preoperative visits: the or nurse unmasks

Private scrub nurses as well as hospital-employed OR nurses make pre and postoperative visits. Rose Mary Smith, RN, left, is a scrub nurse for a chest and heart surgeon in Denver.

Preoperative visits: The OR nurse unmasks Carol Alexander, RN, MS flinor Schrader Julie Kneedler, RN, MS

I want to find out why we should do preoperative visits when so many others come to see the patient. The patient has so many visitors he doesn’t get any rest.

Participant, AORN preoperative seminar

Should the operating room nurse leave the confines of the operating room suite to visit surgical patients before and after their operative procedure ?

AORN’s answer is an emphatic yes. The definition of professional operating room nursing, adopted by the House of Delegates in 1969, includes this statement:

The objective of the clinical practice of professional operating room nursing is to provide a standard of excellence in the care of the patient before, during and after surgical interven- tion.’ To achieve this, the OR nurse

identifies the physiological, psychological and socio-cultural needs of each patient, and develops an indi- vidualized nursing care plan. This means the OR nurse should see the patient before he comes to the OR. It is equally important that she see the patient following surgery to evaluate the effectiveness of her nursing care.

AORN Journal, February 1974, Vol 19, NO 2 401

Last year, the objective of providing efficient patient care by engag- ing in preoperative and postoperative visits was reiterated in the statement approved by the House of Delegates on the necessity for the registered nurse in the operating room.2

Yet despite these statements, ap- parently relatively few OR nurses are making pre and postoperative visits on a regular basis. Some are reluc- tant to leave the OR suite where they feel secure. They avoid face-to- face contact with the patient which may make them uncomfortable. Others are interested in making visits, but do not know how to establish a program or overcome the resistance they may encounter from physicians and even fellow nurses.

More encouraging however, AORN believes that the number of preoperative and postoperative visiting programs is increasing. Many have bee? stimulated by the AORN educational seminars on preoperative and postoperative visits. Because of the interest, these seminars will be offered again in 1974.

The seminar was originally developed by Mrs Alexander in 1971. As demand increased, Mrs Kneedler be- came the second leader. The present content of the seminars reflects the thinking and experience of both leaders as well as the contributions

Carol Alexander, RN, MS, is AORN director of education. She developed the preoperative and postoperative visit seminars and i s a seminar leader. She has a BSN from the University of Iowa and MSN from the University of Colorado.

Elinor S Schrader, editor of the Journal, i s a graduate of Cornell University.

Julie Kneedler, RN, MS, assistant director of education, is also a seminar leader. She has a BS from W a l l a W a l l a College and MS from Loma Linda University.

of the participants. More than 800 OR nurses have attended the 24 na- tional seminars offered in the past three years, and many others have attended one-day workshops.

During the two-day seminars, participants learn how to conduct preoperative and postoperative visit programs. The leaders also conduct sensitivity exercises to help OR nurses look a t their own feelings, especially those about death and sexuality, often difficult subjects for nurses to cope with in patient interviews.

From the seminar in November, four areas have been selected for this article.

I Why operating room nurses should conduct preoperative visits.

I1 How to set up a program. I11 How to conduct preoperative

visits. IV Why postoperative visits are

important.

Why operating room I nurses should conduct preoperative visits

The preoperative visit gives the OR nurse an opportunity to gather data which she translates into action in the operating room. Primarily, it is an efficient and effective way for the OR nurse to improve patient care in the OR.

Before talking with the patient, the OR nurse reviews the chart, checks the surgical permit, and talks with the floor nurses. During her visit with the patient, she makes ob- servations about the patient’s weight,

402 AORN Journal, February 1974, Vol 19, N o 2

About 70 persons attended seminars on the pre and postoperative visit Nov 6'7 in Honolulu. Due to the large turnout two seminars were presented simultaneously. Shown are seminar leaders, Julie Kneedler, RN, left, and Carol Alexander, RN, below right. Photos: Elinor Schrader.

The seminars include lectures and workshop sessions. Winona N Puha, Arcadia, Calif, takes notes. Victor Pagan, Bronx, NY, left, lists points at a group session.

403

size or any infirmities. This information permits her to plan for effective nursing care in the OR in regard to such things as positioning, instm- mentation and sutures. From her interview she will also make an ap- praisal of what his psychological responses to surgical events will be.

Initially proponents of preoperative visits believed the OR nurse could ally the patient’s anxiety about his impending surgery. This has proved a controversial hypothesis, and research can be cited to support or contradict it. Because of the con- flicting evidence, we have re-exam- ined our thinking and no longer say that preoperative visits will neces- sarily reduce the patient’s anxiety. The OR nurse does, however, assist the patient and his family in managing their anxiety. The emphasis, then, is on managing rather than alleviating anxiety.

Many nurses are convinced that the preoperative visit makes the patient more cooperative and accepting of equipment and procedures in the pre and postoperative period.

The preoperative visit helps the OR nurse provide continuity of care. Through her involvement in the pre, intra, and postoperative periods of the patient’s surgical experience, she is able to coordinate OR nursing care with his other hospital care. She also collaborates with the other members of the OR team to increase the effectiveness of the care rendered by the whole team. Her visit should complement the visits of the surgeon and anesthesiologist, and the floor nurse.

Many OR nurses have expressed concern about legal difficulties they may encounter as a result of what

Objectives of preoperative visits 0 To make a nursing assessment of the physiological, psychological, and sociocultural status of the patient. 0 To increase the effectiveness, efficiency, and safety of nursing care rendered within the operating room. 0 To provide for continuity of care through direct patient contact preoperatively and postoperatively as well as during surgery. 0 To assist the patient and family members with the management of anxiety. 0 To provide information and answer questions about those aspects of hospitalization for which OR nurses are responsible.

To complement the roles of team members in preparing the patient for surgery, thus strengthening interdisciplinary interrelationships and enhancing patient care. 0 To provide a means whereby OR nurses can expand their role and self-insight, thereby increasing self-actualization.

they tell the patient. Although this is a complex question, a good guideline for the OR nurse might be to stay within the framework of nursing care. She should assess the patient’s understanding of the procedure. If

404 AORN Journal, February 1974, Vol 19, No 2

she thinks he should have additional information, she can review the procedure in general, but specific questions about the procedure should be referred to the physician.

In addition to providing better nursing care, the OR nurse benefits from the visits through her own professional development. She has an opportunity to use her nursing skills and knowledge in an expanded role. She is prompted to examine her own response to pain, disfigurement, anger and other areas that increase her self-awareness. This can make her more effective in all her interpersonal relationships. Through postoperative visits, she is able to assess and improve her nursing care. She becomes a more effective member of the OR team because she is involved in working with others outside the OR as well as within.

Increased patient contact gives many OR nurses increased job satisfaction. Patient contact outside the OR should lead to greater patient support within the OR. Nurses are not so’apt to ignore patients waiting for surgery whom they visited earlier. More concern for patients may make OR nursing more ap- pealing to students who sometimes reject OR nursing because they believe it is technically oriented rather than patient-oriented nursing.

There is the other side to preoperative visits, and these are reasons OR nurses cite for not making preoperative visits. Although involvement with patients can be re- warding, it can also be extremely painful, especially if the patient has a terminal illness, or dies.

“We had a program,” one nurse re-

lated at the seminar, “but it fizzled out. On our neurosurgical unit, it was sometimes too depressing to make postoperative visits. Some patients were worse off after surgery.”

“I am afraid of emotional involvement,” confessed another nurse who works in open heart surgery. “We had several children who died. If I get involved, it is very difficult.”

This is a real facet of patient involvement which the OR nurse must accept a s she increases her contact with patients.

The visits also put other demands on the staff. When will the OR nurse find time? Often the visits are done when the nurses are tired after a full day in the OR.

Conflicts occur with other members of the OR staff who see the nurse as infringing on their territory. Even the floor nurse may resent the OR nurse’s visits as an intrusion.

And there may be friction among the OR nurses themselves. One nurse described this experience:

Our nurses who don’t want to do visits resent us. They feel they are left behind to do the dirty work. But they are not, we do that too. They are just sitting in the lounge.

For the OR nurse, preoperative visits are a two-edged sword. They can be an enriching extension of her nursing skills to provide better patient care. At the same time, they may bring her into conflict with others on the staff and also cause her to suffer pain from emotional involvement.

AORN Journal, Februarg 1974, Vol 19, N o 2 405

How to set up a II preoperative visit program

At present we are not doing preoperative visits. Z hope to learn enough to teach the staff nurses.

Z am here to have questions answered. W e are just starting a program.

Although some participants were making preoperative visits, many were at the seminar because they wanted to learn how to establish a program in their hospital.

We stress that the first step is to develop a philosophy of OR nursing. This should be done within the nursing group, involving as many as possible. The group should discuss the underlying concepts of the preoperative visit program. Preoperative visits should be defined as nursing action resulting in better nursing care in the OR.

It is important to write out the nursing philosophy and program objectives. One of the primary reasons programs fail is because OR nurses do not justify preoperative visits as nursing action. Often they prema- turely seek approval by other disciplines of a partially formulated program. Such a practice can defeat a program. OR nurses must assume the responsibility of defining nursing in their specialty instead of allowing other disciplines to tell them what they can or cannot do. Their definition must be based upon documenta- tion whenever possible.

The next step is to talk to the nursing director or administrator in

charge of the OR and present why you are implementing the program based on a philosophy of OR nursing care. Since preoperative visits are nursing action, it is not necessary to seek approval. The program should be presented to them for their information. Certainly, their support is desired, for the cooperation of other hospitd personnel is essential if a program is to be successful. If OR nurses go ahead with a preoperative visit program without letting others know what they are doing, there will be resentment and distrust.

OR nurses sometimes meet resistance when they attempt to initi- ate a preoperative visit program. Physicians and anesthesiologists may be suspicious; other nurses may be antagonistic. Perhaps much depends on pre-existing morale and team spirit. If the staff works as a team, there probably will be willingness to support the effort; if there is dis- satisfaction and dissension, there may be resistance.

Staff meetings and open communi- cation can be effective in dealing with resistance. A nurse who is knowledgeable about the program and an effective communicator should respond to specific arguments, answer questions, clarify misconcep- tions and incorporate the group’s suggestions.

In addition to written goals and objectives, resistance from surgeons and anesthesiologists can best be countered by evidence that the program will be translated into effective and efficient nursing care in the OR. It should be emphasized that the OR nurse is not usurping the physician’s function, but complementing his ex- planation and offering additional


psychological support to the patient. Inviting a physician to go with the OR nurse on a joint interview may show him that the nurse is not in- truding on his territory. Nurses should be willing to demonstrate their competency, and show others the general content and format of their interviews.

At first, OR nurses might interview patients of surgeons who support the program. Later, surgeons

ally may request their patient be visited because of the positive responses of colleagues and patients.

Administrators will be receptive to evidence that increased efficiency in the OR will result in economic benefits. They will also be interested in good public relations for the hospital. Preoperative visits from the OR nurse can create a friendly and caring atmosphere which improves

who have resisted the program initi- the hospital’s community image.

Guidelines for preoperative visits c] Introduce yourself and explain the purpose of your visit. Tell the patient that such visits are routine so that he does not feel he has been singled out because he is extremely ill. 0 Tell the patient the time of his surgery, about how long it will take, and how long he will probably be in the recovery room. This will be helpful to his family. They will know how long they will have to wait and when to plan their visits. Make sure the patient and his family know where the operating room waiting room is.

Obtain information from the patient. Ask him to tell you what his understanding is of his surgical procedure. 0 Review the preoperative preparations that he will experience and instruct the patient briefly about what to expect postoperatively. Tell him the floor nurse will give him more information.

Tell the patient that the anesthesiologist will visit him

to discuss specific questions relative to anesthesia. 0 Answer the patient’s questions regarding the surgical procedure in general terms. Encourage the patient to ask his physician any specific questions. 0 Discuss the patient’s and family’s feelings or anxieties regarding the surgery and anticipated results.

If available use audiovisual materials-pamphlets, notebooks, photographs, drawings, etc-to supplement the interview. 0 Make a note of any information which will improve nursing care in the operating room, ie physical problems which might affect positioning or require special set ups.

Give the patient an opportunity to ask questions.

Offer reassurance when possible, especially regarding the competency of the staff. Maintain an attitude of hope.

AORN Journal, February 1974, Vol 19, N o 2 407

Patients can help nurses overcome negative response to the program. One nurse reported that when patients told them that their visits were helpful, they asked them to write to physicians and administrators. She commented, “It was an unorthodox, but effective way to convince personnel of the benefits of the program.”

If extensive resistance is encoun- tered, OR nurses may want to sug- gest a trial program to test the validity of the visits. At the end of a trial period of three to six months, all personnel can evaluate the program and make suggestions. Then, based on actual experience, the staff can decide whether to continue with the visits.

How to conduct Ill preoperative visits

“I am Karen from the operating room. I have come to talk to you about your surgery tomorrow and try to answer any questions you have.”

Karen’s manner is friendly and direct. She has already reviewed the patient’s chart. She asks the attrac- tive dark-haired woman in her late forties what she expects to happen tomorrow.

The patient tells Karen that this is her third breast biopsy. The other two were not malignant and since this one feels the same, she is confi- dent that it is benign. The operation is scheduled for 2 pm, and her physician will do an aspiration in the morning.

“Has your doctor talked to you about the possibility of a radical mastectomy?” Karen ash.

“No, he hasn’t. My sister has had a radical, but I haven’t really thought about it this time. I’ve been taking anti-depressants, maybe that’s why.’’

“Perhaps when you see your doctor tonight, you might want to talk to him about it,” Karen suggests.

She adds, “If you are not ready for a radical mastectomy tomorrow, make sure that you sign only for a breast biopsy when you sign the operative permit.”

At the end of the interview, the patient told Karen that she appreci- ated the visit. She recalled an experience she had as a child in a hospital when she had needed someone, and a nurse had been there. To her, Karen’s visit meant someone cared. Once OR nurses decide to start a preoperative visit program, they still face a myriad of details. Should the visits be done on a one-to-one basis? Do all the OR nurses have to partici- pate in the program? When should the visits be scheduled? What interviewing techniques should be used? How should information be recorded?

Although the one-to-one patient- nurse preoperative visit is effective, we believe that group teaching can be used, especially in conjunction with individual counseling. In larger institutions, group sessions may be more practical, but in smaller institutions one-to-one interviewing is often possible. With group instruc- tion, the OR, RR, and staff nurses might work together as a team. Audiovisual materials such as pamphlets, photographs, slides, film strips and videotapes can be used to explain preoperative and postoperative routines.

Preoperative visits should be vol- untary for the nurses. Some OR nurses do not feel comfortable visit-

408 AORN Journal, February 1974, Vol 19, No 2

ing with patients, and this should be respected. Some nurses do not have the interpersonal skills or interest in developing these skills, and they should not be pushed into making visits.

Nurses should also be allowed the choice of not doing interviews if they are tired, have personal problems, or simply don’t feel up to it. As one nurse put it, “If I have personal unhappiness, I can’t bolster the patient.”

OR nurses often mention the difficulties of scheduling the interviews. “When are you going to find time?” asked one seminar participant. Stag- gered scheduling should be consid- ered. Often patient visits can be accomplished through innovative scheduling without adding additional staff. These are some of the ways participants a t the seminar scheduled visits :

Some nurses come in from 11 am to 7 pm, relieve for lunch and do the preoperative visits in late afternoon and early eve- ning. Instead of coming in at 7 am, some of us rotate from 8 am to 5:30 pm. We see most of the patients; the OR nurses on the 3 to 11 pm shift finish. We start with the patients who are scheduled first. If we don’t get to some patients, we can visit them the next morning before their surgery. People on call come in and do visits at 7 pm. They are paid time and a half with a guaran- tee of two hours. We do about ten cases a day, and one person does all the visits. Ideally, each patient should be

Barriers to visits During the seminar, participants are asked to write down one thing that would interfere with their doing preoperative visits. These are some of their responses:

I am not good with words.

I can’t handle dying, because I can‘t accept it. I can’t deal

with the terminal cancer patient who doesn’t accept it-the 27-year- old woman with breast cancer who

says everything i s just fine.

I have trouble with people who are emotionally upset. I am

afraid that I will fall apart too.

I can’t handle angry patients. I take the anger personally.

For years I have been without patient contact. I am agressive

and strong. I am afraid that this will interfere with patient

interviews.

visited. If this is not possible, the OR nurse has to be selective. The OR nurse might not need to spend as much time with a patient who ap- pears knowledgeable and comfortable about his surgery. She might elect to spend more time with more anxious patients.

At the seminar, several nurses asked how long the interviews should be. Usually 10 to 15 minutes is appropriate, but the OR nurse should be willing to spend more time if the patient has special needs.

When starting a program, it may be helpful to have two nurses inter-


A scene from "The preoperafive visit,'' a film to be premiered at Congress, shows Linda Wessel, RN, talking to a patient. She is the film's author, and director of operating rooms at the Medical Center of Central Georgia in Macon.

view together. They can support each other and critique each other's technique. Until the OR nurse is comfortable doing interviews, she may want to review the content she plans to cover prior to entering the room.

After the OR nurse has checked the patient's chart, surgical permit, and talked with the floor nurse, she is ready to talk to the patient. Pa- tient interviewing takes skill and practice. Through inservice programs, OR nurses can learn interviewing techniques through role- playing, films, and speakers. Self- examination is necessary for good interviewing.

The effective interview is a bal- ance of factual and feeling questions. It is important to give the patient an opportunity to communicate on a feeling level. Many nurses who went to school before 1960 were taught that it is unprofessional to show feelings. They need to be re-educated that it is all right to share feelings with patients in an appropriate way.

Some steps for successful interviews are outlined in the seminar.

Put the patient at ease. The initial approach to the patient is of primary importance. When she enters the room, the nurse should assess the ac- tivity. If the patient is involved with other hospital personnel or family, it may be better to return later. The atmosphere must be conducive to putting the patient at ease.

Call the patient by name and introduce yourself, tell him such visits are routine and state the purpose of your visit. Sit near the patient. Distance creates a barrier in interviewing. Through manner, approach and words, the nurse should communicate her ability to understand and accept the patient's feelings and needs.

Establish rapport. Confidence can be instilled when the patient and nurse share a feeling that they are working together on a common problem. An attitude of warmth, accept- ance, objectivity, and compassion


is essential for effective interviewing. The nurse who does preoperative visits should t ry to free herself from biases, and other personal atti- tudes which interfere with her role. It may be necessary for the nurse to work through some of her personal feelings such as inadequacy, helpless- ness, rejection, hostility or depend- ence which might arouse anxiety in her as she interacts with patients. In relating to patients, she needs to increase her objectivity about human conditions such as pain, mutilative surgery, sexuality, abortion, and death and dying. Recognizing that all behavior has meaning, the nurse should demonstrate respect for the patient.

Collect data. Various interviewing techniques can be used to gather data from the patient. Two popular meth- ods are directive and non-directive interviewing. In directive interviewing, the nurse is more assertive and asks direct questions. She uses techniques of confrontation and interpre- tation. In non-directive interviewing, the nurse is less assertive. She takes a receptive, listening attitude. As she listens, she is alert for important information which she redirects to the patient. She does not force or push the patient, but lets him take the initiative.

Give understanding or insight to the patient. The patient may need to be encouraged to look at his problem differently, therefore coming to a new conclusion about what is bother- ing him. The nurse helps the patient gain perspective and objectivity by helping him look a t things in retro- spect and determining relationship of actions, thoughts and feelings. She should not be afraid to confront the patient with painful aspects.

Motivate the patient to perform differently. The nurse evaluates the interview as it moves towards termi- nation. Will the patient feel differently, will his actions show behavior changes, will this be reflected during the pre and postoperative periods? Can he think critically and objec- tively? Does the patient realize his own resources in working out the solution?

When interviewing patients, OR nurses should avoid:

0 The temptation to tell their own experiences in detail 0 Promising something they can’t do 0 Giving false encouragement 0 Interrupting the patient while he is talking 0 Arguing or making argumenta- tive comments 0 Making loose, meaningless statements; using jargon or complex ex- planations 0 Contradicting themselves 0 Leaving the patient abruptly The OR nurse should terminate the

interview properly and make sure her patient understands what she is try- ing to communicate.

It is best not to take notes or fill out forms while conducting the interview. This can prevent the patient from talking freely. The OR nurse can fill out assessment forms, make notes or dictate a report after she leaves the room.

Why postoperative IV visits are important

~~

Postoperative visits give me the most problem, especially i f the


news hasn’t been good. My surgeon is always honest. I t is my job to let them get it off their chests after he has talked to them. I cry right along with them. M y main job is listening.

The postoperative visit provides the OR nurse with an opportunity to evaluate the safety and effectiveness of the nursing care given in the op- perating room. If she sees electrical burns on a patient caused by faulty positioning or grounding, she can take corrective action to prevent sim- ilar occurrences. When she sees patients with postoperative infections, she will want to review the case to see if a break in technique in the operating room may have been the cause. She may observe skin trauma and nerve damage caused by pres- sure or hyperextension, or undo pain or discomfort caused by inappropri- ate use of retractors.

During her visit, the nurse can also assess the safety and reliability of products used in the OR. If patients have a higher than average incidence of reaction to products, she should re-evaluate these products. She will also see whether some products used in the OR such as catheters and drainage tubes are functional for patient care on the unit.

The OR nurse can also ask the patient about her preoperative visit. She might ask, “What did I say that helped you? What did I say that scared you?” Or, “What do you wish I had told you that I left out?”

The patient may say, “You forgot to tell me about the postop period.” Or, “I didn’t expect the swelling or the bleeding.” “I didn’t know that it would hurt when I coughed or

breathed.” “You didn’t begin to tell me about the pain.” These comments will give the nurse a better idea of what to tell other patients in her preoperative visits.

OR nurses who are starting a preoperative and postoperative visit program may want more formal evaluation from patients. A written questionnaire that the patient does not sign can be an effective way to get an honest response.

Through the postoperative visit, the OR nurse terminates the relationship with the patient which com- menced with the preoperative visit. She shows her genuine concern by following through with the patient. The postoperative visit does not need to be long. Long-term nursing support in the postoperative period will be handled by the nurse on the unit.

Although postoperative visits are sometimes painful for the OR nurse, especially if the patient’s prognosis is not good, they can also be reward- ing. At this time, the patient has an opportunity to say thanks and to tell the OR nurse that she is doing a great job.

Many nurses find the relationship they have with patients mutually beneficial. One nurse put i t this way: “It has done me as much good as I have done for the patients.”

She added: “People are a big help to each other.”

FOOTNOTES

I . Definition and objective for clinical practice of professional operating room nursing, AORN Statement Committee, AORN Journal, 10 (No- vember 1969) 43-48.

2. Delegates approve statements on RN and nursing student in OR, institutional licensure, abortion, AORN Journal, 17 (April 1973) 188-189.


preoperative visits: the or nurse unmasks

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