Volume 2 Issue 2 October 2007 

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The Official On-line Journal of IFPN
Editor: Kathryn Schroeter PhD, RN,CNOR
Past President: Kate Woodhead RGN, DMS
October 2007 Volume 2 Issue 2
ISSN- 1816-9104

Table of Contents
Message from the President
Editorial – Working Together
IFPN Update
Cuttings – news and views
Perioperative organisations conference dates
Articles –
A culture of Safety: Building Foundations; reducing risks. Shelia Allen
RN, BSN,CNOR, CRNFA
Technician or Nurturer: Discourses within the Operating Room. Dr
Marilyn Richardson-Tench RN, RCNT, B.App.Sc( Adv Nsq) M.Ed, Stud
PhD.
Oh by the way the patient is pregnant! Joan Porteous RN, BN, CPN(C)
Peri-Operative Care for the Non Obsterical Pregnant Patient. Poster
A Muses Corner
Articles (Continued)
The lived experiences of job satisfaction amongst perioperative nurses: a
phenomenological study. Ruiz Laconcepcion Maria Cruiz. MSc( Nurs)
BSc ( Hons)
The Treatment of a Fallot Tetralogy. Lynda Bleazard DipRN ( Hons)&
Dr Robin Kinsley MBBCH, FCS(SA)
Walter Sisulu Paediatric Cardiac Centre History.
The Final Count

Instructions for authors
Information for readers: The Journal is designed so that articles may be downloaded
singly or you may wish to read them all ( as it is hoped). However, colleagues in all
corners of the globe, do not have ready access to the internet at home, or colour
printers. The journal team has these readers in mind to promote a truly
internationally accessible journal. We hope that you enjoy it.

Presidents message
Friends and colleagues
To those of you who are new to this journal a big welcome and to those of you
returning for another fabulous edition, a big welcome back. Once again our
two K’s, Kathryn and Kate have excelled in putting together another wonderful
edition, without their efforts we would not have this incredible resource which
provides unprecedented opportunity for exposure of Perioperative articles.
It is early spring here in Australia and the beginnings of renewed life are
emerging from dormancy, daffodils and jonquils are blooming and cherry
blossom is lining many of our streets. Spending time in my garden today with
my children in such renewal caused me to reflect, we all need a time of
dormancy when we can renew and regenerate ready to take on new
challenges. In recent months I feel that IFPN has been gaining strength ready
to face the exciting challenges ahead. The new web site will be available in
the next 2 weeks and I am sure you will be pleased with the fresh new look
and the ease of navigating around the site. Each member of the board has
been working on sections of the strategic plan and contemplating the exciting
new direction the CNR have considered for us.
We are very much looking forward to the World Conference on Surgical
Patient Care to be held in Seoul in early October and are most grateful to the
Association of PeriOperative Registered Nurses (AORN) for generously
allocating 2 networking sessions and an international forum, we look forward
to meeting as many people as possible.
A number of CNR representatives will also be heading on from Seoul to
Harrogate for the Association for Perioperative Practice (AfPP) congress
where again AfPP have inculcated a number of international speakers into
their programme
Please enjoy this edition and like spring, emerge from this edition refreshed
and renewed ready to face the challenges of our specialty.
Kind regards
James Harrison
President IFPN

Editorial
Working together effectively takes effort on the part of everyone!
By Kathryn Schroeter, PhD, RN, CNOR
Have you ever been the victim of an abusive surgeon or coworker? Such an
experience can leave a nurse feeling hurt, incompetent and angry. It may also result in
an increased chance of making an error in patient care.1
The perioperative environment is a workplace that is not immune from horizontal
violence, abuse, harrassment and disruptive behavior. It is also true that nurses,
historically, have been victims of such non-ethical behavior over the years due to the
hierarchical aspects of their role which include physician dominance over nurses as well
as male dominance over females.2 Is it no wonder then that some nurses may feel a
resentment regarding physicians and either take out that resentment in negative
behavior directed toward surgeons and/or medical students? By treating medical
students as “low men on the totem pole”, nurses are perpetuating the cycle of abuse
that stems from the historical hierarchy of roles within the medical profession.
Does such abuse still exist today? According to the National Institute of
Occupational Safety and Health (NIOSH), it does.3 Who are the abusers now? The
abusers, potentially, can be any of us. Nurses are not the only victims of abuse. While
there are instances where nurses may be right to blame others, there are also times
when nurses are perpetrators of abuse - not only to each other, but to their coworkers,
e.g. surgeons, techs, students, etc. Why does this behavior happen? There are many
reasons, actually, too many to analyze in this brief editorial.
It's not surprising, though, that nurses, physicians, and other health care workers
still have relationship problems because these conflicts are rooted in human factors
such as personalities, attitudes, feelings, and communication styles. For things to
change, nurses have to approach the problem directly and initiate strategies to improve
things, rather than merely complaining about them. The most important thing to do is to
recognize the problem and make the necessary change, both personal change if
needed and also a change of culture in the perioperative environment.
How, then, can we change our conduct and/or departmental culture and stop the
abuse? It stops with each individual nurse, physician, technologist, assistant etc.,
making a conscious decision to change his or her behavior. It is not always up to others
to change, it is ultimately up to each individual. Human beings have the ability to
choose what to do and how to act, both of which are ethical in nature. In fact, the
responsibility and accountability that nurses share with their patients must also be
shared with their coworkers. In order to be responsible and accountable, nurses must
act under a code of ethical conduct that respects the dignity and worth of all others.
So how can this goal be accomplished? We can start by focusing on ourselves
and our behaviors. We can make concerted efforts to foster positive relations among
patients, patient’s families/friends, visitors, co-workers, medical staff and basically, any
and all, others. It really boils down to that olde golden rule: do unto others as you would
have them do unto you.
I suggest that nurses to try to remember a clinical preceptor who really had a
positive impact on them when they were students. Think back to the qualities of that
special nurse who, most likely, exuded warmth, respect and worth to a student. Our
goal should be to be that nurse – that positive role model of ethical behavior and
conduct - for someone else. It really is not behaviors will be the example upon which
student nurses will use to describe perioperative nurses from that point on. In every
interaction, strive to treat each person with dignity, respect and compassion and to
conduct yourself with integrity.
It is not hard to show respect and warmth to others through positive
communication in a professional, pleasant and warm manner, e.g., greeting people by
name, using Mr., Mrs., Ms., Dr., acknowledging their presence, smiling, asking how you
can help. Additionally, it is important to provide reasonable responses to reasonable
requests for services made by others such as co-workers, supervisors, doctors and
patients. While sarcasm may be a form of humor, it is often a misperceived method of
communication.
We need to be aware of and concerned about how our attitudes and actions
affect patients, families/friends, visitors, co-workers, medical staff and all others with
whom we interact. We must also remind colleagues when their attitudes or behavior
are inconsistent with our professional standards of conduct. We must also remember to
identify issues directly with others in a confidential and professional manner.
Compliment coworkers when their actions comply with the standards of ethical
conduct. Support team work within and between teams. We are team members, but as
members, we are also individuals and responsible for our own actions. One way in
which we can demonstrate our respect for others is to arrive on time and complete work
to the best of our ability. We can take responsibility for maintaining a safe work
environment and fulfill job functions in a safe manner. These are all ways in which we
can show respect for all those who we encounter in our work environment.
Nurses are aware of professional codes of conduct when it comes to practice
and it is no far stretch to say that ethical behavior is expected of practicing nurses.
However, it is not enough to direct ethical behavior toward patients alone. Nurses do
not practice in a vacuum. Remember that all behaviors and services you perform must
be done so in an ethical manner. Therefore, nurses must take into account all those
with whom they share the workplace environment and make the effort to ensure a safe,
competent, and non-abusive environment in which all may practice. In this way we, as
well as our patients, will benefit.
_____________________________
1. Rosenstein AH, O'Daniel M. Disruptive behavior & clinical outcomes: Perceptions
of nurses and physicians. AJN. 105(1):54–64, January 2005.
2. P Bruder, “Verbal abuse of female nurses: An American medical form of gender
apartheid?: Hospital Topics 79 (Fall 2001) 30-34.
3. “Violence: Occupational Hazards in Hospitals,” publication no 2002-101, April
2002, National Institute for Occupational Safety and Health,
http://www.cdc.gov/niosh/2002-101.html.
IFPN 2007 International Journal of Perioperative Care
August 07 Sheila Allen, Secretary IFPN 1

Update on International Federation of Perioperative Nurses [IFPN]
Formed in 1999 as a result of interest on the part of a number of countries, IFPN provides
formalised links between countries, support and infrastructure to developing nations, a
focal point for representing perioperative nursing internationally, and a forum to discuss
international issues.
Members of the IFPN are perioperative organisations in countries around the world. The
Federation represents around 100,000 perioperative nurses globally and is the only
perioperative organisation to be an affiliate of the International Council of Nurses [ICN].
Member organisations have a representative on the Council of National Representatives
(CNR) that communicate regularly using electronic communication to effect business and
make decisions between face-to-face meetings that occur annually.
Membership in the IFPN provides an opportunity for CNR members to network and
interact with their colleagues globally, to gain knowledge and participate directly with the
International Council of Nurses [ICN], and to enhance and share their knowledge with
perioperative nurses throughout the world to assist in providing the safest, most efficient
care to perioperative patients.
The website of IFPN is a virtual resource for members and the wider perioperative
community. Currently the site is undergoing revision to add more versatility to the site and
to extend its value to all by the provision of free educational downloads. www.ifpn.org.uk is
regularly updated with new documents and information and to continue to attract an
excellent number of monthly visitors.
The Executive Board of IFPN consists of officers from member organisations, who meet at
face-to-face at least once each year in a variety of locations, depending on member
organisations’ conferences. The structure of the IFPN is continually evolving to meet the
needs of the organization and its member countries. To build a more fluid, transparent
method of operation, meetings are integrated to enrich the dialogue.
Current members of the Executive Board are:
James Harrison, President Australia
Betty Shultz, Vice President USA
Sheila Allen, Secretary USA
Melanie van Limborgh, Acting Treasurer UK
Margaret Farley, Board Member Canada
Kim Hepper, Board Member Australia
Membership in IFPN and additional information is available on the website, and all
perioperative organisations are invited to participate in membership to enhance their ability
to share information and join the global perioperative community.
Current and Future Activities
IFPN presented educational programmes at the Canadian Operating Room Nurses
Association in April 2007. For further details please visit www.ifpn.org.uk and
www.ornac.ca. IFPN (CNR members and officers will present educational sessions at
the World Conference of Surgical Patient Care in Seoul, South Korea in October. Working
with colleagues from KAORN and AORN, the Federation will conduct networking sessions
and an international forum to facilitate discussions of current issues in perioperative
nursing. IFPN will utilize the input to create guidance statements and resources for
colleagues around the world.
IFPN 2007 International Journal of Perioperative Care
August 07 Sheila Allen, Secretary IFPN 2
Through collaboration with industry colleagues, guidelines for developing practice and
IFPN position statements are available as downloads from the website www.ifpn.org.uk
We are grateful to all the medical device companies who support us in publishing the
guidelines. New guidelines are continuously being written and published, enabling a more
comprehensive overview of ‘best principles’ which are referenced from a wide variety of
worldwide texts. CNR and Executive members provided suggestions for the development
plan for guidelines and position statements. Vice President Shultz will coordinate the
volunteers from member organisations who will create a list of documents to be added to
our collection.
In 2007, IFPN continues to publish a 4-page newsletter that appears in the public section
of the website. Editor/Board Member Kim Hepper solicits information from all member
organisations and is interested in having input from all facets of the perioperative
environment. Each edition will spotlight one of our member organisations.
Additionally, CNR requested that a packet be developed to educate member Boards and
constituencies about IFPN. An educational packet was developed containing an
introductory letter from President Harrison, a brochure, front pages from publications and
the website, overview information about the Federation, and a power-point presentation
encompassing the development of IFPN and its current activities.
Through its support to the development of a perioperative organisation in Papua New
Guinea over the last two years, a toolkit has been developed to assist group in forming
perioperative nursing organisations. The final toolkit is being evaluated in other areas
before final publication to CD-ROM. Reports on PNGPNA’s activities are on our website.
Interested parties should contact IFPN via the website.
Recently, the IFPN was invited by the Joint Commission International to participate in the
online field surveys to be utilized by the World Health Organisations’s Collaborating Centre
for Patient Safety to assist in determining the final content of the initial set of Patient Safety
Solutions to be distributed next year. The nine patient safety solutions reviewed and
commented upon were as follows:
? Look-Alike, Sound-Alike Medications,
? Patient Identification,
? Communication During Hand-Overs,
? Wrong Site, Wrong Procedure or Wrong Person Surgery,
? Concentrated Electrolyte Solutions,
? Medication Reconciliation,
? Catheter and Tubing Misconnections,
? Needle Reuse and Injection Safety, and
? Hand Hygiene.
This dynamic, young organisation has grown through the support and encouragement of
all its members and the committed individuals who serve past and present. For more
information, please visit, on a regular basis, our website at www.ifpn.org.uk . We invite
participation at many levels; so take a look and become a part of this exciting group.
This page is for your topical news and views! Please contact IFPN via the website
or send your news direct to the editor, to contribute!

Cuttings
WHO launches 'Nine patient safety solutions'
Solutions to prevent health care-related harm
2 MAY 2007 | WASHINGTON/GENEVA -- WHO is today launching "Nine patient safety solutions"
to help reduce the toll of health care-related harm affecting millions of patients worldwide.
"Recognizing that health care errors affect one in every 10 patients around the world, the
WHO's World Alliance for Patient Safety and the Collaborating Centre have packaged nine
effective solutions to reduce such errors," said WHO Director-General Dr Margaret Chan.
"Implementing these solutions is a way to improve patient safety."
Sir Liam Donaldson, Chair of the Alliance and Chief Medical Officer for England, said: "Patient
safety is now recognized as a priority by health systems around the world. The Patient Safety
Solutions programme of work is addressing several vital areas of risk to patients. Clear and
succinct actions contained in the nine solutions have proved to be useful in reducing the
unacceptably high numbers of medical injuries around the world.
The nine solutions are now being made available in an accessible form for use and adaptation by
WHO Member States to re-design patient care processes and make them safer. They come
under the headings of:
1. Look-alike, sound-alike medication names;
2. patient identification;
3. communication during patient hand-overs;
4. performance of correct procedure at correct body site;
5. control of concentrated electrolyte solutions;
6. assuring medication accuracy at transitions in care;
7. avoiding catheter and tubing misconnections;
8. single use of injection devices; and
9. improved hand hygiene to prevent health care-associated infection.
The Patient Safety Solutions, a core programme of the WHO World Alliance for Patient Safety,
brings attention to patient safety and best practices that can reduce risks to patients. It ensures
that interventions and actions that have solved patient safety problems in one part of the world
are made widely available in a form that is accessible and understandable to all.
Reference website: www.who.int/patientsafety
ICN and WMA Welcome the Release of Bulgarian Nurses and
Palestinian Physician
Geneva, Switzerland, 24 July 2007– The International Council of Nurses (ICN) and
the World Medical Association (WMA), today welcomed the news that the five
Bulgarian nurses and one Palestinian physician incarcerated for eight years in Libya
have been released. The health professionals had been accused by Libya of
deliberately infecting more than 400 Libyan children with HIV. The charges have
been definitively disproved by world-leading scientists and HIV experts. The death
sentences that had been handed down to the health professionals last year were
dropped and all left Libya for Bulgaria today. ICN and WMA are calling for support
and reintegration into society and work life for the health professionals.
World Conference on Surgical Patient Care
October 1-4, 2007
COEX Center
Seoul, South Korea
You are invited to attend the 2007 World Conference on Surgical Patient
Care,
The World of Perioperative Nursing: Evidence, Practice, Future. This biannual
event, hosted by AORN, has a rich tradition of bringing the
worldwide community of operating room nurses together to discuss
common practice issues, challenges, and concerns.
You will come to find that the perioperative issues that exist in your
country exist to some extent in every country. Hear the latest in international research, the
activities
of the International Federation of Perioperative Nursing, the progress being made to
improve patient safety, and the issues facing perioperative practice. The conference
theme this year, The World of Perioperative Nursing: Evidence, Practice, Future, identifies
important elements of our practice.
Continuing education contact hours will be available for education sessions you attend and
clinical posters you review.
Networking is one activity that everyone remembers - time to meet new friends
and renew old friendships.
Extend your stay and visit the fascinating city of Seoul. The city offers an eclectic mix of
traditional Korean culture with a newer, technologically enhanced side. Join your perioperative
colleagues from around the globe for this unique learning experience!
Enjoy…
? 4 Full Days of Education Sessions
? Access to Exhibiting Companies
? International Fellowship Night (evening celebration)
? Tours of Hospitals in Seoul
Come Explore Critical Issues In…
? Infection Prevention & Sterilization
? Creating a Culture of Safety
? Best Practices in Recruitment and Retention
? ... And Much More!
Hospital Tours
World Conference participants are invited to tour select Seoul hospitals on Friday, October 5,
just following the conference. Hospital tours are included for full conference registrants. To signup,
select the hospital tours option on your registration form. Additional details coming soon!
Language Translation
The official language of the conference is English. Simultaneous translation will be offered in
English, Korean, Chinese, Japanese, and Italian.
Collaboration with KAORN
AORN would like to thank the Korean Association of Operating Room Nurses (KAORN) for
assisting AORN in putting together this year's event in Seoul. We are excited to share this
experience with the preoperative nursing professionals in Korea
International Counts comparison
The IFPN website is now carrying a very useful tool comparing some of the
national members standards and recommended practices on Sponge counts,
following a presentation of the same topic by Kim Hepper IFPN Board
Member ( Australia).
It can be seen that fundamentally the principles of safe practice vary very little
from one country to another. Perioperative organisations wishing to write their
own standards would be wise to use this helpful document as well as the
IFPN Guideline for Developing Practice, available on the same web address,
to guide the development, rather than trying to re-invent the wheel.
Reference www.ifpn.org.uk
* * *
CNOR certification exam to be offered at the AORN World Conference
By Robin Lazenby and Nancy Lilliott
The Competency and Credentialing Institute (CCI) will offer the CNOR certification
exam at the AORN World Conference in Seoul, South Korea. CCI has partnered with
AORN to offer a low-cost option for attendees of the World Conference to prepare for
and take the CNOR certification exam.
Registrants can take the AORN online preparation course and the CCI CNOR
certification exam for a discounted price for both the prep course and the exam. And to
date, the response has been remarkable. CCI has received nearly 100 applications for the
exam to be given on September 29th. It is obvious that many of the South Korean
perioperative nurses understand the value of the CNOR credential.
CCI representatives, President Robin Lazenby and Past President Laura Kerby will be
attending and speaking at the 2007 AORN World Conference in Seoul, South Korea.
Other staff from CCI attending will be CEO, Shannon Carter, and Director of
Credentialing, Mary O’Neale. All three are pictured below with some AORN Congress
attendees from South Korea in Orlando this past March.
Perioperative Conference Dates 2007-2008 - 2009
Perioperative Nurses College of New Zealand, Dunedin, South Island, New Zealand,
August 30- September 1 2007. “Unmasking our potential”
ZOTNIG ( Zambian Operating Theatre Nurses Interest Group) 3rd Annual
Conference, Lusaka, Zambia. Theme: Circles of Quality versus HIV/AIDS Nurse
Education. 5-7 September 2007.
World Conference Seoul South Korea October 1-4th 2007
Association for Perioperative Practice, Harrogate North Yorkshire, UK 8-11 October
2007. Conference Theme: “Realising potential”
Association of perioperative Registered Nurses, Anaheim, California March 30- April
3 2008
The ACORN National Conference will be held at the Gold Coast Convention and
Exhibition Centre, Broadbeach, Queensland, Australia from 21 - 24 May 2008.
EORNA Conference Call for Abstracts Copenhagen, 17-19 April 2009 “Professional
Development – Bridging Perioperative Care”
Call for abstracts
The European Operating Room Nurses Association invites perioperative colleagues to submit abstracts for
consideration to present at the EORNA Congress 2009 in Denmark.
Abstracts in general subject area, e.g. clinical practice, education, research, management, service
development or any other issues relevant to perioperative nursing are welcome.
The deadline for abstract submission is 1 June 2008.
Please add to this information for all perioperative practitioners around the world by
advertising your conference dates in the International Journal of Perioperative Care
by emailing the editor with your dates or Call for Abstracts notices! We will be
pleased to help you increase the global influence of your conference!
2007 1
Narrative Biography
Sheila L. Allen, RN, BSN, CNOR, CRNFA
Sheila Allen has been a perioperative nurse for more than 38 years. Allen has served in many
leadership roles in nursing organizations. She has published articles in the AORN Journal on
clinical, motivational, and organizational issues, contributing author and author for international and
national publications including the Alexander’s Care of the Patient In Surgery, 13th edition [2006].
Sheila was the first American to present the Daisy Ayris Lecture in 2003 for the Association for
Perioperative Practitioners [formerly NATN – UK]. Allen currently serves as Secretary for the
International Federation of Perioperative Nurses [IFPN] and served as national AORN President
2001-2002.
A culture of safety: Building foundations; reducing risk
Patient safety is a worldwide issue; however it has been studied in relatively few countries.
Some of the existing data regarding the number of deaths and injuries is frightening:
? USA – at least 90,000 deaths per year from medical errors,
? United Kingdom – 850,000 harmful adverse events per year,
? New Zealand – 12.9 percent of all hospital admissions have an adverse event. [1]
Identifying the kinds of medical errors that occur, determining how often and why, and making sure
that the same errors do not occur again is the framework of creating a safe environment for
patients.
10 Tips:
Medical errors can occur at many points in the health care system, particularly in hospitals.
Practical tips for promoting patient safety from evidence-based research help healthcare facilities
provide the highest quality care possible. While facilities have made incredible strides in reducing
the likelihood of patient harm, they continue to seek ways to promote patient safety on a day-to-day
basis. [2] These 10 tips for hospitals resulted from findings resulting from studies by the Agency for
Healthcare Research and Quality (AHRQ), which has funded more than 100 patient safety projects
since 2001.
Many findings from AHRQ research can immediately be put into practice in hospitals by following
10 simple tips:
1. Survey staff in individual units and throughout the hospital need to assess and
improve the culture of patient safety, as noted in the 1999 Institute of Medicine report, To
Err is Human. The AHRQ survey and its accompanying toolkit materials are designed to
provide hospital officials with the basic knowledge and tools needed to conduct a safety
culture assessment, along with ideas for using the data. 3
Facilities often invest large sums to have consultants come into the organization to suggest ways
to improve safety without first investing the time to provide a forum for employees to solve their own
2007 2
problems. Many professionals who work within the healthcare environment are continually reading
and learning ways to improve care. Their expertise and creativity needs to be tapped to assist
facilities in finding the solutions to their challenges.
2. Limit shifts of more than 24 hours for medical residents and make sure they do not
drive home after working extended shifts. Medical residents who work longer than 24
hours are more than twice as likely to have a car crash leaving the hospital and 5 times as
likely to have a near-miss incident on the road than medical interns who work shorter shifts.
4
Multiple studies have documented the effects of fatigue on aviation employees; so what makes the
medical profession think it is less prone to the same effects of fatigue? The empirical evidence
vrifies that risk is an inherent factor in fatigue. In order to be safe, we must be awake/alert/vigilant
with reflexes that initiate a prompt response. We all have an obligation to speak up when we feel
that fatigue may compromise the safety of our care.
3. Eliminate the tradition of shifts of more than 30 consecutive hours by interns working
in hospital ICUs. The rate of serious medical errors at two Boston hospital intensive care
unites (ICUs) committed by first-year interns dropped by 36 percent when 30-hour-in-a-row
work shifts were eliminated. 5
Skeptics still exist in spite of the rising body of information about the effects of fatigue. The medical
community may see compromise to the devotion-to-practice reputation, fear of abandonment
accusations, or financial concerns to stimulate the drive to practice long hours. Healthcare
providers need to take care of themselves by getting the proper amount of rest to be at their best to
provide their patients with the most efficient care.
4. Adopt interventions to reduce the incidence of ventilator-associated pneumonia in
critically ill patients. Putting patients in a semi-recumbent position and using sucralfate
rather than H2- antagonists to prevent stress ulcers can prevent ventilator-associated
pneumonia in critically ill patients. 6
By employing the current methodologies to prevent complications in the critically ill patients,
healthcare providers can assist in decreasing the incidence of pneumonia in ventilator-dependent
patients.
5. Count surgical instruments and sponges before and after procedures, and X-ray
patients after surgery to reduce the likelihood of objects being left inside patients.
These simple techniques can reduce the incidence of these types of medical errors, which
occur in more than 1,500 patients each year. 7
Retained objects are becoming increasingly prevailent in our world. At a healthcare facility in the
US, certain parameters were utilized in an education campaign on surgical counts:
? Counts must be conducted on all procedures.
? Baseline counts must be completed before the patient enters the room.
? Count audibly.
? Counts should not be interrupted.
? No patient will leave the OR unless every team member is sure that the count is reconciled.
[8]
2007 3
Nursing organizations around the world publish guidelines and standards to provide practitioners
with the foundations in practice to help safeguard patient care.
6. Use senior nurses and maintain appropriate round-the-clock staffing levels in ICUs to
prevent airway tube complications. A study of adverse events occurring in adult and
pediatric ICUs found that more than half were considered preventable. Airway events
occurred less frequently during daytime hours (7:00 a.m. to 3:00 p.m.), and their negative
impact was limited by skilled assistants, backup, and cross-coverage. ICU managers should
take steps to ensure that appropriate staffing and training levels are maintained to limit the
impact of adverse events. 9
Experiential knowledge and the wisdom of age provide senior staff with the intangible tools that can
assist in recognizing problems with patients almost intuitively. Coordinators of care in healthcare
facilities owe it to the patients to provide the same standard of care throughout the day to the
patients for whom they serve.
7. Ensure that personal digital assistant-based drug information is readily available at
the point of care. Epocrates RxPro, Lexi-Drugs, and mobileMicromedex met AHRQ's
quality and safety criteria by reducing potential errors associated with insufficient or
incomplete drug information. 10
If at all possible, the most efficient technology for the delivery of medications should be employed.
All equipment should be tested on a regular basis to prevent useless medication errors and
problems with equipment function.
8. Download a free software tool to identify ways to improve medication safety in the
ambulatory care setting. The tool, called the Medication Safety Best Practices Guide,
helps hospitals identify ways to create safe practices for medication use, manage medical
errors, and contribute to patient safety education in the ambulatory care setting.11 Go to:
http://chrp.creighton.edu/documents/bestpractices.pdf. PDF Help.
Healthcare providers have an obligation to keep abreast of the latest tools to educate staff in safe
medication use. Nursing organizations have provide “toolkits” for the safe delivery of medications
and should be accessed and utilized as they become available. Many are available on the internet
in documents such as the one listed above.
9. Use computer-based order entry to reduce catheter-related urinary tract infections. A
computer-based order entry system prompting catheter removal after 72 hours decreases
the duration of urinary catheterization by about one-third, or 3 days. 12
Handwriting has long been used as a means to justify error and rightfully so. With the advent of
computer-based documentation fields, the human problems with penmanship can be eliminated.
Of course, not all facilities have computer-based systems in place. As technology advances and
those systems become more fiscally prudent, more facilities will move to this 21st century method of
communication and documentation.
10. Minimize interruptions and other distractions faced by the nursing staff in their dayto-
day routines. Researchers have visually re-created the fast-changing nature of nurses'
work, highlighting areas where interruptions can affect patient safety. 13
2007 4
Cell phones, Blackberries, Palm Pilots, and the various means of communication tools that exist in
our modern world have brought with them a myriad of distractions for the practitioners that deal with
all the technology that can enhance and detract from our care. Nurses are often the pivotal
communication link between the patient and the members of the healthcare team. [14]
Initiatives to support patient safety
The 100,000 Lives Campaign. The Institute for Healthcare Improvement (IHI) was
launched in the US in January 2005 to prevent avoidable deaths by implementing proven changes
in patient care. IHI provides how-to guides and tools for data measurement and submission and
tracks acute care inpatient mortality rates in participating hospitals. Joint Commission. National
and international initiatives have established patient safety goals to promote specific improvements
in patient safety, particularly in problematic areas. Surgical Care Improvement Project (SCIP).
Concerned organizations [CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI, and JC] initiated
this project in 2003 to improve patient safety by reducing postoperative complications. Each of
these entities, although based in the US, have comparable groups all over the world. [15]
SCIP top ten
The SCIP initiative has compiled a top ten list of tips for OR Nurses that can be utilized by
any facility that embraced the model. The project has four target areas of focus: surgical site
infections, perioperative cardiac events, venous thromboembolism, and ventilator-associated
pneumonia. As you can see, the work of these patient safety-focused groups overlaps and
provides a firm foundation on which to base practice. The tips are the following:
1. Understand why SCIP is important. 22 percent of preventable deaths among patients are
caused by error or by not following evidence-based guidelines.
2. Get a team together. A multidisciplinary team composed of nurses, surgeons, anesthesia
providers, and others is a requisite for successful implementation of any project.
3. Examine your policies and protocols for delivery of care. All documents should be founded
in evidence-based guidelines and be effectively implemented.
4. An educated staff will get the best results. A staff that is committed to life-long learning will
employ the latest tools, interventions and other information on which to base their care. Visit
www.medqic.org/scip for the latest information.
5. Remove all razors and replace them with clippers. Evidence supports this recommendation
to prevent surgical site infections.
6. Work with your SCIP team to develop preprinted protocols for antibiotic selection.
7. Develop a policy that assigns responsibility for giving antibiotics within one hour of incision.
Members of the facility team work together to compile data on which to base their protocols.
8. Modify OR forms to provide “triggers” for appropriate care. Computer-based programs can
provide prompts for the”time out” to identify patients to prevent wrong-site, wrong-patient,
wrong-procedure, etc.; maintain perioperative normothermia in patients having abdominal
surgery.
9. Identify SCIP physician champions. These physicians can assist to educate others about
the SCIP measures and collaborate to have successful implementations.
10. Encourage your hospital leadership to identify measures and results. These should be
reported to the Board of Directors and to groups that identify best practice. [16]
Conclusion
2007 5
The challenges that face today’s healthcare providers are both multifaceted and demand
constant vigilance. This creates a balancing act to maintain efficient and effective systems; provide
safe, quality care; keep all stakeholders and customers satisfied; while operating within budgetary
parameters. A disequilibrium can result when challenges arise in any one of the areas of operation
causing a ripple effect. Facilities may not have the capacity to commit internal or external
resources to investigate options and issues can become mired in inactivity and indecision.
Agencies whose focus is patient safety exist throughout the world and are providing tools to assist
practitioners in creating environments that revolve around safety and quality care. It behooves
each of us to be appraised of the valuable resources that are available to us and share those with
our healthcare systems.
References :
1. “ A Safety Culture is Essential”, Quality Review in Anesthesia, May/June 2007, 10 (2), p.1.
2. “AHRQ Offers Evidence-Based Tips to help Hospitals Promote Patient Safety,” AANA
News Bulletin, January 2007, p 10-11.
3. Project Title: Hospital Survey on Patient Safety Culture. Developed under contract for the
Agency for Healthcare Research and Quality. Reference:
http://www.ahrq.gov/qual/hospculture/
4. Project Title: Effects of Extended Work Hours on ICU Patient Safety Principal
Investigator: Charles Czeisler, M.D. Reference: Barger LK, et. al. Extended work shifts
and the risks of motor vehicle crashes among interns. N Engl J Med 2005 Jan
13;352(2):125-34.
5. Project Title: Effects of Extended Work Hours on ICU Patient Safety. Principal
Investigator: Charles Czeisler, M.D. Reference: Landrigan, CP, et. al. Effect of reducing
interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004 Oct
28;351(18):1838-48.
6. Project Title: Targeting Interventions to Reduce Errors Principal Investigator: Timothy
Hofer, M.D. Reference: Collard, HR, et. al. Prevention of ventilatorassociated pneumonia:
an evidence-based systematic review. Ann Intern Med 2003 Mar 18;138(6):494-501.
7. “Human Factors, education help sharpen the OR count process,” OR Manager. December
2006, 22(12), p.1,7,9-11.
8. Project Title: Malpractice Insurers' Medical Error Prevention Study Principal Investigator:
David M. Studdert, M.D. Reference: Gawande, AA, et. al. Risk factors for retained
instruments and sponges after surgery. N Engl J Med 2003 Jan 16;348(3):229-35.
9. Project Title: Intensive Care Safety Reporting System Principal Investigator: Peter
Pronovost, M.D. Reference: Needham, DM, et. al. A systems factors analysis of airway
events from the Intensive Care Unit Safety Reporting System. Crit Care Med 2004
Nov;32(11):2227-33.
10. Project Title: Training Physicians to Use a Handheld Device for Electronic Prescribing
Principal Investigator: Kimberly Galt, Pharm.D Reference: Galt, KA, et. al. Personal
digital assistant-based drug information sources: potential to improve medication safety. J
Med Libr Assoc 2005 Apr;93(2):229-36.
11. Project Title: Impact of Personal Digital Assistant Devices on Medication Errors in Primary
Care Principal Investigator: Kimberly Galt, Pharm.D. Reference:
http://chrp.creighton.edu/documents/BestPractices.pdf
12. Project Title: Targeting Interventions to Reduce Errors Principal Investigator: Timothy
Hofer, M.D. Reference: Cornia, PB, et. al. Computer-based order entry decreases duration
of indwelling urinary catheterization in hospitalized patients. Am J Med 2003 Apr
1;114(5):404-7.
13. Project Title: Work Environment Effects on Quality of Healthcare Principal Investigator:
Bradley Evanoff, M.D. Reference: Potter, P et. al. An analysis of nurses' cognitive work: a
new perspective for understanding medical errors. In: Battles J, et al. (Editors). Advances in
2007 6
Patient Safety; Vol. 1—Research Findings (AHRQ Publication No. 05-0021-1). Rockville,
MD: February 2005; p. 39-51.
14. “Communication,” infoLaw, Canadian Nurses Protective Society, May 2006, 15(3).
www.cnps.ca
15. “The OR Connection”, 2006 Medline Industries, Inc. Volume 1, p. 6.
16. Ibid. p. 7-9.
Internet Citation:
10 Patient Safety Tips for Hospitals. AHRQ Publication No. 06-P020, May 2006. Rockville, MD,
Agency for Healthcare Research and Quality. http://www.ahrq.gov/qual/10tips.htm
1
TECHNICIAN OR NURTURER: DISCOURSES WITHIN THE
OPERATINGROOM.
Abstract
Whilst the ethics of caring frames nursing pedagogies, the embodiment role of the
patient differs for the operating room nurse. In this highly specialized and complex
area, the patient becomes an object, a body to be examined, parts repaired and
replaced with the need for technological expertise taking precedence over the
traditional role of nurse as carer. This paper reports findings from an ethnographic
study that was conducted with operating room nurses in Victoria, Australia. The
study explored the way in which the operating room nurse constructed the patient. A
Foucauldian understanding of discourse provides a perspective for analyzing nursing
practice in the operating room. This paper presents selected findings from the study
to explore the ways in which the operating room nurse locates her practice.
INTRODUCTION
The reality of surgery, which produces the ‘silent body’ of the surgical patient, presents
a dilemma for perioperative nursing. Great emphasis is placed on the notion of the
nurse as ‘carer’, ‘nurturer’, but how does this accommodate the expert practitioner in the
operating room where for the majority of procedures the patient is unconscious, ‘silent’,
and the primary focus is on the ‘technical’? Opportunities for caring in the traditional
and limited way is restricted in the operating room and has resulted in the positioning of
operating room nursing as task-orientated (McGee 1991). The work of Michel Foucault
specifically that of power/knowledge, discourse and subjectivity is drawn upon to
analysis this area of nursing practice.
This paper draws upon findings from ethnographic research to explore the way in which the
operating room nurse1 constructs the patient in this technological environment.. The study
consisted participant observation and interviews with eighteen operating room nurses to gather
a richness of data which shapes her2 daily activities. Extracts from interviews with two of the
operating room nurses Sarah3 and Amanda4 is presented to exemplify discourses within this
specialised area of professional nursing, in particular those that address the implications for
1 Operating rooms are staffed in Australia by Registered Nurses (RN)
2 The nurse shall be referred to as she throughout this paper
3 Fictitious name
4 Fictitious name
2
holistic practice that technology is having. The focus of this paper is to explore discursive
practices within the operating room which create the subjectivity of the operating room nurse,
her discourse of the body and the way in which she positions the patient.
Foucauldian understandings of power/knowledge; discourse;
subjectivity
Power/knowledge
Foucault (1970; 1973; 1975) argued that power and knowledge are inextricably
entwined in the form of a power/ knowledge relation. This relation is understood to be
both a limiting and productive force which constitutes and defines boundaries of
thought, emotion and action. It is evident in its structuring of people’s everyday
practices and its concomitant power to constitute their identity or subjectivity. The
power/knowledge relation involves the notion that power is relational, existing only
when it is exercised at the level of everyday activity by individuals within the context of
a relationship such as that between nurse and patient, surgeon and operating room nurse.
Riley and Manias (2001) suggest the development of operating room nursing can be
explained in terms of Foucault’s productive nature of power. I argue the operating room
is a site where power/knowledge relations are acted out.
Discourse
Discourses are the means by which a body of knowledge is expressed, power relations
both constitute and reaffirm discourses, which in turn constitute and reaffirm power
relations (Foucault 1975). The person is understood as discursively constituted, that is,
they are spoken into existence by the available discourses. Hence, discourse is not just
the spoken word but what is able to be said and thought, and more importantly who can
say it. It is the mode through which power-knowledge operates.
Subjectivity
Subjectivity is viewed as a product of the discursive context within which each
individual is located and, by implication, of the discourses to which s/he has both access
3
to, and accesses (Foucault 1975). It encompasses both the conscious and unconscious
elements that make up an individual's identity. Subjectivity must be understood in its
social context, that is, in relation to the history and experiences of the individual.
Subject positions are made available within discourses and also by social practices, the
'roles' of people within a society: the nurse as carer, essentially a female role assisting
the doctor as the healer, the male, the independent practitioner. As a person
accumulates new knowledge and experiences through life, the discourses and subject
positions that constitute them, and thus their subjectivity, will alter. Once a person
becomes aware of how they are positioned within discourses they are able to decide if
they choose to continue with that particular position. A great deal of our subjectivity is
both historically and discursively determined and this may present itself in the form of
meanings and values, which are often contradictory. As individuals we act in terms of
beliefs and values we have taken up as our own. However, depending on the discursive
field in which we are positioned, these beliefs and values are again reshaped and
developed by the particular historical moment and by being positioned in one discourse
or another.
Application to the operating room and operating room nursing practice
The modern hospital and technologies have ensured the focus has been maintained on
the scientific body. The patient’s personal identity is stripped away; their voice silenced
by ritualistic practices aimed at ensuring compliance, their subjectivity subsumed by the
aseptic environment. Surgical procedures take place whereby joints are replaced, organs
such as hearts, lungs, livers, and pancreas are transplanted and the body’s mechanism
regulated; the body is communal and interchangeable in its parts. The discursive
construction of the patient is that as object, someone who is deprived of agency and who
is subjected to the agentic role of others. In the operating room the patient’s agentic role
has been ‘given’ to someone else, the surgeon in the first instance who then carries out
whatever surgical procedure is considered necessary, and to the nurse secondly, who
prepares the patient for this objectification. In the operating room the nurse makes
ordinary what are extraordinary events, the handling of someone’s internal organs
becomes an everyday event for the operating room nurse.
4
Discourses of operating room nursing
Multiple discourses emerged from the textual analysis of the data; nursing, technology,
collegiality and subordination. I have chosen two cases that typify the tensions
surrounding the Discourse of Nursing and the Discourse of Technology. The Discourse
of Nursing comprises efficiency, caring, and professional approach. The Discourse of
Technology comprises biomedical model and technical expertise.
CASE-STUDY – SARAH
Sarah is 24 years of age and has just completed a university qualification in
‘perioperative nursing’ that is she has covered technical and professional aspects of
operating room practice, and is currently employed at a metropolitan hospital with high
acuity. Sarah discussed her view of patient care in this area:
You’re playing a big part in helping someone’s life. Although the patient is
the primary focus they are not there long enough to form a primary
relationship. You certainly can gain the trust of the patient. The outside world
would see so much of our job as not really being focused on the patient in that
when you’re getting set up and that type of thing is so important but would just
be seen to the outside world as being just a task. Every aspect of what we do is
for the benefit of the patient but people sit back and say well you’re just
cleaning up a theatre, what’s that got to do with the patient? But if you don’t
have a clean theatre the next patient is in jeopardy, their procedure is in
jeopardy, the chances of infection are certainly very high so I guess everything
that we do is for the benefit of the patient and ensuring they get the optimal
care that they need and deserve so that they won’t have further complications
because of something that we’ve done or not done. Everything that is done is
worked around the patient despite that fact that the patient might not be there
at the time you do your job and you go about doing your job for the ultimate
end to the patient coming in and having what they want done.
Sarah continues with her construct of the patient:
Maybe this isn’t the attitude I should have but I think a lot of people do, once
the patient is asleep in a sense, I no longer consider them to be a person. I’m
not talking about losing the focus of who they are or what they are but
generally, particularly if you’re on the scrub side, with some big cases
sometimes in order to protect yourself from what is going on, particularly if it
is a procedure for removing cancer, you’re focusing in on just what you’re
working on and then when they are awake they are a person again. Because
they are covered with drapes and you’re just focusing in on such a small part
of them, in order to I guess remain apart from what you are doing and not
become emotionally involved in every single case, I don’t consider them to be
a person at the time. Once we’re finished and they are awake, great,
everything went well; yes we do look at them as a whole. I couldn’t cope in
5
everyday life if I got emotionally attached to every patient that came through.
So that’s the way I deal with it. So technically we are not looking after them
holistically, we can’t do that because we don’t see them enough, and we are
not with them long enough, so it makes it hard.
There are tensions for Sarah between the nursing philosophy of caring and the
imperatives of technology as she positions herself using different discourses. She uses
a discourse of efficiency when talking about the practices necessary in the operating
room. A discourse of technology is then used in which she has positioned herself as the
technician in which the importance of technical mastery is emphasised, taking primacy
over the pedagogy of caring. Although she takes on the position of carer at one stage,
this is done in a nursing practice discourse of distance. Primarily Sarah has positioned
herself safely so that no emotional involvement is required of her. The meaning she
gives to her experience is one of detachment. It is a discourse of ‘safety’ and noninvolvement
where the patient is positioned as object
CASE-STUDY - AMANDA
Amanda is 36 years of age with over 10 years of experience working in operating
rooms. She has a hospital certificate in this speciality and is currently working at a
different high acuity metropolitan hospital to Sarah. Amanda speaks about her reasons
for choosing this area of nursing practice:
I think the most important aspect of operating room nursing is that you are
actually looking after a patient who absolutely can do nothing for themselves.
We have such an important role but also a very intimate role with the technical
side. I always remember being told as a student by a nurse to ‘treat this patient
like you would like to be treated yourself if you were in that situation’.
Amanda expounds on her notion of patient care:
Patient care in theatre is so broad but just things like making sure they are
warm, they’re comfortable, they are reassured. I always make sure that people
are introduced especially if I’m doing anaesthetics. It’s the most horrifying
experience for most people. They’re often going in for surgery that can be life
threatening and they think they’re going to die and if they don’t die they might
be maimed for life. So you are looking after the individual patient from that
personal sort of comfort perspective. Then you extend it even further to the
sterility of the instruments, looking after their allergies, making sure the prep
solution, the bandages, everything like that is not going to cause them a
6
problem, looking after their dentures. You make sure that the equipment you
need is there and it’s safe to use, it’s just this continual thing. That you are in a
situation that is as perfect as possible and everything is ready and available, all
of those sorts of things, the calf stimulators, is the IV solution the right one, is
it warm, is it recorded; all those things are looking after the patient.
Amanda explicates her construction of the patient:
Generally I think you see the patient as ‘the appendix’ or something like that.
Unfortunately that is the way we do see the patient unless I’m actually doing
anaesthetics when I develop some rapport with the patient, limited as it may
be. But because we don’t have any pre-op contact with that patient, the first
thing we see is someone asleep with the ET tube hanging out and we look to
see if their body alignment is proper and those things. So unfortunately we do
see them as a body. Sometimes I feel a little frustrated with the fact that I have
a limited level of patient contact, so I think we have to divide it into patient
contact and nursing. The interesting thing is that operating room nurses
probably care for the patient on a more intimate level.
The dominant discourse used by Amanda is that of caring. She has positioned the
patient as subject whilst acknowledging that at times the imperatives of the surgical
procedure creates objectification of the patient.
Discussion
There are multiple discourses within this area of nursing practice. The discourses
emerging from the case studies of Sarah and Amanda reveal this. They recognise that
the powerful discourse of technology is very seductive and that the nursing discourse of
caring may appear to be overtaken by the imperative needs of the surgical procedure.
Thus there is a need for the operating room nurse to move from one discourse to another
to conform to the subject position created for her. For Sarah there is conflict between
the pedagogy of caring and the technical skills required in this area with the patient
positioned as object. Sarah’s positioning is that of novice where humanistic caring
cannot occur until psychomotor skills are mastered, thus the nursing practice discourse
of distance is used and the patient is objectified. Amanda has created a different subject
position and uses a discourse of patient as subject. Amanda positions herself as an
expert practitioner, providing care that encompasses both technical and nursing care
with less obvious tensions between the divergences of these two aspects of care. Bull
and Fitzgerald (2006) argue the combination of technological proficiency and a patient7
focused ethic of care suggests ‘nursing’ is what operating room nurses do. The
combination of these discourses as demonstrated by Amanda and Sarah can be argued as
an example of operating room ‘nursing’.
The role of technician is legitimated in the operating room because of the very nature of
the work undertaken there; that of repair and replacement of body parts. For the
operating room nurse, the increased use of technology has created tensions for their
construction of self and the discursive practices undertaken. The ethics of caring frames
nursing theories and practice but in this specialised and complex area the patient by
necessity becomes an object a body to be examined parts repaired and replaced. Hence
the need for technological expertise takes precedence over the traditional role of the
nurse as carer. However operating room nurses must combine their specialist knowledge
of technology with the humanistic caring aspect of their role to ensure the person is not
subjected to invasive procedures for technologies’ sake. The skill involved for any
operating room nurse is to ensure that that the agentic role presumed given by the
patient by their consent to operation is never abused and the primacy of safe patient care
is never compromised.
Conclusion
Operating room nursing advances the nurse’s role as having moved from task-oriented
to patient-centred and has introduced the term ‘perioperative’ to describe the role of the
professional nurse through each stage of the person’s surgical experience; preoperative,
intraoperative and postoperative. A redefinition of nursing practice in this area
articulates the patient-centred focus that provides continuity of care using scientific and
behavioural principles in order to meet each patient’s individual needs. Operating room
nursing is unique in that all of the patient’s needs must be met and in that s/he is reliant
for protection from harm. It enables the professional nurse to ensure a safe therapeutic
environment by maintaining safe standards of nursing care practice and to be
responsible and accountable for actions relating to that care. The operating room nurse
is seen as a professional who bridges the gap between the technological and humanistic
care.
8
About the author:
Dr Marilyn Richardson-Tench
Dr Richardson-Tench is a Senior Lecturer in the School of Nursing and Midwifery, Victoria University,
Melbourne Australia. She obtained an operating room qualification from the Royal Melbourne Hospital
and has practiced operating room nursing in Melbourne and in the U.K, specifically at The Hospital for
Nervous Diseases, Queens Square London; Hospital for Sick Children, Great Ormond Street London and
University College Hospital, Gower Street London. Dr Richardson-Tench obtained her Clinical Teaching
Certificate in the UK and her B.App.Sc.(Adv.Nsg.); M.Ed.Stud. and PhD in Melbourne. Her PhD study
explored operating room nursing practice. Her current research projects cover areas such as day surgery
and nursing ethics. Dr Richardson-Tench has presented papers at national and international conferences.
9
References
Bull, R. & Fitzgerald, M. Nursing in a technological environment: Nursing care in the
operating room. International Journal of Nursing Practice. 2006; 12: 3-7
Foucault, M. The order of things. New York: Random House, 1970
Foucault, M. The Birth of the Clinic. London: Tavistock, 1973
Foucault, M. Discipline and Punish, the Birth of the Prison System.
London: Penguin, 1975
McGee, P. Perioperative nursing: A review of the literature. British Journal of Theatre
Nursing. 1991; 1: 12-17
Riley, R. & Manias, E. Foucault could have been an operating room nurse. Journal of
Advanced Nursing. 2002; 39(4): 316 - 324
10
Dr Marilyn Richardson-Tench
RN, RCNT, B. APP. SC.(Adv.Nsg.), M.Ed. Stud), PhD
Senior Lecturer
School of Nursing and Midwifery
Faculty of Health Engineering and Science
Victoria University
Melbourne
Australia
Tel: 61 3 9919 2205
Fax: 61 3 9758 4016
E’mail: marilyn.richardson-tench@vu.edu.au
11
Technician or Nurturer: Discourse Within the Operating Room.
Keywords
Nursing Knowledge
Operating room Discourse
Foucault Subjectivity
Poststructuralism Technology
Power Embodiment
No. words: 3493
12
Parker, J. 1993 "Searching For The Body In Nursing". (Unpublished Paper: Copy with
Author). 1-39
“Oh, By the Way, the Patient is Pregnant!”
Author: Joan Porteous, RN, BN, CPN(C)
Perioperative Nurse Educator
Health Sciences Centre
820 Sherbrook Street
Winnipeg, MB R3A 1R9
Contact: Email: jporteous@hsc.mb.ca
This paper was given as a verbal presentation during the ORNAC Conference in
Victoria, BC Canada in May 2007.
Abstract:
The pregnant patient who undergoes surgery presents a unique challenge to the
perioperative nurse and the entire surgical team. This paper will focus on urgent and
emergent non-obstetrical surgical procedures in situations where surgery cannot be
postponed until after delivery.
The paper explores physiological changes and risks to the mother and her fetus,
anesthesia considerations and medication usage. It includes goals of perioperative
care for pregnant patients undergoing urgent or emergent procedures associated with
cholecystitis, urinary calculi, bowel obstruction and trauma. Care for a pregnant
patient in cardiac arrest is also discussed.
The information will assist perioperative nurses to develop care plans for pregnant
women having urgent or emergent surgery; processes which will promote the health
and safety of both patients; the mother and her developing fetus, during their time in
the surgical suite.
“Oh, By the Way, the Patient is Pregnant!”
Approximately 1-3% of pregnant women undergo surgery that is unrelated to their
pregnancy.1 In Canada this represents about 5000 patients each year that present
unique challenges to the perioperative nurse and the entire surgical team.2
Approximately 5-10% of these patients are involved in trauma, which causes 46.3%
of maternal deaths.2,3,4
A small percentage of elective procedures are carried out in the first trimester, before
the patient herself is aware of the pregnancy. The majority of procedures are required
for urgent and emergent conditions that require surgery despite the risks to the mother
and fetus.2
This article will discuss perioperative care of the non-obstetric pregnant patient and to
introduce a nursing care guideline that can be used as a quick-reference tool. The care
discussed in the appended Guideline focuses on the pregnant condition and is
designed to be used in conjunction with routine perioperative care practices.
Semi-elective and urgent surgery is not contraindicated by pregnancy, although
anesthetic and surgical approaches must be modified to promote the safety of mother
and her fetus. If possible, the surgery should be postponed to the second trimester.4
By this time major systems of the fetus are formed and the uterus does not yet infringe
on abdominal structures and manipulation may be kept to a minimum. In the first
trimester, spontaneous abortion is the greatest risk at 12%. This decreases to less than
5% in the second and third trimesters. Pre-term labor presents the greatest risk in the
second and third trimesters.2,3,4
The most common need for surgery in pregnancy is associated with appendicitis,
biliary tract disease, intestinal obstruction, urinary calculi and trauma.4
Appendicitis:
Appendicitis is the most common surgical problem in pregnancy and it causes the
most fetal loss.3 One case of appendicitis is reported for every 550 pregnancies.
Appendicitis, treated immediately, has a 2-8% incidence of fetal loss that rises as high
as 35% with rupture and peritonitis.4 This is because of the varied presentation of
symptoms, the greater chance of delayed diagnosis and the significant risk that
surgery presents to the fetus. The symptoms of appendicitis mimic symptoms of
normal pregnancy; anorexia, nausea, vomiting and abdominal discomfort. To
complicate matters, an elevated temperature is not consistent in pregnant women with
appendicitis. The appendectomy should be carried out in the usual timely fashion.
Biliary Tract Disease:
Acute cholecystitis is the second most common emergency in pregnant women.5
Increased progesterone levels associated with pregnancy decrease motility of the
gallbladder resulting in bile stasis that promotes stone formation.
Surgery during pregnancy is reserved for complications such as choledocholithiasis,
pancreatitis, cholecystitis and biliary colic.
Intestinal Obstruction:
Most bowel obstructions during pregnancy are caused by adhesions from previous
surgery (80%) or volvulus.4 A small bowel obstruction is often presumed for any
patient presenting with nausea, vomiting and a history of abdominal surgery, until it is
proven otherwise. If x-rays are required, the risk of radiation exposure to the fetus is
weighed against the potential morbidity and mortality of a missed diagnosis.
Urinary Calculi:
The pregnant patient with an untreated urinary obstruction combined with an infection
has a high risk for abortion and premature labor. Ureteral stones may be treated with
ureteroscopy and stone removal by basket or laser lithotripsy. Ultrasonic lithotripsy is
contra-indicated because the effect of shock waves on the fetus is unknown.
Ultrasound may be used for stent placement to relieve hydronephrosis associated with
kidney stones, which can be removed later after delivery.2
Trauma:
Trauma occurs in 5-10% of all pregnancies.6 Motor vehicle accidents account for up
to 60% of trauma in pregnant women, followed by falls (22%) and domestic violence
(21%).4
The pregnant trauma patient is managed in essentially the same way as a nonpregnant
patient. The mother is the first priority. Stabilization of the mother
improves both maternal and fetal survival.
In hypovolemic shock, blood is shunted away from the uterus ant the expense of the
fetus. The fetus becomes hypoxic very quickly because the pregnant uterus is viewed
as a non-essential organ in this situation. Fetal demise is 80% in maternal
hypovolemic shock. The usual indicators of hypovolemic shock are unreliable in the
pregnant trauma patient due to an increased heart rate and increased oxygen
requirements of pregnancy.7 It is assumed the pregnant trauma victim is in shock
until proven otherwise.
In the event of a ruptured uterus, a cesarian section and hysterectomy may be required
with preparation for neonatal resuscitation. If the maternal condition is critical, the
primary concern is to save the mother.6
Cardiac Arrest:
When a cardiac arrest occurs in a pregnant woman, standard resuscitative measures
and standard drug therapy should be used without modification.8 The key to
resuscitation of the fetus is to resuscitate the mother.7 In a pregnant patient close to
term, the supine position without a wedge can result in a 30% decrease in cardiac
output as a result of compression on the inferior vena cava. The patients’ torso should
be angled 30-40 degrees from the OR bed. The uterus may need to be displaced to the
left manually during resuscitation. Standard drug therapy should be used without
modification. Ventricular fibrillation should be treated with the standard shock
therapy. Shocks have not been found to transfer a significant current to the fetus.8
If a maternal pulse has not been restored, the decision to perform a cesarian section
should be made rapidly with delivery affected within 4-5 minutes of the arrest.
Delivery of the fetus may relieve aortal compression and allow recovery of the venous
return to the heart. If resuscitation efforts are successful before surgical delivery is
attempted, cesarian section is not recommended, because in-utero resuscitation is
likely.8
While the optimal interval of arrest to delivery is within 5 minutes, there are case
reports of intact infant survival after more than 20 minutes of maternal arrest.8 If
gestation is less than 24 weeks, pregnancy viability is probable following a successful
resuscitation. When hypoxic episodes cause fetal brain damage, intrauterine fetal
demise is the usual result. The fetus often survives when there has been no brain
damage due to the “all or nothing” rule.9
Goals of Perioperative Care:
Gestational age plays a pivotal role in planning care. Goals of perioperative care for
the pregnant patient include:
1. A thorough preoperative assessment is conducted, including:
- What is the gestation of the pregnancy?
- What is the maternal and fetal condition?
- Is there an obstetrics consult?
- What are the patient’s anxieties?
- Will intra-operative x-ray or ultrasound procedures be required?
2. Reassure the patient:
- The family may have had little time to adjust to the uncertain outcome
and risks
- The family’s happiness is replaced with anxiety about the risks
associated with the surgery
- Discomfort and pain often complicate normal coping strategies
- Sympathetic nerve fiber discharge results in decreased uterine blood
flow
- Provide as much reassurance as possible
- If regional anesthesia is utilized and the fetus is being monitored, the
volume on the monitor can be increased
- The anesthetist will be prepared to discuss concerns about
teratogenicity associated with medications and discuss other concerns
3. Monitor maternal oxygenation and blood pressure:
- Pulse oximetry readings should remain above 94% to prevent fetal
hypoxia
- Continuous oxygen is usually administered6
- Maternal hemoglobin levels are closely monitored. Maternal
hemoglobin levels may be decreased, due to the increased proportion
of serum plasma associated with pregnancy
- A maternal blood pressure of less than 90 mm Hg is likely associated
with impaired placental perfusion
- A second IV site may be established or an arterial line may be inserted
for monitoring
4. Use appropriate medications:
- The majority of anesthetic agents cross the placenta and enter fetal
circulation1
- Some drugs that adversely affect fetal development during the first
trimester include nitrous oxide, halogenated agents, sedatives,
tranquilizers, antidepressants and amphetamines. Many of these drugs
may be administered in the second and third trimesters6
- The fetal liver is immature and metabolizes narcotics slowly, so shortacting
drugs may be preferable
- Local and regional anesthetics have not shown teratogenicity
- Lidocaine is preferable to Bupivicaine which may cause bradycardia4
- Heparin does not cross the placenta
- The anesthetist’s goal is to limit drugs to those that are known to be
safe for the pregnant patient
5. Prevent aspiration:
- Gastric emptying is delayed and there is an increased acid
accumulation in the stomach associated with pregnancy
- An antiemetic or antacid may be prescribed preoperatively
- The patient is treated as if she has a full stomach with increased acidity
associated with pregnancy
- Cricoid pressure is required during endotracheal intubation as directed
6. Avoid pre-term labor
- There is no association of any single anesthetic agent with an increase
or decrease of pre-term labor6
- Vasopressors and drugs used to reverse muscle relaxants may stimulate
the uterus to contract and initiate pre-term labor
- The use of halogenated agents in the third trimester decreases uterine
tone and may prevent uterine contractions6
- Surgical manipulation of a gravid uterus may initiate pre-term labor
7. Minimize the patients’ time under anesthesia:
- Local anesthetics with sedation and regional anesthetics are used
whenever possible
- Be prepared to perform skin prep and draping before induction of a
general anesthetic
- Have devices for electronic or ultrasonic fetal monitoring functioning
before anesthetic induction begins. This may well provide some
reassurance and comfort to the mother
- Some techniques to produce a light general anesthetic may increase the
possibility of awareness under anesthesia10
8. Monitor the fetal heart rate (FHR):
- Although fetal heart rate can be heard at 10-14 weeks gestation, it is
generally not reliable under 18 weeks and is most useful beyond 22
weeks. Many anesthetists may choose not to monitor FHR before the
fetus is viable.4 Instead, they will focus their close attention to
optimizing the maternal condition. However, pre-viable fetal
monitoring may initiate actions to preserve fetal wellbeing.1,4,7,12
Positioning adjustments to improve placental blood flow and
increasing fetal oxygenation by increasing maternal oxygenation may
benefit the fetus.
- Fetal tachycardia may be the first sign of maternal hypoxia
- A FHR of less than 100 or more than 160 should alert the anesthetist to
search for causes12
- If fetal monitoring is used, personnel competent in monitoring
techniques should be involved.1,4,6,7
- Optimizing maternal physiological status also optimizes placental
perfusion and is more important than any mode of fetal monitoring.
9. Monitor for pre-term uterine contractions:
- If the uterus is being monitored for contractions, it should be carried
out by experienced personnel.1,4,6,7 Because the anesthetist is focusing
on the patient, an obstetrical nurse may be required.
10. Positioning
- Position the patient in a left tilt position after 20 weeks gestation to
relieve pressure on the vena cava and aorta.
i. Arrange to have the patient positioned in the left tilt position
when being transported to the OR on a stretcher
ii. Position the patient with a wedge under her right hip on the OR
bed
iii. Placing her left arm at 90 degrees on an armboard will help to
stabilize her tilt
- Because of the hypercoagulable state associated with pregnancy, apply
sequential compression stockings and/or TEDS preoperatively. This
hypercoagulable state is nature’s protection against bleeding at the
time of delivery.
11. Prevention of hypothermia:
- Maternal hypothermia should be prevented
i. Maternal hypothermia causes decreased utero-placental
perfusion and may cause bradycardia
ii. Hypothermia is associated with ventricular fibrillation in the
mother and in the fetus
iii. Pre-term labor is associated with re-warming the mother
- Theatre temperature should be at about 24 degrees Celcius6
- Use pre-warmed solutions and warming blankets
- Keep the patient’s head covered
12. Electro-surgery:
- General safety principles associated with electro-surgery are followed
- The amniotic fluid absorbs and conducts energy well
- Use the lowest settings possible
13. Radiological investigation:
- Effects such as malformation, growth retardation, CNS abnormalities
and fetal loss are dependant
on exposure time and dosage6
- Radiation exposure should be minimized and radiation doses carefully
documented
- Clear communication with the radiology technician may help to limit
radiation exposure
- CT scans and x-rays must be used cautiously
- Ultrasonography and MRI do not use ionizing radiation and may be
sufficient
- The pregnant uterus should be shielded from above and also from
below if fluroscopy is used
- The patient should be informed of the risks associated with radiation
14. Urinary catheter insertion:
- Bladder distention can cause uterine irritability and preterm labor
- After 12 weeks gestation, the bladder should be decompressed to allow
adequate exposure in the pelvis and lower abdomen6
- A foley catheter is recommended for procedures lasting more than 1
hour
- Urine output should be approximately 25 ml/hour
15. Laparoscopic surgery:
- The benefits of laparoscopic surgery probably outweigh the risks4
- Use an open technique to insert the primary trocar
- Increased abdominal pressure leads to decreased uterine blood flow,
decreased maternal vena cava blood return and decreased maternal
residual capacity
- Use the lowest possible intra-abdominal insufflation pressure. Less
than
15 mm Hg is recommended
- A trans-vaginal Doppler could be used for fetal monitoring
- Be prepared to convert to laparotomy swiftly and efficiently if required
16. Be prepared for pre-term delivery when applicable:
- The fetus is viable after 24 weeks gestation
- In the event of untimely rupture of the membranes, pre-term labor or
fetal
distress, a cesarian section may be required to save the fetus
- If a cesarian section is a possibility:
iv. Notify the obstetrician
v. Notify the neonatal team
vi. Have neonatal equipment available
17. Facilitate postoperative care:
- Inform Post Anaesthesia Care Unit ( PACU) about the patient’s
pregnancy and condition well ahead of time to allow them to prepare
- Ensure the patient is in a left tilt position on the recovery bed or
stretcher
- Supplemental oxygen may be administered on transport to PACU
- Fetal monitoring initiated in the OR will continue in PACU
- Patients in their second and third trimesters may be monitored for
uterine
contractions
- Abruptio placenta occurs in 40-60% of major trauma victims, often
occurring after surgery11
Conclusion:
Careful planning which incorporates the gestational age of the fetus as well as
maternal physiological and emotional changes will ensure the best outcome for the
pregnant surgical patient and her unborn child. Appendix A is a planning tool which
can be utilized by perioperative nurses who are about to care for a pregnant patient
who requires urgent or emergent surgery. This tool will be helpful to plan care when
the nurse hears a colleague state “Oh and by the way, the patient is pregnant!”
REFERENCES
1. Penning, D. (2004). Does anesthesia increase the risk to the parturient
undergoing non0obstetric surgery? In Fleisher, L. (Ed). Practice of
anesthesiology. Toronto: Saunders.
2. Yarnell, R. (1995). Emergency surgery during pregnancy. Winterlude 95.
http://www.anesthesia.org/winterlude/w195/w195_6.html Retrieved 8/4/06.
3. Parungo, C. & Brooks, D. (2002). The pregnant surgical patient.
http://www.midwestheartsurgery.com/perf/sec7-2pregnantpatient.htm
4. Romanoski, S. (2006). Management of the special needs of the pregnant
surgical patient. Nursing clinics of North America, 299-311.
5. Committee on Obstetrical Practice (2004). Non-obstetric surgery in
pregnancy. Compendium of selected publications. Washington: The
American College of Obstetricians and Gynecologists.
6. Phillips, N. (2004). Berry & Kohn’s operating room technique(10th ed).
Mosby: Evolve.
7. Rothrock, J. (2007). Alexander’s care of the patient in surgery (13th ed).
Toronto: Mosby/Elsevier.
8. American Heart Association (2007). ACLS review. Lippincott, Williams &
Wilkins: AHA.
9. Mitchell, L (1995). Cardiac arrest during pregnancy: Maternal-fetal
physiology and advanced cardiac life support for the obstetric patient. Critical
Care Nurse, February, 56-59.
10. Woodhead, K. & Wicker, P. (2005). A textbook of perioperative care.
Toronto: Elsevier.
11. Committee on Obstetrical Practice (2004). Obstetric aspects of trauma
management. Compendium of selected publications. Washington: The
American College of Obstetricians and Gynecologists.
12. Burden, N. (2000). Ambulatory surgical nursing (2nd ed). Toronto: WB
Saunders.


Sometimes it DOES take a Rocket Scientist!!
Scientists at Rolls Royce built a gun specifically to launch dead chickens at the windshields of
airliners and military jets all travelling at maximum velocity. The idea is to simulate the
frequent incidents of collisions with airborne fowl to test the strength of the windshields.
American engineers heard about the gun and were eager to test it on the windshields of their
new high speed trains. Arrangements were made, and a gun was sent to the American
engineers.
When the gun was fired, the engineers stood shocked as the chicken hurtled out of the barrel,
crashed into the shatterproof shield, smashed it to smithereens, blasted through the control
console, snapped the engineer's back-rest in two and embedded itself in the back wall of the
cabin like an arrow shot from a bow.
The horrified Yanks sent Rolls Royce the disastrous results of the experiment, along with the
designs of the windshield and begged the British scientists for suggestions.
Rolls Royce responded with the following one-line memo:
'Defrost the chicken.'
* * *
'Dear IT Support:
Last year I upgraded from Boyfriend 5.0 to Husband 1.0 and noticed
a distinct slow down in the overall performance, particularly in
the Flower and Jewellery applications, which operated flawlessly
under Boyfriend 5.0. In addition, Husband 1.0 un-installed many
other valuable programs, such as Romance 9.5 and Personal
Attention 6.5 and then installed undesirable programs such as:
Football 5.0, Rugby 4.3 and Cricket 3.0.
Conversation 8.0 no longer runs; it simply crashes the system.
I've tried running Nagging 5.3 to fix these problems, to no avail.
What can I do?
Signed, Desperate
Dear Desperate:
First keep in mind, Boyfriend 5.0 is an Entertainment Package,
while Husband 1.0 is an Operating System. Try entering the
command: C:/I-THOUGHT-YOU-LOVED-ME to download Tears 6.2, which
should automatically install Guilt 3.0. If that application works
as designed, Husband 1.0 should then automatically run the
applications Jewellery 2.0 and Flowers 3.5.
But remember, overuse of the above application can cause Husband
1.0 to default to Grumpy Silence 2.5, Happy Hour 7.0, or Beer 6.1.
WARNING: Beer 6.1 is a very nasty program that will create Snoring
Loudly.
CAUTION: Whatever you do, DO NOT install Mother-in-law. This is
not a supported application and will crash Husband 1.0.
In summary, Husband 1.0 is a great program, but it does have
limited memory and cannot learn new applications quickly. You
might consider buying additional software to improve memory and
performance. I personally would recommend Hot Food 3.0 and
Lingerie 7.7.
Good Luck, IT Support
* * *
You might not have known this, but a lot of non-living objects are
actually either male or female.
Here are some examples:
FREEZER BAGS: They are male, because they hold everything in, but you
can see right through them.
PHOTOCOPIERS: These are female, because once turned off, it takes a
while to warm them up again. Also they are an effective reproductive
device if the right buttons are pushed, but can also wreak havoc if you
push the wrong buttons.
TYRES: Tyres are male, because they go bald easily and are often
over-inflated.
HOT AIR BALLOONS: Also a male object, because to get them to go
anywhere, you have to light a fire under their arse. Then of course,
there's the hot air factor.
SPONGES: These are female, because they are soft, squeezable and retain
water.
WEB PAGES: Female, because they're constantly being looked at and
frequently getting hit on.
TRAINS: Definitely male, because they always use the same old lines for
picking up people.
EGG TIMERS: Egg timers are female because, over time, all the weight
shifts to the bottom.
HAMMERS: Male, because in the last 5000 years, they've hardly changed at
all, and are occasionally handy to have around.
REMOTE CONTROL: Female. Ha! You probably thought it would be male, but
consider this: It easily gives a man pleasure, he'd be lost without it,
and while he doesn't always know which buttons to push, he just keeps
trying.
PERKS OF BEING OVER 50
1. Kidnappers are not very interested in you.
2. In a hostage situation you are likely to be released first.
3. No one expects you to run--anywhere.
4. People call at 9 pm and ask, " Did I wake you ???? "
5. People no longer view you as a hypochondriac.
6. There is nothing left to learn the hard way.
7. Things you buy now won't wear out.
8. You can eat dinner at 4 pm.
9. You can live without sex but not your glasses.
10. You get into heated arguments about pension plans.
11. You no longer think of speed limits as challenge.
12. You quit trying to hold your stomach in no matter who
walks into the room.
13. You sing along with elevator music.
14. Your eyes won't get much worse.
15. Your investment in health insurance is finally
beginning to pay off. Your joints are more accurate
meteorologists than the national weather service.
16. Your secrets are safe with your friends because they
can't remember them either.
17. Your supply of brain cells is finally down to
manageable size.
18. You can't remember who sent you this list
And you notice these are all in Big Print for your
convenience.
* * *
Unavoidable Laws
These are the unavoidable laws of the natural universe…
1. Law of Mechanical Repair: After your hands become coated with grease or sunscreen
your nose will begin to itch or you’ll have to pee.
2. Law of the Workshop: Any tool, when dropped, will roll to the least accessible corner.
3. Law of probability: The probability of being watched is directly proportional to the stupidity
of your act.
4. Law of the Telephone: When you dial a wrong number, you never get a busy signal.
5. Law of the Alibi: If you tell the boss you were late for work because you had a flat tire, the
very next morning you will have a flat tire.
6. Variation Law: If you change lines (or traffic lanes), the one you were in will start to move
faster than the one you are in now. ( works every time).
7. Bath Theorem: When the body is fully immersed in water, the telephone rings.
8. Law of Close Encounters: The probability of meeting someone you know increases when
you are with someone you don’t want to be seen with.
9. Law of the Result: When you try to prove to someone that a machine won’t work, it will.
10. Law of Biomechanics: The severity of the itch is inversely proportional to the reach.
11. Theater Rule: At any event, the people whose seats are furthest from the aisle arrive last.
12. Law of Coffee: As soon as you sit down to a cup of hot coffee, your boss will ask you to
do something which will last until the coffee is cold.
13. Murphy’s Law of Lockers: If there are only two people in a locker room, they will have
adjacent lockers.
14. Law of Dirty Rugs/Carpets: The chances of an open-faced jelly sandwich of landing face
down on a floor covering are directly correlated to the newness, color and cost of the
carpet/rug.
15. Law of Location: No matter where you go, there you are.
16. Law of Logical Argument: Anything is possible if you don’t know what you are talking
about.
17. Brown’s Law: If the shoe fits, it’s ugly.
18. Oliver’s Law: A closed mouth gathers no feet.
19. Wilson’s Law: As soon as you find a product that you really like, they will stop making it.
* * *
1
THE LIVED EXPERIENCES OF JOB SATISFACTION AMONG
PERIOPERATIVE NURSES: A PHENOMENOLOGICAL STUDY
Ruiz Laconcepcion, Maria Cruz MSc (Nurs), BSc (Hons), Diploma in Perioperative
Practice, Diploma in Medical Prevention & Health Promotion, Theatre Charge Nurse
Greenlane Clinical Centre ADHB, Auckland, New Zealand
.
e-mail: mari8ruiz@yahoo.es
ABSTRACT
There is enough evidence to suggest that the way that nurses respond to their jobs is
highly related to their levels of job satisfaction (Adams & Bond 2000, Callaghan 2002). Job
satisfaction can affect job performance, staff turnover, retention, absenteeism and
nurses’ commitment to the organisation. However, there are few studies exploring job
satisfaction among perioperative nurses and no study has been reported examining the
views of Spanish nurses. The aim of this study was to provide an in-depth view of job
satisfaction of Spanish theatre nurses. The research question was: "What are the lived
experiences of job satisfaction among theatre nurses?”. Using a phenomenological
approach, data was collected using one-to-one semi-structured interviews from a
purposive sample of four nurses. Data analysis was carried out following Colaizzi’s
method (1978). Pride in professional practice, being an essential member of the
multidisciplinary theatre team and professional learning emerged as aspects of job
2
satisfaction. Main sources of dissatisfaction were job insecurity and poor relationships
between surgeons and nurses. Shortage of nurses was not perceived. The study provided
insight into the perioperative nurses’ perceptions of their work and the factors that
generate job satisfaction and dissatisfaction. It is suggested that these findings could be
used by managers, educators and researchers to improve the situation of theatre nurses,
their practice, the organization and the related consequences to patients.
Keywords: job satisfaction, perioperative nurses, theatre nursing, phenomenology,
Spanish
INTRODUCTION
Job satisfaction is a complex and multidimensional concept influenced by many
interrelated factors(Lu et al 2005). It is known that some factors such as the physical
working conditions, salary, job security, promotion, relationships with co-workers and
managers, responsibility and hours of work are generally accepted as being related to
job satisfaction among nurses (e.g.: Tovey & Adams 1999, Adams & Bond 2000,
Newman & Maylor 2002).
Job satisfaction for nurses is one of the criteria for establishing a positive working
environment (Tovey & Adams 1999, Adams & Bond 2000). Satisfied nurses have better
job performance and are more efficient, also they have a greater commitment to the
organisation (Newman & Maylor 2002, Shields & Ward 2004). The level of job
satisfaction has been seen as the key to retention and turnover of nurses. Improved job
satisfaction results in less physical and mental injuries to the nurses, consequently
reducing absenteeism (Adams & Bond 2000, Callaghan 2002).
Little is known about job satisfaction among perioperative nurses and no study has been
carried out on Spanish theatre nurses. Research on job satisfaction tends to be among
nurses working on wards (Lu et al 2005). Due to the special characteristics of the
operating department, findings from these studies might not be generalised to theatre
nurses. Theatre nurses appear to seek a challenging, exciting and interesting workplace
and working within a good team structure (Kalideen 1994). Theatre nursing is a core
component of the healthcare system and perioperative nurses are vital to the success of
3
the surgical interventions. Given the magnitude of the role of the perioperative nurse,
gaining insight into perioperative nurses’ experiences of their work is an important issue
that needs further exploration. Therefore, that was the purpose of this study and the
research question evolved: "What are the lived experiences of job satisfaction among
theatre nurses?”
RESEARCH DESIGN AND METHODS
Nurses’ job satisfaction has been studied using a variety of quantitative instruments
(Stamps & Piedmonte 1986, Mueller & McCloskey 1990, Blegen 1993, Nolan et al
1995, Misener et al 1996). However, qualitative studies of nurses’ descriptions of their
job satisfaction are limited, with a notable lack of studies with theatre nurses. Since little
is known about job satisfaction of theatre nurses, qualitative inquiry appeared the most
appropriate approach. Qualitative research emphasizes the dynamic, holistic, and
individual aspects of the human “…experiences and what lies at the core of their lives”
(Holloway & Wheeler 2002, p.3). Such methods attempt to capture those aspects of life
experiences in their entirety, within the context of those who are experiencing them
(Polit & Hungler 1999).
A phenomenological approach seemed to be the most appropriate to achieve the purpose
of the study. Phenomenology focuses on “what people experience in regard to some
phenomenon and how they interpret those experiences” (Polit & Hungler 1999, p.246).
Also, as the focus is on the voice of the nurse, the chosen data collection method makes
this approach the most appropriate.
Ethical approval for the study was obtained from the Spanish Hospital Ethics
Committee.
4
Setting
The characteristics of the setting are described as follows:
A large 550-bedded teaching hospital in
Spain
9 main theatres Covering a wide range of specialities
except: open heart, ophthalmology and
aesthetic surgery.
34 nurses There are 2 nurses per theatre: a scrub and
a circulating nurse. The circulator, at the
same time plays the role of anaesthetic
nurse.
1 health care assistant (HCA) every three
theatres, 3 orderlies, cleaners and 1
secretary.
1 supervisor and 1 coordinator.
Shift patterns are early, late and night,
Monday to Friday and Monday to Sunday.
Nurses were invited to participate in the study. An explanation of the purpose of this
study was given to gain their support, with assurance anonymity and confidentiality of
information. Participants had the choice to withdraw from the study at any time.
Participants
A small purposive sample of four nurses was selected. According to Creswell (1998)
four subjects in a phenomenological study represent a small but acceptable size. Fully
informed participants signed a consent form before the interview. Table 1 summarises
the inclusion and exclusion criteria used in the purposive sample.
Table 1 Criteria for sampling
5
Interviews
Semi-structured interviews with open-ended questions aimed to elicit responses relating
to the lived work experiences of perioperative nurses. Appropriate prompts were deemed
suitable for the exploration of the perceptions and opinions of participants regarding
complex and sensitive issues. This enabled the researcher to probe for more information
and clarification of answers as the interviews progressed (Parahoo 1997).
Procedure
In-depth face to face interviews lasting 45-90 minutes were undertaken for this study.
Participants gave their permission to have the interviews recorded on audio-tape. The
same open-ended questions were posed to each participant. Follow-up questions varied
according to the flow of each interview in order to investigate thoroughly the areas
emphasized by the participant. Face-to-face interviews enabled observation of
participants’ non-verbal communication.
All interviews were held in a quiet and comfortable room familiar to the participants in
the department.
Data analysis
Following the completion of each interview, the content of the tapes were transcribed.
Transcripts were analysed using Colaizzi’s method (1978) which consists of eight steps
(Table 2).
Table 2. Colaizzi’s method of data analysis: the eight steps followed
Inclusion criteria Exclusion criteria
Nurses from early, late and night shifts
Female or male nurses
Nurses with different years of experience
Nurses with permanent & no permanent
contracts
Full time and part time nurses
Nurses from different surgical specialities
Nurses in position of management
Nurses who also work in recovery
6
a) Description of the phenomena of interest by the researcher
b) Collection of nurses’ description of their work experiences
c) Reading all the nurses’ descriptions of their work experiences
d) Returning to the original transcripts and extracting significant statements
e) Trying to spell out the meaning of each significant statements
f) Organizing the aggregate formalized meanings into clusters of themes
g) Writing an exhaustive description
h) Returning to the nurses for validation of the description
The researcher bracketed (suspended) her own knowledge and beliefs about satisfaction
in perioperative nursing in order to address personal bias. Descriptive field notes with
participant comments were written after each interview. These notes helped to discern
how the direction of the interviews might have been influenced and contributed to
bracketing during subsequent interviews. During data analysis, the researcher also wrote
memos about ideas that were emerging from the data and monitoring any subjectivity in
data collection and interpretation (Bogdan & Biklen 1998, Merriam 1998). Validation of
data was achieved by returning to each participant and checking that the exhaustive
description reflected their experiences, thus ensuring trustworthiness of data analysis
(Parahoo1997)
FINDINGS
Themes identified in the study included:
Attractiveness for theatre
The reasons why these participants were working as a theatre nurse were: previous
experience and contact with theatre nursing during training; the specific functions and
responsibilities of the perioperative nurse in different roles; and working closely with
people. Perioperative nursing was perceived as challenging, exciting, happening at a fast
pace and satisfying. Part of the attraction was based on the nature of patient intervention
and patient care involved as illustrated by one nurse:
7
“I enjoy the life-threatening emergencies; I like to help
to save someone’s life … I like to have the whole
situation under control, this is a rewarding and
fulfilling sensation. This is not possible on the ward,
since you have many patients to take care of ... after a
week from the operation I like to ask the surgeon about
that patient and I feel pleased knowing that he is well
…In theatre there is an intense period like a one hour
adrenalin rush time”. (D)
The operating theatre was perceived as unique - a place where problems are sorted
out: the patient would arrive with a problem and leaves without the problem. This still
surprised some:
“a patient arrives with a broken femur and leaves the theatre
with the femur fixed, and this process cannot be seen on the
ward”. (C)
The work environment was seen as stimulating and motivating, where morale was
high and the nurses could not imagine doing anything else.
Teamwork
Team structure and the specific relationships in the surgical team were seen as
dominant characteristics. However, teamwork was also a source of concern, with
relationships among nurses being perceived as not good enough and/or nurses not
helping each other. One example of dissatisfaction was related to the lack of
communication between the day staff and the night staff, leading to a lack of
awareness of new developments in theatres.
The perioperative nurse’s role within the multidisciplinary team was perceived as
essential to the effective functioning of the services where the nurse controlled the
whole theatre situation. The rest of the team members cannot function without the
presence of the nurse. That was a rewarding and fulfilling sensation. However, the
hard nurse’s work was not always recognised, leading to a sense of dissatisfaction.
Sometimes there were too many competing responsibilities. Non-nursing obligations,
such as administrative duties, too large amounts of paperwork, and undertaking the
surgeon’s or anaesthetist’s responsibilities were less satisfying. This suggested the
need for a better definition of the role and related activities of each team member.
8
Relationships with, and attitudes towards, physicians were major concerns and
sources of dissatisfaction. Doctors were seen as domineering, powerful, and
disrespectful toward nurses. This was illustrated with the following excerpt:
“Theatre is real teamwork …but everybody bosses you
… there are not good relationships amongst the
members of the team … physicians change their
behaviour in theatre, they see it like their private place
… they are rude, there are some bad behaved surgeons
who can make your life very difficult … although it is
much emphasized that we have to work as a team, it
looks like more an adversary team … I would like to be
treated as a person”. (C)
Experiences of stress were related to pressure and tension in the work environment.
Opting for a nursing work environment more independent, working with fewer people
and fewer responsibilities appeared to be a consideration to minimise dissatisfaction
with perioperative nursing.
Nurses experienced lack of inter-professional dialogue with doctors and felt that
nurses’ opinions were not given due consideration.
“In some situations we only can comment, but our
opinion is never taken seriously” (A)
Work schedule, salary
Salary was not described as an important issue.
“Although the salary could be better, it is not bad” (B, D).
Comparison with other nurses, in the same and different hospitals, with better
conditions, better pay, less responsibility often drew expressions of disappointment.
However, for the participants, an inferior salary was compensated by other
opportunities such as learning at the work place and work schedule fitting in well with
life style. But it would seem that nurses worked Bank Holidays and weekends
reluctantly since there were no extra remunerations.
“I would like the same salary as nurses from other
hospitals; we are all the same, theatre nurses …we are
low paid compared to other jobs that do not require
university studies …too many responsibilities for that
9
salary …my dream is working Monday to Friday,
having Bank Holidays off” (C)
Job security
This is the main source of concern among the non-permanent nurses. Short term
contracts and difficulty with securing a full time position were associated with
feelings of insecurity. At a personal level it was expressed thus:
“After eight years of finishing my nursing studies, I am
still looking for a permanent position. I do not have a
fixed roster. I only work few shifts a week. I have to wait
for someone to get sick and last minute phone calls from
the hospital to work. I need to work in few hospitals to
obtain a decent salary and have a minimum of job
security. I would be happy working on a full time
position in one hospital, any shift” (D)
Workload
Working in a hurry and under pressure for no other reasonable explanation than the
work practices of other team members was seen as unsatisfying.
“We work under pressure by the anaesthetists and
surgeons to finish earlier, thus, they can go home or
rest …I do not mind to rush for an emergency …the
operating lists are too long and we have to finish them
during the shift …sometimes we do not have time for a
break and these conditions provoke a tense atmosphere
in the team” (C)
The late shift experienced even more pressure because of the need to finish the day
list during that time.
Professional and educational development
Opportunities to increase knowledge of perioperative nursing, at the work place or
with further studies, were a source of job satisfaction and attraction to the work.
“I am learning something new everyday, every case is different.
It is not boring at all” (B).
Lack of support from the hospital with money and time for advanced education was
not an obstacle. Professional and educational development was seen as personal
advancement rather than a means to greater financial rewards. Continuing learning
10
activities such as postgraduate courses provided self satisfaction. The lack of support
from the hospital was not seen as a source of dissatisfaction, it was perceived as ‘the
normal situation’.
DISCUSSION
On the whole, there was an expressed commitment to perioperative nursing. Job
satisfaction was derived by the nurses from being part and essential of the surgical
team. They were proud of being perioperative nurses. And the opportunity to learn
was amazingly important.
The relationships within the team are very important for role perceptions and related
responsibilities. Motivation to work in the surgical team was an important factor in
job satisfaction.
These participants discussed the poor relationships between nurses and doctors. The
main source of job dissatisfaction was not being treated respectfully by surgeons,
what was also a cause of stress in an already physically and psychologically
demanding work environment (Fox 2003). This situation creates a tense atmosphere
where nurses cannot provide good care to the patients. However, Tanner & Timmons
(2000) argue that the relationship between medical and nursing staff in theatre is
usually friendly. But, McNeese-Smith’s study (1999) supported this research where
nurses continue complaining about rude physicians.
The interviewees were dissatisfied by working under constant pressure. These
findings were similar to the ones found by Allen & Beyea (2002). According to
Wicker (1997), cancelling operations to work more relaxed is an important source of
satisfaction.
Salary was not perceived as a key source of dissatisfaction. This may be due to their
acceptance that nursing staff are generally regarded as low-paid despite their
responsibilities, skills and qualifications (Shields & Ward 2004). However, in other
studies, such as Tovey & Adams’s study (1999), low pay appeared to be related to job
dissatisfaction.
Learning was a main source of satisfaction. Professional development was valued
despite receiving no support or compensation from the hospital and without any
improvement at work conditions. These nurses were not valued for their advanced
11
professional development and did not have any opportunity for promotion once
further qualifications were achieved. However, in other studies the lack of support for
further education, and little opportunity for promotion seem to be particularly
demoralizing (Callaghan 2002). In this study, lack of promotion was not a major
concern.
Some findings here support other studies, like work location close to home as
contributing to job satisfaction (McNeese-Smith 1999) or increased paperwork, being
frustrating to nurses (Tovey & Adams 1999).
Poor morale leading to job dissatisfaction among nurses has been reported in many
studies (Tovey & Adams 1999, Callaghan 2002, Shields & Ward 2004). However, the
morale of the interviewees was quite high. They could not do anything else that
satisfies them more than theatre nursing, similar to findings from the Spanish study of
Prieto-Rodriguez (2005). This does not reflect the negative experiences of nurses
from other studies (Lu et al 2005).
The interviewees were proud of being theatre nurses, they liked their specific
functions and roles, which they reported to be professionally rewarding. For the
interpretation of these results, it is important acknowledge the environment where
these nurses worked. They concentrated exclusively on nursing functions: e.g. they
did not have to mop the floor, did not have to tidy and restock the theatre, pushing
trolleys, moving heavy equipment from theatre to theatre, etc. These non-nursing
functions are the types of issues that can interfere with job satisfaction. These types of
tasks do not require highly qualified staff. Perhaps that is the reason why a shortage of
nurses was not perceived in this study, unlike most other countries (Tovey & Adams
1999), despite Spain having one of the lowest densities of nurses in the developed
world (WHO 2004).
Job insecurity has been seen as the main source of dissatisfaction. It seems that the
participants with no permanent employment contracts appear more dissatisfied, their
main concern is the difficulty securing a full time and permanent position. This
finding was supported by other studies (Tovey & Adams 1999, Callaghan 2002).
LIMITATIONS
Because this is an exploratory study, the results can only reveal the participant’s
perceptions of job satisfaction at the time of the study and the findings may not be
12
transferred to perioperative nurses from other hospitals. However, these findings
could serve to enhance understanding of job satisfaction in perioperative nurses.
It could be argued that this study may be open to researcher bias. However, awareness
of the importance of bracketing researcher preconceptions and beliefs in a
phenomenological study ensured receptiveness to the participants’ descriptions of
their experiences.
IMPLICATIONS
The findings of this study add insight into perioperative nurses’ perceptions of their
work and betters our understanding of the factors that produce them satisfaction and
dissatisfaction.
Some findings from this study were similar to those from other countries: work
conditions, work pressure, salary. However, regarding level of satisfaction,
perioperative nurses seemed to be significantly more satisfied with their jobs than
participants from many other overseas’ studies, which show low levels of job
satisfaction. In addition, lack of staff was not perceived as a factor influencing the
perceptions of the respondents. Therefore, these findings might be used as a guideline
for developing strategies to increase level of job satisfaction among perioperative
nurses.
CONCLUSION
Despite the paucity of research on job satisfaction among perioperative nurses, these
data appear fairly consistent in identifying job satisfaction as substantially impacting
job performance and well-being of the nurse.
It seems that job satisfaction would increase recognising the essential role of the
theatre nurse, keeping the workplace challenging and interesting, enhancing job
security and improving the relations between surgeons and nurses. Supporting further
education would lead to job satisfaction too.
If the perioperative nurses were highly satisfied, they would be more efficient, the
organisation, more productive and patients would have better outcomes. This study
could also support those stating the strong relation of job satisfaction with turnover.
Given the importance of job satisfaction in perioperative nurses, this subject should be
of great concern to any organization, educators and researchers. Therefore, results
from this study should be challenged by future research.
13
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organizational characteristics Journal of Advanced Nursing 32 (3) 536-543.
Allen SL, Beyea SC 2002 The health care worker: nurses offer their perspective
Bulletin of the American College of Surgeons 87 (6), 8-12.
Blegen MA 1993 Nurses’ job satisfaction: a meta-analysis of related variables
Nursing Research 42 (1) 36-41.
Bogdan R, Biklen S 1998 Qualitative research for education: an introduction to
theory and methods Boston, Allyn & Bacon.
Callaghan M 2002 Nursing morale: what is it like and why? Nursing and Health Care
Management Issues 42 (1) 82-89.
Colaizzi PF 1978 Psychological research as the phenomenologist views it. In R Valle
and M King (Eds.) Existential phenomenological alternative for psychology New
York, Oxford University Press.
Creswell JW 1998 Qualitative inquiry and research design: choosing among five
traditions Thousand Oaks, Sage.
Fox R 2003 Perioperative nurses’ responses to workplace stress ACORN 16 (4) 26-31.
Holloway I, Wheeler S 2002 Qualitative research in nursing. 2nd ed. Oxford:
Blackwell Science.
Kalideen D 1994 Why nurses choose theatre nursing British Journal of Theatre
Nursing 3 (10) 16-25.
Lu H., While AE, Barriball, K 2005 Job satisfaction among nurses: a literature
review. International Journal of Nursing Studies, 42 (2) 211-227.
McNeese-Smith DK 1999 A content analysis of staff nurse descriptions of job
satisfaction and dissatisfaction Journal of Advanced Nursing 29 (6) 1332-1341.
Merriam SB 1998 Qualitative research and case study applications in education. San
Francisco, Jossey-Bass.
Misener TR, Haddock KS, Gleaton JU, Abu Ajamieh AR 1996 Toward an
international measure of job satisfaction Nursing Research 45 (2) 87-91.
Mueller CW, McCloskey JC 1990 Nurses’ job satisfaction: a proposed measure
Nursing Research 39 (2) 113-117.
Newman K, Maylor U 2002 The NHS Plan: nurse satisfaction, commitment and
retention strategies Health Services Management Research 15 93-105.
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Nolan M, Nolan J, Grant G 1995 Maintaining nurses’ job satisfaction and morale
British Journal of Nursing 4 (19) 1148-1154.
Parahoo K 1997 Nursing research: principles process and issues London, Macmillan.
Polit D, Hungler BP 1999 Nursing research: principles and methods 6th ed.,
Philadelphia, Lipincott.
Prieto-Rodriguez MA 2002 Employment relations in nursing (Spanish) Metas de
Enfermeria 5 (43) 62-65.
Shields MA & Ward M 08-12-2004 Improving nurse retention in the British National
Health Service: the impact of job satisfaction on intentions to quit (accessed: 03-01-
2005) available: ftp://repec.iza.org/RePEc/Discussionpaper/dp118.pdf
Stamps PL, Piedmonte E 1986 Nurses and work satisfaction: an index for
measurement Michigan, Health Administration Press.
Tanner J, Timmons S 2000 Backstage in the theatre Journal of Advanced Nursing 32
(4) 975-980.
Tovey EJ, Adams AE 1999 The changing nature of nurses’ job satisfaction: an
exploration of sources of satisfaction in the 1990s Journal of Advanced Nursing 30
150-158.
WHO/EIP/HRH 2004 Global atlas of the health workforce. Geneva, World Health
Organisation.
Wicker P 1997 Retaining and recruiting perioperative nursing staff Nursing Standard
12 (3) 42-43.
THE TREATMENT OF A FALLOT OF TETRALOGY
By Lynda Bleazard and Dr Robin Kinsley
This article first appeared in the SATS Journal Volume 32 Issue 2, June 2007
INTRODUCTION
The Walter Sisulu Paediatric Cardiac Centre for Africa (WSPCCA) - based at Netcare
Sunninghill Hospital in Johannesburg - is a non-profit organisation, established under
the patronage of former State President, Nelson Mandela in November 2003, as a
living tribute to the late Walter Sisulu.
The WSPCCA’s primary aim is to provide surgical intervention and treatment to the
countless children born with correctible cardiac conditions on the African continent
who do not have access to either the funds to pay for the surgery, or the means of
accessing that intervention.
One in 100 children born worldwide suffers from a correctible cardiac problem, but
less than 1% of African children have access to healthcare insurance. The WSPCCA
is a totally self-funding, self-sustaining organisation that raises funds to perform these
life-saving interventions. The Centre also ensures that, as funds become available,
these procedures are carried out in one of the most modern, advanced cardiac
facilities available - worldwide.
This article details the life-saving intervention provided to one of the children from
Rwanda whose operation was successfully undertaken and fully sponsored by the
WSPCCA.
CASE STUDY
Jovanissi Gatesi as born in Rwanda on 30 October 2005, following a term pregnancy.
She had a birth weight of 3.2kg and there were no neonatal problems. Her cardiac
problems were first discovered at three months of age, when she presented with
lethargy and coughing.
Jovanissi was a breastfed infant who drank fairly well but was subjected to bouts of
sweating, panting and coughing. In addition, her weight gain was slow and she had to
be admitted to hospital on three occasions since birth. Her developmental milestones
were normal - she sat at seven months and had started crawling - when she was
presented to the WSPCCA in August 2006.
Examination:
On examination, the patient weighed 6.9kg
but appeared wasted. She was acyanotic
with no signs of right-sided heart failure.
Jovanissi
pre-surgery
Pulses were all present and equal and, surprisingly, were easily palpable throughout
the examination. The apex beat was displaced outside the mid-clavicular line in 4LIS.
S1 was normal, with S2 narrowly split. A 3/6 aortic ejection systolic murmur was
heard. The murmur radiated widely throughout the praecordium and, in fact, was best
head in 2LIS. The chest was clear to auscultation and no significant visceromegaly
was detected.
Electrocardiogram:
This showed features suggestive of mirror-image dextrocardia with inverted P-waves
in V1 and upright in aVR. The heart rate measured 110/min. The mean frontal QRS
axis was +80o when P-wave axis was +240o. A paucity of right ventricular forces
was seen with voltage criteria suggestive of left ventricular enlargement. No strain
pattern was seen. T-waves were inverted over the right-handed praecordial leads.
Echocardiogram:
A situs solitus was present with levocardia and evidence of both atrio-ventricular and
ventricular-arterial concordance. The inferior vena cava was interrupted with
hemiazygos continuation. The left-sided superior vena cava was not seen and a large
right-sided superior vena cava drained into the right atrium. Pulmonary venous
drainage was normal. The atrial septum bulged into the right side and no atrial septal
defect was seen. The ventricular septum was intact. The mitral valve was normal with
mitral annulus of 13mm. No gradient or regurgitation was recorded across the mitral
valve.
Marked concentric left ventricular hypertrophy was present with septum measuring
12.4mm and left ventricular posterior wall 9.6mm. The left ventricular size was
normal with end-diastolic diameters of 23.5mm and 13.9mm, shortening fraction 41%
and ejection fraction of 0.74. The left atrium was also enlarged with LA: Aortic ratio
of 1.6:1.
A moderately tight subaortic membrane was noted with a gradient of 100mHg to
120mmHg was recorded across the outflow tract. The aortic valve was bicuspid and
commissures in the coronal plane. The anterior leaflet was thickened with the
posterior leaflet immobile.
Fusion of the leaflets occurred on the right side. Mild aortic regurgitation was present.
Post-stenotic dilatation of the ascending aorta was present. The aorta arched to the left
side, and no coarctation was present. A small to moderate patent ductus arteriosus was
detected with left to right shunting. The right side of the heart was normal and no
signs of cardiac failure were detected.
Assessment:
This nine-month-old infant girl has a subaortic membrane together with a bicuspid
aortic valve with a significant gradient across the left ventricular outflow tract and
mild aortic regurgitation. In addition, there is marked concentric left ventricular
hypertrophy. A small to moderate sized patent ductus arteriosus is also present.
Surgical excision of the subaortic membrane, together with an aortic valvotomy and
septal myectomy, is indicated together with ligation of the patent ductus arteriosus.
This will be performed at the Sunninghill Hospital.
PROCEDURE
Diagnosis: Subaortic LV outflow tract stenosis
i) Subaortic membrane
ii) Severe LVOT muscular hypertrophy - hypertrophic obstructive
cardiomyopathy - acquired
iii) Absence of the IVC
iv) Left Atrial Isomerism
Operation: Resection of the subaortic stenosis
i) Resection of the Subaortic Fibrous Membrane
ii) Extensive Subaortic Muscular Resection
Surgeon: Dr Robin Kinsley
Assistant: Dr Hendrik Mamorare
Anaesthetist: Dr N Els
Procedure:
The patient was subjected to a pre-operative echocardiograph. A severe LV outflow
tract gradient was demonstrated. It was considered that the aortic valve was probably
bicuspid with an eccentric left sided opening. However, there was a definite subvalvar
membrane and the IVOT was markedly thickened with muscular hypertrophy - the
ventricular septum was 12mm thick. It was, therefore, decided that the patient had
severe subvalvar aortic stenosis - both muscular and fibrous - with a bicuspid aortic
valve. This diagnosis was not absolutely correct.
A mediansternotomy was performed. The pericardium was opened. A small segment
of pericardium was removed in the event that it should be required for the repair. The
right pleural cavity was opened. A large thymus gland was removed. The ascending
aorta was slightly dilated and elongated. Marked muscular hypertrophy was present in
the left ventricle. Prominent coronary arteries were also noted. There was obviously
left atrial isomerism. The right sided appendage had a left atrial configuration.
Cardiopulmonary bypass was instituted with a size 10 DLP cannula in the ascending
aorta and a single venous drain. The patient was cooled to 25oC. The aorta was crossclamped
and cardioplegia was infused. A vent was inserted in the left atrium via the
right superior pulmonary vein. Initially the aorta was transsected just above the aortic
valve. The aortic valve itself was not stenotic. There were three cusps with a smallish
non-coronary cusp. The anterior right coronary cusp was perhaps the largest cusp.
However there was no stenosis of the aortic valve. In saying that, deep to the valve
there was a very tight fibro-muscular stenosis. There was a fibrous membrane and a
massive muscular hypertrophy.
The membrane was excised together with an enormous amount of muscle. After the
resection, a 10mm Hegar’s dilator could be squeezed into the LV cavity. This was a
good relief of the obstruction and the aorta was then reconstituted. The patient was
rewarmed and cardiopulmonary bypass was gradually discontinued without much
difficulty.
Bypass time was 52 minutes. The aorta was cross-clamped within 39 minutes. A
single dose of cardioplegia was administered. The pericardium was partially closed
superiorly. Drains were inserted in the pericardial cavity, the right chest and the
mediastinum. The chest was closed in the routine manner.
Jovanissi post surgery.
Permission was received by the patient’s mother for her name to be mentioned and
pictures to be shown in the SATS and IJPC Journals.
About the Authors
Lynda Bleazard
ACADEMIC QUALIFICATIONS
Diploma in General Nursing, 1981 with Honours
Diploma in Midwifery, 1982 with Honours
Diploma in Neo-natal/Paediatric ICU, 1985 with Honours
Diploma in Community Health Science, 2000
Diploma in Health Science Education, 2001
B Curr Degree in Health Science Education and Community Health Service and
Occupational Health and Safety, 2006
CURRENT POSITION HELD
Chief Executive Officer of the Walter Sisulu Paediatric Cardiac Centre for Africa
ACADEMIC AWARDS
General Nursing Gold Medal Award for Honours in all subjects, 1982
Midwifery prize for Best Student, 1983
Neo-natal ICU Best Student award, 1985
Child Accident Prevention Foundation award for commitment to Child Safety,
2001/2
POST GRADUATE EXPERIENCE
2000 to 2004, Marketing Manager, Netcare Olivedale Clinic, in Johannesburg,
1997 to 1999, Chief Professional Nurse in charge of Neo-Natal ICU, Paediatrics and
Maternity at Netcare Olivedale Clinic in Johannesburg
1995 to 1997, co-owned a crèche with 30 babies aged from birth to 2,5 years old
1987 to 1993, deputy (part-time) NICU Unit Manager at Sandton Clinic in
Johannesburg
NAME
Robin Howard Kinsley
CURRENT POSITION HELD
Head Cardio-thoracic Surgeon at the Walter Sisulu Paediatric Cardiac Centre for
Africa, based at Netcare Sunninghill Hospital in Johannesburg, South Africa
Jovanissi, 5
days post
surgery.
ACADEMIC QUALIFICATIONS
MBBCh (University of Witwatersrand) 1963
FCS (South Africa) 1968
FACC
ACADEMIC AWARDS
Medical Graduates Association Prize, 1963 for best student in Medicine
(undergraduate)
Glaxo-Allenbury’s Prize for Surgeons-in-Training, 1967
Jamie Miller Prize, 1968, for best surgical student from the University of
Witwatersrand for the year (post graduate)
Cecil John Adams Travelling Fellowship, 1972
POST GRADUATE EXPERIENCE
1972 - 1973 Cardiac Surgery Trainee at Mayo Clinic Rochester, Minnesota, USA
1974 – 1977 Consultant Cardio-Thoracic Surgery – Dept Cardiothoracic Surgery
University of Witwatersrand
1986 – 2002 Cardio-Thoracic Surgeon at the Morningside Medi-Clinic
January 2003 to date Head Cardio-Thoracic Surgeon at the Walter Sisulu Paediatric
Cardiac Centre for Africa, based at Sunninghill Hospital
Asked to join the Constitutional Council for the World Society for Pediatric and
Congenital Heart Surgery, and delivered a paper on TOF in Developing Nations at
the inaugural meeting of the World Society for Pediatric and Congenital Heart
Surgery in January 2007
* * *
Patron Nelson Mandela
Walter Sisulu Paediatric Cardiac Centre for Africa
THE WALTER SISULU PAEDIATRIC CARDIAC CENTRE FOR AFRICA
On 07 November 2003, under the patronage of our former president Nelson ‘Madiba’
Mandela, the Walter Sisulu Paediatric Cardiac Centre for Africa (WSPCCA) located at
Sunninghill Hospital in Johannesburg opened its doors with a mission to successfully provide
treatment and expert medical care to all children on the continent of Africa suffering from
correctible heart disease. Today, almost all cardiac conditions in children can be corrected
- or at least well palliated. Tragically, due to a lack of funding, only a small fraction of the
children of Africa receive corrective cardiac surgery - should they require it.
In the USA, 1 222 patients per million of the population have open-heart surgery. In Africa,
the figure is only 19, with the majority of operations being undertaken in South Africa. In
addition, 95% of heart defects in babies and young children can be treated and, after
undergoing treatment, these children can go on to live healthy, normal lives. This reflects
how many patients - in Africa as a whole - are in need of palliative care, but cannot obtain
these life-saving procedures.
Operating under the expert guidance of Dr Robin Kinsley, the team at the WSPCCA is
working tirelessly to correct that imbalance – but the issue of payment for surgeries for the
children is on going. The surgeons at the WSPCCA have reduced their fees dramatically and
the average operation now costs only R140 000-00 per patient. But, the centre is a
privately-run unit and receives absolutely no government assistance. The result is that it
needs to be totally self-sustaining and self-funding.
The centre currently sponsors about 40 operations per year at a cost of around R5,6-million
while undertaking an additional 400 cases covered by medical aids. Their goal is to perform
as many sponsored operations per year as those paid for by the medical aids - and that
number could still grow to 800 cases a year.
2
Organisational structures and mechanisms for governance
Legal status – Registered as Walter Sisulu Paediatric Healthcare Foundation IT 8161/05 and
NPO number 045874.
South African Revenue Services (SARS) 18A tax exemption in terms of which – according to
the Act - The public benefit organisation has been approved for purposes of section 18A (1)
(a) of the Act and donations to the organisation will be tax deductible in the hand of donors
in terms of and subject to the limitations prescribed in Section 18 A of the Act.
Auditors - KPMG
Powers of the organisation
Patron: Former State President, Mr Nelson Mandela
Board of Trustees:
Founding Trustee: Mrs Albertina Sisulu (wife of Walter Sisulu)
President: Mr Lungi Sisulu (son of Walter Sisulu)
Chairman: Judge Merwyn King
Trustee: Minister Lindiwe Sisulu – (daughter of Walter Sisulu)
Trustee: Dr Robin Kinsley – Cardiac-Thoracic Surgeon (Sunninghill Hospital)
Trustee: Mrs Lynda Bleazard – CEO of the Walter Sisulu Paediatric Cardiac
Centre for Africa
Trustee: Mr Norman Weltman – Retired Businessman
Trustee: Mrs Jenna Clifford – Business Woman
To date, 130 surgeries have been performed on children through the WSPCCA Trust,
facilitated by the generous donation of companies whom we have called the South African
Friends of the Walter Sisulu Paediatric Cardiac Centre for Africa. Our current South African
Friends include Barclays, ABSA Foundation, Vodacom Foundation, Telkom Foundation,
Transnet Foundation, Xstrata, Bayer Healthcare, Netcare and Johnson & Johnson who have
all pledged amounts varying between R1-million and R100 000.00 per annum over a three
year period.
Banking Details
Trust Fund Account Details
Name: The Walter Sisulu Paediatric Healthcare Foundation
Bank: Nedbank Sandown
Branch code: 193305
Account number: 1933 199 881
Walter Sisulu was a remarkable servant of South Africa and the African continent. As
Madiba wrote in the foreword of the book In Our Life Time, ‘Walter Sisulu’s life embodied
selflessness, the best, the noblest, the most heroic and most deeply humane. He had a
passion for the youth and for justice.’ What better way to honour his memory than through
a paediatric cardiac surgical centre for the continent of Africa? Innumerable African
children, surviving into adulthood after corrective cardiac surgery, will one day be able to
3
stand up proudly and say: ‘I was cured at The Walter Sisulu Paediatric Cardiac Centre for
Africa’.
And as Madiba said in his address at the opening of the WSPCCA: “The Walter Sisulu
Paediatric Cardiac Centre for Africa is an initiative that deserves the support of all of us -
private and corporate. The centre needs financial as well as moral support. I trust that the
private sector shall respond as generously in support of this centre as I have always found
them to do when I called upon them for support.”
The WSPCCA wants to make a real difference to the lives of cardiac children on the African
continent. To be successful it will require substantial financial assistance.
For more information, visit www.wspcca.org.za
This is your page to identify items of clinical or managerial topical interest in
perioperative care. Contributions for future issues should be sent to the editor, please.
Contribution 1 from UK
Safer anaesthesia for morbidly obese patients
Britain’s obesity epidemic is causing problems for hospitals that are not kitted out to
cope with the needs of this particular patient group.
New guidelines from the Association of Anaesthetists of Great Britain and Ireland
suggest that hospitals haven’t put plans in place to deal with the needs of morbidly
obese patients—not only with equipment but also with their treatment and care. They
warn it isn’t enough to see and treat morbidly obese patients as simply larger or
heavier than non-obese patients as they have specific health and safety needs.
Absence of planning for these patients is putting patient safety at risk.
‘Obesity is now a problem that is presenting itself to every hospital in the country, not
just a few and not just occasionally,’ said Dr William Harrop-Griffiths of the
Association. ‘Our fear is that there are many hospitals out there that do not have plans
or the equipment for treating people of these sizes and patient safety is at risk.’
The new guidance (5) recommends:
? All patients should have their height, weight and body mass index (BMI)
recorded.
? Every hospital should have a named consultant anaesthetist and a named
theatre team member to ensure equipment and processes are in place for
perioperative management of morbidly obese patients.
? Every hospital providing surgery should have one theatre and several critical
care beds equipped for morbidly obese patients. All beds, trolleys and operating
tables should be clearly marked with maximum weight loads.
? Items such as larger gowns, stockings, blood pressure cuffs and tourniquets
should be available.
? Other special equipment should also be available in all hospitals.
Contribution 2 from UK
What’s stopping the hand washing?
Psychologists have been asked to find out what’s stopping Scottish NHS staff washing their
hands. The work is part of a new research network, launched this week in Scotland, to
improve the quality and quantity of research into healthcare-related infections.
The Scottish Infection Research Network (SIRN) is based at Glasgow University. It will bring
together experts to:
? investigate the causes of hospital infections
? search for new treatments
? devise effective programmes for changing NHS staff behaviour.
Changing behaviour is key to winning the battle against the superbugs, which in Scotland
affect 1 in 10 patients in acute care. Behavioural psychologists are joining the
multidisciplinary initiative to find out what stops clinical staff using alcohol handrub between
each patient contact and to devise new ways of supporting compliance with hand hygiene.
Handwashing is effective against the spread of infection in hospitals. Yet current research
suggests that NHS staff only wash their hands between patient contact only 70% of the time.
SIRN’s director, Dr Alistair Leanord, said they already had some ideas why staff did not
always clean their hands. ‘Some of it is to do with time and some of it is to do with the
facilities but even once that is taken account of there is still a behavioural imperative that
needs to be looked into and this is an area that has not yet been explored.’
Professor Peter Davey, infectious disease expert, said barriers to changing behaviour
included recognising the problem and convincing people it was possible to make
improvements.
Contribution 3 from Canada
OCTOBER 8- 13 2007
Building on the success of last year's campaign, the CPSI and the CPSW
Advisory Committee are looking forward to an even more exciting Canadian
Patient Safety Week 2007. This year the committee chose a theme that
applies to many healthcare settings and that builds on a fundamental and
key element – communication – between and among patients, clients,
consumers and caregivers. Our theme this year is:
Patient Safety: Be Involved. Ask. Talk. Listen.
Contributions to this page are very welcome, to add to general interest health topics
which may have future impact on perioperative practice. Please send your
contributions, questions and snippets from health press and journals, or tell us about
useful websites!