What are the attractions of surgical nursing? Surgical nurse Catriona Kaczon has worked on the same ward at Hutt Hospital for the last six years and still begins a new shift excited by what challenges may lie ahead.

'Being a surgical nurse, you get to help fix things and see people regain their quality of life. People come in for their elective surgery and, all going well, this can restore their health and fitness to what it once was. This is immensely satisfying nursing." Surgical nurse Catriona Kaczon (nicknamed Tush by her colleagues) is clearly enthusiastic about her work and is just as committed to her staff nurse role on the general surgical and gynaecology ward at Hutt Hospital as she was when she started there six years ago. A latecomer to nursing, she competed her nursing degree at the then Wellington Polytechnic in 1999. After spending some time gaining nursing experience in a local rest-home and working on a short-term contract in the hospital's rehabilitation ward, she applied for a position on the surgical ward. "Getting the relevant experience wasn't so easy in the late '90s. Now the hospital runs its own new graduate programme, which makes things much easier for new nurses," she said.

Kaczon had intended going nursing when she was 17 and had actually applied to join the last nursing school intake at Hurt Hospital. However, early marriage intervened in these plans, though she did find some satisfaction working for 15 years--"on and off between having my babies"--at a local medical centre. After a year's training, medical receptionists were able to undertake some procedures like taking blood pressures, urine samples and recording patients' weight. This practice stopped once the practice nurse subsidy was introduced in 198?

Although Kaczon has some regrets about not getting into nursing sooner, she has made up for lost time since, completing a postgraduate perioperative surgical course at Whitireia Community Polytechnic and a postgraduate diploma in nursing. She completed the last of the four diploma papers last year. If she does another four papers, she would receive her master's qualification. However, she finds studying on top of full-time work very demanding and is not so sure she will complete the extra papers. Kaczon works alongside a very stable group of nurses, around 10 of whom have worked on the ward for a number of years. "We are all of a similar age." The ward has 27 beds and is always busy. "Traditionally, January was always our quieter month where we could enjoy a bit of a break, but this year it has been as busy as any other. Most days, the ward is at full capacity, even at weekends when usually our numbers reduce to around 20 patients. In the middle of winter, we often get some extra medical cases admitted to the ward, due to high work loads during these months."

Over the last six years, Kaczon has observed many changes to the way procedures are done and who now qualifies for elective surgery. "We now operate on people who wouldn't have been given surgery a few years ago, especially people with cancer. Older patients would more likely have been given a palliative option for their tumours rather than being offered surgery. As anaesthetics have improved and surgical procedures become easier, more people are being offered surgery. Being older, they might take longer to recuperate, but some will gain a better quality of life and most will have a longer life span as a result of having surgery. Others may look back and regret their decision to have surgery if their pain persists and there are no obvious improvements. "

Kaczon enjoys the variety of surgical cases admitted to the ward, especially now that some contracts for elective surgery are returning to the hospital rather than going to the private sector. "Procedures can range from ear, nose and throat (ENT) to mastectomies, bowel resections, acute gynaecology for miscarriages, ectopic pregnancies and hysterectomies, and Crohn's disease and colitis operations. It is great to see improvements in many surgical techniques. Some large bowel resections, for example, can now be done laparoscopically and microwave ablation is being used for some uterine procedures. Less invasive surgery certainly helps patients recover faster.

"Pain relief is also much better through the use of epidurals and patients being able to control their own pain with a morphine pump. So many surgical procedures are now much less threatening to people than in previous years. People either have a very short hospital stay or they may require more complicated nursing cares and stay longer. We do have our share of sadness on the ward when surgery just hasn't helped and a patient dies. Often, however, this might be because of post-operative complications and other medical conditions rather than as a direct result of the surgery."

Hutt Hospital is a secondary hospital rather than tertiary like its near neighbour Wellington Hospital It is also a teaching hospital, and, says Kaczon, a good place for a new house surgeon to gain experience. "Our house surgeons get good support here. We have also had several overseas surgeons working here and presently have a well qualified Iraqi surgeon. "We try hard to build good relationships with the surgeons and surgical registrars who are with us for six months at a time. Sometimes conflicts arise when the nurses don't agree with how the surgeons are managing patients, but we always try to find a middle ground. Mostly we work together well."

Hutt Hospital has four operating theatres and they are busy all the time. There is a proposal to build another theatre wing in the near future, which would provide an additional two theatres, with provision for another two. Although Kaczon looks forward to this addition, she is concerned at how the hospital will attract sufficient staff. "We already have a shortage of nurses and some surgeons from the Wellington area have moved to Auckland. We have recently had to send a patient with a pancreatic condition to Palmerston North Hospital and another to Christchurch. This is not ideal. Keeping good staff is not easy."

A recent feature at the hospital has been the arrival of the mobile surgical bus, which now spends around a day every five weeks parked at the back of the hospital. (See feature story p16-17.) Although there was some initial op position to this import, there is now much greater acceptance of the service among nurses and surgeons. "We used to think having the bus here was a stupid idea, but it's always busy and it's helping keep our waiting lists under control. Our ENT surgeons don't mind working on the bus, especially if our theatres are fully booked."

Most nurses work rostered and rotating shifts. Kaczon doesn't particularly enjoy the night shifts and looks back with some nostalgia to the days when the hospital employed permanent night staff. However, she enjoys the continuity of care the ward provides patients. Particularly successful, she says, is the system where two of the nurses do all patient pre-assessments on the ward, rather than having this done by some other nurse in an outpatients department. These two nurses spend half their time doing pre-assessments and the other half nursing on the ward. "This system helps us really know our patients and to appreciate the challenges they will face post-surgery. Nursing patients who stay on the ward a bit longer also increases our work satisfaction. This gives us the chance to really get to know them and their families.

"Each nurse on any particular shift is given a patient load, which is worked out on acuity. We all try to keep the same patients for a certain number of shifts in order to give them some continuity of care. Afternoon shifts are usually our busiest, as that's when we receive a lot of acute admissions. We would normally be given four or five patients each. Some of these will already be on the ward; others I will pick up from the recovery area. Those four or five patients will include one 'heavy' patient, who might require hourly or two-hourly observations; one not so heavy; one who might need a dressing change; and perhaps another about to be discharged. Nurses with more experience obviously get assigned the more complicated patients. A nurse co-ordinator does the ward rounds with the doctors on the morning shifts. She writes up a round book with the instructions for the day, and plays a vital liaison role between the doctors, nurses and support staff. 'Recently I have been on a run of afternoon shifts. When you begin your shift you have to be ready to cope with any emergency that might arise, eg a patient who suddenly develops acute pain. Any plans you might have for the day might be out the window as you deal with a sudden crisis. You have to be prepared to have your day thrown into chaos. As a surgical nurse you have to be able to anticipate problems and watch trends like a falling blood pressure or low urine count. You have to be able to ask yourself why these problems are occurring and then find solutions as quickly as possible."

Getting patients motivated after their surgery can be a challenge, she said. Some want to lie still in their beds and recuperate, but the hazard of this is the possibility of a chest infection or deep vein thrombosis developing. "Some patients accuse us of bullying them to get out of bed. They do not always appreciate we are doing this to aid their recovery and prevent complications."

A key team member in helping mobilise patients is the ward physiotherapist. She works closely with the nurses, instructing them on how best to get people up after their surgery. Another key member is the dietician. Patients undergoing different procedures will require different diets, particularly those waiting for their bowels to start functioning again. Those on total parental nutrition are fed intravenously.

Kaczon intends working on the surgical ward for the rest of her nursing career. Nursing on a medical ward doesn't appeal to her--"It seems you just wait for a patient's next medical crisis to occur"--nor does theatre work. "I couldn't stand having to stay still in all that gear, trying to anticipate what the surgeon wants. I wouldn't mind working in recovery, but I need a job where I can keep moving."

Fortunately for Hutt Hospital, Kaczon has found just the ward that suits her personality, her preferences and her skills.