Chapter 12 Professional development and future roles and practice
This chapter explores perioperative nursing knowledge development and its application to perioperative patient care, as well as the professional development required of the perioperative nurse. Educational opportunities that exist from entry to practice through to postgraduate programs are identified and discussed. The development of nursing organisations is outlined, with particular emphasis on the development of international and national specialist perioperative nursing organisations and their activities. Their role in the development of standards and competencies for practice is discussed in detail. The use of evidence in providing nursing care based on research findings is highlighted. The influences on the perioperative workplace are identified and, finally, a range of advanced practice perioperative roles are described.
There are two divisions of nurse in the Australian health care system. The first division is the registered nurse (RN) (Division 1 in Victoria and Western Australia), who, since the mid 1980s, is university prepared at the bachelor degree level. The second division is the enrolled nurse (EN, or RN Division 2, Victoria and Western Australia, hereafter referred to as EN), who is vocationally prepared at Certificate IV or diploma level. The EN provides care to patients in a model of delegation and supervision by the RN. The Australian perioperative nursing workforce includes both RNs and ENs, who do not require specialist qualifications to gain entry to this practice environment, even though perioperative nursing is recognised as an area of specialty nursing practice (Australian Health Workforce Advisory Committee [AHWAC], 2006).
Continuing education providers, such as technical and further education (TAFE) institutions, and the College of Nursing (formerly the NSW College of Nursing) offer short, introductory programs in perioperative nursing for both RNs and ENs, which do not require employment in a perioperative setting. Courses such as these can only provide an overview of the perioperative specialty; however, participation in them can demonstrate to potential employers the nurse’s interest in perioperative nursing care and their desire to enter the specialty. In New Zealand, District Health Boards (DHBs) are funded to support nursing entry to practice (NETP) programs for newly graduated RNs (NZ Ministry of Health, 2006).
Like many specialty areas of nursing practice that were once part of hospital-based training, perioperative nursing is no longer a core component of the undergraduate curriculum in Australia (AHWAC, 2006) or New Zealand (P. Hames, personal communication, 2007). Consequently, the newly qualified RN may have little knowledge or experience in the care of the unconscious patient during general anaesthesia and surgery, the principles of aseptic technique or the management of a patient’s recovery from anaesthesia and surgery. An undergraduate curriculum that does not offer perioperative experience affects graduates as well as perioperative nurse managers. For example:
The international experience is similar in as much as the current perioperative recruitment issues in the United States have been linked to the loss of perioperative nursing from the undergraduate curriculum in the 1980s (Gutierrez et al., 1989; Happell, 2000; Jones & Sorrell, 1989). This is compounded by the ageing of the nursing workforce (Australian Institute of Health & Welfare [AIHW], 2005).
For undergraduate nurses in Australia and New Zealand, entry to the perioperative environment may be possible during a rotation or clinical placement on a surgical ward. Astute perioperative managers and educators will encourage these short, observational visits during undergraduate clinical placements (P. Hames, personal communication, 2007) as a means of attracting nurses to consider the specialty on graduation (NSW Operating Theatre Association, 2007).
In recent years, universities in Australia (e.g. University of Technology, Sydney) have begun to offer the perioperative specialty as an elective in second or third year nursing curricula, while others offer it as a core subject (e.g. Notre Dame University). The Australian Catholic University (ACU) has offered a perioperative elective in the final year nursing practicum since 2005, when 25 students were enrolled. This number has increased almost four-fold in the 2 years since, with 95 students enrolled in 2007 (Frotjold et al., 2007).
This growing interest in perioperative nursing at the undergraduate level echoes the findings of a US study (Gutierrez et al., 1989) and supports the inclusion of the perioperative specialty in the nursing curriculum in Australia. Effective collaborations between nursing faculties and operating suites have many benefits for potential employers. The ACU students’ evaluations of the perioperative elective indicate the program’s success as a recruitment strategy; 88% of students indicated that they would consider employment in the operating suite on graduation as a direct result of their positive experiences during the clinical placement. Indeed, the hospitals participating in the ACU elective have reported an increasing number of graduates recruited to the perioperative specialty since the inception of the undergraduate elective (Frotjold et al., 2007).
Clearly, undergraduate programs with outcomes such as this can have a positive impact on the graduate workforce. This is borne out by recent research in the United Kingdom (Andrews et al., 2002), which investigated the impact of clinical placements on 650 past and present nursing students. The research was carried out in two large, metropolitan universities, using questionnaires, focus groups and interviews. A key finding from the research was that the organisations that provided a supportive learning environment for the nursing students during their clinical placements became the nurses’ preferred employers on graduation. The authors concluded that employers will attract and retain more nurses by creating a positive workplace—one in which learning is encouraged and supported (Andrews et al., 2002).
Newly graduated registered nurses also have opportunities to enter the perioperative pecialty. New graduate transition programs may include a placement in (or rotation to) the operating suite; these rotations vary in duration from weeks to months, with some employers offering an entire year of specialist perioperative nursing practice. These latter ‘dedicated stream’ models, which include rotations to each of the perioperative roles, are suitable for graduates who have a strong desire for perioperative nursing practice as a career choice, or for those who have perioperative experience as an enrolled nurse and have subsequently completed a Bachelor of Nursing conversion course.
The shorter, 3–4 month rotation of most new graduates to the operating suite provides time beyond orientation for the nurse to explore the practice of a single perioperative role only. By the end of a 4-month rotation in anaesthetics, for example, the new graduate nurse should be able to manage the care, within a limited range of elective patients, at induction and emergence from anaesthesia with minimal direction and support. Similarly, the new graduate circulating and instrument nurse should have developed the knowledge and skills to prepare the environment, patient and equipment for a limited range of elective procedures under the guidance of an experienced nurse. During the short rotation, neither of these nurses would have developed the knowledge or skills of the other roles; however, they should have developed an understanding of the relationship between the nursing roles and the teamwork required to provide effective patient care in the perioperative environment. Longer rotations, such as the ‘dedicated stream’ models, do allow movement within the full range of perioperative roles.
The educational preparation of the EN in Australia has undergone intensive review in recent years in response to the National Review of Nursing Education (Australian Department of Education, Science and Training [DEST], 2002). A key recommendation was the development of a national qualification that would incorporate the EN competencies of the Australian and Nursing Council (ANC), now known as the Australian Nursing and Midwifery Council (ANMC). This has culminated in the development of the Health Training Package HLT07 (Certificate IV, Diploma and Advanced Diploma in Enrolled Nursing/ Division 2 Nursing), which is available for delivery across Australia (Community Services & Health Industry Skills Council [CS&HISC], 2007). New Zealand does not have an EN category; the entry level for all nurses is registration via a 3-year bachelor degree program (NZ Ministry of Health, 2007).
The availability of the health training package in Australia means that the EN qualification will be delivered by a greater number of providers. Previously, the largest provider of the EN qualification in Australia has been TAFE institutions, which are the vocational arms of the state and territory departments of education and training. Some, but not all, of the TAFE pre-enrolment programs have included employment in a hospital setting with the potential for a clinical rotation to the operating suite. The benefit of such a rotation is that trainee ENs can observe and practise the beginning skills of the perioperative nurse in preparation for permanent employment in a perioperative setting.
ENs may work in the anaesthetic nurse role with or without a post-enrolment qualification, such as the Certificate IV in Anaesthetic Technology (CS&HISC, 2007). Those ENs who posses this qualification are able to function in the role of anaesthetic technician. A smaller number of perioperative ENs may work in the circulating and instrument nurse role; however, there are fewer post-enrolment qualifications for this specialised role, which has most often been performed by the RN within Australian jurisdictions (NSW Health, 2007b). As opportunities increase for advanced practice roles for RNs, so too, will opportunities increase for ENs. This is explored further under advanced practice on pages 301–302.
Without exposure to the perioperative environment, the majority of nursing graduates, be they RNs or ENs, will have received little theory or clinical practice in the care of the perioperative patient during their initial education. Operating suites that do attract graduates to specialty practice must, therefore, provide comprehensive orientation and clinical programs to equip these new recruits for a role in the perioperative environment. Table 12-1 lists activities that are appropriate for inclusion in an orientation program.
Table 12-1 Sample content of a 5-day orientation program
| Perioperative roles |
|---|
| 1. Medicolegal principles and policy |
| 2. Patient and environmental safety |
| 3. Principles of asepsis and infection control |
South Eastern Sydney Illawarra Area Health Service (2006)
The Association of periOperative Registered Nurses (AORN) in the United States offers the ‘Perioperative Curriculum 101’, which was first developed in 1999 and is now available as an online educational resource (AORN, 2007). Members of the Perioperative Nurses College (PNC) of the New Zealand Nurses Organisation (PNCNZNO) are able to purchase a perioperative education manual, which has been approved by the New Zealand Nurses Organisation (Marenzi, 2006). A key goal of the PNC is the establishment of a national perioperative education program and, to this end, the College structure includes an education subcommittee.
Currently, there is no equivalent program offered by the Australian College of Operating Room Nurses (ACORN). Orientation to specialty practice, therefore, is provided by individual healthcare facilities in Australia (ACORN, 2007) and, in some cases, centralised orientation and clinical programs are provided across an organisation or health service. The duration of these programs ranges from a few days orientation to 6-month or 12-month extended clinical programs. These extended programs may supplement the content of new graduate RN rotations, or they may provide an alternative pathway to specialty practice as part of an organisational recruitment strategy (South Eastern Sydney Illawarra Area Health Services, 2007).
In addition to a structured orientation, extended programs offer a theoretical framework of regular study days, as well as supported clinical practice and assessment. Extended programs may also be recognised for subject credit in tertiary-level graduate programs. This relationship exists between Deakin University and Barwon Health in Victoria, Adelaide University and the Royal Adelaide Hospital in South Australia and, in New South Wales, the ACU and St Vincent’s Hospital, as well as the Wollongong University and Wollongong Hospital, to name just a few examples.
Progress along the nursing career pathway requires a commitment to ongoing education and professional development. This commitment is even more important in specialty areas such as perioperative nursing, where technology, health policy and nursing practice are continually developing and changing (Senate Community Affairs References Committee, 2002). The knowledge and skills that the beginning RN or EN develops during the orientation period are the foundation upon which specialty practice is built. Ongoing perioperative nursing practice requires the acquisition of further qualifications and/or work experience. The role that training and education plays in the elevation of the profession’s status is explored on page 293.
Australian and New Zealand universities and colleges provide a range of postgraduate programs for perioperative nurses, including graduate certificates, graduate diplomas, masters and doctoral programs. Historically, hospital-based certificates were the mainstay of professional development courses for perioperative nurses (AHWAC, 2006). Even though certificates were available for anaesthetic and postanaesthesia recovery unit (PARU) nurses, there were many more for instrument and circulating nurses. These certificates were routinely of 12 months’ duration, during which time the students were required to rotate through the major surgical specialties, as well anaesthetics and PARU.
Since the transition of nursing education to the tertiary sector in the mid 1980s, these certificates have disappeared from hospitals; however, some have re-emerged (in somewhat smaller numbers) as graduate certificate courses in the tertiary sector. There are some notable exceptions as a few facilities continue to offer hospital-based programs, including the Fremantle Hospital in Western Australia, the Queen Elizabeth Hospital in South Australia, and the Liverpool Hospital in New South Wales (AHWAC, 2006). In New Zealand, the DHBs fund postgraduate nursing studies based on local need, as well as providing clinical learning placements (NZ Ministry of Health, 2007).
In a survey of Australian course coordinators in 2005, the Australian Health Workforce Advisory Committee (AHWAC, 2006) identified 16 providers of postgraduate programs for perioperative nurses. This figure included the three hospitals mentioned above, 12 universities and the College of Nursing. At the time, students enrolled in perioperative specialisations outnumbered anaesthetic and PARU students by 3:1, echoing the trend seen in hospital-based certificates (AHWAC, 2006).
The AHWAC noted that, at the time, there were no providers of postgraduate perioperative programs in the Australian Capital Territory, Northern Territory or Tasmania. Residents of these jurisdictions would, however, be able to access distance (online) programs, such as those offered by Curtin University in Western Australia or the distance education courses offered by the College of Nursing. In New Zealand, the Auckland University, Massey University and the Whitireia Community Polytechnic offer postgraduate education for perioperative nurses (P. Hames, personal communication, 2007).
In 2002, the Senate Inquiry into Nursing reported that continuing education for perioperative nurses was:
… essential for the ongoing maintenance of professional expertise and therefore professional standards. With the rapid development of new technologies in the operating room environment, nurses need access to professional development programs on a regular basis (Senate Community Affairs References Committee, 2002, p 192).
The Senate Inquiry made a number of suggestions, including the need for more opportunities for specialist nurses, in particular, to maintain knowledge and skills. At much the same time, another review into the nursing profession was underway in Australia. Not surprisingly, similar themes emerged. The National Review of Nursing Education also recommended that nurses undertake lifelong learning as a means of maintaining competence (Australian DEST, 2002).
Even though nurses may recognise the need to maintain their competence to practise, they may not recognise the broad range of continuing education activities that are available in the perioperative environment. Informal teaching and learning activities are no less valid than formal courses as a demonstration of the nurse’s commitment to lifelong learning. Such activities might include participation in:
Professional portfolios can be used to record these activities and will, more importantly, provide an effective mechanism for the nurse to reflect on practice. In fact, self-reflection is vital because it ensures that the individual nurse’s portfolio is more than a list of activities completed, but rather it enables the nurse to demonstrate what has been achieved through participation in the activities (McMullan et al., 2003).
A commitment to lifelong learning is not simply valued by the nursing profession; nursing and midwifery registering authorities have begun to stipulate continuing education hours as a requirement for annual licence renewal (ANMC, 2006a; National Nursing and Nursing Education Taskforce [N3ET], 2006). The ANMC’s position is articulated in its Continuing Competence Framework (ANMC, 2007b). This framework comprises the elements of:
The professional portfolio is recognised here as one of the best methods for nurses to document their maintenance of competence (ANMC, 2007b; Davies & Hamlin, 2003). Certainly, then, the professional portfolio can serve many purposes for the perioperative nurse.
The division of labour is also a division of knowledge, with consequential implications of reciprocal dependence and vulnerability between participants (Dingwall & Lewis, 1983, p 12).
In Australia in the 1880s, assisting surgeons during operations was fundamental to the work of all nurses because they attended operations in the home, hospital ward and operating suite. Initially, all nurses were trained to meet the skill requirements of this role: to prepare patients, the environment, the necessary equipment and dressings, and then assist patients to recover from their operation. As with any occupation, it was important for nursing to gain recognition as a profession because it carried with it status and security; furthermore, as with any occupation, professional status provides a basis for protection from occupational competition (Freidson, 1983).
As medical specialties developed, nursing specialties emerged alongside to meet gaps in skills and knowledge. Training was important in elevating nursing’s professional status (Bessant & Bessant, 1991). Freidson (1994) argued that the division of labour is specialisation and that (former) operating suite nursing is an example of a dynamic nursing specialty that continues to evolve into super-specialty areas of skills and knowledge that are not constrained by geographical boundaries. For example, within perioperative nursing, nurses may specialise and work exclusively in areas such as cardiothoracic surgery or neurosurgery, or they move into day surgery settings and work across the continuum of ambulatory patient care.
As nursing evolved from a service to a trained practice, and scientific and technological advances developed in medicine, nurses were measured not only by their character but increasingly by their technical skills and knowledge, which gave them portability to practice in the hospital or to work privately. Perioperative nurses, as with other specialist nurses, are identified not only by the geographical locus of work (in this case operating suites, perioperative units, outpatient clinics and day surgery units) but also by their specialist skills and knowledge. That is, their specialist skills and knowledge admit them into a world of specialist practice as a professional and differentiate them from generalist nurses (Heartfield, 2006).
There has been much debate among nurses (and others) about whether nursing has achieved professional status (Schwirian, 1998). Although there is no universally accepted definition, the term ‘profession’ refers to an occupation that controls its own boundaries of work, is organised by a set of institutions and is informed by a particular ideology of expertise and service. While the line between nursing and domestic service could hardly be drawn in the mid-19th century (Rosenberg, 1987) and the term ‘quintessential domestic scientists’ was used to describe nurses at this time (Bashford, 2000), operating room nurses made sense of germ theory and incorporated this knowledge into their practice to make it more scientific. As anaesthesia advanced and the complexity of surgery increased, so too did the range of the nurse’s skills, and an occupational gap was created for a worker with specialised knowledge and skills to care for patients, but mainly to assist surgeons during operations. Technical virtuosity was inextricably related to status for institutions as well as individuals (Rosenberg, 1987).
Control over the labour market is one of the defining characteristics of a profession and this may be achieved by giving credentials to members of the profession (Leicht & Fennell, 2001). Individually, most nurses have limited control over their work, and the role of the perioperative nurse is constantly being renegotiated by policy makers, nurses and employers. Because of this renegotiation, specialist nurses are never secure in their role. The renegotiation is played out in the contest for physical and professional space in the operating room, where medical and nursing hierarchies are often reinforced (Lingard et al., 2002).
Professional associations may be defined as those whose primary purposes are to protect, enhance and advance the common interests of the organisation, and their professional and non-professional members. They operate at local, state, national and international levels, and perform a number of functions, including gaining support through political lobbying, providing education, and developing standards for practice, care-givers, resources and the environment. These activities may also include establishing and enforcing a code of ethics, stimulating and promoting the professional development of practitioners, and ensuring members’ financial and general welfare (Brooks & Berman Brown, 2002). For nurses, they also provide an opportunity to develop a bigger picture of nursing and health care overall (Frank, 2005).
From a sociological perspective, professional organisations are a convenient way of mobilising practitioners’ allegiance to the profession (Freidson, 1983, 1994). The nursing profession is no exception and the role of one of the earliest Australian organisations, the Australasian Trained Nurses’ Association, which was formed in 1899, was to protect the public from ignorant and incompetent nurses, to improve and standardise general nurse training and to promote the professionalisation of trained nurses (Hamlin, 2005).
In Australia and New Zealand, more than 60 professional nursing organisations represent clinical, managerial, educational, research-based and industrial interests. Most have small membership numbers, and this proliferation of organisations can be counterproductive to the overall aims and goals of nursing. In Australia, the two most significant national nursing organisations are the Royal College of Nursing, Australia (RCNA), which is affiliated with the International Council of Nurses (ICN), and the Australian Nurses Federation (ANF), which is an industrial body. Both have state branches or chapters. Many of the state and national specialist organisations are part of a coalition, the National Nursing Organisations (NNO). Formed in 1991, the NNO acts as a lobby group and provides a forum for discussion about future directions in nursing. Importantly, recent work conducted by an NNO workgroup and funded through the National Nursing and Nursing Education Taskforce (NNO, 2006), resulted in the publication of a toolkit on governance standards for nursing and midwifery organisations. The toolkit is in the process of being implemented by several national specialist nursing organisations and should result in an improvement in the governance of them, and better accountability to members.
In New Zealand, there is one coalition of all nurses’ organisations, called the New Zealand Nurses Organisation (NZNO), which is affiliated with the ICN. It is the largest union and professional organisation of nurses, midwives and caregivers in that country and, in serving both the professional and industrial needs of nurses, is similar to the Royal College of Nursing (RCN) in the United Kingdom.
However, specialist organisations, such as those of interest to perioperative nurses, generally better meet the interests of their membership because they are focused largely on the specialty of interest (Hamlin, 2005). Contemporary nurses must be committed to lifelong learning in order to maintain their nursing registration and to practise safely. Although few of the specialist professional organisations offer formal education programs, they meet a need for ongoing development in the specialist nursing community by providing continuing education for their members. This is through their national, state or regional member groups, which organise study days, seminars and conferences, and via publication of journals and newsletters. These activities also provide opportunities for networking with specialist colleagues. Perioperative organisations are examined in closer detail below.
As well as writing standards for practice and conducting conferences and educational meetings, most specialist nursing organisations, including perioperative associations, publish journals or newsletters and have established websites. The opportunities provided by professional associations include:
In Australia, there are six state- or territory-based perioperative nursing organisations, which (with the exception of the NT Perioperative Nurses group) evolved independently during the 1950s and 1960s. They subsequently joined forces to form the Australian College (formerly the Confederation) of Operating Room Nurses in 1977 (Hamlin, 2005). The state/territory groups that are branches of ACORN include the:
As with many clinically oriented professional associations, ACORN is focused on improving and standardising nursing care, and educating and supporting nurses. In ACORN’s case, the focus occurs within perioperative settings. The formation of ACORN was deemed necessary because of a wide variety in practice in operating suites at the time and, in many areas, no written standards (Hamlin, 2005). This was believed by perioperative nurse leaders to be a significant deficit in perioperative nursing care. Of particular concern at that time was the need to standardise the way the surgical count was conducted (Richardson, 2004). Another key driver was organising and conducting a national conference every 3 years to bring operating room nurses together nationally to discuss perioperative nursing issues.
In the early 1990s, ACORN funded a 6-year research project, which identified and subsequently validated the ACORN competency standards for perioperative nurses (the competencies) (Hilbig, 1999). These were published in 1999 (ACORN, 1999) and a research project to revalidate them was completed in 2006 (Williamson & Hill, 2007). However, ACORN has previously rejected the development of an accreditation service. ACORN has also funded the development, writing and introduction of a curriculum to prepare nurses for the extended role of perioperative nurse surgeon’s assistant (PNSA) in conjunction with the Southern Cross University (NSW) (Richardson, 2004). However, it has no formal relationship with this university currently.
Although ACORN is a member of the NNO, it remains an independent, limited company. The state/territory perioperative nursing associations, even though they are branches of ACORN, are themselves independently incorporated entities (with the exception of VPNG). Neither state branches nor ACORN itself meet perioperative nurses’ industrial needs.
Two or three of ACORN’s state or territory member organisations previously had a relationship with the ANF, an industrial organisation. This remains the case for VPNG, which is a special interest group of ANF (Victorian Branch). Consequently, although VPNG is a member of ACORN, it is more closely associated legally with ANF (Victorian Branch).
In contrast to ACORN, the PNC is an affiliated NZNO. The PNC has a membership of 680 nurses across nine member regions (Marenzi, 2006). These are Auckland, Central North Island, Hawke’s Bay, Ruahine/Egmont, Wellington, Nelson/Marlborough, Canterbury/West Coast, Otago and Southland.
The PNC is closely associated legally with the NZNO. It has similar goals to that of most national perioperative organisations, which include:
The PNC provides a national perioperative nursing education program and offers endorsed modules, which give successful students advanced standing when completing further studies in some NZ tertiary institutions. PNC also offers an accreditation process for perioperative nurses. The PNC model for accreditation was developed during 2000–01 and the first perioperative nurses were accredited in 2003. These processes were recently re-endorsed by the Board of the NZNO (Board of Directors, 2007). The PNC appears to be proactive on many professional issues and, at an annual conference in Invercargill in 2006, concern was raised by members about roles not being performed by nurses in the operating room; a working party was formed to address this issue (Nelson, 2006).
Globally, the International Federation of Perioperative Nurses (IFPN) is an organisation of national perioperative nursing organisations. The IFPN promotes education and research for nurses in perioperative settings to provide best practice based on the latest and best available evidence. The member associations of IFPN include:
The IFPN is particularly committed to improving standards of patient care in developing countries, and its activities are focused on providing universally applicable guidelines for practice, which IFPN Board members develop. Some of the IFPN guidelines, which are available on their website (see Resources), include:
The IFPN is a member of the International Council of Nursing (ICN), a global federation of national nurses’ associations. The ICN works globally and the focus of its activities is to ensure quality nursing care, sound health policies globally and the advancement of nursing knowledge (ICN, n.d.).
Many other organisations represent nurses working in a diversity of roles in perioperative settings. The European Operating Room Nurses Association (EORNA) is another international specialist nursing organisation that represents perioperative nurses and is now a member of IFPN.
Other professional associations, such as the Association of periOperative Registered Nurses (AORN) in the United States, the Association for Perioperative Practice (AfPP) in the United Kingdom and the Operating Room Nurses Association Canada (ORNAC), also provide a variety of educational opportunities and other benefits. An important difference between the AfPP and other national nursing organisations is that the AfPP represents non-nurses working in the perioperative setting. This is a critical issue for the specialist nursing organisations, as well as much more widely, because, as the nursing workforce ages, members will retire and membership numbers will start to decline.
The ANMC provides competency standards for Nurse Practitioners, RNs and ENs, as well as codes of practice and conduct; the NZ Nursing Council performs a similar role in New Zealand. More recently, the ANMC published a decision-making framework (ANMC, 2007a), which has subsequently informed the activities of the state- and territory-based nurse regulatory authorities in Australia. Standards for practice, including competency standards (hereafter called standards for practice and/or competency), have also been developed by many of the specialist nursing organisations over the last decade. They both inform and underpin specialty nursing practice.
Many professional nursing organisations now view the development of standards for practice as part of their role and in Australia this has led to the development of a plethora of standards by the clinical specialty organisations. This includes ACORN, which has been involved in the publication of standards for use in perioperative settings since its inception, and the PNC, which publishes standards and guidelines for safe practice for perioperative nurses in New Zealand (2005).
ACORN’s standards for perioperative nursing, including nursing roles, guidelines, position statements and competencies (the ACORN standards), were first published in 1980 (without competency standards) by the (then) Australian Confederation of Operating Room Nurses and have since been regularly reviewed, revised and updated (Richardson, 2004). Although initially published every 3 years, they are now published biennially, which is a reflection of the dynamic perioperative environment. Table 12-2 provides a summary overview of the ACORN standards.
Table 12-2 An overview of the ACORN Standards
The term ‘competency’ may be defined as ‘the ability to perform the activities within an occupation or function to the standard expected in employment’ (Heywood et al., 1992, p 99). Competency standards specify the level of achievement expected, and the tasks and contexts of professional practice in which competency may be demonstrated (Gonczi et al., 1990). In a nursing context, and for the purposes of this discussion, competency is defined as, ‘The combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance in a profession/occupational area’ (ANMC, 2006c, p 8).
RN and EN competency standards were first published by the ANMC in the 1990s, and most of the specialist colleges, including ACORN and PNC, have now published their own competency standards for specialist practice. A proliferation of nursing specialty competency documents are available; additionally, the ANF published competency standards for the advanced nurse in 1997, which have subsequently been revised and validated as the competency standards for the advanced RN (ANF, 2006). The terminology associated with specialist and advanced practice remains confusing despite being addressed comprehensively in a publication by the National Nursing and Nursing Education Taskforce (Heartfield, 2006).
The use of competency standards is contentious and, while their stated intent is to indicate a minimum standard of practice, provide evidence to the public that professionals are competent in meeting a standard of care and guide curriculum content, little is actually known about their dissemination, uptake or how they impact on specialist nurses and/or practice settings (Hendry et al., 2007).
Nursing research is essential to providing optimal patient care and ensuring that patient outcomes are based on contemporary knowledge. It is critical that nursing care be evidence-based and that nurses know how to access research, interpret it and then implement findings as appropriate. Excellence in the delivery of quality nursing care is achieved by translating research into evidence-based practice (EBP) and then evaluating its effectiveness in terms of patient outcomes.
The Joanna Briggs Institute is an international research and development agency, made up of 26 interdisciplinary collaborating centres, incorporating nursing and midwifery research findings. Membership is required to access most of its materials. The Cochrane Collaboration is an easily accessible resource for nurses and contains a large number of research reviews. Although largely medically focused, the Cochrane Collaboration provides summaries of the latest research findings that may be useful to nurses. The Cochrane Collaboration uses systematic reviews of the effects of health care interventions to provide the latest information to improve health care delivery.
In order to use these resources effectively and incorporate research into clinical practice, nurses need to be able to appraise research. In the workplace, nurses need to be confident in their skill level in the critical analysis of research and evaluation. Experience in conducting literature reviews and searching databases assists in building confidence. Increasingly, this knowledge is gained via formal postgraduate education. Other reliable sources of information are specialty specific journals, such as the Journal of Advanced Perioperative Care (JAPC), Journal of Perioperative Practice (JPP) and AORN Journal; other sources include the Journal of Clinical Nursing, Journal of Advanced Nursing, Australian Journal of Advanced Nursing and The Collegian.
The benefits of evidence utilisation are well documented in the literature and most health care facilities now have an emphasis on the provision of cost-effective quality care. This means that perioperative nurses must make judgements about the appropriateness and possible effectiveness of different treatment regimens, while at the same time taking cost into account. Confidence in the effectiveness of the nursing intervention is also an important factor. This requires that nurses know how to quickly search and access the data, evaluate the latest findings and make considered judgements about treatment options for best outcomes. Areas of perioperative nursing practice that have proved of interest to researchers include examining hand antisepsis practices (Tanner et al., 2007) double gloving (Tanner & Parkinson, 2002), the surgical count (Hamlin, 2005) and communication in the operating room (Lingard et al., 2002).
While EBP is increasingly being used by nurses, the role of professional associations in undertaking or supporting the dissemination of results or otherwise using research findings is very limited (Holleman et al., 2006). In their study of international professional associations, including Australia, Holleman et al. (2006) discovered that most EBP activities were competence- and attitude-oriented, suggesting that an effective course of action would be for organisations to target members to establish a link between their association membership. A level of commitment on the part of members could be made and then a stronger professional profile promoted.
In an era of rapid technological advancement, the delivery of a safe and efficient health service requires a highly educated and flexible health workforce. Several reviews of the Australian health workforce have been undertaken in recent years. These include:
All reviews have made numerous recommendations, including some related to advanced practice. The most significant report was Australia’s health workforce from the Productivity Commission (2006). It identified the need for workforce innovation, with a particular emphasis on the development of roles that cross professional boundaries. In the perioperative environment, roles that might cross professional boundaries of doctors include perioperative Nurse Practitioner roles, and ancillary workers’ roles, which might cross the professional boundaries of nurses. The report warns that changes in one area can have flow-on effects in other areas; for example, ‘enhancing the ability for nurses to substitute for doctors in some areas could exacerbate an existing nursing shortage’ (Productivity Commission, 2006, p 58).
The RCNA (2007) acknowledges the need for these workforce innovations and supports a collaborative approach to the development of new roles, advising that this must be primarily in response to the changing health care needs of the community. The RCNA advocates for regulation of any new roles as a means of ensuring public safety and providing uniformity with new practice boundaries.
This is a complex issue for the perioperative environment, where ancillary workers, doctors and nurses work effectively in many combinations and teams. Ancillary workers have varying levels of education and skills sets, and work as assistants in nursing, and as orderlies and healthcare assistants. Unlike doctors and nurses, these roles are not regulated, and without regulation there may be a lack of clarity about professional boundaries, as well as limited accountability, in the delivery of patient care. However, national, competency-based education packages at certificate and diploma level have been developed and published recently (CS&HISC, 2007), which is an important step. Clear policies and practice guidelines, as well as collaboration and multidisciplinary educational support, are required to ensure that all members of the perioperative team continue to have the knowledge and skills required for safe patient care.
In Australian and New Zealand operating rooms, ancillary workers represent a small but important part of the workforce. ACORN’s position on ancillary workers is that they must work under the supervision and management of appropriately educated and experienced RNs at all times (ACORN, 2006c), providing indirect patient care only. It remains to be seen if this position is sustainable in the future, especially as it is not the case in the United Kingdom, where the RN works in a team that includes diploma- prepared, non-nurse, operating department practitioners who undertake activities traditionally completed by nurses. Similarly, in the United States, the non-nursing role of the scrub technologist is one that is supervised by the RN circulating nurse. In many US states, legislation has been enacted to ensure that there is at least one RN present in the operating room, working as the circulating nurse (AORN, 2006a, 2006b, 2008a, 2008b), to oversee nursing care and supervise these workers.
Discussions about professional boundaries in the perioperative environment remain controversial, both here (NSW Operating Theatre Association, 2007) and overseas. Letters to the editor from nurses and operating department practitioners in Australian and British publications suggest that opinions are diverse and the debate seems likely to continue for some time (Anonymous, 2008; Fletcher, 2008; Goodley et al., 2008).
Advanced practice can be defined as practice in which the nurse uses an extended knowledge and skills base to initiate the delivery of complex nursing care, either autonomously or in a model of collaboration with the health care team (RCNA, 2006). However, there is no absolute consensus; for example, the National Nursing and Nursing Education Taskforce (N3ET) draws the distinction between practice that is ‘extended’, such as the performance of tasks (medication administration), and practice that is ‘advanced’, such as the performance of a role at an advanced level (N3ET, 2005b).
The advanced RN demonstrates critical reflection, decision-making and problem-solving skills and functions within a nursing framework that includes assessment and diagnosis, planning, implementation and evaluation of care. Further, advanced practice is the foundation from which the Nurse Practitioner role develops (ACORN, 2006b; ANMC, 2006b; Nurse Practitioner Advisory Committee of New Zealand, 2006; RCNA, 2006). The Nurse Practitioner role has evolved over the last two decades or so in Australia and New Zealand, with Nurse Practitioners authorised to prescribe medications, order diagnostic tests and make referrals, which are activities traditionally performed by medical practitioners. Thus, Nurse Practitioners work at an advanced practice level in an extended role (N3ET, 2006). In Australia, the title and role of Nurse Practitioner is protected by legislation (ANMC, 2006b). ACORN recognises advanced practice perioperative nursing roles and supports those nurses who are in transition towards Nurse Practitioner roles. ACORN’s position is underpinned by the views of both the RCNA and the ANMC, and acknowledges the legislative and regulatory framework in which Nurse Practitioner must work (see Ch 11). As mentioned previously, the National Nursing and Nursing Education Taskforce has also completed work more generally on advanced practice roles and the role of the Nurse Practitioner (N3ET, 2005a).
Even though Nurse Practitioner roles are slowly emerging within the Australian perioperative workforce (Michael, 2007; Ward & Hamlin, 2006), advanced practice roles already exist for both the RN and EN. The perioperative nurse surgeon’s assistant (PNSA) is perhaps the most recognised advanced practice role for the RN, and the instrument nurse is an advanced practice role for ENs. Advanced practice roles also exist for anaesthetic and PARU RNs in areas such as pain management and intravenous access. Advanced practice roles may develop without the support and structure of formal education; however, completion of a recognised program may be a requirement of employers or professional bodies (ACORN, 2006a).
The PNSA is an advanced practice role for RNs and includes all stages of patient care delivery. Most notably during the intraoperative stage, the PNSA provides surgical and technical support, such as tissue retraction and dissection, haemostasis and wound closure as the surgeon’s first assistant (ACORN, 2006a). While many consider this to be a new role, nurses have assisted with the technical aspects of surgery in the past. Today, the role of the PNSA may extend into the preoperative stage and include patient assessments, patient history taking and patient education (Brennan, 2001). The PNSA may also evaluate the patient’s care during the postoperative stage and collaborate with the surgical team in preparation for the patient’s discharge. However, there is no published evidence about the number of PNSAs or how their roles are enacted.
Educational preparation of the PNSA has been provided in Australia since 2000 as a result of an innovative collaboration between ACORN and the Southern Cross University in New South Wales (Brennan, 2000). This university remains the single provider for the PNSA course in Australia. The role has been picked up mostly by the private sector and in rural areas of Australia, complementing the dwindling supply of general practitioner surgical assistants (Brennan, 2001). Even though nurses develop the knowledge and skills required of the PNSA role as a result of informal, on-the-job education and instruction, the ACORN position description for the PNSA nurse stipulates that a PNSA course is a mandatory qualification for the role (ACORN, 2006a). It is important to note that, during surgery, while the PNSA may also be a perioperative nurse, he or she should not concurrently function as the instrument nurse. Equally, the perioperative nurse should not perform the activities of the surgical assistant without the appropriate education and credentials (Campbell, 2001). It is important to note that, while the PNSA is recognised as a perioperative advanced practice role, it is not a Nurse Practitioner role and does not have prescribing or referral privileges. ACORN acknowledges, however, that the PNSA role has the potential to develop into a perioperative Nurse Practitioner role (ACORN, 2006b).
Internationally, there are many other advanced practice roles for the perioperative nurse, many of which have been developed in response to the current and expected workforce shortages of medical staff (see Table 12-3). In the United Kingdom, the National Health Service Knowledge and Skills Framework (NHS KSF) was implemented in 2004, in response to the ‘Agenda for Change’. This involved a single pay system for the health workforce, excluding doctors and dentists, and was expected to simplify the development of extended roles and to provide greater flexibility across all roles (UK Department of Health, 2007). Not all stakeholders, however, have viewed these new roles in a positive light, particularly when these roles are seen to cross the professional boundaries of doctors. In a recent development in the United Kingdom, nurses have been trained to perform surgical procedures in some National Health Service hospitals, a move which some surgeons and consumer groups have labelled as dangerous and unnecessary (Laurance, 2005).
Table 12-3 Advance practice roles
| Australia | Perioperative Nurse Surgeon’s Assistant (PNSA) |
| United Kingdom | |
| United States |
Nonetheless, in response to the European directive on junior doctors work hours, and political will, many initiatives have evolved, and will continue to (Kneebone et al., 2006). One example of an innovative approach has been taken in the United Kingdom at the Good Hope Hospital NHS Trust. This work was driven by the need to manage the flow of surgical emergencies more efficiently (Radford et al., 2003). The result is a clinical nurse specialist role that ‘navigates’ the complex path that emergency patients travel, from admission through to the operating room and beyond. Preoperatively, nurses in this role are authorised to order diagnostic tests, interpret results, make referrals to other specialist services and plan for surgical intervention and postoperative care.
The nursing professions in Australia and New Zealand are endeavouring to develop advanced practice and Nurse Practitioner roles within a nursing framework, with roles focused on improvements of health outcomes for patients and the greater population (NSW Health, 2007a) rather than simply acting as doctor substitutes.
Several state health departments and the NZ Ministry of Health provide advice to those nurses seeking to develop Nurse Practitioner roles. One example is the development and planning of a paediatric orthopaedic Nurse Practitioner role, with a focus on the perioperative environment (E. Harford, personal communication, 2007). Ward and Hamlin (2006) have also described an advanced practice role in New South Wales, which is currently a transitional perioperative Nurse Practitioner, similar to that described by Radford et al. in the United Kingdom (2003). With a scope of practice that extends beyond the operating room, this truly ‘perioperative’ role provides nurses in Australia and New Zealand with an appropriate model for the development of the perioperative Nurse Practitioner role.
As a result of the work being undertaken around nursing skill mix and the evolution of a more flexible nursing workforce, opportunities are emerging for suitably qualified ENs to work in advanced practice roles. These new roles have developed, in part, as a result of the development of advanced practice roles for RNs and, in Australia, partly because of the recent nationalisation of the EN qualification. This nationalisation itself has occurred as a result of the scope of practice of ENs recently being extended to incorporate medication administration.
The nursing profession and national organisations have recognised that extended and advanced practice roles need to be supported by the appropriate education, regulation and policy framework. Examples are listed below.
The last few years have seen the formalisation of an EN advanced perioperative practice role: the EN instrument nurse in New South Wales (Sutherland-Fraser, 2007). Even though the instrument nurse role has been performed by ENs in other parts of Australia and also internationally, it is a role that traditionally has been performed in New South Wales by RNs (NSW Health, 2007b). In 2003, a large area health service developed and piloted an in-house clinical program, known as the Perioperative Education Program for ENs (PEPEN). The successful pilot was followed by equally successful new PEPEN programs offered annually, with evidence that suitably selected and educated ENs in the instrument nurse role add to the flexibility of the nursing team and enhance patient care (Sutherland-Fraser, 2007).
In recognition of its success, a certificate course for this advanced practice role has been developed and offered by the College of Nursing since 2006 as part of its continuing education program (College of Nursing, 2007). In other states, such as Queensland, similar education programs are being developed to support this EN advanced practice role (Vargus, 2007).
Nationally, there are other providers of education programs for the perioperative EN, most notably TAFE institutions in New South Wales and South Australia. Currently, these programs do not prepare the EN for advanced practice roles; however, these certificates are valuable in terms of ongoing professional development for ENs and in preparation for employment in the perioperative environment.
This chapter has provided an outline of the perioperative nursing workforce and opportunities for entry to practice, as well as the importance of both formal and informal education. A brief overview of the development of nursing organisations and their role noted that specialist nursing organisations provide many valuable functions that contribute to the development of the nursing profession, as well as individual members. They have a key role in the development of standards for practice that, combined with evidence-based nursing, contribute to better patient outcomes. Finally, this chapter has considered the future for the perioperative nurse and explored the development and value of advanced practice roles.
You have commenced employment in the operating suite and are keen to join a professional association.
You are a nurse new to perioperative nursing and would like to participate in a formal education program in your area of perioperative nursing.
Identify one aspect of perioperative nursing practice that you have participated in or observed and consider the available evidence that supports this practice.
You think you would like to become a Nurse Practitioner in the operating suite. List your reasons for this, considering the following:
American Association of Nurse Anesthetists www.aana.com
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