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The Perioperative Patient Focused Model: A literature review
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The Perioperative Patient Focused Model: A Literature Review Dr Sharon Ann Van Wicklin PII: DOI: Reference:
S2405-6030(19)30021-4 https://doi.org/10.1016/j.pcorm.2019.100083 PCORM 100083
To appear in:
Perioperative Care and Operating Room Management
Received date: Revised date: Accepted date:
28 May 2019 9 December 2019 15 December 2019
Please cite this article as: Dr Sharon Ann Van Wicklin , The Perioperative Patient Focused Model: A Literature Review, Perioperative Care and Operating Room Management (2019), doi: https://doi.org/10.1016/j.pcorm.2019.100083
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
The Perioperative Patient Focused Model
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HIGHLIGHTS
The Perioperative Patient Focused Model has been established as the conceptual framework for perioperative nursing practice since 2000.
The Model is patient centered and outcome focused.
Perioperative RNs practice within the health system, and the practices implemented by perioperative RNs promote patient safety, and optimal physiological and behavioral responses.
Whether the Model is a grand or middle range theory has not been determined.
The Perioperative Patient Focused Model warrants further research testing and validation and should be applied to perioperative practice.
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The Perioperative Patient Focused Model: A Literature Review Author, Credentials
Dr Sharon Ann Van Wicklin Perioperative and Legal Nurse Consultant, 8256 South Shawnee Street, Aurora, CO 80016, United States. Phone: +1 615-260-6231 E-mail: [email protected]
ABSTRACT In 2000, the AORN Board of Directors established the Perioperative Patient Focused Model as the conceptual framework for perioperative nursing practice. Consistent with the Model, perioperative registered nurses working within the health system promote patient safety and optimal physiological and behavioral responses in perioperative patients. This literature review describes the history and development of the Perioperative Patient Focused Model, identifies key constructs and relationships among constructs of the Model, discusses the strengths and limitations of the Model, explains how the Model has been used in perioperative practice and research, examines whether the Model should be classified as a grand or middle range theory, and demonstrates use of the Model in practice and research. An important finding from this review is that there is only minimal literature demonstrating use of the Model in practice or research. The Perioperative Patient Focused Model warrants further research testing and validation and application to perioperative practice.
Key words: Perioperative Patient Focused Model, conceptual framework, grand theory, middle range theory, patient outcomes. Page 2 of 29
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1.1 INTRODUCTION The Perioperative Patient Focused Model is the conceptual framework for perioperative nursing practice.1 The Model is patient centered. A primary role of perioperative registered nurses (RNs) is to provide effective perioperative patient care and serve as the patient’s advocate. Secondary to being patient centered, the Perioperative Patient Focused Model is outcome focused.1 The care provided by perioperative RNs is directed toward achieving high quality patient outcomes. Consistent with the Perioperative Patient Focused Model, the evidence-based practices implemented by perioperative RNs working within the health system promote patient safety, and optimal physiological and behavioral responses in perioperative patients.1 The purpose of this literature review is to
describe the history and development of the Perioperative Patient Focused Model,
identify key constructs and relationships among constructs of the Model,
discuss the strengths and limitations of the Model,
explain how the Model has been used in perioperative practice and research,
examine whether the Model should be classified as a grand or middle range theory, and
demonstrate use of the Model in practice and research.
2.1 REVIEW METHODS AND FINDINGS To address the questions to be answered by the literature review, a search of the online PubMed, CINAHL, and Scopus databases, and the Cochrane Database of Systematic Reviews for published literature was conducted using the phrase, “Perioperative Patient Focused Model.”
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The reference lists from relevant articles were examined to locate additional applicable references and also searched for applicable articles written by individuals identified in the literature as experts in the field. The criteria for inclusion in the literature review were articles written in English with any discussion or application of the Perioperative Patient Focused Model. The article abstracts were reviewed for eligibility and full-text copies of all potentially eligible articles were obtained. The literature search identified only 12 articles. After removal of duplicates, and elimination of one article not published in English, only five articles remained (Figure 1). These articles included a description of how the Model was selected1; a discussion of the difficulties of determining intraoperative patient outcomes using the Model2; a personal statement on nursing and how the author implemented the Model in her personal practice,3 a report of how the Model supports the delivery of care and the association between safety and patient education in a charity medical program,4 and a survey of 857 perioperative RNs related to covering and observing prepared sterile tables.5 Only two of these articles demonstrated use of the Model in practice,3,4 and only one demonstrated use of the Model in research.5
3.1 HISTORY AND DEVELOPMENT OF THE MODEL Development of the Perioperative Patient Focused Model was initiated in 1998 by a working group selected by the AORN Board of Directors. Members of the working group were asked to review existing nursing theories and models and ascertain whether one theory or model was particularly germane to perioperative nursing. The working group conducted a literature search for relevant nursing theories and models, reviewed the various theories generated by the search,
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and compiled a list of 15 models and theories for greater in-depth exploration. These theories and models included the
American Association of Critical Care Nurses: Synergy Model6;
AORN: Data Elements Coordinating Committee Model1;
Beckwith Institute for Innovation in Patient Care: Transformational Model for Professional Practice in Health Care Organizations7;
Joyce Fitzpatrick: Life Perspective Rhythm Model8;
David John Hickson: Strategic Contingencies’ Theory of Intraorganizational Power9;
Imogene M. King: Theory of Goal Attainment and Transactional Process10;
Myra Estrin Levine: Conservation Model11;
Margaret Newman: Theory of Health as Expanding Consciousness12;
Dorothea E. Orem: Self-Care Deficit Nursing Theory13;
Ida Jean Orlando: Deliberative Nursing Process14;
Rosemarie Parse: Human Becoming Paradigm15;
Josephine E. Paterson and Loretta T. Zderad: Theory of Humanistic Nursing16;
Martha E. Rogers: Theory of Science of Unitary and Irreducible Human Beings17;
Callista Roy: Roy Adaptation Model18; and
Jean Watson: Theory of Caring Science as Sacred Science.19
The AORN Board of Directors assigned each member of the working group to review and evaluate specific theorists and models from the 15 that had been identified. The AORN librarians provided each member of the working group with multiple resources specific to their assigned theorists.1
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The working group rated each theory or model using Barnum’s Criteria for Theory Evaluation,20 a criteria used for evaluating nursing theories that discriminates between internal and external criticisms. Internal criticism evaluates the way the various concepts of a theory fit together.21 Internal criteria include clarity (ie, whether the components of the theory are clearly stated and easily understood), consistency (ie, whether the terms, definitions, interpretations, principles, and methods of the theory are constant and congruent), adequacy (ie, whether the topics addressed by the theory are sufficiently addressed), logical development (ie, whether the conclusions of the theory are reasonable and well supported), and the level of development (ie, whether the concepts of the theory are well-defined).20 External criticism explores the way a theory interacts with the existing environment.21 External criteria include reality convergence (ie, whether the assumptions of the theory reflect the real world), utility (ie, whether the theory generates researchable hypotheses), significance (ie, whether the theory addresses essential nursing issues), discrimination (ie, whether the theory differentiates between nursing activities and non-nursing activities), scope (ie, whether the range of the theory is narrow and applicable to practice or broad with global application), complexity (ie, whether the theory contains multiple complicated concepts), and marketability (ie, whether the theory is easily translated to practice).20 The working group met in February 1999, to review the 15 theories and discuss their relation to perioperative nursing. After assessing each theory rating, summary, and recommendation of the working group member who had reviewed the model or theory, the working group designated the AORN Data Elements Coordinating Committee Model, later termed the Perioperative Patient Focused Model, as the conceptual framework for perioperative nursing practice.1 The Model (Figure 2) was introduced by the Association in May 2000.
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3.1.1 Model Update In 2016, the AORN changed some of the terminology in the Model and also updated the colors and fonts used in the Model illustration (Figure 3). These revisions included
simplifying the domain of Behavioral Responses: Family & Individual to Behavioral Responses,
changing the sub-domain of Nursing Diagnoses located in the Safety, Physiological Responses, and Behavioral Responses domains to Actual or Potential Nursing Problems, and
amending the Benchmarks/Desired Outcomes, Report Cards, and Structural Elements sub-domains located in the Health System domain to Health Care Economics & Outcomes, Analytical Reporting, and Standardized Data Elements, respectively.
The AORN did not publish any explanation as to the reason for these changes; however, because the AORN perioperative nursing data set (PNDS) and AORN Guidelines are updated and revised on an ongoing basis, the AORN Board of Directors believed it was appropriate to update the Model to reflect the more current health care terminology used in the PNDS and also present an appearance that better aligned with the contemporary AORN branding style (J. Kelly, president, AORN Syntegrity, written communication, July 3, 2018).
3.1.2 Perioperative Nursing Data Set The PNDS “is the standardized nursing language developed and refined by AORN and recognized by the American Nurses Association to describe the nursing care, from preadmission to discharge, of patients undergoing operative or other invasive procedures.”22(p3) The PNDS
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enables perioperative RNs to document perioperative nursing care in a standardized manner that allows the effectiveness of perioperative nursing interventions and patient outcomes to be audited using reliable clinical data that can be collected and compared to improve practice.22 The evidence-based AORN guidelines provide the foundation of perioperative nursing knowledge, interventions, and activities to inform practice from which the PNDS is derived (Figure 4). 22
4.1 KEY CONSTRUCTS AND RELATIONSHIPS AMONG CONSTRUCTS The Perioperative Patient Focused Model depicts the relationship between the patient, patient’s family or caregivers, and the nursing care delivered by perioperative RNs.23 The icon representing the perioperative patient is located at the center of the model. As with many nursing specialties, perioperative nursing care is centered on the patient. During operative procedures when the patient is anesthetized, the perioperative RN serves an important role as the patient’s advocate and also oversees the patient’s perioperative care. Concentric circles in the Model expand beyond the patient, representing the perioperative domains and sub-domains of the Model, which further depict perioperative nursing care.23
4.1.1 Patient Safety There are four domains in the Perioperative Patient Focused Model. The three domains of Safety, Physiological Responses, and Behavioral Responses are patient-centered and embody essential elements of care for the perioperative patient.1The Health System domain focuses on the structural elements that describe the health care environment in which perioperative RNs provide patient care.
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The PNDS and Model define the domain of Safety as, “The absence of signs and symptoms of physical injury unrelated to the intended therapeutic effects of an operative or other invasive procedure.” 23(p56) During the perioperative continuum, which includes the preoperative, intraoperative, and postoperative phases of an operative procedure, perioperative RNs should provide care that protects the patient from physical injury. Using the example of patient positioning, this would include providing perioperative nursing care that helps ensure there are no signs and symptoms of patient injury caused by surgical positioning (eg, pressure injury).
4.1.2 Physiological Responses The PNDS and Model define the domain of Physiological Responses as, “The physical, biochemical, and functional responses to the intended therapeutic effects of an operative or other invasive procedure.”23(p56) Physiological responses refer to the healthy or normal responses of living organisms.24 During the perioperative continuum, perioperative RNs should provide care that maintains the patient’s physiological responses as anticipated for the individual patient. Using the example of patient positioning, this would include providing perioperative nursing care that identifies the patient’s baseline tissue perfusion status and recognizes impairments or other risk factors that may affect the physiological status of the patient before the procedure (eg, diabetes, peripheral vascular disease).
4.1.3 Behavioral Responses The PNDS and Model define the domain of Behavioral Responses as, “The psychologic, sociologic, and spiritual responses of patients and their families to the operative or other invasive procedure.”23(p56) This domain also includes the patient and family members’ knowledge about
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the procedure and perioperative experience. During the perioperative continuum, perioperative RNs should help the patient understand the perioperative process. To ensure the patient’s and patient’s family members’ psychological, sociological, and spiritual needs are met, perioperative RNs should adhere to the Code of Ethics for Nurses with Interpretive Standards25 and AORN’s Perioperative Explications for the ANA Code of Ethics for Nurses with Interpretive Statements.26 Using the example of patient positioning, this would include providing perioperative nursing care that respects the dignity and privacy of the patient during patient positioning and ensures equitable, compassionate, and optimal care without bias or intolerance.27(p675)
4.1.4 Health System The PNDS and Model define the Health System domain as, “The structural data elements that exist in the perioperative environment or health system.”23(p56) The Health System domain includes administrative concerns and structural elements.23 Using the example of patient positioning, this would include ensuring there are sufficient numbers of competent personnel to assist with the positioning process; having adequate quantities of appropriate positioning supplies; and verifying that the necessary positioning devices and equipment are clean, wellmaintained, and readily available during patient positioning activities.27(p687)
4.1.5 Patient Outcomes In addition to being patient-centered, the Perioperative Patient Focused Model is focused on patient outcomes.1,23 According to Petersen,23 nursing models and theories should encompass all aspects of the nursing process including assessment, diagnosis, outcomes identification, planning, and implementation, but should especially emphasize patient outcomes. The
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Perioperative Patient Focused Model depicts the outcomes focus of perioperative RNs with a concentric circle representing the sub-domain of Patient Outcomes positioned immediately adjacent to the three patient care domains (ie, Safety, Physiological Responses, Behavioral Responses). This is followed by two additional concentric circles expanding outward to represent the sub-domains of Nursing Diagnoses and Interventions. Perioperative RNs conduct an outcome-focused patient assessment that assists with identifying nursing diagnoses and selecting individualized nursing interventions for each patient undergoing an operative or invasive procedure. Within the health care system, perioperative RNs implement nursing interventions to help the patient attain the best outcomes possible throughout the perioperative continuum.23(p138) The inter-relationships of the four domains and sub-domains provide an illustration of perioperative care that guides nursing practice and provides opportunities for research testing and validation. Thus, the Perioperative Patient Focused Model accurately depicts the patient’s operative experience within the health system and also reflects the interdependent relationships between the three domains of nursing care provided by perioperative RNs.
5.1 STRENGTHS AND LIMITATIONS OF THE MODEL The Perioperative Patient Focused Model is simple for perioperative RNs to use to inform and enhance practice. Placing the patient icon at the center of the Model visibly depicts the concept of perioperative nursing care centered on the patient. The domains of Safety, Physiological Responses, Behavioral Responses, and the Health System portray the care provided by perioperative RNs for patients undergoing operative procedures. An additional strength of the Model is that it emphasizes an outcome-driven process. However, by suggesting that perioperative RNs consider patient outcomes before developing
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nursing diagnoses, the Model deviates from the well-established nursing process, wherein diagnoses are developed before outcomes are identified. This Model concept has not been tested; therefore, whether considering patient outcomes before developing nursing diagnoses improves the care of perioperative patients is unknown and warrants research testing and validation. The greatest strength of the Perioperative Patient Focused Model is that it was created for perioperative RNs and perioperative patients by perioperative RNs. As a result, the Model is credible, straightforward, and generalizable to all perioperative practice settings and patient populations.1 The Model is useful and relevant for perioperative RNs, administrators, educators, and researchers. A weakness of the Model may be that the nature of the Model’s theoretical concepts are descriptive rather than objective and measurable.1According to Kleinbeck and McKennett, “it is difficult at times to identify specific measurable criteria an OR [operating room] nurse might use to evaluate care delivered during a surgical procedure.”2(p845) For example, nursing interventions implemented to prevent pressure injury when positioning surgical patients include preventing “skin and tissue trauma secondary to mechanical sources including the use of devices such as positioning equipment, tourniquets, sequential compression devices, razors, clippers, tape, and the OR bed.”23(p182) It is not possible for perioperative RNs to know immediately after surgery whether these interventions were effective in preventing a pressure injury because the first manifestation of an OR-acquired pressure injury is likely to be a deep tissue injury that does not appear until 48 to 72 hours after surgery.28 As a result, it may be incorrect for the nurse to document immediately after surgery that the patient’s peripheral tissue perfusion is consistent with preoperative status.
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Having perioperative RNs identify and document intermediate steps toward achieving the specified final outcome in the Perioperative Patient-Focused Model at the end of the intraoperative phase provides a potentially effective solution to this dilemma.2 Specific patient outcomes are documented to establish that the patient benefitted from the care provided by perioperative RNs.2 Documenting achievement of an intermediate step toward the desired outcome provides evidence that perioperative RNs were aware of and responded to the information obtained through an intraoperative patient assessment performed at established intervals during the procedure. Perioperative RNs can report implementing specific intraoperative interventions to prevent pressure injury as part of the nursing assessment and documented report performed by RN circulators when the patient is discharged from the OR to the care of perianesthesia RNs in the post anesthesia care unit. One additional limitation of the Model is that it does not include criteria to distinguish the specific contribution of perioperative RNs in achieving the desired patient outcomes. For example, positioning the patient is a collaborative effort that may include the perioperative RN, surgeon, anesthesia professional, first assistant, and other perioperative team members. It may be impossible to separate the contribution of the perioperative RN from the contributions of other perioperative team members.
6.1 USE OF THE MODEL IN PRACTICE AND RESEARCH The Perioperative Patient Focused Model has been established as the model of perioperative care since 2000. Surprisingly, there is only minimal literature to demonstrate its use in practice or research.
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As a gastroenterology nurse, McCutcheon3 incorporated several theoretical models into her personal belief system, one of which is the Perioperative Patient Focused Model. The author posited that the Model’s placement of the patient as the most important element of perioperative nursing care and its focus on patient outcomes was extremely relevant to her personal practice. The author also suggested that the Model’s domains of Safety, Physiological Responses, Behavioral Responses, and Health System were applicable to her practice. When patients receive moderate sedation, as is the case during many gastroenterological procedures, patient safety is a particular concern for the nurse. The nurse must monitor and treat the patient’s physiological responses during procedures. The nurse must also assess the patient’s behavioral responses and intervene if necessary. The health system must provide adequate numbers of qualified perioperative team members for the procedure and ensure the necessary equipment is clean, functional, and available. All of these elements are necessary to ensure optimal patient outcomes. Flippin4 used the Perioperative Patient Focused Model as a framework for providing patient-centered care in a program that provided “free reconstructive plastic surgery, laser treatments, dental care, speech therapy, and related services to disadvantaged children and young people with physical deformities cause by birth defects, accidents, abuse, or disease.”(p145) The author affirmed that to achieve the best outcomes possible, the care provided by perioperative RNs must be specific to and centered on the patient and must also include comprehensive individualized patient education. The author further explained that although the domain of Safety may be assumed to be centered on intraoperative care provided by the nurse, effective preoperative patient education provided by perioperative RNs can improve patient outcomes by
ensuring correct site surgery;
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encouraging the patient’s adherence to the recommended postoperative diet, thereby reducing the potential for postoperative nausea and vomiting;
providing effective medication management, thereby reducing the patient’s postoperative pain, nausea, and vomiting, and the potential for allergic reactions;
encouraging the patient to limit or avoid specific activities, thereby reducing the patient’s postoperative fatigue and pain; and
educating the patient about the postoperative wound care plan, thereby reducing the risk of wound infection and ensuring timely recovery.
Providing effective preoperative education also encompasses the domain of Behavioral Responses by ensuring patients and their family members understand the procedure and perioperative processes related to anticipated patient responses, dietary control, medication administration, pain management, rehabilitation, and wound therapy. This author used the Model as the conceptual framework for a research project involving a survey of 857 perioperative RNs that assessed whether the knowledge and attitudes of perioperative RNs involved in operative procedures were associated with the practices of covering and observing prepared sterile tables during periods of delay or non-use.5 The Model was applicable to this research because the practices implemented by perioperative RNs during patient care are centered on the patient and are ultimately determined by the knowledge and personal attitudes of the nurse. Implementing the practice of covering prepared sterile tables during periods of delay or non-use is influenced by the role of the perioperative RN as a patient advocate and is encompassed by the domain of Safety because implementing this practice may reduce the patient’s risk for surgical site infection. The practices of covering and observing prepared sterile tables is also encompassed by the Health System domain because the practice of
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covering prepared sterile tables can increase productivity and efficiency, and decrease health care costs and the risk of postoperative infection, thereby improving patient outcomes whereas the practice of having a perioperative team member directly observe prepared sterile tables during periods of delay decreases productivity and efficiency, increases health care costs, and has not been shown to improve patient outcomes.
7.1 GRAND OR MIDDLE RANGE THEORY One reason for the relative lack of use of the Perioperative Patient Focused Model in practice and research is that the Model may be considered a grand theory. Grand theories are multifaceted and extensive. They attempt to explain comprehensive issues with the nursing discipline. According to McEwen, “Grand theories are nonspecific and are composed of relatively abstract concepts that lack operational definitions. Their propositions are also abstract and are not generally amenable to testing. Grand theories are developed through thoughtful and insightful appraisal of existing ideas as opposed to empirical research.”29(p37) Notably, of the original 15 theories and models considered by the AORN Board of Directors during selection of the Perioperative Patient Focused Model, the nine following are grand theories:
Joyce Fitzpatrick: Life Perspective Rhythm Model;
Imogene M. King: Theory of Goal Attainment and Transactional Process;
Myra Estrin Levine: Conservation Model;
Margaret Newman: Theory of Health as Expanding Consciousness;
Dorothea E. Orem: Self-Care Deficit Nursing Theory;
Rosemary Parse: Human Becoming Paradigm;
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Martha E. Rogers: Theory of Science of Unitary and Irreducible Human Beings;
Callista Roy: Roy Adaptation Model; and
Jean Watson: Theory of Caring Science as Sacred Science.30-33
The American Association of Critical Care Nurses: Synergy Model and Ida Jean Orlando: Deliberative Nursing Process are middle range theories.34 The Beckwith Institute for Innovation in Patient Care: Transformational Model for Professional Practice in Health Care Organizations and David John Hickson: Strategic Contingencies’ Theory of Intraorganizational Power are leadership and management theories.35,36 The Josephine E. Paterson and Loretta T. Zderad: Theory of Humanistic Nursing is a humanistic theory37 and the remaining model is the AORN: Data Elements Coordinating Committee Model, which became the Perioperative Patient Focused Model. The Perioperative Patient Focused Model may be better classified as a middle range theory, rather than a grand theory. The method used to determine which nursing theories are grand theories, and which are middle range theories is not completely clear. The designations are somewhat arbitrary and subjective.38A theory considered to be middle range by one nursing theorist may be considered a grand theory by another nursing theorist. Likewise, a theory considered to be grand by one theorist may be considered middle range by another.38 When compared with grand theories, middle range theories are more precise, have fewer concepts, and present a more limited view of humanity.38(p213) Middle range theories are identified by several characteristics. They have simple principle concepts; ponder a limited number of variables or concepts; emphasize patient difficulties and outcomes, along with the results of nursing interventions on patient outcomes; and they are specific to nursing, potentially specifying a practice area, patient age range, nursing intervention, or suggested outcome.23,39
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Middle range theory is more precise than grand theory, yet hypothetical enough to provide for generalization and operationalization.38 The Model is easily considered a middle range theory because its concepts are simple and limited; its focus is on patient outcomes and the effects of nursing interventions on patient outcomes, and it is specific to the perioperative area of practice. Notably, the AORN has made no statement as to whether the Model should be considered a grand or middle range theory.
8.1 APPLICATION TO PERIOPERATIVE PRACTICE AND RESEARCH The Perioperative Patient Focused Model is inordinately applicable to perioperative practice and can be applied to many different areas of perioperative nursing practice. The simplicity of its application can be verified using the domain of Safety and the example of patient positioning. Perioperative RNs first select safe patient outcomes related to patient positioning. The expected outcome is that there will be no signs or symptoms of patient injury caused by positioning.23 Using the PNDS, perioperative RNs may select additional, more specific patient outcomes associated with the respiratory system (eg, the patient will breathe effectively), the cardiovascular system (eg, the patient’s cardiac output will improve or have no reduction from preoperative status), the neuromuscular system (eg, the patient’s abduction, flexion, or extension of the extremities will improve or have no reduction from preoperative status), and the integumentary system (eg, the patient’s pressure points will show no signs or symptoms of pressure injury). Based on a preoperative assessment of the patient and the planned surgical procedure, perioperative RNs determine the actual or potential nursing diagnoses (eg, risk for neuromuscular injury caused by surgical positioning), and then implement nursing interventions for preventing injury to the neuromuscular system and safely positioning the patient. These
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interventions may include ensuring correct alignment of the patient’s body, and avoiding compression, pressure, stretching, and hyperextension. To prevent positioning injury, perioperative RNs anticipate and obtain the necessary positioning equipment, coordinate patient transfer and positioning actions with the surgical team, apply effective body mechanics and ergonomic principles, provide an ongoing assessment of the patient’s integumentary, musculoskeletal, respiratory, circulatory, and neurological systems, and attend to the patient’s safety and comfort throughout the perioperative continuum. By adhering to the evidence-based practices recommended in the AORN Guideline for Positioning the Patient,27 perioperative RNs can reduce the risk of patient harm and improve patient outcomes associated with surgical positioning. To prevent injury to both patients and perioperative personnel, positioning the patient is a task that must be performed safely and correctly. The concepts of the Perioperative Patient Focused Model are thus applicable not only to the task of positioning surgical patients, but to all tasks associated with perioperative nursing practice. The Perioperative Patient Focused Model is exceedingly applicable to perioperative research. Since the Model provides the conceptual framework for perioperative nursing practice it can be applied to almost all areas of perioperative nursing research. Perioperative RNs practice within the health system, and the evidence-based practices implemented by perioperative RNs promote patient safety, and optimal physiological and behavioral responses.
9.1 CONCLUSIONS This literature review has described the history and development of the Perioperative Patient Focused Model, identified key constructs and relationships among constructs of the Model, discussed the strengths and limitations of the Model, explained how the Model has been used in
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perioperative practice and research, examined whether the Model should be classified as a grand or middle range theory, and demonstrated how the Model can be applied in practice and research. An important finding from this review is that there is only minimal literature demonstrating use of the Model in practice or research. As the established model of perioperative care, the Perioperative Patient Focused Model warrants further research testing and validation and should be applied to perioperative practice.
Notes: PubMed is a registered trademark of the US National Library of Medicine, Bethesda, MD. CINAHL is a registered trademark of EBSCO Industries, Birmingham, AL. SCOPUS is a registered trademark of Elsevier BV, Amsterdam, Netherlands.
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REFERENCES 1. Rothrock JC, Smith DA. Selecting the perioperative patient focused model. AORN J. 2000;71(3):1030-1037. 2. Kleinbeck SVM, McKennett M. Challenges of measuring intraoperative patient outcomes. AORN J. 2000;72(5):845-853. 3. McCutcheon T. Statement on nursing: a personal perspective. Gastroenterol Nurs. 2004;27(5):226-229. 4. Flippin CI. Patient safety through patient education in a charity medical program. Plast Surg Nurs. 2006;26(3):145-148. 5. Van Wicklin SA. Are knowledge and attitudes of perioperative registered nurses associated with the practices of covering and monitoring sterile tables? Perioperative Care Operating Room Manage. 2018;12:16-25. 6. American Association of Critical Care Nurses. AACN Synergy Model for Patient Care. https://www.aacn.org/nursing-excellence/aacn-standards/synergy-model. Accessed December 9, 2019. 7. Wolf G, Aukerman M, Boland S. The Transformational Model for Professional Practice in Health Care Organizations. Pittsburg, PA: The Beckwith Institute for Innovation in Nursing; 1995. 8. Fitzpatrick JJ. A life perspective rhythm model. In: Fitzpatrick JJ, Whall AL, eds. Conceptual Models of Nursing, 2nd ed. Norwalk, CT: Appleton Lange; 1989: 295–302.
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9. Hickson DJ, Hinings CR, Lee CA, Schneck RE, Pennings JM. A strategic contingencies' theory of intraorganizational power. Admin Sci Q. 1971;16(2): 216-229. doi: 10.2307/2391831 10. King IM. A theory of goal attainment: philosophical and ethical implications. Nurs Sci Q. 1999; 12(4):292-296. doi: 10.1177/08943189922107205 11. Gonzalo A. Myra Estrin Levine: The Conservation Model of Nursing. Nurseslabs.com Web site. https://nurseslabs.com/myra-estrin-levine-the-conservation-model-of-nursing/. Published August 22, 2019. Accessed December 9, 2019. 12. Petiprin A. Health as expanding consciousness. Nursing-theory.org Web site. https://nursingtheory.org/theories-and-models/newman-health-as-expanding-consciousness.php. Published 2016. Accessed December 9, 2019. 13. Gonzalo A. Dorothea Orem: Self-care deficit theory. Nurseslabs.com Web site. https://nurseslabs.com/dorothea-orems-self-care-theory/. Published August 12, 2014. Accessed December 9, 2019. 14. Gonzalo A. Ida Jean Orlando: Deliberative Nursing Process Theory. Nurseslabs.com Web site. https://nurseslabs.com/ida-jean-orlandos-deliberative-nursing-process-theory/. Published October 21, 2014. Accessed December 9, 2019. 15. Parse RR. Human becoming: Parse’s theory of nursing. Nurs Sci Q. 1992;5(1):45-42. doi: 10.1177/089431849200500109 16. Paterson J, Zderad LT. Humanistic Nursing. New York, NY: National League for Nursing; 1988. 17. Gonzalo A. Martha Rogers: Science of Unitary Human Beings. Nurseslabs.com Web site.
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https://nurseslabs.com/martha-e-rogers-theory-unitary-human-beings/. Published September 9, 2014. Accessed December 9, 2019. 18. Gonzalo A. Sister Callista Roy: Adaptation Model of Nursing. Nurseslabs.com Web site. https://nurseslabs.com/sister-callista-roys-adaptation-model/. Published August 19, 2014. Accessed December 9, 2019. 19. Watson JW. Caring Science as Sacred Science. Philadelphia, PA: FA Davis Company; 2005. 20. Barnum BJS. Nursing Theory: Analysis, Application, Evaluation. 3rd ed. Glenview, IL: Scott, Foresman/Little, Brown; 1990. Cited by McEwen M. Theory analysis and evaluation. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:95-113. 21. McEwen M. Theory analysis and evaluation. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:95-113. 22. AORN, Inc. Introduction to the 2018 edition. In: Conner R, ed. Guidelines for Perioperative Practice. 2018. Denver, CO: AORN, Inc; 2018:1-6. 23. Petersen C, ed. Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. 3rd ed. Denver, CO: AORN, Inc; 2011. 24. Physiological. Merriam-Webster’s online dictionary. https://www.merriamwebster.com/dictionary/physiological. 2019. Accessed March 17, 2019. 25. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. 2nd ed. Silver Spring, MD: ANA; 2015. 26. Schroeter K, Flowers J, Davidson J, Van Wicklin SA. AORN’s Perioperative Explications for the ANA Code of Ethics for Nurses with Interpretive Statements. Denver, CO: AORN, Inc; 2017.
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27. Van Wicklin SA. Guideline for positioning the patient. In Conner R, ed. Guidelines for Perioperative Practice. 2018. Denver, CO: AORN, Inc; 2018:673-743. 28. National Pressure Ulcer Advisory Panel. NPAUP pressure injury stages. 2016. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injurystages/. Accessed March 17, 2019. 29. McEwen M. Overview of theory in nursing. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:23-48. 30. Wills EM. Grand nursing theories based on human needs. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014: 131-158. 31. Wills EM. Grand nursing theories based on interactive process. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:159-191. 32. Wills EM. Grand nursing theories based on unitary process. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:192-212. 33. Fitzpatrick J. Life perspective rhythm model. Nursing Theories: A Companion to Nursing Theories and Models. 2011. http://currentnursing.com/theory/Rhythm_Model_Fitzpatrick.html. Accessed March 17, 2019. 34. McEwen M. Overview of selected middle range theories. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:229257.
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35. Obertleitner MG. Theories, models, and frameworks from leadership and management. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:354-385. 36. Hickson DJ. Strategic contingencies theory. 2016. http://www.leadershipcentral.com/strategic-contingencies-theory.html#axzz5KPPrOuaF. Accessed March 17, 2019. 37. Paterson & Zderad: Humanistic nursing. (n.d.). Paterson and Zderad theory overview. https://humanisticnursing.weebly.com/the-theory.html. Accessed March 17, 2019. 38. McEwen M. Introduction to middle range nursing theories. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:213228. 39. Meleis LC. Theoretical Nursing: Development and Progress. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2012. Cited by McEwen M. Introduction to middle range nursing theories. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:213-228.
Funding. This literature review did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.
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Additional records identified (n = 1)
PubMed = 4 CINAHL = 4 Cochrane Database of Systematic Reviews = 0 Scopus = 3
Results after duplicates removed (n = 6)
Duplicates removed (n= 6)
Screening
Records screened (n = 5)
Records excluded (n = 1)
Eligibility
Records including duplicates (n = 12)
Full-text reports obtained (n = 5)
Full-text reports excluded (n = 0)
Included
Identification
Records identified through database search (n = 11)
Full-text reports included in literature review (n = 5)
Figure 1. Flow Diagram of Literature Search Results. Adapted from Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement, by D. Moher, A. Liberati, J. Tetzlaff, D. G. Atman and The PRISMA Group, 2009, PLoS Medicine, 6(6), e1000097. Page 26 of 29
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Figure 2. Perioperative Patient Focused Model (2000). Reprinted with permission from Guidelines for Perioperative Practice. Copyright © 2016, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.
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Figure 3. Perioperative Patient Focused Model (2017). Reprinted with permission from Guidelines for Perioperative Practice. Copyright © 2018, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.
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Figure 4. Perioperative RNs use the PNDS language to document the care provided. Nursing diagnoses, interventions, and outcomes are coded using PNDS. Coding allows for consistent measurement and analysis in quality or research reporting; thus, providing the evidence to establish guidelines that provide recommendations for interventions and activities implemented by perioperative RNs. PNDS = perioperative nursing data set. Adapted from Petersen C, ed. Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. 3rd ed. Denver, CO: AORN, Inc; 2011.
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The Perioperative Patient Focused Model: A Literature Review Dr Sharon Ann Van Wicklin PII: DOI: Reference:
S2405-6030(19)30021-4 https://doi.org/10.1016/j.pcorm.2019.100083 PCORM 100083
To appear in:
Perioperative Care and Operating Room Management
Received date: Revised date: Accepted date:
28 May 2019 9 December 2019 15 December 2019
Please cite this article as: Dr Sharon Ann Van Wicklin , The Perioperative Patient Focused Model: A Literature Review, Perioperative Care and Operating Room Management (2019), doi: https://doi.org/10.1016/j.pcorm.2019.100083
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
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HIGHLIGHTS
The Perioperative Patient Focused Model has been established as the conceptual framework for perioperative nursing practice since 2000.
The Model is patient centered and outcome focused.
Perioperative RNs practice within the health system, and the practices implemented by perioperative RNs promote patient safety, and optimal physiological and behavioral responses.
Whether the Model is a grand or middle range theory has not been determined.
The Perioperative Patient Focused Model warrants further research testing and validation and should be applied to perioperative practice.
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The Perioperative Patient Focused Model: A Literature Review Author, Credentials
Dr Sharon Ann Van Wicklin Perioperative and Legal Nurse Consultant, 8256 South Shawnee Street, Aurora, CO 80016, United States. Phone: +1 615-260-6231 E-mail: [email protected]
ABSTRACT In 2000, the AORN Board of Directors established the Perioperative Patient Focused Model as the conceptual framework for perioperative nursing practice. Consistent with the Model, perioperative registered nurses working within the health system promote patient safety and optimal physiological and behavioral responses in perioperative patients. This literature review describes the history and development of the Perioperative Patient Focused Model, identifies key constructs and relationships among constructs of the Model, discusses the strengths and limitations of the Model, explains how the Model has been used in perioperative practice and research, examines whether the Model should be classified as a grand or middle range theory, and demonstrates use of the Model in practice and research. An important finding from this review is that there is only minimal literature demonstrating use of the Model in practice or research. The Perioperative Patient Focused Model warrants further research testing and validation and application to perioperative practice.
Key words: Perioperative Patient Focused Model, conceptual framework, grand theory, middle range theory, patient outcomes. Page 2 of 29
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1.1 INTRODUCTION The Perioperative Patient Focused Model is the conceptual framework for perioperative nursing practice.1 The Model is patient centered. A primary role of perioperative registered nurses (RNs) is to provide effective perioperative patient care and serve as the patient’s advocate. Secondary to being patient centered, the Perioperative Patient Focused Model is outcome focused.1 The care provided by perioperative RNs is directed toward achieving high quality patient outcomes. Consistent with the Perioperative Patient Focused Model, the evidence-based practices implemented by perioperative RNs working within the health system promote patient safety, and optimal physiological and behavioral responses in perioperative patients.1 The purpose of this literature review is to
describe the history and development of the Perioperative Patient Focused Model,
identify key constructs and relationships among constructs of the Model,
discuss the strengths and limitations of the Model,
explain how the Model has been used in perioperative practice and research,
examine whether the Model should be classified as a grand or middle range theory, and
demonstrate use of the Model in practice and research.
2.1 REVIEW METHODS AND FINDINGS To address the questions to be answered by the literature review, a search of the online PubMed, CINAHL, and Scopus databases, and the Cochrane Database of Systematic Reviews for published literature was conducted using the phrase, “Perioperative Patient Focused Model.”
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The reference lists from relevant articles were examined to locate additional applicable references and also searched for applicable articles written by individuals identified in the literature as experts in the field. The criteria for inclusion in the literature review were articles written in English with any discussion or application of the Perioperative Patient Focused Model. The article abstracts were reviewed for eligibility and full-text copies of all potentially eligible articles were obtained. The literature search identified only 12 articles. After removal of duplicates, and elimination of one article not published in English, only five articles remained (Figure 1). These articles included a description of how the Model was selected1; a discussion of the difficulties of determining intraoperative patient outcomes using the Model2; a personal statement on nursing and how the author implemented the Model in her personal practice,3 a report of how the Model supports the delivery of care and the association between safety and patient education in a charity medical program,4 and a survey of 857 perioperative RNs related to covering and observing prepared sterile tables.5 Only two of these articles demonstrated use of the Model in practice,3,4 and only one demonstrated use of the Model in research.5
3.1 HISTORY AND DEVELOPMENT OF THE MODEL Development of the Perioperative Patient Focused Model was initiated in 1998 by a working group selected by the AORN Board of Directors. Members of the working group were asked to review existing nursing theories and models and ascertain whether one theory or model was particularly germane to perioperative nursing. The working group conducted a literature search for relevant nursing theories and models, reviewed the various theories generated by the search,
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and compiled a list of 15 models and theories for greater in-depth exploration. These theories and models included the
American Association of Critical Care Nurses: Synergy Model6;
AORN: Data Elements Coordinating Committee Model1;
Beckwith Institute for Innovation in Patient Care: Transformational Model for Professional Practice in Health Care Organizations7;
Joyce Fitzpatrick: Life Perspective Rhythm Model8;
David John Hickson: Strategic Contingencies’ Theory of Intraorganizational Power9;
Imogene M. King: Theory of Goal Attainment and Transactional Process10;
Myra Estrin Levine: Conservation Model11;
Margaret Newman: Theory of Health as Expanding Consciousness12;
Dorothea E. Orem: Self-Care Deficit Nursing Theory13;
Ida Jean Orlando: Deliberative Nursing Process14;
Rosemarie Parse: Human Becoming Paradigm15;
Josephine E. Paterson and Loretta T. Zderad: Theory of Humanistic Nursing16;
Martha E. Rogers: Theory of Science of Unitary and Irreducible Human Beings17;
Callista Roy: Roy Adaptation Model18; and
Jean Watson: Theory of Caring Science as Sacred Science.19
The AORN Board of Directors assigned each member of the working group to review and evaluate specific theorists and models from the 15 that had been identified. The AORN librarians provided each member of the working group with multiple resources specific to their assigned theorists.1
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The working group rated each theory or model using Barnum’s Criteria for Theory Evaluation,20 a criteria used for evaluating nursing theories that discriminates between internal and external criticisms. Internal criticism evaluates the way the various concepts of a theory fit together.21 Internal criteria include clarity (ie, whether the components of the theory are clearly stated and easily understood), consistency (ie, whether the terms, definitions, interpretations, principles, and methods of the theory are constant and congruent), adequacy (ie, whether the topics addressed by the theory are sufficiently addressed), logical development (ie, whether the conclusions of the theory are reasonable and well supported), and the level of development (ie, whether the concepts of the theory are well-defined).20 External criticism explores the way a theory interacts with the existing environment.21 External criteria include reality convergence (ie, whether the assumptions of the theory reflect the real world), utility (ie, whether the theory generates researchable hypotheses), significance (ie, whether the theory addresses essential nursing issues), discrimination (ie, whether the theory differentiates between nursing activities and non-nursing activities), scope (ie, whether the range of the theory is narrow and applicable to practice or broad with global application), complexity (ie, whether the theory contains multiple complicated concepts), and marketability (ie, whether the theory is easily translated to practice).20 The working group met in February 1999, to review the 15 theories and discuss their relation to perioperative nursing. After assessing each theory rating, summary, and recommendation of the working group member who had reviewed the model or theory, the working group designated the AORN Data Elements Coordinating Committee Model, later termed the Perioperative Patient Focused Model, as the conceptual framework for perioperative nursing practice.1 The Model (Figure 2) was introduced by the Association in May 2000.
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3.1.1 Model Update In 2016, the AORN changed some of the terminology in the Model and also updated the colors and fonts used in the Model illustration (Figure 3). These revisions included
simplifying the domain of Behavioral Responses: Family & Individual to Behavioral Responses,
changing the sub-domain of Nursing Diagnoses located in the Safety, Physiological Responses, and Behavioral Responses domains to Actual or Potential Nursing Problems, and
amending the Benchmarks/Desired Outcomes, Report Cards, and Structural Elements sub-domains located in the Health System domain to Health Care Economics & Outcomes, Analytical Reporting, and Standardized Data Elements, respectively.
The AORN did not publish any explanation as to the reason for these changes; however, because the AORN perioperative nursing data set (PNDS) and AORN Guidelines are updated and revised on an ongoing basis, the AORN Board of Directors believed it was appropriate to update the Model to reflect the more current health care terminology used in the PNDS and also present an appearance that better aligned with the contemporary AORN branding style (J. Kelly, president, AORN Syntegrity, written communication, July 3, 2018).
3.1.2 Perioperative Nursing Data Set The PNDS “is the standardized nursing language developed and refined by AORN and recognized by the American Nurses Association to describe the nursing care, from preadmission to discharge, of patients undergoing operative or other invasive procedures.”22(p3) The PNDS
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enables perioperative RNs to document perioperative nursing care in a standardized manner that allows the effectiveness of perioperative nursing interventions and patient outcomes to be audited using reliable clinical data that can be collected and compared to improve practice.22 The evidence-based AORN guidelines provide the foundation of perioperative nursing knowledge, interventions, and activities to inform practice from which the PNDS is derived (Figure 4). 22
4.1 KEY CONSTRUCTS AND RELATIONSHIPS AMONG CONSTRUCTS The Perioperative Patient Focused Model depicts the relationship between the patient, patient’s family or caregivers, and the nursing care delivered by perioperative RNs.23 The icon representing the perioperative patient is located at the center of the model. As with many nursing specialties, perioperative nursing care is centered on the patient. During operative procedures when the patient is anesthetized, the perioperative RN serves an important role as the patient’s advocate and also oversees the patient’s perioperative care. Concentric circles in the Model expand beyond the patient, representing the perioperative domains and sub-domains of the Model, which further depict perioperative nursing care.23
4.1.1 Patient Safety There are four domains in the Perioperative Patient Focused Model. The three domains of Safety, Physiological Responses, and Behavioral Responses are patient-centered and embody essential elements of care for the perioperative patient.1The Health System domain focuses on the structural elements that describe the health care environment in which perioperative RNs provide patient care.
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The PNDS and Model define the domain of Safety as, “The absence of signs and symptoms of physical injury unrelated to the intended therapeutic effects of an operative or other invasive procedure.” 23(p56) During the perioperative continuum, which includes the preoperative, intraoperative, and postoperative phases of an operative procedure, perioperative RNs should provide care that protects the patient from physical injury. Using the example of patient positioning, this would include providing perioperative nursing care that helps ensure there are no signs and symptoms of patient injury caused by surgical positioning (eg, pressure injury).
4.1.2 Physiological Responses The PNDS and Model define the domain of Physiological Responses as, “The physical, biochemical, and functional responses to the intended therapeutic effects of an operative or other invasive procedure.”23(p56) Physiological responses refer to the healthy or normal responses of living organisms.24 During the perioperative continuum, perioperative RNs should provide care that maintains the patient’s physiological responses as anticipated for the individual patient. Using the example of patient positioning, this would include providing perioperative nursing care that identifies the patient’s baseline tissue perfusion status and recognizes impairments or other risk factors that may affect the physiological status of the patient before the procedure (eg, diabetes, peripheral vascular disease).
4.1.3 Behavioral Responses The PNDS and Model define the domain of Behavioral Responses as, “The psychologic, sociologic, and spiritual responses of patients and their families to the operative or other invasive procedure.”23(p56) This domain also includes the patient and family members’ knowledge about
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the procedure and perioperative experience. During the perioperative continuum, perioperative RNs should help the patient understand the perioperative process. To ensure the patient’s and patient’s family members’ psychological, sociological, and spiritual needs are met, perioperative RNs should adhere to the Code of Ethics for Nurses with Interpretive Standards25 and AORN’s Perioperative Explications for the ANA Code of Ethics for Nurses with Interpretive Statements.26 Using the example of patient positioning, this would include providing perioperative nursing care that respects the dignity and privacy of the patient during patient positioning and ensures equitable, compassionate, and optimal care without bias or intolerance.27(p675)
4.1.4 Health System The PNDS and Model define the Health System domain as, “The structural data elements that exist in the perioperative environment or health system.”23(p56) The Health System domain includes administrative concerns and structural elements.23 Using the example of patient positioning, this would include ensuring there are sufficient numbers of competent personnel to assist with the positioning process; having adequate quantities of appropriate positioning supplies; and verifying that the necessary positioning devices and equipment are clean, wellmaintained, and readily available during patient positioning activities.27(p687)
4.1.5 Patient Outcomes In addition to being patient-centered, the Perioperative Patient Focused Model is focused on patient outcomes.1,23 According to Petersen,23 nursing models and theories should encompass all aspects of the nursing process including assessment, diagnosis, outcomes identification, planning, and implementation, but should especially emphasize patient outcomes. The
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Perioperative Patient Focused Model depicts the outcomes focus of perioperative RNs with a concentric circle representing the sub-domain of Patient Outcomes positioned immediately adjacent to the three patient care domains (ie, Safety, Physiological Responses, Behavioral Responses). This is followed by two additional concentric circles expanding outward to represent the sub-domains of Nursing Diagnoses and Interventions. Perioperative RNs conduct an outcome-focused patient assessment that assists with identifying nursing diagnoses and selecting individualized nursing interventions for each patient undergoing an operative or invasive procedure. Within the health care system, perioperative RNs implement nursing interventions to help the patient attain the best outcomes possible throughout the perioperative continuum.23(p138) The inter-relationships of the four domains and sub-domains provide an illustration of perioperative care that guides nursing practice and provides opportunities for research testing and validation. Thus, the Perioperative Patient Focused Model accurately depicts the patient’s operative experience within the health system and also reflects the interdependent relationships between the three domains of nursing care provided by perioperative RNs.
5.1 STRENGTHS AND LIMITATIONS OF THE MODEL The Perioperative Patient Focused Model is simple for perioperative RNs to use to inform and enhance practice. Placing the patient icon at the center of the Model visibly depicts the concept of perioperative nursing care centered on the patient. The domains of Safety, Physiological Responses, Behavioral Responses, and the Health System portray the care provided by perioperative RNs for patients undergoing operative procedures. An additional strength of the Model is that it emphasizes an outcome-driven process. However, by suggesting that perioperative RNs consider patient outcomes before developing
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nursing diagnoses, the Model deviates from the well-established nursing process, wherein diagnoses are developed before outcomes are identified. This Model concept has not been tested; therefore, whether considering patient outcomes before developing nursing diagnoses improves the care of perioperative patients is unknown and warrants research testing and validation. The greatest strength of the Perioperative Patient Focused Model is that it was created for perioperative RNs and perioperative patients by perioperative RNs. As a result, the Model is credible, straightforward, and generalizable to all perioperative practice settings and patient populations.1 The Model is useful and relevant for perioperative RNs, administrators, educators, and researchers. A weakness of the Model may be that the nature of the Model’s theoretical concepts are descriptive rather than objective and measurable.1According to Kleinbeck and McKennett, “it is difficult at times to identify specific measurable criteria an OR [operating room] nurse might use to evaluate care delivered during a surgical procedure.”2(p845) For example, nursing interventions implemented to prevent pressure injury when positioning surgical patients include preventing “skin and tissue trauma secondary to mechanical sources including the use of devices such as positioning equipment, tourniquets, sequential compression devices, razors, clippers, tape, and the OR bed.”23(p182) It is not possible for perioperative RNs to know immediately after surgery whether these interventions were effective in preventing a pressure injury because the first manifestation of an OR-acquired pressure injury is likely to be a deep tissue injury that does not appear until 48 to 72 hours after surgery.28 As a result, it may be incorrect for the nurse to document immediately after surgery that the patient’s peripheral tissue perfusion is consistent with preoperative status.
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Having perioperative RNs identify and document intermediate steps toward achieving the specified final outcome in the Perioperative Patient-Focused Model at the end of the intraoperative phase provides a potentially effective solution to this dilemma.2 Specific patient outcomes are documented to establish that the patient benefitted from the care provided by perioperative RNs.2 Documenting achievement of an intermediate step toward the desired outcome provides evidence that perioperative RNs were aware of and responded to the information obtained through an intraoperative patient assessment performed at established intervals during the procedure. Perioperative RNs can report implementing specific intraoperative interventions to prevent pressure injury as part of the nursing assessment and documented report performed by RN circulators when the patient is discharged from the OR to the care of perianesthesia RNs in the post anesthesia care unit. One additional limitation of the Model is that it does not include criteria to distinguish the specific contribution of perioperative RNs in achieving the desired patient outcomes. For example, positioning the patient is a collaborative effort that may include the perioperative RN, surgeon, anesthesia professional, first assistant, and other perioperative team members. It may be impossible to separate the contribution of the perioperative RN from the contributions of other perioperative team members.
6.1 USE OF THE MODEL IN PRACTICE AND RESEARCH The Perioperative Patient Focused Model has been established as the model of perioperative care since 2000. Surprisingly, there is only minimal literature to demonstrate its use in practice or research.
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As a gastroenterology nurse, McCutcheon3 incorporated several theoretical models into her personal belief system, one of which is the Perioperative Patient Focused Model. The author posited that the Model’s placement of the patient as the most important element of perioperative nursing care and its focus on patient outcomes was extremely relevant to her personal practice. The author also suggested that the Model’s domains of Safety, Physiological Responses, Behavioral Responses, and Health System were applicable to her practice. When patients receive moderate sedation, as is the case during many gastroenterological procedures, patient safety is a particular concern for the nurse. The nurse must monitor and treat the patient’s physiological responses during procedures. The nurse must also assess the patient’s behavioral responses and intervene if necessary. The health system must provide adequate numbers of qualified perioperative team members for the procedure and ensure the necessary equipment is clean, functional, and available. All of these elements are necessary to ensure optimal patient outcomes. Flippin4 used the Perioperative Patient Focused Model as a framework for providing patient-centered care in a program that provided “free reconstructive plastic surgery, laser treatments, dental care, speech therapy, and related services to disadvantaged children and young people with physical deformities cause by birth defects, accidents, abuse, or disease.”(p145) The author affirmed that to achieve the best outcomes possible, the care provided by perioperative RNs must be specific to and centered on the patient and must also include comprehensive individualized patient education. The author further explained that although the domain of Safety may be assumed to be centered on intraoperative care provided by the nurse, effective preoperative patient education provided by perioperative RNs can improve patient outcomes by
ensuring correct site surgery;
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encouraging the patient’s adherence to the recommended postoperative diet, thereby reducing the potential for postoperative nausea and vomiting;
providing effective medication management, thereby reducing the patient’s postoperative pain, nausea, and vomiting, and the potential for allergic reactions;
encouraging the patient to limit or avoid specific activities, thereby reducing the patient’s postoperative fatigue and pain; and
educating the patient about the postoperative wound care plan, thereby reducing the risk of wound infection and ensuring timely recovery.
Providing effective preoperative education also encompasses the domain of Behavioral Responses by ensuring patients and their family members understand the procedure and perioperative processes related to anticipated patient responses, dietary control, medication administration, pain management, rehabilitation, and wound therapy. This author used the Model as the conceptual framework for a research project involving a survey of 857 perioperative RNs that assessed whether the knowledge and attitudes of perioperative RNs involved in operative procedures were associated with the practices of covering and observing prepared sterile tables during periods of delay or non-use.5 The Model was applicable to this research because the practices implemented by perioperative RNs during patient care are centered on the patient and are ultimately determined by the knowledge and personal attitudes of the nurse. Implementing the practice of covering prepared sterile tables during periods of delay or non-use is influenced by the role of the perioperative RN as a patient advocate and is encompassed by the domain of Safety because implementing this practice may reduce the patient’s risk for surgical site infection. The practices of covering and observing prepared sterile tables is also encompassed by the Health System domain because the practice of
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covering prepared sterile tables can increase productivity and efficiency, and decrease health care costs and the risk of postoperative infection, thereby improving patient outcomes whereas the practice of having a perioperative team member directly observe prepared sterile tables during periods of delay decreases productivity and efficiency, increases health care costs, and has not been shown to improve patient outcomes.
7.1 GRAND OR MIDDLE RANGE THEORY One reason for the relative lack of use of the Perioperative Patient Focused Model in practice and research is that the Model may be considered a grand theory. Grand theories are multifaceted and extensive. They attempt to explain comprehensive issues with the nursing discipline. According to McEwen, “Grand theories are nonspecific and are composed of relatively abstract concepts that lack operational definitions. Their propositions are also abstract and are not generally amenable to testing. Grand theories are developed through thoughtful and insightful appraisal of existing ideas as opposed to empirical research.”29(p37) Notably, of the original 15 theories and models considered by the AORN Board of Directors during selection of the Perioperative Patient Focused Model, the nine following are grand theories:
Joyce Fitzpatrick: Life Perspective Rhythm Model;
Imogene M. King: Theory of Goal Attainment and Transactional Process;
Myra Estrin Levine: Conservation Model;
Margaret Newman: Theory of Health as Expanding Consciousness;
Dorothea E. Orem: Self-Care Deficit Nursing Theory;
Rosemary Parse: Human Becoming Paradigm;
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Martha E. Rogers: Theory of Science of Unitary and Irreducible Human Beings;
Callista Roy: Roy Adaptation Model; and
Jean Watson: Theory of Caring Science as Sacred Science.30-33
The American Association of Critical Care Nurses: Synergy Model and Ida Jean Orlando: Deliberative Nursing Process are middle range theories.34 The Beckwith Institute for Innovation in Patient Care: Transformational Model for Professional Practice in Health Care Organizations and David John Hickson: Strategic Contingencies’ Theory of Intraorganizational Power are leadership and management theories.35,36 The Josephine E. Paterson and Loretta T. Zderad: Theory of Humanistic Nursing is a humanistic theory37 and the remaining model is the AORN: Data Elements Coordinating Committee Model, which became the Perioperative Patient Focused Model. The Perioperative Patient Focused Model may be better classified as a middle range theory, rather than a grand theory. The method used to determine which nursing theories are grand theories, and which are middle range theories is not completely clear. The designations are somewhat arbitrary and subjective.38A theory considered to be middle range by one nursing theorist may be considered a grand theory by another nursing theorist. Likewise, a theory considered to be grand by one theorist may be considered middle range by another.38 When compared with grand theories, middle range theories are more precise, have fewer concepts, and present a more limited view of humanity.38(p213) Middle range theories are identified by several characteristics. They have simple principle concepts; ponder a limited number of variables or concepts; emphasize patient difficulties and outcomes, along with the results of nursing interventions on patient outcomes; and they are specific to nursing, potentially specifying a practice area, patient age range, nursing intervention, or suggested outcome.23,39
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Middle range theory is more precise than grand theory, yet hypothetical enough to provide for generalization and operationalization.38 The Model is easily considered a middle range theory because its concepts are simple and limited; its focus is on patient outcomes and the effects of nursing interventions on patient outcomes, and it is specific to the perioperative area of practice. Notably, the AORN has made no statement as to whether the Model should be considered a grand or middle range theory.
8.1 APPLICATION TO PERIOPERATIVE PRACTICE AND RESEARCH The Perioperative Patient Focused Model is inordinately applicable to perioperative practice and can be applied to many different areas of perioperative nursing practice. The simplicity of its application can be verified using the domain of Safety and the example of patient positioning. Perioperative RNs first select safe patient outcomes related to patient positioning. The expected outcome is that there will be no signs or symptoms of patient injury caused by positioning.23 Using the PNDS, perioperative RNs may select additional, more specific patient outcomes associated with the respiratory system (eg, the patient will breathe effectively), the cardiovascular system (eg, the patient’s cardiac output will improve or have no reduction from preoperative status), the neuromuscular system (eg, the patient’s abduction, flexion, or extension of the extremities will improve or have no reduction from preoperative status), and the integumentary system (eg, the patient’s pressure points will show no signs or symptoms of pressure injury). Based on a preoperative assessment of the patient and the planned surgical procedure, perioperative RNs determine the actual or potential nursing diagnoses (eg, risk for neuromuscular injury caused by surgical positioning), and then implement nursing interventions for preventing injury to the neuromuscular system and safely positioning the patient. These
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interventions may include ensuring correct alignment of the patient’s body, and avoiding compression, pressure, stretching, and hyperextension. To prevent positioning injury, perioperative RNs anticipate and obtain the necessary positioning equipment, coordinate patient transfer and positioning actions with the surgical team, apply effective body mechanics and ergonomic principles, provide an ongoing assessment of the patient’s integumentary, musculoskeletal, respiratory, circulatory, and neurological systems, and attend to the patient’s safety and comfort throughout the perioperative continuum. By adhering to the evidence-based practices recommended in the AORN Guideline for Positioning the Patient,27 perioperative RNs can reduce the risk of patient harm and improve patient outcomes associated with surgical positioning. To prevent injury to both patients and perioperative personnel, positioning the patient is a task that must be performed safely and correctly. The concepts of the Perioperative Patient Focused Model are thus applicable not only to the task of positioning surgical patients, but to all tasks associated with perioperative nursing practice. The Perioperative Patient Focused Model is exceedingly applicable to perioperative research. Since the Model provides the conceptual framework for perioperative nursing practice it can be applied to almost all areas of perioperative nursing research. Perioperative RNs practice within the health system, and the evidence-based practices implemented by perioperative RNs promote patient safety, and optimal physiological and behavioral responses.
9.1 CONCLUSIONS This literature review has described the history and development of the Perioperative Patient Focused Model, identified key constructs and relationships among constructs of the Model, discussed the strengths and limitations of the Model, explained how the Model has been used in
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perioperative practice and research, examined whether the Model should be classified as a grand or middle range theory, and demonstrated how the Model can be applied in practice and research. An important finding from this review is that there is only minimal literature demonstrating use of the Model in practice or research. As the established model of perioperative care, the Perioperative Patient Focused Model warrants further research testing and validation and should be applied to perioperative practice.
Notes: PubMed is a registered trademark of the US National Library of Medicine, Bethesda, MD. CINAHL is a registered trademark of EBSCO Industries, Birmingham, AL. SCOPUS is a registered trademark of Elsevier BV, Amsterdam, Netherlands.
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REFERENCES 1. Rothrock JC, Smith DA. Selecting the perioperative patient focused model. AORN J. 2000;71(3):1030-1037. 2. Kleinbeck SVM, McKennett M. Challenges of measuring intraoperative patient outcomes. AORN J. 2000;72(5):845-853. 3. McCutcheon T. Statement on nursing: a personal perspective. Gastroenterol Nurs. 2004;27(5):226-229. 4. Flippin CI. Patient safety through patient education in a charity medical program. Plast Surg Nurs. 2006;26(3):145-148. 5. Van Wicklin SA. Are knowledge and attitudes of perioperative registered nurses associated with the practices of covering and monitoring sterile tables? Perioperative Care Operating Room Manage. 2018;12:16-25. 6. American Association of Critical Care Nurses. AACN Synergy Model for Patient Care. https://www.aacn.org/nursing-excellence/aacn-standards/synergy-model. Accessed December 9, 2019. 7. Wolf G, Aukerman M, Boland S. The Transformational Model for Professional Practice in Health Care Organizations. Pittsburg, PA: The Beckwith Institute for Innovation in Nursing; 1995. 8. Fitzpatrick JJ. A life perspective rhythm model. In: Fitzpatrick JJ, Whall AL, eds. Conceptual Models of Nursing, 2nd ed. Norwalk, CT: Appleton Lange; 1989: 295–302.
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9. Hickson DJ, Hinings CR, Lee CA, Schneck RE, Pennings JM. A strategic contingencies' theory of intraorganizational power. Admin Sci Q. 1971;16(2): 216-229. doi: 10.2307/2391831 10. King IM. A theory of goal attainment: philosophical and ethical implications. Nurs Sci Q. 1999; 12(4):292-296. doi: 10.1177/08943189922107205 11. Gonzalo A. Myra Estrin Levine: The Conservation Model of Nursing. Nurseslabs.com Web site. https://nurseslabs.com/myra-estrin-levine-the-conservation-model-of-nursing/. Published August 22, 2019. Accessed December 9, 2019. 12. Petiprin A. Health as expanding consciousness. Nursing-theory.org Web site. https://nursingtheory.org/theories-and-models/newman-health-as-expanding-consciousness.php. Published 2016. Accessed December 9, 2019. 13. Gonzalo A. Dorothea Orem: Self-care deficit theory. Nurseslabs.com Web site. https://nurseslabs.com/dorothea-orems-self-care-theory/. Published August 12, 2014. Accessed December 9, 2019. 14. Gonzalo A. Ida Jean Orlando: Deliberative Nursing Process Theory. Nurseslabs.com Web site. https://nurseslabs.com/ida-jean-orlandos-deliberative-nursing-process-theory/. Published October 21, 2014. Accessed December 9, 2019. 15. Parse RR. Human becoming: Parse’s theory of nursing. Nurs Sci Q. 1992;5(1):45-42. doi: 10.1177/089431849200500109 16. Paterson J, Zderad LT. Humanistic Nursing. New York, NY: National League for Nursing; 1988. 17. Gonzalo A. Martha Rogers: Science of Unitary Human Beings. Nurseslabs.com Web site.
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https://nurseslabs.com/martha-e-rogers-theory-unitary-human-beings/. Published September 9, 2014. Accessed December 9, 2019. 18. Gonzalo A. Sister Callista Roy: Adaptation Model of Nursing. Nurseslabs.com Web site. https://nurseslabs.com/sister-callista-roys-adaptation-model/. Published August 19, 2014. Accessed December 9, 2019. 19. Watson JW. Caring Science as Sacred Science. Philadelphia, PA: FA Davis Company; 2005. 20. Barnum BJS. Nursing Theory: Analysis, Application, Evaluation. 3rd ed. Glenview, IL: Scott, Foresman/Little, Brown; 1990. Cited by McEwen M. Theory analysis and evaluation. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:95-113. 21. McEwen M. Theory analysis and evaluation. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:95-113. 22. AORN, Inc. Introduction to the 2018 edition. In: Conner R, ed. Guidelines for Perioperative Practice. 2018. Denver, CO: AORN, Inc; 2018:1-6. 23. Petersen C, ed. Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. 3rd ed. Denver, CO: AORN, Inc; 2011. 24. Physiological. Merriam-Webster’s online dictionary. https://www.merriamwebster.com/dictionary/physiological. 2019. Accessed March 17, 2019. 25. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. 2nd ed. Silver Spring, MD: ANA; 2015. 26. Schroeter K, Flowers J, Davidson J, Van Wicklin SA. AORN’s Perioperative Explications for the ANA Code of Ethics for Nurses with Interpretive Statements. Denver, CO: AORN, Inc; 2017.
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27. Van Wicklin SA. Guideline for positioning the patient. In Conner R, ed. Guidelines for Perioperative Practice. 2018. Denver, CO: AORN, Inc; 2018:673-743. 28. National Pressure Ulcer Advisory Panel. NPAUP pressure injury stages. 2016. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injurystages/. Accessed March 17, 2019. 29. McEwen M. Overview of theory in nursing. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:23-48. 30. Wills EM. Grand nursing theories based on human needs. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014: 131-158. 31. Wills EM. Grand nursing theories based on interactive process. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:159-191. 32. Wills EM. Grand nursing theories based on unitary process. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:192-212. 33. Fitzpatrick J. Life perspective rhythm model. Nursing Theories: A Companion to Nursing Theories and Models. 2011. http://currentnursing.com/theory/Rhythm_Model_Fitzpatrick.html. Accessed March 17, 2019. 34. McEwen M. Overview of selected middle range theories. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:229257.
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35. Obertleitner MG. Theories, models, and frameworks from leadership and management. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:354-385. 36. Hickson DJ. Strategic contingencies theory. 2016. http://www.leadershipcentral.com/strategic-contingencies-theory.html#axzz5KPPrOuaF. Accessed March 17, 2019. 37. Paterson & Zderad: Humanistic nursing. (n.d.). Paterson and Zderad theory overview. https://humanisticnursing.weebly.com/the-theory.html. Accessed March 17, 2019. 38. McEwen M. Introduction to middle range nursing theories. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:213228. 39. Meleis LC. Theoretical Nursing: Development and Progress. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2012. Cited by McEwen M. Introduction to middle range nursing theories. In: Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2014:213-228.
Funding. This literature review did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.
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Additional records identified (n = 1)
PubMed = 4 CINAHL = 4 Cochrane Database of Systematic Reviews = 0 Scopus = 3
Results after duplicates removed (n = 6)
Duplicates removed (n= 6)
Screening
Records screened (n = 5)
Records excluded (n = 1)
Eligibility
Records including duplicates (n = 12)
Full-text reports obtained (n = 5)
Full-text reports excluded (n = 0)
Included
Identification
Records identified through database search (n = 11)
Full-text reports included in literature review (n = 5)
Figure 1. Flow Diagram of Literature Search Results. Adapted from Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement, by D. Moher, A. Liberati, J. Tetzlaff, D. G. Atman and The PRISMA Group, 2009, PLoS Medicine, 6(6), e1000097. Page 26 of 29
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Figure 2. Perioperative Patient Focused Model (2000). Reprinted with permission from Guidelines for Perioperative Practice. Copyright © 2016, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.
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Figure 3. Perioperative Patient Focused Model (2017). Reprinted with permission from Guidelines for Perioperative Practice. Copyright © 2018, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.
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Figure 4. Perioperative RNs use the PNDS language to document the care provided. Nursing diagnoses, interventions, and outcomes are coded using PNDS. Coding allows for consistent measurement and analysis in quality or research reporting; thus, providing the evidence to establish guidelines that provide recommendations for interventions and activities implemented by perioperative RNs. PNDS = perioperative nursing data set. Adapted from Petersen C, ed. Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. 3rd ed. Denver, CO: AORN, Inc; 2011.
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