- Email: [email protected]
Dynamic Change through Research
The potential contribute nursing
of research can and ‘will
to the aims of operating procedures,
room administration,
and direct patient
care.
DYNAMICCHANGE THROUGHRESEARCH Myrtle
Irene Brown, R.N., Ph.D.
Myrtle Brown received her B.A. from Eureka College in Eureka, Illinois and is a graduate of Methodist Hospital School of Nursing in Peoria. She received a B.S. and M.S. from the University of Minnesota and a Ph.D. from New York University. She is now associate professor of the School of Nursing at the University of Missouri, an associate professor in Community Health and Medical Practice in their School of Medicine, and conducts research as a nurse-sociologist within the medical school’s Program Evaluation Center, Miss Brown has been with the World Health Organization, The Johns Hopkins Unioersity School of Hygiene and Public Health, and the American Nurses Foundation. She is a member of ANA, National League for Nursing, American Public Health Association, and the American Sociological Association, and has contributed numerous articles to the nursing journals.
July-Aug 1966
One is amazed with the rapid changes that have taken place and are still occurring in operating room nursing. The complexity of the operations performed, the profusion of equipment, the extreme conditions of patients undergoing operation, the shift of emphasis on nursing roles, the soaring costs, and the heterogeneity of disciplines working in the operating room all contribute to the necessity for continuous reassessment of habit and routine. All change brings disruption of traditional patterns of behavior. Innovations bring displacements, denial of previously satisfying experiences, and the loss of security from familiar procedures and materials. People are replaced with machines which monitor selected vital signs of patients. The former scrub nurse may see her cherished helping position beside the highly respected surgeon taken by the technician. With the use of dis-
59
posable equipment and the extensive development of central supply services, nurses’ time previously spent in the familiar preparation of supplies and packs is now used to visit patients preoperatively. In the midst of the resulting confusion and tension, we ask how nurses may bring about these changes in an orderly, controlled way, so that patients receiving surgical therapy may be safeguarded. The nurse’s contribution to this dynamic process of change will depend in large part on what OR nurses know as a basis for what they do. Knowledge may be thought of as two kinds, depending on the source of that knowledge. First, there is knowledge which comes through learning that which is already known to the group or society of which one is a part. This is the kind of knowledge that comes through training or education. In a rapidly changing society, this knowledge quickly becomes obsolete unless refreshed and modified. The other kind of knowledge is newly discovered or created understandings about fundamental relationships in nature or reality. This is gained by research. It, too, becomes obsolete as further research findings provide new insights. To make a significant contribution, nurses must continue to seek both kinds of knowledge. It is essential to have good basic education in appropriate schools for the professional nurse and other nursing personnel, as well as continuing inservice education and staff development programs. In addition, research must be freely used to seek new knowledge for a sound basis in practice and teaching. Research is fundamental to the determination of the very nature of nursing. Fortunately, the operating room, and nurses working in it. carry a tradition of investigation and innovation. Let us review how nurses in the operating room have and are using research. Most of the early nursing studies in the
60
operating room were administrative in nature, and were conducted by nurses who were responsible for its administration. These nurses borrowed their investigative techniques from industry. At least 50 years ago, time-study methods were used to secure information on fatigue of the worker in the operating room, and its effect on work output.1 Time and motion studies continued in the operating room until at least the midcentury. Nurses continue to use methods analysis to make more effective use of time, materials, and personnel.2.39 4 . 5 The addition of administrative assistants and operating room managers has increased the frequency of such management studies, with emphasis on use of personnel.6 Industrial management methods are particularly useful in studying the problems of any specific operating room. Primarily, they provide techniques for collecting quantitative information about events in the operating room for specified segments of time. Usually, these numerical data can be translated by very simple formulae into ratios, making it possible to compare the findings from several situations. For example, Morris London, Associate Director of the Hospital Utilization Project in Pittsburgh, recognizing the value of the bed occupancy rate as a basic measure of inpatient utilization of facilities, described the use of an operating room vacancy rate as a comparable measure to assess utilization of operating rooms and their staffs.? Such studies of functions of various kinds of personnel, cost analyses, time and motion studies, work simplification, and variability of practice and techniques provide valuable information to the administrator to aid in decision-making, and for planning and evaluating service. EDUCATION O F PERSONNEL Closely related to administrative research are studies of the preparation of nurses and surgical technicians for staffing the operat-
AORN Journal
ing room. Provision of adequately prepared staff is a fundamental concern of all administrators. In addition to studies of in-staff education and staff development, much thought is going into the planning of learning experiences in the operating room for student nurses. In 1962, questionnaires were sent to the 114 National League for Nursing accredited collegiate basic programs in the United States to determine the approach used to teaching OR nursing in the classroom and in the clinical area.* Lucie S. Young, the investigator, reported great variability in these programs of study. She says that, “Operating room nursing might be anything from complete integration of principles throughout the curriculum with only observation or limited participation in operating room activities, to a six-credit course with 10 to 12 weeks of practice.” 9 Changes that were contemplated in these schools placed primary emphasis on “including or increasing follow-throughs and integrating, shortening, or eliminating the classical operating room experience.”lo Surveys of educational practice, like administrative studies, give us sound information with which to think and plan for staffing. Two implications of Young’s survey are: 1) the need for increased opportunities for graduate study in the nursing care of patients during surgery, and 2) the need for standardized educational programs for operating room technicians. In addition to giving us knowledge with which to think and plan, the ultimate goal of research is to find dependable relationships between factors so that the outcomes of controlled behavior can be predicted. Such ability to predict and control is based on principles which can be applied in any situation. Research that tests principles is far more complex and costly than studies or surveys of work simplification, educational practice, and administration.
J ~ l y - A u g1966
One such fundamental research project has been conducted by a team composed of engineers, physicians, a psychologist, a nurse and sociologist, known as the Systems Research Group, at the Engineering Experiment Station of the Ohio State University. 1, 1 2 *l 3 Their original aim was to develop a procedure by which any hospital could measure the level of patient care it was providing, and to identify areas for improvement. Learning to work together was difficult. Each saw the problem through the frame of reference of his science or area of specialization, and attacked it with the tools of his discipline. It was finally in cybernetics that a common approach to the problem was found. When the hospital was conceived of as a goaldirected system, or man-machine, a theory of regulation and control became a potential. A model of the process by which the hospital functioned in the total community was conceived. Within that model, a sub-system of patient, nurse, and doctor was studied. Though the ultimate goals of this project have not been reached, the team has provided us with the useful concept of the monitoring role of the nurse in the patientnurse-physician trial. Some of you may have heard Dr. Wanda McDowell, the former nurse-participant on that team, report at the Clinical Sessions of the 1962 American Nurses’ Association Csnvention. If not, I recommend her paper “Nurse-Patient-Physician Behavior: Nursing Care and the Regulation of Patient Behavior.”l4 The importance of the monitoring functions of the nurse in the operating room has been emphasized by the increased use of various telemetering equipment, and adds credence to this partially tested theory. Unless there is a display panel continuously recording all monitored data, the nurse must regularly observe the signal. Often she must compare it with a pre-determined level of control and selectively communicate the significant information. Knowing also the prob-
61
able action the physician will take to regulate such deviation from the expected norm, she sends for or prepares the materials that he will need to control the undesirable variance in patient state. In some situations, she institutes action to bring the patient’s state back to a safe range. Change of position, adjustment of the flow of intravenous fluids or medicines, and administration of a narcotic are examples of nursing action to control patient condition. This research has contributed to a theory that places the nurse in the direct nursing care of the patient, and faces realistically that nursing is usually carried out in at least a three-person relationship-patient, doctor, and nurse. Does this theory not add to the value and meaning of the circulating nurse’s function as the nurse of the patient? ~
ENVIRONMENT CONTROL Another large group of nursing studies in the operating room has been aimed at environmental control. These studies have ranged in scope from air-sanitation to the training of personnel. They have been concerned primarily with the safety and protection of patients and personnel in an area of fairly high hazard potential. Most emphasis has been on the prevention of contamination and resulting infection. Research conducted to establish sterilization procedures and equipment standards has long since moved out of operating rooms and into laboratories. Commercial suppliers of sterilizing equipment and pre-sterilized supplies have employed bacteriologists, chemists, engineers, and others to establish safe practices in the preparation, care, and use of their equipment. Among those employed have been nurses, who brought their intimate knowledge of patient need, operating room practice, and personnel behavior to the testing of products.15 With laboratories designing equipment, the testing of hardware in specific operating
62
room settings has been left to hospital personnel. After all the work has been done by commercial companies on products and standards, nurses have synthesized the information into funotional procedures for their use, sometimes alone; more often together with bacteriologists, physicians, engineers and, more recently, with architects.16, 179 18 Germ-free animal laboratory methods used in immunological research and space science have contributed a recent step in the prevention of infection of highly susceptible patients through the surgical isolator. This plastic tent with its related equipment may isolate only the operative site, or it may encase the entire patient. Major Maria L. LaConte, of the Army Nurse Corps, worked as a member of the research team in the development and testing of this equipment in an animal laboratory, and with patients. l 9 * O Team work in research is as essential as it is in patient service. Surgical staffs, ever vigilant for breaks in aseptic techniques, have instigated investigations when episodes of postoperative infection have occurred. Criteria and measurement tools for sterility of equipment developed in laboratories have been incorporated into administrative control practices. An enormous amount of investigatory work has been carried out on equipment, procedures, techniques, and housekeeping, in order to achieve environmental control of surgical infection. Let me quote from a leader in operating room studies, Janet L. Fitzwater, R.N., presently chief of the Surgical Nursing Service, Department of Nursing, Clinical Center, National Institutes of Health. Miss Fitzwater, writing in 1 W , summarized some of the recent work directed toward decreasing the number and severity of infections. Each area was documented, in a bibliography of some 42 items.21 Said Miss Fitzwater: “Activities have included bacteriological surveys; investigations of trafbc patterns; air
*
AORN Jsurnal
studies; evaluation of clothing, gloves, footwear, caps and masks; consideration of the pros and cons of ultraviolet irradiation; work to improve the techniques of skin preparation; appraisal of antiseptics; revision of housekeeping procedures; air sampling relative to open and closed cabinets; controversial debates on the value of anesthesia rooms; studies on the transport of patients and equipment; fabrication of isolettes and plastic drapes; evaluation of scrubbing techniques and agents; investigation of scrub rooms and similar undertakings.”z 2 NURSING PROCEDURES AND NURSING CARE An important part of environmental control is the standardiaation of procedures. Nurses have often concentrated on procedures which are carried out as a part of direct nursing care, or in behalf of patients. Such a procedure is the surgical hand scrub, which has been extensively studied. In spite of all the work by pharmaceutical companies on detergents and skin disinfectants, studies still demonstrate the importance of the scrub procedure.2 3 Sometimes a new product has necessitated a complete change in procedure. This has been particularly true of procedures concerned with the care and sterilization of equipment when a presterilized disposable product was furnished by the supply houses. For example, a comparative study was made of two types of surgeons’ gloves: disposable and r e ~ s a b l e . 2On ~ the basis of findings concerning cost, saving of personnel time, acceptability, and durability, these investigators recommended “that serious consideration be given to the adoption of disposable gloves and abolishing all glove processing.”2 Methodology included a cost analysis and trials of both kinds of gloves in actual operations. This study was conducted by a nurse and a well-known statistician who
has helped nurses extensively with research methods. The project was so soundly designed and conducted, and gave such solid information about the two methods of supplying gloves, that operating room administrators had a good basis for changing to a new product and concurrently scrapping glove care procedures. Nurses continue to evaluate nursing procedures but today their approach tends to be different. General problem areas selected for study still arise from clinical situations but the problem selected is stated in terms of the concepts of one of the following sciences: physiology, physics, social psychology, or psychology.26 Working from theory in one of these sciences, an hypothesis is formulated to test a specific principle as it functions in nursing action. A project is then set up in a laboratory to test it. An excellent example of such a project was reported by Lewis and Gunn27 in which they evaluated, in a laboratory model, the praotice of administering oxygen to tracheotomized patients through a catheter inserted into the tracheostomy tube. Working from the laws of physics concerned with resistance to a flow of air through a given tube, they investigated resistance factors associated with the insertion of different sized catheters, different sized tracheostomy tubes, varying tidal volumes, and six different flow rates of oxygen. They reported that an oxygen catheter placed within a tracheostomy tube acts as an obstruction to simulated expiratory air flow. This resistance is augmented by increasing the size of the catheter, the flow rate of oxygen, and the tidal volumes, and by decreasing the size of the tracheostomy tube. These investigators recommended that further study be made of physiologic changes of the person when the tracheostomy tube has been obstructed by an oxygen catheter. Further, they recommended testing, in the clinical situation, an improvised method for
63
administering oxygen to patients using a paper cup to hold the tip of the oxygen catheter just over the tracheostomy tube. This basic research project by Lewis and Gunn tested the theory of air flow resistance through a tube. It reaffirmed that principle in a procedure we use in nursing, and it opened up a scientific basis for the innovation of a sounder procedure to be tested in a clinical situation. Some nursing care research is amenable only to clinical study. A scientific framework can not be conceived at this time, nor can a controlled laboratory design for the project be planned. This is particularly true of studies of patient behavior and nurse-patient interaction. The following two studies illustrate such clinical nursing study. Both have small samples and findings which are only suggestive. Cassady and Altrocchi, in a study conducted in partial fulfillment of the requirements for a Master’s degree, elicited from 40 preoperative patients their fears and concerns.28 Those expressed most frequently were concerned with diagnosis, death, helplessness, and socio-economic problems. Many more such studies are needed of patient characteristics but with larger, well-selected samples, and with better tools to measure amounts and kinds of behavior, both verbal and non-verbal. A highly promising group of research projects on nurse-patient interaction is being conducted at the Yale School of Nursing. One of these is particularly relevant to nurses working with patients experiencing surgical therapy. Dumasz9 hypothesized that a nursing process which was directed toward helping the patient relieve psychological distress preoperatively would be significantly correlated with less postoperative vomiting. Her research was designed to test this. Though the carly reports of Dumas and Leonard were on three small groups totaling only 25 patients in the experimental group, and 26 in
64
the control group, the findings did tend to support their hypothesis. . Further research might affirm that appropriate nursing care can better prepare the patient psychologically for his surgical experience. If indeed this is proven to be true, should this not then become as important to preoperative nursing preparation as the skin prep? Already we are seeing a few operating room nurses move out of the surgical suite to visit patients preoperatively in order to gain information about them to better plan their nursing care in the operating room, and to answer their questions. Patients have repeatedly expressed how much they appreciate these visits; the operating room seemed a less strange and fearful place. In other situations, operating room nurses also give some care to patients in the recovery room. How logical this would seem. The patient’s needs relative to the operation extend from the preparation, through the operating room, and into recovery room until he is recovered sufficiently to return to the surgical nursing unit. His nursing needs are continuous during this complete cycle. Should not the nursing care for this whole therapeutic episode be given by the nurses who really know what the patient experiences in the operating room? Several of the studies mentioned here add to our concept of nursing, in particular the one at Ohio State with its concept of the nurse as monitor of patient state, and the one from Yale that suggests that nursing care is directly therapeutic in the operative sequence. Research of this kind begins to build into a theory of nursing that provides principles to guide us in the practice of our profession of nursing. These two research projects provide content for nursing patients, just as earlier studies in the operating room helped nurses to know how better to assist surgeons and to carry out the functions of the hospital through administration,
AORN Journal
education and environmental control.
SUMMARY It is quite apparent that unthinking tradition and routines cannot survive in the operating room. To the contrary, a healthy and rapidly growing body of findings from studies and research is developing as a source of knowledge to which OR nurses can turn as an aid to solving their service and educational problems. The projects discussed here have been grouped into three areas: administration, environment and equipment, and procedures and nursing care. The kinds of studies conducted within each of these broad classes have changed in a number of important aspects. I shall summarize four: 1) purpose, 2 ) place, 3 ) preparation of persons, and 4) the potentiality for application. 1) Purpose-Early studies in operating rooms were primarily problem solving, and aimed at finding answers to specific problems in specific settings. As nurses have gained higher levels of education, with knowledge of the behavioral as well as the natural sciences, the purpose of projects has become the testing of scientific principles in actual nursing situations in order to gain knowledge with which to predict and control the outcome of what nurses do, 2) Place-Today, initial research in a specific area of knowledge frequently begins in the laboratory where conditions can be controlled far better than in the clinical situation. After hypotheses have been tested in such controlled situations, the clinical studies follow on surer ground, with less waste of time and energy, and with sounder results. 3 ) Preparation of persons-As for the preparation of nurse researchers, advanced study in institutions of higher learning has enabled some nurses to function on multidisciplinary teams as colleagues with their fellow-scientists. In the colleague capacity,
J d y - A u g 1966
nurses can determine what problems shall be studied in nursing. This not only has given them control of the use made of nurses in research but opens up the way to building a body of nursing theory or knowledge, on which basis they can function as professional practitioners. 4) Potential for application-Thus nurses have gained a potential for applying the findings of research in the improvement of patient care. The practitioner has a great responsibility for using the best knowledge available. Today, this means that all professional nurses must learn enough about research to read and understand the reports, such as one finds in Nursing Research. Staff members must be aided to read this kind of nursing article effectively, to discuss reports until they are understood, to consider their implications for practice, and to apply this new knowledge in practice. As the body of scientific nursing knowledge grows and can be unified into valid concepts and dependable principles, it will be easier to use the products of research. Today we must study each research report, assess the care with which it was carried out, and think individually about its implications. Later, as our nurse scientists begin to relate their work to the larger body of nursing knowledge, application will be easier for the practitioner and teacher. I hope that I have made it clear that research related to nursing in the operating room is following the same pattern of development as nursing research in general. With the current emphasis on research, the nature of nursing of the patient during surgical therapy is moving, along with all nursing, toward the development of a sound body of knowledge for direct patient care. Related research will help the administrator of nursing service, and the educator of nursing personnel. The most promising research, however, is focused on nursing care of the patient.
65
REFERENCES 1. Gilbreth, F. B., “Motion Study in Surgery,” Canadian Journal of Medicine, #40, 1916, pp. 22-31. 2. Clarke, Alice R., “Challenging New Study Made of Traditional O.R. Practice,” Hospital Topics, Vol. 38, #3, 1960, pp. 85-89 and Vol. 38, #4, 1960, pp. 95-98. 3. Prickett, Edna, “Application of the Methods Improvement Technic in Operating Room Nursing,” in Kethleen W. Phillips and Sadye T. Travers (eds.) Military Operating Room Nursing, Walter Reed Army Institute of Research, Washington, 12, D.C., 1956. 4. Fitzwater, Janet, “The Selection of Instruments for Major Operations,” Nursing Research, Vol. 9, #3, 1960, pp. 129-136. 5. Zimmerman, Otto Carl, “Utilizing Operating Room Time,” Hospital Topics, Vol. 41, #2, 1963, pp. 99-102. 6. Arnivine, Don L., “Nursing Personnel Needs for the Operating Room,” Hospital Management, Vol. 91, #l, 1961, pp. 62-64. 7. London, Morris, “Know Your OR Vacancy Rate to Improve Surgical Scheduling,” The Modern Hospital, Vol. 103, #4, 1964, pp. 110-114. 8. Young, Lucie S., “O.R. Experience for Students,” Nursing Outlook, Vol. 12, #12, 1964, pp. 47-49. 9. Ibid., p. 48. 10. Ibid. 11. Howland, Daniel, “Approaches to the Systems Problem,” Nursing Research, Vol. 12, Summer, 1963. (Reprint.) 12. Howland, Daniel, “A Hospital System Model,” Nursing Research, Vol. 12, Fall, 1963. (Reprint.) 13. Howland, Daniel, and McDowell, Wanda E., “The Measurement of Patient Care: A Conceptual Framework,” Nursing Research, Volume 13, Winter, 1964. (Reprint.) 14. McDowell, Wanda E., “Nurse-Patient-Physician Behavior: Nursing Care and the Regulation of Patient Condition,” The Nurse-Patient-Doctor Triadic Relationships, #21, 1962, of the Clinical Session of
66
the 1962 ANA Convention, New York, American Nurses’ Association. 15. Prickett, Edna, “OR Fact and Principle,” AORN Journal, Vol. 1, #1, 1963, p. 83. 16. Fitzwater, Janet, “Scrub Sinks Harbor Potential Danger,” AORN Journal, Vol. 1, #I, 1963, pp. 36-37. 17. Rockwell, Virginia Tyler, “Surgical Hand Scrubbing,” American Journal of Nursing, Vol. 63, 8 6 , 1963. (Reprint.) 18. Jacobs, Jr., Robert H., “The Architects Guide to Surgical Infection,” AORN Journal, Vol. 1, #3, 1963, pp. 47-63. 19. Doberneck, Raymond C., Nunn, LaConte, Kimler, and Pulaski, “Portacaval Shunt Operation in a Surgical Isolator: A study of Cultures During Operation and Wound Healing Thereafter,” Military Medicine, March, 1963, pp. 259-263. 20. Ginsberg, Miriam K., and LaConte, Maria L., “Reverse Isolation,” American Journal of Nursing, Vol. 64, #9, 1964, pp. 88-90. 21. Fitzwater, Janet, “Focus on Asepsis,” AORN Journal, Vol. 2, #1, 1964, pp. 47-52. 22. Ibid, p. 47. 23. Rockwell, Virginia Tyler, op. cit. 24. Struve, Mildred, and Levine, Eugene, “Disposable and Reusable Surgeon’s Gloves,” Nursing Research, Vol. 10, #2, 1961, pp. 79-86. 25. Ibid, p. 86. 26. Thompson, Vera K., and Dolan, Michael F., “Tissue Bank Methods,” Hospital Topics, Vol. 41, #12, 1963, pp. 64-68. 27. Lewis, Betty, and Gunn, Ira, “Tracheostomy, O2 Administration and Expiratory Air Flow Resistance,” Nursing Research, Vol. 13, #4, 1964, pp. 301-308. 28. Cassady, June R., and Altrocchi, John, “Patients’ Concerns About Surgery,” Nursing Research, Vol. 9, #4, 1960, pp. 219-221. 29. Dumas, Rhetaugh, and Leonard, Robert, “The Effect of Nursing on the Incident of Postoperative Vomiting,” Nursing Research, Vol. 12, #1, 1963, pp. 12-15.
AORN Journal
of research can and ‘will
to the aims of operating procedures,
room administration,
and direct patient
care.
DYNAMICCHANGE THROUGHRESEARCH Myrtle
Irene Brown, R.N., Ph.D.
Myrtle Brown received her B.A. from Eureka College in Eureka, Illinois and is a graduate of Methodist Hospital School of Nursing in Peoria. She received a B.S. and M.S. from the University of Minnesota and a Ph.D. from New York University. She is now associate professor of the School of Nursing at the University of Missouri, an associate professor in Community Health and Medical Practice in their School of Medicine, and conducts research as a nurse-sociologist within the medical school’s Program Evaluation Center, Miss Brown has been with the World Health Organization, The Johns Hopkins Unioersity School of Hygiene and Public Health, and the American Nurses Foundation. She is a member of ANA, National League for Nursing, American Public Health Association, and the American Sociological Association, and has contributed numerous articles to the nursing journals.
July-Aug 1966
One is amazed with the rapid changes that have taken place and are still occurring in operating room nursing. The complexity of the operations performed, the profusion of equipment, the extreme conditions of patients undergoing operation, the shift of emphasis on nursing roles, the soaring costs, and the heterogeneity of disciplines working in the operating room all contribute to the necessity for continuous reassessment of habit and routine. All change brings disruption of traditional patterns of behavior. Innovations bring displacements, denial of previously satisfying experiences, and the loss of security from familiar procedures and materials. People are replaced with machines which monitor selected vital signs of patients. The former scrub nurse may see her cherished helping position beside the highly respected surgeon taken by the technician. With the use of dis-
59
posable equipment and the extensive development of central supply services, nurses’ time previously spent in the familiar preparation of supplies and packs is now used to visit patients preoperatively. In the midst of the resulting confusion and tension, we ask how nurses may bring about these changes in an orderly, controlled way, so that patients receiving surgical therapy may be safeguarded. The nurse’s contribution to this dynamic process of change will depend in large part on what OR nurses know as a basis for what they do. Knowledge may be thought of as two kinds, depending on the source of that knowledge. First, there is knowledge which comes through learning that which is already known to the group or society of which one is a part. This is the kind of knowledge that comes through training or education. In a rapidly changing society, this knowledge quickly becomes obsolete unless refreshed and modified. The other kind of knowledge is newly discovered or created understandings about fundamental relationships in nature or reality. This is gained by research. It, too, becomes obsolete as further research findings provide new insights. To make a significant contribution, nurses must continue to seek both kinds of knowledge. It is essential to have good basic education in appropriate schools for the professional nurse and other nursing personnel, as well as continuing inservice education and staff development programs. In addition, research must be freely used to seek new knowledge for a sound basis in practice and teaching. Research is fundamental to the determination of the very nature of nursing. Fortunately, the operating room, and nurses working in it. carry a tradition of investigation and innovation. Let us review how nurses in the operating room have and are using research. Most of the early nursing studies in the
60
operating room were administrative in nature, and were conducted by nurses who were responsible for its administration. These nurses borrowed their investigative techniques from industry. At least 50 years ago, time-study methods were used to secure information on fatigue of the worker in the operating room, and its effect on work output.1 Time and motion studies continued in the operating room until at least the midcentury. Nurses continue to use methods analysis to make more effective use of time, materials, and personnel.2.39 4 . 5 The addition of administrative assistants and operating room managers has increased the frequency of such management studies, with emphasis on use of personnel.6 Industrial management methods are particularly useful in studying the problems of any specific operating room. Primarily, they provide techniques for collecting quantitative information about events in the operating room for specified segments of time. Usually, these numerical data can be translated by very simple formulae into ratios, making it possible to compare the findings from several situations. For example, Morris London, Associate Director of the Hospital Utilization Project in Pittsburgh, recognizing the value of the bed occupancy rate as a basic measure of inpatient utilization of facilities, described the use of an operating room vacancy rate as a comparable measure to assess utilization of operating rooms and their staffs.? Such studies of functions of various kinds of personnel, cost analyses, time and motion studies, work simplification, and variability of practice and techniques provide valuable information to the administrator to aid in decision-making, and for planning and evaluating service. EDUCATION O F PERSONNEL Closely related to administrative research are studies of the preparation of nurses and surgical technicians for staffing the operat-
AORN Journal
ing room. Provision of adequately prepared staff is a fundamental concern of all administrators. In addition to studies of in-staff education and staff development, much thought is going into the planning of learning experiences in the operating room for student nurses. In 1962, questionnaires were sent to the 114 National League for Nursing accredited collegiate basic programs in the United States to determine the approach used to teaching OR nursing in the classroom and in the clinical area.* Lucie S. Young, the investigator, reported great variability in these programs of study. She says that, “Operating room nursing might be anything from complete integration of principles throughout the curriculum with only observation or limited participation in operating room activities, to a six-credit course with 10 to 12 weeks of practice.” 9 Changes that were contemplated in these schools placed primary emphasis on “including or increasing follow-throughs and integrating, shortening, or eliminating the classical operating room experience.”lo Surveys of educational practice, like administrative studies, give us sound information with which to think and plan for staffing. Two implications of Young’s survey are: 1) the need for increased opportunities for graduate study in the nursing care of patients during surgery, and 2) the need for standardized educational programs for operating room technicians. In addition to giving us knowledge with which to think and plan, the ultimate goal of research is to find dependable relationships between factors so that the outcomes of controlled behavior can be predicted. Such ability to predict and control is based on principles which can be applied in any situation. Research that tests principles is far more complex and costly than studies or surveys of work simplification, educational practice, and administration.
J ~ l y - A u g1966
One such fundamental research project has been conducted by a team composed of engineers, physicians, a psychologist, a nurse and sociologist, known as the Systems Research Group, at the Engineering Experiment Station of the Ohio State University. 1, 1 2 *l 3 Their original aim was to develop a procedure by which any hospital could measure the level of patient care it was providing, and to identify areas for improvement. Learning to work together was difficult. Each saw the problem through the frame of reference of his science or area of specialization, and attacked it with the tools of his discipline. It was finally in cybernetics that a common approach to the problem was found. When the hospital was conceived of as a goaldirected system, or man-machine, a theory of regulation and control became a potential. A model of the process by which the hospital functioned in the total community was conceived. Within that model, a sub-system of patient, nurse, and doctor was studied. Though the ultimate goals of this project have not been reached, the team has provided us with the useful concept of the monitoring role of the nurse in the patientnurse-physician trial. Some of you may have heard Dr. Wanda McDowell, the former nurse-participant on that team, report at the Clinical Sessions of the 1962 American Nurses’ Association Csnvention. If not, I recommend her paper “Nurse-Patient-Physician Behavior: Nursing Care and the Regulation of Patient Behavior.”l4 The importance of the monitoring functions of the nurse in the operating room has been emphasized by the increased use of various telemetering equipment, and adds credence to this partially tested theory. Unless there is a display panel continuously recording all monitored data, the nurse must regularly observe the signal. Often she must compare it with a pre-determined level of control and selectively communicate the significant information. Knowing also the prob-
61
able action the physician will take to regulate such deviation from the expected norm, she sends for or prepares the materials that he will need to control the undesirable variance in patient state. In some situations, she institutes action to bring the patient’s state back to a safe range. Change of position, adjustment of the flow of intravenous fluids or medicines, and administration of a narcotic are examples of nursing action to control patient condition. This research has contributed to a theory that places the nurse in the direct nursing care of the patient, and faces realistically that nursing is usually carried out in at least a three-person relationship-patient, doctor, and nurse. Does this theory not add to the value and meaning of the circulating nurse’s function as the nurse of the patient? ~
ENVIRONMENT CONTROL Another large group of nursing studies in the operating room has been aimed at environmental control. These studies have ranged in scope from air-sanitation to the training of personnel. They have been concerned primarily with the safety and protection of patients and personnel in an area of fairly high hazard potential. Most emphasis has been on the prevention of contamination and resulting infection. Research conducted to establish sterilization procedures and equipment standards has long since moved out of operating rooms and into laboratories. Commercial suppliers of sterilizing equipment and pre-sterilized supplies have employed bacteriologists, chemists, engineers, and others to establish safe practices in the preparation, care, and use of their equipment. Among those employed have been nurses, who brought their intimate knowledge of patient need, operating room practice, and personnel behavior to the testing of products.15 With laboratories designing equipment, the testing of hardware in specific operating
62
room settings has been left to hospital personnel. After all the work has been done by commercial companies on products and standards, nurses have synthesized the information into funotional procedures for their use, sometimes alone; more often together with bacteriologists, physicians, engineers and, more recently, with architects.16, 179 18 Germ-free animal laboratory methods used in immunological research and space science have contributed a recent step in the prevention of infection of highly susceptible patients through the surgical isolator. This plastic tent with its related equipment may isolate only the operative site, or it may encase the entire patient. Major Maria L. LaConte, of the Army Nurse Corps, worked as a member of the research team in the development and testing of this equipment in an animal laboratory, and with patients. l 9 * O Team work in research is as essential as it is in patient service. Surgical staffs, ever vigilant for breaks in aseptic techniques, have instigated investigations when episodes of postoperative infection have occurred. Criteria and measurement tools for sterility of equipment developed in laboratories have been incorporated into administrative control practices. An enormous amount of investigatory work has been carried out on equipment, procedures, techniques, and housekeeping, in order to achieve environmental control of surgical infection. Let me quote from a leader in operating room studies, Janet L. Fitzwater, R.N., presently chief of the Surgical Nursing Service, Department of Nursing, Clinical Center, National Institutes of Health. Miss Fitzwater, writing in 1 W , summarized some of the recent work directed toward decreasing the number and severity of infections. Each area was documented, in a bibliography of some 42 items.21 Said Miss Fitzwater: “Activities have included bacteriological surveys; investigations of trafbc patterns; air
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studies; evaluation of clothing, gloves, footwear, caps and masks; consideration of the pros and cons of ultraviolet irradiation; work to improve the techniques of skin preparation; appraisal of antiseptics; revision of housekeeping procedures; air sampling relative to open and closed cabinets; controversial debates on the value of anesthesia rooms; studies on the transport of patients and equipment; fabrication of isolettes and plastic drapes; evaluation of scrubbing techniques and agents; investigation of scrub rooms and similar undertakings.”z 2 NURSING PROCEDURES AND NURSING CARE An important part of environmental control is the standardiaation of procedures. Nurses have often concentrated on procedures which are carried out as a part of direct nursing care, or in behalf of patients. Such a procedure is the surgical hand scrub, which has been extensively studied. In spite of all the work by pharmaceutical companies on detergents and skin disinfectants, studies still demonstrate the importance of the scrub procedure.2 3 Sometimes a new product has necessitated a complete change in procedure. This has been particularly true of procedures concerned with the care and sterilization of equipment when a presterilized disposable product was furnished by the supply houses. For example, a comparative study was made of two types of surgeons’ gloves: disposable and r e ~ s a b l e . 2On ~ the basis of findings concerning cost, saving of personnel time, acceptability, and durability, these investigators recommended “that serious consideration be given to the adoption of disposable gloves and abolishing all glove processing.”2 Methodology included a cost analysis and trials of both kinds of gloves in actual operations. This study was conducted by a nurse and a well-known statistician who
has helped nurses extensively with research methods. The project was so soundly designed and conducted, and gave such solid information about the two methods of supplying gloves, that operating room administrators had a good basis for changing to a new product and concurrently scrapping glove care procedures. Nurses continue to evaluate nursing procedures but today their approach tends to be different. General problem areas selected for study still arise from clinical situations but the problem selected is stated in terms of the concepts of one of the following sciences: physiology, physics, social psychology, or psychology.26 Working from theory in one of these sciences, an hypothesis is formulated to test a specific principle as it functions in nursing action. A project is then set up in a laboratory to test it. An excellent example of such a project was reported by Lewis and Gunn27 in which they evaluated, in a laboratory model, the praotice of administering oxygen to tracheotomized patients through a catheter inserted into the tracheostomy tube. Working from the laws of physics concerned with resistance to a flow of air through a given tube, they investigated resistance factors associated with the insertion of different sized catheters, different sized tracheostomy tubes, varying tidal volumes, and six different flow rates of oxygen. They reported that an oxygen catheter placed within a tracheostomy tube acts as an obstruction to simulated expiratory air flow. This resistance is augmented by increasing the size of the catheter, the flow rate of oxygen, and the tidal volumes, and by decreasing the size of the tracheostomy tube. These investigators recommended that further study be made of physiologic changes of the person when the tracheostomy tube has been obstructed by an oxygen catheter. Further, they recommended testing, in the clinical situation, an improvised method for
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administering oxygen to patients using a paper cup to hold the tip of the oxygen catheter just over the tracheostomy tube. This basic research project by Lewis and Gunn tested the theory of air flow resistance through a tube. It reaffirmed that principle in a procedure we use in nursing, and it opened up a scientific basis for the innovation of a sounder procedure to be tested in a clinical situation. Some nursing care research is amenable only to clinical study. A scientific framework can not be conceived at this time, nor can a controlled laboratory design for the project be planned. This is particularly true of studies of patient behavior and nurse-patient interaction. The following two studies illustrate such clinical nursing study. Both have small samples and findings which are only suggestive. Cassady and Altrocchi, in a study conducted in partial fulfillment of the requirements for a Master’s degree, elicited from 40 preoperative patients their fears and concerns.28 Those expressed most frequently were concerned with diagnosis, death, helplessness, and socio-economic problems. Many more such studies are needed of patient characteristics but with larger, well-selected samples, and with better tools to measure amounts and kinds of behavior, both verbal and non-verbal. A highly promising group of research projects on nurse-patient interaction is being conducted at the Yale School of Nursing. One of these is particularly relevant to nurses working with patients experiencing surgical therapy. Dumasz9 hypothesized that a nursing process which was directed toward helping the patient relieve psychological distress preoperatively would be significantly correlated with less postoperative vomiting. Her research was designed to test this. Though the carly reports of Dumas and Leonard were on three small groups totaling only 25 patients in the experimental group, and 26 in
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the control group, the findings did tend to support their hypothesis. . Further research might affirm that appropriate nursing care can better prepare the patient psychologically for his surgical experience. If indeed this is proven to be true, should this not then become as important to preoperative nursing preparation as the skin prep? Already we are seeing a few operating room nurses move out of the surgical suite to visit patients preoperatively in order to gain information about them to better plan their nursing care in the operating room, and to answer their questions. Patients have repeatedly expressed how much they appreciate these visits; the operating room seemed a less strange and fearful place. In other situations, operating room nurses also give some care to patients in the recovery room. How logical this would seem. The patient’s needs relative to the operation extend from the preparation, through the operating room, and into recovery room until he is recovered sufficiently to return to the surgical nursing unit. His nursing needs are continuous during this complete cycle. Should not the nursing care for this whole therapeutic episode be given by the nurses who really know what the patient experiences in the operating room? Several of the studies mentioned here add to our concept of nursing, in particular the one at Ohio State with its concept of the nurse as monitor of patient state, and the one from Yale that suggests that nursing care is directly therapeutic in the operative sequence. Research of this kind begins to build into a theory of nursing that provides principles to guide us in the practice of our profession of nursing. These two research projects provide content for nursing patients, just as earlier studies in the operating room helped nurses to know how better to assist surgeons and to carry out the functions of the hospital through administration,
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education and environmental control.
SUMMARY It is quite apparent that unthinking tradition and routines cannot survive in the operating room. To the contrary, a healthy and rapidly growing body of findings from studies and research is developing as a source of knowledge to which OR nurses can turn as an aid to solving their service and educational problems. The projects discussed here have been grouped into three areas: administration, environment and equipment, and procedures and nursing care. The kinds of studies conducted within each of these broad classes have changed in a number of important aspects. I shall summarize four: 1) purpose, 2 ) place, 3 ) preparation of persons, and 4) the potentiality for application. 1) Purpose-Early studies in operating rooms were primarily problem solving, and aimed at finding answers to specific problems in specific settings. As nurses have gained higher levels of education, with knowledge of the behavioral as well as the natural sciences, the purpose of projects has become the testing of scientific principles in actual nursing situations in order to gain knowledge with which to predict and control the outcome of what nurses do, 2) Place-Today, initial research in a specific area of knowledge frequently begins in the laboratory where conditions can be controlled far better than in the clinical situation. After hypotheses have been tested in such controlled situations, the clinical studies follow on surer ground, with less waste of time and energy, and with sounder results. 3 ) Preparation of persons-As for the preparation of nurse researchers, advanced study in institutions of higher learning has enabled some nurses to function on multidisciplinary teams as colleagues with their fellow-scientists. In the colleague capacity,
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nurses can determine what problems shall be studied in nursing. This not only has given them control of the use made of nurses in research but opens up the way to building a body of nursing theory or knowledge, on which basis they can function as professional practitioners. 4) Potential for application-Thus nurses have gained a potential for applying the findings of research in the improvement of patient care. The practitioner has a great responsibility for using the best knowledge available. Today, this means that all professional nurses must learn enough about research to read and understand the reports, such as one finds in Nursing Research. Staff members must be aided to read this kind of nursing article effectively, to discuss reports until they are understood, to consider their implications for practice, and to apply this new knowledge in practice. As the body of scientific nursing knowledge grows and can be unified into valid concepts and dependable principles, it will be easier to use the products of research. Today we must study each research report, assess the care with which it was carried out, and think individually about its implications. Later, as our nurse scientists begin to relate their work to the larger body of nursing knowledge, application will be easier for the practitioner and teacher. I hope that I have made it clear that research related to nursing in the operating room is following the same pattern of development as nursing research in general. With the current emphasis on research, the nature of nursing of the patient during surgical therapy is moving, along with all nursing, toward the development of a sound body of knowledge for direct patient care. Related research will help the administrator of nursing service, and the educator of nursing personnel. The most promising research, however, is focused on nursing care of the patient.
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REFERENCES 1. Gilbreth, F. B., “Motion Study in Surgery,” Canadian Journal of Medicine, #40, 1916, pp. 22-31. 2. Clarke, Alice R., “Challenging New Study Made of Traditional O.R. Practice,” Hospital Topics, Vol. 38, #3, 1960, pp. 85-89 and Vol. 38, #4, 1960, pp. 95-98. 3. Prickett, Edna, “Application of the Methods Improvement Technic in Operating Room Nursing,” in Kethleen W. Phillips and Sadye T. Travers (eds.) Military Operating Room Nursing, Walter Reed Army Institute of Research, Washington, 12, D.C., 1956. 4. Fitzwater, Janet, “The Selection of Instruments for Major Operations,” Nursing Research, Vol. 9, #3, 1960, pp. 129-136. 5. Zimmerman, Otto Carl, “Utilizing Operating Room Time,” Hospital Topics, Vol. 41, #2, 1963, pp. 99-102. 6. Arnivine, Don L., “Nursing Personnel Needs for the Operating Room,” Hospital Management, Vol. 91, #l, 1961, pp. 62-64. 7. London, Morris, “Know Your OR Vacancy Rate to Improve Surgical Scheduling,” The Modern Hospital, Vol. 103, #4, 1964, pp. 110-114. 8. Young, Lucie S., “O.R. Experience for Students,” Nursing Outlook, Vol. 12, #12, 1964, pp. 47-49. 9. Ibid., p. 48. 10. Ibid. 11. Howland, Daniel, “Approaches to the Systems Problem,” Nursing Research, Vol. 12, Summer, 1963. (Reprint.) 12. Howland, Daniel, “A Hospital System Model,” Nursing Research, Vol. 12, Fall, 1963. (Reprint.) 13. Howland, Daniel, and McDowell, Wanda E., “The Measurement of Patient Care: A Conceptual Framework,” Nursing Research, Volume 13, Winter, 1964. (Reprint.) 14. McDowell, Wanda E., “Nurse-Patient-Physician Behavior: Nursing Care and the Regulation of Patient Condition,” The Nurse-Patient-Doctor Triadic Relationships, #21, 1962, of the Clinical Session of
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the 1962 ANA Convention, New York, American Nurses’ Association. 15. Prickett, Edna, “OR Fact and Principle,” AORN Journal, Vol. 1, #1, 1963, p. 83. 16. Fitzwater, Janet, “Scrub Sinks Harbor Potential Danger,” AORN Journal, Vol. 1, #I, 1963, pp. 36-37. 17. Rockwell, Virginia Tyler, “Surgical Hand Scrubbing,” American Journal of Nursing, Vol. 63, 8 6 , 1963. (Reprint.) 18. Jacobs, Jr., Robert H., “The Architects Guide to Surgical Infection,” AORN Journal, Vol. 1, #3, 1963, pp. 47-63. 19. Doberneck, Raymond C., Nunn, LaConte, Kimler, and Pulaski, “Portacaval Shunt Operation in a Surgical Isolator: A study of Cultures During Operation and Wound Healing Thereafter,” Military Medicine, March, 1963, pp. 259-263. 20. Ginsberg, Miriam K., and LaConte, Maria L., “Reverse Isolation,” American Journal of Nursing, Vol. 64, #9, 1964, pp. 88-90. 21. Fitzwater, Janet, “Focus on Asepsis,” AORN Journal, Vol. 2, #1, 1964, pp. 47-52. 22. Ibid, p. 47. 23. Rockwell, Virginia Tyler, op. cit. 24. Struve, Mildred, and Levine, Eugene, “Disposable and Reusable Surgeon’s Gloves,” Nursing Research, Vol. 10, #2, 1961, pp. 79-86. 25. Ibid, p. 86. 26. Thompson, Vera K., and Dolan, Michael F., “Tissue Bank Methods,” Hospital Topics, Vol. 41, #12, 1963, pp. 64-68. 27. Lewis, Betty, and Gunn, Ira, “Tracheostomy, O2 Administration and Expiratory Air Flow Resistance,” Nursing Research, Vol. 13, #4, 1964, pp. 301-308. 28. Cassady, June R., and Altrocchi, John, “Patients’ Concerns About Surgery,” Nursing Research, Vol. 9, #4, 1960, pp. 219-221. 29. Dumas, Rhetaugh, and Leonard, Robert, “The Effect of Nursing on the Incident of Postoperative Vomiting,” Nursing Research, Vol. 12, #1, 1963, pp. 12-15.
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