Using Your Surgical Conscience in Perioperative Nursing

When I first started in the OR, I was very unsure of myself. I was not a new nurse, having previously worked on a maternal newborn floor for seven years, but I was new to the OR. Shortly after finishing my OR internship, I had a case with an attractive younger woman who was undergoing a breast procedure. Before the case started, I noticed that there were a lot of unnecessary staff members in the room looking at the patient as she was being prepared for the procedure. I was uncomfortable but did not dare speak up and tell them to leave. Later, I felt bad that I had not said anything, as they seemed to have no reason to be there other than to look at my patient.  

When internal and external constraints prevent us from acting in accordance with our core values and perceived obligations, we undergo moral distress.⁴ Studies have shown that failing to act on our moral obligations results in moral residue, meaning that we carry feelings and emotions of that experience of moral distress with us.⁵ I carried a lot of guilt about this patient. I do not think there was any deficiency in our surgical care, but I certainly did not feel that I had done my best for my patient. That feeling remains with me today. 

A few years later, I had a patient who used herbal supplements and developed priapism and a hydrocele. He was ashamed of the condition and in great pain. We brought him to the OR, and suddenly, I was in the same situation with many onlookers who had no reason to be in the room other than to stare at my patient. This immediately took me back to my previous patient and the moral residue of that situation. This time, I stood up, pointed to the door, and said, “If you don’t have a reason to be here, then you need to leave.” There was some grumbling, but they did leave. I was able to perform my job without the onlookers and provide the best care to my patient. 

As a result of these experiences and others, I wanted to share the following lessons that I learned: 

1. It is your job to protect your patients—protecting both their physical safety as well as their privacy and dignity. Do not ever be afraid to speak up and do what is right by your patient.
2. Treat patients like you would your own family member. If you would be uncomfortable with your family member being treated in a certain manner, it is not appropriate for your patient.
3. It is your responsibility to react in a professional manner. Whether it be unsafe use of equipment, poor positioning, or a provider who is unsafe to be performing surgery, always speak up for patient safety. This applies to any situation where you do not feel comfortable with the care being provided. Even if you are mistaken in your concern, if you speak up in a respectful and professional manner, you are doing the right thing. 
4. Discern the difference between people who are learning versus those who are simply curious. Sometimes, it is difficult to distinguish between people who want to look because of curiosity and those who truly want to learn about disease processes or conditions, especially in a teaching hospital. If a person is not assigned a role or a specific task in that OR, they should not be there. Increased traffic is associated with higher risk of infection, which is another reason to protect your patient from unneeded persons in the OR. 

Preparing for Moral Challenges 

One way to prepare for these types of challenging situations is to use a tool called cognitive rehearsal.⁶ This involves practicing what to do or say if you find yourself in a situation where you need to act on your surgical conscience.  

Early in my career, when immediate-use steam sterilization was more common, I worked in an OR where the industry representatives would bring in equipment to be washed in the scrub sink and thrown into the sterilizer. I knew this was not best practice. So, I armed myself with policy and a champion in sterile processing. The next time an instrument was dropped, I was told to wash it in the scrub sink and throw it in the sterilizer. I refused and took it to the decontamination area and enlisted the leader in the sterile processing department to help me locate a sterile instrument. When you are new to the OR, find people who will support you in using best practices and familiarize yourself with proper techniques, policies, and AORN standards. 

Conclusion 

Upholding patient dignity is a cornerstone of perioperative nursing. When a patient is most vulnerable, it is our job to stand up for the patient’s dignity. We must always lean on our surgical conscience to do the right thing. If we are to remain America’s most trusted profession, we must uphold our profession to the highest standards.