Any surgery, whether it is a hip replacement or cardiac procedure, requires an experienced, multidisciplinary team, including a surgeon, anesthesiologist, physician's assistant and the circulating nurse.
"They are the ones who care for the patients throughout their surgical experience," said Eleonora Shapiro, MHA, RN, CNOR, vice president of perioperative services at Mount Sinai Hospital, New York, NY. "They provide continuous care, offering support to the patient and entire surgical team before, during and after the procedure."
"Our responsibilities span every aspect of surgery," added Natalie Trezza, MS, RN, CNOR, clinical nurse I at the Hospital for Special Surgery (HSS), New York, NY. "We are the glue that keeps everything together, leading the multidisciplinary team to ensure patient safety and a smooth procedure."
Circulating nurses make sure every detail is in place before a surgery, all the while advocating for the physical and emotional needs of the patient.
At a time of intense vulnerability, patients undergoing surgery must feel confident their well-being is the priority, which is why the circulating nurse's role is so vital.
"Since the patients are going to be under anesthesia, they will not be able to speak up for themselves. It is our job to be their eyes, ears and voice," Trezza emphasized.
To be an effective patient advocate, circulating nurses must earn their patients' trust before surgery. At HSS, this bond is formed during the circulating nurse's initial assessment.
"When the circulating nurse first meets the patient and their family in the holding area, they have a small amount of time to build that relationship and gain their trust before they go into the OR," said Tracy Willett, MSN, MBA, RN, CNOR, director of operating rooms, HSS. "It is critical they not only possess the necessary clinical knowledge, but also the people skills to cement this patient-caregiver bond."
Everything the circulating nurse does from that first meeting to postop is for the benefit of patients and their safety. "It is up to you to hold the line and make sure that the right thing is done in that room for the patient," Willett said.
OR ACTION: Natalie Trezza, MS, RN, CNOR reviews a surgical safety checklist during a hip replacement procedure. Photos by Jeffrey Leeser
Tasked with ensuring a safe procedure, these nurses must remain vigilant for the sake of their team and their patient. No detail can be overlooked; in the OR the smallest error can have tragic results.
"These nurses are involved in every part of the procedure," Shapiro said. "They perform patient assessments, prepare the OR, check equipment and supplies, and complete any necessary documentation.
"Circulating nurses are responsible for counting sponges, instruments and sharps," she added. "They must use the technology correctly every day, for every patient and procedure."
Following the guidelines of the World Health Organization, HSS uses a safety checklist throughout surgery. The first check occurs in the holding area.
Once in the OR, before anesthesia is induced there is another time-out between the anesthesiologist and the circulating nurse.
"During this time, we make sure we have the proper patient, laterality and procedure," said Monyne Bowman, RN, clinical nurse II at HSS. "We make sure all of the needs of the patient are met and that we have all of the necessary equipment. Safety is always our main concern."
The "official" time-out occurs immediately before the incision with the entire surgical team. Following the procedure, a final check is completed.
"We determine if there are any special needs for the patient postoperatively and identify anything that needs to be addressed that happened during the procedure," Trezza added.
Always ready to assist the team, a good circulating nurse does not wait for a request. "They make sure the surgery continues to progress," said Ron Perez, JD, RN, CNOR, vice president of perioperative services at HSS. "They are anticipating the needs of the surgeon and the anesthesiologist so the surgery continues to move at an appropriate pace."
The surgical team at the Hospital for Special Surgery in New York includes, from left, Tracy Willett, MSN, MSA, RN, CNOR, Sorina Bucor, RN, Ofelia Fabellore, RN, Danilo Sanchez, RN, Natalie Trezza, MS, RN, CNOR, and Monyne Bowman, RN.
"No one has to ask a good circulator for what they need," Trezza said. "We already have what they need ready before they even have their hand out."
This level of anticipation requires extensive knowledge and an understanding of various procedures.
Working in the OR exposes circulating nurses to a wide variety of procedures, which makes them invaluable resources. Over the course of their career, they will witness and participate in countless surgeries, building an incomparable knowledge base.
"The circulating nurse is looked at as an expert in the field because oftentimes they will have seen more of the procedures than a lot of other people," Perez noted.
Circulating nurses must not only learn their role in the OR. They also must have an understanding of the part every team member plays.
"Our job isn't just our job. We have to know what each individual in the OR is doing, what they may need and what could go wrong," Trezza said. "Our job goes far beyond the skills that are just our responsibility."
"Once the surgery begins, our job isn't done," she added. "We have to constantly be aware of what else is going on to properly advocate for the patient and guarantee their safety."
Uninterrupted, effective communication is equally important when it comes to a safe environment. Circulating nurses maintain contact with the "outside world" during surgery, whether it is to make the necessary arrangements or request assistance.
Natalie Trezza, MS, RN, CNOR assists with gowning.
"If we need to communicate any additional information to the PACU in advance, if we need any inter-operative consult, the circulating nurse would be the one that would, for example, call for the vascular surgeon or the urologist," Perez said. "An open line of communication is critical."
Whether it is communicating with the patient or other professionals, circulating nurses have the experience and expertise to provide information and support regardless of the procedure.
Within the surgical team, circulator nurses must be able to voice their opinions, especially when they believe the patient's well-being is at risk. This requires courage and conviction as well as a diplomatic nature.
"A good circulator is confident in what they do; they can stand up for what they believe in because they know the patient is depending on them," Perez said. "This position requires diplomacy because they are navigating the needs of a lot of different people at the same time."
"We are problem-solvers," Trezza added. "We can never give up. When equipment breaks or something is missing, we are the ones expected to get the job done. We have to find a solution."
Perioperative nursing is a unique specialty that upholds the highest standards of care. Constant education and improvement is required so the most effective tools and procedures are utilized to ensure patient safety and optimal care.
Certification is invaluable. "Every OR nurse should be certified," Shapiro said. "That is the gold standard that should be used by all nurses in the OR because they truly do have so much knowledge."
At HSS, education sessions are held twice a week to stay up to date on the latest advancements to patient care. In addition, the facility's nurse residency program for incoming OR nurses include 6 months of training and education, according to Perez.
Circulating nurses are imperative to patient safety, offering unparalleled knowledge coupled with patient advocacy.
"It is a very challenging environment, but you keep going no matter what because at the end of the day you simply want what is best for the patient," Bowman said.
Catlin Nalley is editorial assistant at ADVANCE.