Essay: Adult nursing – circulating nurse

This essay aims to explore an aspect in my practice in adult nursing. I have selected the roles and responsibilities of the circulating nurse in the perioperative setting. I have carefully picked this topic because as a future qualified theatre practitioner, being knowledgeable in the extensive duty of a circulating nurse is essential to be competent in my placement. Working in a specialised unit such as the theatre is not a surprise to be challenging. There have been several researches, journals and articles in the field of nursing however, the roles of perioperative nursing particularly that of the circulating nurse are not clearly identified.
The two primary functions of the runner are acting as the patient advocate and preserving patient safety. This essay will cover these two roles on how the circulating nurse will carry this out in practice. Moreover, this essay will examine the circulating nurse’s function in maintaining safety to other members of the surgical team and identify their responsibilities and discuss measures that encompasses their practice.
1. It is the duty of the circulating nurse to examine the medical equipment, check availability of instrument sets, cleaning the theatre and resupplying of consumable stocks
Nurses are familiar with the importance of preparing, cleaning and resupplying of the theatre (Murphy, 2002a). Before the start of any surgical procedure, the runner must ensure that the theatre is set up accordingly.
This includes such things as checking medical equipment needed for the surgery are readily available and functions appropriately. For instance, the overhead light, diathermy and suction machine are switched on and are tested to be working properly; decontaminating the theatre according to trust policy; lining the bins with color coded plastic bags; making sure operating table is working properly and discussing with the scrub nurse the correct set up of the furniture and equipment in the theatre ready for the procedure. Equipment that are to be used to position the patient must also be prepared; restocking the supplies such as the swabs, drapes, gowns and other needed disposables that are normally used; sets to be used are discussed with the scrub nurse and are brought in the theatre. In line with this, inspection of the expiration dates of instrument sterility and supplies are also checked.
Murphy (2002b) explains that although these habits of cleaning the rooms and equipment seemed tedious, they are essential measures in promoting patient safety. Ensuring a safe environment for every patient is critical for it is our legal duty as nurses. As healthcare providers, we must know or lower the potential risks of danger of our patient (NMC, 2015a). By doing routine checks before surgery commences, we are effectively exercising our roles to preserve patient safety.
2. Carry out the Surgical Safety Checklist
Implementation of the World Health Organization Surgical Safety Checklist is a vital practice in the theatre. As the circulating nurse, one must be able to understand the content of the manual to carry out the checklist in each patient for surgery.
During sign in, the patient is identified by the anaesthetist together with the Operating Department Practitioner, the procedure and the surgical site is confirmed and most importantly, the consent is checked. This step is crucial so as not to operate on the wrong patient, site or procedure (WHO, 2008). In this step, we also need to check on the site mark, this is another way to make sure surgery is done on the correct site. Additionally, the safety of providing anaesthetics is verified with the anaesthetist. This includes inspection of anaesthetic equipment, verification of drug- related concerns and overall safety of the patient particularly the patient’s airway. Ensuring the patient is hooked to the patient monitor before giving anaesthetic drugs and verifying patient’s drug or food allergies are also included in this segment.
During time out, everyone in the surgical team is halted briefly to make sure all vital checks were carried out (WHO, 2008a). In this stage, everyone in the theatre introduces their name and role, the anaesthetist and surgeon is asked for any anticipated events that might be crucial intraoperatively so the team can prepare the necessary drugs, equipment, instruments and resources to prevent any complications. Furthermore, the sterility of instruments is verified with the scrub nurse, the surgeon is asked for the need of antimicrobial to decrease risk of surgical site infection and lastly, the need for essential imaging is added in for surgeons requiring them for review.
The last phase can be done by the runner, surgeon or the anaesthetist and should be accomplished with the presence of the surgeon (WHO, 2008b). Sign out encompasses the following: verification of the surgical procedure with the surgeon and the theatre team, confirmation of the correct counting of instruments, swabs and needles, verification of specimens labelling, concerns with regards the equipment and instruments are dealt with and theatre team is asked about recovery concerns of the patient.
Nurses must work cooperatively with others by delivering effective communication and disclose information to the team to distinguish possible problems (NMC, 2015b). Implementation of the WHO checklist is the best time to collaborate with other members of the team. We must not assume anything without delivering it to the multidisciplinary team involved as communication errors are the most common grounds of blunder in the healthcare field. If information is not passed to the right person, errors are very likely to occur and this can be critical to the safety of the patient.
3. Competently handle and manage specimens according to local procedures
The RCN (2012) describes that proper collection, handling and labelling of specimens is vital as the property of specimen obtained has propositions for any microbiological diagnosis that may be reported. To conform to the local policy of University Hospital of Lewisham (2009), the following guidelines must be observed:
‘ Once the specimen is taken from the patient’s body, the scrub nurse will confirm with the surgeon the type of specimen collected and where it is to be sent. For instance, it will be sent for histology or microbiology.
‘ Specimen must be secured in a durable container with cap and must be free of contaminants. Container must be adequately labelled with patient’s details, type of specimen and date of collection. In cases where there is more than one specimen, bottles should be numbered.
‘ Theatre staff must not remove specimen in the operating room without having the Surgeon confirm the specimen labelling and clinical details are written by the Surgeon himself on the request forms.
‘ The circulating and scrub nurse will check together the content and expiration of fixatives if the specimen is to be placed in formal saline and ensure that it covers the sample adequately.
‘ Specimen pots must be placed in a sealable plastic container and if there is a risk for infection, plastic bag should be labelled to alert other healthcare workers.
‘ Specimen must be documented on the register by two theatre staff wherein one is a qualified practitioner.
Standard infection control measures should be practiced by healthcare staffs who have direct exposure to bodily fluids, blood and secretions of patients (European Biosafety Network, 2010). Safer working practices include performing hand hygiene, making use of personal protective equipment based on judgment of exposure to bodily fluids and adherence to trust’s safe handling and management of specimens.
4. Implement precautionary actions for infection control
Infection control should fundamentally focus on prevention (J. Rothrock et al, 2015). The spread of microorganisms follows a sequence of events and prevention is highly achievable if healthcare workers break the chain. Infection control practices of the unsterile worker in the theatre, whom is the circulating nurse, is achievable when adherence to the following sections are presented:
‘ Proficient in proper disposal of wastes and sharps
Sharps which includes needles, syringes, scalpels and broken glass must be disposed in a specifically designed container intended for it. Healthcare staff must be knowledgeable of the different sharp disposal color coding: Orange lidded disposals are used solely for sharps not contaminated with cytotoxic products while yellow lidded containers are used for sharps contaminated with prescription only medicines and equipment.
The Health and Safety (Sharp Instruments in Healthcare) Regulations (2013) has come up with guidelines to manage sharp injury prevention and control in ways such as finding alternatives to utilise sharps or if unavoidable, use safer sharps; never recapping needles after use; and ensuring sharp containers are placed close to work area.
In addition, the following standard actions should be taken by clinical staffs to prevent and reduce inoculation injury (Infection and Control Team, 2011): Sharp boxes should not be overfilled above the mark that signifies it is filled; sharp boxes must be labelled properly with the date and name of staff who assembled it; sharp containers should be placed in a safe location, above ground level favourably hanged on the wall; sharp disposals should temporarily be closed when not in use or when brought to work area.
Though circulators are not directly in contact with needles and sharps intraoperatively, one should know the action to take in the event of an inoculation injury. Immediately after the injury, encourage bleeding of site without squeezing. Wash it thoroughly, dry it and apply dressing. Report to line manager and complete filling out risk assessment form. Finally, go to A&E.
Circulating nurses must also identify the correct waste receptacles for proper segregation. Yellow bag are to be used for clinical waste for incineration while Orange bag are used for infectious waste which will be needing treatment or may be managed under incineration. These UN approved bags must be used properly according to wastes intended for its use (NHS, 2010). Additionally, white bags in the theatre are for disposable materials.
Proper segregation of wastes is crucial in the clinical setting to prevent cross contamination (Department of Health, 2004). To accomplish it, employees must be have a continuous training programme for adherence to policies. In the theatre, safe waste disposal must also be guaranteed to those handling clinical wastes by wearing appropriate personal protective equipment. The bag should be removed from container when ?? full and closed with securement tag or with a bag tie. Bins should be lined with new bags after every procedure. Finally, it must be placed in a storage area for collection such as the dirty utility.
‘ Ensure cleaning and disinfecting of the theatre for each patient
Contamination in the theatre can happen from different sources. The room must be cleaned to establish a safe environment to every patient. To fulfil this, theatre staff nurse evaluates the cleanliness of the room and initiates disinfecting the theatre if needed (AORN, 2013).
The theatre room must be kept to a minimum to decrease air turbulence and the possibility of contamination. Thus doors must be kept shut once the surgery begins. Regular cleaning and disinfecting of theatre environment aids in preventing surgical site infections and protects the entire theatre team from exposure to transmittable microorganisms.
Before the start of the first procedure, the room ought to be dusted with the approved local disinfectant. While the surgery is ongoing, theatre practitioners need to keep contaminants to a certain area inside the theatre. For instance, swabs need to be placed in a plastic receptacle and be covered when handling them for collection. Personal protective equipment should be observed when doing so. Finally, after every procedure color coded receptacles need to be discarded as well as scalpels used should go in the approved sharps boxes (OSHA, 2001).
‘ Vigilant of traffic control- knows sterility circu
‘ Observe universal, standard and transmission based precautions
Healthcare professionals are at risk of getting blood-borne diseases such as HIV, AIDS, Hepatitis B and C. Although theatre practitioners are aware of the importance of wearing personal protective equipment, more often than not safeguards are set aside to function quicker during busy theatre procedures. Thus, it is essential to reinforce precautionary measures to theatre practitioners. The following has been recommended by the Center for Disease Control (2007) under the ‘Guideline for Isolation Precautions’ and requires healthcare workers to ensure practice of standard precautionary measures:
a. Blood and bodily fluids are considered potentially infectious and needs standard precautionary measures.
b. During invasive procedures standard precautions should be applied.
c. Execute standard precaution for specimen handling as they are regarded as theoretically infectious.
d. Apply standard precaution for management and disinfecting equipment.
e. Carry out standard precaution for disposal of clinical rubbish and sharps.
The most important form of preventing spread of pathogens is by performing handwashing. It needs to be done between patient contact, after handling of blood and body fluids and before invasive procedures. The use of PPE such as gloves, apron, goggles and masks are indispensable tools to protect yourself and your patient in the perioperative phase. However healthcare staff need to remember when to change PPE to stop spread of infectious organisms (Dix K, 2001). Correspondingly, transmission based precautions needs to be used for patients with known transmittable diseases such as airborne, droplet and contact infections.
5. Execute proper handling and movement of patient
The Association of Surgical Technologist (2014) defines the aim of surgical positioning as to deliver ideal visualisation of and access to the surgical site that causes the least physiological compromise, while preventing injury to patient’s skin and joints. If not done correctly, patient is at risk of formation of pressure sores, injure skin integrity, and trigger neuromuscular problems. To prevent any injury to the patient during transfer, his/her body must be moved as a whole unit. Moreover, knowledge, planning and teamwork of the surgical team are the key components to a successful transfer of the patient.
The AORN (2008) recommends the following procedures when performing patient positioning in the theatre:
‘ Before patient is brought in the theatre, position to be used must be identified and discussed with the surgeon.
‘ Ensure any necessary equipment is available and cleaned for safe transfer of patient and is in working order.
‘ A dedicated theatre practitioner should coordinate to ensure safe transfer of patient to bed.
‘ After skin preparation, theatre staff must check correct body alignment and skin integrity of patient and be recorded in documentation.
Every healthcare practitioner must ensure patient safety to avoid the preventable complications mentioned from mal-positioning. Planning for patient transfer and positioning is crucial in the theatre and it must be done in a safe and syncronised manner with other team members. There should be enough staff to help in moving the patient to the bed. It is also essential to check the patient preoperatively and postoperatively to assess for signs of mal-positioning problems.
6. Record keeping to include counting of swabs, instruments and sharps
Documentation is an essential aspect in the healthcare practice and the theatre is not exempted from it. Apart from improving the perioperative practice, record-keeping has also played a significant role in legal and professional incidents. NMC (2015c) emphasizes that nurses must ‘keep clear and accurate records relevant to your practice’. As nurses, it is part of our professional duties that we owe to our patients so we can deliver efficient care and uphold safety.
Healthcare workers should observe the principles of good record keeping (NMC, 2009) which consist of writing entries legibly and accurately, following local policies with regards to documentation, entries should be factual and no alterations nor falsification should be made, and when feasible, patients should be included in the documentation process. As the runner in the theatre, it is their responsibility to ensure the documentation is done correctly and is reviewed by the scrub nurse after the surgery. Nurses should work collaboratively with other colleagues to evaluate practice and of the entire team (NMC, 2015d).
There are a wide range of perioperative records and it encompasses the following (AFPP, 2011):
The theatre care plan which embraces the pre, intra and post-operative care of the patient. This can be a combination of electronic and paper record that provides a complete note of the patient in the perioperative phase and sometimes covers implants used and decontamination labels from sets used in the procedure.
The count which is documenting items used during surgery. It includes putting entries in the white board, in the theatre register and the care plan. The counting sheet requires the scrub and circulating nurse’s signature who have done the count to verify complete counting of items used and identify staffs who have been on the team.
The safe surgery checklist which is an essential aspect in the perioperative period. During Time out, the surgical team pauses to discuss areas relating to patient care and safety prior to starting the procedure.
Argument:
Generally, in comparison from my previous practice in the Philippines, due to lack of resources, management of infection control has still a few steps to go to equally be highly regarded to the practice here in the United Kingdom. I feel that the practice in the Philippines puts their healthcare workers at risks by not providing adequate gears to safeguard themselves. I extremely admire how the NHS makes available the appropriate supplies to bring about safety to those receiving care, to healthcare workers and those working in the hospitals susceptible to clinical wastes.
On the other hand, the responsibilities of a circulating nurse in the Philippines is comparable to the practice here in the UK. However as new practitioners, learning the local protocols and general system of healthcare should be identified and learned.
All the theatre responsibilities I have stated are important. Though the one segment I feel is the focal point in the perioperative phase to promote safety of the patient is the implementation of the WHO checklist. According to WHO (2008c), many might find it as an unnecessary tool and wish to proceed directly to surgery. As O’Conner et al points out that the barriers to completing the checklist are the requirement for signatures, lack of time and assertiveness of staff. Moreover, poor teamwork and the timing of when the checklist is carried out are highlighted as barriers (O’Conner et al, 2013). NPSA (2009) expounds that the WHO checklist should be used to all patients (in-patients and day case) who will undergo a surgery, needing general or local anaesthetics. Thus, by covering the WHO checklist to each patients, we are evaluating altogether in a quick and comprehensive way the perioperative issues such as completeness of surgical count and site marking.
Conclusion:
To sum up, the circulating nurse has a massive role in the theatre that begins pre-, intra- and post- operatively to sustain patient’s safety as well as the rest of the surgical team. By ensuring the theatre is equipped with the necessary tools and materials prior to the first procedure, executing the Surgical Safety Checklist and other documentations, following the local policy for managing specimens, adhering to infection control procedures and practicing proper handling techniques when moving patients, circulating nurses are actively committed in performing their role in the perioperative team.
To review the competencies and adherence of theatre practitioners to common procedures that a circulating nurse normally does, I aspire to assemble a lecture in my placement in the University Hospital of Lewisham main theatres during clinical audit with regards the topic I have selected. I am certain that by doing so, it will invigorate and promote the skills and knowledge of my colleagues and correct wrong methods of implementation of staffs who need induction.
ere…