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Delegates apporve first assistant study, educational expansion
Delegates approve first aSS iSt ant St Udy , educational expansion
The new format of three House of Delegates meetings and two Forums initiated at the 1977 Anaheim Congress provided an opportunity for more discussion of AORN business by delegates and members. Open debate at Forums explored questions and proposals presented by the members as well as the Board of Directors. Some proposals were revised or withdrawn depending on discussion and reception by the audience. Far-reaching action taken by delegates at the House of Delegates included 0 consideration of the concept of the function of first assistant in the role of the nurse practitioner in the OR 0 approval of an educational expansion unit 0 approval for the Board of Directors to continue investigation toward joint certification with the American Nurses' Association (ANA) 0 approval of a committee to investigate
the feasibility of developing an educational process for certification adoption of five of the six proposed bylaw changes approval of continued participation in the Federation of Specialty Nursing Organizations and ANA. W A study on the concept of including the function of the first assistant in the role of the nurse practitioner in the operating room during the intraoperative phase of the nursing process was approved by the House of Delegates after much debate in the House and Forums. The recommendation presented by the Board of Directors reads: The AORN Board of Directors recommends the House of Delegates consider the concept that the function of the first assistant be included in the role of the nurse practitioner in the OR during the intraoperative phase of the nursing process. Rationale: 1 . to ensure provision of competent professional care for the patient during the intraoperative phase 2. to provide the patient with continuity of the nursing process, which only the professional nurse can implement 3. to progressively increase involvement with the surgical patient through better communication of the intraoperative events with those responsible for postoperative nursing care 4. to augment the diminishing supply of surgical residents due to the recent health manpower legislation. (PL 94484) The implementation of this recommendation would require appointment of a committee to delineate the qualifications and criteria necessary for the nurse practitioner in the operating room. The recommendation was presented at the first session of the House of Delegates with the final vote coming at the third session. Many members have indicated an interest in serving on the committee to study the concept. During Forum discussion, Barbara Gruendemann, AORN vice-president, who presented the recommendation, expanded on
Delegates listen intently to discussion at one of the three House of Delegates sessions. the fourth rationale, explaining that by July 1977, 35% of residencies must be in primary care; by July 1978, 40%; and thereafter, 50%. She stated, “We are concerned primarily about the quality of patient care in the OR at a future time when (surgical) residencies will be at a premium. We are also concerned about who would assume this role if we did not.” In speaking for the recommendation, Mary Nolan of the South Bay Chapter said, “This concept is a reality.” She suggested the role of the registered nurse could include as one function the behavior of first assisting. “If first assisting is the only role, we cannot afford the luxury. If it is one of the functions, we can take it and define it and make it nursing,” she stated. She predicted this role will not diminish and “may even increase” the supply of nurses in the operating room. Although the OR nurse may give up functions she now performs if she accepts this role. Nolan contended these “are tasks that are not nursing functions.“ Also supporting the recommendation, Ann Hoffman of Connecticut stated, “We cannot and must not back away from this issue.” At
AORN Journal, May 1977, Vol25, N o 6
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one Forum while speaking for the recommendation, she asked, “How can we ignore the already ‘now’ of the situation?” In a show of hands requested by Hoffman, a great number of nurses indicated they were acting as first assistants. Opposition to the recommendation came from many members. Pat Stasiowski, Massachusetts Chapter I, felt it might confirm to educators and others that “OR nursing is technical in scope and not a viable part of the nursing curriculum.” Mary Hanson of Tar Heels East Chapter stated, “Nursing is filling in for everyone else’s problems.” Joan Driscoll, New York City, agreed, saying, “First assisting is not a nursing function. We should not be filling in for the physician.” One delegate asked, “Who invited us to fill this role?” Barba Edwards, president, replied, “The patient’s need has invited us.” In Virginia, registered nurses may serve as first assistants according to a policy adopted by the Committee of the Joint Boards of Medicine and Nursing. Ruth Vaiden of the Virginia delegation stated that Virginia nurses have ambivalent feelings about the nurse as first assistant. They are concerned about the role or definition of first assistant, however, and whose criteria to use-the state’s, hospital’s, or surgeon’s. She expressed fear that smaller hospitals will use technicians to fill the role if registered nurses do not. One member suggested Project 25, which will be exploring the role of the nurse in the operating room, could evaluate the role of the nurse as first assistant. In a statement read before the vote was taken, Ann Baker of the Washington State delegation stated, “The role problem is an established fact for some of our colleagues.” She said Washington nurses “see this new role component as the addition of a new level and dimension of practice for operating room nursing” offering a career choice that rewards OR nurses for expertise in patient care. She expressed trust in the Board of Directors’ responsiveness to the membership’s concerns regarding quality of care. A resolution that “an educational expansion unit be provided’ was presented by the Busy hands find diverse ways to keep occupied.
d+ 1096
AORN Journal, May 1977, Vol25, No 6
Board of Directors and approved by the House of Delegates. The expansion's prevailing thrust will be in producing additional educational programs and publications for members' use at the local level. This will entail concomitant expansion of the AORN Education Department staff and physical facility. Originally, the Association had included in its long-range planning a school for operating room nursing education at Headquarters in Denver. It was envisioned as offering postgraduate courses in operating room nursing. AORN also hoped to obtain cooperation from universities in the Denver vicinity for academic credit for the courses. Two years ago at the 1975 Dallas Congress, the Greater Kansas City and Topeka chapters spearheaded a fund-raising campaign for the school and asked the Board of Directors to consider moving the school from a long-term goal to a short-term goal. Since then r e quests have been made for members' input on their educational needs, advice has been sought on financial and construction considerations, and an a d hoc committee for the proposed education center has presented recommendations based on data from questionnaires sent to chapter presidents and members-at-large. The unanimous decision by the Board of Directors to present the resolution took into consideration all these facts and was based on responses by members indicating support for locally offered educational sessions. The consensus was it would present a hardship to many members to attend educational offerings at the Headquarters site. Members, however, did indicate interest in an operating room management course at Headquarters. In presenting the rationale for the resolution, Nancy Ertl, AORN president-elect, noted that the expanded program would include audiovisual learning modules and seminars on implementation of nursing standards, peer review, legal aspects of nursing in the operating room, and human sexuality. These programs will augment existing national seminars. To house the additional staff needed to enlarge the educational program, a freestanding building will be constructed on Headquarters-owned property next to the existing Headquarters building. This new
structure will contain offices, conference rooms, a library, and an audiovisual center. W Investigationwill continue toward joint certification with the American Nurses' Association if deemed appropriate by the Board of Directors. This action was approved by the House of Delegates. In making the motion to continue investigation, Nancy Ertl, AORN president-elect, said the Board does not b e
Nominating Committee Chairman Joan Fabian invites members' input in report on criteria used in candidate selection. lieve the Association can financially afford to initiate its own certification program. The question also was raised as to the credibility of certifying its own members. Ertl told members the Board was aware of their concerns and would continue to react to them. She said, "By this motion, we are asking you to permit the Board to continue monitoring the ANA certification process, and if we believe it will benefit the AORN members, we may act at that time." Gwen Dodge, AORN assistant director of education and Headquarters representative
AORN Journnl, May 1977, Vol25, No 6
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to ANA on the certification process, reported on recent ANA developments on certification. Noting that the option is still open for joint certification, she indicated that the ANA Medical-Surgical Division has not made a decision as to competence or excellence levels. She said she had an “inkling” it would depend on AORN’s preference. Dodge stated that AORN would have equal representation on the joint certification committee and could conceivably chair the committee. The concept for the examination would be the entire responsibility of OR nurses, and item writers would be from AORN or nurses practicing in the operating room. At the 1976 Congress in Dallas, the House of Delegates approved AORN participation in certification for excellence in collaboration with ANA, sharing the costs on a 50/50 basis. However, at its June convention in Atlantic City, ANA announced it was eliminating the single approach to certification for excellence and substituting a two-pronged approach offering certification for competence and diplomate status in a new American College of Nursing Practice for nurses with master’s degrees. Because of that action, the AORN Board of Directors voted at its June meeting to place a moratorium on all activities relative to ANA certification until ANA changes its new concept or until delegates vote at the Anaheim Congress. In voting for the motion in Anaheim, the delegates kept the door open for certification with careful investigation by the Board. W An educational program to assist in preparing OR nurses for certification was proposed by the Houston chapter. The House adopted this resolution. A committee be formed composed of AORN members directly involved in patient care, management, and education, selected by the Board of Directors, to investigate the feasibility of developing certification to include an education process. Although the proposal seemed to indicate investigating a new approach to certification, Shirley Humphries of the Houston chapter explained the proposal was intended to look into the feasibility of an educational program to prepare nurses for certification but was not directed toward a new certification process.
1loo
The proposal was first read at a Forum by Judith I Pfister, newly elected member of the Board, who has since been named chairman of the committee. Pfister is assistant director of operating rooms, Methodist Hospital, Houston. C Joan Gowin, director and associate professor of nursing, operating and recovery rooms, Case Western Reserve University, Frances Payne Bolton School of Nursing, University Hospitals of Cleveland, has also been selected for the committee. The third member will be an OR staff nurse. A diagram shown at the Forum pictured the education process as including three phases. It would provide an educational avenue for members wishing to become certified, particularly those in areas where research facilities are not available and educational opportunities are limited. Seen as a six-month endeavor, the process would begin with a correspondence course containing a comprehensive bibliography. The bibliography would relieve the individual from the onus of doing all the research, which would be of particular benefit to those members in unpopulated areas with limited research resources. The second phase is viewed as a “brainstorming” course with an exchange of information among those in practice and an instructor. This could be a two-week course on a campus or a three-to-four week seminar in a local area. The third phase would be an evaluation process covering theory and practicum. During Forum discussion on the process, Pfister noted that this would be “certification through education” and that more nurses would get certified. She commented that this process would benefit not only the nurse but “would provide the patient with something” as the “recipient of knowledge.” Candidates for national office will no longer be required to hold membership in the American Nurses’ Association (ANA) or the National League for Nursing. This bylaw amendment was approved after considerable debate. Opponents stated that membership is necessary in one of these organizations to be aware of what is happening in nursing. Those who supported the amendment believe ANA membership might present a conflict of interest for those in supervisory
AORN Journal, May 1977,Vol25, N o 6
AORN Past-president Ruth Metzger speaks at one of the Delegates sessions. positions because of ANAs collective bargaining activities. There was no opposition to the other four approved amendments that (1) change the phrase in the statement of purposes of the Association from “better and safer care of the patient in the operating room” to “optimum care of the patient before, during, and after surgery”; (2) stipulate that the Nominating Committee will elect its chairman at the midyear meeting; (3) add to the duties of the Board of Directors “establishes policies for the AORN Journal; and (4) delineate the responsibilities of the Editorial Committee to reflect its current duties. Of the six proposed changes, the only amendment defeated would have eliminated for the office of president-elect the eligibility requirement to have served at least one year as a member of the Board of Directors. B e cause the president-elect candidate has not been opposed for the past three years, supporters of the amendment believed it might make more members eligible for the office. Opponents of the amendment suggested the president-elect needs the experience of sewing on the Board of Directors prior to her year as president-elect.
W Delegates gave overwhelming approval for AORN’s continued participation in the Federation of Specialty Nursing Organizations and ANA. In making the motion, Nancy Mehaffy, a member of the Board of Directors, stated membership in the Federation would provide unity in nursing. She noted that although the Federation is not a powerful decision-making organization, it could develop in that direction. W The Forums provided an arena for concerns of members and reports by committee chairmen. Joan Fabian, Nominating Committee chairman, spoke of the point system used as criteria for selecting the slate of candidates for the 1977 Congress. She stressed the criteria were devised solely for the committee’s use this year and future committees were under no obligation to use them. She said the criteria were only one tool used in the selection process. Also considered were the chapter president’s evaluation, personal references, and the statement of the potential candidate. She noted that the committee invites input from the membership and welcomes recommendations for evaluating candidates. The National Committee on Education (NCE) posed two questions for Forum discussion. Having received inquiries from the membership on consultation for one-day workshops similar to that available from NCE for regional institutes, NCE queried where the funding would come from. Many options were suggested and the consensus was the chapter would have to assist in funding. The second query concerned whether or not regional institutes and workshops should be open to other members of the health care team. Attendance at regional institutes has been restricted to registered nurses while attendance at workshops has been open. Ruth Metzger, Houston, believed by opening regional institute registration, it would be “difficult to write objectives for such a broad audience.” Claire Plourde feared it “may downgrade the educational content of the material, which would be unfair to the RN.” The tenor of the audience favored a status quo approach to attendance.
AORN Journal, May 1977,Vol25, No 6
Dora B D’Amico Assis tant editor 1103
The new format of three House of Delegates meetings and two Forums initiated at the 1977 Anaheim Congress provided an opportunity for more discussion of AORN business by delegates and members. Open debate at Forums explored questions and proposals presented by the members as well as the Board of Directors. Some proposals were revised or withdrawn depending on discussion and reception by the audience. Far-reaching action taken by delegates at the House of Delegates included 0 consideration of the concept of the function of first assistant in the role of the nurse practitioner in the OR 0 approval of an educational expansion unit 0 approval for the Board of Directors to continue investigation toward joint certification with the American Nurses' Association (ANA) 0 approval of a committee to investigate
the feasibility of developing an educational process for certification adoption of five of the six proposed bylaw changes approval of continued participation in the Federation of Specialty Nursing Organizations and ANA. W A study on the concept of including the function of the first assistant in the role of the nurse practitioner in the operating room during the intraoperative phase of the nursing process was approved by the House of Delegates after much debate in the House and Forums. The recommendation presented by the Board of Directors reads: The AORN Board of Directors recommends the House of Delegates consider the concept that the function of the first assistant be included in the role of the nurse practitioner in the OR during the intraoperative phase of the nursing process. Rationale: 1 . to ensure provision of competent professional care for the patient during the intraoperative phase 2. to provide the patient with continuity of the nursing process, which only the professional nurse can implement 3. to progressively increase involvement with the surgical patient through better communication of the intraoperative events with those responsible for postoperative nursing care 4. to augment the diminishing supply of surgical residents due to the recent health manpower legislation. (PL 94484) The implementation of this recommendation would require appointment of a committee to delineate the qualifications and criteria necessary for the nurse practitioner in the operating room. The recommendation was presented at the first session of the House of Delegates with the final vote coming at the third session. Many members have indicated an interest in serving on the committee to study the concept. During Forum discussion, Barbara Gruendemann, AORN vice-president, who presented the recommendation, expanded on
Delegates listen intently to discussion at one of the three House of Delegates sessions. the fourth rationale, explaining that by July 1977, 35% of residencies must be in primary care; by July 1978, 40%; and thereafter, 50%. She stated, “We are concerned primarily about the quality of patient care in the OR at a future time when (surgical) residencies will be at a premium. We are also concerned about who would assume this role if we did not.” In speaking for the recommendation, Mary Nolan of the South Bay Chapter said, “This concept is a reality.” She suggested the role of the registered nurse could include as one function the behavior of first assisting. “If first assisting is the only role, we cannot afford the luxury. If it is one of the functions, we can take it and define it and make it nursing,” she stated. She predicted this role will not diminish and “may even increase” the supply of nurses in the operating room. Although the OR nurse may give up functions she now performs if she accepts this role. Nolan contended these “are tasks that are not nursing functions.“ Also supporting the recommendation, Ann Hoffman of Connecticut stated, “We cannot and must not back away from this issue.” At
AORN Journal, May 1977, Vol25, N o 6
1095
one Forum while speaking for the recommendation, she asked, “How can we ignore the already ‘now’ of the situation?” In a show of hands requested by Hoffman, a great number of nurses indicated they were acting as first assistants. Opposition to the recommendation came from many members. Pat Stasiowski, Massachusetts Chapter I, felt it might confirm to educators and others that “OR nursing is technical in scope and not a viable part of the nursing curriculum.” Mary Hanson of Tar Heels East Chapter stated, “Nursing is filling in for everyone else’s problems.” Joan Driscoll, New York City, agreed, saying, “First assisting is not a nursing function. We should not be filling in for the physician.” One delegate asked, “Who invited us to fill this role?” Barba Edwards, president, replied, “The patient’s need has invited us.” In Virginia, registered nurses may serve as first assistants according to a policy adopted by the Committee of the Joint Boards of Medicine and Nursing. Ruth Vaiden of the Virginia delegation stated that Virginia nurses have ambivalent feelings about the nurse as first assistant. They are concerned about the role or definition of first assistant, however, and whose criteria to use-the state’s, hospital’s, or surgeon’s. She expressed fear that smaller hospitals will use technicians to fill the role if registered nurses do not. One member suggested Project 25, which will be exploring the role of the nurse in the operating room, could evaluate the role of the nurse as first assistant. In a statement read before the vote was taken, Ann Baker of the Washington State delegation stated, “The role problem is an established fact for some of our colleagues.” She said Washington nurses “see this new role component as the addition of a new level and dimension of practice for operating room nursing” offering a career choice that rewards OR nurses for expertise in patient care. She expressed trust in the Board of Directors’ responsiveness to the membership’s concerns regarding quality of care. A resolution that “an educational expansion unit be provided’ was presented by the Busy hands find diverse ways to keep occupied.
d+ 1096
AORN Journal, May 1977, Vol25, No 6
Board of Directors and approved by the House of Delegates. The expansion's prevailing thrust will be in producing additional educational programs and publications for members' use at the local level. This will entail concomitant expansion of the AORN Education Department staff and physical facility. Originally, the Association had included in its long-range planning a school for operating room nursing education at Headquarters in Denver. It was envisioned as offering postgraduate courses in operating room nursing. AORN also hoped to obtain cooperation from universities in the Denver vicinity for academic credit for the courses. Two years ago at the 1975 Dallas Congress, the Greater Kansas City and Topeka chapters spearheaded a fund-raising campaign for the school and asked the Board of Directors to consider moving the school from a long-term goal to a short-term goal. Since then r e quests have been made for members' input on their educational needs, advice has been sought on financial and construction considerations, and an a d hoc committee for the proposed education center has presented recommendations based on data from questionnaires sent to chapter presidents and members-at-large. The unanimous decision by the Board of Directors to present the resolution took into consideration all these facts and was based on responses by members indicating support for locally offered educational sessions. The consensus was it would present a hardship to many members to attend educational offerings at the Headquarters site. Members, however, did indicate interest in an operating room management course at Headquarters. In presenting the rationale for the resolution, Nancy Ertl, AORN president-elect, noted that the expanded program would include audiovisual learning modules and seminars on implementation of nursing standards, peer review, legal aspects of nursing in the operating room, and human sexuality. These programs will augment existing national seminars. To house the additional staff needed to enlarge the educational program, a freestanding building will be constructed on Headquarters-owned property next to the existing Headquarters building. This new
structure will contain offices, conference rooms, a library, and an audiovisual center. W Investigationwill continue toward joint certification with the American Nurses' Association if deemed appropriate by the Board of Directors. This action was approved by the House of Delegates. In making the motion to continue investigation, Nancy Ertl, AORN president-elect, said the Board does not b e
Nominating Committee Chairman Joan Fabian invites members' input in report on criteria used in candidate selection. lieve the Association can financially afford to initiate its own certification program. The question also was raised as to the credibility of certifying its own members. Ertl told members the Board was aware of their concerns and would continue to react to them. She said, "By this motion, we are asking you to permit the Board to continue monitoring the ANA certification process, and if we believe it will benefit the AORN members, we may act at that time." Gwen Dodge, AORN assistant director of education and Headquarters representative
AORN Journnl, May 1977, Vol25, No 6
1099
to ANA on the certification process, reported on recent ANA developments on certification. Noting that the option is still open for joint certification, she indicated that the ANA Medical-Surgical Division has not made a decision as to competence or excellence levels. She said she had an “inkling” it would depend on AORN’s preference. Dodge stated that AORN would have equal representation on the joint certification committee and could conceivably chair the committee. The concept for the examination would be the entire responsibility of OR nurses, and item writers would be from AORN or nurses practicing in the operating room. At the 1976 Congress in Dallas, the House of Delegates approved AORN participation in certification for excellence in collaboration with ANA, sharing the costs on a 50/50 basis. However, at its June convention in Atlantic City, ANA announced it was eliminating the single approach to certification for excellence and substituting a two-pronged approach offering certification for competence and diplomate status in a new American College of Nursing Practice for nurses with master’s degrees. Because of that action, the AORN Board of Directors voted at its June meeting to place a moratorium on all activities relative to ANA certification until ANA changes its new concept or until delegates vote at the Anaheim Congress. In voting for the motion in Anaheim, the delegates kept the door open for certification with careful investigation by the Board. W An educational program to assist in preparing OR nurses for certification was proposed by the Houston chapter. The House adopted this resolution. A committee be formed composed of AORN members directly involved in patient care, management, and education, selected by the Board of Directors, to investigate the feasibility of developing certification to include an education process. Although the proposal seemed to indicate investigating a new approach to certification, Shirley Humphries of the Houston chapter explained the proposal was intended to look into the feasibility of an educational program to prepare nurses for certification but was not directed toward a new certification process.
1loo
The proposal was first read at a Forum by Judith I Pfister, newly elected member of the Board, who has since been named chairman of the committee. Pfister is assistant director of operating rooms, Methodist Hospital, Houston. C Joan Gowin, director and associate professor of nursing, operating and recovery rooms, Case Western Reserve University, Frances Payne Bolton School of Nursing, University Hospitals of Cleveland, has also been selected for the committee. The third member will be an OR staff nurse. A diagram shown at the Forum pictured the education process as including three phases. It would provide an educational avenue for members wishing to become certified, particularly those in areas where research facilities are not available and educational opportunities are limited. Seen as a six-month endeavor, the process would begin with a correspondence course containing a comprehensive bibliography. The bibliography would relieve the individual from the onus of doing all the research, which would be of particular benefit to those members in unpopulated areas with limited research resources. The second phase is viewed as a “brainstorming” course with an exchange of information among those in practice and an instructor. This could be a two-week course on a campus or a three-to-four week seminar in a local area. The third phase would be an evaluation process covering theory and practicum. During Forum discussion on the process, Pfister noted that this would be “certification through education” and that more nurses would get certified. She commented that this process would benefit not only the nurse but “would provide the patient with something” as the “recipient of knowledge.” Candidates for national office will no longer be required to hold membership in the American Nurses’ Association (ANA) or the National League for Nursing. This bylaw amendment was approved after considerable debate. Opponents stated that membership is necessary in one of these organizations to be aware of what is happening in nursing. Those who supported the amendment believe ANA membership might present a conflict of interest for those in supervisory
AORN Journal, May 1977,Vol25, N o 6
AORN Past-president Ruth Metzger speaks at one of the Delegates sessions. positions because of ANAs collective bargaining activities. There was no opposition to the other four approved amendments that (1) change the phrase in the statement of purposes of the Association from “better and safer care of the patient in the operating room” to “optimum care of the patient before, during, and after surgery”; (2) stipulate that the Nominating Committee will elect its chairman at the midyear meeting; (3) add to the duties of the Board of Directors “establishes policies for the AORN Journal; and (4) delineate the responsibilities of the Editorial Committee to reflect its current duties. Of the six proposed changes, the only amendment defeated would have eliminated for the office of president-elect the eligibility requirement to have served at least one year as a member of the Board of Directors. B e cause the president-elect candidate has not been opposed for the past three years, supporters of the amendment believed it might make more members eligible for the office. Opponents of the amendment suggested the president-elect needs the experience of sewing on the Board of Directors prior to her year as president-elect.
W Delegates gave overwhelming approval for AORN’s continued participation in the Federation of Specialty Nursing Organizations and ANA. In making the motion, Nancy Mehaffy, a member of the Board of Directors, stated membership in the Federation would provide unity in nursing. She noted that although the Federation is not a powerful decision-making organization, it could develop in that direction. W The Forums provided an arena for concerns of members and reports by committee chairmen. Joan Fabian, Nominating Committee chairman, spoke of the point system used as criteria for selecting the slate of candidates for the 1977 Congress. She stressed the criteria were devised solely for the committee’s use this year and future committees were under no obligation to use them. She said the criteria were only one tool used in the selection process. Also considered were the chapter president’s evaluation, personal references, and the statement of the potential candidate. She noted that the committee invites input from the membership and welcomes recommendations for evaluating candidates. The National Committee on Education (NCE) posed two questions for Forum discussion. Having received inquiries from the membership on consultation for one-day workshops similar to that available from NCE for regional institutes, NCE queried where the funding would come from. Many options were suggested and the consensus was the chapter would have to assist in funding. The second query concerned whether or not regional institutes and workshops should be open to other members of the health care team. Attendance at regional institutes has been restricted to registered nurses while attendance at workshops has been open. Ruth Metzger, Houston, believed by opening regional institute registration, it would be “difficult to write objectives for such a broad audience.” Claire Plourde feared it “may downgrade the educational content of the material, which would be unfair to the RN.” The tenor of the audience favored a status quo approach to attendance.
AORN Journal, May 1977,Vol25, No 6
Dora B D’Amico Assis tant editor 1103