The Australian College of Operating Room Nurses (ACORN) encompasses standards that should be shown adherence by perioperative nurses for maintaining their accountability and staying true to their responsibilities in perioperative practice (ACORN 2014). Perioperative nursing refers to the nursing specialty where the nursing professionals are expected to work with patients, who are subjected to a wide range of invasive or other operative procedures (Rauta et al. 2013). A plethora of challenges are most often encountered by perioperative nurses on a regular basis, while participating in patient operations. Their primary role is related to delivering healthcare services in a way that addresses the surgical outcomes of the patients, who are being treated under sterile conditions (Neil 2013). Clinical experience and evidence based practice help the perioperative nurses to successfully carry out their roles.
Hence, the ACORN competency standards have been formulated with the aim of enhancing the professional development of the perioperative nurses and improve their learning abilities, through continued competence and a journey of lifelong learning. The standards act as references that assist the nurses to present formal evidences of their ongoing professional development and also facilitate the nurses in demonstrating accomplishment of the intended clinical goals. This reflective essay will illustrate a clinical scenario that encompassed a challenging situation related to laparoscopic radial nephrectomy of a bariatric patient. The essay will utilise the theoretical model of the Gibb’s reflective cycle that will act as a framework for this reflective writing (Husebø, O'Regan and Nestel 2015). The different elements of the cycle namely, a description of the scenario, my feelings, my evualation, analysis and the action plan will also help demonstrating my thoughts and perceptions that arose, while encountering the clinical scenario.
A bariatric patient, Ms. X (name withheld) was to be operated upon using the minimally invasive process of laparoscopic radical nephrectomy for the presenting complaint of renal cancer. The patient had been suffering from renal cancer for over one year. Conduction of a CT scan, in addition to USG helped in the detection of renal cancer. It also helped the concerned surgeon to get an estimate of the size of the renal carcinoma, and its extension. Prior to conducting the surgery, a routine blood test was conducted. This was followed by conduction of liver and renal function tests that facilitated assessment of the contralateral renal function and patient fitness. The surgery began as decided earlier. However, at the middle of the operation, the surgeon found it extremely difficult to proceed with the macroscopic procedure due to excess fat accumulation in the patient body. Thus, an immediate decision to switch over the operation to open nephrectomy was taken. Owing to the fact that the decision to change the mode of operation was taken by the surgeon in haste, we could not inform the patient or her family members about the sudden change in the surgical procedure. The patient was changed from the lateral position to a supine position for this purpose. The surgeon made an incision in the side of the abdomen, generally referred to as the flank area. There was no need of removing a rib for the procedure. We assisted the surgeon to cut away the ureter and the renal blood vessels from the kidney, following which the kidney having carcinoma was removed.
We used several sterilized and disposable surgical sponges (raytec), for absorbing liquids and blood from the surgical site. These sponges helped us in controlling bleeding. After removal of the kidney, we closed the incision with stitches. However, during wound closure, we failed to find one raytec. This made us inform the surgeon and concerned nurse for conduction of an urgent x-ray that would help us to detect presence of the missing raytec in the patient body (if any). Failure to locate the missing raytec following an x-ray made the surgeon put forth a request for CT scan at the concerned department, located downstairs. We closed the patient wound and transferred her to the CT scan area, with the support of ventilators and found the raytec inside the abdomen. This helped us draw the conclusion that changing the patient position, while switching from radical nephrectomy to the open surgery might have resulted in movement of the raytec to the deeper tissues of the abdomen. Following obtaining an informed consent of the family members of the patient, we again operated upon the wound to retrieve the raytec. The senior nurse involved in the operation filled out the RiskMan form, as per the hospital policies.
This kind of a scenario is quite common in surgical settings. My knowledge helped me gain information on the fact that approximately a dozen sponges and other harmful surgical instruments are left inside the body of patients, on a regular basis. This often results in 4,500-6,000 cases of retained surgical bodies, per year (Dieter 2013). Owing to the vast nature of the surgeries that are conducted on a regular basis across all healthcare settings, I was initially nervous and anxious about my participation in this nephrectomy surgery of the patient. This anxiety of mine got reflected as a direct manifestation of the shift from laparoscopic surgery to open nephrectomy for which we had to quickly prepare the patient. I was annoyed at the sudden decision change of the surgeon and also found it a violation of the standards of practice, when neither the patient, nor her family was informed about the change of surgical procedure, in the operation theatre. I became agitated and started losing focus. In order to cope with this anxious situation, I began to prioritise patient care and started re-assessing the concerned situation. This helped me to respond in an appropriate manner to the situation. I was also extremely worried about the safety of the patient and tried to avoid all possible physical harms, while changing the patient from a lateral to a supine position.
After completion of the operation, I initially felt relaxed that the patient health and safety had not been compromised. However, failure to locate the missing surgical sponge while counting them after wound closure, added to my worries. I became extremely nervous about retained surgical sponge in the abdomen of the patient X due to the fact that it might contribute to discomfort, pain and bloating. I was anxious about the patient and wanted to take all possible efforts to remove the raytec from the abdomen, to avoid sepsis. Furthermore, I was also annoyed at the hospital authorities for not having provisions of CT scan in the surgical department. My annoyance was heightened by the fact that shifting the patient in such a critical condition might have worsened the health condition, or cause death of the patient. Reflecting back on the situation, I felt relieved when we successfully retrieved the retained sponge from the abdominal tissues, without much blood loss or deterioration in health status of the patient. After having completed the wound closure, following retraction of the raytec, I discussed the patient condition with the other scout nurses and felt guilty about our inefficiency to remove all surgical sponges from the abdomen, post her operation. However, the surgeon and senior nurse thanked all of us for effectively retrieving the raytec. This helped me become more aware of my duties as a perioperative nurse.
The ACORN competency standards, scope of practice and the policies of the hospitals will be used for evaluating my role in the scenario. I will also use clinical evidences to support the standards and competencies that are expected from us. Initially, the patient X had been provided with the preoperative checklist, following which an informed consent was taken from her, and her family members regarding the radical nephrectomy that was intended to be performed upon her (ACORN 2014, p.2). An initial rapport had been established with the patient. This generally encompasses providing a sound understanding of the potential benefits and adverse effects of the surgical procedure (Aboumatar et al. 2013). Furthermore, patient confidentiality was also maintained and we took all possible efforts to prevent disclosure of patient information to any other individuals. Informed consent and a confidential relationship between a patient and a physician is integral to the process of delivering sound medical care (Lamont, Jeon and Chiarella 2013). This was in accordance with the competency standard 2 that focuses on conduction of perioperative nursing practice, within the scope of an ethical framework.
Owing to the fact that I was involved in caring for the patient from the time of surgery, I requested performing a check of the paperworks, before beginning the operation. The fact that I had conducted a perioperative nursing assessment of the patient X shows my adherence to the standard 4 (ACORN 2014, p.7). I collected information relevant to the patient from a variety of sources such as, the interview conducted during pre-admission, observation of the visual assessment signs and previous records of the patient based on past medical history, and diagnosis of renal carcinoma. I also asked for the anaesthetic assessment records of the patient to identify practices or procedures that we might have to avoid during the surgery. A count of the surgical sponges and gauze was performed at the beginning and end of the surgery. This is associated with the competency standard 1 (element 1.1) that illustrates the importance of accurately completing relevant perioperative nursing documentations (ACORN 2014, p.2). I also demonstrated skills that correspond to the standards 3, where I applied the necessary principles of microbiology and infection control. I also practiced appropriate hand washing procedures and wore personal protective attire.
However, there was a failure on our part to maintain safety precautions during handling sharps, blood and body fluids, during the operation. This failure to meet the standard led to retained surgical sponge in the abdomen (ACORN 2014, p.4). Furthermore, we also showed accordance to the standards 4 while changing the operation procedure, depending on the physical needs of the patient. Patient centred care often involves care approaches that are responsive to and respectful of the individual preferences, values and needs of the patient. This standard was met when we prepared the open surgery setup, depending on the excess fat accumulation. However, failure to inform the patient about the sudden change in surgical procedure demonstrated a violation of the standard 1 that pertained to legal aspects of perioperative practice (ACORN 2014, p.2). The standard 6 elements were also not met since adequate efforts were not taken to implement individual nursing care for achieving intended patient outcomes. The absence of CT scan equipments in the surgical department failed to meet the element 6.1 that illustrates the importance of providing appropriate equipments in good working order (ACORN 2014, p.8). The elements 6.2 were also not met since retained sponge in the abdomen failed to meet the standards of promoting patient safety and optimal health conditions (ACORN 2014, p.9).
We also failed to maintain proper vigilance of the patient’s physiologic status, which in turn accounted for the movement of raytec in the abdominal tissues while changing patient position. The competency standards 7 were appropriately addresses since we were involved in an effective collaboration with the surgeon and the senior nurse to ensure timely removal of the retained surgical sponge (ACORN 2014, p.11). This helped in fostering an effective collegial relationship with members of the multidisciplinary team. Although the patient and concerned family members were not informed about the change of nephrectomy procedure and retained raytec, a conversation was intiated over the phone to obtain their consent regarding retrieval of the sponge. We also maintained the standards 8 and 9 that focus on evaluating the effectiveness of the care procedure and collaboration with multidisciplinary team members. Individualised care plans are unique to each patient and should be organsied depending on the specific needs. I also met the element 6.3 and took all efforts to reduce excess loss of blood from the incision site (ACORN 2014, p.10). Furthermore, hospital policies were duly followed by completing the RiskMan form that helped in recording unexpected outcomes, adverse events or staff and patient injuries (Lederman et al. 2013).
Patient safety is considered as an important element of an efficient and effective healthcare system where optimal equality prevails (Battié 2013). Patient safety focuses on lack of harm of the patient and tries to avoid all adverse events or bad incidents (Gregory, Bolling and Langston 2014). It is imperative for all healthcare professionals in a way that reduces the likelihood of medication mistakes. This is also encompassed by the NMBA standards 2 that focus on fostering a cultural of safety and learning by engaging with healthcare professionals to deliver a person-centred care (Nursingmidwiferyboard.gov.au 2018). An analysis of the aforementioned clinical scenario indicates that adequate efforts were not taken to maintain patient safety, thereby increasing the susceptibility of the patient X, to adverse effects. The retention of surgical sponge inside the abdomen during operation was an unavoidable adverse event that could have been easily prevented by following the competency standards.
Moreover, effective communication also forms an integral aspect of ensuring patient safety that begins with the provisioning of information, available on any operational site (White and Spruce 2015). Communication has been found to reduce administrative burden and release the operating staff, thereby using operational demand by showing an adherence to the executable standards and procedures (Blum and Burns 2013). The use of effective communication between healthcare professionals and patients has been found critical for achieving optimal health outcomes (Battié and Steelman 2014). However, in this case there was a lack of communication with the patient, when decision regarding change of the surgical procedure was taken.
Moreover, the NMBA Standard 6 that elaborates on providing an appropriate safe and responsive quality nursing practice was also not maintained, due to the fact that there was lack of attention to presence of any surgical sponge is inside the patient body (Nursingmidwiferyboard.gov.au 2018). Commonly referred to as gossypiboma, the intraoperative mistake when one or more surgical instruments are left behind in the operative field after closure of the wound often become a nidus for infection (Boltz et al. 2013). Research evidences have correlated this preventable medical error with occurrence of internal bleeding and puncture in the blood vessels and vital organs (Russell, Burke and Gattis 2013). Thus, the chaotic environment during the surgery while changing the operation procedure, and lack of attention in producing an accurate count might be identified as the contributing factors that increased the risk of forgetting the surgical tool (Moffatt-Bruce et al. 2014).
With the aim of performing better in similar challenging situations that I face in near future, I intend to develop my communication skills that will help me in preventing adverse events. My future plan would be focused on enhancing my verbal and nonverbal communication skills by treating the patients with respect, showing them empathy, communicating in a way that fits their names and obtaining their informed consent, prior to implementing any form of intervention. Moreover, I would also try to maintain the confidentiality and privacy of all patients.
I would also try to avoid communicating through email or telephone, to reduce risks of missing nonverbal messages. My future goals are also directed to reduce the number of accidents associated with retained surgical instruments. I intend to carry out a thorough investigation of the first count when the instruments will be set up and the sponges will be unwrapped. Conducting the next count right before the operation and another immediately as the closure begins, followed by a final count during skin closure, will help me in avoiding such incidents in future, thereby enhancing patient health outcome.
Aboumatar, H.J., Carson, K.A., Beach, M.C., Roter, D.L. and Cooper, L.A., 2013. The impact of health literacy on desire for participation in healthcare, medical visit communication, and patient reported outcomes among patients with hypertension. Journal of general internal medicine, 28(11), pp.1469-1476.
ACORN 2014, Standards for perioperative nursing: including nursing roles, guidelines, position statements, competency standards, The Australian College of Operating Room Nurses, Adelaide
Battié, R. and Steelman, V.M., 2014. Accountability in nursing practice: why it is important for patient safety. AORN journal, 100(5), pp.537-541.
Battié, R.N., 2013. Perioperative nursing and education: what the IOM Future of Nursing report tells us. AORN journal, 98(3), pp.249-259.
Blum, E.P. and Burns, S.M., 2013. Perioperative communication and family members' perceived level of anxiety and satisfaction. ORNAC journal, 31(3), pp.14-16.
Boltz, M., Capezuti, E., Wagner, L., Rosenberg, M.C. and Secic, M., 2013. Patient safety in medical-surgical units: can nurse certification make a difference?. Medsurg Nursing, 22(1), p.26.
Dieter, R.A., 2013. Retained surgical sponges. Journal of the American College of Surgeons, 216(3), p.509.
Gregory, S., Bolling, D.R. and Langston, N.F., 2014. Partnerships and new learning models to create the future perioperative nursing workforce. AORN journal, 99(1), pp.96-105.
Husebø, S.E., O'Regan, S. and Nestel, D., 2015. Reflective practice and its role in simulation. Clinical Simulation in Nursing, 11(8), pp.368-375.
Lamont, S., Jeon, Y.H. and Chiarella, M., 2013. Assessing patient capacity to consent to treatment: An integrative review of instruments and tools. Journal of Clinical Nursing, 22(17-18), pp.2387-2403.
Lederman, R., Dreyfus, S., Matchan, J., Knott, J.C. and Milton, S.K., 2013. Electronic error-reporting systems: A case study into the impact on nurse reporting of medical errors. Nursing outlook, 61(6), pp.417-426.
Moffatt-Bruce, S.D., Cook, C.H., Steinberg, S.M. and Stawicki, S.P., 2014. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. journal of surgical research, 190(2), pp.429-436.
Neil, J.A., 2013. Perioperative nursing care of the patient undergoing bariatric revision surgery. AORN journal, 97(2), pp.210-229.
Nursingmidwiferyboard.gov.au., 2018. Nursing and Midwifery Board of Australia - Registered nurse standards for practice. [online] Available at: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx [Accessed 6 May 2018].
Rauta, S., Salanterä, S., Nivalainen, J. and Junttila, K., 2013. Validation of the core elements of perioperative nursing. Journal of clinical nursing, 22(9-10), pp.1391-1399.
Russell, R.A., Burke, K. and Gattis, K., 2013. Implementing a regional anesthesia block nurse team in the perianesthesia care unit increases patient safety and perioperative efficiency. Journal of PeriAnesthesia Nursing, 28(1), pp.3-10.
White, S. and Spruce, L., 2015. Perioperative nursing leaders implement clinical practice guidelines using the Iowa Model of Evidence-Based Practice. AORN journal, 102(1), pp.50-59.