The development of plastic & reconstructive surgery nursing (Part II).
Part one of this article (published in The Dissector, Vol. 45, No. 2) outlined the emerging speciality of plastic and reconstructive surgery (PRS) and how nursing developed within the speciality until the end of World War One (WW1). It became clear that WW1 pushed the speciality to develop new and innovative ways to repair, care for and manage patient rehabilitation. The aim was always to give patients the ability to live a functional, integrated life after suffering traumatic and disfiguring injuries. The following 20 years provided an opportunity for plastic and reconstructive surgery to fine-tune some reconstructive and wound management techniques. These skills would ultimately become integral to managing the next influx of casualties in World War Two (WWII). This article will be looking at how nursing continued to develop throughout this period and rose to the challenge of caring for patients who came to need the care and skills of this developing speciality.
Nursing development between the wars
After the passing of the Nurses Registration Act (NRA) in the United Kingdom in 1919, nursing finally began to take its place as a profession. The NRA laid the foundations for formal training and qualifications for nurses. PRS, like any other nursing area of practice, would have been able to begin to develop educational and professional skills for Registered Nurses that became standards of care within the speciality. Formalised nursing training in specialist centres, lectures and articles in journals all provided the opportunity for nurses to develop their skills, share information and experience and reflect on clinical practice. These early examples of professional practice development were demonstrated in a lecture given by the Vice President of the Royal College of Surgeons to nurses in 1933 (British Journal of Nursing, 1933) where he emphasised the need to understand the mechanisms of wound healing; he specifically focussed on the importance of wound care not denigrating into a mechanical process.
Plastic Surgical Nursing between the wars
The reconstructive process continued between the world wars. It became increasingly clear that plastic and reconstructive surgery, in relation to traumatic injuries, required a series of surgeries--the aim being to achieve a finished result that was acceptable to the patient, the surgical team and society.
Sir Harold Gillies and his team performed some 11,000 operations at The Queen's Hospital in Sidcup, Kent between 1917 and 1925 (Furness, 2012). Many of these reconstructive surgeries would be on the same patient as flaps, grafts and specialist reconstructive options were adapted to suit the patient.
When Archibald McIndoe (cousin to Sir Gillies) arrived in the United Kingdom from New Zealand in the 1930s, he set up in practice with Sir Gillies. Together they developed flap and grafting techniques that were to become invaluable during the Second World War (Mayhew, 2016). The practice and experience of the surgeons at Sidcup and in their private practice throughout the 1920s and 1930s would have been mirrored by the nursing staff caring for these patients.
Throughout this period the nursing profession was addressing the need to have a formal, standard educational system in place for nurse training. The Royal College of Nursing (RCN) in the United Kingdom set out to establish nursing as a profession, with a specific set of knowledge and skills--for which all nurses should be fully trained (McGann, Crowther and Dougall, 2010). One of their concerns in the 1920s was to prevent the sudden influx of semi-trained women into the profession post-war. Therefore the 1920s and 30s were a period of consolidation and a struggle for influence and this often involved nursing organisations developing political and social influence to effect change.
As WWII approached, nursing came under increasing pressure to supply more numbers to meet the expected demand. The educational standards and skills established over the last 20 years would become invaluable.
The introduction of registration led to very small hospitals not offering training, whereas large hospitals, such as The Queen's Hospital in Sidcup, Kent where Sir Gillies worked, were able to sustain a nursing training programme (Abel-Smith, 1964). Nurses working in these Plastic Surgery wards and theatres in the 1920s and 1930s would have had to undergo formal nurse training.
The challenge of managing severely injured patients
Up until the end of the 1930s, severe injuries, especially burns over 30 per cent, killed nearly everyone who suffered them almost immediately; whereas after 1939 they did not (Mayhew, 2016). The 1930s saw the most significant breakthroughs in the treatment of burn shock. In 1921, after the New Haven Rialto Theatre Fire, Frank Underhill observed that burn shock was related to intravascular fluid loss rather than direct toxic effects of injury (Peeters, Vandervelden, Wise & Malbrain, 2015). He noted that deaths following a severe burn injury occurred due to an overwhelming systemic inflammatory response with associated capillary leak syndrome. This resulted in hypovolaemic shock due to fluid shifts that reached a maximum at 12 to 24 hours post injury (Peeters et al., 2015).
The nursing role was to closely monitor those patients having plasma and saline transfusions and to report and deal with responses to treatment (Mayhew, 2016). As experienced nurses do today, the nurse on a plastic surgical ward in the 1930s would have become expert at managing these patients. This would have provided a level of skill capable of managing the influx of burns patients about to present throughout WWII.
Wound management techniques were also undergoing research and innovations in the inter-war years. Coagulants had until then been the mainstay of burn treatments (Abdelsamie, 1936). Tannic acid, which was used in leather works to stiffen hides, was applied to burns and other wounds to provide a barrier to infection and to provide immediate pain relief. This was stored in emergency departments and was an effective way to manage minor burns; however, when applied to major burns it was disastrous for the patient.
Mayhew (2016) reports that when tannic acid was applied circumferentially to fingers and thumbs, it stiffened into an unyielding casing which compromised circulation and blocked the dispersal of post traumatic oedematous swelling. The dressing would have to be removed, which caused considerable pain and potentially destroyed any viable surface for grafting. After much debate and trials of alternative methods of managing major burns (Mayhew, 2016) a system of simple gauze and petroleum jelly became standard practice for burn management in WWII. This system allowed nursing and medical staff to closely observe wounds at regular intervals, they could then detect infection and necrosis at an early stage and manage it more appropriately.
This new system, although superior to tannic acid, was also labour intensive. Plastic surgery wards had a higher ratio of nurse to patient than seen on any other hospital ward (Mayhew, 2016). Nurses needed to perform numerous daily dressings and the liquid nature of the dressings also meant that bed clothes had to be changed frequently. The need to monitor pressure areas would have become paramount as the skin was often moist and compromised by patient immobility. Ward beds were rearranged, given removable head boards and wheels to allow ease of access for facial dressings or circumferential wounds.
The otherwise well patient
An article by Barron (1941) in The Nursing Times discussed the principles of plastic surgery and how the nursing approach differs because you are often dealing with a patient who is often systemically well. The psychological aspects of nursing became a core aspect of plastic surgery nursing as patients required as much emotional as physical care. Mayhew (2016) reports a patient's experience of undergoing a series of facial reconstructive surgeries. The patient reported the "sometimes chaotic" nature of the ward and theatre with activity everywhere, but in the middle of everything, there was a constant, calm and proficient presence of the nurse.
Although Barron (1941) does not go into detail about what aspects of psychological care were addressed, the calming and normalising presence of an educated, proficient nurse would have been invaluable to patient psyche.
Sandeluss (2017) reports her perception of the nursing role as one that includes personal, medical and psychological care. The nurse is the one who is there when the patient struggles to perform personal hygiene tasks and makes it acceptable to receive help with the most personal cares. It is the role of the nurse to do this without embarrassment or limitation.
The experienced plastics nurse was learning to provide the care and emotional support to these traumatised patients that would eventually lead to the patient's re-integration into normal society. The next stage of the development of the PRS nurse occurred during WWII and saw all the experiences and preparation of the inter-war years come to the fore.
About the author Juliet Asbery, Nurse Practitioner (Acute Care) trained at Derbyshire Royal Infirmary in the United Kingdom. She emigrated to New Zealand in 2005 where she initially worked in theatres at Wakefield Hospital, Wellington. Juliet is a member of the Professional Practice Committee of the PNC and is the National Committee Representative for the PNC (Wellington Section). Juliet currently works full time as a Nurse Practitioner throughout the perioperative continuum in Plastic and Reconstructive Surgery. She is passionate about patient advocacy and education.
Abdelsamie, L. (1936). The Disadvantages of Tannic Acid in Mild Burns. The Lancet. Retrieved from the RCN Archives July 2017
Abel-Smith, B. (1964). The Hospitals 1800-1948: A Study in Social Administration in England and Wales. Heinemann. United Kingdom
Barron, J, N. (1941). The Principles of Plastic Surgery Nursing. Nursing Times. Retrieved from the RCN archives July 2017
British Journal of Nursing. (1933). A Report on the Conference of the National Union of Trained Nurses. Accessed at the RCN Archives July 2017. London
Furness. (2012). Pioneering plastic surgery records from First World War published. Retrieved from https://www.telegraph.co.uk/history
Mayhew, E, R. (2016). The Reconstruction of Warriors. Croydon. England
McGann, S., Crowther, A., Dougall, R. (2010). A Voice for Nurses: A History of the Royal College of Nursing, 1916-90. Retrieved from http://www.history.ac.uk/reviews
Peeters, Y., Vandervelden, S., Wise, R., Malbrain, M. (2015). An overview on fluid resuscitation and resuscitation endpoints in burns: Past, present and future. Part 1-historical background, resuscitation fluid and adjunctive treatment. Anaesthesiology Intensive Therapy. Retrieved from https://researchgate.net/publication/283051622
Sandeluss, S. (2017). What do nurses do? The Dissector. Volume 44 (4), 13-14.
By Juliet Asbery
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|Publication:||The Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation|
|Article Type:||Occupation overview|
|Date:||Jun 1, 2018|
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