Postoperative ACORN Standard: Reflecting On A Challenging Situation During Distal Tibial Nailing Surgery

Discuss about the Postoperatively the ACORN standard.

ACORN focuses on improving and standardising perioperative nursing care, supporting and educating preoperative nurses.  ACORN’s mission statement is to represent perioperative nursing and the organisation undertakes the range of operation to accomplish its mission.  Perioperative nurses have an obligation that numerous other counterparts see as highly procedural and task concentrated (Butterworth, Mackey and Wasnick 2013, pp. 64). Yet, proficient and well educated perioperative professionals are believed to be important for patient attention to warrant appropriate medical results.  Similarly, perioperative nurses in Australia oversee their own practices, and as a group of professional nurses, act to construct understanding that enlightens practices on a broader specialised level. Perioperative health care comprises a numerous specialty duties such as circulating, scrubbing, holding bay, anaesthetic, or instrument nurse (Keene 2009, pp. 13). Other obligations include patient assessment, education and surgeon’s assistant.  It is quite often that perioperative nurses can fill more than one responsibility during specific procedure depending on the complexity and nature of the operation (Ross, Dressler and Scheurer 2016, pp. 24). Similarly, some  nursing titles are used interchangeably in varying hospital and medical facilities. Thus, the prominence of nursing presence during surgery, in terms of nurse’s capability to ensure safe outcomes for the patient, is being progressively identified.

The challenging scenario is being encountered by perioperative scrub and scout nurses on a day-to-day basis. The perioperative nurse learns their practice through clinical experience and education in their normal learning schedule. The Australian Council of Perioperative Nurses (ACORN) brings the guidelines and teaching to the arena for the Australian perioperative nurses.  Thus, the learning offered by the perioperative sections in which the nurse is hired is steered by the ACORN competency standards.  The competency standards monitor the nurses to acquire the talents to competently provide perioperative care in the most courses of actions or where the disaster situation in which each medical practitioner’s competency is tested.  Thus, this reflective paper will concentrate on specifically challenging situation operation encountered by myself, junior nurse, and surgeon. The Gibbs reflective model, 1988, will be utilised to reflect on the challenging situation (Mindtools 2016). The paper will also deliberate on my feeling of anxiety in these challenging situations.  The assessment of this setting will display my accomplishment of the ACORN competency standards through the operations, and the incidence where the progression of my abilities and counterparts is vital.  During the examination of this reflection, clinical proof will display the importance of interdisciplinary communiqué and the paybacks of using checklist for intraoperative perioperative exercise.  The paper will also display the importance of checking an extra set of equipment prior to surgery and the importance of theatre operation manager liaising with the procurement department to buy new Trigen tibial nailing apparatus.  An action plan will illustrate how I harness my competencies for emergency in regard to the Distal Tibial Nailing in the future.

Feelings

One of my late weekend shift (1 pm to 9:30 pm) we received a patient for Distal Tibial Nailing. I was the only staffs who know orthopedic surgery on that shift. My other colleague was junior and she scrubbed only one time for Nailing. She told me she wants to scrub for the case for her up skilling. We checked the patient in and checked the consent against patient ID. Checked the implants with surgeons such as Tibial Nail Size, all disposable guide wire and drill bit and were ready for the surgery. I informed radiology department that we are ready for an x-ray.   I told the surgeon the scrub nurse does not have much experience in this case and surgeon was happy to scrub with her. Anesthetist put the patient in sleep. She scrubbed in and I opened all the instruments and consumables in a sterile manner. Surgery started and I had to explain to the scrub nurse how to assemble the instruments and the sequence of the surgery during the procedure. I had to do the entire circulating job and on top, I had to guide the scrub nurse made I bit stressful.

According to the size of Tibial nail reaming is done. Nail opened and the surgeon was about to put the nail in. Suddenly the JIG fell on the floor from the scrub nurse. That was a terrible situation for all of us. The instrument that we used for the nailing was Trigen. We have only two Trigen sets in our facility. I ran to set up a room and looked for the second Trigen nailing set and I could not find it. I rang floor coordinator and ask her to look for it. She checked with CSSD staff and realised it is in the washer. I informed the surgeons about it, they were so annoyed. The surgeon was not happy to put the nail without the JIG and also not appropriate. I could not explain the stress that I went through that situation. Scrub nurse apologised many times.

Finally, the surgeon decided to do the open reduction and internal fixation (ORIF). He asked me to get small fragment set and distal tibial plate. I took it from setup room and opened everything for ORIF. It took another two hours to finish the surgery. This incident causes extra anaesthetic and surgery time. Also, it wasted an implant which cost a lot.

Evaluation

The above challenging situations were very hard for me as I was only the nurse with the orthopaedic knowledge at that time. I had stress and apprehension due to the urgent nature of the operations, the lack of specialist staff with relevant knowledge, and the needs to prepare for the distal tibial nailing so fast.  Since I knew I was the only person I could help the surgeon, I concentrated on prioritising the nursing intervention needed, instead of being distracted by the anxiety and the stress.  At the period when Trigen was needed, I felt annoyed to myself for not preparing for the situation or not orienting the scrub nurse about the consequences of not handling the JIG properly.  When the surgeon completed doing an open reduction and internal fixation (ORIF), I felt relieved that the course had been successful although without following due process.  On the patient side, I really sympathised with him as he had undergone long hours of surgery and the right procedure was not followed as stipulated by medical practices.

Reflecting on the situation, all the personnel in communication relaxed that the emergent and challenge scenario was brought without many hurdles. After the process, we discussed with a scrub nurse that we were not careful and very inefficient that we did not project the alternative of JIG.  Although the surgeon was very furious, he thanked the entire group for the sign of responding to the situation prompting but we had a lot to do and improve. Thus, this made me and my colleague very positive on the work we had done.

For me to evaluate myself from the above situation, it crucial my nursing inventions performed to be equated to the  ACORN competence, the clinical approaches guiding the course were suitable and backing clinical evidence through the perioperative, intraoperative and post-operative stages of the attention.

Preoperatively, the patient had a preoperative list done, the assent form was also present and the medical checklist was piloted by the scrub nurse.  As I was the only around with appropriate knowledge of the orthopaedic procedure, I requested to countercheck the list prior to scrubbing.  The above nursing interventions align with the ACORN standard 1, element 1.1 which deals with the verifying the consent and patient identification according to approved protocols (ACORN, PP. 2). According to the literature, backup evidence for this nursing intercession was well-versed about the patient feelings which would minimise the occurrence of anaphylactic response in the perioperative situation, thereby correlating with ACORN competency standard 4, element 4.1.  My vital controlling focus before the cleaning was to make sure that surgeon and I was conversant about the patient's allergy standing and ensuring that legal consent form is exist (Nilsson et al. 2010, pp. 179). 

In the course of the intraoperative sage, ACORN competency standard 5, element 5.1 was illustrated by me by effectively being in discussion with the other healthcare providers such as junior nurse and surgeon.  But, the breach of appropriate communication was displayed in the lack of equipment during the surgery process.  If I had addressed the menace to the surgeon or junior nurses, the open reduction and internal fixation would not be performed on the patient.

During the operation, I displayed competency standard 6 by applying the decision making and problem-solving approach, by proceeding very first to the request for the JIG.  Therefore, it correlates with the principles of understanding and anticipating complication and implementing the subsequent invention that may be needed during the process. The above mentioned guideline, correlates to the competency standard 6, element 6.2. The mentioned factors are very essential as it deals with the delicate matter in regard to the patient healing and recovery.  It is worth noting the above issue was not tackled to perfection.  Under normal condition, the preoperative nurses should project the surgeon’s needs such as checklists and react to them promptly.  However, junior preoperative nurses had only done the scrubbing once and there were relying on my clinical experience to direct them in perioperative nursing intervention in this challenging situation.

Considering the scrubbing prior to the distal tibial nailing, I revealed my realisation of competency standard 7 which supports coworkers in an objective style.  I verified my fulfilment of the standard 7 element 7.1 which  states that  nurse should effectively communicate  and documents  relevant  information to provide  comprehensive  perioperative  care.

I displayed my capability with ACORN competency standard 3, element 3.2 and 3.3, by dressing in personal protective gears, ensuring the junior nurse perform surgical scrub and putting in place sterile attire and upholding the sterile area (ACORN 2014, pp. 4).

Intraoperative, scrubbing was done by junior nurse prior to the distal tibial nailing. The above is well linked to the ACORN competency 1, elements 1.1, (ACORN 2014, pp.2).

Upon reflection, I demonstrated the use of approaches to conflict resolution.  It was needed whereby there was lack of alternative for JIG.  I identified and considered the desires of others in connection to challenging conditions (ACORN standard 6, element 6.2). Also, offered additional assistance in getting and communicating with other healthcare providers (ACORN 2014, pp. 9). 

The ACORN standard for the operative phase regarding the finding data and documenting was significantly displayed (competency 6, elements 6.3) (ACORN 2014, pp. 10).  Postoperatively the ACORN standard and clinical guidelines were followed by the achievement of the intraoperative record and the patient had endured an upsurge of case setting resulting to the open reduction and internal fixation (Braaf, Manias and Riley 2011, pp. 1026).

Communication within the operating room is hotly debated topic in the nursing and medical journals.  It is worth noting that communication is usual for  perioperative nursing exercise  with the  ACORN  practices ( competency standard 7) but also  a must for all  registered nurses as  specified in the  Nursing and Midwifery Standard for Practice which states that ‘communicates effectively, and is respectful of a person’s dignity, culture, values, beliefs and rights’ (NMBA 2016, pp. 3). Assessing of the situation displays that emergency action could be enhanced if the interdisciplinary communiqué was active. Gill and Randell (2017) discussing the work of Arriaga et al (2014) claims that communication and coordination has been ‘identified as the leading cause of preventable patient injury and death’ (pp.9).  The surgeon's requirement would be projected more quickly if I and the junior nurse had used a checklist when preparing for the distal tibial procedures.  Thus, the above fundamental components of the perioperative action will be analytically studied to direct my preoperative practice and operations (Gardner, Russo, Jabbour, Kosemund and Scott 2016, .pp. 550)

It is broadly accepted that communication blunder is a frequent intraoperative stage of perioperative care (Wallace 2017, pp. 53). It is clear that nurses depend on informative and directive communication from the surgeon to update the requirement and advancement for further equipment (Sevdalis 2012, p. 2933).  Without timely directive communication from the operating surgeons, clinical study illustrates that nursing inefficiencies outcomes, and frequently result in teams’ tension. The scenario I and my counterpart encountered illustrates the above principles of communication breakdown whereby the nursing inefficiency resulted into a procedural delay (Hu et al. 2012, pp. 39).  However, no adverse effect occurred to the patients as the surgeon was able to rise to an occasion and do the open reduction and internal fixation. 

The use of a checklist for an emergency of the distal tibial operation would have been useful in these challenging situations. The medical literature concentrating on non-technical abilities of the perioperative nurses displays the techniques such as checklist will help in preparedness intraoperative (McNamara 2011, pp. 161).

While the ACORN standard does not have a statement concerning the maintenance and use of surgeon checklists, competency standard 5, element 5.1 dealing with the development and documentation of nursing model of cares claim that collaboration with other teams members is vital (ACORN 2014, pp. 7). Am certain that appropriate records of surgeon checklist are important to readiness and have connection to patient care (Mitchell et al. 2012, pp. 205). Therefore, the ACORN standards and practices should incorporate the above suggestion for the preoperative routine (Mitchell et al. 2011, 819).

I would like to discuss with the entire clinical nurse's fraternity, on generating a checklist for the distal tibial nailing to be incorporated into emergency set up.  Am quite sure the above will assist me and counterpart when they encounter such challenging situation.   I would suggest checking about an extra set of apparatus before the commencement of surgery.

Having new set of Trigen tibial nailing set is of essence. Therefore, I  would request the theatre  operation manager  to liaise with the  procurement department  to ensure new  apparatus are purchased so as to avert any deficiency which might arise in future.

Additionally, to assist me to do the best in future with conductive and stress-free areas,   facilitating effective communication would sound better (Rothrock and McEwan 2011, pp. 10).  It is advisable if all the health care providers used the same communication direction such as a directive and informative communication.  In a world of nursing and medical field, keeping in check with current events is of essence (Goodman and Spry 2013, pp. 22). Therefore, I would engage in reading the medical literature so as to improve my communication which is necessary in case of the emergency scenarios like the previously encountered (Gillespie, Chaboyer, Longbottom and Wallis 2010, pp. 733).

Conclusion

Apparently, the reflective paper comprises the explanation of the challenging setting I and my junior encountered in responding to the distal tibial nailing.  The paper also discusses the feelings, evaluating my performances against the ACORN competency standard through the process of preoperative, intraoperative and post-operative stages of attention and exploration of medical evidence that assisted me to comprehend and suggest the action strategy and how it can be executed.  The action will assist me and other medical professionals to put the factor of a patient cure first in their operation. The above can only be accomplished by providing an effective communication channel and checklist operating from the perioperative nurse up to the surgeon.  This reflective work has demonstrated and illustrated significance contemplation for the ACORN to include the checklist in the competency standards. The above evidence shows that checklist tools are missing and considerably affect the attention of the patients intraoperative.

References

ACORN 2014, Standards for perioperative nursing: including nursing roles, guidelines, position statements, competency standards, The Australian College of Operating Room Nurses, Adelaide.

Braaf, S., Manias, E. and Riley, R., 2011. The role of documents and documentation in communication failure across the perioperative pathway. A literature review. International journal of nursing studies, 48(8), pp.1024-1038.

Butterworth, J.F., Mackey, D.C. and Wasnick, J.D., 2013. Morgan & Mikhail's clinical anesthesiology (Vol. 15). New York: McGraw-Hill, pp. 62-66.

Gardner, A.K., Russo, M.A., Jabbour, I.I., Kosemund, M. and Scott, D.J., 2016. Frame-of-reference training for simulation-based intraoperative communication assessment. The American Journal of Surgery, 212(3), pp.548-551.

Gill, A. and Randell, R., 2017. Robotic surgery and its impact on teamwork in the operating theatre. ACORN: The Journal of Perioperative Nursing in Australia, 30(1), p.9.

Gillespie, B.M., Chaboyer, W., Longbottom, P. and Wallis, M., 2010. The impact of organisational and individual factors on team communication in surgery: a qualitative study. International journal of nursing studies, 47(6), pp.732-741.

Goodman, T. and Spry, C., 2013. Essentials of perioperative nursing. Jones & Bartlett Publishers, pp. 19-26.

Hu, Y.Y., Arriaga, A.F., Peyre, S.E., Corso, K.A., Roth, E.M. and Greenberg, C.C., 2012. Deconstructing intraoperative communication failures. Journal of surgical research, 177(1), pp.37-42.

Keene, A.M. ed., 2009. Medical-surgical nursing: Clinical management for positive outcomes (Vol. 1). Saunders Elsevier, pp. 12-16.

McNamara, S.A., 2011. Instrument readiness: an important link to patient safety. AORN journal, 93(1), pp.160-164.

Mindtools, 2016. Gibbs’ reflective cycle: helping people learn from experience. [Online]. Available from:https://www.mindtools.com/pages/article/reflective-cycle.htm [Acessed on 16 May 2018].

Mitchell, L., Flin, R., Yule, S., Mitchell, J., Coutts, K. and Youngson, G., 2011. Thinking ahead of the surgeon. An interview study to identify scrub nurses’ non-technical skills. International journal of nursing studies, 48(7), pp.818-828.

Mitchell, L., Flin, R., Yule, S., Mitchell, J., Coutts, K. and Youngson, G., 2012. Evaluation of the scrub practitioners’ list of intraoperative non-technical skills (SPLINTS) system. International journal of nursing studies, 49(2), pp.201-211.

Nilsson, L., Lindberget, O., Gupta, A. and Vegfors, M., 2010. Implementing a pre?operative checklist to increase patient safety: a 1?year follow?up of personnel attitudes. Acta anaesthesiologica Scandinavica, 54(2), pp.176-182.

Nursing and Midwifery Board of Australia, 2016. Registered nurse standards for practice.  Melbourne, Victoria, [Online]. Available from: www.nursingmidwiferyboard.gov.au. [Accessed on 16 May 2018], pp. 2-6.

Rothrock, JC and McEwan, DR (2011) Alexander’s care of the patient in surgery, 14^th ed, Elsevier Mosby, St. Louis, pp. 8-19.

Sevdalis, N, Wong, HL, Arora, S, Nagpal, K, Healey, A, Hanna, GB, & Vincent, CA 2012, 'Quantitative analysis of intraoperative communication in open and laparoscopic surgery', Surgical Endoscopy, vol. 26, no. 10, pp. 2931-2938.

Ross, J.J., Dressler, D.D. and Scheurer, D. eds., 2016. Principles and practice of hospital medicine. McGraw-Hill Medical Publishing Division, pp. 23-33

Wallace, D.C. ed., 2017. Nursing care of the pediatric neurosurgery patient. Springer, pp. 51-57.