Perioperative Nursing Reflection: Distal Tibial Nailing Scenario

This reflective paper details a challenging perioperative nursing experience involving a distal tibial nailing procedure. The author, a junior nurse, recounts a situation where equipment malfunction and a lack of experience among the surgical team led to complications, requiring a shift to an open reduction and internal fixation (ORIF). The paper utilizes the Gibbs reflective model to analyze the events, feelings of anxiety, and the application of ACORN competency standards. It highlights the importance of interdisciplinary communication, the use of checklists, and the need for thorough equipment checks. The author evaluates their actions, identifies areas for improvement, and proposes an action plan for future emergency situations, emphasizing the significance of effective communication and anticipating potential complications within the operating room setting. The reflection underscores the impact of communication breakdowns on patient safety and the necessity for continuous professional development.

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PERIOPERATIVE NURSING
Name:
Department:
School:
Date:

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Introduction
ACORN focuses on improving and standardising perioperative nursing care, supporting
and educating preoperative nurses. ACORN’s mission statement is to represent perioperative
nursing and the organisation undertakes the range of operation to accomplish its mission.
Perioperative nurses have an obligation that numerous other counterparts see as highly
procedural and task concentrated (Butterworth, Mackey and Wasnick 2013, pp. 64). Yet,
proficient and well educated perioperative professionals are believed to be important for patient
attention to warrant appropriate medical results. Similarly, perioperative nurses in Australia
oversee their own practices, and as a group of professional nurses, act to construct understanding
that enlightens practices on a broader specialised level. Perioperative health care comprises a
numerous specialty duties such as circulating, scrubbing, holding bay, anaesthetic, or instrument
nurse (Keene 2009, pp. 13). Other obligations include patient assessment, education and
surgeon’s assistant. It is quite often that perioperative nurses can fill more than one
responsibility during specific procedure depending on the complexity and nature of the operation
(Ross, Dressler and Scheurer 2016, pp. 24). Similarly, some nursing titles are used
interchangeably in varying hospital and medical facilities. Thus, the prominence of nursing
presence during surgery, in terms of nurse’s capability to ensure safe outcomes for the patient, is
being progressively identified.
The challenging scenario is being encountered by perioperative scrub and scout nurses on
a day-to-day basis. The perioperative nurse learns their practice through clinical experience and
education in their normal learning schedule. The Australian Council of Perioperative Nurses
(ACORN) brings the guidelines and teaching to the arena for the Australian perioperative nurses.
Thus, the learning offered by the perioperative sections in which the nurse is hired is steered by

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the ACORN competency standards. The competency standards monitor the nurses to acquire the
talents to competently provide perioperative care in the most courses of actions or where the
disaster situation in which each medical practitioner’s competency is tested. Thus, this reflective
paper will concentrate on specifically challenging situation operation encountered by myself,
junior nurse, and surgeon. The Gibbs reflective model, 1988, will be utilised to reflect on the
challenging situation (Mindtools 2016). The paper will also deliberate on my feeling of anxiety
in these challenging situations. The assessment of this setting will display my accomplishment
of the ACORN competency standards through the operations, and the incidence where the
progression of my abilities and counterparts is vital. During the examination of this reflection,
clinical proof will display the importance of interdisciplinary communiqué and the paybacks of
using checklist for intraoperative perioperative exercise. The paper will also display the
importance of checking an extra set of equipment prior to surgery and the importance of theatre
operation manager liaising with the procurement department to buy new Trigen tibial nailing
apparatus. An action plan will illustrate how I harness my competencies for emergency in regard
to the Distal Tibial Nailing in the future.
Description
One of my late weekend shift (1 pm to 9:30 pm) we received a patient for Distal Tibial
Nailing. I was the only staffs who know orthopedic surgery on that shift. My other colleague was
junior and she scrubbed only one time for Nailing. She told me she wants to scrub for the case
for her up skilling. We checked the patient in and checked the consent against patient ID.
Checked the implants with surgeons such as Tibial Nail Size, all disposable guide wire and drill
bit and were ready for the surgery. I informed radiology department that we are ready for an x-
ray. I told the surgeon the scrub nurse does not have much experience in this case and surgeon

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was happy to scrub with her. Anesthetist put the patient in sleep. She scrubbed in and I opened
all the instruments and consumables in a sterile manner. Surgery started and I had to explain to
the scrub nurse how to assemble the instruments and the sequence of the surgery during the
procedure. I had to do the entire circulating job and on top, I had to guide the scrub nurse made I
bit stressful.
According to the size of Tibial nail reaming is done. Nail opened and the surgeon was
about to put the nail in. Suddenly the JIG fell on the floor from the scrub nurse. That was a
terrible situation for all of us. The instrument that we used for the nailing was Trigen. We have
only two Trigen sets in our facility. I ran to set up a room and looked for the second Trigen
nailing set and I could not find it. I rang floor coordinator and ask her to look for it. She checked
with CSSD staff and realised it is in the washer. I informed the surgeons about it, they were so
annoyed. The surgeon was not happy to put the nail without the JIG and also not appropriate. I
could not explain the stress that I went through that situation. Scrub nurse apologised many
times.
Finally, the surgeon decided to do the open reduction and internal fixation (ORIF). He
asked me to get small fragment set and distal tibial plate. I took it from setup room and opened
everything for ORIF. It took another two hours to finish the surgery. This incident causes extra
anaesthetic and surgery time. Also, it wasted an implant which cost a lot.
Feelings
The above challenging situations were very hard for me as I was only the nurse with the
orthopaedic knowledge at that time. I had stress and apprehension due to the urgent nature of the
operations, the lack of specialist staff with relevant knowledge, and the needs to prepare for the

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distal tibial nailing so fast. Since I knew I was the only person I could help the surgeon, I
concentrated on prioritising the nursing intervention needed, instead of being distracted by the
anxiety and the stress. At the period when Trigen was needed, I felt annoyed to myself for not
preparing for the situation or not orienting the scrub nurse about the consequences of not
handling the JIG properly. When the surgeon completed doing an open reduction and internal
fixation (ORIF), I felt relieved that the course had been successful although without following
due process. On the patient side, I really sympathised with him as he had undergone long hours
of surgery and the right procedure was not followed as stipulated by medical practices.
Reflecting on the situation, all the personnel in communication relaxed that the emergent
and challenge scenario was brought without many hurdles. After the process, we discussed with
a scrub nurse that we were not careful and very inefficient that we did not project the alternative
of JIG. Although the surgeon was very furious, he thanked the entire group for the sign of
responding to the situation prompting but we had a lot to do and improve. Thus, this made me
and my colleague very positive on the work we had done.
Evaluation
For me to evaluate myself from the above situation, it crucial my nursing inventions
performed to be equated to the ACORN competence, the clinical approaches guiding the course
were suitable and backing clinical evidence through the perioperative, intraoperative and post-
operative stages of the attention.
Preoperatively, the patient had a preoperative list done, the assent form was also present
and the medical checklist was piloted by the scrub nurse. As I was the only around with
appropriate knowledge of the orthopaedic procedure, I requested to countercheck the list prior to

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scrubbing. The above nursing interventions align with the ACORN standard 1, element 1.1
which deals with the verifying the consent and patient identification according to approved
protocols (ACORN, PP. 2). According to the literature, backup evidence for this nursing
intercession was well-versed about the patient feelings which would minimise the occurrence of
anaphylactic response in the perioperative situation, thereby correlating with ACORN
competency standard 4, element 4.1. My vital controlling focus before the cleaning was to make
sure that surgeon and I was conversant about the patient's allergy standing and ensuring that legal
consent form is exist (Nilsson et al. 2010, pp. 179).
In the course of the intraoperative sage, ACORN competency standard 5, element 5.1 was
illustrated by me by effectively being in discussion with the other healthcare providers such as
junior nurse and surgeon. But, the breach of appropriate communication was displayed in the
lack of equipment during the surgery process. If I had addressed the menace to the surgeon or
junior nurses, the open reduction and internal fixation would not be performed on the patient.
During the operation, I displayed competency standard 6 by applying the decision
making and problem-solving approach, by proceeding very first to the request for the JIG.
Therefore, it correlates with the principles of understanding and anticipating complication and
implementing the subsequent invention that may be needed during the process. The above
mentioned guideline, correlates to the competency standard 6, element 6.2. The mentioned
factors are very essential as it deals with the delicate matter in regard to the patient healing and
recovery. It is worth noting the above issue was not tackled to perfection. Under normal
condition, the preoperative nurses should project the surgeon’s needs such as checklists and react
to them promptly. However, junior preoperative nurses had only done the scrubbing once and
there were relying on my clinical experience to direct them in perioperative nursing intervention

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in this challenging situation.
Considering the scrubbing prior to the distal tibial nailing, I revealed my realisation of
competency standard 7 which supports coworkers in an objective style. I verified my fulfilment
of the standard 7 element 7.1 which states that nurse should effectively communicate and
documents relevant information to provide comprehensive perioperative care.
I displayed my capability with ACORN competency standard 3, element 3.2 and 3.3, by
dressing in personal protective gears, ensuring the junior nurse perform surgical scrub and
putting in place sterile attire and upholding the sterile area (ACORN 2014, pp. 4).
Intraoperative, scrubbing was done by junior nurse prior to the distal tibial nailing. The
above is well linked to the ACORN competency 1, elements 1.1, (ACORN 2014, pp.2).
Upon reflection, I demonstrated the use of approaches to conflict resolution. It was
needed whereby there was lack of alternative for JIG. I identified and considered the desires of
others in connection to challenging conditions (ACORN standard 6, element 6.2). Also, offered
additional assistance in getting and communicating with other healthcare providers (ACORN
2014, pp. 9).
The ACORN standard for the operative phase regarding the finding data and
documenting was significantly displayed (competency 6, elements 6.3) (ACORN 2014, pp. 10).
Postoperatively the ACORN standard and clinical guidelines were followed by the achievement
of the intraoperative record and the patient had endured an upsurge of case setting resulting to
the open reduction and internal fixation (Braaf, Manias and Riley 2011, pp. 1026).

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Analysis
Communication within the operating room is hotly debated topic in the nursing and
medical journals. It is worth noting that communication is usual for perioperative nursing
exercise with the ACORN practices ( competency standard 7) but also a must for all
registered nurses as specified in the Nursing and Midwifery Standard for Practice which states
that ‘communicates effectively, and is respectful of a person’s dignity, culture, values, beliefs and
rights’ (NMBA 2016, pp. 3). Assessing of the situation displays that emergency action could be
enhanced if the interdisciplinary communiqué was active. Gill and Randell (2017) discussing the
work of Arriaga et al (2014) claims that communication and coordination has been ‘identified as
the leading cause of preventable patient injury and death’ (pp.9). The surgeon's requirement
would be projected more quickly if I and the junior nurse had used a checklist when preparing
for the distal tibial procedures. Thus, the above fundamental components of the perioperative
action will be analytically studied to direct my preoperative practice and operations (Gardner,
Russo, Jabbour, Kosemund and Scott 2016, .pp. 550)
It is broadly accepted that communication blunder is a frequent intraoperative stage of
perioperative care (Wallace 2017, pp. 53). It is clear that nurses depend on informative and
directive communication from the surgeon to update the requirement and advancement for
further equipment (Sevdalis 2012, p. 2933). Without timely directive communication from the
operating surgeons, clinical study illustrates that nursing inefficiencies outcomes, and frequently
result in teams’ tension. The scenario I and my counterpart encountered illustrates the above
principles of communication breakdown whereby the nursing inefficiency resulted into a
procedural delay (Hu et al. 2012, pp. 39). However, no adverse effect occurred to the patients as
the surgeon was able to rise to an occasion and do the open reduction and internal fixation.

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The use of a checklist for an emergency of the distal tibial operation would have been
useful in these challenging situations. The medical literature concentrating on non-technical
abilities of the perioperative nurses displays the techniques such as checklist will help in
preparedness intraoperative (McNamara 2011, pp. 161).
While the ACORN standard does not have a statement concerning the maintenance and
use of surgeon checklists, competency standard 5, element 5.1 dealing with the development and
documentation of nursing model of cares claim that collaboration with other teams members is
vital (ACORN 2014, pp. 7). Am certain that appropriate records of surgeon checklist are
important to readiness and have connection to patient care (Mitchell et al. 2012, pp. 205).
Therefore, the ACORN standards and practices should incorporate the above suggestion for the
preoperative routine (Mitchell et al. 2011, 819).
Action plan
I would like to discuss with the entire clinical nurse's fraternity, on generating a checklist
for the distal tibial nailing to be incorporated into emergency set up. Am quite sure the above
will assist me and counterpart when they encounter such challenging situation. I would suggest
checking about an extra set of apparatus before the commencement of surgery.
Having new set of Trigen tibial nailing set is of essence. Therefore, I would request the
theatre operation manager to liaise with the procurement department to ensure new apparatus
are purchased so as to avert any deficiency which might arise in future.
Additionally, to assist me to do the best in future with conductive and stress-free areas,
facilitating effective communication would sound better (Rothrock and McEwan 2011, pp. 10).
It is advisable if all the health care providers used the same communication direction such as a

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directive and informative communication. In a world of nursing and medical field, keeping in
check with current events is of essence (Goodman and Spry 2013, pp. 22). Therefore, I would
engage in reading the medical literature so as to improve my communication which is necessary
in case of the emergency scenarios like the previously encountered (Gillespie, Chaboyer,
Longbottom and Wallis 2010, pp. 733).
Conclusion
Apparently, the reflective paper comprises the explanation of the challenging setting I
and my junior encountered in responding to the distal tibial nailing. The paper also discusses the
feelings, evaluating my performances against the ACORN competency standard through the
process of preoperative, intraoperative and post-operative stages of attention and exploration of
medical evidence that assisted me to comprehend and suggest the action strategy and how it can
be executed. The action will assist me and other medical professionals to put the factor of a
patient cure first in their operation. The above can only be accomplished by providing an
effective communication channel and checklist operating from the perioperative nurse up to the
surgeon. This reflective work has demonstrated and illustrated significance contemplation for
the ACORN to include the checklist in the competency standards. The above evidence shows
that checklist tools are missing and considerably affect the attention of the patients
intraoperative.

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