Volume 33 Issue 4 Article 3

11-23-2020

From theatre to perioperative: A brief history of early surgical

Lois Hamlin [email protected]

Follow this and additional works at: https://www.journal.acorn.org.au/jpn

Part of the Perioperative, Operating Room and Commons

This work is licensed under a Creative Commons Attribution 4.0 License.

Recommended Citation Hamlin, Lois (2020) "From theatre to perioperative: A brief history of early surgical nursing," Journal of : Vol. 33 : Iss. 4 , Article 3. Available at: https://doi.org/10.26550/2209-1092.1107 https://www.journal.acorn.org.au/jpn/vol33/iss4/3

This Feature is brought to you for free and open access by Journal of Perioperative Nursing. It has been accepted for inclusion in Journal of Perioperative Nursing by an authorized editor of Journal of Perioperative Nursing. Feature

Author Dr Lois Hamlin From theatre to perioperative: DNurs, RN, FACN, FACORN A brief history of early surgical nursing

Abstract Perioperative nursing is believed to be the first specialisation to arise in nursing and tracing its beginnings is an interesting exercise. The scientific advances made during the latter part of the 19th century resulted in increased numbers of in . Though previously shunned by all but the poorest, hospitals now provided an environment that was safer for than a ’s home, and needed skilled nurses as a result. established a school of nursing in England teaching ‘sanitary nursing’ and ensuring probationary nurses knew about antiseptics and disinfectants. Ms Nightingale stated that it was the duty of every nurse on surgical wards to prevent infection, and until the end of the 19th century the nurses who cared for surgical patients in the wards pre- and postoperatively also prepared for and assisted during surgery. However, in 1889* the first dedicated operating room nurse was employed in the USA, and thereafter the role of the theatre nurse became entrenched. That role has evolved significantly since then and continues to do so. Introduction nebulous, wasn’t always recorded or is not accessible, and is sometimes This paper presents an overview contested**. The author welcomes of perioperative nursing from feedback from readers with verifiable when the specialty began in the material offering confirmatory or th latter part of the 19 century until alternate viewpoints. the latter part of the 20th century. Surgical interventions and models The beginnings of of care have changed dramatically during the last several decades, perioperative nursing due to the impact of technological It is reasonable to state that , rising costs, increasing perioperative nursing was not a demand and an ageing population1, discrete specialty 120 years ago and these have impacted on and was still embryonic in the first the role of perioperative nurses. decade of the 20th century. The However, these impacts are much beginnings of perioperative nursing better documented than those that arose from caring for surgical occurred in the first hundred years patients, as all nurses needed to or thereabouts and so have not been be trained to prepare for and assist addressed here. Delving into the at operations2 as well as care for past in order to identify the origins patients before and after operations. of perioperative nursing is no easy This begs the question: when did task, not least because its history is nurse training commence, and why?

* Note (May 2021): This was originally published incorrectly as 1899. ** An early caveat is that this article is not a systematic review and critical analysis on the topic, and is further constrained by the availability of appropriate sources, not all of which have been digitised. This is especially the situation regarding material from the latter half of the 19th century and the first half of 20th century.

Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au e-19 to supersede surgical nursing’7 (p.164). Nightingale also ensured that probationers were taught about antiseptics and disinfectants10. Importantly, she stated that, ‘In surgical wards, one duty of every nurse certainly is prevention ... [of] fever, or gangrene, or pyoemia, or purulent discharge’7 (p.165). Even in the last decade of the 19th century the nurses who cared for their surgical patients in the wards prior to surgery also prepared for and assisted during surgery2,13 as well as caring for them after surgery14. In some training schools in the USA, a significant amount of a nurse’s time during training was spent caring for Alton Cottage Hospital operating theatre, Hampshire, (c.1890–1910) Source: US National Library of (C01045) surgical patients and working in the operating theatre (OT)15. There is little evidence of formal knowledge of asepsis and the need training before the mid-1850s other to keep bacteria out of wounds grew. Operation-specific duties included than that associated with religious Consequently, the number of surgical ensuring that all instruments, orders since nursing care was cases increased as did the range of sponges, dressings and the water mostly delivered by family members surgical interventions, and surgical used in an operation were sterilised or household servants3. However, procedures were undertaken in and, if the operating table was long Florence Nightingale’s belief in hospitals whereas previously many enough, the nurse should ‘admit and implementation of sanitarian had been conducted in patients’ a hot water bottle at the patient’s 14 (p. 211) principles (hygiene, ventilation, light, homes. feet’ . In some instances, nourishing diet and activity) along nurses prepared patients for These hospitals needed a skilled with advocacy for better resources theatre by dressing them in a clean nursing workforce. Florence 13 for hospitals and injured and sick chemise, nightgown and stockings . Nightingale established a school of soldiers fascinated the Victorian Alternatively, they were dressed in nursing at St Thomas’ hospital in public. This, along with Nightingale’s lamb’s wool or flannel leggings, 18607, and in subsequent decades high personal profile, brought the and a loose lamb’s wool jacket – Nightingale-inspired schools were question of hospital reform and the although a loose lamb’s wool founded in Australia8, the United training of nurses to the forefront coat-shaped operating gown was States of America (USA)9, Sweden of British consciousness in the late also advocated, perhaps for female and elsewhere10. While Florence 1850s4. patients! The nurse also had to Nightingale was initially reluctant prepare herself in the following th The latter half of the 19 century to accept ‘germ theory’, she was manner: ‘A hot carbolic bath should also saw many scientific discoveries. staunch in advocating the need be taken on the morning of the Of note was the work of Pasteur for cleanliness, light, fresh air and operation, and perfectly clean with bacteria and of Lister, a British ventilation; their precepts had clothes put on’14 (p. 211). , who was developing underpinned her success during the and using antiseptic solutions5. in the early 1850s11,12, One of the first examples of a nurse There was also the advent of and her teachings focused on the who specialised in working solely anaesthesia as well as many need for nurses to ensure that in the operating theatre (perhaps other pertinent developments and sanitary conditions were created and even the first) was Caroline Hampton much social reform occurring3. All maintained at all times. She regarded Halsted* at the Johns Hopkins 6,16 these developments resulted in ‘sanitary nursing as essential in Hospital in Baltimore in 1889 . It is the rapid growth of hospitals6 as surgical as in medical cases, but not likely there were dedicated nurses

* Note (May 2021): This was originally published incorrectly as Hampstead. e-20 Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au 1933 and in Western Australia (WA) a couple of years later20.) Evolution of the role During this period the role began to evolve; in Australia, Jane Bell, the Lady Superintendent of Nursing at the Royal Melbourne Hospital, appointed a theatre sister in 1912, the hospital’s first such appointee21. An early edition of the British Journal of Nursing also outlined the nursing staff of a suite of four theatres in a UK hospital. These included a sister in overall charge, an instrument nurse, a sponge nurse and an assistant nurse in each theatre. The and nurses tending to a patient on an operating table at King George Military role of the assistant nurse was, ‘to Hospital, London, England (1915) Source: US National Library of Medicine (D05817) do whatever she may be told.’22 (p. 46–47). working in various European hospital century, developed their own nurse In due course, the sister in charge OTs at this time, perhaps even earlier, training courses, there being no role eventually became the theatre 23 given that surgery was ‘...far more national curriculum or standardised superintendent in the UK . During a advanced in Germany, Belgium and examinations. However, at that time, comparable time period in Australia, France’17 (p. 513). all nurses spent time in theatre as student nurses, ‘returned to a great Even before the start of the 20th part of their training6,18 and did so deal of solid cleaning’ in their fourth century, nursing textbooks included without the benefit of any lectures! year of training when they went to 18 (p.164) a chapter on the nurse’s role before Instead, they learnt by watching. In theatres . Here they scrubbed and during surgery2,13 and there was Australia, the Australasian Trained the walls, lights and the floors with much information published on this Nurses’ Association (ATNA) was lysol following the departure of the topic in The Nursing Record (later The formed in 189919, the first Australian surgeon, a task which took four hours. Nursing Record & Hospital World), nursing organisation which was self- Each theatre had a sister and two the forerunner of the British Journal governing and whose office bearers student nurses. The role of the sister of Nursing. These publications were were ‘prominent medical men and was to assist the surgeon, although not only an educational source of leading hospitals in a notable exception was the Royal regarding the practice of theatre Sydney’8 (p.18). ATNA was established Prince Alfred Hospital (RPA) in Sydney nursing but also informed readers to protect the public from ignorant where some surgeons (but not all) of new developments in operating and incompetent nurses, to had ‘instrument men’ until 1932. theatre design and surgical practice, improve and standardise general The role of these ‘instrument men’ among many other things. In the USA nurse training and to promote comprised the care and maintenance by 1900 the term ‘operating room the professionalisation of trained of instruments and sterilisation (OR) nurse’ had come into general nurses. For more than ten years the of catgut as well as assisting the use as a term of respect for nursing’s association determined standards of surgeon. In these latter cases, the 18 first speciality6. However, this was entry, training (including in theatre sister was the sponge nurse . not the case in other parts of the techniques) and examination, and Over the course of the 20th century globe; for example the term used in professional and personal codes of as the nursing curriculum evolved Australia and the United Kingdom conduct. (Note: in New South Wales and its theoretical content increased, (UK) was ‘theatre nurse’, which (NSW) in 1924, the state took over and concepts associated with theatre persisted for many decades. introduced the Nurses Registration nursing were introduced and taught. Act 1924 (NSW), with other states th Australian hospitals, like many in By the middle of the 20 century, and territories doing likewise shortly the UK and the USA prior to and a minimum of 40 days practical thereafter. For example, in the ACT, during the early part of the 20th experience working in OTs was nursing registration commenced in mandated and this was completed

Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au e-21 carried an artificial airway, tongue forceps and a gag. There was no mention of a recovery room and at that time there were very few in evidence in the UK23, 25. In Australia, the NSW College of Nursing offered the first theatre course for registered nurses (RNs), which commenced in 195026, while in 1955 the Melbourne-based College of Nursing Australia offered a six-month, full-time theatre management and teaching diploma course which was available to nurses from all states in Australia as well as to nurses from overseas27. Hospital-based theatre nursing courses which Back table set up (c. 1950s) © Victorian Perioperative Nurses Group had their own sister tutor evolved during the latter part of the 20th during a student nurse’s final comprised of compelling theatre century and were largely based in 8 year . Thereafter, if a student nurse staff to observe all principles teaching hospitals in capital cities. showed an aptitude for working in and techniques of asepsis, and For example, the RPA inaugurated the OT, the theatre sister in charge included an explanation of theatre a course on operating theatre would invite them to return on attire techniques in 196426, and the Royal completion of their basic training! • antiseptic and disinfectant North Shore Hospital did likewise Despite these curricular changes, 24 solutions shortly thereafter . Following the the work of student nurses changed move of nurse to the little; they cleaned up the theatres • types of suture materials (including tertiary sector in the latter part of the 23 and scrubbed instruments . Even kangaroo catgut!) and needles (all 20th century these courses followed in the 1950s and 1960s nurses’ (and reusable) suit, and postgraduate training is sisters’) work in theatres at the • basic information about asepsis now offered collaboratively with weekend included winding spools of and how to undertake various tasks various universities as well as by catgut and sterilising them; working without contaminating sterile items the Australian College of Nursing in the clean room, testing, drying, or the surgical team, including (formerly the NSW College of Nursing powdering and packing gloves ready the correct method for putting on and the Royal College of Nursing for sterilising; counting gauze swabs gloves Australia). into packs of five ready for sterilising; th polishing instruments and soaking • swabs – which, seemingly, were The latter part of the 20 century them in ‘instrument milk’; and only counted once, before the also saw the formation of theatre folding linen24. Unusually, at Royal wound was closed nursing organisations in Australia and elsewhere globally. In Australia, North Shore Hospital, Sydney, theatre • prevention of burns and sisters put student nurses at the the NSW Operating Theatre explosions, and the correct use of Association was founded in 1957 as instrument table to learn while they surgical diathermy were at the sponge table24. was the Theatre Sisters section of • the requirements and duties of the Royal Victorian College of Nursing An English textbook from the 1960s, the ward nurse – who brought (now the Victorian Perioperative 25 Surgery for Nurses , had a 13-page the patient to and from theatre. Nurses Group)27. The formation chapter on ‘Asepsis and theatre It is noted that the ward nurse ‘is of state-based entities in other technique’ containing information on entirely responsible for the patient jurisdictions followed in due course the following: during transit from the theatre to with the Theatre Sisters Section of 25 (p.102) • a short section on ‘theatre the ward’ . The ward nurse was the Australian Nursing Federation technique’ – which, seemingly, was exhorted, above all else, to keep in Western Australia (which became the airway clear, and to that end the Operating Room Nurses

e-22 Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au St Georges Hospital major operating theatre, Melbourne, Australia (1953) © Victorian Perioperative Nurses Group

Association Western Australia and entities had, and continue to exert, worked in perioperative nursing is now ACORN WA) in 1966, South a significant impact on the delivery management positions and as Australian Perioperative Nurses of perioperative patient care via perioperative nurse researchers. Association in 1970, Perioperative the development of standards of Advanced OR roles such as that of Nurses Association of Queensland care, educational endeavours and and perioperative (now ACORN Queensland) in 1972, networking opportunities. nurse surgeon’s assistant (PNSA) Tasmanian Operating Room Nurses also came into being. Consequently, In Australia, at the same time as (now ACORN Tasmania) in 1973, and around the turn of the century, the these changes in education along the Northern Territory Perioperative term ‘perioperative’ was adopted, with the formation of professional Nurses Association, the final representing the care of patients not nursing organisations were occurring, group to be formed, in 1990. These only during surgery but across all the role of the ‘operating room groups collaborated in 1977 to form stages – preoperative, intra-operative nurse’ was also evolving as was the the Australian Confederation of and post-operative30. associated terminology. Scrub and Operating Room Nurses29 (now the scout nurses became instrument Australian College of Perioperative and circulating nurses, while some References Nursing or ACORN). In the USA, nurses specialised in particular 1. Rapley L, Hamlin L. Evolving models of care. the Association of periOperative types of surgery (e.g. working In Hamlin L, Davies M, Richardson-Tench Registered Nurses (AORN, formerly M, Sutherland-Fraser S (eds). Perioperative only in highly complex cardiac or the Association of Operating Nursing: An Introduction. Chatswood, NSW: neurosurgical arenas) or stages of Elsevier; 2016, 358–382. Room Nurses) was formed in 1949 the patient’s journey (e.g. working 2. Nightingale K. The past as prologue to the and, in the UK, the Association for only in pre-admission, anaesthesia future. Br J Perioper Nurs 2000;10(7):354–363. Perioperative Practice (AfPP, formerly or recovery) reflecting the increasing 3. Dingwall R, Rafferty AM, Webster C. An the National Association of Theatre complexity and nature of surgery Introduction to the Social . Nurses) formed in 196428. All these London: Routledge; 1988. and anaesthesia. Additionally, nurses

Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au e-23 4. Nelson S. The Nightingale imperative. In 13. St John’s Hospital training school. The 22. Morison R. The instrument nurse. Br J Nurs S Nelson, AM Rafferty (eds). Sister: A Manual for Candidates 1912;48:46–47. Available from: rcnarchive. Nightingale: The Influence and Legacy of a and Novices of Hospital Communities. rcn.org.uk/data/VOLUME048-1912/page048- Nursing Icon. Ithaca, NY: Cornell University Springfield, Ill: St John’s Hospital Training volume48-20thjanuary1912.pdf. ILR Press; 2010, 9–27. School; 1899. 23. Ellis H. ‘The Sister’ in the early days of the 5. Ellis H. The Cambridge Illustrated History 14. The ’s Council. A practical NHS. J Perioper Pract 2016;26(4):50–52. of Surgery. 2nd ed. Cambridge: Cambridge demonstration concerning the nursing 24. Rice M. The Close of an Era: A History of University Press; 2009. of operations on the intestinal canal. Nursing at the Royal North Shore Hospital, 6. Clemons B. Diploma schools; the operating The Nursing Record & Hospital World 1887–1987. St Leonards, NSW: Royal room, nursing’s first specialty. RN 1896;16:210–212 [Internet]. Available North Shore Hospital Graduate Nurses’ 1973;36(2):OR1–9. from: rcnarchive.rcn.org.uk/data/ Association; 1988. VOLUME016-1896/page210-volume16- 7. Nightingale F. Notes on Nursing: What it is 25. Moroney J. Surgery for Nurses. 11th ed. 14thmarch1896.pdf. and what it is not. New York: Appleton & Co; Edinburgh: Churchill Livingstone; 1967. 15. Clemens B. Rules for OR nursing, 1899. RN 1860. Available from: www.fulltextarchive. 26. Croll Wilson H. The Second Fifty Years: A 1973;36(2):OR 9. com/pdfs/Notes-on-Nursing.pdf. History of Nursing at the Royal Prince Alfred 8. Russell L. From Nightingale to Now: 16. Ellis H. Surgical gloves. J Perioper Pract Hospital, Sydney from 1932–1982. St Ives, in Australia. Sydney: W.B. 2010;20 (6):219–220. NSW: Braxus Press; 2000. Saunders/Bailliere Tindall;1990. 17. Nursing on the continent. Br J Nurs 27. Williams CR. Unmasked: A history of the 9. Whelan, J. American nursing: An 1914;52:513–514. Available from rcnarchive. Victorian Perioperative Nurses Group. East introduction to the past [Internet]. rcn.org.uk/data/VOLUME052-1914/page513- Melbourne: Victorian Perioperative Nurses th Philadelphia: University of Pennsylvania volume52-06 june1914.pdf. Group (ANF Vic); 2010. School of Nursing; n.d. (cited 2020 July 22). 18. Armstrong DM. The First Fifty Years: A 28. Cox N. History of the NATN: 40 years and Available from www.nursing.upenn.edu/ History of Nursing at the Royal Prince Alfred counting. Br J Perioper Nurs 2005:15(5):197– nhhc/american-nursing-an-introduction-to- Hospital, Sydney from 1882 to 1932. Sydney: 205. the-past. Royal Prince Alfred Hospital Graduate 29. Cornell J. The History and Activities of Nurses’ Association; 1965. 10. McDonald L. Florence Nightingale: The the New South Wales Operating Theatre Nightingale School: Collected Works of 19. Strachan G. Labour of Love: The History Association Inc. 1957–2007 Celebrating 50 Florence Nightingale, Volume 12. Waterloo, of the Nurses’ Association of Queensland, years. Burwood, NSW: New South Wales ON: Wilfrid Laurier University Press; 2009. 1860–1950. Sydney: Allen & Unwin; 1996. Operating Theatre Association Inc.; 2007. 11. Ellis H. Florence Nightingale: Creator of 20. Crisp J, Douglas C, Rebeiro G (eds). Potter & 30. Sutherland-Fraser S, Osborne S, Bryant K. th modern nursing and public pioneer. J Perry’s Fundamentals of Nursing, 4 ANZ ed. Perioperative nursing. In Hamlin L, Davies Perioper Pract 2008;18(9):145–146. Sydney: Mosby; 2012. M, Richardson-Tench M, Sutherland- 12. Schmalbach CE. /quality 21. The Royal Melbourne Hospital (RMH). Fraser S (eds.). Perioperative Nursing: An improvement (PS/QI): Florence Nightingale History of the city campus [Internet]. Introduction. Chatswood, NSW: Elsevier; 2016, prevails. Otolaryngol Head Neck Surg Melbourne: RMH; n.d. (cited 2020 August 18). 1–29. 2015;152 (5):771–773. Available from: www.thermh.org.au/about/ about-rmh/our-history/history-city-campus.

e-24 Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au