From theatre to perioperative: A brief history of early surgical nursing

Perioperative nursing is believed to be the first specialisation to arise in nursing and tracing its beginnings is an interesting exercise. The scientific advances made during the latter part of the 19th century resulted in increased numbers of patients in hospitals. Though previously shunned by all but the poorest, hospitals now provided an environment that was safer for surgery than a patient’s home, and needed skilled nurses as a result. Florence Nightingale established a school of nursing in England teaching ‘sanitary nursing’ and ensuring probationary nurses knew about antiseptics and disinfectants. Ms Nightingale stated that it was the duty of every nurse on surgical wards to prevent infection, and until the end of the 19th century the nurses who cared for surgical patients in the wards preand postoperatively also prepared for and assisted during surgery. However, in 1899 the first dedicated operating room nurse was employed in the USA, and thereafter the role of the theatre nurse became entrenched. That role has evolved significantly since then and continues to do so.


Introduction
This paper presents an overview of perioperative nursing from when the specialty began in the latter part of the 19 th century until the latter part of the 20 th century. Surgical interventions and models of care have changed dramatically during the last several decades, due to the impact of technological innovations, rising costs, increasing demand and an ageing population 1 , and these have impacted on the role of perioperative nurses. However, these impacts are much better documented than those that occurred in the first hundred years or thereabouts and so have not been addressed here. Delving into the past in order to identify the origins of perioperative nursing is no easy task, not least because its history is nebulous, wasn't always recorded or is not accessible, and is sometimes contested * . The author welcomes feedback from readers with verifiable material offering confirmatory or alternate viewpoints.

The beginnings of perioperative nursing
It is reasonable to state that perioperative nursing was not a discrete specialty 120 years ago and was still embryonic in the first decade of the 20 th century. The beginnings of perioperative nursing arose from caring for surgical patients, as all nurses needed to be trained to prepare for and assist at operations 2 as well as care for patients before and after operations. This begs the question: when did nurse training commence, and why? Feature Author Dr Lois Hamlin DNurs, RN, FACN, FACORN * An early caveat is that this article is not a systematic review and critical analysis on the topic, and is further constrained by the availability of appropriate sources, not all of which have been digitised. This is especially the situation regarding material from the latter half of the 19 th century and the first half of 20 th century.
There is little evidence of formal training before the mid-1850s other than that associated with religious orders since nursing care was mostly delivered by family members or household servants 3  The latter half of the 19 th century also saw many scientific discoveries. Of note was the work of Pasteur with bacteria and of Lister, a British surgeon, who was developing and using antiseptic solutions 5 . There was also the advent of anaesthesia as well as many other pertinent developments and much social reform occurring 3 . All these developments resulted in the rapid growth of hospitals 6 as knowledge of asepsis and the need to keep bacteria out of wounds grew. Consequently, the number of surgical cases increased as did the range of surgical interventions, and surgical procedures were undertaken in hospitals whereas previously many had been conducted in patients' homes.
These hospitals needed a skilled nursing workforce. Florence Nightingale established a school of nursing at St Thomas' hospital in 1860 7 , and in subsequent decades Nightingale-inspired schools were founded in Australia 8 , the United States of America (USA) 9 , Sweden and elsewhere 10 . While Florence Nightingale was initially reluctant to accept 'germ theory', she was staunch in advocating the need for cleanliness, light, fresh air and ventilation; their precepts had underpinned her success during the Crimean war in the early 1850s 11,12 , and her teachings focused on the need for nurses to ensure that sanitary conditions were created and maintained at all times. She regarded 'sanitary nursing as essential in surgical as in medical cases, but not to supersede surgical nursing' 7 (p. 164) . Nightingale also ensured that probationers were taught about antiseptics and disinfectants 10 . Importantly, she stated that, 'In surgical wards, one duty of every nurse certainly is prevention ...
[of] fever, or hospital gangrene, or pyoemia, or purulent discharge' 7 (p. 165) . Even in the last decade of the 19 th century the nurses who cared for their surgical patients in the wards prior to surgery also prepared for and assisted during surgery 2, 13 as well as caring for them after surgery 14 . In some training schools in the USA, a significant amount of a nurse's time during training was spent caring for surgical patients and working in the operating theatre (OT) 15 .
Operation-specific duties included ensuring that all instruments, sponges, dressings and the water used in an operation were sterilised and, if the operating table was long enough, the nurse should 'admit a hot water bottle at the patient's feet' 14 (p. 211) . In some instances, nurses prepared patients for theatre by dressing them in a clean chemise, nightgown and stockings 13 . Alternatively, they were dressed in lamb's wool or flannel leggings, and a loose lamb's wool jacketalthough a loose lamb's wool coat-shaped operating gown was also advocated, perhaps for female patients! The nurse also had to prepare herself in the following manner: 'A hot carbolic bath should be taken on the morning of the operation, and perfectly clean clothes put on' 14 19 , the first Australian nursing organisation which was selfgoverning and whose office bearers were 'prominent medical men and matrons of leading hospitals in Sydney' 8 (p. 18) . ATNA was established to protect the public from ignorant and incompetent nurses, to improve and standardise general nurse training and to promote the professionalisation of trained nurses. For more than ten years the association determined standards of entry, training (including in theatre techniques) and examination, and professional and personal codes of conduct.

Evolution of the role
During this period the role began to evolve; in Australia, Jane Bell, the Lady Superintendent of Nursing at the Royal Melbourne Hospital, appointed a theatre sister in 1912, the hospital's first such appointee 21 . An early edition of the British Journal of Nursing also outlined the nursing staff of a suite of four theatres in a UK hospital. These included a sister in overall charge, an instrument nurse, a sponge nurse and an assistant nurse in each theatre. The role of the assistant nurse was, 'to do whatever she may be told.' 22 (p. 46-47) .
In due course, the sister in charge role eventually became the theatre superintendent in the UK 23 . During a comparable time period in Australia, student nurses, 'returned to a great deal of solid cleaning' in their fourth year of training when they went to theatres 18 (p. 164) . Here they scrubbed the walls, lights and the floors with lysol following the departure of the surgeon, a task which took four hours. Each theatre had a sister and two student nurses. The role of the sister was to assist the surgeon, although a notable exception was the Royal Prince Alfred Hospital (RPA) in Sydney where some surgeons (but not all) had 'instrument men' until 1932. The role of these 'instrument men' comprised the care and maintenance of instruments and sterilisation of catgut as well as assisting the surgeon. In these latter cases, the sister was the sponge nurse 18 .
Over the course of the 20 th century as the nursing curriculum evolved and its theoretical content increased, concepts associated with theatre nursing were introduced and taught. By the middle of the 20 th century, a minimum of 40 days practical experience working in OTs was mandated and this was completed during a student nurse's final year 8 . Thereafter, if a student nurse showed an aptitude for working in the OT, the theatre sister in charge would invite them to return on completion of their basic training! Despite these curricular changes, the work of student nurses changed little; they cleaned up the theatres and scrubbed instruments 23 . Even in the 1950s and 1960s nurses' (and sisters') work in theatres at the weekend included winding spools of catgut and sterilising them; working in the clean room, testing, drying, powdering and packing gloves ready for sterilising; counting gauze swabs into packs of five ready for sterilising; polishing instruments and soaking them in 'instrument milk'; and folding linen 24 . Unusually, at Royal North Shore Hospital, Sydney, theatre sisters put student nurses at the instrument table to learn while they were at the sponge table 24 .
An English textbook from the 1960s, Surgery for Nurses 25 , had a 13-page chapter on 'Asepsis and theatre technique' containing information on the following: • a short section on 'theatre technique' -which, seemingly, was comprised of compelling theatre staff to observe all principles and techniques of asepsis, and included an explanation of theatre attire • antiseptic and disinfectant solutions • types of suture materials (including kangaroo catgut!) and needles (all reusable) • basic information about asepsis and how to undertake various tasks without contaminating sterile items or the surgical team, including the correct method for putting on gloves • swabs -which, seemingly, were only counted once, before the wound was closed • prevention of burns and explosions, and the correct use of surgical diathermy • the requirements and duties of the ward nurse -who brought the patient to and from theatre. It is noted that the ward nurse 'is entirely responsible for the patient during transit from the theatre to the ward' 25  In Australia, at the same time as these changes in education along with the formation of professional nursing organisations were occurring, the role of the 'operating room nurse' was also evolving as was the associated terminology. Scrub and scout nurses became instrument and circulating nurses, while some nurses specialised in particular types of surgery (e.g. working only in highly complex cardiac or neurosurgical arenas) or stages of the patient's journey (e.g. working only in pre-admission, anaesthesia or recovery) reflecting the increasing complexity and nature of surgery and anaesthesia. Additionally, nurses worked in perioperative nursing management positions and as perioperative nurse researchers.
Advanced OR roles such as that of nurse practitioner and perioperative nurse surgeon's assistant (PNSA) also came into being. Consequently, around the turn of the century, the term 'perioperative' was adopted, representing the care of patients not only during surgery but across all stages -preoperative, intra-operative and post-operative 30 .