Surgical Conscience: A guiding light in the modern OR
Regardless of their spiritual beliefs, almost everyone would agree that, as human beings, each of us has a conscience. It’s that “little voice” inside that helps each of us distinguish between right and wrong.
In recent years, the idea of a human conscience has been extended to the operating room, where “surgical conscience” has become a rallying cry for many health care professionals and patient safety advocates. The term refers to the concept of human conscience as it applies to the performance of all of the activities that occur in the operating room.
Specifically, we’re referring to the policies, standards and best practices recommendations that dictate proper procedures for every or activity—from scrubbing/gowning/gloving techniques to patient positioning, aseptic techniques and maintenance of infection control measures.
“Perioperative nurses draw upon an extensive and unique body of knowledge and training to deliver the highest level of care for their patients during surgical procedures,” says Linda Groah, the executive director and CEo of the association of perioperative registered Nurses (AORN). “all of this comes together to make up the surgical conscience of a perioperative nurse.”
In its strictest sense, surgical conscience is about much more than just using good surgical technique or not taking shortcuts. It’s about consistently exhibiting ethical behavior and promoting patient safety all the time, in every circumstance—and doing the “right thing” in a surgical setting even if nobody else is watching or is aware that patient safety has been compromised, however minor or insignificant the compromise may appear to be.
“I believe that most nurses intend to practice surgical conscience, and that most of the time, the nurse and the surgical team hit the mark,” says Sharon Greene-Golden, CRCST, FCS, the manager of the Central Sterile Supply Department for Bon Secours, Mary Immaculate Hospital in Newport News, Va. “It’s a matter of integrity: While the day-to-day routine sometimes allows for nurses to briefly think that they do not need to adhere to the surgical principles they have been taught, a nurse has to stand for what is right all the time to protect the patient.”
Tiffany Brown, RN, BSN, CNor, the manager of outpatient surgery at Clark Memorial Hospital in Jeffersonville, Ind., concurs: “I do believe that surgical conscience is a guiding principle in perioperative care today, and that most nurses exercise this in their daily practice. Surgical conscience is ingrained in nurses at most hospitals and throughout nursing school, and they exercise their surgical conscience on a daily basis. We take pride in our
work and we want the best possible outcomes for our patients.”
“As patient advocates, nurses must have a strong surgical conscience to ensure that the patient has a safe perioperative experience,” adds Jody Still, RN, SIS system admin with Clark Memorial Hospital-Surgical Services in Jeffersonville, Ind. “It only takes one negligent mistake to make a big change in a patient’s life, so we must all practice with the safest intent for the patient. Surgery can already be a vulnerable experience for patients, so we don’t need to add to that vulnerability by ‘letting things slide.’”
Collective Surgical Conscience
All of these nurses and health care professionals agree that while surgical conscience on the part of individual nurses is important, it’s the collective surgical conscience of the entire or team that’s most critical to ensuring the highest level of patient safety. “as a team, everyone in the or has the responsibility to the patient to practice surgical conscience for that particular case,” says Greene-Golden. “Patients will benefit from their ethical motivation to practice strict aseptic techniques.”
Unfortunately, some potentially significant barriers to the practice of surgical conscience in the or still remain. “The external forces and powers that control health care practices today, such as insurance company demands and legislative requirements, may interfere with personal surgical conscience and make it difficult to uphold,” Groah says.
“These influences may force decisions on care that lead to the omission of some necessary activities. as a result, nurses may be pushed to practice in ways they know to be unsafe—performing an incomplete skin prep, for example—or they may fear retaliation for adhering to standards they know should be maintained.”
So what does practicing surgical conscience actually look like? a few examples of following surgical conscience include:
Calling a break in the sterile field, even if it means having to tear down and set up a case again. “Suppose the sterile field on a complicated case becomes contaminated— not grossly, but someone just brushes against it,” says Still. “Nurses may hesitate to tear down the sterile field so as not to waste money or cause delays. But even if they just think they saw a sterile contamination, nurses should halt movement and have the issue corrected.”
Calling a surgical “time out.”
Groah notes that collective surgical conscience is demonstrated by participation in the surgical time out that’s mandated by the Joint Commission and fostered by AORN and its collaborating partners.
“The surgical time out is one activity on a checklist that includes the safety checks outlined in the World Health organization’s (WHo) Surgical Safety Checklist, and it also meets the safety checks within the Joint Commission’s universal Protocol,” she says.
“AORN and the american College of Surgeons were included in the discussions that resulted in the development of the checklist.”
Not taking shortcuts. according to Groah, there is a heavy emphasis on efficiency of or management at many hospitals today. “This can lead to unrealistic expectations on the part of hospital administrators with regard to or turnaround time, and efficiency can become more important than doing things the right way.”
Conducting proper counting of instruments, needles and sponges is one area where shortcuts can be tempting, but also deadly. In fact, retained surgical items are the most frequent and costly surgical “never event” and the number one Sentinel Event reported to the Join Commission. AORN’s recommended practice is that these should be counted before and after all surgical procedures, Groah says. “you can’t take shortcuts here, even if it’s just a small case.”
Speaking up—even when it’s difficult. This is the most challenging part of following surgical conscience for many perioperative nurses. “unfortunately, some surgeons and or staff members can be demanding, rude and even hateful, and nurses are sometimes afraid to stand up to them,” Still says. “If anyone on the surgical team observes anything that could be harmful to the patient or the procedure’s outcome, he or she needs to speak up and not be afraid of rocking the boat.”
The Silent Treatment, a comprehensive study conducted by AORN, VitalSmarts and the american association of Critical Care Nurses (AACN), makes clear the extent of this problem. Eighty-five percent of the nurses who responded to the survey said they had been in a situation where a safety tool warned them of a problem. However, more than half (58 percent) said they either felt it was unsafe to speak up or they were unable to get others to listen.
Promoting Surgical Conscience
Education and leading by example are two of the keys to helping promote surgical conscience. “By demonstrating surgical conscience in action and verbalizing it to student nurses, perioperative nurses can show student nurses how to be strong patient advocates and uphold the highest nursing values,” Groah says.
“Perioperative nurses must make sure that all members of the surgical team understand the consequences that can arise from not exercising their surgical conscience, such as post-operative infections that can lead to long hospital stays,” adds Brown. “We must educate all team members that it’s o.k. to speak out and assure them that they will not be reprimanded for being a patient advocate.”