Staff nurses rn rn can inspire

OR changes Mary Lou Sullins, RN

Mary Lou Sullins, RN, MM, is an operating room staff nurse and educational coordinator in Hastings, Neb. She earned her MEd degree at Colorado State University, Fort Collins, and her BSN at Baylor University School of Nurs- ing, Dallas.

The author wants to acknowledge the help of Lt Col Sue Buchanan, USAF, in developing ideas for changing organizations.

Nurse A just contaminated her glove in- traoperatively. Her gloves are removed by Nurse B, the circulator. As Nurse A begins to don her gloves using the closed gloving method, Nurse B says, rrYou can’t do that. The cuffs on your sleeves are contaminated. You have to use the open gloving method.” Nurse A replies, ‘T have always done it this way and be- sides, now is no time to correct me.”

This scene between two nurses working together in the operating room is not uncommon. OR staff nurses need a sys- tem to vent their ideas. It would be rare for an OR nurse to be in a setting where all of her values of style, approach, and technique are followed. Yet, during the operative procedure is hardly the ap- propriate time or place to hash out opin- ions and variations about technical skills.

The staff nurse does not always have an avenue for suggesting change. A leading cause of job dissatisfaction among nurses is the lack of input they have into issues that concern them. There are, however, ways to design a system whereby the staffnurse can em- ploy a rational approach to reviewing practices in her work setting. By under- standing the elements of change and using a problem-solving approach, the staff nurse can affect change within a department. Use of some well-known management principles can provide groundwork for implementing effective changes.

Organizational development is con- cerned with planned change in complex organizations. Management specialist Fred Luthans states that the major aim of organizational development’s efforts is the development of an organi- zation’s human resources and its im- proved performance.’ One approach is team building. The advantages of this approach, according to Luthans, are those also attributed to teamwork, ie,

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e wanted our W proposed changes to be understood.

the process creates a team effort under an open, participative climate? The fol- lowing is an example of the use of team building and staff development as an approach to changing methods in an operating room.

Patient care can be upgraded when technical variations are brought to the attention of all concerned. Nurses at Poudre Valley Memorial Hospital, Fort Collins, Colo, agreed to form an avenue for problem solving. Through a formal committeee, we could list areas of con- cern, review rationale for our approach, compare our method to national stan- dards, then evaluate our actions. Once the evaluation was complete, we could direct our rationale for change through management channels. Hence, we be- gan our Standards Review Committee.

Most often the discrepancies brought to the Standards Review Committee were variations in the way a peer, sur- geon, or manager approached a tech- nique. The staff nurse who viewed the discrepancy as an interruption in the work flow would usually describe the happening as a less than ideal tech- nique. It is often easier to overlook a small discrepancy than to confront the issue, especially during a busy case. In- terruptions at the time of the grey area of performance could be more disruptive than worthwhile, so the observer often elects to say nothing. Furthermore, bringing it up after the procedure may seem to be a petty interaction between

two experienced OR nurses. As staff nurses, we wanted manage-

ment and physicians to understand our philosophy for any proposed changes. We adopted a philosophy assuming management expects professionals to identify potential causes of nosocomial infections. We prefaced our reports with the following statement: “We will as- sume that as our proposals are not im- pertinent in intent, likewise that our observations will be objectively consid- ered in regard to upgrading patient care.’’

Once administration accepted our philosophy, we structured the commit- tee. Membership consisted of four staff nurses who agreed to work on two pro- posals. We also included an OR adminis- trator for support and assistance with implementation of proposed changes. While the number of committee mem- bers was small enough to be effective, we extended an open invitation to all staff to spur interest and provide a means of modeling committee functions to potential members.

Selecting a chairman for each project was our first order of business. We tried to meet every two weeks, and our goal was to complete each project before be- ginning a new one. While initiative was high, we were careful to select minor projects that had a reasonable chance for results. For example, we knew that any major OR restructuring proposal would be too major a project and ulti-

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mately unrealistic. Such proposals for change would not only threaten the or- ganization but also frustrate the com- mittee. Request for change involving major financing, ie, purchase of new equipment, was an area to avoid.

One of the first discrepancies brought to the attention of the Standards Re- view Committee was the fact that some surgeons did not remove glove powder from their gloves before a surgical pro- cedure. Some staff nurses knew that rinsing was the manufacturer’s sug- gested practice. The committee did a lit- erature search of the principles and causes of starch granuloma. The surgi- cal staff and operating room manage- ment staff received a memo from the committee stating its concern, ration- ale, and suggested method to rinse gloves. Time was allowed for staff re- sponse. With staff approval, the sug- gested practice became policy.

Another example of a change insti- tuted by the Standards Review Com- mittee concerned the storage of sterile supplies. For years, the supplies were wrapped in cloth and stored in open shelves in busy hallways. Nurses famil- iar with the AORN recommended prac- tices wanted to upgrade this situation. The committee reported on the differ- ence between present practice and rec- ommended practice. We suggested ways to use closed storage areas in less busy areas, and the plan was implemented.

Our committee’s success was a result, in part, of understanding reasons for human resistance to change. They are insecurity, economics, and sociopsy- chological factor^.^ Insecurity is the most obvious resistance factor; change is often seen as a threat to security. There are perceptual, emotional, and cultural barriers to change. With each project, we were sensitive to these natural reactions to our proposals.

In the team building process, organi- zational development management ex-

pert Kurt Lewin describes the classic change procedure in three steps: un- freezing, moving, and refreezing. 1. Unfreezing. The first task is to

make the team aware of the need for change. A climate of openness and trust is developed so that the group is ready for change.

2 . Moving. Basically using a survey- feedback technique, the team evaluates their present actions and develops specific plans to reach their goals.

3. Refreezing. Once the plans have been carried out and evaluated, the team starts to stabilize into more effective perf~rmance.~

Our committee was careful to discuss topics before we attempted to facilitate change. We viewed this as unfreezing. After careful research and determina- tion of feasible implementation within our department, the committee de- veloped proposals for change. Our plans consisted of a report, complete with rationale, which we addressed to those who would be affected by the change.

The formal committee established well-defined goals and measurable ob- jectives, stated functions of members, and took minutes of committee activi- ties. Our efforts were reinforced as we read how another group of OR nurses turned vented criticism into construc- tive change through formation of a committee.5 Like our committee, these nurses demonstrated how staff nurses can use committee structure to resolve work issues.

Through group efforts, we began sev- eral projects. We started by providing rationale for clean mopheads to clean the floor between each case. We in- cluded a thorough study of cost and aseptic implications. We then ap- proached the topic of starch granulo- mas. As our credibility for providing facts increased, we tackled the problem of revising paperwork to provide nurses

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with more t ime for patient care. The OR director appreciated our ef-

forts, She v iewed o u r ac t i v i t ies as watchdog efforts for trouble areas. Sur- geons responded with increased aware- ness o f our professional concern. They never argued with our proposals when presented with rationale. The depart- ment benefited f rom standardization, and the staff nurses had a system to implement change.

A standards review committee i s not a substitute for a quality assurance pro- gram. In fact, Poudre Valley Memor ia l Hospital has now decided that the i r standards committee can combine i t s objectives with the i r audit committee. Now that staff members realize they have a direct route for ideas, comments,

and complaints, they have gained the self-assurance to vent the i r suggestions and concerns to the more regimented audit commit tee. Any depar tmen t wi thout a comfortable avenue for the individual s taf f nurse t o speak o u t might consider a standards committee. The committee structure offers a n or- ganized approach to uniting the many voices that can exist in every operating room department. 0 Notea

York: McGraw-Hill, 1977) 529. 1. Fred Luthans, Organizarional Behavior (New

2. Ibid, 547. 3. Ibid, 532. 4. /bid, 546. 5. Ann E Hett, Elizabeth Fahey McDevitt, Eleanor

M Toohey, “OR nursing committee works for change,” AORN Journal 31 (March 1960) 701-706.

Rhinoplasty patient contracts toxic shock It has been reported for the first time that a woman contracted toxic shock syndrome after undergoing a normal rhinoplasty procedure. About 12 hours after surgery, the woman developed symptoms of toxic shock syndrome and laboratory tests confirmed the presence of Staphylococcus aureus. Stephanie W Thomas, MD, who reported on the case at Riverside Methodist Hospital, Columbus, Ohio, believes this case lends credence to the hypothesis that packing a body cavity with sterile gauze predisposes the patient to development of toxic shock. The woman recovered but experienced peeling of the skin on her hands, according to Dr Thomas’s report in the Journal of the American Medical Association.

reported that since April 9, 1982, there have been 1,660 cases of toxic shock, meeting the CDC definition of that syndrome. Of those cases, 96% involved women, and 92% of the women had an onset of toxic shock syndrome during menstruation. Nonmenstrual-related cases

The Centers for Disease Control (CDC)

have been reported following childbirth, infection of surgical wounds, hydradenitis, lymphadenitis, deep abscesses, and infected cutaneous and subcutaneous lesions.

Physicians want laws punishing drunk drivers Removal of drunk drivers from US hjghways is the aim of a policy statement recently adopted by the American College of Emergency Physicians (ACEP).

ACEP President B Ken Gray, MD, said the organization supports “legal repercussions, such as suspension of the driving license or a jail term for the drunk driver.“

Gray adds that ACEP thinks these actions “should be combined with mandatory rehabilitation programs.”

According to ACEP, more than 25,000 Americans are killed and 750,000 are seriously injured each year as a result of drunk driving incidents.

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