The importance of keeping our hand in the scrub role

Article Outline

• The Circulating Role
• The Scrub Role
• Knowing the Scrub Role
• A Part of the Perioperative Nurse Role
• Copyright

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• William J. Duffy, RN

Perioperative nurses' primary role in the OR is that of the circulating nurse. The circulating role is complex and requires licensed nurses to wear two hats simultaneously. One hat is that of the efficiency expert whose efforts are dedicated to facilitating the start and completion of the surgical procedure. The second, more important, hat is that of the patient advocate whose actions are dedicated to ensuring that the patient's rights and wishes are respected and carried out.

Wearing this second hat may require us to stand firm and take actions that slow the start or completion of a procedure until the surgical team can align its actions with the patient's expectations. It may require us to help sterile team members manage a crisis on the surgical field. Although other surgical team members may have the training to fulfill the efficiency role, only nurses have the assessment training with which to fulfill the role of circulating nurse.

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The Circulating Role 

The critical importance of the circulating nurse cannot be diminished. The circulating nurse has only a short time to establish a bond with the patient before the procedure so he or she can be an effective advocate for that patient. Preventing wrong site surgery and medication mishaps are just two examples of the critical errors that are on our radar screen as circulating nurses.

During complex procedures there are literally thousands of things that can go wrong. It is our job as circulating nurses to try to anticipate and prevent them from occurring. In many instances, we do this without conscious thought because our assessment skills lead us naturally to survey the environment, note a potential issue, and take action to resolve the problem. Many times, the surgeon, other teammates, and the patient are not aware of our interventions; however, taking care of the situation without fanfare does not lessen the importance of its impact. In fact, in my eyes, it heightens our value.

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The Scrub Role 

A trend I have encountered in some institutions around the country is to limit the role of the RN to circulating. I believe that in the long run this is a mistake. Effective circulating nurses have to understand the surgical process and know what the surgical team is doing. When I hear directors say that they only train their RNs to circulate, I wonder how these nurses can anticipate the needs of sterile team members if they have never been in sterile attire at the OR bed. If the goal is to increase efficiency during the procedure while maintaining the patient's safety, it makes sense that providing the circulating nurse with exposure to the scrub role will help him or her better appreciate the challenges and needs of the sterile team and be more efficient.

The importance of knowing about the scrub role when fulfilling the circulating role was made clear to me early in my perioperative career. My practice was focused on ear, nose, and throat and retinal surgery, but one day, I was assigned to scrub for a major vascular case. My circulating nurse was a young lady who would later become my wife. Chic is the best perioperative nurse I have ever worked with, and I still hope that someday my practice will reach her level. During the procedure, she moved constantly, keeping the surgeons happy about the lights, the anesthesia care provider up to speed on blood loss, and me provided with lap sponges and sutures. Suddenly from across the room I heard her say “Bill, get your DeBakey's.” I turned to look at her, and as I did, I saw the resident's reaction as he pulled too hard, tore the vessel, and lost the edge. In seconds, the surgeon said “DeBakey's, please” as Chic already was placing more laps and some suture on my back table.

She then went to the telephone to inquire about more blood without my saying a word. For the rest of the procedure I was in awe that she saw the problem from across the room, immediately went into action, and took the time to alert me to an impending request from the surgeon. To me that is circulating, and I do not think many nurses could meet that level of service as effectively if they did not have some scrub experience.

I am sure many of you have similar stories where quick intervention by the circulating nurse eliminated or lessened a potentially bad experience. If you have such a story, you can share it with your colleagues in the “Faces of Caring” page in the AORN Journal.

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Knowing the Scrub Role 

I know there is an initial cost associated with a staffing pattern that supports enough nurses so that some can scrub on a daily basis, but we need to look beyond the immediate effect and keep an eye on planning for the future. Any additional expense should be viewed as an investment in improving the quality and efficiency of care in the perioperative department. In my experience, a circulating nurse's scrub knowledge can lead to a decrease in the length of the surgical procedure, faster turnover between procedures, and increased patient safety.

Some individuals may argue that there are examples where RNs functioned in a circulating role only and there were no patient injuries. Although this may be true, it also is true that many ORs used to have all RNs on staff. These nurses gained experience in the scrub role, and this experience has been invaluable for hospitals holding the line on patient safety and efficiency.

As time moves on, however, perioperative nurses with scrub experience are retiring and taking their knowledge with them. Hospitals across the country are facing significant departures among nurses with scrub experience. When that expertise is gone, it will take years to reclaim. As leaders, we should prepare for that loss now by allowing more nurses the opportunity to scrub.

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A Part of the Perioperative Nurse Role 

Other individuals may say that nonnursing team members with extensive scrub experience can fill the circulating role. I believe this over-simplifies the circulating role. These people are confusing the benefit nurses gain by enhancing their assessment and patient advocacy skills through occasionally scrubbing with thinking that scrubbing experience alone can replace advocacy skills taught throughout nursing curricula. Scrubbing does not train someone to be an advocate nor does it train someone in the art of assessment; however, it can give a nurse insight into the needs of the patient and the surgical team, which helps sharpen the skills taught in nursing school.

Colleagues, as we move forward, I encourage both managers and staff nurses to embrace the benefits of periodically performing in the scrub role. By expanding the skills of team members to include the scrub role, patients, surgeons, and health care facilities all will be better served. Look for the opportunity, advocate for the opportunity, and gain the experience. Scrubbing is and always will be part of the perioperative nurse role.