It can be fun to look back at the history of various professions, especially perioperative nursing. A look back reveals how perioperative nursing emerged as the first recognized nursing specialization in the late 1800s and grew to become the highly specialized field that it is today.
This month, we examine the history of perioperative nursing and focus on some of the most instrumental nurses in the advancement of this specialization.
In the Beginning
The history of perioperative nursing begins with Florence Nightingale. Though she wasn’t technically an OR nurse, her groundbreaking work with the British military during the Crimean War in the mid-19th century laid the groundwork for modern nursing.
Nightingale was an upper-class British woman who led a group of volunteer female nurses to the Crimea in 1854 to help care for British soldiers who were wounded during the fighting. The conditions were brutal as medicines were in short supply and hygiene was being neglected, resulting in mass infections and death.
In fact, many more soldiers were dying from battlefield illnesses than from wounds themselves. Nightingale believed that implementing basic sanitary principles like hygiene, ventilation and hand washing were the key to preventing infections. It’s estimated that her work was instrumental in reducing the death rate among wounded British soldiers in the Crimea from 42% to just 2%.
When she returned to England after the war, Nightingale established nurse education programs in British hospitals based on what she learned out in the field. The programs were organized around Nightingale’s beliefs and ideas about how nurses should be educated, which came to be known as “Nightingale Principles.”
The Nightingale Training School was established in 1860 and the first Nightingale-trained nurses started work five years later at the Liverpool Workhouse Infirmary, which is now called the Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care. In 1859, Nightingale wrote “Notes on Nursing,” which is still considered a classic introduction to the nursing profession.
Scientific Advancements Increase Surgeries
The late 1800s saw several scientific advancements and discoveries in healthcare, including the advent of anesthesia, that resulted in a growing number of hospitals and surgical cases. Before this, surgeries were usually performed in patients’ homes.
This led to the need for specialized surgical nurse training. The use of a surgical assistant first appears in the literature in the late 1800s and student nurses were first assigned to assist in surgeries in 1891. These early OR nurses were mainly given responsibility for cleaning and sterilizing instruments, preparing patients for surgery, bandaging and hemostasis.
The term “operating room nurse” first came into general use around the turn of the century. One of the first nurses to specialize in the OR was Caroline Hampton Halstead. She was appointed the chief nurse of the OR at the Johns Hopkins Hospital in Baltimore in 1889 by world famous surgeon Dr. William Halsted, whom she would later marry.
While working as Dr. Halsted’s scrub nurse, Caroline Halsted developed a severe contact dermatitis due to contact with disinfectants mercuric chloride and carbolic acid. Dr. Halsted asked the Goodyear Rubber Company to manufacture two pair of thin rubber gloves with gauntlets for her to wear during surgeries. Thus, Caroline Halsted was the first nurse to wear surgical gloves in the OR.
Post-War Perioperative Nursing
Another influential early perioperative nurse was Edith Dee Hall, who was born in Nebraska in 1897. At the outbreak of World War I, Hall answered the call to serve along with thousands of other women by applying to the Army School of Nursing in 1918. Between her acceptance in 1919 and her graduation in 1921, Hall received training at military hospitals in Fort Des Moines, Iowa; Fort Hill, N.Y.; St. Lukes Hospital, N.Y.; Camp Dix, N.J.; and Walter Reed Hospital in Washington, D.C.
After the war, Hall became the OR supervisor at the New York Polyclinic Medical School and Hospital. She strongly believed it was important for OR nurses to organize to increase their ability to provide better patient care.
Hall’s education, Army experience and work with surgeons and nurses all over the country uniquely positioned her to help create the Association of Operating Room Nurses. This later became the Association of periOperative Registered Nurses (AORN), the nation’s largest organization devoted to uniting and empowering perioperative nurses and healthcare organizations to support safe surgery for every patient.
After founding AORN, Hall served as the first AORN Executive Secretary from 1957-1962. Before her death in 1971, Hall worked as a consultant and writer for “Hospital Management” magazine.
Amy Armour Smith is an early 20th century nurse who made her mark as an author. Though she wasn’t technically an OR nurse, Smith wrote “The Operating Room: A Primer for Pupil Nurses,” which discussed concepts and ideas that were revolutionary at the time. For example, she stressed the importance of personal follow-up visits so nurses knew how patients were progressing post-operatively and to learn the results of product use first-hand.
Smith advocated for refinements in aseptic techniques and recommended OR practices that soon became common, such as caps and masks going on first instead of last, boiling instruments after every operation, using white canvas laundry bags in metal wheeled frames, and avoiding leaning over a sterile field.
In addition, Smith championed the continuing development and education of OR nurses, recommending recertification every three years through theoretical and practical examinations. She promoted standardization of perioperative practices and more frequent conference attendance by OR nurse supervisors, as well as visits to other hospitals to discuss common problems and compare methods.
Edythe Louise Alexander is another pioneering OR nurse who made her mark as an author. In 1943, Alexander published the first edition of “Operating Room Technique,” which remains a staple for new nurses entering the perioperative arena. The third and fourth editions of this landmark book, retitled “Care of the Patient in Surgery, Including Techniques,” were published in 1958 and 1967, while later editions of the book bore her name: “Alexander’s Care of the Patient in Surgery.”
Promises Made, Promises Fulfilled
One of the most influential perioperative nurses during the later part of the 20th century was Jane Rothrock, who served as the president of AORN in 1994-1995. Upon assuming the presidency, she made a number of promises to the perioperative community which were fulfilled during her tenure.
The first was to be a “back to basics” president who would form partnerships with AORN members. This was accomplished through outreach and collaboration with chapter presidents, national committee members and committee liaisons to establish strategic alliances with other professional organizations.
Rothrock also pledged to focus on substantive issues related to the perioperative workplace. During her tenure, AORN devoted time and energy to investigating workplace redesign and promoting reimbursement for RN first assistants. Instead of being drawn into debates that focus on function or who completes tasks, she remained adamant that the performance and evaluation of patient care requisites cannot be separated.
She demonstrated her commitment to accessibility by making 100 phone calls each month in response to AORN members who had reached out to her and visiting 50 different chapters over the year. In addition, AORN undertook a number of activities to influence public policy, provide professional development opportunities and support the vital work of AORN’s specialty assemblies during her tenure.
Rothrock received numerous awards throughout her career, including the AORN Jerry G. Peers Distinguished Service Award, a Recognition Award for Excellence in Nursing Practice from the Nightingale Awards, and the Christian R. and Mary F. Lindback Distinguished Teaching Award. In addition, she was a longtime editor of “Alexander’s Care of the Patient in Surgery.”
Spearheading the Drive to the Surgical Time Out
In 2004, Bill Duffy became just the second man to serve as the president of AORN after serving in various leadership roles since joining AORN in 1983. He has made numerous contributions to perioperative nursing throughout his long and distinguished career, especially in the area of nurse education.
Duffy has published numerous journal articles and made dozens of national and regional presentations covering virtually every aspect of perioperative nursing. In addition, he has written three books: “Care Coordination and Transition Management Core Curriculum” “Perioperative Services: Administration; Resource Management and Patient Care;” and “Leadership in Action: A Manager’s Guide to Success.”
Perhaps his most influential work were his efforts to make the surgical Time Out a standard OR practice. The surgical Time Out is a groundbreaking perioperative practice that some have compared with wearing gloves and following sterile procedures as among the most important changes in perioperative history.
In the early 2000s, The Joint Commission published a list of “never events” that should never occur in the operating room. Also referred to as sentinel events, these include wrong site, wrong patient and wrong procedure surgeries.
Duffy observed that in their efforts to avoid making these errors, some surgeons were marking the surgical site while others were marking the site not to be operated on. He believed it was important to establish a standardized process for all surgeons to follow to avoid sentinel events.
Working together with the AORN Board of Directors, they created a taskforce to develop a standardized process for the surgical Time Out. A surgical Time Out toolkit was mailed to every AORN member and hospital in the country and AORN soon received requests for toolkits from hospitals in Canada, Europe and Asia as well.
The final step was making the public aware of the surgical Time Out and getting their buy-in. AORN hired a PR firm which helped create the National Time Out Day, which occurs annually on the second Wednesday of June. Duffy conducted interviews with major media outlets such as the CBS Early Show, Fox News, NPR, the Associated Press, USA Today and The Wall Street Journal.
More than 150 AORN members from 14 states even marched in Chicago’s St. Patrick’s Day parade in 2009 carrying a banner that read, “Time Out: Every Patient, Every Time.” Over the past two decades, the surgical Time Out has become a worldwide practice that’s performed in the vast majority of surgical procedures.
A Beloved Cardiac Leader
Patricia Seifert was an influential perioperative nurse who specialized in cardiac surgery and helped pioneer the RN First Assistant (RNFA) role. In an interview with OR Manager before her passing in 2022, she described how soon after starting work in cardiac service, a surgeon asked her to move up to the chest to assist him.
At that time, the RNFA role was just beginning and only two states interpreted their nurse practice acts to include first assisting. After this surgery, Seifert began first assisting and promoting the opportunity to first assist to other members of the cardiac perioperative team. She also started an RNFA class that included surgeons, anesthesia personnel and expert staff members as teachers.
Over the next 40 years, Seifert personally assisted in more than 3,000 cardiac procedures. She told OR Manager that this experience gave her numerous insights into patients, colleagues and administrators, as well as anatomy, techniques, rules and other aspects of cardiac surgery. Her work resulted in the first comprehensive textbook on the perioperative nursing care of cardiac surgery patients, which was published in 1994.
Seifert, who served as AORN president in 1999-2000, was a big believer in “sharing” instead of “hoarding” knowledge. As a leader, she had a clear vision, respect for team members at all levels (both RN and non-RN) and wanted to help each team member succeed, stated OR Manager. While her expectations for other team members were high, she worked to be fair and encouraging and to provide “tough love” when it was needed.
Seifert was beloved by the many perioperative professionals she worked with throughout her long career. She shared these parting words of wisdom to live by with OR Manager:
“Make it your primary, personal and professional goal to help others succeed in an environment that focuses on patient safety. One of the ever-present considerations that guides our practice is that we have the ability to do harm, so it must be a perioperative leader’s top priority to provide a safe environment for the patient and team members.”
