Nurses challenge the operating room culture: a model of nurse-led care at Starship Children's Hospital's operating rooms has used play and humour to win the trust of a frightened patient.
Wounds and injuries (Care and treatment)
Wounds and injuries (Management)
|Publication:||Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 New Zealand Nurses' Organisation ISSN: 1173-2032|
|Issue:||Date: August, 2011 Source Volume: 17 Source Issue: 7|
|Topic:||Event Code: 360 Services information; 200 Management dynamics Computer Subject: Company business management|
|Product:||Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
The operating room (OR) focuses on surgical intervention and cure. Historically, it is a "doctor-driven" area where nurses have sometimes been described as "handmaidens" (1) Operating room time is a valuable commodity and resources are expensive and limited. Time can be a source of tension and interpersonal conflict, as individuals compete for control of its use. (2)
Our paediatric ORs at Starship Children's Hospital in Auckland were challenged when invasive surgical treatment of scalp and leg wounds ceased for a little girl named Claudia and her care became "palliative" However, she still required twice-weekly dressing changes under general anaesthetic (GA). A perioperative nurse-led model of care was developed that challenged our OR culture.
In 2004, Claudia presented to the children's emergency department with shoulder pain. She was just over three years old. A month later she was diagnosed with acute myeloid leukaemia (AML) and underwent treatment, including a bone marrow transplant. Unfortunately, Claudia developed Graft-versus-Host disease, which affected her skin, muscle, joints and gastro intestinal tract. She had large non-healing scalp wounds that were continually infected; the skin grafting donor sites on her thighs also became infected and non-heating; contractures occurred that affected her mobility; she had major gut problems requiring nasogastric feeding; and strictures with the oesophagus and airway made her a major GA risk.
Up until the beginning of 2009, Claudia had numerous skin grafting and dressing changes to try to heal her extensive wounds. These procedures required a GA each time and were carried out by plastic surgeons or paediatric general surgical registrars. Claudia was always upset coming into the theatre environment and would scream and hide under a blanket.
A model of nurse-led care
The concept of a nurse-led model of care for Claudia was based on the plastic surgical service's final decision that there was no cure for Claudia and no intervention that could heat her wounds. It was decided her care would be "palliative". Claudia's cares were complex and nurses found they were always explaining and showing registrars how to do the wound care and dressing changes. This was because registrars changed every three to six months. Time constraints and workloads for surgical registrars also meant it was difficult to get a surgeon for dressing procedures.
Surgical registrars did not see dressings as part of their "core business". Perioperative nurses saw this as care they could provide. At this time the initiative of nurses providing care for Claudia in the OR was discussed. The proposal was supported by the surgeon and oncologist overseeing Claudia's treatment.
Claudia and her family were approached with the idea that nurses wanted to provide care for Claudia in the OR. I explained that theatre nurses would take responsibility for the dressing changes and that this would provide continuity. An anaesthetist in the paediatric department developed an anaesthetic care plan that detailed Claudia's own anaesthetic preferences, a pain management regime and intravenous (IV) access details. This provided Claudia with some control and built trust between her and the anaesthetists.
Nutrition is extremely important in wound management and any prolonged fasting times can potentially affect wound healing. If Claudia was triaged within our acute patient workload, delay or postponement could occur. I sought approval from our unit clinical director to allocate the same day and time (twice weekly) in our acute theatre for Claudia. We started training nurses to provide continuity of care and created an individual perioperative care plan for Claudia. Nurses started a journal for each theatre visit, documenting Claudia's psychosocial state preoperatively, pain levels, condition of wounds, issues occurring during the week, overall well-being, dressing products used, nurses present, temperature and post-anaesthetic details.
Theatre nurses increased their skills in wound care management by attending study days and lectures, and by discussing aspects of Claudia's care with wound care specialists.
Our first consideration was to make the theatre visits less traumatic for Claudia. We did this by dressing up, having fun, celebrating birthdays and holidays. We found out Claudia's interests and hobbies, and started talking about them with her preoperatively. We invited Claudia to bring in her cat to the pet corner in our hospital and completed the pre-op check in there. These interventions helped form a trusting nurse/patient/family relationship. A rapport was created with Claudia and she started to interact with us and make eye contact.
At this time, we also began working closely with Claudia's psychotherapist. We started getting Claudia used to sensation and people touching her, in anticipation of her eventually having dressing changes done without a GA. We started hugging her and holding her hand. We involved Claudia in decision-making and were always honest with her. The anaesthetic champion ensured the anaesthetic plan was adhered to and Claudia's pain was managed.
We had an antibiotic regime in place where, if her wounds were infected, we could give her an immediate dose of IV antibiotic in the OR. We used a lot of laughter, play and humour, at times singing, dancing and using other distraction tools, and we had regular multi-disciplinary meetings and reviews.
Family perceptions of care
The biggest fear nurses had initially was whether Claudia's family would perceive this nurse-led initiative as inferior to one led by doctors. If Claudia's condition deteriorated, they might attribute it to the nursing care. The nurses had to constantly justify the time allocated for Claudia on the acute list, the costs of dressings and OR expenses. We had endless discussions and debate about an individual's perception of their quality of life. Some members of the wider team were rather negative about the notion of palliative care being provided in the theatre environment.
It was a challenge for nurses to advocate for Claudia and to communicate effectively to ensure her anaesthetic care plan was followed. There were constant challenges having a nurse-led model of care within this acute area, especially as Claudia was not under a surgical speciality. We had multi-disciplinary team meetings to update members on Claudia's progress. Managing the nursing resource for her dressing changes had to be planned carefully.
Benefits to Claudia
The major benefit to this model of nurse-led care was that Claudia became much happier and was no longer terrified of coming to the OR. Seven years after her first contact with our unit, she now looks forward to coming to theatre and does not scream or cry. Her pain is under control and she trusts the care provided. The wounds on her legs are completely healed and the wounds on her head have dramatically improved. Claudia's quality of tile has improved. She gets out of bed now, goes to school, goes horse riding, and dresses in different clothes (she used to wear the same outfit everyday). She wears underwear (she never used to) and often wears her wig over her head dressing.
Claudia, now aged ten, has started wearing her glasses and is interacting socially. She has become independent since getting her electronic wheelchair and enjoys going out. Claudia's systemic illness is improving. She has recently had her nasogastric tube removed and is eating and drinking orally.
Nursing model now accepted
The challenge to the OR culture at our unit has been considerable. Over the two years nurses have been responsible for Claudia's care, a subtle power shift has occurred. The constant need to justify our nursing actions and advocate for Claudia has diminished and the nursing model has been accepted. The acute theatre time is protected and the twice-weekly dressing changes have been reduced to weekly.
The wounds are now only on a small area of her head and we are hoping these will heal in the very near future. Claudia is no longer palliative and her do-not-resuscitate order has been removed.
Theatre staff got involved with other members of the multi-disciplinary team caring for Claudia and obtained an electronic wheelchair and bathing hoist.
Individually we have all had to consider the meaning of "quality of life" and how our own beliefs and perceptions can affect the care we give our patients.
Some staff initially considered the idea of dressing up and having fun in this setting to be inappropriate but I believe, over these last two years, Claudia's transformation and other patients' preoperative smiling and laughter have dearly demonstrated the unique opportunity we have to lead the way in the paediatric OR arena.
There is much evidence linking the importance of play with children's ability to cope with distress. Play and fun alleviate anxiety and increase adjustment. Play also acts as a coping tool during stressful situations and events in which a child feels a toss of control. (3) Dressing up and having fun provided the communication tools we needed to build a trusting rapport with Claudia.
As Claudia's mother said last year: "I have no doubt that without the fantastic team looking after Claudia, she would not be where she is today ... I feel it is significantly due to her feeling of happiness, which the theatre staff have given her. I would never underestimate the power of happiness and laughter in healing."
I leave the last words to Claudia: "I used to feel terrified, upset and I was crying and screaming. I hid in a pillowcase and I didn't trust anyone in theatre. I was scared of waking up in pain, but now I look forward to going and seeing the nurses. I know and trust everyone in theatre and I have fun and I laugh when I'm in pre-op. I enjoy dressing up."
* I would like to acknowledge and thank Claudia and her family for their willingness to have this story told.
(1) Riley, R. & Manias, E. (2006) Governance in operating room nursing: nurses' knowledge of individual surgeons. Social Science & Medicine; 62, pp1541-1551.
(2) Riley. R. & Manias. E. (2005) Governing time in operating rooms. Journal of Clinical Nursing; 15, pp546-553.
(3) Gariepy, N & Howe, N. (2003) The therapeutic power of play: Examining the pray of young children with leukaemia. Child: Core, Health & Development; 29: 6, pp523-537.
Ngaire Murray, RN, is charge nurse in general, urology, endoscopy and oncology in the operating rooms at Starship Children's Hospital, Auckland.
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