Perioperative nursing in Australia is one of the oldest nursing specialties and has existed as a distinct entity for almost a hundred years, dating back to 1910 (Richardson-Tench, 2002). Operating room nursing underwent considerable change throughout the 20th century. The advent of sophisticated anaesthesia with its associated complexity of surgical procedures and the increased use of technology required the operating room nurse to develop commensurate knowledge and skills. In the 1970s, the term “perioperative nursing” gained acceptance with a shift in emphasis away from the traditional geographic boundaries inside the operating suite to the temporal boundaries of preoperative patient assessment, intraoperative care and postoperative evaluation. The advancing technology and changes in the healthcare system has impacted upon perioperative nursing practice, providing the professional nurse with a variety of roles to practice. Perioperative nursing practice is flexible, with the scope of practice inclusive of all aspects of care of the surgical patient (Richardson, 2000).

Historically, surgical interventions have taken place in the traditional environment of the hospital operating suite. Advances in surgical technology and procedures, improvements in anaesthetic techniques and changes in the healthcare environment have altered where and how surgery is performed.

Perioperative nursing as a concept

The perioperative nurse is a professional who provides complex care for patients in a high-dependency situation. The care encompasses safe and effective management in collaboration with other health team members; the nurse also safeguards the patient’s integrity by acting as an advocate for patients during their perioperative experience. Furthermore, the perioperative nurse explores strategies for the enhancement of practice through continuing education, research and habits of lifelong learning.

Professional nursing in the operating room has been defined in the United States as:

the identification of the physiological, psychological and sociological needs of the patient, and the implementation of an individualised program of nursing care that co-ordinates the nursing interventions, based on a knowledge of the natural and behavioural sciences, in order to restore, or maintain, the health and welfare of the patient before, during, and after surgery (Atkinson & Fortunato, 2000, p 22).

Even though the literature is replete with descriptions of the role of Australian perioperative nursing, there does not appear to be an explicit definition. Richardson-Tench (2002) describes the role of the perioperative nurse as follows:

The perioperative nurse is in a unique and privileged position as s/he assists with the surgical procedure. S/he is the consciousness of the unconscious patient. The perioperative nurse maintains the personhood of the patient by the provision of psychological care and by making ordinary the extraordinary event of surgery. S/he designs, co-ordinates and delivers care comprised of nursing knowledge and psychomotor skills which are a blend of thinking and doing, to meet the needs of the surgical patient. While scientific nursing techniques underpin perioperative nursing practice, competent fulfilment of the role is based on the knowledge and critical application of the biological, physiological, behavioural and social sciences (p 37).

Perioperative nursing is a highly skilled specialty with subspecialties, and a clearly defined role in terms of the surgical team and the patient. It requires nurses to be educated in nursing theory and the health sciences and to have attained appropriate interpersonal communication skills. The delivery of perioperative patient care requires complex knowledge and skills to effect safe outcomes for the surgical patient (Richardson-Tench, 2002).

Philosophy of perioperative nursing

Ideally, perioperative nursing practice is based on a written stated philosophy, which blends with the hospital’s mission statement and describes values and beliefs that pertain to professional nursing practice. Perioperative nurses’ primary professional responsibility is to the patients for whom they care. In the perioperative setting, healthcare personnel from different professional disciplines work together for a common objective: to provide competent, skilled and appropriate patient care. The philosophy of perioperative nursing encompasses a holistic, multidisciplinary approach that is concerned with:

• the need to provide a safe physical environment

• the protection of patients from adverse events

• the achievement of optimal patient outcomes

• promoting the knowledge and skills of all multidisciplinary team members to enable cost-effective, research-based health care delivery

• the acknowledgement of the dignity of persons with diverse physical, emotional and cultural backgrounds.

Thus, perioperative nurses possess unique knowledge and skills. They provide holistic care and are particularly aware of the fears and anxieties of the patient, as well as their physical needs (e.g. warmth and comfort), spiritual needs (e.g. support from staff) and sociological needs (e.g. acquaintance with staff and environment). Perioperative nurses constantly analyse, reflect and evaluate their performance. In other words, how they deliver patient care reflects their professionalism.

Caring role versus technical role

The technical dominance that defines perioperative culture inevitably links the evolution of nurses’ roles to the development of technology. Technology can be best understood in terms of knowledge, skills, techniques, artefacts and resources (Barnard, 2007). Of necessity, perioperative nurses need to have technical aplomb for the wide array of machinery and equipment used in the provision of patient care. Moreover, some research suggests that there is still theoretical distancing of perioperative nursing from mainstream nursing based on conventional notions of the nurse–patient relationship that develops between people (Yamaguchi, 2004). Defining nursing care in the perioperative setting within this narrowly conceived traditional model has contributed to stereotypical perceptions that cast nurses as “handmaidens” to the surgeons (Gruendemann, 1970), and positions the specialty as task-orientated and technical (Sandelowski, 1999). These descriptions imply that nurses’ interpersonal relationship with patients in the perioperative setting is restricted; and that the nature of “caring” is considerably diminished because of the differences in role orientation. There is continuing debate about whether perioperative nursing can even be considered nursing (Sandelowski, 1999), or even if nurses need to be present in the operating suite (Bull & FitzGerald, 2006).

For example, one field study found that perioperative nurses experienced role confusion as they were socialised to perform exclusively as technicians and assistants to the surgeons, not as nurses (Yamaguchi, 2004). This study demonstrated that nurses’ roles in the perioperative environment were more technically focused and task-orientated, and substantiates the struggle that many perioperative nurses have working within a non-traditional area of nursing. The apparent conflict between caring and technical roles as the level of technology increases in the perioperative context has the potential to distance nurses from their patients, and erode the quality of care that patients receive (Bull & FitzGerald, 2006). Likewise, technical competence is often recognised and rewarded in the perioperative setting, and nurses with these attributes are held in high esteem—they are trusted and consulted (Bull & FitzGerald, 2006; Gillespie et al., 2008b). Consequently, perioperative nurses may find themselves faced with something of a predicament because of the dual nature of their perioperative role. The caring aspect of their role is what makes them “real nurses” and yet the technological component is what earns perioperative nurses professional respect (Bull & FitzGerald, 2006). An example of the conflict that nurses experience between the technical and caring roles is emphasised in research conducted by Richardson-Tench (2007), presented in Box 1-1.

Box 1-1 Dialectic between caring and technical roles

Findings from Richardson-Tench’s (2007) field study illustrate the tensions that perioperative nurses experience in their dual roles as carers and technicians. It appeared that for some of the lesser experienced nurses, the caring role was subsumed in the technical imperative that was associated with learning the surgical procedure. Consequently, for the novice, ‘humanistic caring’ could not take place until there was mastery of the psychomotor skills that defined the technical aspect of the perioperative role.

Patient care presents many challenges as perioperative nurses often have minimal time to establish rapport or provide reassurance, as well as obtain important clinical and/or psychosocial information. Perioperative nurses must have the ability to assess the patient quickly and become attuned to the patient’s verbal and non-verbal cues. In many instances, the nurse is the last person that patients see before they are anaesthetised (Sigurdsson, 2001). For perioperative nurses, the central purpose of the patient–nurse relationship is to ensure the safe passage of patients during the perioperative period (Bull & FitzGerald, 2006). Perioperative nurses are in a unique position, as they must ensure a safe therapeutic environment for patients by maintaining practice standards (Richardson-Tench, 2007). Patients are at their most vulnerable when they enter the operating suite and are profoundly reliant on the skills and expertise of the nurses who care for them. In combining the technical and caring aspects of their perioperative role, nurses are the human conduits that provide the physical link between the patient and the machine (Glaze, 1999; Sandelowski, 1999).

Perioperative care roles

Nursing roles in the perioperative setting are based on both behavioural and technical components of clinical competence. The perioperative nurse plans and directs nursing care for patients undergoing operative and other invasive procedures. The scope of practice may include (but is not limited to) preadmission nurse, anaesthetic nurse, circulating nurse, instrument nurse, postanaesthetic recovery unit (PARU) nurse, perioperative nurse surgeon’s assistant (PNSA), manager, educator and researcher. The roles of anaesthetic nurse and PARU nurse are usually exclusively designated—that is, nurses working in these roles do not routinely undertake other perioperative roles—but this may be dependent on staffing levels and skills. However, the traditional intraoperative roles of circulating nurse and instrument nurse are undertaken interchangeably throughout the day’s operating list. Importantly, perioperative and surgical outcomes are influenced by the standard of care delivered by the nurse working within each of these roles (ACORN, 2006; PNCNZNO, 2005).

Preadmission nurse

The preadmission nurse plays an important role in the preparation of the patient for surgery by functioning in a screening role, detecting medical or physical conditions that may generate a referral to the surgeon or anaesthetist.

Anaesthetic nurse

The presence of an appropriately educated anaesthetic nurse/assistant is integral for the safe and efficient administration of anaesthesia (ACORN 2006; ANZCA 2003; PNCNZNO 2005). Specifically, the role of the anaesthetic nurse is to collaborate with the anaesthetist to provide patient care and procedural support (ANZCA, 2003). If an anaesthetic technician is required to fulfil this role briefly, then they require the appropriate professional education.

A registered nurse (RN) or enrolled nurse (EN) (Division 2 Registered Nurse, Victoria/Western Australia) may perform the anaesthetic nurse role. Perioperative nurses who work in this role have an option to obtain specialty education through an accredited postgraduate program. The Australian and New Zealand College of Anaesthetists recommends 150 contact hours (ANZCA, 2003). Enrolled nurses must work within their defined scope of practice as determined by the relevant state registration board authority (ACORN 2006; PNCNZNO 2005). Some of the role responsibilities of the anaesthetic nurse are outlined in Box 1-2.

Circulating nurse

Perioperative nurses’ primary role in the operating room is that of the circulating nurse. This is a complex role encompassing management of nursing care of the patient within the operating room and coordination of the needs of the surgical team and other care providers necessary for the completion of surgery (Matson, 2001). The circulating nurse’s duties are performed outside the sterile area. Using critical thinking skills, the circulating nurse observes the surgery and the surgical team from a broad perspective and assists the team to create and maintain a safe and comfortable environment for the patient. The circulating nurse assesses the patient’s condition before, during and after the operation to ensure an optimal outcome for the patient. Most patients undergoing surgery are anaesthetised or sedated and are powerless to make decisions on their own behalf during the intraoperative phase.

The critical importance of the circulating nurse cannot be understated (Matson, 2001). The circulating nurse serves as patient advocate while patients are least able to care for themselves. However, they have limited time to establish a bond with the patient before the procedure in order to be an effective advocate. Some of the role responsibilities of the circulating nurse are summarised in Box 1-3.

Instrument nurse

The instrument nurse works directly with the surgeon within the sterile field, passing instruments, packs and other items needed during the procedure. Both the circulating and instrument nurses have a dual role in checking to ensure that all appropriate sterile instrumentation and surgical supplies are available and functional before the start of the list (ACORN, 2006; PNCNZNO, 2005). During surgery, the instrument nurse’s role should be distinct from, and not overlap with, the role of the first surgical assistant, that is, the person assisting the surgeon. While there may be situations where there is a transient overlap of these roles (e.g. patient haemorrhage, difficult access), this situation should not occur routinely. Knowledge in relation to standards of perioperative practice (e.g. standards for cleaning and practice, aseptic technique, infection control, medicolegal requirements, anatomy/physiology, surgical procedures) is essential to perform these roles safely and effectively. To assist nurses to develop a broad knowledge base, specialty perioperative education through an accredited program is recommended (ACORN, 2006; PNCNZNO, 2005). Depending on the policy of the particular hospital, the instrument nurse may be an RN or an EN. ENs must work within their defined scope of practice as determined by the relevant state regulation authorities and must be under the supervision of an RN (ACORN, 2006). The role responsibilities of circulating/instrument nurse(s) may overlap a little with that of the anaesthetic nurse, depending on the policy of the relevant operating room department, scope of practice of individual nurses within the team and the structure of the surgical team. For instance, in some operating suites, it is the role of the anaesthetic nurse to check the patient’s details (i.e. correct identity/surgical site, consent, allergies, etc.) when they arrive, whereas this duty may be incorporated in the role of the circulating nurse in other departments. Box 1-4 highlights some of the responsibilities associated with the instrument nurse role.

Perioperative nurse surgeon’s assistant

It has been recognised for many years that nurses have acted as assistants to surgeons in the capacity of first assistant, where the nurse provides skilled assistance but not surgery (McGarvey et al., 2000). However, more recently, changes in health care delivery have precipitated the emergence and recognition of an extended practice role for RNs in the perioperative setting (ACORN, 2006). The PNSA role in Australia incorporates the preoperative, intraoperative and postoperative phases of care. Within its most limited scope of practice, the PNSA role may be restricted to the intraoperative phase (Riley & Peters, 2000). The Australian College of Operating Room Nurses endorses the ongoing development and expansion of the PNSA as a Nurse Practitioner role (ACORN, 2006), which would require educational preparation to a Masters degree. Essentially, the scope of practice within the PNSA role is determined by state and federal legislation. Box 1-5 details some of the role responsibilities undertaken by the PNSA.

Box 1-5 Role responsibilities of the PNSA

• Undertake physical patient assessment, including medical history, and, in collaboration with the surgeon, organise required clinical investigations.

• Collaborate with patient, surgeon and other health care team members to develop a clinical pathway.

• Develop education programs for patients/staff.

• Assist with skin preparation, draping, haemostasis, cutting sutures/ligatures, retracting organs and skin closure.

• Provide postoperative care in wound management, education, dressing application, etc.

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