Bylaws amendments, member at large delegates, redefinition of perioperative nursing top business issues this year

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Business Proceedings

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ylaws amendments, member at large delegates, redefinition of perioperative nursing top business issues this year

Monday, March 14, through Thursday, March 17

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ORN Forums provide members and delegates with information about issues that may be presented to the House of Delegates. This year, several issues were raised, including changes to the Bylaws, member at large delegate representation, the Strategic Plan and revised Mission Statement, a proposed dues increase, and the redefinition of perioperative nursing.

First Forum

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he proposed Bylaws change was the first business at Monday’s Forum. Bylaws changes. The proposed bylaws changes, introduced by Cheryl A. Sangermano, RN, BSN, CNOR, CNA, chairman of the Bylaws Committee, included substituting the words Specialty Assemblies (rather than Organizational Units as initially proposed) for the word Committees in the title of Article VIII and inserting a new section (ie, Section 3), which states, To achieve the mission and purposes of AORN, the Board of Directors may establish speciuity assemblies to serve special interests of the membership.

In response to this proposed for expansion in the future change, Janice Parfitt, RN, without need for further bylaws MSN, CNOR, AORN of amendments. Pittsburgh, voiced concern that Strategic Plan, revised the wording would not be suffi- Mission Statement. Ruth E. cient to recognize state councils Vaiden, RN, CNOR, CRNFA, as groups defined within the introduced the 1994- 1995 structure o f AORN. Because Strategic Plan, which was specialty assemblies are the approved by the AORN Board only special groups that exist in of Directors at its pre-Congress AORN’s current structure, said meeting. (See “1994-1995 Cynthia C. Spry, RN, MA, Strategic Plan.”) In regard to MSN, CNOR, AORN Pres- providing innovative and effecident, the proposed wording tive education by redesigning was changed from the more educational programming and generic terms Organizational delivery systems (ie, goal three, Units to the more specific strategy two), one member expressed concern about the terms Specialty Assemblies. Discussion continued about difficulty of acquiring contact the inclusion of state councils hour credit for chapter activiunder the AORN umbrella, ties. Mary Clare Wilson, RN, with Kay A. Ball, RN, MSA, BSN, CNOR, cochairman of CNOR, speaking for the Ohio the Continuing Education ApState Council of Operating Room Nurses, saying that state councils would be especially important during health care reform. When Spry asked for a show of hands about preference of wording, the majority of audience respondents indicated support for the generic words Organiza- Mary Clare Wilson speaks at the first tional Units to allow Forum. 1167

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proval Committee (CEAC), responded that educational contact hours for chapters are available through Headquarters. President Spry acknowledged the concern about the contact hour approval process and suggested that members contact Board members, CEAC members, or Headquarters staff members. Vaiden also introduced the new AORN Mission Statement, which was revised based on the responses of more than 250 participants in 3 1 focus groups. (See “Revised Mission Statement.”) The term representation in the Mission Statement is intended to mean legislative and other representation, Vaiden said, not collective bargaining. She asked members to think about whether the term representation adequately expressed their intent and to share their ideas for other terminology. Health care reform. Daniel J. O’Neal, 111, RN, MA, CNS, AORN’s lobbyist in Washington, DC, presented his thoughts about health care reform and invited comments from members. He emphasized that lobbying occurs not only on the national level; local participation provides the most significant achievements. “All of us are lobbyists,” he said. Nurses influence, educate, clarify, amplify, validate, define, and apply knowledge and power to influence change in the desired direction. To be most effective, O’Neal said, nurses should develop long-term relationships with policymakers and demonstrate

1994-1995 Strategic Plan Goal 1: Promote excellence in perioperative nursing practice. Strategy 1: Identify research activities to validate clinical and professional practice. Strategy 2: Collect, develop, and disseminate information on perioperative nursing practice. Strategy 3: Implement the top 10 strategies from the Project Team on the Effectiveness Initiative. Strategy 4: Expand AORN’s international growth, influence, and leadership in perioperative nursing. Goal 2: Maintain organizational strength and viability. Strategy 1: Ensure that funds are available to meet current and future Association needs. Strategy 2: Facilitate partnerships among chapters, volunteer Association leaders and Headquarters staff regarding their responsibilities, roles. and performance within the Association. Strategy 3: Promote an organizational culture that supports quality and system improvements. Strategy 4: Produce a comprehensive written business plan for AORN. Goal 3: Provide innovative and effective education. Strategy I : Assess educational needs of perioperative nurses. Strategy 2: Redesign educational programming and delivery systems. Strategy 3: Expand collaboration with other education providers. Goal 4: Respond to emerging issues affecting perioperative nurses. Strategy 1 :Provide current and timely information on issues and practice concerns. Strategy 2: Position AORN as an active participant in regulatory and legislative policy-making. Strategy 3: Develop a communication plan that will meet ongoing needs of internal and external customers. Goal 5 : Provide services that support the Association’s mission. Strategy 1 : Maintain a continuous process to assess member needs, expectations, and preferences. Strategy 2: Develop an integrated telecommunication system.

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Revised Mission Statement The Association of Operating Room Nurses, Inc, is the professional organization of perioperative nurses that unites its members by providing education, representation, and standards for quality patient care. a commitment and willingness to participate in developing legislation and regulations. O’Neal said he believes the changes in the workplace, such as downsizing, were precipitated by events in the past. Health care reform will continue to change the nursing profession. He urged nurses to prepare to retrain, retool, and cross-train to be more effective, saying that flexibility will be nurses’ best asset in a changing market. Regulated medical waste statement. Also discussed at the Monday Forum was the adoption of the definition of regulated medical waste. Jeannie Botsford, RN, MS, CNOR, chairman of the Special Committee on Environmental Issues, asked that the

Daniel J. O’Neal, 111, emphasizes lobbying on a local level.

document be ratified by the House of Delegates to establish it as the official position of AORN. Botsford assured members that it is a collaborative document created with cooperation from manufacturers and solid waste disposal industries and urged members to complete a pilot survey at Congress to provide information on individual institutions’ environmental waste issues.

Second Forum

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he second Forum, held on Tuesday, March 15, began with a report from the AORN Foundation. AORN Foundation report. Linda K. Groah, RN, MS, CNOR, CNAA, President of the AORN Foundation Board of Trustees, reported that 164 chapters had contributed a total of $19,691 to the Foundation. Member at large delegate representation. Joy Don Baker, RN, MS, MBA, CNOR, CNA, chairman of the Project Team to Develop a Model for the Association’s Organizational Structure, discussed member at large (MAL) delegate representation and addressed the concerns of the Project Team, saying that chapter delegation of 1,500 seats would not change.

Baker said, “This delegate change will represent an addition to the number of delegates.” Baker emphasized that the number of MAL delegates is based solely on active members because only active members may be seated as delegates. Sandra J. Hoffman, RN, AORN of Appalachian Area of MD, PA, & WV, expressed concern that the method of MAL delegate selection (ie, by random drawing) could allow all MAL delegates to be from one area. Evelyn A. Gunter, RN, BS, AORN of the Gulf Coast of Florida, said, M y chapter has 32 members and seven delegates. I don’t think that 15 delegates representing 2,500 MALs is too much. &the

Jeannie Botsford asks House to ratify medical waste statement. 1171

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Evelyn A. Gunter speaks in favor of an increase in member at large delegates.

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Congress is now included in the redefinition of perioperative nursing. “The Project Team heard and felt your emotions at last year’s House of Delegates,” Wells said. You asked us to use the JCAHO [Joint Commission on Accreditation of Healthcare Organizations] definition for invasive procedures-it’s in there. Wells stressed that the Project Team’s charge was not to define membership criteria but rather to define perioperative practice; however, concerns from members about this distinction were discussed. Lillian H. Nicolette, RN, MSN, CNOR, AORN of Philadelphia, commented that no matter what the definition of perioperative nursing is, AORN members have the ability to determine who can and cannot be a member of AORN and reminded members that those not in direct patient care roles can be associate members of AORN.

chapter process fur delegate representation were used, MAL delegates would number about 70. Baker also said the Project Team would not be addressing the issue of mandatory versus voluntary chapter membership. This decision was based on results of a survey taken at last year’s Congress, Baker said. AORN chapter membership will remain mandatory. Baker announced that volunteers are important to the functioning of the Association, and the Project Team did not want to impede that process in any way. Therefore, the cabinet structure previously discussed by AORN is not being pursued at this time. Redefinition of perioperative nursing. Maryann P. Wells, RN, MS, CNOR, chairman of the Project Team to RedefinejReconceptualize Perioperative Nursing, told Lillian H. Nicolette reminds attendees that everything mem- members that they determine bers asked for at last year’s AORN’s membership. 1174

Robert K. Johnston questions the proposed dues increase. Pat Niessner Palmer, RN, MS, AORN deputy executive director, told attendees this new definition would be published and would be an official AORN position if adopted. Proposed d u e s increase. Susan K. White, RN, BSN, CNOR, AORN of Greater Houston, suggested that the Board hold a special meeting to discuss presenting a dues increase of $20 (ie, an increase of approximately $1.65 per month, per member) to the House of Delegates on Thursday. White said, W e f e e l the goals and strategies identified by this House, the discussion about the need for assistance with research, implementation of the 800 number, upgraded computer systems, and other ongoing Association needs warrant a dues increase immediately. Robert K. Johnston, RN, CNOR, AORN of Reno, questioned the rationale that warrants

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a 33% increase in dues. He said that the current dues of $45 represents 40% of the expense to provide services to each AORN member (ie, $112.90) and suggested a $5 (ie, 11%) increase. In response, Linda K. Groah, AORN Treasurer, explained that the dues of an Association typically comprise between 40% and 47% of all revenues, not expenses. AORN’s $45 dues represent approximately 16.3% of AORN’s revenues, and the proposed increase would upgrade that percentage to only 20%, she said. In support of the increase, Rudolph J. Mancuso, RN, BSN, CNOR, AORN of Baton Rouge, said, $I .65 is about the cost of a pack of cigarettes. . . . Many of us here would purchase a cocktail at any available opportunity, and the proposed increase of $I .65 per month per member represents less than one third of one cocktail. I believe this increase is appropriate.

House of Delegates

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resident Spry convened the House of Delegates on Monday, March 14. Monday’s House meeting. Delegates amended the Bylaws and ratified the definition of regulated medical waste with very little discussion. Cheryl Sangermano moved to amend Article VTTI of the AORN Bylaws by adding a new section 3 to delineate authority of the Board of Directors to estab-

lish specialty assemblies within new Bylaw. This motion was the structure of AORN. With adopted without discussion. no discussion, the motion (See “Bylaws Amendments.”) Reg u 1ate d medic a 1 waste passed. Sangermano also definition. Presenting a motion moved, from the Board, Joy Don T o amend the AORN Baker, Vice President, asked Bylaws, Article VIII, by the delegates to ratify the docustriking the word Comment on regulated medical mittee in the title and waste as it appears in the substituting the nvords January issue of the AORN Organizational Units. This motion broadens the Journal, which they did. (See title of Article VIII and, “Regulated Medical Waste according to Sangermano, is Definition and Treatment: A more appropriate than adding a Collaborative Document.”)

Bylaws Amendments Article VIII Organizational Units

Section 1: Standing Committees The standing committees of the Association are appointed annually by the President with the approval of the Board. Each committee consists of a chairman and at least two (2) members. A majority of the members of the committee constitutes a quorum. A. The standing committees of the Association are the Audiovisual Committee, Awards Committee, Bylaws Committee, Legislative Committee, Membership Committee, National Committee on Education, Nursing Practices Committee, Nursing Research Committee, and Recommended Practices Committee. B. The purposes and duties of these committees are listed in the AORN Board Manual. Section 2: Special Committees Special committees may be appointed by the President and cease to exist when the purpose for which they were created is completed. Secrion 3: Organirational Units To achieve the mission and purposes of AORN. the Board of Directors may establish organizational units to serve special interesrs of the membership. 1175

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Regulated Medical Waste Definition and Treatment: A Collaborative Document In November 1992 in Atlanta. AORN convened a collaborative meeting. Representatives of 13 organizations participated in the discussion of the issues that resulted in rhis document.

Introduction

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here are three types of regulated waste from health care facilities. The first two are radioactive waste, which is regulated by the Nuclear Regulatory Agency, and hazardous chemical waste, which is regulated by the US Environmental Protection Agency (EPA). The third type is potentially infective waste, which, for the purposes of this document, will be referred to as regulated medical waste. This document will focus primarily on the environmental issues arising from regulated medical waste. This document addresses what hospital waste should be considered as regulated medical waste and what should constitute acceptable treatment, on site or off site, to allow safe handling and disposal of such waste. Two concerns arise when discussing the disposal of items that have been in contact with potentially infectious materials. The first of these concerns is the transmission of disease through occupational exposure (ie, contact that occurs from the point of contamination to final disposal). This concern is addressed by the proper adherence to the December 1991 Occupational Safety and Health Administration (OSHA) final rule on bloodborne pathogens.’ The second concern is the environmental and public health implications of regulated medical waste.

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onsiderable confusion and difference of opinion exist in what should be desig-

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nated as regulated medical waste and how it should be managed. The importance of properly defining regulated medical waste is shown in a recent study by Rutala.2 This study estimates that under the Centers for Disease Control and Prevention (CDC) definitions, about 6%of hospital waste would he considered regulated medical waste, whereas under the Medical Waste Tracking Act (MWTA) definitions from the EPA. as much as 45% of hospital waste could be cmsidered regulated medical waste. On average. American hospitals designate approximately 15% of their waste as regulated medical waste. Regulated medical waste i s 0.3%of the total municipal solid waste Americans produce annually.’ In a 1990 report from the Agency for Toxic Substances and Disease Registry to Congress. the executive summary states that “the general public’s health is not likely to be adversely affected by medical waste generated in the traditional healthcare ~ e t t i n g . ” ~ The 1991 OSHA rule on bloodhome pathogens designates certain types of medical waste as “regulated waste.” If these designations are included in the definition of regulated medical waste, the amount of health care waste considered as regulated would be further increased. The Department of Transportation (DOT) recently issued performance-oriented packaging standards specifying package requirements for transportation of regulated medical waste. The definition of regulated medical waste used in these standards matches that of the EPA.S In addition to multiple federal definitions. stales, counties, itnd municipalities have developed their own requirements, leading to further confusion. Medical waste contains a significantly lower content of microbes than household waste, and it is widely recognized that

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household waste poses no threat. According to the position paper on this issue by the Society for Hospital Epidemiology of America (SHEA), Household waste coiztains more niir~roorgaiiismswith pathogenic potential f i l l . humans o r ) averugc. thun niedical Mvaste. We can deduce,from our daily esposure to household waste arid the decades of sanitary lancifill burial that the public health risksfor the less niic~rohiallq’contaminated hospitul waste are While there are documented instances of occupational illness resulting from exposure to regulated medical waste, there are no known instances of public illness caused by such exposure. The definition and treatment of regulated medical waste from health care facilities should be based on scientifically sound epidemiological and microbiological information.

costs

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scalating health care costs are a growing concern to both the public and governmental officials. Regulated medical waste is only one component of these costs, but it is one that can be reduced by adopting the uniform definitions and treatment recommendations contained in this document. As mandated by Congress in the MWTA, the EPA has conducted a demonstration project to regulate and track medical waste. As the result of this project, which terminated in June 1991, the EPA is to provide Congress with recommendations for managing medical waste. The definition of medical waste used in this program includes “any solid waste generated in the diagnosis, treatment, or immunization of human beings or animals” and specifies seven classes of regulated medical waste. The EPA originally estimated that the average cost per hospital for complying with

the MWTA would be $3,757 per year. Several studies have shown that the actual costs to hospitals are many times more than that. In one anecdotal example, a New York teaching/medical center reported an increase in the amount of regulated medical waste of 315% between 1984 (443,000 Ib) to 1989 ( 1,837,000 lb). The cost increased 700% from $106,000 to $835,000 per year largely as a result of considering a larger portion of medical waste as regulated medical waste and the resultant higher cost of treatment and di~posal.~ Another study conducted by the Voluntary Hospitals of America showed that when 10 sample hospitals went to MWTA requirements from the previous CDC guidelines, their increased costs of complying with the new rules ranged from $80,000 to $700,000 per year. Again, these higher costs were due to both increased amounts of regulated waste and higher costs of treatment and disposaL8 Such cost increases will be incurred by health care providers and passed directly on to the public. In an era of health care cost containment, it is critical that any new rules and regulations for managing regulated medical waste be based on scientific evidence of need and demonstrated benefit to public health and the environment.

Definition of Regulated Medical Waste

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lthough it is generally agreed that regulated medical waste refers to that portion of medical waste that has the potential to transmit infectious disease, no uniform definition of what constitutes regulated medical waste has been universally accepted. Any definition of waste capable of causing infectious disease must consider the factors related to induction of such disease in humans: 0 There must be the presence of a

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pathogen. Pathogens are microorganisms that can cause infection. Many microorganisms are incapable of causing infection in humans. 0 The pathogen must be of sufficient virulence. Virulence is the disease-evoking power of a microorganism. Not all pathogens are equally capable of causing infectious disease. The pathogen must be present in sufficient dose. There must be a sufficient number of microorganismspresent for infection to occur. This number varies with several factors (eg, organism type, host susceptibility, portal of entry). 0 The organisms must have a portal of entry or a way to get into the body (eg, puncture, cut, wound). 0 There must be a susceptible host. All persons are not equally susceptible to infectious diseases? Because it is not practical or realistic to assay medical waste to determine the presence and number of suspected pathogens, the identification of regulated medical waste tends to focus on the potential presence of pathogens and possible portal of entry. Based on these considerations, there are four categories of medical waste that should be included in the definition of regulated medical waste because of risk they represent to the public health and the environment. Sharps (used and unused). Discarded medical devices that have been used in animal or human patient care, medical research, or industrial laboratories and that are capable of puncturing or cutting the skin, thereby creating a portal of entry, should be classified as regulated medical waste. This includes, but is not limited to, needles; syringes with needles attached; trocars; pipettes; scalpel blades; blood vials; and broken or unbroken glassware that has been in contact with infectious agents including serum culture bottles, slides, and cover slips. Rarionale. Used sharps have been associ-

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ated with injury and disease transmission in occupational settings and represent the greatest hazard for health care workers and trash handlers because of potential contamination with infectious agents and their ability to cause a portal of entry. Unused sharps are included since it may not be apparent whether discarded sharps have been used or not. Cultures and stocks of infectious wastes. Discarded cultures and stocks of infectious agents and associated microbiologicals should be considered regulated medical waste. This category includes human and animal cell cultures from medical and pathological laboratories; cultures and stocks of infectious agents from research and industrial laboratories; wastes from the production of biologicals; discarded live and attenuated vaccines; and culture dishes and devices used to transfer, inoculate, and mix cultures of infectious agents. Rationale. Cultures and stocks of infectious agents pose a potential risk for disease transmission because they have a higher number of microorganismsand therefore a higher potential for survival of sufficient numbers to produce disease. Also, they are usually in glass or plastic containers that, if broken, become contaminated sharps that can create a portal of entry. Animal waste. Discarded material originating from animals inoculated with infectious agents during research or production of biological or pharmaceuticaltesting is regulated medical waste. Examples are carcasses, body parts, blood, and bedding of animals known to have been in contact with infectious agents. Rationale. These waste materials pose a potential risk because they can contain a sufficient number of viable infectious agents to cause disease provided an appropriate portal of entry is present in a susceptible host. Selected isolation waste. Biological waste and discarded materials contaminated with

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blood, excretion, exudates, or secretions from humans who are isolated to protect others from certain highly virulent diseases (ie, Class 4 etiologic agents) or from isolated animals known to be infected with these diseases should be treated as regulated medical waste. Rationale. Although very rarely seen in the United States, there are certain highly virulent diseases, such as Lassa Fever, that deserve special mention. These diseases are caused by Class 4 etiologic agents as defined by the CDC, and waste from patients treated in isolation for these diseases should be considered regulated medical waste.’O The following two categories of waste are usually included in regulated medical waste, not because they pose any environmental or public health risks but because of aesthetic concerns of the public. Pathological waste. Discarded pathological wastes (eg, human tissues, organs, body parts) removed during surgery, autopsy, or other medical procedures. Human blood, blood products, body fluids. This category includes discarded freeflowing human blood and blood products (eg, plasma, serum), any free-flowing body secretion containing blood components (eg, pleural, peritoneal, amniotic fluid), and any other fluid visibly contaminated with blood. Human excretions (eg, urine, stool) are specifically excluded because they have accepted means of disposal. Rationale. Although blood, blood products, and body fluids containing blood components may represent an occupational hazard, especially in the presence of sharps, they do not pose a risk to public health or the environment when disposed of properly. We recognize that these substances present a heightened concern to the public: however, scientific information and practical experience have demonstrated that they only need to be included from an aesthetic viewpoint.

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Disposal, Treatment of Regulated Medical Waste

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or the four categories that pose some public health risk, some treatment to reduce the microbiological content is recommended. Methods usually employed to decontaminate medical waste are divided into three general categories: heat treatment (eg, incineration, autoclaving, microwaving, pyrolysis), chemical treatment (eg, hypochlorite, chlorine dioxide), and, much less popular, radiation treatment (eg, gamma ray, electron beam).” Each method’s efficacy and efficiency depends on factors such as contact time: bioload (ie, number of microorganisms in the material to be treated); and organic content, volume, and physical state of the waste (ie, liquid, solid). The presence of other waste products (eg, radioisotopes, hazardous chemicals) also must be taken into account when determining the proper method of waste treatment. For the categories that represent aesthetic concerns, there are recognized standard practices for dealing with this waste. Pathological waste should be incinerated or interred. Free-flowing blood and body fluids should be discarded into a sanitary sewer system taking proper precautions to prevent exposure to those dispensing the fluid into the drain. Although there are no known health risks associated with the current treatment technologies, further research of efficacy, cost, and environmental impact needs to be done to allow valid scientific comparisons. Notes 1. “Occupational exposure to bloodbornc pathogens; Final rule,’’Federal Register 56 (Dec 6, 1991) 64175. 2. W A Rutala, R 1 Odette, G P Samsa, “Managementof infectious waste by US hospitals,” Jourtiul of the Amoicun Medical Associarim 262 (Sept 22, 1989) 1635-1640. 3. Agency for Toxic Substances and Disease

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Registry, The Public Health Implications of Medical Waste: A Report to Congress (Atlanta: US Department of Health & Human Services, 1990). 4. Ihid. 5. “Performance-oriented packaging standards,” Federal Register 56 (Dec 20, 1991) 66144-66 145. 6. W A Rutala, C G Mayhall, “SHEA position paper: Medical waste,” Infection Control and Hospital Epidemiology 13 (January 1992) 43-44. 7. J T Marchese et al, “Regulatedmedical waste disposal at a university and university hospital: Future implications,”paper presented at the Third International Conference on Nosocomial Infections, Atlanta, August, 1990. 8. Modern Healthcare,4 Nov 1991,19; Medical Waste News, 3:22,31 Oct 1991. 169170. 9. US Environmental Protection Agency, Infectious Waste Management Guidelines (Springfield, Va: National Technical Information Service, 1986). 10. American Hospital Association, Shaping State and Local Regulation of Medical Waste and Hazardous Materials: A Report of the Ad Hoc Committee on Medical Waste and Hazardous Materials (Chicago: American Hospital Association, 1990). 1 1. Agency for Toxic Substances and Disease Registry, The Public Health Implications of

AORN Mission Statement, goals, strutegies. Sheri J. Voss, RN, BS, CNOR, member of the Strategic Planning Team, moved to accept the new Mission Statement. Voss said the new statement clearly communicates what the members value about AORN. “We made it concise so everyone knows our values are education, representation, and quality patient care.” The motion passed, and the Mission Statement, goals, and strategies for the Association were adopted. AORN Foundation report. After introducing the mem-

Medical Waste:A Report to Congress. The following organizations participated in the Atlanta meeting. American Association of Critical-Care Nurses American Association of Nurse Anesthetists American College of Surgeons American Hospital Association American Societyfor Microbiology American Society of Anesthesiologists Association of Operating Room Nurses, Inc Association of Practitioners in Infection Control Centersfor Disease Control and Prevention Emergency Nurses Association Medical Waste Institute Society of Hospital Epidemiologists of America University of North Carolina School of Medicine The following organizations have reviewed and endorsed this document as of May 3, 1994: American Association of Critical-CareNurses American Association of Nurse Anesthetists Association of Operating Room Nurses, Inc Emergency Nurses Association American College of Surgeons

bers of the AORN Foun- legacy,” Groah said. Financial statement. Peter J. dation Board of Trustees and staff, Linda K. Groah chal- Derschang, AORN director of lenged the delegates to con- finance, presented the Assotribute $20,000 to the Foun- ciation’s financial statement. dation by the end of Con- Derschang said AORN ingress. The donations will be creased gross revenues in 1993 used for the trunk of the by 8.6%and decreased expensGiving Tree. The trunk repre- es by 11.6%, which led to a sents the strength of the orga- $2.5 million swing in net revnization and, therefore, is enue over expenses. This is a dedicated to AORN members. complete financial turnaround The Tree, which was chosen from 1992. After adjusting income proas the symbol because it repjections downward and cutting resents growth, will be perexpenses, the budget was manently mounted at AORN brought to a break-even point; Headquarters. “As the Giving AORN, however, exceeded its Tree grows, s o grows the revenue forecast by $7 1,000, Foundation and the AORN 1183

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which resulted in a net revenue from which five research priorthe quality of patient care, over expense of $701,000 (com- ities were identified: patient impact of current regulapared to the budgeted amount of outcomes, future roles, clinical tions in the practice setting, $8,000). Derschang broke down issues, staffing, and health care 0 implications of nurse the sources of revenues and delivery. These priorities, monitoring of patients expenses and ended on a posi- Diomede said, will give direcreceiving local or IV contive note. AORN has paid off an tion to future research and will scious sedation anesthesia, additional $600,000 of long- help form a complex picture of 0 development of instruterm debt, finishing the year perioperative nursing focus. mentsltools to measure with a balance of $5.1 million. From these five priorities, patient outcomes, Meet the candidates format. Diomede said, a questionnaire the effect of preoperative Noreen McHugh, RN, MS, was developed. Participants in preparation on patient CNOR, chairman of the the study rated each of the 65 outcomes, and Nominating Committee, topics on the questionnaire. the effect on patient outreported that the Committee Results were analyzed for priorcomes of using nursing recreviewed alternative formats ities within the 65 topics, the ommended practices versus for the “Informal Meet the five categories, the five practice ritualistic procedures. Candidates” session and roles, and the five regions. Top Diomede said future rebelieves this year’s format met research priorities identified are search should generate scientifAORN members’ needs. The specific, measurable out- ic knowledge for recommended event was held in the largest comes of perioperative practices and activities leading area available, and candidates nursing, to desired patient outcomes and repeated questions before clinical indicators or stan- forge a proactive future in perianswering them so those dard perioperative nurs- operative nursing. around could hear. She also ing practices that affect Work redesign. Patricia A. stated that only elected offipatient outcomes, Mews, RN, MA, CNOR, chaircers’ names would be anAORN standards and rec- man of the Task Force on nounced after elections this ommended practices, Assistive PersonnellWork Reyear. In the past, vote tallies validation of clinical design, presented the Task were announced with the competencies, Force’s report. The Task Force names; 68% of survey responcost-effective nursing was formed in response to dents at the 1993 Congress, interventions that affect members’ concerns about however, expressed the being transferred out of desire to eliminate the the OR or losing posinumbers from the tions to less-expensive, announcements. Election less-qualified caregivers. results were posted at The Task Force was the Congress Headcharged with identifying quarters office and are work redesign initiatives available to all AORN in perioperative nursing. members. The Task Force deterDelphi study. Barbara mined that i t needed Diomede, RN, MSN, member input to identify CNOR, chairman of the the issues surrounding Nursing Research Comunlicensed assistive permittee, presented the sonnel and work redesign before it developed results of the Corn- Barbara Diomede presents Delphi Study strategies and an action mittee’s Delphi Study, results. 1184

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lowed by the actions and plan. The Task Force sent surveys to 2,500 randomly interventions expected to prevent or resolve the selected individuals; 650 surveys were returned. problem. The first series Results of this initial of data is expected to be survey show that perioperready this spring, ative nurses are not being Ensminger said. Ensreplaced by assistive perminger invited members sonnel to the extent the to review the Task Task Force members had Force’s work and to proexpected. Less than 20% vide advice and input as the Task Force works of nurses surveyed have been transferred to other toward a data base to valiunits, and less than 20% of Patricia A. Mews says perioperative date the activities of the OR nurses are expected to nurses are not being replaced by assistive nurse in the perioperative cross-train in other nurs- uersonnel to the extent suspected. setting. Potentially, Ensing units. The study minger said, this data base results also show that could be used to attach a assistive personnel function in ing; the data set meets the value-added piece to the the scrub role 40% of the time, needs of multiple, diverse data actions of nurses in the periopthey function as the first assis- users throughout the health erative setting and lead to tant less than 20% of the time, care system. future reimbursement based on and they function as the circuTo make the document com- outcomes of nursing care. The lator less than 4% of the time, mon to all practice settings, Task Force expects to have a Mews said. The survey was Ensminger said, the Task Force set of data elements for presenmade available at Congress for has agreed to use the published tation at next year’s Congress those who wished to respond. outcome standards of perioper- that will help nurses name what Data elements task force. ative nursing as the goal state- they do so it can be evaluated, Jane A. Ensminger, RN, BS, ments in the initial data devel- financed, and positioned i n CNOR, chairman of the Task opment. Specific nursing diag- public policy. Force on Perioperative Data noses and problems will be Thursday’s House meeting. Elements, presented the Task identified for each goal, fol- The first order of business at Force’s report. This Task Thursday’s House of Force was formed to Delegates session was the establish a minimum data motion by Joy Don Baker, set (ie, data base) that AORN Vice President, to describes perioperative approve a change in the nursing. The Task Force MAL delegate formula to began with existing defiincrease the number of nitions as a base, includdelegates for each percent ing the nursing minimum of active MALs in the total data set (NMDS) as active membership (ie, adopted by the American from one to three). Baker Nurses Association. The said that based on discusNMDS is an essential set sion during the Forums at of information items with Congress, this was the uniform definitions and Patricia s. Stein expresses concern about most appropriate action for categories related to nun- member at large communication. the House to take. 1186

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Delegates agreed a dues increase was necessary, but they were concerned about voting without consulting the membership. Patricia S. Stein, RN, BSN, CNOR, AORN of Twin Cities, expressed concern regarding MAL delegate communication among themselves (ie, how do MAL delegates communicate with one another so that they represent a group rather than just themselves). Bonnie G. Denholm, RN, MS, CNOR, AORN chapter relations manager, responded that there is an MAL representative on the Membership Committee. The MALs also publish information in Inside AORN, can hold caucuses, and usually schedule a meeting before Congress. With no further discussion, the motion passed. The policy change is effective for the 1995 Congress. Redefinition of perioperative nursing. Vickie E. Pierce, RN, BSN, CNOR, introduced the second order of business: the conceptual model and redefinition of perioperative nursing. The motion (ie, to approve the conceptual model of perioperative nursing, including the philosophy, scope of practice, definition of recipients of care, definition of perioperative nurse, and goal of perioperative nursing practice) passed after no discussion from the floor. The new document replaces the position paper approved in 1978. (See “Philosophy of Perioperative Nursing Practice,” “Definition of Recipients of Pe r i o pe rat i v e C are, ”

“Definition of Perioperative Nurse,” “Goal of Perioperative Nursing Practice,” “Glossary,” and “Scope of Perioperative Nursing Practice.”) Membership dues increase. At the request of members attending this Congress, the Board held a special meeting to discuss an increase in membership dues. The increase would support new programs requested by the members. Regarding the proposed dues increase of $20, Linda K. Groah, AORN Treasurer, reminded members of AORN’s dependence on industry support. “If industry reduces its support for Congress by just 20%, it would cut our revenues by $1 million,” she said. The total dues of $65 per year would represent approximately 21 % of AORN’s revenues in 1994-1995. Groah also commended the delegates on their willingness to accept responsibility and accountability for the financial well-being of the Association by considering a dues increase proposal at the 1994 House. The motion, introduced by AORN Secretary Janet A. Lewis, RN, MA, CNOR, was to approve a dues increase of $20 per year so that annual dues would be $65 effective July 1, 1994. Although most of the members who spoke from the floor agreed that a dues increase was

necessary and appropriate, they expressed concern about voting on the issue without consulting the entire membership. As Mary Thurman, RN, AORN of Atlanta, said, The members need prior knowledge of issues to be voted on by the House of Delegates. Nothing about this issue was presented before this Congress, and it would be a big mistake not to give the members the opportunity to speak. This sentiment was reflected by other delegates, and the motion was defeated. Health care reform endorsement. When President Spry asked if there was any further new business, James H. McNair, RN, BSN, CNOR, San Antonio chapter, expressed his concern that the Board had supported the Clinton Administration’s health care reform plan without consulting the membership. The action of the Board this week in re-evaluating the endorsement of the Clinton Plan has shown me that they are indeed open and receptive to the membership. I feel that my voice made a difference . . . and that they [the B o a r d ] are willing to listen and act according to the will of the membership. 1187

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Philosophy of Perioperative Nursing Practice

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ursing is a social institution providing an essential and significant component of the health care services needed by people. As such, nursing must be concerned with meeting evolving societal needs in relation to the nature and delivery of such services. Nursing is a science and derives a large portion of its knowledge base from the natural, behavioral, and social sciences and the humanities. Nursing integrates and applies these principles through use of the nursing process directed to and from the focal point of all nursing activities-the patient. The practice of nursing is directed toward the patient who, as a biopsychosocia1 being, is a product of and responds to internal and external phenomena. Nursing responds by helping to alter these phenomena to promote and maintain health, to help cure disease, to assist adaptation to chronic disease, or to support the achievement of a peaceful, dignified death. Nursing is a caring art based on the creative application of knowledge, skills, and interpersonal competencies to provide quality, individualized patient care. The patient who experiences the prospect or performance of an operative or other invasive procedure is the focus of perioperative nursing. Perioperative nursing practice addresses resulting patient needs amenable to nursing intervention. While basic life-sustaining needs may be of the highest priority, the perioperative nurse is concerned with all physiological, psychological, sociocultural, and spiritual dimensions of their patients’ human responses. Perioperative nurses provide care designed to meet individual patient needs

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through use of the nursing process. Perioperative nursing occurs within a social setting characterized by rapidly changing technological, economic, and cultural forces that require continuous adaptation by professional practitioners. The complexity of knowledge and skill required to effectively care for recipients of perioperative nursing compels nurses to be well educated and to continue their education beyond generic nursing programs. Perioperative nursing practice includes providing direct care, coordinating comprehensive care, educating recipients of perioperative nursing, and generating perioperative nursing knowledge in a variety of settings. The perioperative nurse uses substantial knowledge, judgment, and skill based on the principles of biological, physiological, behavioral, social, and nursing sciences. Knowledge and skills acquired by the nurse are used to implement the nursing process and the “Standards of [Perioperative] Nursing Practice.”’ In this context, the perioperative nurse works with the patient to make decisions regarding the patients’ needs and to assist and support the patient. The perioperative nurse also works in collaboration with other health professionals to meet patients’ needs. The perioperative nurse has primary responsibility and accountability for the nursing care of patients who are experiencing operative and other invasive procedures. Note 1. “Standards of nursing practice,”in AORN Stundurds and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1993) 57-90.

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Definition of Recipients of Perioperative Care

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ecipients of care are patients, their families, and significant others who vary in age, degree of wellness, and socioeconomic and educational status. Patients are those whose protective reflexes and/or self-care abilities are potentially diminished by the prospect or performance of an operative or other invasive procedure. Recipients have widely diverse knowledge levels and capabilities for self-care. They have both predictable and unique needs caused by these procedures. Some needs can be predicted based on the nurse’s knowledge of the procedure and the technology to be used; others are unique to the individual.

Definition of Perioperative Nurse

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erioperative nurse is detined as the registered nurse who, using the nursing process, designs, coordinates, and delivers care to meet the identified needs of patients whose protective reflexes or self-care abilities are potentially compromised because they are having operative or other invasive procedures. Perioperative nurses possess and apply knowledge of the procedure and the patient’s intraoperative experience throughout the patient’s care continuum. The perioperative nurse assesses, diagnoses, plans, intervenes, and evaluates the outcome of interventions based on criteria that support a standard of care targeted toward this specific population. The perioperative nurse addresses the physiological, psychological, sociocultural, and spiritual responses of the individual that have been caused by the prospect or performance of the invasive procedure.

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Goal of Perioperative Nursing Practice

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he goal of perioperative nursing practice is to assist patients, their families, and significant others to achieve a level of wellness equal to or greater than that which they had prior to the procedure.

Glossary Invasive procedures: Those in which the body is entered (eg, by use of a scalpel, tube, device, ionizing or nonionizing radiation, or any other invasion) and in which protective retlexes or self-care abilities are potentially compromised. Perioperative: Surrounding the operative and other invasive experience (ie, before, during, and after). Perioperative nursing care: The nursing activities that address the needs of patients, their families, and significant others that occur preoperatively, intraoperatively, and postoperatively. Perioperative nursing services: Services extended to a variety of other groups to enhance the care ultimately provided to the patient. These groups include but are not limited to hospitals, clinics, schools and collcgcs of nursing. physicians, other nurses, insurers, and medical device and pharmaceutical manufacturers.

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Scope of Perioperadive Nursing Practice

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erioperative nursing practice begins with the prospect of an operative or other invasive procedure and is completed by evaluating the extent to which the recipient’s needs have been met. Perioperative nurses interact with both the patient and/or the patient’s significant others throughout the continuum of patient care. Perioperative nursing practice takes place in the patient’s environment and includes, but is not limited to, surgical suites, ambulatory care settings, clinics, physicians’ offices, communities, and homes. The management of the recipient’s needs, both unique and predictable, may be through direct or indirect interventions. These interventions are planned to assist the recipient in meeting the projected outcome in an efficient and appropriate manner. Perioperative nursing care is implemented by registered nurses who strive to assist the patient to meet projected outcomes by functioning in various roles--clinical practitioner, manager, educator, and researcher. Perioperative nursing varies and may include, but is not limited to, 0 peer education and patient/family teaching, 0 support and reassurance,

Election results. Noreen E. McHugh, RN, MS, CNOR, chairman of the Nominating Committee, presented the Tellers report, announcing that 1,406 ballots were cast, with five invalid ballots. President Spry announced the three new members of the Nominating Committee: Vivian C. Watson, RN, CNOR; Cecil A. King,

advocacy, control of the environment, 0 efficient provision of resources, maintenance of asepsis, 0 monitoring physiologic and psychologic status, 0 management of aggregate patient needs, 0 supervision of ancillary personnel, 0 perioperative exploration and validation of current and future practices, 0 integration and coordination of care across settings and among disciplines, and 0 collaboration and consultation. These activities are based on using the problem-solving approach in practice, management, education, and research. The reason for the existence of perioperative nursing practice is the care of persons undergoing operative and other invasive procedures. Perioperative nursing services are extended to a variety of other groups to enhance the care ultimately provided to the patient. These groups include hospitals, clinics, schools and colleges of nursing, physicians, other nurses, insurers, and medical device and pharmaceutical manufacturers. 0 0

RN, CNOR; and Marlene R. Craden, RN, BSN, CNOR, CRNFA. Members elected to the Board of Directors are Cynthia A. Bray, RN, MSEd, CNOR; Patricia C. Seifert, RN, MSN, CNOR, CRNFA; and Brenda C. Ulmer, RN, BS, CNOR. The Secretary is Janet A. Lewis, RN, MA, CNOR; the new Vice President is Ruth P.

Shumaker, RN, BSN, CNOR; and the new President-elect i s Ellen K. Murphy, RN, JD, CNOR, FAAN. Photographs of the 19941995 Board of Directors and Nominating Committee appear in the “Closing Session” section of this issue. LYNNHOLLADAY AVERY ASSOCIATE EDITOR 1191