BRITISH MEDICAL JOURNAL 7 MAY 1977 1199

Ward, J N, Draper, J W, and Lavengood, R W, Journal of Urology, 1967, 1' Wolfson, M, et al, Dialysis and Transplantation, 1976, 6, 66.
12 Lazarus, J E, et al,Jfournal of the American Medical Association, 1971, 217,
98, 48.
6 Halpern, M H, Dalrymple, G, and Young, J, Journal of Urology, 1970, 1821.
13 Salvatierra, 0, Kountz, S L, and Belzer, P 0, Surgery, Gynaecology and
103, 21.
Hatfield, P M, and Pfister, R C, Journal of the American Medical Asso- Obstetrics, 1973, 137, 431.
14 Mendez, R, et al, Urology, 1975, 5, 26.
ciation, 1972, 222, 1527.
8 Kendall, A R, Pollack, H M, and Karafin, L, Urology, 1974, 4, 635. 15 _ourtl of the American Medical Association, 1975, 233, 787.
16 Oettinger, C W, et al, New England Journal of Medicine, 1974, 291, 458.
9 Keith, N M, Wagener, H P, and Barker, N W, American Journal of
Medical Science, 1939, 197, 332.
10 Williams, G, Mitcheson, H D, and Castro, J E, in press. (Accepted 13_January 1977)

The nurse's role in immediate postoperative care

British Medical Journal, 1977, 1, 1199-1202 anaesthetics were given each year in England and Wales alone.
The Registrar General's figures do not identify the stage when
death occurred, nor do they distinguish between avoidable and
Summary unavoidable deaths. Wylie recently examined the Medical
Defence Union records of the past 20 years and reported that
From the time that a patient leaves the care of the anaes- about a third of the complications associated with anaesthesia
thetist after an operation until he wakes in the ward his occurred in the postoperative period, about half of these
physiological state should be continuously and expertly culminating in cardiac arrest.2 These figures suggest that failure
supervised. Postoperative nurses are provided only when in postoperative management may have been responsible.
the operating theatre has a recovery room. A survey Immediately after operation patients are exposed to certain
among consultants and nurses in one region showed that risks such as regurgitation and vomiting, obstruction of the
many surgical units did not have recovery rooms and respiratory passages, and cardiac insufficiency. Well-trained
that inexperienced ward nurses were often sent to staff and adequate resuscitation equipment are essential for
collect patients. The survey showed that most nurses treating, and whenever possible preventing, these complications.
were competent to care for unconscious patients so long The equipment is best provided in a modern recovery room
as an emergency did not arise. In many hospitals the within easy reach of the anaesthetist. 3 Theatre nurses are officially
facilities for the safe nursing of postoperative patients provided to care for postanaesthetic patients only if there is a
were totally inadequate. recovery room attached to the theatre. If there is no such room
The very least that is needed is good communications the theatre nurse usually relinquishes her responsibility for the
with the anaesthetist, adequate lighting, and a source of patient to a ward nurse as soon as possible. The ward nurse may
oxygen and suction. Because of the shortage of nurses be inexperienced, frightened, and uncertain of her role in these
it would be realistic to recognise that trainee nurses are circumstances. And, because there is no recovery room, she may
likely to have to care for postanaesthetic patients early have to care for the patient in a poorly lit, draughty corridor
on and to train them accordingly. Nevertheless, recovery while the anaesthetist is by this time busy with the next case.
nurses, whose sole responsibility is to care for a patient The continuing shortage of nurses, the ever-increasing volume
until he has recovered from anaesthesia, should be of surgery,4 and the lack of special equipment are making it
appointed for all busy surgical units. increasingly difficult to provide adequate care in the critical
postanaesthetic period.
Most anaesthetists are aware of these problems and modify
Introduction their techniques so that patients will wake promptly at the end
of surgery and rapidly regain their reflexes. This is not always in
In parts of Europe and the United States of America specially the best interests of the patient, who might benefit from a
trained nurses take an active though limited part in the conduct peaceful recovery in a safe environment. The patients who
of anaesthetics. In the United Kingdom they play no part in the take the longest time to wake are those who have had an inhala-
specialty. British anaesthetists defend this anomalous position tion anaesthetic (as distinct from a muscle relaxant artificial
by maintaining that nurses are not qualified to accept the res- ventilation technique) lasting half an hour or more. These
ponsibilities that the specialty demands. Yet immediately the anaesthetics are given for such common and relatively simple
patient leaves the operating theatre his care passes into the hands procedures as herniorrhaphy and varicose vein surgery in other-
of a nurse, who may be a fully trained sister or a first-year wise fit people, and it is often these patients who unexpectedly
trainee. Although the anaesthetist remains responsible for the provide the most problems in the recovery period.
patient, he is invariably not readily available to deal with any Although they are trained in their part in the management of
emergency that may arise in the patient who has just passed cardiorespiratory arrest, nurses are not generally sufficiently
out of his hands. aware of the particular complications that arise in the immediate
It is a tribute to modern anaesthesia and postoperative postoperative period and how they can be prevented. Records
nursing care that only about 100 unexplained deaths associated of complications, even of cardiac arrest, are often inadequate, and
with anaesthesia occurred yearly in 1959-70,1 while over 4 000 000 in many cases nothing is recorded in the patient's notes if
resuscitation has been successful.
We decided to investigate this further, concentrating on
Medway Hospitals Group, Kent nursing knowledge and competence and on the facilities provided
D S B STEPHENS, MB, FFARCS, consultant anaesthetist for postoperative recovery in a cross-section of hospitals in this
J BOALER, DOBSTRCOG, FFARCS, consultant anaesthetist
region.
1200 BRITISH MEDICAL JOURNAL 7 MAy 1977
Nursing knowledge and experience RESULTS

One hundred and sixty-three nurses in one health district were The results for questions 1-6 in the groups of trained nurses and
asked to complete a confidential questionnaire to assess their know- trainees are shown in table I.
ledge and attitudes to caring for patients immediately after operation. Group 1-SENs provided the greater proportion of incorrect
The questionnaire was constructed with the advice of senior clinial answers except for question 6a. There was no significant difference
and tutorial nurses. The nurses were randomly selected but we tried between the proportion of incorrect answers provided by SRNs and
to have roughly equal numbers in each of four categories: trained SENs to questions 1, 2, 3, or 6, but there was a significant difference
State-registered nurses (SRNs) and trained State-enrolled nurses (P = 0-05) between the proportions of incorrect answers given to ques-
(SENs) (group 1), and student nurses and pupil nurses (group 2). tions 4 and 5, with the SENs giving significantly more incorrect
Only trainees with over six months' training were included, as we answers.
assumed that less experienced trainees would not be expected to Group 2-The pupil nurses provided the greater proportion of
take responsibility for patients in the early postoperative period. incorrect answers to all questions. There was no significant difference
Each nurse was interviewed individually by one of us (DSBS or JB). between the proportions of incorrect answers to questions 1, 2, 3,
We provided individual help and guidance when appropriate, and the and 6b, but there was a significant difference between the proportion
element of nervous tension that accompanies any test was thereby of incorrect answers given to questions 4 (P = 0-01), 5 (P = 0-01), and
minimriised. Each nurse was asked to provide details of his or her 6a, with the pupils showing a significant number of incorrect answers
experience and what training he or she had received in the problems in each case.
likely to be encountered in the postoperative period. The questions The results to questions 7-9 are shown in tables II and III.
are shown in fig 1.

TABLE iI-Results of questions 7 and 8 in trained nurses and trainees

Group 1 Group 2
(1) What are the two important things a nurse does on taking over an
unconscious patient after surgery under a general anaesthetic ? SRNs SENs Students Pupils
(2) What three observations should be carried out on the patient? Question 7
(3) What is the ideal position of an unconscious patient after a (a) Conscious .. 36 18 24 13
general anaesthetic ? (b) Semiconscious .. 9 18 17 17
(4) What three things would you do if the patient stopped breathing ? (c) Unconscious .. 0 0 1 0
Question 8
(5) What three things would you do if the patient vomiited or re- Satisfactory answer.. 54 33 42 28
gurgitated ? Unsatisfactory answer 1 3 0 2
(6) What difficulties would you expect with:
(a) Obese patients ?
(b) Coloured patients ?
(7) At what time do you think the patient is ready to return to the ward ?
(a) When fully conscious? TABLE III-Answers to question 9
(b) When the airway has been ejected?
(c) While still unconscious-that is, immediately?
(8) If you were the only nurse on the ward and one patient was Group 1 Group 2
unconscious describe how you would care for this patient and also No No
other patients in the ward. Recovery recovery Recovery recovery
(9) Have you encountered any disturbing experiences when collecting room room room room
patients from the theatre ? Respiratory 33 13 2 7
Cardiac.. . 1 6 0 1
Other 0 10 1 6
FIG 1-Questions the nurses were asked. Total .. 34 29 3 14

The answers to the first six questions were compared within the
two groups: between SRNs and SENs in group 1 and between One hundred and seven nurses gave information about the point
student and pupil nurses in group 2. The answers were labelled during their training when they were first asked to collect a patient
correct or incorrect, the latter including "unknown" answers. The from the operating theatre. They were also asked whether or not they
number of incorrect answers was expressed as a percentage of the felt confident for this task. The results are as shown in table IV.
total answers for each question. Data were analysed using the x2 test
with Yates's correction or Fisher's exact test when small numbers were
used.
Another 116 nurses were asked to give the approximate point of TABLE Iv-Nurses' answers about the time when they first collected postoperative
their training when they were first asked to collect a patient from the patients and how confident they felt
operating theatre. They were asked to state whether or not they
thought that they were sufficiently experienced for this task. Again, Time in training (months): <3 6 ---12 >12
the questionnaire was conducted on a random, voluntary, and con- No (°0%) who felt confident .. 0 4 (17) 15 (44) 20 (71)
fidential basis. This group included nurses who had trained in other No (%O) who did not feel confident 22 (100) 19 (83) 19 (56) 8 (29)
regions, and the results might therefore be more representative of Total .. 22 23 34 28
practice generally.

TABLE I-Proportions of incorrect answers given by nurses in both groups

Group 1 Group 2
SRNs (n = 55) SENs (n = 36) Students (n = 42) Pupils (n = 30)
Question
No of No (°%) Nouof No (°% ) No of No (°0) No of o
answers incorrect answers incorrect answers incorrect answers incorrect
(1) Postoperative procedure (2 answers) 110 2 (1-8) 72 3 (4 2) 84 4 (4-8) 60 4 (6 7)
(2) Observing patients (3 answers) 165 7 (4 2) 108 16 (14-8) 126 8 (6-3) 90 7 (7 8)
(3) Position of patient 55 6 (10-9) 36 5 (13-9) 42 4 (9 5) 30 3 (10)
(4) Respiratory arrest (3 answers) 165 11 (6.7) 108 16 (14-8) 126 22 (17 5) 90 32 (35-6)
(5) Vomiting (3 answers) .. 165 25 (15-2) 108 28 (25-9) 126 27 (21-4) 90 37 (41-1)
(6) Difficulties with:
(a) Obese patients. . 55 16 (29-1) 36 9 (25) 42 13 (310) 30 18 (60)
(b) Coloured patients ..55 2 (3 6) 36 4 (111) 42 5 (1109) 30 2 (67)
BRITISH MEDICAL JOURNAL 7 MAY 1977 1201
Recovery facilities recovery rooms were usually closed. Staff shortages proved to be the
main continuing problem. In spite of this patients were usually kept
Consultant anaesthetists in the South-east Thames Region were in theatre until they regained consciousness before being returned to
asked to provide information on the recovery facilities in the main possibly even more inadequately staffed wards.
surgical units where they worked and to say whether they were Question 13: day-case facilities-Six hospitals had day-case or
satisfied with these facilities. The questions asked are shown in fig 2. short-stay wards, but in only three did they include provision for
postoperative recovery.
Question 14: degree of satisfaction-Thirteen consultants said that
they were generally satisfied with the facilities where they worked,
FIG 2-Questions the consultant anaesthetists were asked. and 14 said that they were not. Three of these who were dissatisfied
were waiting for the new hospitals to be opened within the next two
years. One consultant anaesthetist said that the only solution would
(1)Number of operating theatres. be a new hospital, as yet only a pipe dream. All those expressing
(2)Number of recovery rooms/areas. dissatisfaction put staffing at the head of the list of priorities for
(3)Do you have a special room ? upgrading.
(4)Do you use a corridor?
(5)Others-please specify.
(6)Lighting of recovery area:
(a) Good daylight or fluorescent "daylight" quality.
(b) Adequate. Discussion
(c) Poor.
(7) Suction: The nurses' replies to the first three questions on their
(a) Immediately to hand. questionnaire were satisfactory, which indicates that nurses are
(b) In adjacent room.
(8) Oxygen: competent to care for the unconscious patient so long as an
(a) Immediately to hand. emergency does not arise. Question 8, which dealt with the care
(b) In adjacent room. of the unconscious patient on the ward, was also well answered.
(9) Communication: This suggests that nurses feel more confident in the stable
(a) Bell-position in relation to nurse. Is it checked regularly ?
(b) Calling for help. atmosphere of the ward, where they would be more likely to be
(c) Other. caring for patients in prolonged coma than after an operation,
(10) Tipping trolley: when the patient is emerging from general anaesthesia. The high
(a) All cases. proportion of incorrect or "missed" answers to questions 4 and
(b) Some cases.
(c) Rare. 5, which dealt with the common postanaesthetic emergencies,
(11) Staff allocation: tendes to confirm this view. In both groups 1 and 2 there
(a) 1 nurse: 1 patient. was a significant difference between the SRNs and SENs in
(b) 1 nurse: 2 patients. the replies to questions 4 and 5, and in group 2 this also applied
(c) Other.
(12) Are there differences in procedure after normal working hours in: to question 6a. This was expected as a higher standard of training
(a) Facilities-for example, closure of recovery rooms. is demanded for State registration, but SRNs and SENs have
(b) Staff allocation. a similar part to play in this essentially practical aspect of
(13) Do you have special facilities for day cases ? nursing, so this difference should be minimised by more
(14) Are you satisfied with immediate postoperative recovery facilities
in your surgical units, and if not, can you suggest how they may emphasis being placed on the subject in the SEN's syllabus.
be improved ? Question 6a referred to the ever-increasing problem of obesity,
which adds to the morbidity and mortality rate after operation.
Nurses are obviously not sufficiently aware of the difficulty of
maintaining a clear airway in obese people or of how obesity
may mask the early recognition of airway obstruction, par-
RESULTS ticularly in the supine position. Nurses more readily appreciated
Twenty-two replies were received giving information on recovery the difficulty of recognising cyanosis in coloured patients,
facilities in 27 surgical units in the South-east Thames Region. The though many had to think about the question, and it was clear
answers to questions 1-11 are shown in table V. that this problem had rarely been brought to their attention
Question 12: differences after normal working hours-Facilities at before.
night were generally thought to be adequate despite the fact that Most training about the care of an unconscious patient is
given in the introductory course, which means that at least six
months intervenes before trainees are expected to put this
TABLE V-Consultants' answers to questionnaire teaching into practice in caring for postanaesthetic patients. This
corresponds with the accounts of their training given by nurses
Question Answers who answered the questionnaire. They remembered the early
teaching in the introductory course but subsequent practical
(1) No of operating theatres (some double units and some in
suites of 3-6) . .56 training tended to be variable and erratic.
(2) No of recovery rooms ..18 Training on the ward obviously depends on the availability of
(3) No of special rooms ..0
(4) Recovery in corridor, etc .7 trained staff, the aptitude of the ward sister, and the amount of
(5) Other arrangements (returning straight to ward in small
hospitals). 2 time she can devote to teaching. The present shortage of nurses
(6) Lighting of recovery room/area: means that the service commitment expected of trainees is far
(a) Good 19
(b) Adequate. 6 too high, and they are sometimes asked to collect patients from
(c) Poor. 2
the operating theatre before they feel confident to do so. Of the
(7) Suction:
(a) Immediately to hand .23 107 nurses who replied to our second questionnaire and gave
(b) In adjacent room. 4
(8) Oxygen: information on the point in their training at which they were
(a) Immediately to hand .26 first asked to collect a patient, well over 40% admitted to
(b) In adjacent room. 1
(9) Communication:
(a) Bell .15
having done this within the first six months of their training and
(b) Calling for help .11 20 o within the first three months. Officially a learner should
(c) Other (telephone) .1 have 12 months' nursing experience before collecting a post-
(10) Tipping trolleys:
(a) All cases .16
(b) Some cases. 9 operative patient unaccompanied, particularly in hospitals with
(c) Rare. 2 no recovery room. Our inquiry confirmed that a nurse feels
(11) Staff allocation: fully confident only after 12 months of training.
(a) 1 nurse:1 patient .19
(b) 1 nurse:2 patients. 7 The replies to question 7 showed that the more experienced
(c) Less than 1 nurse:2 patients .1
the nurse, the more likely he or she is to prefer to return a
1202 BRITISH MEDICAL JOURNAL 7 MAy 1977
postoperative patient to the ward when fully conscious. Over rather than concentrating all such training into the introductory
6000 of the SRNs said that they preferred this. The other groups course. Practical refresher courses should be provided from
were divided more equally in their preference to return patients time to time for trained nurses, particularly those who have
either semiconscious or fully conscious. Only one nurse was been away from nursing for some time. More emphasis should
happy to return an unconscious patient. be given to using resuscitation equipment such as oxygen and
suction. A surprising number of nurses forget to open the
Acidbrink valve between the mask and the reservoir bag when
RECOVERY FACILITIES administering oxygen. Many nurses said that they expected to
use the gauze and sponge holder to remove vomit rather than
The answers to question 9 confirm the value of recovery suction.
rooms. By far the most emergencies occurred in patients who Although nurses should be trained to use the emergency
were still unconscious in hospitals with no recovery rooms. instruments they take with them to the ward (mouth gag, tongue
Nurses have vivid memories of these incidents, which are depressor, and sponge holder) we hope that they may never be
obviously very frightening, particularly for learners. The feeling required to use them. All nurses should be competent at
of not clearly knowing what to do in an emergency accounted administering oxygen and removing secretions and vomit by
for many nurses' lack of confidence. Most of the emergencies suction. More emphasis should also be given to the particular
were episodes of respiratory arrest or depression, and haemor- problems likely to be encountered in certain types of patients-
rhage was not mentioned as a postoperative problem in this for example, the obese, the coloured patient, and very young or
survey-a compliment to modern surgery. very old patients.
The fact that nurses are being asked to take on the responsi- Nurses in charge of recovery should be able to help the clinical
bility for the postoperative care of patients alone at an increasingly tutors in teaching, and anaesthetists should also be prepared to
early stage in their training is compounded in many cases by help in the practical aspects of training. It is vital that anaes-
the inadequacy of the facilities provided. Although the financial thetists should show an active interest in the stage of emergence
stringencies of the NHS have delayed and will continue to delay from anaesthesia, so that nurses can feel confident that help will
the provision of fully equipped and staffed recovery rooms, there always be there when needed. Continuous co-operation between
seems to be little excuse for some inadequacies. For example, in anaesthetists and nursing tutorial staff is essential to ensure that
12 of the 27 surgical units considered in our third questionnaire the training programme fulfils and continues to fulfil the
help could be obtained in an emergency only by shouting for requirements of the particular district.
help or knocking on the theatre door. The fact that suction was
not immediately to hand in four units and oxygen not imme- We would like to acknowledge the help of the following in the
diately available on the patient's trolley in one case is equally preparation of this paper: the nursing staff who helped to draft the
unsatisfactory. nurse questionnaire, the nurses who took part in the questionnaire,
and the consultant anaesthetists who provided information on
recovery facilities. We should also like to thank Mrs S Smith, Mrs R
Clifford, and Mrs M Fisher for their secretarial help.
Conclusions
A fully equipped recovery bay or area close to expert help is
mandatory in all busy surgical units. The cost of such a room References
should not be excessive, requiring only good communications, Registrar General's Statistical Review, pt I Tables, Medical, 1950-1970,
adequate lighting, and a source of oxygen and suction. Only in a London, HMSO, 1952-72.
"cottage" hospital, where minor surgery is carried out, it is 2 Wylie, W D, Annals of the Royal College of Surgeons, 1975, 56, 175.
reasonable to return the patients straight to the ward, which is 3Department of Health and Social Security, Hospital Building Recom-
usually close to the theatre. It may then be desirable to nurse mendation, C9 SFB 4025 26, London, DHSS, 1967.
4 Operating theatre records, St Bartholomew's Hospital, Rochester, 1972.
the patient in the lateral position as soon as he is returned to bed.
(Accepted 12 February 1977)

POSTOPERATIVE NURSE
The shortage of nursing staff is likely to remain chronic while
NHS resources are limited. It is therefore vital to make the most What is the present treatment of herpes genitalis ?
effective use of currently available trained nursing staff. Using
a ward nurse, no matter how well-trained, is a poor compromise. Unfortunately there is no curative treatment. Local applications of
idoxuridine and other preparations have proved disappointing both in
Her departure to collect a patient after operation will deplete shortening the duration of individual attacks and in preventing
the ward staff (usually very busy on an operation day), so she recurrences. This is not surprising, as it is now well established that the
will be reluctant to stay near the theatre until the patient has virus invades the nerve sheaths and the posterior root ganglia during
fully recovered from anaesthesia. She may be tempted to the primary attack, and to eradicate it a systemic antiviral agent is
return the patient before it is safe for him to make the journey, required.' At present there is no such preparation of proved value.
or she may try to wake the patient forcibly, which is most Treatment consists of keeping the lesions clean, and the regular
undesirable. All busy surgical units should therefore have a application of physiological saline solution is probably as satisfactory
trained nurse whose sole responsibility is to care for post- as anything else and is harmless. If there is severe pain appropriate
operative patients until they are fully conscious. One nurse analgesics should be given, and when the lesions become secondarily
infected a sulphonamide or co-trimoxazole by mouth at the usual
should be provided for every one patient or, at most, two dosage for five or seven days is often helpful. Treponemocidal anti-
patients. biotics are better avoided. The recurrent nature of the condition
should be explained to the patient, who should also be told of the
risk of infecting a sexual partner when active open lesions are present.
TRAINING Women with genital herpes should be advised to have regular annual
cervical cytology. In many patients the attacks become progressively
It should be recognised that trainee nurses might be expected less frequent and less severe and often cease after a few years. Moder-
to collect postoperative patients fairly early in their training, ate optimism about the long-term prognosis is therefore reasonable as
perhaps after the first six months. Further demonstrations or a many patients become depressed by frequent recurrences of the
lesions.
refresher course on the care of the unconscious postanaesthetic
patient should be given after five to six months of training ' Baringer, J R, New England journal of Medicine, 1974, 291, 823.