Theatre Etiquette

A Students’ Guide to Theatres

The Association for Perioperative Practice

Contents
Page
The Operating Department 2
Health and Safety 3-4
Before the Operation 5-6
The Operating Theatre Team 7-8
Access to Information and Confidentiality 9
Five Steps to Safer Surgery 10
The Operating Room 11 - 12
Ten Objectives for Safe Surgery 12
Top Tips from AfPP Members 13
Online Resources 14

Contact us
Tel: 01423 881300
Email: membership@afpp.org.uk
Web: www.afpp.org.uk
The Association for Perioperative Practice
Daisy Ayris House
42 Freemans Way
Harrogate
HG3 1DH

1
 The Operating Department

The operating theatre is a unique environment with unfamiliar sights, sounds

and odours. This guide offers students, and those new to surgery, an overview
of what to expect and how to behave whilst in the operating department.

The Operating Department

The layout of the operating department is designed to minimise the risk of transmitting
infection and will likely be divided into a series of zones. As the patient travels through
each zone, levels of cleanliness increase, with the operating room considered the area
of optimum cleanliness. This means that access is more restricted the further you move
through the department.
To ensure the operating department operates at maximum efficiency and is largely self-
sufficient, areas of activity include:
• Anaesthesia
• Intra-operative care
• Post-anaesthesia

Entering the Department

• Only enter the operating department if you are fit and well. If you are unsure, ask a
member of the team
• When you arrive, introduce yourself to everyone, show your identification badge and
be friendly
• Be aware that everyone will wear the same clothing, regardless of their role. However,
personnel may be identified with different coloured headwear.
• Behave professionally – you are there to learn and represent your profession
• Ask appropriate questions and address everyone professionally
• Remember that you are responsible for your own actions. You are accountable to the
patient, yourself, your colleagues, and your university or organisation.

2
Health & Safety

Security and Personal Belongings

• Sign the visitors’ book if required
• You may be provided with an area or secure locker to store your belongings
• Do not take personal items such as bags into theatres
• Do not take your phone into the operating theatre
• Do not give passcodes to others
• Ensure doors close securely behind you

Health and Safety

Whilst in the operating department, you • Smoke plume, gases, laser and
should be able to: radiation
• Demonstrate knowledge and • Sharps safety and associated injuries
familiarity with national and local • Risk assessment
health and safety policies
• PPE requirements
• Identify and deal with hazards in the
• Manual handling
perioperative environment
• Waste management
You should never open any doors that • Damage to equipment or building
lead directly into the theatre when: • Fire safety
• A procedure is taking place • Stress
• Certain interventions are in progress • Equipment
• Privacy and dignity may be an issue
• Radiology or a laser is being used
In the operating department there
are systems in place to ensure a safe
environment for patients, staff and
visitors. All operating departments must
demonstrate a commitment to the Health
& Safety at Work Act (HMSO 1974) by
having clearly defined up to date policies
and procedures relating to:

• Infection control / cross infection

• COSHH – dealing with hazardous
substances

3
 Health and Safety: Clinical Waste

The correct segregation of healthcare waste on site is vital to ensure that waste is stored,
transported and disposed of in the correct manner. The Department of Health “Safe
Management of Healthcare Waste Memorandum” (HTM 07-01) outlines a best practice
waste segregation colour coding scheme as follows:

Cytotoxic/Cytostatic - HAZARDOUS
Waste consisting of, or contaminated with, cytotoxic and/or cytostatic products
which requires disposal by incineration.
e.g. Blister packs, tablets in containers, unopened medicine vials, patches, gloves,
gowns, aprons, wipes contaminated with cytotoxic and/or cytostatic medicines,
cytotoxic waste disposal.

Anatomical - HAZARDOUS/NON-HAZARDOUS
Anatomical waste which requires disposal by incineration.
e.g. Body parts, organs, blood bags, blood preserves, anatomical waste.

Clinical/Highly Infectious - HAZARDOUS

Highly infectious waste which requires disposal by incineration.
e.g. Couch roll, wipes, gloves, dressings, bandages, aprons, disposable garments,
infectious waste.

Medicinal - NON-HAZARDOUS
Waste medicines, out of date medicines, denatured drugs, which requires
disposal by incineration.
e.g. Tablets in containers, blister packs, unopened medicine vials, liquids in bottles,
inhaler cartridges, droplet bottles with pipettes.

Clinical/Infectious - HAZARDOUS/NON-HAZARDOUS
Infectious waste which may be treated to render safe prior to disposal or
alternatively it can be incinerated.
e.g. Wipes, gloves, dressings, bandages, aprons.

Offensive - NON-HAZARDOUS
Non-infectious, offensive/hygiene waste which may be recycled, incinerated
(waste for energy) or deep landfilled.
e.g. Colostomy bags, incontinence pads, nappies & wipes, gloves,
disposable garments.
Mixed Municipal Waste - VARIOUS
Municipal wastes and similar commercial, industrial and institutional wastes
including separately collected fractions. Requires disposal by landfill.
e.g. Packaging, tissues, disposable cups & drinks cans, sandwich wrappers, flowers.

4
Before the Operation

Before an Operation
• Always arrive on time for your shift.
• It can be tiring standing up and concentrating during a long operation and there is a
risk of fainting, so make sure you have a substantial breakfast.
• Don’t forget to go to the toilet.
• Make sure you know which theatre you need to go to after you get changed.

Theatre Attire
Operating theatre attire is designed to reflect the exceptionally clean approach to surgery.
You should wash your hands before you change. Your headwear (usually disposable)
will be the first item you put on and should cover your hair
completely.
At the beginning of each shift, staff change into a two-
piece scrub suit, which consists of trousers and a top.
These should be changed if soiled or contaminated.
The suit is made from cotton with a weave density
that minimises the risk of bacterial strike-through.
Long sleeves are not allowed, even under scrub
suits, and you must be bare below the elbows in all
clinical areas.
There will often be a choice of different sized scrubs in
the changing room, usually with a coloured band around
the collar of the tops and waist of the trousers that indicates
the size.
5
 Before the Operation

Footwear
Operating department footwear is usually supplied by the employer. Your theatre shoes
should be put on last and you will find a selection of sizes to choose from.
These shoes are robust and designed to minimise injury in case of spillage or dropped
items. They must be comfortable, the right size, easily washable and may have anti-static
properties.
Operating department shoes should only be worn in the department and never outside
the surgical environment. You should ensure that your shoes are cleaned when visibly
soiled, at the end of a shift, and as directed by local policy.
You should never wear your own shoes to theatre as this will increase the patient’s risk of
infection.

Jewellery
Local uniform policy directs that jewellery should not be worn. However, a plain wedding
band may be worn on one finger as long as it is removed during hand washing and
decontamination. Name badges, wrist watches and other items such as earrings, face
jewellery and necklaces should not be worn.

Patient Vulnerability
Safeguarding is a fundamental part of patient safety.
You will be caring for the patient when their ability to
communicate is impaired due to the nature of surgery
and anaesthesia, and where they do not have the
support of relatives or a next of kin.
• You have a duty of care to the patient and should
consider yourself and advocate for their safety and
wellbeing.
• You should always treat every individual with dignity
and respect to ensure they feel safe in theatres and
empowered to make choices and decisions.
• Do not enter the anaesthetic room whilst the patient is being anaesthetised, unless
you have direct permission from both the patient and anaesthetist.
• Do not consider them a ‘procedure’ for the day but as a vulnerable person who
needs the best care possible to decrease any complications related to their surgical
procedure.

6
The Operating Theatre Team

The operating theatre team consists of a range of personnel, and practitioners frequently
choose to practice in a particular area of care such as scrub, anaesthetics or recovery.
Job roles include lead practitioners (who may be titled matron, senior/theatre manager,
or team leader), registered nurses, and registered Operating Department Practitioners
(ODPs).
Other members of the team include healthcare support workers, porters, and domestic
and reception/clerical staff. Surgeons, anaesthetists and other doctors attend the
department on a daily basis for what is termed ‘the list’, which is an allocation of surgical
time. These are sometimes supported by non-medical practitioners such as surgical care
practitioners.
Other staff who may be allocated to the department intermittently include pharmacists,
supplies personnel, service managers, radiographers, plaster technicians and ODP/
nursing/midwifery and medical students.

Theatre Managers
Accountable for the management of the department including leading, motivating
and supervising a multidisciplinary team of qualified and support staff, undertaking
human resource management, resource management, business management, budget
management, business planning and development, audits and clinical governance,
infection prevention, health and safety, and risk analysis.

Team Leaders/Matrons
Lead the theatre teams in maintaining high standards of patient care and managing
services to increase theatre efficiency, productivity and utilisation. They manage
theatre teams to deliver elective and non-elective services, support appraisals and staff
development, and promote a positive working environment .

Anaesthetists
Care for patients by choosing the appropriate anaesthetics, monitoring their wellbeing
during operations and painful procedures, supervising their recovery, and providing
further pain relief if needed. On average, nearly half their time is spent in the operating
theatre.

Physicians’ Assistant (PA-A)

Physicians’ assistants (anaesthesia) are part of the multidisciplinary anaesthesia team, led by
a consultant anaesthetist. They look after patients undergoing many aspects of critical care.

7
 The Operating Theatre Team

Operating Department Practitioners and Theatre Nurses

Primarily employed within operating theatres but increasingly in other critical care areas
of a hospital. They also manage the preparation of the environment and equipment,
and act as the link between the surgical team and other parts of the operating theatre
and hospital. They must be able to anticipate the requirements of the surgical team and
respond effectively.

Theatre Support Workers/Healthcare Assistants

An important part of the work of theatre support staff is reassuring patients, who may be
anxious about going into the operating theatre. As a member of the theatre support staff,
they may also move patients on trolleys, reassure family members, set out instruments
and equipment ready for surgery, maintain stock levels, clean and tidy theatre areas after
surgery, scrub for surgical cases, and deal with specimens.

Surgical Care Practitioner (SCP)

A registered healthcare professional (nurse, ODP or other allied health professional)
who has extended the scope of their practice to work as a member of a surgical team.
They perform surgical intervention and preoperative and postoperative care under the
supervision and direction of a consultant, although not independently.
(Royal College of Surgeons of England 2013)

Surgical First Assistant (SFA)

A registered healthcare professional who provides continuous competent and dedicated
assistance under the direct supervision of the operating surgeon throughout the
procedure, whilst not performing any form of surgical intervention. They will be a
registered theatre practitioner (nurse or ODP).

Surgeons
Most surgical work takes place within hospital settings . As well as performing operations,
surgeons will undertake ward rounds, outpatient clinics, administrative duties and
teaching. Surgery comprises ten main specialities which have further options for
sub-specialisation embedded within them. These include cardiothoracic, general,
neurosurgery, oral/maxillofacial, ENT (ear, nose and throat), paediatric, plastic, trauma and
orthopaedic, urology and vascular. Throughout a surgical career, surgeons will work in a
number of different jobs.

8
Access to Information and Confidentiality

Information that can identify individual patients must not be used or disclosed for
purposes other than healthcare without the individual’s explicit consent.

You need to:

• Understand every patient’s right to privacy and confidentiality
• Explore the modes of information transmission and related issues
• Know the benchmarks that govern confidentiality

The Human Rights Act (1998) - “Everyone has the right for his private and
family life, his home and correspondence to be private unless it is in the
interests of national security, public safety or the protection of others”.

AfPP Standard 2.13 - A patient’s right to privacy should be adhered to

at all times and consent should be obtained for the presence of visitors/external
contractors during the patient’s surgical care pathway. A policy should be in place for the
management of visitors/external contractors to the perioperative setting.
Data Protection Act 1998 - This became law in 2000. It sets the standards that must be
satisfied when obtaining, recording, holding, using or disposing of personal data. The Act
is summarised in 8 data protection principles. These state that data must:

1. Be processed fairly and lawfully

2. Be processed for specified purposes
3. Be adequate, relevant and not excessive
4. Be accurate and kept up-to-date
5. Not be kept for longer than legislative requirements
6. Be processed in accordance with the rights of
data subjects
7. Be protected by appropriate security
(practical and organisational)
8. Not transferred outside the EEA
(European Economic Area) without
adequate protection

9
 Five Steps to Safer Surgery

1 Team brief
Team brief takes place at the beginning of the list. The core team meet to discuss
the requirements of that list, including safety concerns, equipment and staffing.

2 Sign in
Sign in occurs for each patient on the list before induction of anaesthesia. A
member of the team reviews with the patient (when possible) that their identity
has been confirmed, that the procedure and site are correct, and that consent for
surgery has been given.
The team member confirms that the operative site has been marked (if appropriate);
that the patient’s risk of blood loss, airway difficulty and allergic reactions have been
recorded; and that a full anaesthesia check has been completed.

3 Time out
The team will pause immediately prior to the skin incision to confirm out loud that
they are performing the correct operation on the correct patient and site. Team
members will verbally confirm, in turn, the critical elements of their plans for the
operation using the WHO Checklist questions for guidance. They will also confirm
that prophylactic antibiotics have been administered within the previous 60
minutes and that essential imaging is displayed, as appropriate.

4 Sign out
Sign out also occurs for each patient on the list. The team will evaluate the
operation, complete swab and instrument counts and label any surgical specimens
obtained. The team will also review equipment malfunctions or issues that need
to be addressed. They will review key plans and concerns regarding postoperative
management and recovery before moving the patient from the operating room.

5 Debrief
The core team gathers to review any issues that occurred, adress any concerns
raised, and to discuss specific incidents or identify how to prevent them
happening again for the next list.

The WHO Surgical Safety Checklist

The WHO Surgical Safety Checklist aims to decrease errors and adverse events by
increasing teamwork and communication. It is a simple tool designed to improve the
safety of surgical procedures by bringing together the whole operating team to perform
key safety checks during vital phases of perioperative care: prior to the induction of
anaesthesia, prior to skin incision and before the team leaves the operating room. Every
member of the team is involved.
10
 The Operating Room

The Operating Room

Information
Anaesthetic Technology
Equipment

Suction
Scrub

Anaesthetist’s
Assistant

An Ma
Anaesthetist

ae chi
st ne
Electrosurgical Unit

he
tic
IV
(ESU)

Waste Disposal
Surgical
Surgeon First
Vents

Assistant
Operating
Airflow Table

Sluice
Scrub
Anaesthetic room

Mayo Stand Scrub Trolley

(Instruments)
Sterile Field
Circulator
Swab Receiver
Count Board Airflow

Exit Vents Setting up room

The Operation
Once the patient has been anaesthetised in the anaesthetic room, and the anaesthetist
has implemented intraoperative physiological monitoring, it is time to transfer the
patient to theatre. Catheterisation may also be required at this point.
The patient is transferred from their bed/trolley to the
operating table with the aid of a PatSlide. During this
process, it is important that the airway and any adjuncts
such as Intravenous Infusion are monitored. The patient
is then positioned for surgery and secured so that they
cannot fall or sustain injury.
The operating table is adjustable so that the operation
site can be accessed easily. It is also designed to reduce
the risk of pressure sores or nerve injuries. Extra adjuncts
may be used to reduce risk of injury.

11
 Ten Objectives for Safe Surgery

Sterile Field
A sterile field is created by providing a barrier between sterile and non-sterile areas,
thereby reducing the risk of cross infection. This is done by ensuring the patient,
operating table, and instrument trolleys are covered in sterile drapes and that all
equipment and instruments are sterile.
All staff operating within the sterile surgical field should have performed a surgical scrub
and be wearing sterile gowns and gloves.

Tips: Keep a record of

• Keep movement to a minimum procedures you have
attended with notes
• Keep opening and closing of doors to a minimum for future reference. Be
• If scrubbed you should remain close to the sterile field sure to keep patient/
staff references
anonymous.

Ten Objectives for Safe Surgery

1. The team will operate on the correct patient at the correct site
2. The team will use methods known to prevent harm from administration of
anaesthetics, while protecting the patient from pain
3. The team will recognise and effectively prepare for life-threatening loss of airway or
respiratory function
4. The team will recognise and effectively prepare for risk of high blood loss
5. The team will avoid inducing an allergic or adverse drug reaction for which the
patient is known to be at significant risk
6. The team will consistently use methods known to minimise the risk for surgical site
infection
7. The team will prevent inadvertent retention of instruments or swabs in surgical
wounds
8. The team will secure and accurately identify all surgical specimens
9. The team will effectively communicate and exchange critical information for the safe
conduct of the operation
10. Hospitals and public health systems will establish routine surveillance of surgical
capacity, volume and results

12
Top Theatre Tips from AfPP Members

s, volunteer to do
Be enthusiastic, ask question
d enjoy it. If in doubt,
stuff, listen to advice/info an
care of the patient.
remember it’s all about the
tment Manager
Ryan Talley, Operating Depar

Wear your uniform properly,

introduce yourself and listen to
your
mentor. Ask questions approp
riately
Paula Quinn, Professional
green (or
Don’t touch anything blue,
pe s are)
whatever colour the dra
Julie Widdecombe, ODP

p away from
If you start to feel unwell, ste drink. It’s
a
the table, sit down or go for
ash am ed of, it’s happened
Have breakfast before nothing to be
to us all – even surgeons!
you start every morning!
e Practitioner
Linda Lynch, Theatre Sister Joanna Deane, Senior Theatr

Remembe
r
once – intr we have all been th
oduce you ere
theatre le
ad – ask, a rselves to the
best of it s
even if it’s k, ask. Make the
not for yo
Leah Dean u.
,S
enior Thea
tre Practiti
oner
Do your research and be intere
sted. If we ask you
a question then think about the
answer, we are
not trying to catch you out or
trip you up, we are
simply assessing your knowledge
base.
Alex Toward, ODP

13
 Online Resources

AfPP Website www.afpp.org.uk

• Latest standards and advice
• Article archive and EBSCO Host
• Student Specialist Interest Group
• Professional Advice Service
• Discounted or FREE Events
(first year of student membership)

AfPP Social Media

Facebook Page www.facebook.com/SaferSurgeryUK
Facebook Discussion Group www.facebook.com/groups/AfPPchat

Twitter @SaferSurgeryUK

LinkedIn Page
www.linkedin.com/company/the-association-for-perioperative-practice/
LinkedIn Job Forum
www.linkedin.com/showcase/afpp-job-forum

Job Opportunities
AfPP Job Forum www.afppjobforum.org.uk
NHS Careers www.healthcareers.nhs.uk

Other Links
Medicines and Healthcare Products Regulatory Agency - MHRA
https://www.gov.uk/government/organisations/medicines-and-healthcare-products-
https://www.gov.uk/government/organisations/medicines-and-healthcare-products-
regulatory-agency
Department of Health - www.gov.uk/government/organisations/department-of-health
NHS Improvement - improvement.nhs.uk
Safeguarding Adults Pocket Guide (NHS England) - www.england.nhs.uk/wp-content/
uploads/2017/02/adult-pocket-guide.pdf
The Checklist - How to do it bit.ly/WHOhowto
The Checklist - How not to do it bit.ly/WHOnotdo

14
 The Association for Perioperative Practice
Daisy Ayris House, 42 Freemans Way, Harrogate, HG3 1DH
01423 881300 | membership@afpp.org.uk
January 2018

AfPP is a Registered Charity Number: 1118444. A company registered in England and Wales,
limited by guarantee: 6035633 AfPP Ltd : A company registered in England and Wales: