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Technicians or nurses in the OR?
~~
Melville Roberts, MD Juliet Vilinskas, MD Guy Owens, MD
Technicians or nurses in the OR? Three surgeons describe the roles of technicians in four hospitals and conclude that nurses are needed in the operating room. Twenty-five surgeons they surveyed agreed with them. During the past ten years the number of surgical technicians employed in operating rooms has increased relative to the number of registered nurses. In some operating rooms surgical technicians now outnumber registered nurses. What do surgeons think about it? We made a small study to find out how the technicians’ role is developing and what surgeons think about these developments . The four institutions studied included a 1,000-bed community hospital (Hospital A ) , a 200-bed Veterans Administration hospital (Hospital B) , a 200-bed university hospital (Hospital C), and a 775-bed community hospital (Hospital D) . All four are in the greater metropolitan area of Hartford, Conn.
Copyright May 1974, the American Journal of Nursing Company. Reprinted from American Journal of Nursing, 74 (May 1974) 906-907.
466
Information was obtained from interviews with operating room supervisors and surgical technician training program directors a t the four institutions. In addition, an attitudinal survey of 25 surgeons, chosen at random from all of the surgical specialties, from the staffs of the four hospitals was made. The surgeons were given a list of 10 statements, to which they responded with agreement or disagreement. They also had an opportunity to elaborate on their reasons for agreement or disagreement. The largest of the four hospitals, Hospital A, had the greatest preponderance of technicians, 64 t o 22 nurses. At Hospital B, the VA hospital, the ratio was 6 to 5, the university hospital (C)had 6 technicians and 4 RNs, and Hospital D had 34 of each. None of the hospitals required certification by the Association of Operating Room Technicians, but 15 of the technicians a t Hospital A and 2 a t Hospital C were so certified. Hospital A required high school graduation. The other three did not make this requirement, but all six technicians at Hospital B were graduates, all but one a t Hospital. C,
AORN Journal, September 1974, Vol 20, N o 3
all but one at Hospital D. One technician at Hospital D held an associate in arts degree. Three of the four hospitals had one-year on-the-job training programs, the one a t Hospital A directed by a technician, those at Hospitals B and C by nurses. Hospital C had had a program but, for financial reasons, discontinued it after only two technicians had been trained there. All four hospitals paid technicians less than nurses, though at Hospital A technicians were permitted to perform all the tasks that nurses did, and even to hold supervisory positions. At the VA and university hospitals (B and C) technicians were not permitted to mix or administer drugs, insert Foley catheters, or count sponges. At Hospital D technicians were barred from those tasks, they scrubbed only on routine cases, and they did not circulate in the operating mom. A t both Hospital A and Hospital D technicians had expressed dissatisfaction over their limitations. At Hospital A, the technicians, in 1969, went so far as to stage a sudden sit-down strike inside the operating room. Agitation by the technicians has been, in part, responsible for a relatively high turnover in supervisory Melville Roberts, MD, Yale Univer-
sity, is chairman of the division of neurological surgery and associate professor o f surgery at the University of Connecticut School of Medicine. Juliet Vilinskas, MD, Medical College of Pennsylvania, is an assistant pro-
fessor of surgery at the same school. Guy Owens, MD,Harvard University, is professor and head of the department of surgery there.
and administrative personnel in the Hospital A operating room. The present operating room director has a master’s degree in psychology, six years of experience in hospital administration, and is neither a registered nurse nor a surgical technician. Surgeons’ Opinions. The majority of the surgeons polled believed that, as a general principle, registered nurses make better scrub nurses than surgical technicians (56%), that the average technician is not as dedicated to patient care as the average registered nurse (76cjo), and that surgical technicians are necessary because enough nurses cannot be hired to staff most operating rooms (885%). Eighty-four percent believed that technicians should be required to pass a certification examination as a condition for employment. Many (64%) also agreed that technicians should not be allowed to assume the same responsibilities as registered nurses in the operating room. Most (84%) opposed technicians’ holding supervisory positions. Most surgeons (92%) believed that many nursing schools are now putting undue emphasis on the administrative and sociologic aspects of nursing. They also believed (885%) that all student nurses should be required to have thorough operating room training. Conclusions. It is possible that operating rooms in the future will be entirely staffed by surgical technicians. If the changes that have occurred at Hospital A (one of the leading hospitals in New England) continue in the same direction, and if these changes are a portent of what is to happen elsewhere, the operating room nurse may become extinct. With an operating room director who is not &to
AORN Journal, September 1974, Vol 20, N o 3
470
467
a registered nurse, a director of the surgical technician training program who is not a registered nurse, and many technicians being given the same responsibilities as registered nurses, there is nothing to prevent an all-technician operating room evolving a t Hospital A. There would be both advantages and disadvantages to staffing an operating room completely with surgical technicians, but to our mind the advantages are far outweighed by the disadvantages. The primary advantage now is economic. Technicians can be paid less, and it takes less time and money to train them. In addition, with the operating room staffed with technicians, nurses would be freed to serve elsewhere. A very serious disadvantage, however, is that the average technician is not capable of handling all operating room jobs with the same degree of competence as the average registered nurse. There are no standards for recruiting and training technicians. Some technician training programs do not even require graduation from high school. Length of training may vary from a month to a year. Though certification exists, most technicians remain uncertified. Hospitals continue to employ and promote technicians who have failed the examination. Technicians are not licensed, and there are no prescribed standards for training programs. Further, no enforceable ethical standards have been set for surgical technicians.
Compare this lack of educational and competence standards to the rigorous training and licensing examination required of registered nurses, and one sees why the majority of surgeons have judged the operating
470
room technician not as competent as the registered nurse. There is no question that with proper screening, training, and quality control an individual can be taught in a year to perform adequately many of the routine tasks in both scrubbing and circulating. It is an error, however, to equate such an individual with a registered nurse as has been done at Hospital A. Only the registered nurse, because of her superior training and judgment, should be allowed to assume the responsibility of managing an operating room during a major surgical procedure. Another serious disadvantage to an all-technician or technician-dominated operating room is the lack of professionalism and dedication to patient welfare. A startling example of lack of professionalism and dedication to the patient’s well-being was seen during the technicians’ sit-down strike at Hospital A. The strike took place suddenly at 7 am, without warning; many patients had already received preliminary medication. In this instance the technicians showed a lack of ethical standards, not because they struck, but because of the way they struck, so as to jeopardize patient care. Nonetheless, the hospital administration gave in to the technicians and did not support the registered nurses who supervised the operating room. Thus it is quite understandable that there has been a brisk turnover of operating room supervisors at Hospital A during the past few years. The ratio of technicians to nurses is probably a critical factor in determining the future direction of an
AORN Journal, September 1974,Vol 20, N o 3
operating room. Ginsberg suggests that a 1:l ratio is ideal. Our findings support this view. Hospital D, for example, has a 1:l ratio and a smoothly running, RN-directed and dominated operating room. At Hospital A, trouble began as the number of technicians exceeded the number of nurses, culminating in the sit-down strike of 1969 and resulting in the present policy of equating technicians with registered nurses. The technician-to-nurse ratio a t Hospital A is now 3:l and will undoubtedly continue to grow until there are no registered nurses left unless present policies are changed. These ratios are important only in relatively large operating rooms. Hospital A, for example, has 64 technicians and 22 nurses. Should the technicians strike, there is no way quickly to replace such a large number of individuals and therefore little alternative but to meet their demands. The specter of another technicians' strike still haunts the operating room a t Hospital A. At small hospitals, however, such as B and C, even though technicians slightly outnumber registered nurses, the actual number of technicians is small and, should they suddenly go on strike, they could be replaced quickly, and the operating room would not have to shut down. Thus very small operating rooms can safely run higher technician-to-nurse ratios than very large ones. There is no question that the operating room technician is here to stay.2 Efforts are now being made to upgrade the technician by instituting standards of training and perform a n ~ e .This ~ , ~ is absolutely necessary if technicians are to gain professional
472
recognition and respect. Nonetheless, if the registered nurse does not remain in firm control of the operating room, an erosion of standards will occur and ultimately the patient will suffer.' The nursing profession must make prompt and vigorous efforts to prevent this calamity. Notes
I.
Frances Ginsberg, "Technicians are fine but
RNs are essential," Modern Hospital, I I I (October
1968) 114. 2.
-.
"Like it or not, surgical technicians
are here t o stay," Modern Hospifal,
I I2
(April
1969) 114. 3. D M Morgan, "Preparation of the operating room technician," Canadian Hospital, 49 ( M a y 1972) 40ff. 4. R S Mekger, "AORN-AORT committee a t work," AORN Journal, 16 (December 1972) 30-32.
Recovery room personnel seminur The Florida Society of Anesthesiologists will conduct its fifth annual seminar for recovery room personnel a t Lake Buena Vistcr, Fla, Oct 31 to Nov 3. The seminar will include special presentations by noted medical authorities, scientific sessions, exhibits of new equipment and services, and social events for all registrants. The registration fee of $50 per person includes breakfasts, lunches, and the seminar banquet. Headquarters will be at the Dutch Inn a t Lake Buena Vista on Walt Disney property neur Orlando. Hotel room rates for registrants will b e $20 for single and $27 for double. No deposit will be required on room reservations and all major credit cards will b e accepted. A certificate of completion will be awarded to each registrant attending the seminar. For reservation forms and further information write Florida Society of Anesthesiologists, 118 W Adoms St, Jacksonville, Fia, 32202,
AORN Journal, September 1974, Vol 20, No 3
Melville Roberts, MD Juliet Vilinskas, MD Guy Owens, MD
Technicians or nurses in the OR? Three surgeons describe the roles of technicians in four hospitals and conclude that nurses are needed in the operating room. Twenty-five surgeons they surveyed agreed with them. During the past ten years the number of surgical technicians employed in operating rooms has increased relative to the number of registered nurses. In some operating rooms surgical technicians now outnumber registered nurses. What do surgeons think about it? We made a small study to find out how the technicians’ role is developing and what surgeons think about these developments . The four institutions studied included a 1,000-bed community hospital (Hospital A ) , a 200-bed Veterans Administration hospital (Hospital B) , a 200-bed university hospital (Hospital C), and a 775-bed community hospital (Hospital D) . All four are in the greater metropolitan area of Hartford, Conn.
Copyright May 1974, the American Journal of Nursing Company. Reprinted from American Journal of Nursing, 74 (May 1974) 906-907.
466
Information was obtained from interviews with operating room supervisors and surgical technician training program directors a t the four institutions. In addition, an attitudinal survey of 25 surgeons, chosen at random from all of the surgical specialties, from the staffs of the four hospitals was made. The surgeons were given a list of 10 statements, to which they responded with agreement or disagreement. They also had an opportunity to elaborate on their reasons for agreement or disagreement. The largest of the four hospitals, Hospital A, had the greatest preponderance of technicians, 64 t o 22 nurses. At Hospital B, the VA hospital, the ratio was 6 to 5, the university hospital (C)had 6 technicians and 4 RNs, and Hospital D had 34 of each. None of the hospitals required certification by the Association of Operating Room Technicians, but 15 of the technicians a t Hospital A and 2 a t Hospital C were so certified. Hospital A required high school graduation. The other three did not make this requirement, but all six technicians at Hospital B were graduates, all but one a t Hospital. C,
AORN Journal, September 1974, Vol 20, N o 3
all but one at Hospital D. One technician at Hospital D held an associate in arts degree. Three of the four hospitals had one-year on-the-job training programs, the one a t Hospital A directed by a technician, those at Hospitals B and C by nurses. Hospital C had had a program but, for financial reasons, discontinued it after only two technicians had been trained there. All four hospitals paid technicians less than nurses, though at Hospital A technicians were permitted to perform all the tasks that nurses did, and even to hold supervisory positions. At the VA and university hospitals (B and C) technicians were not permitted to mix or administer drugs, insert Foley catheters, or count sponges. At Hospital D technicians were barred from those tasks, they scrubbed only on routine cases, and they did not circulate in the operating mom. A t both Hospital A and Hospital D technicians had expressed dissatisfaction over their limitations. At Hospital A, the technicians, in 1969, went so far as to stage a sudden sit-down strike inside the operating room. Agitation by the technicians has been, in part, responsible for a relatively high turnover in supervisory Melville Roberts, MD, Yale Univer-
sity, is chairman of the division of neurological surgery and associate professor o f surgery at the University of Connecticut School of Medicine. Juliet Vilinskas, MD, Medical College of Pennsylvania, is an assistant pro-
fessor of surgery at the same school. Guy Owens, MD,Harvard University, is professor and head of the department of surgery there.
and administrative personnel in the Hospital A operating room. The present operating room director has a master’s degree in psychology, six years of experience in hospital administration, and is neither a registered nurse nor a surgical technician. Surgeons’ Opinions. The majority of the surgeons polled believed that, as a general principle, registered nurses make better scrub nurses than surgical technicians (56%), that the average technician is not as dedicated to patient care as the average registered nurse (76cjo), and that surgical technicians are necessary because enough nurses cannot be hired to staff most operating rooms (885%). Eighty-four percent believed that technicians should be required to pass a certification examination as a condition for employment. Many (64%) also agreed that technicians should not be allowed to assume the same responsibilities as registered nurses in the operating room. Most (84%) opposed technicians’ holding supervisory positions. Most surgeons (92%) believed that many nursing schools are now putting undue emphasis on the administrative and sociologic aspects of nursing. They also believed (885%) that all student nurses should be required to have thorough operating room training. Conclusions. It is possible that operating rooms in the future will be entirely staffed by surgical technicians. If the changes that have occurred at Hospital A (one of the leading hospitals in New England) continue in the same direction, and if these changes are a portent of what is to happen elsewhere, the operating room nurse may become extinct. With an operating room director who is not &to
AORN Journal, September 1974, Vol 20, N o 3
470
467
a registered nurse, a director of the surgical technician training program who is not a registered nurse, and many technicians being given the same responsibilities as registered nurses, there is nothing to prevent an all-technician operating room evolving a t Hospital A. There would be both advantages and disadvantages to staffing an operating room completely with surgical technicians, but to our mind the advantages are far outweighed by the disadvantages. The primary advantage now is economic. Technicians can be paid less, and it takes less time and money to train them. In addition, with the operating room staffed with technicians, nurses would be freed to serve elsewhere. A very serious disadvantage, however, is that the average technician is not capable of handling all operating room jobs with the same degree of competence as the average registered nurse. There are no standards for recruiting and training technicians. Some technician training programs do not even require graduation from high school. Length of training may vary from a month to a year. Though certification exists, most technicians remain uncertified. Hospitals continue to employ and promote technicians who have failed the examination. Technicians are not licensed, and there are no prescribed standards for training programs. Further, no enforceable ethical standards have been set for surgical technicians.
Compare this lack of educational and competence standards to the rigorous training and licensing examination required of registered nurses, and one sees why the majority of surgeons have judged the operating
470
room technician not as competent as the registered nurse. There is no question that with proper screening, training, and quality control an individual can be taught in a year to perform adequately many of the routine tasks in both scrubbing and circulating. It is an error, however, to equate such an individual with a registered nurse as has been done at Hospital A. Only the registered nurse, because of her superior training and judgment, should be allowed to assume the responsibility of managing an operating room during a major surgical procedure. Another serious disadvantage to an all-technician or technician-dominated operating room is the lack of professionalism and dedication to patient welfare. A startling example of lack of professionalism and dedication to the patient’s well-being was seen during the technicians’ sit-down strike at Hospital A. The strike took place suddenly at 7 am, without warning; many patients had already received preliminary medication. In this instance the technicians showed a lack of ethical standards, not because they struck, but because of the way they struck, so as to jeopardize patient care. Nonetheless, the hospital administration gave in to the technicians and did not support the registered nurses who supervised the operating room. Thus it is quite understandable that there has been a brisk turnover of operating room supervisors at Hospital A during the past few years. The ratio of technicians to nurses is probably a critical factor in determining the future direction of an
AORN Journal, September 1974,Vol 20, N o 3
operating room. Ginsberg suggests that a 1:l ratio is ideal. Our findings support this view. Hospital D, for example, has a 1:l ratio and a smoothly running, RN-directed and dominated operating room. At Hospital A, trouble began as the number of technicians exceeded the number of nurses, culminating in the sit-down strike of 1969 and resulting in the present policy of equating technicians with registered nurses. The technician-to-nurse ratio a t Hospital A is now 3:l and will undoubtedly continue to grow until there are no registered nurses left unless present policies are changed. These ratios are important only in relatively large operating rooms. Hospital A, for example, has 64 technicians and 22 nurses. Should the technicians strike, there is no way quickly to replace such a large number of individuals and therefore little alternative but to meet their demands. The specter of another technicians' strike still haunts the operating room a t Hospital A. At small hospitals, however, such as B and C, even though technicians slightly outnumber registered nurses, the actual number of technicians is small and, should they suddenly go on strike, they could be replaced quickly, and the operating room would not have to shut down. Thus very small operating rooms can safely run higher technician-to-nurse ratios than very large ones. There is no question that the operating room technician is here to stay.2 Efforts are now being made to upgrade the technician by instituting standards of training and perform a n ~ e .This ~ , ~ is absolutely necessary if technicians are to gain professional
472
recognition and respect. Nonetheless, if the registered nurse does not remain in firm control of the operating room, an erosion of standards will occur and ultimately the patient will suffer.' The nursing profession must make prompt and vigorous efforts to prevent this calamity. Notes
I.
Frances Ginsberg, "Technicians are fine but
RNs are essential," Modern Hospital, I I I (October
1968) 114. 2.
-.
"Like it or not, surgical technicians
are here t o stay," Modern Hospifal,
I I2
(April
1969) 114. 3. D M Morgan, "Preparation of the operating room technician," Canadian Hospital, 49 ( M a y 1972) 40ff. 4. R S Mekger, "AORN-AORT committee a t work," AORN Journal, 16 (December 1972) 30-32.
Recovery room personnel seminur The Florida Society of Anesthesiologists will conduct its fifth annual seminar for recovery room personnel a t Lake Buena Vistcr, Fla, Oct 31 to Nov 3. The seminar will include special presentations by noted medical authorities, scientific sessions, exhibits of new equipment and services, and social events for all registrants. The registration fee of $50 per person includes breakfasts, lunches, and the seminar banquet. Headquarters will be at the Dutch Inn a t Lake Buena Vista on Walt Disney property neur Orlando. Hotel room rates for registrants will b e $20 for single and $27 for double. No deposit will be required on room reservations and all major credit cards will b e accepted. A certificate of completion will be awarded to each registrant attending the seminar. For reservation forms and further information write Florida Society of Anesthesiologists, 118 W Adoms St, Jacksonville, Fia, 32202,
AORN Journal, September 1974, Vol 20, No 3