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Celebrating 40 Years of Progress in Perioperative Nursing Techniques
NOVEMBER 1994, VOL 60, NO 5 Dunscombe Rial1 9
Celebrating 40 Years of Progress in Perioperative Nursing Techniques
T
he first national conference of operating room members of the newly formed AORN. Tremendous clhange has occurred during the nurses was held at the Hotel New Yorker, New York City, in February 1954. Approxi- past 40 years; these changes have required many mately 1,700 nurses and 300 guests and adjustments by nurses in perioperative practice. The exhibitors attended. The terms Congress and concept of conducting nursing research to achieve Association of Operating Room Nurses became offi- improvement through cooperation and to encourage cia1 in 1957 when the organization was formed at the inventiveness has been described as, “Perioperative national conference in Los Angeles.’ Since that time, nursing will continue to be a link between technical OR nursing has evolved into perioperative nursing, advances and effective humanistic care.”7 The techand nurses have seen innumerable changes in periop- nical phases of perioperative nursing, shown in the photographs in this article, illustrate the opportunity erative practice. The presence of nurses in the operating room for basic research to provide armamentaria for was recognized as essential in the early 1900s. The improved patient care and to broaden nursing perscrub and circulating roles were defined in the spectives. Research methods are described in the 1920s.2 Those definitions have expanded to include videotape Research, You Can Do It!,8 which prethe perioperative time frame, giving the OR nurse miered at the 1992 AORN Congress. This article uses photographs from the 1950 preoperative and postoperative responsibilities in film based on Alexander’s book; the techniques addition to intraoperative duties. Much can be learned by reviewing the progress illustrated were considered acceptable in 1954. The made by perioperative nurses during the past four modern scenes show technological advances that decades. Improved patient care is the result of rapid have changed the practice of perioperative nursing. advances in surgical and nursing techniques, new THE PERIOPERAWE CONCEPT technology, and hcreased knowl-A very early recognition of edge. The differences in operating room techniques are evident in A B S T R A C T perioperative nursing concepts is the 1950 film Setting U p the Perioperative nurses have shown in the 1960 film Positive Operating Room3 and the 1991 seen innumerable changes in Patient Safe@ Through Simplified videotape This is Perioperative their practices. During the past OR technic^.^ The nurse authors Nursing .4 4 0 years, new surgical and of the film recommended 25 In the early 1940s, Edythe nursing techniques, new tech- changes in methodology and techLouise Alexander, RN, wrote an nology, and increased knowl- nique; these changes became genauthoritative text titled Operating edge have resulted in improved erally accepted practice within Room Technic.5 It was followed care of the surgical patient. five years of the film’s release. by a film developed by Davis + Much can be learned by review- The journal OR Nursing (forerunGeck, Danbury, Conn, which ing the progress made by peri- ner of the AORN Journal) reportbecame a standard for practice operative nurses during the past ed some of the many changes until 1956.6 Changes were taking four decades. AORN J 60 (Nov suggested in the film: place rapidly, encouraged by the 1994) 742-752. preparation of the patient’s
743 AORN JOURNAL
NOVEMBER 1994, VOL 60, NO 5 Dunscombe Rial1 9
Figure 1 This photograph shows a table setup for a celiotomy as demonstrated in the first film on operating room technique.
Figure 2 Today‘s techniques, including the surgery setup shown here, are more efficient and allow nurses to function efficiently.
skin should begin before his or her admission, the patient should not be shaved until immediately before surgery, the OR should not be set up before the patient arrives, an RN must be present during anesthesia induction, the closed method of gloving should be used, and splash basins, sponge racks, and transfer forceps should be eliminated.’O In 1973, a step closer to the perioperative concept was the introduction of patient interviews conducted by the OR nurse before surgery. Patient interviews were discussed in a film developed under the direction of the AORN Audiovisual Committee.” Reference to this and other films showing perioperative influence appear in a November 1993 AORN Journal article, “History of the AORN Audiovisual Committee.”’z PRODUCT AlYD TECHNOLOCY DeVaLOPMENT
Disposable supplies, better packaging, and advanced technology have made practices from the 1950s obsolete. Today’s techniques are more efficient and allow perioperative nurses to function at their maximum ability (Figures 1 and 2). Many of the changes were initiated by nursing research and were encouraged by AORN. In the 1950s, new items were developed and new techniques were evaluated by nurses cooperating 744 AORN JOURNAL
Figure 3 Surgical hand scrubs in the 1950s required the use of rough scrubbing brushes with stiff bristles that abraded the skin, which frequently increased bacterlal counts. Figure 4 Many variations of disposable sponges have virtually eliminated use of the brush shown in Figure 3. Foamed scrub preparations and gel-prep applications are more recent developments.
NOVEMBER 1994, VOL 60, NO 5 Dunscombe Riall
Figure 5 In 1954, a stainless steel pitcher was used to obtain sterile water from the sterilizer. The pitcher was sterilized and covered with a towel until needed.
Figure 6 Today, sterile water and normal saline are provided in sealed plastic bottles that ensure sterility, ease of handling, and one-time use.
with manufacturers, who had products they wanted to market. Unfortunately, this method did not always permit extensive input from nurses, and the manufacturers often changed the product as little as possible. The reverse procedure (ie, a nurse conceives of an improvement in a device and seeks the help of a manufacturer in improving and marketing it) has developed during the past 40 years. An early example of nurse involvement with product development is Wanda Burley, RN, who was director of surgery at New York Hospital, New York City. Burley wanted an improved scrub brush that would be less abrasive and still provide the desired cleansing action. Her concept was reviewed by a research panel composed of 150 OR nurses and organized by Davis + Geck. Prototypes were designed and tested, and a product was developed (Figures 3 and 4). An article describing the pilot study of the new scrub brush and technique appears in a 1966 issue of the AORN Journal. The author states, “The guaranteed sterility of the scrub sponge and the fact that the packaging is carefully designed to protect sterility until use, reassures us and represents improved patient care.”L3 Other developments led to improved technique and patient care. For example, in the 1950s, sterile water was removed from the sterilizer with stainless steel pitchers. The development of plastic bottles to transport sterile water ensured the water’s sterility and made it safer and easier to handle (Figures 5 and 6). Today, ecological considerations are influencing manufacturers to develop recyclable and biodegradable materials. The Kimberly Clark Corp,
Figure 7 In the 1950%sterile sutures in glass tubes were supplied in jars, cans, or boxes. The OR nurse was responsible for sterlllzlng the outside of the tubes.
Figure 8 This photograph shows a nurse transferring glass tubes of sterile sutures from a jar containing alcoholic formaldehyde solutlon.
Figure 9 Today‘s double packaging makes sterile sutures easier to open, maintains sterility, and Is a major advancement In aseptic practice as well. 745
AORN JOURNAL
NOVEMBER 1994, VOL 60, NO 5 * Dunscombe Rial1
Figure 10 In 1954, moisture was removed from a basin before it was placed on the sterile table. There is not a comparable 1994 photograph, because this technique is no longer considered acceptable. If the basin is wet, the pack is considered contaminated and not used.
Figure 12 Counting sponges was a common practice in 1954; however, the method of holding them in unopened groups led to count errors. When disposable sponge packs became available in the 1960% manufacturers packaged them in multiples of six.
Figure 11 Needles were kept in wire racks and hand threaded in 1954. Today, surgical needles are "swagged" or othefwise connected to the suture or are "pop-off" needles.
Figure 13 Today's practice requires that sponge packs be opened to reveal radiopaque tape and ensure count accuracy. At the insistence of OR nurses, manufacturers now package sponges in multiples of five or 10.
Roswell, Ga, for example, provides extensive data regarding medical waste management and recycling of its sterile wrap product. One of the most dramatic changes in technique during the past 40 years has been the change in how sterile surgical sutures are packaged and handled. Sterile sutures in glass tubes date back to the turn of the century. In 1944, sterile sutures in glass tubes were supplied in cardboard boxes. The OR nurse was responsible for sterilizing the exterior of the tube. In the 1944 film OR Technic, the sterilization process is explained as follows. Remove the glass tubes from the cardboard box, wash them in green soap solution, and
place them in a large glass jar containing alcoholic formaldehyde solution (ie, Bard-Parker solution). In use in the OR, the tubes are transferred to the tuble using transferforceps.I4 Ethicon, Somerville, NJ, introduced sterile sutures in cans containing the solution in 1946; this was soon followed by similar packaging using glass jars instead of cans (Figures 7 and 8). Sterile sutures in double envelopes werl: developed by Davis + Geck in 1957; this development eliminated the need for cans, jars, and solution. Glass tubes were replaced by plastic or paper foil envelopes. The use of transfer forceps was rejected in 1960. Today, the handling of sterile sutures is simplified
747 AORN JOURNAL
NOVEMBER 1994, VOL 60, NO 5 Dunscombe Rial1 8
Figure 14 Opaque rubber tubing was used as suction tubing in 1954. It was difficult to clean, sterilize, and deodorize.
Figure 16 In 1954, packs to be sterilized were wrapped in heavy muslin wrapping and secured with pins, which were reused.
Flgure 1 5 Development of sterile, dlsposable, synthetic tubing eliminated problems of cleaning, sterilizing, and deodorizing and greatly enhanced safe patient outcomes.
Figure 17 Today, drape, gown, and sponge packs to be sterilized are less bulky and are secured with indicator tapes or plastic strips, which are used only once.
by the use of double-wrapped plastic or paper foil envelopes; these are an improvement in aseptic practice as well as a time saver (Figure 9). Other developments include endoscopic loops and sutures with introduction devices. Technological advances in supplies and equipment are depicted in figures 10, 11, 12, and 13. Another example of a practice improvement that was suggested by an OR nurse concerned rubber tubing. When drainage tubing was returned “clean” to the OR after use, the persistent odor could be destroyed entirely by placing the tubing in a solution of common household vinegar and allowing it to stand for two to three hours. The tubing was then rinsed with clear water, drained, and dried thoro~ghly~~ (Figures 14 and 15). Manufacturers now are developing reusable drapes and wrappings as shown in Concepts of Surgical Draping, a videotape that premiered at the 1993 AORN Congress. These may reduce the use of disposables and allay concerns about waste disposal and environmental impact (Figures 16 and 17).
In addition to economic and disposal factors, safety issues also influence new product development. One example is improved surgical gloves that eliminate the need to powder gloves and, therefore, reduce the incidence of granuloma (Figures 18 and 19). Manufacturers have developed glove protectors, and recently, a manufacturer began marketing a surgical needle that will not penetrate gloves, according to the manufacturer. New skin closure methods also have improved patient care and aseptic technique during the past 40 years (Figures 20 and 21). A STLP TOWARD THE -RE
More than 70 years ago, surgeons began investigating the use of telescopes and lights to assist in delicate surgery. Fifty years ago, primitive surgical instruments that permitted illumination and improved visualization were developed. Minimally invasive arthroscopic and gynecologic surgery became common in the 1970s. By the late
748 AORN JOURNAL
-
NOVEMBER 1994, VOL 60, NO 5 Dunscombe Rial1
Figure 18 Powdering rubber gloves with talc was common practice in the 1950s. This practice later was recognized to cause granuloma formation. Figure 20 This photograph shows Michel clips being individually loaded for use in skin closure in the 1950s. Their use was limited, but they were the forerunner of the sophisticated closure devices now available.
Figure 19 Improvements in the texture of surgical gloves and prepowdering have greatly reduced the problem of granuloma formation. This photograph shows an ophthalmic surgeon donning gloves for surgery.
Figure 21 Stapling instruments are now used for skin closure as well as for gastrointestinal anastomosis. Absorbable clips and staples also are available.
1980s, more versatile instruments and supplies (eg, fiber optics, miniature lenses) permitted surgical procedures that resulted in less patient pain and scarring, shortened hospital stays, and reduced recovey times. Although advances in minimally invasive surgery are most noticeable and best known for cholecystectomies, a broad range of procedures are being adapted to laparoscopic techniques. Hundreds of instruments have been developed specifically for use in minimally invasive surgery, and knowledge of these instruments and procedures will be essential to perioperative nurses of the future (Figure 22). Many instruments and devices have been designed since the beginning of this decade to meet the requirements of minimally invasive surgery and improve other surgical techniques. Perioperative nurses will be more involved with these and new products of the future; they will be asked to evaluate
new products and assess their applications in the ORs of tomorrow. Among these new items are an aortic punch used by cardiovascular surgeons during coronary artery bypass grafting; a device that provides illumination, suction, and irrigation at the surgeon’s fingertips during deep cavity surgery; and an innovative biclfragmentable anastomosis ring used in both traditional and laparoscopic gastrointestinal surgeries. The changes mentioned in this article are only some of the dramatiic technological improvements that have occurred during the past 40 years. Life-sustaining interventions are of the highest priority in perioperative settings. Perioperative nurses possess a complexity of knowledge, judgment, and skills to provide cost-effective, quality, individualized care in
751 AORN JOURNAL
NOVEMBER 1994, VOL 60, NO 5
Dunscombe Riall
Figure 22 A laparoscopic surgeon works with the aid of a television and new armamentaria.
this rapidly changing technological, economical, and social environment. Perioperative nurses have experienced and will continue to experience radical change as the twentyfirst century approaches. What will perioperative nursing look like in the year 2000? Certainly the full implementation of the perioperative concept will contribute on an even broader basis in the future than it has in the past 40 years. Already, perioperative nurses’ responsibilities for educational and professional standards and product considerations have progressed far beyond the scope of the 1950s. A
Althea Dunscombe, RN, MS, CIVOR, CRNFA, is president of Professional Assistants PRN, Inc, Naples, Fla. NOTES 1. J Driscoll, Preserving the Legacy (Denver: Association of Operating Room Nurses, Inc, 1990) 2-4. 2. L K Groah, Operating Room Nursing: The P erioperative Role (Reston, Va: Reston Publishing Co, 1983) 6. 3. E L Alexander, Setting Up the Operating Room (Danbury, COM: Davis + Geck, 1950) Film. 4. L Revell, This is Perioperative Nursing (Danbury, Conn: Davis + Geck, 1991) Videotape. 5 . E L Alexander, OR Technic (St
Charles T. Riall, Venice,Fla, was the director of professional relations of Davis + Geck division of American Cyanamid Co, Danbury, Conn, until he retired in 1979. He is the 1992 recipient of the Jerry G. Peers Distinguished Service Award. The authors wish to express appreciation to Davis + Geck, Danbury, Conn,for providing the historical photographs; to the staff members of Venice (Fla) Hospital for providing the modern photographs, which were taken by Cindy Carberry, RN; and to Donnita Simon, RN, CIVOR, and Megs Lewis, RN, CNOR,for their help selecting scenes from the 1950film to use in this article. The authors also wish to express appreciation to the leaders of A O R N s Project 2000 for their foresight and efforts to prepare perioperative nurses for the twenty-first century.
Louis: The C V Mosby Co, 1940). 6. E L Alexander, OR Technic (Danbury, COM:Davis + Geck, 1944) Film. 7. Groah, Operating Room NUI-sing: The Perioperative Role, 17. 8. W Fernsebner, Research, You Can Do It! (Danbury, COM:Davis + Geck, 1992)Videotape. 9. R Pendleton, M V Schwendeman, Positive Patient Safev Through Simplijied OR Technics (Danbury, Conn: Davis + Geck, 1960) Film. 10. “Positive patient safety through simplified OR technics,” (Film Review) OR Nursing 2
752 AORN JOURNAL
(May/June 1961) 58-60,94,98. 11. L K Groah, C Alexander, P erioperative Interview (Danbury, COM: Davis + Geck, 1973) Film. 12. C T Riall, “The AORN Audiovisual Committee: Thirty-three years of perioperative nursing education,” AORN Journal 58 (November 1993) 980-988. 13. M Alexine, “Pilot study on new scrub technique,” AORN Journal 4 (NovemberDecember 1966) 73. 14. Alexander, OR Technic, Film. 15. J L O’Curran, “Obliterating odors from rubber tubing,” ORS no 5 (March 1951) 2.
Celebrating 40 Years of Progress in Perioperative Nursing Techniques
T
he first national conference of operating room members of the newly formed AORN. Tremendous clhange has occurred during the nurses was held at the Hotel New Yorker, New York City, in February 1954. Approxi- past 40 years; these changes have required many mately 1,700 nurses and 300 guests and adjustments by nurses in perioperative practice. The exhibitors attended. The terms Congress and concept of conducting nursing research to achieve Association of Operating Room Nurses became offi- improvement through cooperation and to encourage cia1 in 1957 when the organization was formed at the inventiveness has been described as, “Perioperative national conference in Los Angeles.’ Since that time, nursing will continue to be a link between technical OR nursing has evolved into perioperative nursing, advances and effective humanistic care.”7 The techand nurses have seen innumerable changes in periop- nical phases of perioperative nursing, shown in the photographs in this article, illustrate the opportunity erative practice. The presence of nurses in the operating room for basic research to provide armamentaria for was recognized as essential in the early 1900s. The improved patient care and to broaden nursing perscrub and circulating roles were defined in the spectives. Research methods are described in the 1920s.2 Those definitions have expanded to include videotape Research, You Can Do It!,8 which prethe perioperative time frame, giving the OR nurse miered at the 1992 AORN Congress. This article uses photographs from the 1950 preoperative and postoperative responsibilities in film based on Alexander’s book; the techniques addition to intraoperative duties. Much can be learned by reviewing the progress illustrated were considered acceptable in 1954. The made by perioperative nurses during the past four modern scenes show technological advances that decades. Improved patient care is the result of rapid have changed the practice of perioperative nursing. advances in surgical and nursing techniques, new THE PERIOPERAWE CONCEPT technology, and hcreased knowl-A very early recognition of edge. The differences in operating room techniques are evident in A B S T R A C T perioperative nursing concepts is the 1950 film Setting U p the Perioperative nurses have shown in the 1960 film Positive Operating Room3 and the 1991 seen innumerable changes in Patient Safe@ Through Simplified videotape This is Perioperative their practices. During the past OR technic^.^ The nurse authors Nursing .4 4 0 years, new surgical and of the film recommended 25 In the early 1940s, Edythe nursing techniques, new tech- changes in methodology and techLouise Alexander, RN, wrote an nology, and increased knowl- nique; these changes became genauthoritative text titled Operating edge have resulted in improved erally accepted practice within Room Technic.5 It was followed care of the surgical patient. five years of the film’s release. by a film developed by Davis + Much can be learned by review- The journal OR Nursing (forerunGeck, Danbury, Conn, which ing the progress made by peri- ner of the AORN Journal) reportbecame a standard for practice operative nurses during the past ed some of the many changes until 1956.6 Changes were taking four decades. AORN J 60 (Nov suggested in the film: place rapidly, encouraged by the 1994) 742-752. preparation of the patient’s
743 AORN JOURNAL
NOVEMBER 1994, VOL 60, NO 5 Dunscombe Rial1 9
Figure 1 This photograph shows a table setup for a celiotomy as demonstrated in the first film on operating room technique.
Figure 2 Today‘s techniques, including the surgery setup shown here, are more efficient and allow nurses to function efficiently.
skin should begin before his or her admission, the patient should not be shaved until immediately before surgery, the OR should not be set up before the patient arrives, an RN must be present during anesthesia induction, the closed method of gloving should be used, and splash basins, sponge racks, and transfer forceps should be eliminated.’O In 1973, a step closer to the perioperative concept was the introduction of patient interviews conducted by the OR nurse before surgery. Patient interviews were discussed in a film developed under the direction of the AORN Audiovisual Committee.” Reference to this and other films showing perioperative influence appear in a November 1993 AORN Journal article, “History of the AORN Audiovisual Committee.”’z PRODUCT AlYD TECHNOLOCY DeVaLOPMENT
Disposable supplies, better packaging, and advanced technology have made practices from the 1950s obsolete. Today’s techniques are more efficient and allow perioperative nurses to function at their maximum ability (Figures 1 and 2). Many of the changes were initiated by nursing research and were encouraged by AORN. In the 1950s, new items were developed and new techniques were evaluated by nurses cooperating 744 AORN JOURNAL
Figure 3 Surgical hand scrubs in the 1950s required the use of rough scrubbing brushes with stiff bristles that abraded the skin, which frequently increased bacterlal counts. Figure 4 Many variations of disposable sponges have virtually eliminated use of the brush shown in Figure 3. Foamed scrub preparations and gel-prep applications are more recent developments.
NOVEMBER 1994, VOL 60, NO 5 Dunscombe Riall
Figure 5 In 1954, a stainless steel pitcher was used to obtain sterile water from the sterilizer. The pitcher was sterilized and covered with a towel until needed.
Figure 6 Today, sterile water and normal saline are provided in sealed plastic bottles that ensure sterility, ease of handling, and one-time use.
with manufacturers, who had products they wanted to market. Unfortunately, this method did not always permit extensive input from nurses, and the manufacturers often changed the product as little as possible. The reverse procedure (ie, a nurse conceives of an improvement in a device and seeks the help of a manufacturer in improving and marketing it) has developed during the past 40 years. An early example of nurse involvement with product development is Wanda Burley, RN, who was director of surgery at New York Hospital, New York City. Burley wanted an improved scrub brush that would be less abrasive and still provide the desired cleansing action. Her concept was reviewed by a research panel composed of 150 OR nurses and organized by Davis + Geck. Prototypes were designed and tested, and a product was developed (Figures 3 and 4). An article describing the pilot study of the new scrub brush and technique appears in a 1966 issue of the AORN Journal. The author states, “The guaranteed sterility of the scrub sponge and the fact that the packaging is carefully designed to protect sterility until use, reassures us and represents improved patient care.”L3 Other developments led to improved technique and patient care. For example, in the 1950s, sterile water was removed from the sterilizer with stainless steel pitchers. The development of plastic bottles to transport sterile water ensured the water’s sterility and made it safer and easier to handle (Figures 5 and 6). Today, ecological considerations are influencing manufacturers to develop recyclable and biodegradable materials. The Kimberly Clark Corp,
Figure 7 In the 1950%sterile sutures in glass tubes were supplied in jars, cans, or boxes. The OR nurse was responsible for sterlllzlng the outside of the tubes.
Figure 8 This photograph shows a nurse transferring glass tubes of sterile sutures from a jar containing alcoholic formaldehyde solutlon.
Figure 9 Today‘s double packaging makes sterile sutures easier to open, maintains sterility, and Is a major advancement In aseptic practice as well. 745
AORN JOURNAL
NOVEMBER 1994, VOL 60, NO 5 * Dunscombe Rial1
Figure 10 In 1954, moisture was removed from a basin before it was placed on the sterile table. There is not a comparable 1994 photograph, because this technique is no longer considered acceptable. If the basin is wet, the pack is considered contaminated and not used.
Figure 12 Counting sponges was a common practice in 1954; however, the method of holding them in unopened groups led to count errors. When disposable sponge packs became available in the 1960% manufacturers packaged them in multiples of six.
Figure 11 Needles were kept in wire racks and hand threaded in 1954. Today, surgical needles are "swagged" or othefwise connected to the suture or are "pop-off" needles.
Figure 13 Today's practice requires that sponge packs be opened to reveal radiopaque tape and ensure count accuracy. At the insistence of OR nurses, manufacturers now package sponges in multiples of five or 10.
Roswell, Ga, for example, provides extensive data regarding medical waste management and recycling of its sterile wrap product. One of the most dramatic changes in technique during the past 40 years has been the change in how sterile surgical sutures are packaged and handled. Sterile sutures in glass tubes date back to the turn of the century. In 1944, sterile sutures in glass tubes were supplied in cardboard boxes. The OR nurse was responsible for sterilizing the exterior of the tube. In the 1944 film OR Technic, the sterilization process is explained as follows. Remove the glass tubes from the cardboard box, wash them in green soap solution, and
place them in a large glass jar containing alcoholic formaldehyde solution (ie, Bard-Parker solution). In use in the OR, the tubes are transferred to the tuble using transferforceps.I4 Ethicon, Somerville, NJ, introduced sterile sutures in cans containing the solution in 1946; this was soon followed by similar packaging using glass jars instead of cans (Figures 7 and 8). Sterile sutures in double envelopes werl: developed by Davis + Geck in 1957; this development eliminated the need for cans, jars, and solution. Glass tubes were replaced by plastic or paper foil envelopes. The use of transfer forceps was rejected in 1960. Today, the handling of sterile sutures is simplified
747 AORN JOURNAL
NOVEMBER 1994, VOL 60, NO 5 Dunscombe Rial1 8
Figure 14 Opaque rubber tubing was used as suction tubing in 1954. It was difficult to clean, sterilize, and deodorize.
Figure 16 In 1954, packs to be sterilized were wrapped in heavy muslin wrapping and secured with pins, which were reused.
Flgure 1 5 Development of sterile, dlsposable, synthetic tubing eliminated problems of cleaning, sterilizing, and deodorizing and greatly enhanced safe patient outcomes.
Figure 17 Today, drape, gown, and sponge packs to be sterilized are less bulky and are secured with indicator tapes or plastic strips, which are used only once.
by the use of double-wrapped plastic or paper foil envelopes; these are an improvement in aseptic practice as well as a time saver (Figure 9). Other developments include endoscopic loops and sutures with introduction devices. Technological advances in supplies and equipment are depicted in figures 10, 11, 12, and 13. Another example of a practice improvement that was suggested by an OR nurse concerned rubber tubing. When drainage tubing was returned “clean” to the OR after use, the persistent odor could be destroyed entirely by placing the tubing in a solution of common household vinegar and allowing it to stand for two to three hours. The tubing was then rinsed with clear water, drained, and dried thoro~ghly~~ (Figures 14 and 15). Manufacturers now are developing reusable drapes and wrappings as shown in Concepts of Surgical Draping, a videotape that premiered at the 1993 AORN Congress. These may reduce the use of disposables and allay concerns about waste disposal and environmental impact (Figures 16 and 17).
In addition to economic and disposal factors, safety issues also influence new product development. One example is improved surgical gloves that eliminate the need to powder gloves and, therefore, reduce the incidence of granuloma (Figures 18 and 19). Manufacturers have developed glove protectors, and recently, a manufacturer began marketing a surgical needle that will not penetrate gloves, according to the manufacturer. New skin closure methods also have improved patient care and aseptic technique during the past 40 years (Figures 20 and 21). A STLP TOWARD THE -RE
More than 70 years ago, surgeons began investigating the use of telescopes and lights to assist in delicate surgery. Fifty years ago, primitive surgical instruments that permitted illumination and improved visualization were developed. Minimally invasive arthroscopic and gynecologic surgery became common in the 1970s. By the late
748 AORN JOURNAL
-
NOVEMBER 1994, VOL 60, NO 5 Dunscombe Rial1
Figure 18 Powdering rubber gloves with talc was common practice in the 1950s. This practice later was recognized to cause granuloma formation. Figure 20 This photograph shows Michel clips being individually loaded for use in skin closure in the 1950s. Their use was limited, but they were the forerunner of the sophisticated closure devices now available.
Figure 19 Improvements in the texture of surgical gloves and prepowdering have greatly reduced the problem of granuloma formation. This photograph shows an ophthalmic surgeon donning gloves for surgery.
Figure 21 Stapling instruments are now used for skin closure as well as for gastrointestinal anastomosis. Absorbable clips and staples also are available.
1980s, more versatile instruments and supplies (eg, fiber optics, miniature lenses) permitted surgical procedures that resulted in less patient pain and scarring, shortened hospital stays, and reduced recovey times. Although advances in minimally invasive surgery are most noticeable and best known for cholecystectomies, a broad range of procedures are being adapted to laparoscopic techniques. Hundreds of instruments have been developed specifically for use in minimally invasive surgery, and knowledge of these instruments and procedures will be essential to perioperative nurses of the future (Figure 22). Many instruments and devices have been designed since the beginning of this decade to meet the requirements of minimally invasive surgery and improve other surgical techniques. Perioperative nurses will be more involved with these and new products of the future; they will be asked to evaluate
new products and assess their applications in the ORs of tomorrow. Among these new items are an aortic punch used by cardiovascular surgeons during coronary artery bypass grafting; a device that provides illumination, suction, and irrigation at the surgeon’s fingertips during deep cavity surgery; and an innovative biclfragmentable anastomosis ring used in both traditional and laparoscopic gastrointestinal surgeries. The changes mentioned in this article are only some of the dramatiic technological improvements that have occurred during the past 40 years. Life-sustaining interventions are of the highest priority in perioperative settings. Perioperative nurses possess a complexity of knowledge, judgment, and skills to provide cost-effective, quality, individualized care in
751 AORN JOURNAL
NOVEMBER 1994, VOL 60, NO 5
Dunscombe Riall
Figure 22 A laparoscopic surgeon works with the aid of a television and new armamentaria.
this rapidly changing technological, economical, and social environment. Perioperative nurses have experienced and will continue to experience radical change as the twentyfirst century approaches. What will perioperative nursing look like in the year 2000? Certainly the full implementation of the perioperative concept will contribute on an even broader basis in the future than it has in the past 40 years. Already, perioperative nurses’ responsibilities for educational and professional standards and product considerations have progressed far beyond the scope of the 1950s. A
Althea Dunscombe, RN, MS, CIVOR, CRNFA, is president of Professional Assistants PRN, Inc, Naples, Fla. NOTES 1. J Driscoll, Preserving the Legacy (Denver: Association of Operating Room Nurses, Inc, 1990) 2-4. 2. L K Groah, Operating Room Nursing: The P erioperative Role (Reston, Va: Reston Publishing Co, 1983) 6. 3. E L Alexander, Setting Up the Operating Room (Danbury, COM: Davis + Geck, 1950) Film. 4. L Revell, This is Perioperative Nursing (Danbury, Conn: Davis + Geck, 1991) Videotape. 5 . E L Alexander, OR Technic (St
Charles T. Riall, Venice,Fla, was the director of professional relations of Davis + Geck division of American Cyanamid Co, Danbury, Conn, until he retired in 1979. He is the 1992 recipient of the Jerry G. Peers Distinguished Service Award. The authors wish to express appreciation to Davis + Geck, Danbury, Conn,for providing the historical photographs; to the staff members of Venice (Fla) Hospital for providing the modern photographs, which were taken by Cindy Carberry, RN; and to Donnita Simon, RN, CIVOR, and Megs Lewis, RN, CNOR,for their help selecting scenes from the 1950film to use in this article. The authors also wish to express appreciation to the leaders of A O R N s Project 2000 for their foresight and efforts to prepare perioperative nurses for the twenty-first century.
Louis: The C V Mosby Co, 1940). 6. E L Alexander, OR Technic (Danbury, COM:Davis + Geck, 1944) Film. 7. Groah, Operating Room NUI-sing: The Perioperative Role, 17. 8. W Fernsebner, Research, You Can Do It! (Danbury, COM:Davis + Geck, 1992)Videotape. 9. R Pendleton, M V Schwendeman, Positive Patient Safev Through Simplijied OR Technics (Danbury, Conn: Davis + Geck, 1960) Film. 10. “Positive patient safety through simplified OR technics,” (Film Review) OR Nursing 2
752 AORN JOURNAL
(May/June 1961) 58-60,94,98. 11. L K Groah, C Alexander, P erioperative Interview (Danbury, COM: Davis + Geck, 1973) Film. 12. C T Riall, “The AORN Audiovisual Committee: Thirty-three years of perioperative nursing education,” AORN Journal 58 (November 1993) 980-988. 13. M Alexine, “Pilot study on new scrub technique,” AORN Journal 4 (NovemberDecember 1966) 73. 14. Alexander, OR Technic, Film. 15. J L O’Curran, “Obliterating odors from rubber tubing,” ORS no 5 (March 1951) 2.