OR nursing committee works for

change Ann E Hett, RN Elizabeth Fahey

McDevitt, RN Eleanor M Toohey, RN

e started out as a maverick group of staff nurses. We knew W we had some problems in our

OR, but we didn’t know how to solve them. Initially, other staff members ig- nored us, but eventually we were able to determine how to solve our problems, and we became an effective and recog- nized organization in the OR. We were able to turn vented criticism into con- structive change.

Our group evolved into a formal committee with a leader, which led to peer support. We were able to develop a philosophy, standards of care, an audit tool, and an orientation program.

Initially, the staff nurses were frus- trated because they had no information about patients coming to the OR. Some nurses wanted to become involved in a preoperative and postoperative inter- viewing program. One nurse set up such a program as a school project and de- veloped goals and objectives, but an adequate plan and assessment were not developed. A number of nurses became involved in this program. Some became quite comfortable in this new role, but no one knew what to do with the infor- mation gathered. Also, there was no as- sessment tool, so many times important information was overlooked or not re- corded. Consequently, the staff became frustrated. When the initiator of the program left, the program ended.

A problem also developed for the nurse monitor, who is assigned to monitor physically and psychologically patients having local anesthesia and in- travenous (IV) medication. Again, there was no plan or assessment tool de- veloped by nursing. The only available information was an extremely brief pa- tient history written by the surgeon. The nurse monitor had only three to five minutes before the case to assess the patient. The available assessment tool included vital signs, current medica- tion, and allergies, but the nurse did not

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have adequate baseline data for nursing judgments. Nursing protested this situ- ation, and the program was stopped. This resulted, however, in no one as- sessing the patient.

Another problem identified by the operating room staff nurses was lack of a planned orientation program and es- tablished operating room standards of nursing practice. Some staff members came to us with knowledge and experi- ence they were unable to use construc- tively. Other staff members came with no experience and became frustrated because each person did the same pro- cedure in a different way. New staff learned by word of mouth.

When our group began to meet, each member had different ideas of where to start. We found we needed to develop a philosophy to establish some agreement among the group. Although they recog- nized they had limited knowledge of the nursing process and no assessment tool, the nurses wanted to do preoperative interviews. But the group had to decide what problems needed to be addressed first-lack of written standards, lack of a formal orientation program, absence of preoperative interviews, or lack of an assessment tool. Since there was little agreement about how procedures should be done, it was decided that standards of practice were the first step. The majority of the group was in- terested in developing standards that would demonstrate clearly the operat- ing room nurses' accountability for their practice.

The rest of the staff was unaware of the purpose of the group's meetings, and there was no OR leadership personnel in the group. Some of the other staff saw the group as elitist and secretive. In truth, the group members themselves did not fully understand what they were trying to do.

As the group members began reading articles and realizing how little they

Setting up a committee In establishing a formal committee, these are some of the elements that will help to elicit support from the operating room staff and establish the credibility of the committee.

The name of the committee should clearly identify it. If the name specifies a division within the nursing department (for example, StandardsiAudit: Operating Room), then it is clear the committee is concerned with standards and audit for the OR. When minutes or reports are circulated, the person reading them knows their origin. Stating "operating room" was necessary for u s because the nursing department had its own audit committee.

Defining the purpose of the committee is a critical and necessary step but one often dealt with casually or not at all. A purpose ensures that all members clearly know what is expected of them. People involve themselves in committee work to meet their own needs as well as the institution's. Defining a purpose if often difficult because the variety of expectations leads to multiple interpretations by the members and impedes effective functioning. Several sessions may be necessary to allow the members to discuss individual perceptions and clarify individual expectations.

Terms should also be clarified or identified during the initial meetings. Goal and purpose are used interchangeably. The purpose of the

knew, they recognized that they needed support and direction. During this time, a senior staff nurse, who had doubts about the opportunity for professional practice in the OR, emerged as an in- formal leader and kept the group meet- ing every week. At the same time, the assistant director for the operating room became chairman of the nursing audit committee for the nursing de- partment and saw as one of her major goals the development of an audit sys- tem in the OR. The assistant director

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committee must be identified clearly before you begin to discuss membership or to write objectives and functions.

Objectives must be stated in terms of results to be achieved and defined in terms of what can be observed. Objectives should be measurable. Objectives evaluate what the committee has accomplished and measure the committee's progress toward goal achievement. Objectives must be clear, concise, and understood by the members before the functions of the committee are established.

Functions identify the steps the committee must take to reach the stated objectives. The functions identify how the committee is going to carry out the tasks and identify frequence and length of meetings, roles of members, how minutes will be distributed and to whom, and the number and composition of the membership. The activities should be recorded in a concise and meaningful set of minutes to communicate with the nursing staff. Minutes serve as a means of evaluating the progress of the committee's activity as well as providing material for an annual report and a historical perspective for new members. There are many ways to handle minutes, and a method and sample are given (Fig 1).

Membership should represent staff levels. The number should range from five to seven, to provide an effective working group although the size may vary depending on the complexity of the OR and size of the department. The group should include a member of the OR nursing administration to provide support for

Fig 1 Sample format for minutes

Date:

Time:

Place:

Present:

Absent:

Minutes:

Topic Discussion Action ~~

the group and assistance with implementation. Additional staff or outsiders may attend with consent of the chairman. Opening attendance to staff allows access by interested staff who may wish to participate in the discussion. Their interest should not be curtailed since they may be potential members. The director of nursing should be kept informed via minutes. Most often, the director of nursing is considered an ex officio member on all nursing committees.

Each member should tell other staff that he or she is a committee member since he or she represents others on the staff. When the work of organizing the committee has been completed, the first order of business is to elect a chairman who is responsible for the smooth running of the committee and meeting the purpose and objectives.

began a t t e n d i n g o u r meet ings. T h e group welcomed h e r as a resource in nurs ing process and standards of care and saw an opportuni ty t o gain support f r o m her. By t h i s t ime, t h e group had completed a w r i t t e n philosophy o f nurs- ing for t h e OR.

The assistant director realized there was a lack of communicat ion with t h e nu rs ing staf f about t h e act iv i t ies and accomplishments of t h e group. T o faci l i - ta te communicat ion and establish rec- ogni t ion for t he group, t he assistant di-

rector introduced a fo rma l commit tee s t ructure. (See r e l a t e d art ic le.) T h e formal commit tee would be a lea rn ing experience for t h e members and could b e repl icated t o deal wi th addi t ional problems.

P r i o r t o t h e committee's work, t h e operat ing room nurses had been func- t i o n i n g in a t e c h n i c a l r o l e and in- t e r e s t e d primari ly in m o v i n g t h e schedule. The w o r k of developing stan- dards enl ightened t h e group, and de- spite t h e effort, t h e nurses began feel ing

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like nurses again and a common goal developed among the staff. The discus- sion of standards moved outside the committee to the coffee room, with reac- tion varying from outright resistance to reluctant participation. In the early phases or developing standards, there was more disagreement than agree- ment. There was much discussion about nursing in the operating room.

At this time, a new member of the staff joined the committee and was elected chairman because of her exper- tise and knowledge of the nursing pro- cess. This chairman began to use the group meetings more effectively and channeled the energy of the group into writing standards of care. The chair- man also worked in disseminating in- formation to the staff by having min- utes posted in the coffee room. More staff began to seek out members for in- formation, and the first draft of stan- dards evolved. A staff meeting was scheduled for discussion and informa- tion brought back to the committee for final work. The standards were then com- pleted and approved by the staff. The standards became the basis for audit.

The committee was now recognized and supported by the staff. Staff mem- bers were anxious to join, membership became sought after, and nurses began to be more aware of their respon- sibilities. With the success of the stan- dards, the committee began to expect the staff to function according to stan- dards in their daily practice.

In discussion at staff meetings, it was again brought up that orientation var- ied, was informal, and appeared to be ineffective. A questionnaire was de- veloped by the assistant director to de- termine the deficiencies and strengths in the current orientation program. This led to the recruiting and hiring of a staff education instructor. She incorpo- rated the standards into a formal orien- tation program for different levels of experience. This allowed staff perfor- mance to be measured according to criteria and provided a more individual orientation.

The time had now come to return to the initial reason for the informal group getting together-to develop a preoper- ative assessment program. This led to additional restructuring of the commit-

~~ ~ ~~

diploma graduate of Boston City Hospital, she has a BS in nursing from Boston College and an MS in administration of nursing services from Boston University. Eleanor M Toohey, R N , MS, is assistant ad- ministrator/director of nursing, Providence Medical Center, Seattle. A diploma graduate of Boston City Hospital, she has a BS in nursing from Boston College and an MS in nursing administration from Boston University.

When this article was written, the authors were on the staff at Affiliated Hospitals Center, Inc, Peter Bent Brigham Division, Boston.

The authors gratefully acknowledge the OR staff nurses who participated in the work of developing the committee and who were re- sponsible for the development of the patient care standards. A special thank you to Janet Carroll Finnegan for her critical support and encouragement.

Ann E Her, RN

Ann E Hett, R N , isa graduate of Central Maine Medical Center, Lewiston, and has a BSN from Boston College. Elizabeth Fahey McDevitt, R N , MS, is nurse manager operating room, University Hospital, Boston (Mass) University Medical Center. A

706 AORN Journal, March 1980, Val 31, No 4

tee and es tab l i sh ing an add i t i ona l pur- pose t o i n s t i t u t e p reopera t i ve i n t e r - views. However , t h i s had t o be post- poned because a need arose t o es tab l i sh gu ide l ines fo r a nu rse m o n i t o r protocol. T h i s project was g i v e n t o an ad hoc s ta f f nu rse group, w h i c h developed a tool. T h e opera t ing r o o m coordinator t h e n reques ted t h e c o m m i t t e e t o deve lop s t e r i l i z a t i o n standards. T h i s reques t acknowledged t h e l eg i t imacy and scope o f t h e s tandard laud i t commi t tee as a group o f concerned professional nurses w h o had accomplished t h e fol lowing: a phi losophy o f ope ra t i ng r o o m nurs ing , standards o f care, an audit tool, and iden t i f i ca t i on o f need fo r an o r ien ta t i on p r o g r a m . T h e c o m m i t t e e had estab- l i shed t h e validity o f a group o f operat- ing r o o m s ta f f nurses p r o v i d i n g impe tus fo r professional g r o w t h and develop- men t .

A l t h o u g h many prob lems r e m a i n and n e w ones occur daily, a system for resolv- ing p a t i e n t care issues h a s been estab- l i shed t h r o u g h a commi t tee s t ruc tu re u s i n g t h e exper t i se o f nu rses in t h e opera t ing room. Individual recogn i t ion and peer suppor t became t h e m a j o r im- petus for change. T h e g roundwork h a s been establ ished, and t h e env i ronmen t i s conducive t o f u t u r e change. A com- m e n t recen t l y made by a s ta f f nu rse re - f lec ts t h e n e w c l ima te : " T h i n g s a r e m u c h be t te r a round here." [I Suggested reading "Delegates approve perioperative role and certifica-

tion." AORN Journal 27 (May 1978) 1103. "House of delegates followup: Implications and di-

rections." AORN Journal 27 (May 1978) l l 53- 1175.

Jordan, Clifford. "Accountability for Nursing Prac- tice." AORN Journal 27 (May 1978) 1076-1080.

Massachusetts Nurses Association Ethics Commit- tee. "A code for nurses." The Massachusetts Nurse (April 1978) 5.

McMillan, Dorothy. "Accountability in nursing educa- tion."Nursing Outlook 23 (August 1975) 501 -503.

Millard, Richard M. "The new accountability." Nurs- ing Outlook 23 (August 1975) 496-500.

Passos, Joyce Y. "Accountability: Myth or man- date?" Journal of Nursing Administration (May- June 1973) 17-22.

Phaneuf, Marie C. "Model for quality: A matrix." AORN Journal 23 (April 1976) 759-765.

Phippen, Mark L. "lntraoperative nursing assess- ment." AORN Journal 28 (July 1978) 160-166.

Tobin, Helen M. "Accountability in staff develop- ment." AORN Journal 23 (April 1976) 924-927.

US Department of Health, Education, and Welfare. Credentialing Health Manpower, Pub No 77- 5057. Washington, DC: US Department of Health, Education, and Welfare, 1977.

Early diagnosis cuts risk of birth defects for older mothers A recent study indicates that with new prenatal diagnostic techniques, coupled with elective abortion, women aged 35 to 44 years have no greater risk of bearing an infant with a detectable severe birth defect than do younger women.

Physicians have long been aware that birth defects occur more frequently among infants born to older women. But because it is now possible to determine early in pregnancy if the infant is likely to suffer severe abnormalities, older women can identify the risk of bearing a child with disorders or defects and consider elective abortion.

Journal of the American Medical Association by Marshall F Goldberg, MD, of the Center for Disease Control in Atlanta. In an accompanying editorial, Norman Fost, MD, of the University of Wisconsin, Madison, points out that the new techniques will by no means find all potential birth defects, but they can reduce the risk of bearing an affected infant.

Dr Fost contends that prenatal diagnosis is ultimately a birth-facilitating rather than a birth-preventing service. More than 95% of the diagnoses in the womb disclose no abnormality of the fetus.

"For the older woman," says Dr Fost, "the availability of such services makes conception acceptable where previously it was often avoided because of irrational fears of the rational desire to avoid even a small risk of having an affected child."

The study is reported in the Nov 23

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