Proposed Standards of Perioperative Nursing

AORN JOURNAL

OCTOBER 1991.VOL 54. NO 4

Proposed Standards of Perioperative Nursing CLINICAL PRACTIC~OFESSIONAL PERFORMANCE

tandards are authoritative statements by which the nursing profession describes the responsibilities for which its practitioners are accountable. Standards of clinical practice. Standards of clinical practice describe a competent level of perioperative nursing as demonstrated by the nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The nursing process encompasses all significant actions taken by the nurse in providing care to all patients and forms the foundation of clinical decision making. Additional nursing responsibilities for all patients, such as providing culturally and ethnically relevant care; maintaining a safe environment; educating patients about their illness, treatment, health promotion, or self-care activities; and planning for continuity of care, are subsumed within these standards. Standards of professional performance. Standards of professional performance describe a competent level of behavior in the professional perioperative role, including activities related to quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource use. The scope of nursing involvement in some professional roles may be dependent upon the nurse’s education, position, or practice environment. Hence, some standards of measurement criteria identify a broad range of activities that may demonstrate compliance with the standards. While standards of professional performance describe roles expected of all perioperative

nurses, many other responsibilities comprise the hallmarks of a profession. The perioperative nurse should be self-directed and purposeful in seeking necessary knowledge and skills to advance career goals. Other activities, such as membership in a professional nursing organization and certification in specialty or advanced practice, are desirable methods to enhance the nurse’s professionalism.

Proposed Standards of Clinical Practice Assessment Standard: The perioperative nurse collects patient health data. Interpretive statement: Assessment is the systematic and ongoing collection of data, guided by the application of knowledge of physiological and psychological principles and experience, used to make judgments and predictions about a patient’s response to illness or changes in life processes. Assessment is essential to establishing a nursing diagnosis and predicting outcomes. Assessment may occur in a variety of settings. Criteria: The priority of data collection is determined by the client’s immediate condition or needs, and the relationship to the proposed intervention. It includes, but is not limited to: current medical diagnoses and therapies; physical status and physiological responses; psychosocial status of the patient;

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cultural and spiritual information; the individual’s understanding, perceptions, and expectations of the procedure; previous responses to illness, hospitalizations, surgical, therapeutic or diagnostic procedures; and results of diagnostic studies. Pertinent data are collected using appropriate assessment techniques. Data collection involves the patient, significant others, and health care providers when appropriate. It may be accomplished through diverse means, such as interview, review of records, assessment, and/or consultation. Data collection is systematic and ongoing. Relevant data are documented in retrievable form.

Diagnosis Standard: The perioperative nurse analyzes the assessment data in determining diagnoses. Interpretive statement: The outcome of assessment is the potential for one or more nursing diagnoses. Nursing diagnoses are concise statements about actual, or high risk for, health problems that are amenable to nursing intervention. Diagnoses result from analysis and interpretation of data about the patient’s problems, needs, and health status. Criteria: Diagnoses are consistent with the assessment data. Diagnoses are validated with the patient, significant other, and health care providers, when possible. Diagnoses are documented in a manner that facilitates the determination of outcomes and plan of care.

Outcome identification Standard: The perioperative nurse identifies expected outcomes unique to the patient. Interpretive Statement: Patient outcomes are derived from nursing diagnoses and direct the interventions to correct, alter, or maintain the nursing diagnoses. Areas for the perioperative nurse to consider when formulating outcomes should include, 812

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but are not limited to: absence of infection; maintenance of skin integrity; 0 absence of adverse effects due to proper use of safety measures related to positioning, extraneous objects, and chemical, physical, and electrical hazards; maintenance of fluid and electrolyte balance; 0 knowledge of the patient and significant others of the physiological and psychological responses to surgical intervention; and participation of the patient and significant others in the rehabilitation process. Criteria: Outcomes are derived from the diagnoses and are mutually formulated with the patient, significant others, and health care providers, when possible. The patient’s present and potential physical capabilities and behavioral patterns are congruent with the expected outcomes. Outcomes are attainable with consideration to human and material resources available to the patient. Outcome statements include measurable criteria for determining expected outcomes as a result of nursing interventions. Outcomes are prioritized. Outcomes are communicated to appropriate people. Expected outcomes are documented i n a retrievable form. Outcomes provide direction for continuity of care.

Planning Standard: The perioperative nurse develops a plan of care that prescribes interventions to attain expected outcomes. Interpretive statement: The outcome statements become the guide for the nursing interventions necessary to achieve desired results. The individualized plan of care reflects the perioperative assessment and a logical sequence to attain outcomes. Priorities for the provision of nursing care are established by the perioperative nurse

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OCTOBER 1991. VOL 54, NO 4

in collaboration with the patient, significant others, and health care providers. Examples of interventions performed include, but are not limited to: assurance of information and supportive preoperative teaching specifically related to the surgical intervention and the operating room nursing care, identification of the patient, verification of the surgical site, verification of the operative consent and reports of essential diagnostic procedures, positioning according to physiological principles, adherence to principles of asepsis, assurance of appropriate and properly functioning equipment and supplies for the patient, provision for comfort measures and supportive care to the patient, environmental monitoring and safety, evaluation of outcomes in relation to the identified interventions, and communication of intraoperative information to significant others and the health care team to provide for continuity of care. Criteria: The plan of care reflects current nursing practice. The plan provides for continuity of care. The plan specifies nursing diagnoses, interventions necessary to achieve the outcomes, and a logical sequence of interventions. Human and materiel resources are available to implement the plan. The plan is communicated to appropriate people. The plan is documented in a retrievable form.

Implementation Standard: The perioperative nurse implements the interventions identified in the plan of care. Interpretive statement:

Interventions are consistent with the established plan of care and provide continuity of nursing care in the perioperative period.

Interventions are based on expert opinion, scientific principles and/or consensus. They reflect the rights and desires of the patient and significant others. Criteria: Interventions are consistent with the established plan of care. Implementation of the plan of care is an ongoing process and is based on the patient’s response. Interventions reflect the rights and desires of the patient and significant others. Interventions are implemented with safety, skill, and efficiency and are adjusted according to patient responses. Documentation reflects interventions provided in the perioperative period.

Evaluation Standard: The perioperative nurse evaluates the patient’s progress toward attainment of outcomes. Interpretive statement:

Evaluation is systematic and ongoing. It is based on observations and patient responses to nursing interventions; the effectiveness of interventions is evaluated in relation to the outcomes. Ongoing assessment data are used to revise diagnoses, the plan of care, andlor outcomes as needed. Revisions are documented. The patient, significant others, and health care providers are involved in the evaluation process. Criteria: Evaluation of the effectiveness of interventions is systematic and ongoing. The effectiveness of interventions is evaluated in relation to outcomes. Ongoing assessment data are used to revise diagnoses, outcome, andlor the plan of care, as needed. Revisions in diagnoses, outcomes, and/or the plan of care are documented. The patient, significant others, and health care providers are involved in the evaluation process when appropriate. Interventions are documented and communicated verbally as appropriate to promote continuity of care. 813

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Proposed Standards of Professional Per$ormance Quality of care Standard: The nurse systematically evaluates the quality of nursingpractice. Interpretive statement: The perioperative nurse will engage in the evaluation of care delivery through a systematic quality assessment/improvement process. This systematic approach will use specific steps to promote patient care quality. Criteria: The perioperative nurse participates in quality of care activities as appropriate to the individual’s position, education, and practice environment. Such activities may include: identifying and assigning responsibility for monitoring and evaluation activities, delineating the scope of patient care activities or services, identifying aspects of care, developing quality indicators for each identified aspect of care, establishing thresholds for evaluation of the quality indicators, collecting data related to the aspects of care and indicators, evaluating care based on the cumulative data collected, taking actions to improve care and/or services, assessing the effectiveness of the action(s) taken and document the outcomes, and communicating data organization-wide. Knowledge gained via the quality assessment and improvement process is used to initiate change in nursing practice. Performance appraisal Standard: The perioperative nurse evaluates his or her practice in context with professional practice standards and relevant statutes and regulations. Interpretive statement: Performance appraisal is a process that includes defining and evaluating professional practice behaviors. The perioperative nurse is responsi-

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ble for self-evaluation as well as receiving constructive feedback from health care team members. Criteria The perioperative nurse: determines the standards of practice that support the level of performance desired within the role(s) of perioperative nursing practice, assesses perioperative practice behaviors on a regular basis seeking constructive feedback, identifies areas for personal and professional development, develops and initiates an action plan to achieve professional development goals identified during the appraisal process, periodically monitors and evaluates the progress of goal achievement, and participates in peer review when appropriate.

Education Standard: The perioperative nurse acquires and maintains current knowledge in nursing practice. Interpretive statement: The purpose of professional development is to build on varied educational and experiential bases for the enhancement of perioperative nursing practice. The perioperative nurse has primary responsibility for his or her continuing education and professional development. The practice setting may provide the support needed for this development. Criteria: The perioperative nurse: completes an orientation based on individualized learning needs that have been identified for the performance description and practice setting in which the individual will perform; identifies learning needs based on performance behaviors that include critical thinking, interpersonal and technical skills; seeks experiences to meet established goals for professional development; 815

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AORV JOCRNAL

demonstrates accountability for maintaining competency within the performance description; and participates in continuing education activities relevant to professional issues and trends in perioperative nursing practice.

Collegiality Standard: The perioperative nurse contributes to the professional growth of peers, colleagues, and others. Interprethv stutement:

The perioperative nurse has an obligation to continue and advance the speciality and the profession by sharing his or her knowledge and expertise, and assisting colleagues in building and maintaining the competencies necessary to provide safe, effective care to patients. This obligation may be fulfilled informally through role modeling, acting as a resource, and mentoring, or formally by serving as a preceptor or instructor in the clinical setting. Criteria The perioperative nurse shares knowledge and skills. This is accomplished through a variety of methods including, but not limited to in-services programs, seminars and workshops, preceptoring and mentoring, role modeling in the clinical setting, publishing, participatiodservice in professional organizations, consultative services, and problem-solving or issues groups. The perioperative nurse provides peers with constructive feedback regarding their practice. Feedback may be provided through the peer review process, quality improvement activities, committee participation, and one-on-one discussions. The perioperative nurse uses appropriate communication techniques to avoid defensive responses and resistance to changing practice. The perioperative nurse contributes to a posi816

tive environment conducive to education of novice perioperative practitioners. The perioperative nurse is a role model for perioperative nursing competencies and correct implementation of policies, procedures, and protocols.

Ethics Standard: The perioperative nurse's decisions and actions on behalf of patients are determined in an ethical manner. Interpretive statement:

The basic human rights of individual patients are not forfeited when the patient enters the health care system. Care and services must be delivered without impeding these basic rights. The perioperative nurse is accountable to patients to safeguard these rights while providing appropriate nursing care or services in the perioperative setting. Nursing practice is guided by the ANA Code for Nurses With Interpretive Statements. Criteria: Patient confidentiality is maintained. The perioperative nurse acts as a patient advocate. Care is delivered in a nonjudgmental and nondiscriminatory manner that is sensitive to cultural, racial, and ethnic diversity. Care is delivered in a manner that preserves and protects patient autonomy, dignity, and rights. The perioperative nurse seeks available resources to help formulate ethical decisions.

Collaboration Standard: The perioperative nurse collaborates with the patient, significant others, health care providers, and others in providing care. Interpretive statement:

Care of the perioperative patient requires cooperative efforts from many people in order to attain optimum outcomes. The perioperative nurse demonstrates accountability, flexibility, and communication skills in collaborating for patient care. Criteria:

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AORN Proposed “Standards for Clinical Practice” and Proposed “Standards of Professional” Performance Comment Form

1 . What is your overall opinion of these standards? Please explain:

Excellent

2. Will these standards be useful in your practice setting? Yes Please explain:

Fair

Good

No

Poor

~

3. Do these standards address all major components of clinical practice and professional performance? No Yes Please explain:

4.Please comment on particular areas of concern in these standards.

5. Is the format workable and easy to understand? Yes

No

6. Are there any additional comments you wish to make to the Nursing Practice Committee?

Please complete and return this form by Nov 16, 1991 to: Nursing Practices Committee AORN, Inc 10170 East Mississippi Avenue Denver, CO, 80231 Fax # (303)755-9454 Attn: Donna Watson, RN, MS, Staff Consultant Thank you for your assistance.

Name (optional): Address: City: State:

Zip: 817

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The perioperative nurse: 0 communicates pertinent information relative to perioperative care, consults with health care providers and others, and makes referrals including provisions for continuity of care as needed.

Research Standard: The perioperative nurse uses research findings in practice. Interpretive statement: Perioperative nursing practice is supported by research. The perioperative nurse uses research to demonstrate the relationship between nursing interventions and patient outcomes. The perioperative nurse, regardless of position. education, or practice environment, participates in various aspects of the research process. Criteriu: Perioperative nurses participate in research by involvement in one or more of the following activities identifying clinical problems, participating in data collection, sharing research activities with others, reading and critiquing research for application to practice, participating on a research committee, and using knowledge gained through research activities to initiate change. Resource use Standard: The perioperative nurse considers factors related to safety, effectiveness, environmental concerns, and cost in planning and delivering patient care. Interpretii,e statement: Human and materiel resources in the perioperative setting are costly and sometimes scarce. The perioperative nurse identifies and promotes the most economical method of providing safe and effective patient care in accordance with established standards. Criterici: The perioperative nurse: evaluates factors related to safety, effec-

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tiveness, environmental concerns, and cost when two or more practice options would result in the same expected outcome, assigns tasks or delegates care based on the needs of the patient and the knowledge and skill of the provider selected, and assists the patient or significant others in identifying appropriate services available to address perioperative patient needs.

Nonprescription Drugs Could Require Prescription In a July 15, 1991, press release, the US Food and Drug Administration (FDA) proposed that all pancreatic enzyme products used to treat cystic fibrosis be sold only as prescription drugs. Currently, some of these products are sold without a prescription. Because these drugs require continuous monitoring by a physician for their safe and effective use, the FDA believes they can be monitored most effectively by making them available by prescription only. The FDA’s proposal also requires that all drugs sold to treat cystic fibrosis have an approved new drug application. The proposal is based on studies that report that the dosage, formulation, and process used to manufacture these drugs have an impact on the effectiveness of their active ingredients. This critical manufacturing data would be part of the new drug application. The FDA is urging manufacturers to comply with the proposal as soon as possible because as many as 16,000 patients rely on these drugs. Besides cystic fibrosis, pancreatic enzymes are used to treat chronic pancreatitis, post-pancreatectomy, post-gastrointestinal bypass, and other conditions.