Historical Perspective of in the Operating Room

Anne Marie Herlehy, RN, MS, CNOR AORN, Board of Directors Objectives for this presentation

• Review historical accounts • Define practice • Discuss ways practice has been promoted • Current mission and vision of AORN • Strategies/initiatives for promoting • No commercial support “You’ve come a long way baby…”

The Perioperative must have an understanding and appreciation of the history of and the development of Operating Room Nursing. It is the foundation on which current practice is built upon, and the guide by which future practice will be defined. • 7000~6500 BC – Middle Eastern evidence of teeth drilling – People believed disease was caused by evil spirits and could only be cured by appeasing the gods through ritual and sacrifice – In France, 120 prehistoric skulls with trepanation holes (burr holes) were discovered • 3300 BC – In ancient , the Hindus removed tumors and infected tonsils, credited with developing techniques in response to the common practice of removing a person’s nose or ears • 2650 BC – Egyptian carvings describe surgical circumcision, surgically removed bladder stones, treated bone fractures and performed amputations First Surgical Renaissance: 800 BC – 1500 AD • 800 BC: Nursing first mentioned in India • Treatment a mixture of religious, astrologic, scientific elements • Wine used as anesthetic, cautery with hot irons. • =“Cheir”(hand) “ergon”(work) • Surgery deemed manual work…not dignified, barbaric. Hippocrates published descriptions of various surgical procedures, providing directions for the proper placement of a surgeon’s hands. • 390 AD: Nursing- a divine calling. Care provided by , virgins, widows. • 625~690 AD Procedures such as the tracheotomy (described in detail by Paul of Aegina) remain relevant today • Surgery by bath keepers, hangmen, and quacks with including bleeding, cupping, leaching • Bloodletting, contributed to the demise of many over the course of many centuries Middle Ages • Few advantages were made in surgical practice • were left to traveling barbers who cut hair, removed tumors, pulled teeth, stitched wounds and performed bloodletting • Red- and white-striped barber poles were inspired by this practice, symbolizing the colors of blood and bandages, respectively • Introduced the , a refuge for elderly, disabled, and homeless • 1300’s: transformed from charity houses to medical facilities. Second Surgical Renaissance:1500-1842 AD

• Rebirth of surgery/medical at universities. • Nursing under secular orders, seen as a domestic service, not a profession. NOT for reputable women!! • 1600-1700’s: Crusades saw providing care to wounded/sick • 1612 1st American hospital (80 beds), all male nurses. • 1628 William Harvey (English ) proved that the heart, not the liver, propelled blood around the body in a continuous circulation • 1633 Order of Sisters of Charity (1st nursing order) • 1700 traveling French practitioner Frère Jacques de Beaulieu, creator of lithotomy procedure for stones • 1714 Gabriel Fahrenheit developed the • 1731 Blockley Hospital in Philadelphia • 1751 Pennsylvania Hospital • 1771 New York Hospital • 1774 Bellevue Hospital in New York • 1774 Electric shock used to restart the heart of a 3 year old girl who fell out of a window • Continental Congress established Army hospitals and nurse/ ratios • 1776 Hospitals improved / hygiene emphasized • 1775-1800 American Revolutionary War – Nurses were camp followers, no training, described as illiterate, heavy-handed, alcoholic, lacking moral standards, unfeeling.

• 1798 Dr. Valentine Seaman organized the first school for nurses at the New York Hospital • 1809 - Mother Seaton founded St. Joseph’s Sisterhood • 1821 Massachusetts General Hospital • 1836 – Reverend Theodor & Friederike Fliedner established a 3 year nursing course in Germany • 1839 - Nurses’ Society established in Philadelphia • 1840, British physician Dr. John Snow pioneered the effective and practical use of anesthetic chemicals (i.e., ether, chloroform) • Hospitals were dirty, overcrowded, with high infection rates, and considered “houses of ” • Usually not a separate operating room theater, but procedure performed in the patients room or on a counter in the hospital Third Surgical Renaissance: 1843 to present day • 1843 - founded • Localism: treating localized areas • 1846 Use of alcohol/opium replaced by ether and cocaine locals (1881) • 1847 Ignaz Semmelweis (Hungarian physician) emphasized hand washing with chlorine rinse • 1859 Drs. Elizabeth & Emily Blackwell founded Nurses Training School in NJ. • 1860 opened her school of nursing in London – “surgery removes the bullet out of the limb, which is an obstruction to cure, but nature heals the wound, and what nursing has to do is put the patient in the best condition for nature to act upon him”. 1861-1865 American Civil War

• 1861 Dorthea Dix, Supt. of Army Nurse Corps, , took supplies/aid stations to the front lines • 1862 Germ discovery by Louis Pasteur • 1865 Joseph Lister-use of antiseptic (carbolic acid) applied to wounds/hands. • 1873 less than 200 hospitals in the United States, of which a third was for the mentally ill • 1873 Nurses brought into the surgical theater • 1874 “notes of ” with techniques for preparation by Dr. C.H. Barnes • 1877 Basic advanced • 1878 First “listerian” surgical procedure performed in the US at Harper Hospital in • 1880 Mayo opened by with good reputations, outcomes (Drs.Wm./Chas Mayo) • 1880’s 1st electrocautery, arterial clamps, cystoscopes • Caps/gowns worn…..no masks/gloves until 1890 • 1880’s: 3 Nursing Schools established on the Nightingale's system • objected to women being educated, feared “THEY WON’T DO AS THEY’RE TOLD!! • 1882 Gustav Neuber of Germany introduced the Operating Room – Surgery not performed in same room as where sterilized goods were stored – Use separate rooms for clean and dirty procedures – Marble terrazzo and slanted floors, round corners – Unnecessary furniture was excluded – Patient segregated on wards and dressed in surgical gowns, pre operatively – Patients washed with soap and water, shaved, and draped with a rubber drape – Tables were heated and operating room doors were closed – Surgeons wore water proof aprons, performed a hand scrub outside and inside the operating room suite, as well as walking through an antiseptic mist – Operating rooms were heated, humidified, and had air circulation renewal every 30 minutes

• 1884 Dr. Halsted came to Bellevue Hospital • 1885 introduction of steam sterilization • 1889 Caroline Hampton wore gloves and was one of the first operating room head nurses • 1889-Johns Hopkins Hospital: set precedent for nursing in the OR – An OR nurse should have…”a level head and keen eyes, ever watchful for all that may be required, a mind not easily irritated or confused, combined with a facility for keeping out of the way and still being of the greatest help….thoroughness, speed, and gentleness especially fit the surgical nurse.” (Asepsis for the Nurse) Late 1800’s

• Post war, general hospitals in were charity, providing free medical care for those without suitable alternatives

• 1893 use of formaldehyde for preservation over alcohol, dry sterile field was necessary

• 1893 Isabel Robb (Cook County Hospital) – “To ensure thoroughness, one nurse should be given responsibility of the operating room” (Nursing: It’s Principles and Practices in the Hospital and Home)

• 1893 World’s Columbian Expedition in Chicago showed the latest hospital technology, autoclaves, rubber gloves, and immaculate operating rooms

• 1898 gloves were worn The Early Times

• Emphasis was on the technical aspect of nursing rather than patient assessment and safety • Although technology was rudimentary, there remains the basic steps – “The duties of an operating-room nurse, especially if they include the care of the sterilizing room, are very numerous. They require a knowledge of the principles of asepsis, careful attention to details, and much forethought in the preparation of supplies.” The Duties of an Operating-Room Nurse, Martha Luce, Boston 1900-1939

• 1901 specialty of operating room was established in “duties of the operating room nurse” published in the 6th issue of the American Journal of Nursing

• 1902: 1st OR Nursing Text-A Nurse’s Guide for the Operating Room (Dr. N. Senn)

• 1903: Formal OR experience required for RN • 1905: OR Nursing Interventions listed prevention of infection, promotion of comfort, physical safety, patient monitoring, resuscitation, and psychological support

• 1908 Droplet infection made masks mandatory

• 1910, pus in a wound was interpreted as a break in aseptic technique.

• Mid 1880-1915, operating room team became fully garbed (1917-1918)

• As late as 1920, techniques on how to convert ordinary residence into surgical setting was popular • 1920 the phrase registered nurse and abbreviation RN was used nationwide • 1900-1940 evolution of surgery with creating the greatest single demand for expansions of hospitals • 1930 operating room personnel organized for a meeting • 1939 first 3 day institute OR Nursing in the 1940’s and later

• Gloves were washed/dried/tested for holes, powdered and re-sterilized

• Sutures were prepared/sterilized

• Instruments were boiled after cases

• Sponges were washed/re-sterilized

• Anesthetics were explosive in nature: clothing must be cotton, shoes conductive, floors & equipment checked for conductivity, humidity at 55% World War II (1941-1945)

• “A surgery nurse must have many good qualities; but first of all, she must be most conscientious of sterile technique used, for the supervising nurse or surgeon is usually not present to watch the setting up of a case. Speed and efficiency are of no avail if a surgical wound breaks down due to an infection received in the operating room. The nurse must be enthusiastic about surgery or else is not able to continue in this type of nursing for long, as it is physically as well as mentally tiring….” (M. Crawford – 1945) Progression

• 1947 Dallas OR supervisors met

• 1948 Discussion of an organization began

• 1949 AORN was established

• 1949 5-day course Korean War 1950-1953

1954 AORN 1st National conference War 1968-1975

Role of the Perioperative Registered Nurse and the ‘surgical conscience’

• “The OR nurse…has a very responsible position. Every set-up a uses is prepared by a nurse. Remember this obligation. Only you can answer the question, Did I use good surgical technique while preparing and executing this procedure? Everyone connected in the procedure is sure you did. Have you betrayed these people and yourself?” J. Willingham (Logic of Operating Room Nursing, 1962)

• 1963 AORN Journal established

• 1966: AORN published “Statement Relating to the Non-professional Technical Assistants in the OR”; recognizing the need for non- professionals in the OR and for supervision by the RN, which was supported by the American College of Surgeons • HMO started to emerge • 1969: AORN defines the Role of OR Nursing • 1970’s Nursing Education programs begin to delete OR nursing from curriculums. • 1974: Medicare condition of participation- RN circulator – challenged by budgetary and political pressures. • 1980: RN circulator revised, allowed RN’s, LPN’s, ST’s • 1983: Revision for RN Circulator only, ST’s may assist • 1986: Allowed ST’s to circulate when “RN is immediately available” Persian Gulf War Fourth Renaissance?

• 1999 Institute of ’s To Err is Human • 2001 Second publication – Dimensions for improvement • Safety • Patient centeredness • Efficiency • Effectiveness • Timeliness • Equity Afghanistan and Iraq Wars

How well are we doing?

The top five risk management issues were identified. • Wrong patient • Wrong procedure performed • Improper consent • Unjustified sponge, needle, or instrument count • Burns from equipment – “Risk management in the operating room” AORN Journal, April 1980, (31) 5 p.876 What has been going on?

•Cosmetic •Bariatric • Transplant • Sterilization • Replantation •Reproductive • Reconstructive • Laparoscopic • Minimally invasive • Prosthetics • Laser • Conjoined twins • Endoscopic •Robotics • Microvascular • Trauma AORN Mission and Vision

• The Association of periOperative Registered Nurse’s (AORN) mission is to promote safety and optimal outcomes for patients undergoing operative and other invasive procedures by providing practice support and professional development opportunities to perioperative nurses. AORN will collaborate with professional regulatory organizations, industry leaders, and other healthcare partners who support the mission.

• The Association of periOperative Registered Nurses (AORN) is the leader in advocating for excellence in perioperative practice and healthcare. Central to promoting our practice

We must:

• Articulate who we are and why we are essential to patient care

• Visually demonstrate our proficiency

• Celebrate our value AORN: Statement on the Perioperative Role

• “The reason for the existence of practice is the care of persons undergoing operative and other invasive procedures….. it begins with the prospect of an operative or other invasive procedure and is completed by evaluating the extent to which the recipient’s needs have been met”. Demonstrating the Importance of Profession

• Value of a Perioperative Nurse • Patient Advocate • Establish a culture of safety for Patients and Staff – AORN Standards and Recommended Practices – The PNDS – Civility in the Workplace »Safety Net » Position Statements – National Goals – Publications – Tool kits »Time Out Day » Correct Site Surgery » Safety »Fire Safety Celebrating our Value

Scholarships & Educational Support for Members

Evidence-based Support for Clinical Practice

Workplace Safety Perioperative Challenges for the Future

• Perioperative nurses must be able to identify / validate the role of the registered professional nurse in then OR. Practitioners must delegate effectively and appropriately. Research must be conducted to identify nursing interventions, not just technical aspects, that positively affect patient outcomes and validate the need for professional registered nurses in the periOperative setting. The future is in our ...YOUR…hands! Sharing our Passion/Heritage

• Recognition of one’s passion usually begins with the reaction we invoke in others. We are all familiar with the influence of our actions on patients, evident by the high rating in public perception polls. Yet, imagine the magnitude of our passion when it can influence the rationale of another nurses’ practice. Strategies for Promoting

• As leaders, you need to understand the factors and forces that have brought us to this moment in time and be able to explain these events to others. • The key to recruitment and retention is to develop a mutually acceptable environment for all generations in our workforce today. Strengthen in Numbers • Set up an infrastructure that compliments each generation’s strengths • Create and maintain an environment where each person is respected • Engage all participants/attendees by being creative with learning (i.e., back to basics) • Learn to coach and mentor each generation • Develop flexible communication styles • Promote team work The passion for the periOperative nursing profession relies on those which can articulate and demonstrate the expertise and knowledge utilized during the performance of the nursing role.