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Table of Contents
CONCEPTS AND ISSUES
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 87-91

Pre-intra-post-operative nursing care pathway: Fragments to fusion, isolation to integration


College of Nursing, CMC, Vellore, Tamil Nadu, India

Date of Submission28-Nov-2019
Date of Acceptance30-Dec-2019
Date of Web Publication01-Jun-2020

Correspondence Address:
Mr. Dinesh Kumar Suganandam
College of Nursing, CMC, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCN.IJCN_12_20

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  Abstract 

Perioperative care refers to the care rendered during pre-operative, intra-operative and post-operative (PIP) care of patients undergoing surgery. A patient undergoes these three phases in different environments and also experiences much stress and anxiety. The relationship between patient and nurse during these phases significantly improves the outcome. Although the operating room (OR) nurses play a pivotal role in patient care, they are often unseen. With the view of linking alleviation of stress and anxiety of the patient and the visibility of OR nurses and also the fragmented and isolated care provision, the PIP nursing care pathway was developed based on the perioperative dialogue model. This pathway helps in connecting the three phases of transition, which ensures the fusion and integration of care. Based on this model, the OR nurse makes a pre-operative visit and explains about the OR environment. The same nurse receives the patient in the OR and assists in surgery. The post-operative visit is also made by the same nurse. Adapting this pathway influences patient and OR nurse satisfaction to a great extent. It also empowers the OR nurses to facilitate managed care. Visibility of OR nurses is improved by this pathway because of their interaction and involvement in all the phases. With the support of management, this pathway can be successful in order to provide effective perioperative care, which is fused instead of fragmented and integrated instead of isolated.

Keywords: Care pathway, fusion, integration, perioperative care, perioperative dialogue


How to cite this article:
Suganandam DK. Pre-intra-post-operative nursing care pathway: Fragments to fusion, isolation to integration. Indian J Cont Nsg Edn 2019;20:87-91

How to cite this URL:
Suganandam DK. Pre-intra-post-operative nursing care pathway: Fragments to fusion, isolation to integration. Indian J Cont Nsg Edn [serial online] 2019 [cited 2020 Jul 14];20:87-91. Available from: http://www.ijcne.org/text.asp?2019/20/2/87/285580


  Introduction Top


Perioperative nursing is defined as the practice of nursing directed towards patients undergoing operative and other invasive procedures. It was initially referred to as operating room (OR) nursing, but later, the term changed to 'perioperative nursing', as the perioperative nurses' responsibilities increased many fold.[1] For ages, it was believed that OR nursing involved only technical work which anybody could do. However, the scope of perioperative nursing has increased considerably, moving from the application of just technical skills of assisting with instruments to efficient use of knowledge and application of evidence-based nursing care to ensure the best quality in care. Perioperative nursing continuum now includes the care provided during pre-operative, intra-operative and post-operative (PIP) phases.[1] Ideally, the transition from one phase to the next within this continuum should happen in a smooth fashion. All the three phases should be linked seamlessly. However, in reality, it is fragmented and isolated to a particular phase in a particular setting. Patients experience these three phases in different environments/contexts and experience undue stress and anxiety. OR nurses, on the other hand, feel stressed because of long duty hours, poor image, failure of completion of care and feeling of poor recognition.[2],[3] According to the definition of perioperative nurse, care should be provided during PIP periods. At present, the perioperative nurses are confined within the walls of OR. Although the concept of perioperative nursing works well in developed countries, it is yet to become operational in developing countries.

When a patient gets admitted, undergoes surgery and recovers, he/she recognises the nursing care provided by the bedside nurses in the wards. The treating surgeon gets most of the credit for the patient's recovery. The OR nurses who are cardinal in ensuring a safe surgical environment in the OR are never recognised or appreciated. Although the concern of invisibility of nurses in the patient recovery is well documented in many settings,[4] OR nurses' visibility is least addressed. Patients hardly have an opportunity to contact perioperative nurses or benefit from the knowledge that they can bring into successful patient care.

Patients should be prepared physically as well as emotionally for a surgery. Most often, the focus is on the physical preparation rather than the emotional preparation. Adequate pre-operative physical, physiological and emotional preparation of patients enables them to have positive post-operative recovery.[5] There are many initiatives that have been identified, tested and used to alleviate stress and anxiety of surgical patients such as pre-operative counselling by counsellors,[6] video-assisted teaching,[7] meditation,[8] music therapy [9] and structured teaching.[10] However, the holistic dimension is unfortunately lacking in any of the interventions mentioned.

Undergoing surgery, whether minor or major, is a fearful and life-threatening experience for patients. They feel anxious and stressed, and they also have fear of unknown, death, fear about surgical mistake and confusion because of fragmented care.[11] OR nurses, on the other hand, experience disappointment related to lack of visibility, power, recognition and accountability and have feelings of despair, depersonalisation and reduced personal accomplishment. They have a sense of not completing the care and missing the opportunity of relating with the patient and caregivers.[3],[12]

A model that addresses both the patient's and nurse's concern related to surgery and that links the PIP phases will enhance the quality of care, patient satisfaction and OR nurses' contributions in the care of surgically ill patients.

Perioperative dialogue is one such model that ensures patients are comfortable as well as nurses feel accomplished. The concept of perioperative dialogue was developed by Post in 1999.[13] In the perioperative nursing dialogue model [Figure 1], the same operating nurse meets the patient in all the three phases. The purpose is to create a place for the dialogue, give time and space, listen to the patient and create a sense of community. It benefits both the patient and the nurse. The continuity of relationship between patient and a nurse forms a coherent whole.
Figure 1: Perioperative dialogue model.

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Findings from many studies show that the perioperative dialogue model has been found as a useful model for delivering perioperative care.[14] It is also evident that patients and nurses themselves found high satisfaction with providing and receiving care when perioperative dialogue was applied in caring.[15] Themes that emerged from the patients' and nurses' point of view as the result of perioperative dialogues are summarised in [Table 1].
Table 1: Themes from Nurses' and patients' point of view

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The perioperative dialogue model effectively addresses the importance of communication between the patient and the nurse. Although the continuity in caring within the dialogical situation is effective, the component of interprofessional communication and planning and executing vital nursing care interventions is missing in this model. Interprofessional communication as well as specific interventions that can be carried out by the perioperative nurses during the perioperative period are also essential elements in making perioperative nursing care and the nurses visible and accountable. Therefore, the author proposes the PIP nursing care pathway which includes the perioperative dialogue as a model for perioperative nursing.


  Pre-Intra-Post-Operative Nursing Care Pathway Top


PIP nursing care pathway is a clinical practice pathway [Figure 2] which will guide the OR nurses to function effectively and bring the best possible outcome in patients undergoing surgery. This pathway is developed to fix the lacunae that have emerged because of fragmented care in the PIP care. As noted, various factors pointed out by patients and nurses were because of the lack of uninterrupted care in all the phases. Therefore, the PIP clinical practice pathway is presented, which can be adapted and modified based on the available resources and support systems.
Figure 2: Pre-intra-post-operative nursing care pathway.

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Pre-operative care

Based on this clinical practice pathway, the nurse working in the OR will make a pre-operative visit for a patient who is posted for surgery for the next day. The nurse will develop a good rapport with the patient and explain about the intra-operative physical set-up, expectations, personnel involved, anticipated events and timelines. Patients' doubts will be clarified and a sense of trusting relationship is built. The nurse can utilise various teaching aids and modalities which are found to be effective in instilling knowledge. A video of intra-operative physical set-up and introduction of team members can be a vital tool in alleviating the fear of unknown. It will also help the nurse to anticipate events that may occur based on the patient's condition. For instance, if the nurse identifies the patient to be claustrophobic, the same information can be transformed to other team members and appropriate action can be taken. Interprofessional communication is the major element in the PIP nursing care pathway as it ensures the safety of the patient and improves the quality of care rendered. The pre-operative visit by the OR nurse will also aid in better preparation for surgical assistance. For example, if the patient is found to be obese, appropriate positioning aids, pressure sore preventive strategies, deep long instruments, etc., can be arranged in advance to ensure the safety of the patient and smooth progress of the surgery. The PIP pathway, thus, not only focuses on the alleviation of fear of unknown for patients, but also provides a means for nurses to improve the quality of care rendered to patients.

Intra-operative care

The same nurse who made the pre-operative visit will receive the patient in the receiving bay of OR. The nurse will remain with the patient and will help in transporting the patient from the receiving bay to the pre-anaesthesia room and assist in interventions such as intravenous cannulation, shifting to OR table, catheterisation and providing anaesthesia. The nurse will also communicate with other team members regarding any care alterations. Further, she/he can function as a circulating nurse for the particular surgery and will be present during extubation of the patient. The physical presence of a familiar nurse itself will boost the confidence of patients, promote a feeling of security and ensure comfort. The nurse will ascertain the safety of the patient by adhering to the WHO Surgical Safety Checklist through the involvement of sign in, sign out and time out.

Post-operative care

The nurse will make a minimum of one post-operative visit the following day to identify how the patient felt inside the OR. This visit will aid in sharing the experiences of both the patient and the nurse. It will also provide an opportunity for the nurse to evaluate the care provided. Based on the feedback from patients, structural or functional modification can be done in the OR. The nurse will also be able to provide surgery-specific post-operative instructions related to oral intake, exercises, adherence to medication, referral to other units, follow-up and liaising with other team members for further care and rehabilitation.

Although the PIP pathway appears tedious for the OR nurse, it can be implemented with tailor-made protocols based on organisational support, leadership abilities and workforce availability. A pool of nurses who can function as perioperative nursing practitioners can be an effective alternative if an individual nurse cannot carry out the PIP model of care.


  Outcome Indicators in Pre-Intra-Post-Operative Nursing Care Pathway Top


The PIP nursing care pathway can be evaluated by the following indicators:

  • Patient satisfaction index
  • Nurse satisfaction index
  • Same-day surgery cancellation rate
  • Post-surgical recovery rate
  • Adverse events in OR
  • Surgical safety adherence
  • Post-operative pain
  • Medication adherence
  • Stress and anxiety [19]
  • Average length of stay [20]
  • Usage of post-operative pain medication.[20]



  Opportunities in Implementing this Pathway Top


  • Creation of perioperative nurses' wing
  • Pool of nurses who can make pre-operative visit, receive the patient and visit the patient postoperatively
  • Strengthening of perioperative nurse specialist role.



  Challenges in Implementing this Pathway Top


There are various challenges in implementing this pathway. Some of them are as follows:

  • Workforce issues
  • Long working hours
  • Reluctance by OR nurses
  • Poor administrative support
  • Training of personnel.



  Future Direction Top


Incorporating technologies in ensuring the continuity of the perioperative care is challenging but can be tried. It can be sending a wish note on the day of surgery/discharge, SMS alerts,[21] phone call alerts, messages through app and E-mail reminders.

Perioperative navigator [Figure 3] is a mobile app which is developed to track the location of the patient inside the OR. Radiofrequency ID band can be used as a tracking element in this navigator. This can be an asset to the relatives who are waiting outside the OR just to get to know about their patient's condition.
Figure 3: Perioperative navigator.

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  Conclusion Top


PIP nursing care pathway is a symbiotic model which has beneficial effects to both the patient and the nurse. It enables the visibility of the nurse as well as improves the satisfaction among patients. The frightening experience of a surgical patient can turn into a non-threatening smooth process by implementing this pathway meticulously. The age-old tradition of OR nurses' role can be enhanced and empowered if the perioperative continuum is taken into consideration by the nurses. By this pathway, the perioperative nurse takes accountability for patient care with great commitment to ensure safety throughout. The key in successful implementation and impact of this pathway lies with the balanced technological input and uncompromising humanistic care. Although this pathway is designed based on the research findings and field experiences, it needs to be tested empirically.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Spry C. Essentials of perioperative nursing. USA: Jones and Bartlett Publishers; 2016.  Back to cited text no. 1
    
2.
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Sillero A, Zabalegui A. Organizational factors and burnout of perioperative nurses. Clin Pract Epidemiol Ment Health 2018;14:132-42.  Back to cited text no. 3
    
4.
Avila LI, da Silveira RS, Lunardi VL, Fernandes GF, Mancia JR, da Silveira JT. Implications of the visibility in professional nursing practices. Rev Gaucha Enferm 2013;34:102-9.  Back to cited text no. 4
    
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Iqbal U, Green JB, Patel S, Tong Y, Zebrower M, Kaye AD, et al. Preoperative patient preparation in enhanced recovery pathways. J Anaesthesiol Clin Pharmacol 2019;35:S14-23.  Back to cited text no. 5
    
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Jalali R, Dehghan F. The effectiveness of individual counseling on preoperative perceived stress in patients with cholelitiasis surgery. Iran J Nurs Midwifery Res 2017;30:1-0.  Back to cited text no. 6
    
7.
Jlala HA, French JL, Foxall GL, Hardman JG, Bedforth NM. Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. Br J Anaesth 2010;104:369-74.  Back to cited text no. 7
    
8.
Kiran U, Ladha S, Makhija N, Kapoor PM, Choudhury M, Das S, et al. The role of Rajyoga meditation for modulation of anxiety and serum cortisol in patients undergoing coronary artery bypass surgery: A prospective randomized control study. Ann Card Anaesth 2017;20:158-62.  Back to cited text no. 8
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9.
Cooke M, Chaboyer W, Schluter P, Hiratos M. The effect of music on preoperative anxiety in day surgery. J Adv Nurs 2005;52:47-55.  Back to cited text no. 9
    
10.
Pinar G, Kurt A, Gungor T. The efficacy of preopoerative instruction in reducing anxiety following gyneoncological surgery: A case control study. World J Surg Oncol 2011;9:38.  Back to cited text no. 10
    
11.
Nigussie S, Belachew T, Wolancho W. Predictors of preoperative anxiety among surgical patients in Jimma University Specialized Teaching Hospital, South Western Ethiopia. BMC Surg 2014;14:67.  Back to cited text no. 11
    
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Peñasales MA, Raquitico FR, Clores MA. Experiences of operating room nurses in promoting quality perioperative patient care. Clin Pract 2017;6:26-32.  Back to cited text no. 12
    
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Post VI. Professional nursing care' from the nurse anaesthetists' and operating room nurses' view. Doctoral Dissertation, Department of Caring Science, A bo AkademyUniversity, Vasa, Finland (in Swedish). 1999.  Back to cited text no. 13
    
14.
Pulkkinen M, Junttila K, Lindwall L. The perioperative dialogue – A model of caring for the patient undergoing a hip or a knee replacement surgery under spinal anaesthesia. Scand J Caring Sci 2016;30:145-53.  Back to cited text no. 14
    
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Rudolfsson G, Ringsberg KC, von Post I. A source of strength-nurses' perspectives of the perioperative dialogue. J Nurs Manag 2003;11:250-7.  Back to cited text no. 15
    
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Lindwall L, von Post I, Bergbom I. Patients' and nurses' experiences of perioperative dialogues. J Adv Nurs 2003;43:246-53.  Back to cited text no. 16
    
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Rudolfsson RN, Hallberg LR, Ringsberg PK, Post VR. The nurse has time for me: The perioperative dialogue from the perspective of patients. J Adv Perioper Care 2003;1:77-84.  Back to cited text no. 17
    
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Rudolfsson G, von Post I, Eriksson K. The expression of caring within the perioperative dialogue: A hermeneutic study. Int J Nurs Stud 2007;44:905-15.  Back to cited text no. 18
    
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Samarel N, Fawcett J, Davis MM, Ryan FM. Effects of dialogue and therapeutic touch on preoperative and postoperative experiences of breast cancer surgery: An exploratory study. Oncol Nurs Forum 1998;25:1369-76.  Back to cited text no. 19
    
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