Clinical nursing theory

Name

Institution

Course

Professor’s name

Date
Statement of the problem

A retained surgical item is any instrument used then unintentionally left inside the patient after

completion of a surgical procedure. An item is termed retained, if discovered to have been left

inside the patient at any time after skin closure. While many instruments can be retained, surgical

sponges are the most frequently reported cases of retained instruments in surgery. Surgical

sponges are retained way more easily than other instruments owing to their relatively small size,

similar appearance to body tissues once they are drenched in blood or their extensive uses during

surgery. The problem of retained surgical sponges is widely referred to as gossypiboma. A study

has shown that one in every 5500 operations results in a retained surgical instrument. Over sixty

percent (60%) of these cases involve surgical sponges alone. Further research has compounded

the gravity of this issue by finding out that around 90% of patients required to extend their study

in hospital after surgery do so following a retained surgical item. About 2% of the cases of

retained surgical sponges lead to fatal injuries. The additional costs of hospitalization and

malpractice expenses is in the region of 360, 000 dollars. There are many risk factors in practice

for retained surgical sponges. However, changing nursing personnel during surgery is a notable

risk factor. Changing nursing personnel during surgery increases the risk of retaining surgical

sponges. Other risk factors are fatigue and long working hours for medical personnel ultimately

due to the lengthy nature of some surgeries, lacking a complete accurate count of the total

number of sponges used during surgery, the urgency of the surgery and excessive loss of blood

during the procedure.

Clinical nursing theory

This paper focuses on a clinical nursing theory that when using sponge counters it reduces the

risk of retained sponge. Sponge counters are considered a safe and convenient yet economical
way to ensure surgical sponges are counted accurately and easily retrieved. This way, surgical

sponges are always accounted for during surgery. Sponge counter bags are usually transparent to

allow for almost excellent visibility of surgical sponges during surgery. Moreover, they reduce

body fluid contact therefore reducing the degree to which sponges conform to body tissues. For

research purposes surgical sponges can be counted, using a surgical sponge detection system. A

surgical sponge detection system is fairly complex with several different components that work

synergistically as a syncytium to account for surgical sponges. Each surgical sponge must be

tagged with a radio frequency (RF) identification tag. The system has a portable reader which

detects the tag hence detecting surgical sponges. The reader, usually referred to as a transponder,

is either a hand- held device or a stationary device.

Furthermore, another component of the system weighs each sponge to calculate the volume of

absorbed blood. This allows for the device to calculate the volume of blood lost that is within

soaked surgical sponges. A third component scans each tag to identify the type of surgical

sponge depending on the type of tag. A disposable bag is also attached to the device. Soiled

sponges are deposited in this bag which is also attached to a weighing scale. The disposable bag

can easily be unmounted and replaced with an unused bag. A control unit processes and analyzes

all the data received from all components of the system, before a display panel shows the count

and the type of sponges used during a particular procedure. The system also encompasses a shelf

for storing unused disposable bags and a rechargeable battery to power the device. Counting

surgical sponges must be done in line with strict hospital guidelines and operation room

procedures. An initial count before beginning a procedure and subsequent counts as the

procedure progresses are required. However, some sponge counting automatic devices only

count the number of sponges and weigh the soaked sponges. Such systems cannot distinguish
between sponges of different kinds. Consequently, determination of blood lost during surgery

must be calculated manually.

Assessing risk has never been an easy task. Risk factors for medical errors, such as retained

surgical sponge are not any different. Risk factors for retained surgical sponges remain poorly

understood for this reason. Performing case- control studies for retained surgical sponges in

patients is a good way of assessing risk factors for this particular error. Cases refers to patients

who after undergoing surgery, suffered retained surgical sponges. Controls on the other hand are

patients who underwent surgery but did not encounter the same problem. Cases can be obtained

by reviewing records of reported incidents of retained surgical sponges or medical personnel

malpractice along the same lines. For each case, a sufficient number of controls who underwent

the same procedure at the same hospital around the same time can also be obtained. Log records

of the procedures for each case and control can be carefully reviewed and the variables that could

have led to different outcomes noted. A data form to record information about each patient can

be developed so that the data is easy to read and can be used to quickly illustrate a certain point.

Important details that should be captured in the data form include: age, sex and weight of the

patient, the cavity being operated on, volume of blood lost, amount of transfused blood, the start

and end time of the procedure and the total duration of the procedure. Any change of personnel

during the procedure or deviation from prior planning due to emergencies that may have taken

place within the duration of the procedure should also be noted. Emergencies that could

necessitate changes during a procedure include unexpected findings, technical complications or

evidence that supports a new diagnosis.

From the data collected, descriptive statistics can be developed and risk can be estimated. Risk

ratios and odds ratios are used to indicate risk. A ratio in excess of one indicates that the factor in
question aggravates the chances of retained sponges, making it a risk factor. A ratio that is less

than one shows that the factor in question is a protective factor, since it reduces the risk of

retained surgical sponges. A ratio that is equal to one indicates that is no associativity between

the factor in question and the event of a retained surgical sponge. For this research the above

steps can be done with the factor in question being the use of sponge counters. Odds ratios can

show the associativity of using sponge counters with the retainment of surgical sponges.

Watson’s theory of nursing is a grand theory; it encompasses the whole world of nursing. It is

commonly called the theory of transpersonal caring, because it stresses the needed to treat

humans in a humane way i.e., humans cannot be treated as objects. One of the ten caritas of this

theory is to deepen. Deepening refers to developing scientific solutions for problems to enhance

caring decision making. The ‘deepen’ caritas of the Watson’s theory is similar to my theory

because the sponge counter is a scientific solution to a problem. The use of radio frequency tags,

weigh scales, rechargeable batteries and a control unit which are without doubt things of science

is in line with Watson’s theory of nursing. According to Jean Watson and her theory of nursing,

deepening refers to using scientific methods to solve problems for care decision making. The

same can be fulfilled in this theory in using a sponge counter to reduce the risk of surgical

sponge retention in patients during surgical procedures.

Leininger’s theory of culture care diversity and universality is a middle range nursing theory; it

is more specific than grand theories with a more realistic view of the nursing practice that can be

easily tested. According to this theory, the goal of nursing is to try and provide culturally

acceptable care to patients. Care must be beneficial to the patient as well as acceptable to the

patient, their family or the group they hail from. This theory stresses the need for nursing to

tailor its services so as to offer diverse services to people of diverse or similar structures.
Leininger’s theory of culture care diversity and universality conforms to my theory since the

solution proposed is a universal one that is applicable to people of diverse or similar cultures.

The use of sponge counters to reduce risk of sponge retention can be applied for patients of

diverse cultural backgrounds.

Discoveries and impacts

Many hospitals and healthcare institutions have reiterated the need to reduce risk of sponge

retention during surgery. In the light of these developments, surgeons, anaestheologists and

nurses are required to adhere to strict policies governing the handling of surgical sponges. While

an initial count complemented by subsequent count of surgical sponges is required, the level of

technology used in most institutions is still below par. The absence of automated sponge

counters necessitates a manual count. Manual counts even when done with absolute care by

professionals with high qualifications are prone to error. Human error in manual counts presents

a major drawback in reducing the risk of surgical sponge retention. Increased the funding

allocated for the counties to implement devolved healthcare could go a long way in availing

standard technology in operation rooms of most hospitals. In addition to this, poor

documentation is another major factor. Even with the right technology and accurate sponge

counts, they must be properly recorded on a count sheet throughout the procedure so that every

sponge is accounted for before skin closure. Laxity, fatigue and reading errors are some causes

of incorrect data entries in count sheets. Incorrect entries may present a false impression that all

sponges have been accounted for even when some sponges are retained in the cavity of

operation.
Conclusion

In a nutshell, this paper describes the problem of retained surgical sponges with evidence from

literature showing the prevalence of the same. A clinical nursing theory has been developed

within this paper, to guide nursing practice to reduce the risk of the above problem occurring.

The theory suggests that when using sponge counters it reduces the risk of sponge being retained.

The theory has been likened to Watson’s theory of transpersonal care as well as Leininger’s

theory of culture care diversity and universality.

References