ursing audits are based on estab-

N lished standards of practice and

are used principally as a mea-
sure of quality. However, as a senior
student at the University of California,
San Francisco (UCSF) School of Nurs-
ing preparing to specialize in operating
room nursing, I discovered the addi-
tional value of the process audit as a
learning tool using direct observation
techniques.
The School of Nursing at UCSF offers

Nursing audit: a unique curriculum that enables senior

students to spend the last six months in
an area of concentration of their choice.
Learning tool A wide range of inpatient and outpa-
tient clinical settings are available to

for students help students enhance their present

Linda Dickey White, RN
nursing skills or train in a specialty
area of nursing. Students who select the
operating room spend 16 clinical hours
per week with an individual preceptor
who is responsible for teaching operat-
ing room skills. In addition, two hours
per week are devoted t o lectures dealing
with the theory and principles ofoperat-
ing room nursing with an emphasis on
nursing process. This part of the course
requires preoperative and postopera-
tive visits. In this paper, I describe my
student experiences and how I incorpo-
rated nursing process into my training
with the assistance of the process audit
tool.
Acquiring organizational skills as a
circulating nurse is an important aspect
of learning to function efficiently in the
operating room. My first clinical ex-
periences were somewhat frustrating
because I found myself memorizing the
order in which tasks were performed
without regard to how they related to
the nursing process. As I began study-
~ ~ ~~~

Linda Dickey White, RN, is a staff nurse at

University of California, San Francisco. She
holds a BSN from the University of California,
San Francisco, School of Nursing, and has a
BA from University of California, Berkeley.

AORN Journal, February 1979,Vol29, No 2 247

 Figure 7

Preoperative assessment form

Patient's name Age Sex- Date
Preoperative diagnosis Surgeon
Surgical procedure Interviewer
Preoperative visit made and charted-
Chart reviewed
Routine explanations
General information on anesthesia

General information on surgery

Patient and family told:

time and length of surgery
when patient to return to room
where family can wait
Preoperative and postoperative routines explained

premedication
mode of transportation
shave preparation
OR environment
postanesthesia recovery room/intensive care unit
pain medication
special dressings

ing process audit, I realized this tool
could provide guidelines for learning
standards of nursing care for the surgi-
cal patient.
According to Mohr, audits are de-
signed to provide standards of excel-
lence in nursing practice and may be
used to identify areas that need change
to improve the overall pattern of care.l
Audits can also help in planning con-
tinuing education, purchasing equip-
ment, and in implementing changes in
policy, procedure, and staffing. Process
audits involve one nurse observing and
evaluating the care given by another
nurse. The desired outcome of an audit
is to improve the quality of care rather
than to serve as a peer review tool.
How then can process audit be effec-
tively employed by students who are
learning nursing process practiced in
the operating room? Nursing process in
the operating room consists of the
preoperative, intraoperative, and post-
operative phases of surgical care; each
involves several components. The audit
tool used at the University of Califor-
nia, San Francisco, is divided into four
sections-assessment, planning, im-
plementation, and evaluation-to cor-
respond with these phases. Preopera-
tive assessment allows the nurse t o col-
lect physical and psychosocial data for
use in formulating a nursing care plan
suited to the needs of the patient. In
addition to patient assessment, the
nurse has the opportunity to educate
the patient about his illness and to dis-

248 AORN Journal, February 1979,Vol29, No 2

 drains
casts
catheters
pressure monitoring lines
electrocardiogram
respiratory equipment
other
Assessment
Physical needs

Safety concerns

Medication instructionslinformation

Socioeconomic situation relevant to health care

Environmental concerns

Teaching

Discharge planning

cuss the operating room experience. while in the operating room.

Because of my inexperience with
preoperative visits, I used the UCSF
audit tool, in addition to the eight as-
sessment categories described by Mun-
ley,2 to serve as a guide for my visits
(Fig 1).Following a preoperative visit,
this form is completed and serves to
facilitate data collection for an assess-
ment. The form also ensures that teach-
ing covered all pertinent information
concerning the patient’s surgical ex-
perience. For example, the category of
physical needs can alert the nurse to
problems with obesity or limitations
due to arthritis. Therefore, the assess-
ment and concomitant nursing care
plan would draw special attention to the
transfer and positioning of the patient
To enhance my teaching skills, I used
the UCSF audit tool whereby the au-
ditor validates with the patient in a
postoperative setting whether or not es-
sential facts were provided preopera-
tively. For example, was NPO status
described, or was the patient told when
he would be returned to his room, where
visitors could wait, and what type of
dressing or special equipment to expect
following surgery? The categories that
cover general information about
surgery and anesthesia are included to
verify what the patient was told by
physicians to assess the patient’s level
of understanding. The patient is en-
couraged to discuss his concerns and
seek additional information from physi-

AORN Journal, February 1979,Vol29, No 2 249

cians if desired.
The second phase in the nursing pro-
cess occurs intraoperatively and con-
sists of planning and implementing the
patient’s care plan. Prior to the sur-
geon’s incision, the nurse is responsible
for seeing t h a t all equipment and
supplies are set up according to stan-
dard care plans and that the patient has
been properly identified and prepared
for the operation. During this phase, the
student can examine his or her perfor-
mance of the necessary tasks and com-
pare it to the standard nursing inter-
ventions contained in the audit. By
using the audit as a checklist, the stu-
dent can review the items either
preoperatively or postoperatively and
note the various tasks as they are com-
pleted. As a result, the student has a
record of care provided and can easily
identify tasks that were improperly per-
formed or omitted.
For example, the checklist may re-
veal t h a t the student is handing
supplies to the scrub nurse rather than
assisting anesthesia during intubation,
failing t o note sponge and needle
counts, or forgetting placement of the
cautery groundplate. Perhaps the
problem of handing supplies to the
scrub nurse could be approached with
the student’s preceptor who could re-
view those items that are needed first
and those that can wait until intubation
is completed. Therefore, audits can be
used as a mechanism that allows moti-
vated students t o learn at their own
pace and concentrate on those aspects of
organization and priority setting that
are the most difficult to master.
The student can review the audit in-
diGidually or select a peer or preceptor
with whom t o discuss questions or con-
cerns that may arise regarding audit
outcomes. Audits performed by stu-
dents should not be used for the same
purpose as those done by experienced
staff. Instead, audits provide an oppor-
250 AORN Journal, February 1979,Vol29, No 2
Figure 2
Postoperative
evaluation form
Application and discharge of physician’slegal
orders
Observations of symptoms and reactions
Supervision of patient
Supervision of other, nonphysician personnel
Reporting and recording
Application and execution of nursing process
Promotion of patient’sphysical and emotional
health by direction and teaching
General comments
tunity for the student to learn according
to established standards of practice;
therefore, a discussion of outcomes be-
comes an essential step in the learning
process. The audit is not intended as a
performance evaluation or peer review,
but rather as a learning experience to
aid students in the mastery of technical
and organizational skills.
The final phase of the nursing process
is the postoperative interview, which
provides an opportunity t o review the
surgical experiencewith the patient. By
asking for information given during the
preoperative visit, the student can as-
sess the patient’s recall and under-
standing and give subsequent rein-
forcement in areas where teaching may
have been inadequate. In addition to a
preoperative assessment sheet, a
guideline (Fig 2) for postoperataive vis-
its was devised based on Phaneuf ’s
seven functions of nursing p r a ~ t i c e . ~
This format also proved useful in self-
evaluation of my role during the in-
traoperative phase of care. For example,
in reviewing the procedure, I could
check if my supervision of the patient
was adequate during transfer and posi-
tioning or if my charting was accurate
and helpful to other nurses. As with the
intraoperative audit tool, I was able to
review my performance, increase my
awareness of the role of the circulating
nurse, and work at strengthening areas
where optimal care was lacking.
By the completion of my training, I
felt that I had mastered the basic skills
of patient care in the operating room as
a result of this process. I believe this
increased experience enhanced my un-
derstanding of nursing concepts and al-
lowed me to pursue the more technical
skills of operating room nursing. By
using a tool such as audit, I found a
guide for outlining criteria for nursing
practice and a n aid in the establishment
of nursing priorities. By combining the
tool with the basic knowledge of the
theory and principles of nursing pro-
cess, I believe students will be able to
incorporate this information, leading to
a better understanding of the role of the
operating room nurse and his or her re-
lationship to patient understanding and
education. Improving patient care in a
manner directly beneficial to the pa-
tient is a primary goal in nursing prac-
tice and in nursing audits. Therefore,
quality assurance efforts are essential
to determine that this goal is met by
practicing nurses as well as those in
training.
Notes
1. B J Mohr, “JCAH patient care audit,” AORN
Journal 22 (August 1975) 187-190.
2. M J Munley, “Directobservation tool,” AORN
Journal 22 (August 1975) 191-194.
3. Maria Phaneuf, “The nursing audit for evalua-
tion of patient care,”Nursing Outlook 14 (June 1966)
51-54.
AORN Journal, February 1979, Vol29, No 2
Child sexual abuse
exceeds reported cases
Actual incidence of sexual abuse of
children is far greater than the reported
number of cases, according to the
responses of physicians questioned in a
survey by the University of Washington
School of Medicine, Seattle.
Reporting in the Journal of the American
Medical Association, Jennifer
James and William M Womack say
physicians seem reluctant to report cases
of child sexual abuse encountered in their
practice. More than half the physicians
responding to the poll said they saw at
least one identifiable sexually abused child
annually, James and Womack said. Many
of the abused children were said to be
suffering from severe emotional shock, and
almost all of them needed professional
counseling.
Two-thirds of the physicians said they
sometimes did not report such cases to
authorities because reporting would be
harmful to the family and that the problem
could be handled better privately. The other
third was dissatisfied with the manner in
which state social service agencies handled
such cases.
Nursing college given
graduate training grant
The Rush University College of Nursing,
Chicago, has received a $180,000 grant
from the U S Department of Health,
Education, and Welfare to continue its
program of developing nursing practitioner
programs at the graduate level.
The grant will be used largely to support
faculty programs in the college’s various
clinical specialties. The college hopes to
expand its efforts in medical-surgical
nursing, gerontological nursing, oncology
nursing, and psychiatric nursing with the
grant, according to Luther P Christman,
R N , dean of the college of nursing.
251