A Perioperative Model and Framework for Practice

Nursing

Introduction

Perioperative care is a unique arena, in which person-centred care is delivered to vulnerable patients in a highly technical and complex environment. This area of nursing is constantly changing and evolving against a backdrop of technological advances that are appearing at a staggering rate in practice. There is an ongoing professional responsibility to keep up to date with all innovations in order to ensure safe practice and the delivery of effective, evidence-based care (NMC 2015a).

In addition, over the past decade, many changes have been implemented within the National Health Service (NHS). These changes have emphasised cost efficiency, financial savings and budgetary control. Innovations are encouraged, focusing on improvement of patient care along with reduced cost to the service. These dual demands have placed both employers and employees under pressure to perform. Service users are well-informed individuals, with high expectations (due to the wealth of information that is available from a vast array of sources). This is a positive thing in two respects, as it brings well-informed patients to the service and it encourages professionals to ensure that they are up-to-date, knowledgeable practitioners. At the same time, from a negative standpoint, patients may be misinformed and may present with undue anxiety.

This book is not designed to give an in-depth description of perioperative care delivery or a detailed history of nursing or nursing theory. Rather, it aims to introduce and define a model and framework for perioperative practice, providing a structure whereby perioperative care can be planned and executed. Ideally, this book will be used alongside a textbook describing perioperative care delivery and practice and detailing the specific care a patient requires during the perioperative period.

The model aims to give perioperative practitioners a practical tool that can be moulded to suit the specialty that they are practising in. Examples of care plan documentation, combining the Cousley Model and the recording of procedural information, are given. This documentation provides a vehicle to record care delivery in perioperative practice, resulting in the achievement of practice objectives.

Furthermore, this book sets the model and framework in context by briefly outlining the history of perioperative practice, noting how our past can shape our future in today's healthcare service, and how practice is defined by the directives set at government level. It describes perioperative practice per se, giving an insight into the circumstances under which patients undergo anaesthesia and surgical procedures. The inter-professional team and the roles within the team are also highlighted, giving the reader an insight into the group dynamics and interaction that take place within perioperative nursing. The role of the anaesthetic nurse specialist (ANS) is described and defined in the context of the Martin Peri-anaesthesia Management of Patient Care Framework.

This framework is introduced, outlining some of the difficulties initially encountered when looking for a model to meet the needs of perioperative patients. The Cousley Perioperative Model is introduced and described, along with the documentation that facilitates the recording of care delivery, following the assessment and planning of individualised patient care. The nursing process, risk assessment and patient-centeredness are fundamental aspects of the Cousley Model and these will be outlined and defined in this context. The introduction and development of a clinic designed to carry out perioperative patient assessment is also discussed, demonstrating how specialist nurses can enhance perioperative care delivery.

This book is not an exhaustive commentary on perioperative practice but one that we hope will encourage the reader to become a more reflective practitioner. To facilitate the process of reflection, each chapter begins with a 'thought', to stimulate the reader's thought processes and enable them to consider the subject of that chapter.

Each chapter is a topic in its own right, which can be read in isolation if readers choose to do so. With this in mind, the 'thought' is followed by an 'outline of content', which enables the reader to judge whether the chapter is relevant to the subject they want to explore. Some 'keywords' are then extracted from the text, giving the reader a further indication of the chapter's relevance.

The authors strongly encourage practitioners to reflect on their practice. 'Reflections' have therefore been included in some of the chapters, to allow the reader to stop and reflect upon relevant areas of their own practice in the context of the chapter theme. Some of the chapters also contain various 'activities', designed to encourage the reader to think about how particular principles could be adopted in their own area of practice.

Our aim is to provide an easily digestible read (a book that can be dipped into during a coffee break), allowing the reader to journey through the chapters, stopping off when and where they wish, and taking time to reflect along the way.

Chapter 1

Perioperative practice

Ann Kerrin

Thought

Some people say that healthcare practitioners working 'behind masks and closed doors' is a thing of the past... Yet in today's perioperative environment practitioners still wear masks and still operate behind closed doors.

Outline of content

This chapter sets the scene, exploring the history of perioperative practice and describing the way it is carried out today. The standards and legislation behind care delivery will be outlined, as emphasis is now placed on accountability, patient safety, productivity and efficiency. The uniqueness of perioperative care (incorporating ethical principles, advocacy and patient experiences) will also be explored.

Keywords

History, perioperative, standards, legislation, accountability, patient safety, efficiency, advocacy, ethical care, definition, roles, technical advances, innovations.

Introduction

During the Victorian era, Florence Nightingale's family prevented her from pursuing a nursing career, and she expressed her frustration and unhappiness when she reflected that 'out of nothing comes nothing. But out of suffering may come the cure. Better pain than paralysis, a hundred struggles and drown in the breakers. One discovers the new world' (Nightingale 1979, p. 29). Today's perioperative practice is certainly a progressive speciality that is both exciting and stimulating. It requires a wide range of skills from committed practitioners who are prepared to dedicate themselves to working in the field (White 2009, Reid 2008). This chapter will discuss the history of perioperative practice and touch upon the standards and legislation surrounding that practice. The intention is to highlight core elements of perioperative practice and to offer a definition.

The history of perioperative practice

According to Fairchild (1993), perioperative nursing practice is the oldest nursing specialty on record. Its history certainly goes back over a hundred years (Jolley 2010). Events such as the Crimean War (1853–1856) and the American Civil War (1861–1865) saw the emergence of men and women who had no professional training but still provided assistance to surgeons (Holder 2003, Schultz 2004). However, nursing as a discipline did not really exist before the middle of the nineteenth century, and this was what made Florence Nightingale such an important figure in the history of medicine. Her 'Notes on Nursing' (first published in 1886) include the earliest reference to the presence of nurses in the operating department (Nightingale 2000).

By the late 1800s, more operations were being performed and, according to Kneedler and Dodge (1994), surgeons began to recognise the vital assistance nurses provided. A Scottish surgeon, Dr Joseph Bell, understood the importance of specialised training for nurses assisting in the operating department and thus the speciality of operating room nursing was born (Groah 1990, Fairchild 1993). Groah (1990) documents that this was nursing's first speciality. By the late 1800s (Groah 1990, McGarvey et al. 2000) and the early 1900s (Fairchild 1993), nurse training programmes included a surgical element, with students spending a rotation in the operating department as part of their initial training. The nurse assigned to the operating department was skilled and duties varied from attending the surgeon and knowledge of asepsis to attention to detail and diligent preparation of supplies (Groah 1990, McGarvey et al. 2000). At that time, anaesthetic and recovery nursing care was performed by a ward nurse, who returned to the ward with the patient and provided patient care until discharge (McGarvey et al. 2000).

Throughout the twentieth century, this nursing speciality underwent considerable change. Acceptance of Lister's discovery of antisepsis and improvements in anaesthesia led to longer operating times, more frequent surgery and decreased patient mortality rates (Olwine 1992). This ultimately had an impact on the role of the operating department nurse who now had to have the necessary intellectual and developmental ability to be trained in the prevention of infection and more complex and demanding surgery (Kneedler & Dodge 1994, Jolley 2010). By this time, the team concept was also being established to provide good-quality patient care, with emerging nursing roles such as the 'circulator' and 'scrub' roles and a physician assisting the surgeon (Groah 1990, Fairchild 1993).

However, it was the two world wars that would have the most profound effect on the role of the nurse in general and particularly on operating department nursing, giving it national interest and importance (Kneedler & Dodge 1994, McGarvey et al. 2000). Nurses returning from active service wanted to retain their increased nursing responsibilities (Kneedler & Dodge 1994, McGarvey et al. 2000). By the late 1940s, the proactive roles they had forged in the management, supervision and administration of patient care and assisting surgeons in civilian hospitals were laying the foundations for modern perioperative nursing practice. However, McGarvey et al. (2000) reported that, while all these developments were very evident in American nursing, British nursing apparently extended little beyond 'housewifely duties'.

Reflection 1.1

Take some time to reflect on the nurses of the past.

•What 'housewifely duties' would they have carried out?

•Do you think nurses today still engage in these activities?

•What do you think has changed in the nurse's role?

Early technological advancement further influenced the operating department nurse's role. For instance, the introduction of pre-sterilised swabs, syringes and instrument trays affected the way operating equipment was prepared and eventually led to the development of central sterile supply departments (CSSD), with Musgrave Park Hospital in Belfast pioneering this service in the early 1960s (NATN 1989). Such developments reduced the operating department nurse's 'housewifely duties' (McGarvey et al. 2000). However, the perception of the perioperative nurse as a 'technical handmaiden' persisted (Kneedler & Dodge 1994, Gilmour 2005).

Nevertheless, all these advances brought into question the technical and ritualistic role of the operating department nurse. In response to this non-patient-centred perspective in the UK, Daisy Ayris formed the National Association of Theatre Nurses in 1964 (Cox 2005). According to McGarvey et al. (2000), similar concerns were voiced by the American nurses who had formed the Association of Operating Room Nurses (AORN) in 1949. This organisation was designed to provide a forum, facilitating the exchange of knowledge and ideas. Both organisations sought to secure the future of the operating department nurse and provide patients undergoing anaesthesia and surgery with nursing care underpinned by standards for perioperative practice. Furthermore, nurses in Europe who wanted to standardise operating room practice set up the European Operating Room Nurses Association in 1980 (Vincent & Jones 1999). The provision of nursing care in the operating department had clearly become an international issue. These groups collectively recognised the importance and benefits of networking with their international colleagues, and thus the International Federation of Perioperative Nurses was launched in Helsinki in 1999 (Vincent & Jones 1999).

One crucial development in the twentieth century was the introduction of the operating department assistant (ODA), following the publication of the Lewin Report in 1970. This new role was created to address staffing shortages and the organisation of the operating theatre, which had led to increased waiting lists (Timmons & Tanner 2004). Whilst this new role created some debate in perioperative practice (Spinks 2006), the ODA was actually not that new. The Second World War saw many experienced nurses leaving hospitals to join the armed forces; to address the resulting shortage, a surgical technician role (a precursor of the ODA role) had been introduced to assist the surgeon with on-the-job training (Fairchild 1993).

Today, the ODA role has expanded to include all spheres of perioperative practice, including the anaesthetic, intraoperative and post-anaesthesia phases. In some hospitals in the UK, additional roles have been developed for operating department practitioners (ODPs) in cardiac arrest teams and resuscitation situations.