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Operating Room: Psychological Vulnerability of Physicians and Nurses

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Page 1: Operating Room: Psychological Vulnerability of Physicians and Nurses

This article was downloaded by: [York University Libraries]On: 16 November 2014, At: 19:13Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office:Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Hospital TopicsPublication details, including instructions for authors and subscriptioninformation:http://www.tandfonline.com/loi/vhos20

Operating Room: Psychological Vulnerability ofPhysicians and NursesNed. H. Cassem M.D. a & Audrey A. Stricker R.N. ba Harvard Medical School-Massachusetts, General Hospital , Boston, USAb Shadyside Hospital , Pittsburgh, Pa, USAPublished online: 13 Jul 2010.

To cite this article: Ned. H. Cassem M.D. & Audrey A. Stricker R.N. (1974) Operating Room: PsychologicalVulnerability of Physicians and Nurses, Hospital Topics, 52:6, 36-38, DOI: 10.1080/00185868.1974.9948052

To link to this article: http://dx.doi.org/10.1080/00185868.1974.9948052

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Page 2: Operating Room: Psychological Vulnerability of Physicians and Nurses

Psycho/ogicu/ Vu/neru&#V of Physicians und Nurses

ROXANNE FOSTER, editor of HOSPITAL TOPICS, attended and reports on the AORN session.

NED. H. CASSEM, M.D. assistant professor of psychiatry, Harvard Medical School-Massachusetts General Hospital, Boston:

Often i n the operating room there is a sense of hushed awe, of marvel, o f miracle workers, o f artistic and heroic ex- p lo i t s . . . things that actually are of wonder and inspiration. Then, there are times when an OR looks l ike a mis-managed pre-school nursery.

What is behind our masks? What is behind your mask? What are our vulnerabilities? Some of our threats are: the work, the patients, fe l low nurses and the physician.

What about the work threat? We o f ten tend to forget that the work itself is horrendous. You're dealing with things that are impossible. The work is very threatening - an abdomen full of bullets, abcesses that open, and so forth.

What kinds of threats come f r o m the patients? The most frightening th ing about patients is A) h o w sick they are. B) h o w scared they are, C) often, h o w old they are. It is much harder t o work w i t h people at either end of the age scale. Our responsibilities are heavy fo r them.

Patients come to us in some kind of desperate situation tha t we are expected to alter or even reverse. x i s very threatening.

What is our response? In the OR we can anesthetize the patient. If effect, that stops his o r her miseries and yours too. I f acupuncture were used for all forms of surgery, that patient could watch everything you do.

What would you think of that? You wou ld have an apprehensive observer adding t o your burdens. Would you be uncomfortable?

Also, of ten what we do f o r the patient to make him well causes him more pain f o r awhile. This is also a burden to us. The more we a l low ourselves t o empathize w i t h the patient, the more one of t w o things happens: (1 ) The more you may feel gui l ty f o r in f l ic t ing pain on the patient, l i ke you are brutal izing him o r something, o r ( 2 ) You can become paralyzed by that and then you can feel l ike you are dehumanizing the patient.

However, if we won't a l low ourselves t o become involved, if we become callous or too cold, then we also feel that we are dehumanizing the patient. Thus, a genuine di lemma about where you stand in regard to the patient exists for health personnel.

Obviously, patients threaten us the most i f they die.

A third threatening source is interpersonal relationships. The basic problem is one of competitiveness and recognition. This can be manifested in two different ways.

There is inter-team compet i t ion as well as the interpersonal aspects w i th in a unit itself.

Also, o f ten supervisors or head nurses are 'damned i f they do help out' and 'damned' if the don't.'

Because o f our needs for self-esteem, all senior level personnel should give support and approval whenever it is deserved. Otherwise they are seen as people w h o only make negative comments.

What about the surgeon? He always seems to be the object of wrath. Vet, a surgeon once said to me after the death of a young patient w h o had charmed the entire hospital staff, "You know, she could have lived another year, but, because of something I did w i t h my t w o hands she's dead."

No one else's responsibility in this situation could have come close to the kind of responsibility assumed by the surgeon for her care.

H o w fool ish it wou ld be under such circumstances for a nurse to go on w i t h the usual mask of saying "How brutish he is" or "How cold he is" when, in actuality, if he seems to be tense or wi thdrawn it is precisely because h e feels all the same things you feel.

A nurse wou ld b e so wise, when a surgeon has a bad day, to maybe put her hand on his a rm and say "I k n o w i ts been a long day."

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Page 3: Operating Room: Psychological Vulnerability of Physicians and Nurses

AUDREY A. STRICKER, R.N., 0 R and R R supervisor, Shadyside Hospital, Pittsburgh, Pa., Member, AORN National Committee on Education:

When I was asked to speak on this subject, I was having qui te a stressful period w i t h my staff w i t h a very l o w morale and general complaining and unhappiness.

We had been in a new surgical suite fo r about 15 months and during that t ime experienced an 18 percent growth in caseload plus the addi t ion of new surgeons to the staff.

At f irst I thought the vulnerability and morale problems were due to all the changes, even though we had t r ied to prepare ourselves fo r change.

We were having so many complaints - main ly scheduling and staffing, apathy, insecurity o f staff nurses, host i l i ty t o surgeons, supervision and each other, and absenteeism and sick time.

Around this t ime we had a meeting of three A O R N chapters and we discussed this vulnerability. I asked these nurses w h y and when they fe l t vulnerable - if, indeed, they did feel vulnerable.

Most o f the reasons they gave were: new situations, lack of knowledge, a surgeon yel l ing or screaming at you and ten other people, change of procedure, physicians al lowing pol i t ics t o replace judgment.

One supervisor commented on the inabi l i ty t o please o n all sides; employer, employee, physician.

My first main point is that I th ink we can get r i d of a lot of our vulnerability b y being prepared and knowledgeable. We should be vulnerable to pain and suffering; but not vulnerable to our o w n inadequacies.

H o w does the manifestation of vulnerabi l i ty affect patient care?

1. A patient ly ing in the holding area, having received medication, i s o f ten more aware than we realize. He can sense lights, tension, chaos. This gives him more insecurity than he deserves.

2. Apathy - the small tasks that are not complete. There- fore, the circulat ing nurse the next day is vulnerable because she doesn't have what she needs.

3. Hostilities. If the circulat ing nurse doesn't have what she needs, the surgeon yells a t her, she gets mad at the technician and soon everyone in the OR is hostile. This al l goes back to the patient.

4. Sick t ime and absenteeism cause less personnel t o do the same work.

In look ing at my o w n situation, I had to define it before I could at tempt to correct it. What was occurring and why?

Why? Growth and change were t w o contr ibut ing factors. However, the pr imary factor was the t ype of staff. The major i ty o f my R N staff was very young, most o n their f i rst job.

This inexperienced staff had been through a 14 week orientat ion program to the OR which shows them where things are and procedures but doesn't teach them clear role identities and leadership abi l i ty.

As an immediate answer t o this problem I intensified staff meetings. I le t them k n o w that I was aware a problem existed and what it was.

We also sought the services of an outside consult ing f irm. They did a study of staffing, scheduling, admi t t ing pro- cedures, tardiness of surgeons, lengths o f t ime spent b y certain surgeons in the OR, delay of cases, and wha t we could d o t o better deal w i t h the situation.

The consultants also talked w i t h the staff and surgeons. We let the staff k n o w that this problem could n o t be remedied overnight. It was long-term.

I also sat d o w n with some of the surgeons w h o were causing the most vulnerabi l i ty problems in my younger nurses. I explained each part icular si tuation w i t h them and it seemed to do some good.

I also met w i t h the staff nurses a couple times. We did some role-playing such as, "How do you tel l a surgeon that you don't feel his technic is appropriate," and "How d o you handle the aide." This helped.

Staff nurses were also able to ventilate their problems. I asked them, "What would you do about it?" O f ten it is so easy to be cri t ical but harder t o combat something yourself.

I a m a front- l ine supervisor. I am always available to help. It is our responsibility to help. We must he lp ou r staff nurses feel as secure as w e do in our leadenhip roles. They shouldn't feel ashamed in coming to us and saying, "I need help w i t h leadership. "

We teach them to ask help on a procedure or where an instrument is, but do we teach them to ask f o r he lp w i t h leadership?

Of ten I think the staff nurse feels neglected if there is a seminar o n management and the supervisor o r head nurse, who probably have attended three or four, are sent. rn

The first thing we have to know is ourselves.

Secondly, we must know our job and have faith in our convictions. Then, we may be virtually unassailable to self-induced vulner- ability. A t that point no one can hurt us except ourselves.

Part of my problem was the inabi l i ty of many of the staff nurses to serve as a leader. They were in t imidated by the surgeon, myself and the aides.

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