SpiritlyANurse

Before I graduated from my nursing program, I eventually knew that I wanted to work as an OR nurse because I was very curious of watching surgeons perform so many different types of procedures. I already knew that OR nursing would be completely different from a traditional bedside nurse, and I did not care about losing certain nursing skills (because what nursing skills would I have as a new graduate nurse anyway??).

OR nursing is even more appealing to me as an introvert who struggles with small talk and in-depth conversations with patients or people I am not familiar with.

When I was in nursing school and even when I got accepted to my first nursing gig, I didn’t really know anything about OR nursing…like in terms of their role and responsibilities other than having to perform time-outs and surgical counts, and that they had to stand pretty much all day inside the operating room. I had no idea that there were two separate nursing entities inside the OR, aka Circulator and Scrub nurse. I basically had a huge knowledge deficit of this specialty even though I was adamant about this position. It wasn’t until I finally gained hands on experience that I finally learned more about OR nursing.

Now that I learned more of this position, do I still enjoy working inside the OR? YES!

With that said, I’d like to share what I know about OR nursing at a surgery center. Hopefully, my post will help nursing students or even people who wish to go into nursing have more knowledge of one of these amazing specialties.

*This is purely my experience only working as a Circulator in an outpatient surgery center. I have very limited knowledge of inpatient OR nursing.*

This post will cover several topics as an OR Circulating nurse:

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Table of Contents

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What is a Circulator?

A circulator is a nurse who is responsible for patient safety, overseeing the surgery, and making sure that all the essential team members including the surgeon, anesthesiologist, and scrub nurse/tech has everything they need for the procedure.

They are the last check for patient safety by checking their concerns, lab values, and medication list before they are brought inside the operating room.

During the operating room, the nurse also makes sure that the patient is properly positioned and secure on the bed. This is one of the most important part of being a circulator. There has been several occasions where I have caught an unlocked bed, risking a chance for the patient to fall or change positions during the procedure.

Besides keeping the patient safe, the circulator is also responsible in making sure that all surgical equipments work, and that all implants, supplies, team members, and counts are proper documented.

Finally, once the surgery is completed, the patient will be transported out to the PACU with the nurse and the anesthesiologist!

Things to know before becoming an OR Nurse Circulator

Circulating can become very repetitive once you know the routine of how a surgery runs. Surgeries generally follow these steps:

1. Prepare the room by ensuring the required medications/supplies are placed on the surgical (blue) table. During this time, the circulator/scrub does an initial count.
2. Scan the patient’s health history and report any alerting lab values.
3. Interview the patient since we are the final safety check before bringing them into the operating room.
4. Transfer the patient to the operating room bed, make sure they are comfortable and properly positioned, then secure them with safety straps.
5. Surgeon comes in and all team members listen for a time-out for a safety check before anesthesia begins.
6. Assist the anesthesiologist with intubation/monitor placements.
7. Insert foley catheter into the patient as needed. The surgeon will inform you (or you ask) if a foley is indicated.
8. Prepare the patient’s surgical site with sterile gloves and sterilizing agent (chloraprep/betadine).
9. Scrub nurse/tech drapes the patient, and wait for the surgeon again to enter the room.
10. Time-out again while assisting the surgeon gown up.
11. Procedure starts and anticipate any necessary supplies.
12. Do a count again to make sure that all sutures/supplies are the same amount before closing the incision.
13. Report count to surgeon.
14. Assist surgeon/scrub nurse/tech with dressings. Can call for turn-over help during this time.
15. Help the anesthesiologist extubate and transfer to PACU.

I know, it is a lot to remember especially when you are first starting out…but trust me…after doing this many times the whole process gets a lot easier!

I also have to note:

Preference cards are your best friend when you are new to circulating. Basically, preference cards are lists of what the surgeon uses for their procedure. This includes the patient positioning, type of equipment the surgeon would use such as the bovie (electrosurgical unit) or the neptune machine (suction machine), suture type, or preferred dressings. New scrubs would also use the preference card as well – They check what sterile tools to place onto the sterile (blue) table. Good surgery centers will always have updated preference cards.

Another important thing to know is that the circulator is in charge of the whole operating room set up. We want to make sure that the floors are cleared from wires/cables because there are times when the scrub nurse/tech or surgeon is walking around a lot or switching to the opposite side of the patient. If the space is narrow and tight, a trick that we use is placing a blanket over the cords to prevent people from tripping.

In cases that are longer than 4 hours (such as plastic surgery cases), the nurse will also place a foley catheter inside the patient to prevent accidental urination release due to a relaxed bladder from anesthesia.

How is Circulating different from a Pre-op/PACU Nurse

Circulating is very different from a Pre-op/PACU since they are two completely different specialities. Pre-op/PACU occurs outside of the surgery. Specifically, Pre-op is admitting the patients before they enter the surgery and PACU is recovering them from the surgery.

Although patient safety is the priority for every aspect of nursing, as a circulator there are other aspects that are just as important. It is the circulator’s job to ensure everything runs smoothly, from ensuring patient safety to a smooth process in equipment handling and assisting the team. Documentation is important but it is not the main responsibility. (Some surgeons may even get inpatient with you for documenting before having everything set up.)

I think a circulator is a completely different role compared to being a Pre-op/PACU nurse since as a Pre-op/PACU nurse, you are only focusing on the patient, witnessing them sign essential documents, addressing concerns prior and after the surgery, and making sure they are safe to go before discharge.

Differences between in-hospital and outpatient OR Cases

There are differences between in-hospital and outpatient OR cases. Outpatient surgeries usually operate on healthier patients, and surgery lengths are generally much shorter than if they were completed in-hospital.

Depending on the type of surgery, the lengths could range from 10 minutes to 6 hours. However, 6 hours is on the longer side and I have only seen them in combo plastic surgery cases (blepharoplasty + face lift) or complicated joint fusions. The length of time also depends on the surgeons’ experience as well.

Cases that take 10-30 minutes are usually pain management, endoscopy cases, or simple orthopedics cases. Pain management includes a focused area such as cervical or lumbar epidural steroid injections or radio-frequency ablations. There are also some surgeons who are very adept in their specialty that can perform really quickly and accurately on cases such as spinal stimulator trials.

Longer cases include plastic surgery such as face-lifts or breast reconstruction/deconstruction, complex orthopedics cases such as anterior cruciate ligament (ACL) repairs or grafts, or urology cases such as stent placements, kidney stone removals, etc. Sorry, I know I am name-dropping quite a lot. All these cases can range from 30 minutes to a few hours.

Obviously, there are more cases then what was mentioned, but I am just stating what I know from my experience!

In-hospital surgeries typically have more complicated cases with high risk patients that require more complex equipment which an outpatient surgery center usually cannot offer. The surgery recovery times can also last up to a few days before discharge, unlike outpatient, where the patient can usually go home within a few hours.

Deciding factors for becoming an OR Nurse Circulator at an ASC

I have heard so many new nurses who wants to work in the operating room but I think one can only flourish in this field if they have a few necessary traits…otherwise burn out will be fast.

For one…you have to be open minded and understand that everyone has their own personality and own way of doing things. If you work inside the operating room, you will meet all kinds of surgeons, anesthesiologists, etc. that may have a nice or nasty attitude. Your ego will have to drop but at the same time, boundaries need to be enforced so you remain professional…but not walked over.

Never take negativity home from you because the next thing you know, you are spreading negativity to your loved ones or demotivating yourself from work. Stop giving your energy away, it is really not worth it.

Another essential trait to have if you want to become an operating room nurse is to have great prioritization skills. You should always know what is the most important task because you may be thrown 20 different things to do all at once.

For example, your anesthesiologist may need you to get a new IV bag as the current one is running out, but the surgeon is requiring you to obtain a surgical tool, or your scrub tech may need more ray-techs (x-ray detectable sponge) so which task do you do first?

You should always scan the field to see which one is the most necessary. If the patient’s IV bag has 100-200 ml left, you can wait to provide the IV bag and try to find the surgical tool first, then give the ray-techs to the scrub tech. However, you should always try to anticipate what your team needs to prevent having to do everything at once and stressing yourself out. Always try to be vocal and don’t be afraid to ask them what they need or prepare things (such as dressings) in advance to help smooth the flow.

For surgeons that do not own the center, they are renting the place and each second matters as they will be paying extra money out of the pocket if they go over the proposed time. (But never neglect patient safety over speed!)

Don’t be that nurse who just stays on the phone and waits for instructions. Even if you are experienced, it’s not cool because if the surgeon needs something, they are just standing there unable to do anything else since they are scrubbed in and sterile until you give them the item they need. Some people will also get annoyed for repeating what they need several times.

This kind of goes in hand with having good prioritization skills, but you also have to be okay with running around a lot and adapt fast. I say this because depending on the type of surgery, it may require more things or the case may end quickly. Again, you will be expected to do many things, grab all the essential items while making sure that your documentation is accurate and your patient is safe. The surgeon is not going to wait for you to finish your documentation before ending a procedure and you may be expected to help with turnovers (cleaning up the operating room and setting up for the next procedure) if short-staffed.

OR Nursing at an ASC is underrated and I am not taking that statement back

While I believe OR nursing is not for everyone, as an individual who is highly work motivated, I find this specialty to be so rewarding and fun. I don’t burn out from working long hours, I am not on-call, and don’t work on weekends, or holidays.

Patients are generally very nice and you usually only see them once, and most of the time they are asleep.

I also love engaging with everyone on the team. During the procedure, I get to bond with the surgeon/scrub/anesthesiologist/rep etc. that you usually wouldn’t have the time to do so if working outside of the operating room. I am still an introvert and talking may not be my specialty, but I can still have a good time.

Also, everyday is not the same, the experiences inside the OR can have such drastic ranges (from calm to chaotic). If you like occasional adrenaline rush, COME TO THE OR!!