The Importance of Having a Surgical Conscience


Advocacy and courage are fundamental values of perioperative nursing. In the OR, we are fortunate enough to have an additional element to help us keep our patients safe: our surgical conscience. Surgical conscience begins with the knowledge of the principles of aseptic technique, infection control, and safety, and is supported by constant awareness of self and surroundings to maintain sterile integrity.1 Upholding surgical conscience involves ethical and moral decision-making and an obligation to speak up and act with courage on behalf of the patient.1

Unfortunately, having a surgical conscience and acting on it are two different things. You may have already experienced how difficult it can be to act on your surgical conscience at times. Whether it is a team member with a complex personality that we must confront about an unsterile act or a missing sponge that must be found, sometimes it feels like the weight of the world is on our shoulders. When it comes down to it, it may seem easier to silence that inner voice inside us rather than deal with the repercussions of raising our hand or stopping the line.

Moral Distress and Residue

As perioperative nurses, our patient’s safe and successful surgery means everything to us. We are the ultimate advocates for protecting and defending our patients. But, did you know that using your surgical conscience benefits your patient and is critical to your longevity as a perioperative nurse? Here is why. When we cannot act according to our core values and perceived obligations, we experience moral distress.2 Studies have shown that when we fail to act on our moral obligations, we carry a piece of that with us in something called moral residue.3 Like any residue, if left to build up over time, it can tarnish the original element and negatively affect its quality.2 The same is true for us. When we fail to act on our morals, we risk developing moral distress and moral residue, which builds up inside us and ultimately leads to burnout.

Cognitive Rehearsal 

One way to get ahead of this problem is to plan for challenging times with a tool known as cognitive rehearsal.4 This is where you intentionally practice what you may do or say if you need to act on your surgical conscience. For example, perhaps a colleague in the room consistently talks and is distracted during the time out. You can use cognitive rehearsal to prepare a statement in your mind for what you would say the next time this occurs. Perhaps you can say, “The patient needs us all to remain quiet and listen during the time out for safety” or “For patient safety, we all need to stop talking and participate in the time out.” Table 1 provides additional sample cognitive rehearsal response statements. You should avoid using “you” or “I” statements, because they may put the listener on defense, but still bring awareness to the fact that the patient needs everyone on the perioperative team to act a certain way.

Table 1. Examples of Cognitive Rehearsal Statements for Potentially Difficult Situations

Potentially Difficult Situation Requiring Surgical Conscience in Action

Sample Cognitive Rehearsal Response (to Prepare Ahead of Time)

Colleague(s) in the room are talking or distracted during the time out.

“The patient needs us all to remain quiet and listen during the time out for safety.”


“For patient safety, we all need to stop talking and participate in the time out.”

The surgical count is incorrect, and it seems nobody wants to pause from what they are doing.

“The patient needs us to pause what we are doing and find this missing (sponge, instrument, etc.).”


“For patient safety, we need to pause what we are doing and find this missing (sponge, instrument, etc.).”

Moments before incision, the surgical field gets contaminated.

“We have just had a break in sterile technique.  Let’s work together to resolve this as quickly as possible for patient safety.”

The patient’s consent said “left-sided oophorectomy” (not bilateral oophorectomy) and you hear the team discussing removing both ovaries during the procedure.

“On the patient’s behalf, let me remind you (or show you) what the patient has consented for prior to surgery.”

The patient is positioned on the OR table in lithotomy position as you begin opening the prep kit. You notice there is a lot of OR traffic as multiple vendor representatives are coming in and out of the room discussing the case with the surgical team. 

“For patient privacy, could we please wait outside the room until the patient is prepped and draped?  I will be sure to call you back into the room once we are through.”


You can intentionally prepare for challenging times with cognitive rehearsal. With some practice, you can act on your surgical conscience no matter what the situation entails. Acting on that inner voice will positively affect your patient and your longevity in perioperative nursing. 


  1. Quintana D. Surgical conscience: A concept analysis for perioperative nurses. AORN J. 2022;116(6):533-546. doi:10.1002/aorn.13827
  2. Fumis RRL, Junqueira Amarante GA, de Fátima Nascimento A, Vieira Junior JM. Moral distress and its contribution to the development of burnout syndrome among critical care providers. Ann Intensive Care. 2017;7:71. doi:10.1186/s13613-017-0293-2
  3. Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20(4):330-342.
  4. Griffin M, Clark CM. Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. J Contin Educ Nurs. 2014;45(12):535-542. doi:10.3928/00220124-20141122-02

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