presence of appropriate behavior models of expert practice for students to observe and copy. Too varied a mixture of professional and nonprofessional behaviors in the work arena may cause the students to get mixed messages about the desired behaviors. Seventh, a highly desirable consideration for operating room nurses is the development of a clinical graduate degree with a major in operating room practice at both the master’s and doctoral levels. Nurses with this form of preparation are needed to lead the advances in practice as have leaders in other professions. The conceptualization of new uses of knowledge and the investigation of clinical problems demand persons with this depth of education. Advances in operating room practice will be pedestrian in pace until there is a liberal sprinkling of nurses with advanced preparation on the OR staffs. All the principles stated in this paper could be more easily achieved and managed with all registered nurse staffs. It is plausible to speculate that
AORN Journal,June 1976, Vol23, No 7
these outcomes for an all registered nurse staff would come t o pass in t h e operating room. To demonstrate this, the nursing staffs of some operating rooms must take it upon themselves t o attempt to implement these principles and to document their The
benefit to patients is riding o n t h i s challenging endeavor.
Notea 1. Private communication from other directors of nursing. 2. Basil Georgopoulos, ed. Organization Research on Health Institutions, lnstwe for social Research (Ann Arbor, Mich: The University of Michigan, 1972) Chapter 2. 3. E Chance, J Arnold, “The effect of professional training, experience, and preference for a theoretical system upon clinical case description.” Human Relations 13 (1960) 195-213.
Possible relief for hypercalcemia Nonsteroid antiinflammatory drugs such as aspirin and indomethacin may relieve the hypercalcemiathat causes physical debilitation and mental disorientation in 10% to 20% of cancer patients. This was reported in an article by Hannsjorg W Seyberth, MD, of the Vanderbilt School of Medicine, Nashville, Tenn, in the spring issue of Prostaglandins & Therapeutics. Dr Seyberth writes that this possibility has been raised by the finding that this hypercalcemia may result from production of abnormally large amounts of certain prostaglandins (PGs) by body tissues. If further research identifies the tumor types likely to produce such hypercalcemia and if benefits are found to outweigh the risks, then drugs such as aspirin and indomethacin-known inhibitors of PG synthesis-may be valuable supplements to cancer therapy, he concludes. Prostaglandins are a family of hormone-like fatty acids, approximately 20 of which have been found to occur naturally in humans. Synthesized normally by tissues throughout the body, PGs are potent regulators of such life functions as inflammation, gastric secretion, fat metabolism, reproduction, nerve impulse transmission, and blood clotting. Hypercalcemiacauses dehydration, weight loss, and grave physical weakness due to patients’ loss of appetite and failure to drink enough liquids. Because calcium is involved in nerve and brain chemistry, hypercalcemia also causes mental disorientation to the point of hallucinations. Physical effects of
hypercalcemia ultimately may be fatal. These symptoms have been found to disappear when normal calcium levels are restored with diuretics, steroids, or mithramycin. Research suggests that calcium is liberated into the blood by PR-medicated action on bone. “The site of the increased prostaglandin production is not known,” Dr Seyberth writes. “Certain prostaglandins might be synthesized in bone in response to a circulating stimulus from the tumor, or a prostaglandin synthesized by the tumor itself could be transported to the bone via the circulation. The Vanderbilt physician analyzed cancer patients’ urine and that of other patients as well for a metabolite of the prostaglandins PGE, and PGEI which he calls PGE-M. “The levels of this prostaglandin metabolite were 10.3-fold elevated when compared with age-matched, hospitalized, control patients,” he reports. Some normocalcemic cancer patients excrete PGE-M in amounts within the control range, and some excrete larger amounts, but in no instance was excretion greater than twice the normal range. “There seems to be a unique association between increased PGE production and hypercalcemia associated with solid tumors, because PGE-M excretion was not elevated in hypercalcemia patients with other hematologic malignancies (multiple myeloma, lymphosarcoma, reticulum cell sarcoma, and malignant lymphoma) or primary hyperparathyroidism.”
AORN Journal, June 1976, Vol23, No 7
1197