Best Kept Secrets of the OR #15- What you ignore or suggest is treated as normal

This isn’t a positive best-kept secret. In fact, it makes me mad and is probably making some of your charge nurses mad too. But not the one who is trying to be your friend and suggested that you call in sick, in front of another charge nurse, because you couldn’t get that day off.

However, this is directed at the other charge nurses who permit this behavior.

Apparently, in today’s working operating room, all you have to do to get the day off that was denied is call in sick. No thought was given to the rest of the OR team that now has to work short. No thought is given to the patients who are going to be worked on that day when the rest of the OR is working short. No thought was given to the person who makes the schedule that you just took a giant dump on.

This is because you didn’t get your way and you are making it everyone else’s problem.

Number one- there are rules for a reason. Only one person per staffing level (scrub tech, registered nurse, orderly) can be off at the same time, on the same day. Writing as a previous staff scheduler whose OR was run a lot leaner than the one you enjoy, there are reasons for that rule. You are damning someone else to work extra. The rules are different in each unit. In this unit, one person per staffing level is allowed off for a specific day.

Number two- this is for the charge nurse who suggested that a team member call in sick to accommodate their desire to have a certain day off. To that charge nurse I say don’t do this. Don’t make the rest of your team work extra so that you can be buddy-buddy with another team member. It reflects badly on you.

Number three- what you permit becomes the new standard. And will most likely come around to bite you in the ass.

Just no.

Don’t do this.

You are UNDERMINING your authority.

Consider that.

Or you might want to be friends with all of your subordinates and wonder why they don’t respect you.

You choose.

Post-it Sunday 11/17/24-all the hats nurses wear

The gown card reads “In the day’s culture it is not enough just to practice nursing, you must also wear different hats.”

This is a bit of a tricky one. I wrote this gown card at a nursing symposium on November 6, 2015. I know because it is listed on the card. I also know because I remember that symposium. It was one of my first in shared governance. I wasn’t involved in the planning of this one, but I was expected, as the hospital chair, to be present and participate. The theme for this one was “Batter up.”

No, not really. But it was baseball-themed, coming less than a week after the end of the 2015 World Series.

There I was, in a very new environment, soaking up all the excitement of the speakers and my fellow shared governance chairs. I took copious notes. Three gown cards full. And I have bitty handwriting.

Something the keynote speaker must have said struck me. It was probably about having to do all the things and be all the departments after hours, as a nurse on the floor.

While I was probably not the only operating room nurse in the room, I was definitely the only OR nurse on the team.

This was when I started to advocate the OR nurse’s inclusion in all aspects of hospital life. I was the first OR nurse they had ever had on the hospital chair level of shared governance. I volunteered for other committees, so many committees, so that the OR could have a voice in all of these committees, and shared governance meetings.

Nurses have to wear many hats. This is true. We have to be our own unit secretary at times, we definitely have to function as a CNA at others, and we have to pinch hit for plant engineering when things go wrong and no one is available to sort out the problem. We also have to be able to figure out the computer charting and also how to troubleshoot when things don’t work the way they should. We have to be able to fix or find another route for a piece of equipment that is definitely older than our nursing career.

While we are doing all of that, we also have to take care of patients. We have to make sure that the bedbound is repositioned every two hours, that the diabetic gets a blood sugar taken before they eat, that morning and evening pass medications are given. And for those of us who do not work the floor unit life, we have to make sure that every surgical case goes as expected. That ALL the equipment that is needed is available and ready, and we also have to find a workable solution when there is a failure. Don’t forget about making sure the proper instrumentation is available and sterile for each surgery, and if there is an instrument that is dropped where to find a replacement instrument because you know that what hit the floor is the only one.

No one nurse is better or worse than another.

We all wear the hats.

We all wear all the hats.

But we are nurses first.

School Me Saturday 10/12/24- mentoring the younguns

This afternoon I was at the grocery store. My cashier was a young bubbly sort who waxed rhapsodically over the brown sugar I was buying. I told them I baked cookies weekly for the operating room department that I worked for. Therefore, I need a LOT of brown sugar.

They were equally enthusiastic about the operating room. They thought that must be so cool.

I assured them that it was. And being an operating room nurse was amazing.

Even if, or because of, all the patients are under anesthesia.

They confessed that they were looking at nursing as a career.

You know, after they graduated from high school. In 2 years.

The thing about being a nurse is that we always feel the need to give back, to give advice on nursing as a possible career. Or to offer encouragement when it is needed.

They asked about my schooling, and how long it took to become a nurse.

I said that was a complicated question.

My ADN took about 2 years. Plus six months on prerequisites.

My BSN took about 18 months.

My MSN took about 2 years.

And my PhD, well, I was in the third year of the program.

They looked astonished by this outpouring of information. And a bit intimidated.

Reining it back, I encouraged them to give serious consideration to becoming a nurse. And the best way to start is with an ADN degree. And that not all nurses did all the other schooling.

The ADN is the foot in the door. Whatever they did after that was icing on their cake.

They said they had always wanted to work with kids. I smiled and said that kids need surgery too.

They grinned and told me to have a good rest of my day and that they would think about what I said.

I didn’t want to tell them that my nursing license was old enough to drink.

Post-it Sunday 7/14/24-Details will save your ass

The gown card reads “Take credit for what you do. All documentation is important.”

This can be thought of in at least two ways.

Yes, write down everything you do during a surgical case. This is important. The OR documentation is a shell, it is up to you to fill in the details.

ALL the details.

This is to protect you when there is a complication.

All the positioning aids are important to note. It is also important to note what position the patient is in during the surgery. If you have to fudge the lithotomy a bit because of their body limitations, write that. Be as detailed as you can.

I don’t care if you’ve done this case 2000 times, document everything you’ve done.

All the medications are important to note. How will the pharmacy and nurses and doctors who take care of the patient AFTER they leave the OR know the details of what medication was given? Be detailed, not only in the medication dispensed to the field, but the total of the medication delivered to the patient. Don’t forget to include the route. Remember the 5 rules of giving medication to a patient from nursing school? Yeah, right patient, right time, right dose, right medication, right route. I would add another right; the right indication for use. If this medication is being used in a way that is unusual, write it down. Give justification as to why. If there are antibiotics added to bone cement, explain that.

All the dressing details are important, even if they can’t be seen without deconstructing the dressing. An addition of an antibiotic or non-adherent film is important to note. Because the nurse or doctor who will be taking down the dressing has to make sure they have all the pieces. Because some of that turns transparent against a wound.

All the people in the room are important. Not only is it up to the circulator to control the traffic in the room and keep the crowd down to necessary people only, but times are important. People I often see not listed on the chart as being present are the correct product representatives or x-ray techs. The times all the people in the room are present may be useful in the future. Not only for productivity tracking.

All the details of the equipment used are important. This is so we can track the equipment used and also aids in tracking down instrumentation if there is an issue with a later patient where the same equipment is used. It is often necessary to note when the equipment is used on patients.

All the supplies are important. In so many ways. This is important on the back end for ordering and correct billing.

Be as detailed as you want to be while charting. But remember, your charting might save your ass in a deposition during a lawsuit in 5 years, 18 if it involves an infant, or until age of maturity if it involves a child.

Post-it Sunday 6/9/24- Don’t be fooled

The gown card reads “Don’t act like you think I’m a moron and I won’t act like you think I’m a moron.”

Look the people who work in the OR and are nurses and doctors are very smart. They have to be. We deal with the intricate workings of the human body. We have to know every part of it, and the mechanism of action of each of it. Not only that, but we have to know all about medications and their actions on every portion of the body.

There is a reason for such a steep learning curve for new OR nurses and techs. There’s a lot to learn. Not only that, you have to learn to anticipate what the surgeon wants. There is a reason that I reassure lap appy patients that if the surgeon falls out (passes out) during surgery the tech and I could band together to finish their surgery while we wait for assistance. It makes them laugh and relax. I once told a surgeon that I tell people this and they laughed and said after 23 years they would hope so.

The point is don’t discount anyone’s intelligence. No one; from the orderly to the circulating nurse.

There is also a soupcon or even a heaping cup of misogyny in there.

There is a prevailing “wisdom” that nurses are nurses because they aren’t smart enough to be doctors. I usually don’t respond to that. Who else is going to carry out the orders and question them when they are inappropriate? Many a life has been saved by a nurse refusing an order as written. Many a license to practice medicine has been saved by the same thing.

Some of us don’t want to be medical doctors and never have wanted to be one. Someone has to watch out for the patients and protect them from everyone else.

Let’s make a deal, you and I.

Don’t act like you think I’m a moron, and I won’t act like I think you are one.

Okay?

I’m glad we’ve had this talk.

Oh, and leave the patronization at the door, will you.

It just clutters up the workspace.

The work-around, what is it and why can it be dangerous?

Picture that you are an operating room nurse going about your day, doing cases, preparing for the next case, taking patients through the entire process of the case, induction of anesthesia, case, emergence from anesthesia, and taking patients to the recovery room. The entire gamut.

Suddenly management appears with what seems to you to be a new nonsensical rule.

Let’s use the example of not having bottles of saline in the warmer above 104 degrees Fahrenheit.

They leave you to your own devices.

You continue on with your shift, cases, lunch, more cases. The usual, you know.

When suddenly a surgeon says out of the blue that they wish the saline that was being used to wash out this patient’s abdomen were a little warmer. They don’t think that 104 degrees Fahrenheit is warm enough. After all, the saline doesn’t feel warm to their gloved fingers. Everyone knows it cools off during pouring and as it sits in the pitcher on the back table. Can’t they just have a little warmer saline? For the patient.

The work-around is used to circumvent the rules. Because the rules don’t make sense to you or to your coworkers. You think to yourself, why should the saline only be at 104, the blankets are heated to 130. I can just stick the bottle of saline in the blanket warmer. The patient will be warmer, the surgeon will get off my case, and everyone wins.

You continue to put the saline bottles in the blanket warmer. The surgeon is happier. Because what is the harm?

That’s the lure of the work-around. Standing up against the nonsensical new rule. Or finding a way to do a task a little faster than the last time. It can feel good to find a useable work-around, kind of like a dopamine hit.

But…

You have to consider why the rules exist. In the litigious realm of healthcare, it usually is because someone fucked up. Somewhere else. And the powers that be overreacted and made a new rule. But the rule is impacting you now. However, consider the possibility that there is danger behind the rule and that management and leadership are trying to protect you and the patient.

Going back to the saline bottle that has been warmed, routinely, 26 degrees more than the rule says. Ever consider that the rule change wasn’t arbitrary? That warming the bottles to 130 degrees had the potential to cause real and considerable negative impacts on the patient. Maybe it was discovered that the plastic of the bottle leached into the saline and therefore into the patient at temperatures above 120 degrees. Maybe there had been a reformulation of the bottle’s chemical formula that let this happen and the company found out about it and was just trying to protect the patient.

Is this scenario unlikely? No, more than likely.

Are the kudos and the dopamine you get from the surgeon enough to risk the patient?

That is why work-arounds, although sometimes useful and needed, are dangerous. Rarely do they give up all the facts when making a change, they may not even think about it because they, as leadership and management, know the reason behind the change. I’ve only met a few management-type people who offer up the reasons behind the change, instead of taking the hard line of “because I said so.”

Even before I went back to school I was always the one who needed the data behind the decision. Nothing has changed.

After all, the patient on the OR table is the reason for our job.

Nursing is tops again for being trustworthy. But…

According to the 2023 Gallup Honesty and Ethics Poll, nurses remain the most trustworthy profession for Americans. Yay, us! I mean, I’m not surprised, are you? This is the 22nd year as the top dog out of the 23 professions ranked.

Nurses are the hardest working, patient facing group of professionals out there. We are at the hospital, at the bedside, 24/7/52. This means 24 hours a day, seven days a week, and 52 weeks a year there is a nurse at a bedside. There are also certified nurse assistants to assist in the work, environmental services to keep everything clean and hygienic, plant engineering to keep all systems like HVAC running, IT professionals on standby to help with software problems in the electronic health record, admission and records people to keep the records straight and admit as needed, dietary people to keep the kitchen running and the patients fed, and pharmacists and pharmacy techs to keep the medications correct and flowing.

Honestly, healthcare takes a village. We all worked together to get the world through a pandemic!

I am not surprised that nursing is at the top again when rated on honestly and ethics.

But…

Here it comes.

But… the ratings, although nursing is at the top, have drifted from their peak. Yes, the peak was in 2020. We all know what happened in 2020.

All the ratings are lower, except for those at the other end of the spectrum, their ratings either worsened or were the same. These are the members of Congress, senators, car salespeople and advertisers and they were all viewed by Americans as the least ethical. I mean, when you at the bottom, is there anywhere to fall?

Surprisingly, yes.

I am sure there will be additional research as to WHY there is an almost across the board decrease in perception of trustworthiniess and ethics. I have a pretty good idea. Don’t you?

Anyway, nurses are on top again as the most trustworthy and ethical profession, members of congress and senators are at the bottom. Fascinating read.

Reference

Brenan, M. & Jones, J.M. (2024, January 22). The ethics ratings of nearly all professions down in U.S. Gallup. DOI.Ethics Ratings of Nearly All Professions Down in U.S. (gallup.com)

Convention planning season, anyone?

If there is something a nursing organization loves it do, it is to plan a convention. I’m a member of the Association of periOperative Nurses (AORN), the North Carolina Nursing Association (NCNA), the Sigma Theta Tau (nursing honor society), a reciprocal member of the American Nurses Association (ANA) through AORN, and the association for nursing professional development (ANPD).

Every single one of these organizations, that I pay and get educational benefits from, has its own national or international convention.

There is only so much money to go to the conventions.

I am a lifetime member of AORN (can’t recommend this enough) this means I paid $950 one time about 10 years ago instead of $150-$200 per year with reimbursement from the hospital. That means I get the benefits of the ANA and AORN for free because I am a lifetime member of AORN. The dues for NCNA usually cost me about $150 because I have a student membership. The dues for Sigma Theta Tau are about $125. I won’t be re-upping ANPD because I don’t have enough time in my life.

I am presenting a poster at AORN and will be traveling to, staying at a hotel for several nights, and attending the conference. We are driving because it is close-ish, just the next state over. I already arranged for our hotel room. The travel and the accommodations will cost money but the conference itself will be $580 with early bird pricing, and $680 after February 1st. I am registered.

Through work, I can get reimbursement of $1,500 on educational opportunities. It isn’t gonna cut it. The $580 I spent on registration will be reimbursed. Leaving $920 to spend on the other organizations and the renewal of my CNOR, which is $380. And the NCNA dues will drop that down to less than $400. I am grateful that there is even that amount for reimbursement.

All the other conferences, I will not be in attendance.

Because I cannot afford to travel to all of the places the conferences are. For example, Sigma Theta Tau’s international conference will be in Singapore. The ANPD conference will be in Chicago. The Magnet conference with ANA will be in New Orleans. The NCNA conference I will consider because it is less than 20 miles away.

Going to conferences is expensive. But the education that you can garner from the conferences is very useful to the bedside nurse.

But the only conference I am planning on this year is the AORN.

School Me Saturday 12/9/23-mutual encouragement session

On the last research assistant day of the semester that really was the week after the last paid research assistant day of the semester, I was in the RA office, working on tasks that the PhD nurse I work for had given me. One of the things that I make sure to do, especially after working until midnight the night before, getting five hours of sleep, and then driving 90 minutes to the university, is drink caffeine. A lot of it! Thank goodness the bathroom is down the hall.

On my way back to the RA office, I ran into a very nice junior nursing student.

She and I chatted on the way back to the office, as she was going to one near there.

I asked how she was doing.

She frowned and said she needed at least an 80 on her last med-surg test of the semester. To pass the course.

She turned to leave.

I stopped her and said, as reassuringly as I could, “Of course you will pass.” I smiled and gave her some test-taking strategies, including going for the first answer that pops in your head. And deep breathing is always important.

She smiled and thanked me.

I pressed on and said the first thing to do is read the question fully, decide what the answer should be without looking at the given answers, and find the one that is the closest.

She asked what class I taught. I told her that I was a PhD student and I was a few years out from teaching. She laughed and said that I would do great. Including passing all my courses.

I call that a mutual encouragement session.

I mean my PhD cohort (classmates) are great but sometimes it is good to hear encouragement from a surprising source.

Oh, and next year I will pay closer attention to the ending date of the RA. I could have saved myself nearly 3 hours of driving time.

The more you learn.

I will definitely continue talking to other nursing students. We all need some encouraging sometimes.