Perioperative Education Perioperative Team Sir Mark Book

S E C TI ON 1 Fundamentals of Theory and Practice
1
Perioperative Education
CHAPTER OBJECTIVES auditory, tactile, sensory, kinesthetic, or performance-oriented
behaviors.
After studying this chapter the learner will be able to: Mentoring A nurturing, flexible relationship between a more
• Compare and contrast the art and science of surgery. experienced person and a less experienced person that
• Identify three characteristics of adult learners. involves trust, coaching, advice, guidance, and support.
• Name five educational resources available for the learner. A sharing relationship guided by the needs of the less experi-
• Define the difference between andragogy and pedagogy. enced person.
• Describe how adult learning principles apply to patient teaching. Objectives Written in behavioral terms, statements that determine
• Discuss the problems associated with disruptive behavior in the the expected outcomes of a behavior or process.
perioperative environment. Orientation Period during which a student or new employee
becomes acquainted with the environment, policies, and proce-
dures of a professional environment.
Pedagogy Teaching and learning processes for immature and/or
CHAPTER OUTLINE pediatric populations. A very directed style is used.
Perioperative Total surgical experience that encompasses preop-
The Art and Science of Surgery erative, intraoperative, and postoperative phases of patient care.
Perioperative Learner Preceptor A person who observes, teaches, and evaluates
Perioperative Educator a learner according to a prescribed format of training or
orientation.
Application of Theory to Practice
Psychomotor Pertaining to physical demonstration of mental
Expected Behaviors of Perioperative Caregivers processes (i.e., applying cognitive learning).
Realities of Clinical Practice Role model A person who is admired and emulated for good
practices in the clinical environment. The relationship between
a role model and a learner can be strictly professional without
KEY TERMS AND DEFINITIONS personalized mentoring.
Skill Application of knowledge into observable, measurable, and
Andragogy Teaching and learning processes for mature adult quantifiable performance.
populations. Surgery Branch of medicine that encompasses preoperative,
Behavior Actions or conduct indicative of a mental state or intraoperative, and postoperative care of patients. The discipline
predisposition influenced by emotions, feelings, beliefs, values, of surgery is both an art and a science.
morals, and ethics. Surgical conscience Awareness that develops from a knowledge
Bullying Power imbalance that involves intimidation, oppression, base of the importance of strict adherence to principles of asep-
or aggression and results in a counterproductive atmosphere. tic and sterile techniques.
Cognition Process of knowing or perceiving, such as learning Surgical procedure Invasive incision into body tissues or a mini-
scientific principles and observing their application. mally invasive entrance into a body cavity for either therapeutic
Competency Creative application of knowledge, skills, and inter- or diagnostic purposes; protective reflexes or self-care abilities
personal abilities in fulfilling functions to provide safe, individu- are potentially compromised during such a procedure.
alized patient care.
Critical thinking The mental process by which an individual solves
problems. EVOLVE WEBSITE
Disease Failure of the body to counteract stimuli or stresses http://evolve.elsevier.com/berrykohn
adequately, resulting in a disturbance in function or structure of • Historical Perspective
any part, organ, or system of the body. • Glossary
Evaluation A process by which the educator measures perfor-
mance by standardized indicators established by a school,
employer, or professional organization. The main focus of this chapter is to establish the baseline or
Knowledge Organized body of factual information. framework for an in-depth study of perioperative patient care
Learning style Individualized methods used by the learner to and support the educational process of the learner. Consideration
understand and retain new information. These may be visual, is given to the perioperative educator, who may not have had a
1
2 SECTION 1 Fundamentals of Theory and Practice
formal education in the teaching of adult learners. Both learn- surgeons, the health of the patient, and the availability of the
ers and educators should understand that the same learning and equipment.
teaching principles apply to patient education. The key terms are The purpose of this text is to provide a baseline for learning
commonly used terms that the learner should understand as the the professional and technical patient care knowledge and skill
basis for learning about and participating in the art and science required to provide safe and efficient care for patients in the peri-
of surgery. operative environment.
The Art and Science of Surgery Perioperative Learner

Health is both a personal and an economic asset. Optimal health The learner in the perioperative environment may be a medi-
is the best physiologic and psychological condition an individual cal, nursing, or surgical technology student enrolled in a formal
can experience. Disease is the inability to adequately counteract educational program, or the learner may be a newly hired ori-
physiologic stressors that cause disruption of the body’s homeosta- entee. Medical students have a surgical rotation that includes
sis. Additional influences, such as congenital anomalies, infection,
or trauma, interfere with optimal human health and quality of
life. As both a science and an art, surgery is the branch of medi- TABLE
cine that comprises perioperative patient care encompassing such 1-1 Common Indications for Surgical Procedures
activities as preoperative preparation, intraoperative judgment and
Indication for Surgical
management, and postoperative care of patients. As a discipline,
Procedure Example
surgery combines physiologic management with an interventional
aspect of treatment. The common indications for surgical inter- Augmentation Breast implants
vention include correction of defects, alteration of form, resto-
Debulking Decreasing the size of a mass
ration of function, diagnosis and/or treatment of diseases, and
palliation. Table 1-1 describes some of the most common indica- Incision Open tissue or structure by sharp
tions for surgery. dissection
In the 1930s the English physician Lord Berkeley George Excision Remove tissue or structure by sharp
Moynihan (1865-1936) said, “Surgery has been made safe for the dissection
patient; we must now make the patient safe for surgery.” Surgical
intervention is becoming a safer method of treating physiologic Diagnostics Biopsy tissue sample
conditions. Most of the former contraindications to surgery that Repair Closing of a hernia
were related to patient age or condition have been eliminated
because of better diagnostic methodologies and drug therapies. Removal Foreign body
More individuals are now considered better candidates for sur- Reconstruction Creation of a new breast
gery; however, each patient and each procedure are unique. Peri-
operative caregivers should not become complacent with routines Palliation Relief of obstruction
but should always be prepared for the unexpected. Surgery cannot Aesthetics Facelift
be considered completely safe all the time, and patient outcomes
Harvest Autologous skin graft
are not always predictable.
A surgical procedure may be invasive, minimally invasive, Procurement Donor organ
minimal access, or noninvasive. An invasive or minimal access
Transplant Placement of a donor organ or tissue
procedure enters the body either through an opening in the tis-
sues or by a natural body orifice. Noninvasive procedures are Bypass/shunt Vascular rerouting
frequently diagnostic and do not enter the body. Technology has Drainage/evacuation Incision into abscess
elevated the practice of surgery to a more precise science that
minimizes the “invasiveness” and enhances the functional aspects Stabilization Repair of a fracture
of the procedure. Recovery or postprocedure time decreases, and Parturition Cesarean section
the patient is restored to functional capacity faster. Improve-
ments in perioperative patient care technology are attributed to Termination Abortion of a pregnancy
the following: Staging Checking of cancer progression
• Surgical specialization of surgeons and teams
• Sophisticated diagnostic and intraoperative imaging tech- Extraction Removal of a tooth
niques Exploration Invasive examination
• Minimally invasive equipment and technology
Diversion Creation of a stoma for urine
• Ongoing research and technologic advancements
Surgical procedures are performed in hospitals, in surgeons’ Implantation Inserting a subsurface device
offices, or in freestanding surgical facilities. Many patients can
Replantation Reattaching a body part
safely have a surgical procedure as an outpatient and do not
require an overnight stay at the facility. The types of surgical Amputation Removing a large structure
procedures performed on an outpatient basis are determined Stenting Using an implant as a supporting device
by the complexity of the procedure and the general health of
the individual. Procedures performed on patients who remain Neoconstruction Face transplant
overnight in the hospital vary according to the expertise of the
CHAPTER 1 Perioperative Education 3
participation in surgical procedures. They learn some of the basic • Students are to maintain patient confidentiality at all times.
principles of surgical technology and sterile technique to ensure • Students may be screened by the school or facility by routine
the safety and welfare of patients. background checks and drug testing.
Some nursing schools offer basic exposure to perioperative • Students should be subject to health screening and vaccina-
nursing, as a short observation period, part of the core curricu- tions followed by titers for proof of immunity (i.e., varicella,
lum, or an elective. After graduating from nursing school the rubeola, DTaP [Diptheria, Tetanus, Pertussis], and hepatitis
nurse needs further education before functioning as a periopera- B). Tuberculosis testing should be performed before clinical
tive professional.1 This education may take place in a postbasic/ rotation.
postgraduate perioperative nursing course offered by a commu- All learners in the perioperative environment are adults and
nity college or a hospital orientation program. Entry-level educa- perform better if given due respect. This concept applies whether
tion for perioperative practice prepares nurses to be generalists. the caregiver is experienced or a novice. Treating an adult learner
Basic perioperative nursing elective programs focus on the role in a pedagogic manner (pedagogy), as a child is treated, is coun-
of the perioperative nurse as both generalist circulator and scrub terproductive and becomes a barrier to learning. The learner can
person. Specialization can follow a period in professional practice become resentful and unable to separate feelings of inexperience
in a specific service. The perioperative nurse’s role encompasses from feelings of inadequacy. Regardless of the level of learning
supervision of unlicensed personnel who scrub in surgery, such required, the general characteristics of the adult learner (andra-
as surgical technologists, and requires knowledge of practices and gogy) as compared with the child learner (pedagogy) apply
procedures performed under this title. (Table 1-2). These concepts also should be applied to patient
Surgical technology programs focus primarily on scrubbing education programs.
in to prepare and maintain the sterile surgical field and handle Not everyone learns at the same speed or assimilates informa-
instruments. Some surgical technology programs offer circulating tion in the same manner. Theoretic knowledge or a skill learned
experiences under the supervision of a registered nurse; however, quickly by one individual may be difficult for another. Cogni-
the role of the circulator requires knowledge and skill not com- tion is premised on the ability to process and retain information.
monly covered in significant depth in shorter training programs. Learning styles vary among individuals and are influenced by
Most surgical technology programs provide scrub experiences in internal and external factors. Examples of learning-style influences
many specialties. After satisfactory completion of the program are listed in Box 1-1. Learning styles were described in the early
many technologists are capable of functioning in the scrub role 1990s by Howard Gardner at Harvard University. Understanding
as a generalist or, in some circumstances, a specialist. Advancing the differences in individual learners is the first step to imparting
technology indicates the need for specialized competencies for knowledge and skill.2 Seven learning skills identified by Gardner
all disciplines of perioperative patient care. Surgeons, periopera-
tive nurses, and surgical technologists should continually strive
to learn new procedures and technologies in a team-oriented TABLE Characteristics of the Adult Learner as
environment. 1-2 Compared with the Child Learner
Perioperative caregivers new to a particular practice setting
should learn the specific performance standards and expectations Adult (Andragogy) Child (Pedagogy)
of that institution. All personnel go through an orientation pro- Is self-directed Is task oriented
cess to familiarize themselves with the philosophy, goals, policies,
procedures, role expectations, and physical facilities specific to Uses activities that follow Uses activities that follow stages
transitions of maturity of development
their institution. Departmental orientation is specific to the area
in which the caregiver is employed. Uses intrinsic thought processes Uses extrinsic thought processes
Many graduates seek employment in the institutions where
Uses problem-solving approach Uses trial-and-error approach
they performed clinical rotations. This is usually beneficial to the
facility and the employee. Some students are hired into appren- Values self-esteem Values self-esteem
ticeships before graduation, enabling them to work in the OR in a
limited capacity in anticipation of a permanent position. Schools
that permit students to work while still in the education process
should have a policy in place to delineate the student role from • BOX 1-1 Learning-Style Influences
the employee role. The policy should be made known in writing
to all clinical facilities hosting students and students performing • Intelligence
clinical rotations where apprenticeships are offered. The following • Attentiveness
are considerations in developing a policy for working students: • Cultural and ethnic background
• Students may not work for compensation during official clini- • Educational preparation
• Motivation to learn
cal hours.
• Concentration and distractibility
• Students may not wear facility name or identification badges • Personality characteristics
while performing clinical rotations as an agent of the school. • Psychologic strengths or deficiencies
• Students may not wear school name or identification badges • Social skills, including communication skills
while performing work for compensation as an agent of the • Manual dexterity
facility. • Physical senses
• Students may not take time off from classroom or clinical rota- • Physical health
tions to work for compensation. • Perceptual preferences and sensory partiality (e.g., visual vs. auditory)
• Students are not part of the clinical staff during clinical rota- • Environment
tion hours.
are summarized as follows with application of teaching methods sterile field. Both disciplines of learners help prepare for, assist a
for perioperative learners: qualified preceptor during, and clean up after surgical procedures,
1. Visual-spatial: Very environmentally aware. Learns well by but they are not considered members of the staff complement.
observation, puzzles, graphics, and modeling. Instructional staff should observe for and guard against laziness in
• The educator can create poster boards with images of instru- the preceptor group. Some preceptors may want to sit back in the
ment pictures and setups. Posters can have backgrounds of pretense of “letting the student take over.” In essence this is not
blank sterile fields constructed of felt and cardboard cut- an improper approach to precepting, but it can be abused if the
outs of instruments with Velcro backing for students to preceptor continually leaves the student to flounder or delay the
place on the surface. progress of the procedure.
2. Bodily kinesthetic: Keen sense of motion and hands-on sense. Some preceptors and surgeons may “bully” the students and
Communicates well by physical practice. become impatient because of the students’ inexperience. Bullying
• The educator can provide sterile drapes and instrument is counter-productive. Students should be taught to respect the
trays for students’ use in preparing sterile fields and set- preceptors and surgeons, but not fear them.3 Most facilities have
ups. The task can be made more challenging by timing the developed a “zero tolerance” policy concerning interprofessional
process and creating competition for the best time with relationships wherein one person causes another person to feel
the highest degree of accuracy. Microscope draping teams intimidated or fearful.
competing against each other make the activity fun and Students should know basic standards and protocol before
exciting. entering the OR for a clinical rotation. Preceptors may have devel-
3. Musical: Learns well by listening and the use of multimedia. oped shortcuts with questionable technique not understood by
Frequently learns better with music in the background. students who are new to the OR environment. Students should
• The educator (with the help of the students) can enumerate not blindly perform tasks directed by preceptors that cause ques-
specific steps to a procedure, such as donning the sterile tion as to technique or safety without fully understanding what
gown and gloves. The steps are recited to a musical beat resultant outcome is expected.4 Educators should discuss the
provided by rhythmic clapping or to an instrumental back- potential for these questionable events and give the student a
ground tune. Most students recognize simple childhood vehicle for professionally or assertively deferring or opting out of
tunes and can sing or say the steps to the music. Also, mod- doing something that is nonstandard by the level of education
ern musical instrumentals are easy to use for this purpose. they have experienced in the classroom. This process can be par-
4. Interpersonal: Group dynamics and study sessions work well for ticularly uncomfortable if the student does not feel supported by
this learner. the educator, who is a mentor in the environment, in doing what
• The educator can assign topics to groups for exploration has been ingrained as the standard of care. Some examples of this
and development. The students present their findings to the activity include but are not limited to the following (these exam-
class in a forum setting. Some students may want to simu- ples actually happened at a clinical site):
late procedures for the class. 1. Event: Preceptor insists on gowning and gloving from the pri-
5. Intrapersonal: Learns well through self-study and indepen- mary sterile field and instructs the student to do so as well.
dence. Highly self-motivated and disciplined. Student deferral vehicle: “My clinical instructor will give me a
• The educator can guide individual students in the creation deficiency grade if I gown and glove from the back table. I am
of personal flashcards or organization of class notes. Stu- required to gown and glove from a separate surface other than
dents who learn best by self-study generally seek assistance the main field.”
only when further explanation or clarification is needed. 2. Event: Preceptor is impatient and goes to sit on a stool in the
6. Linguistic: Very good with language and auditory skill. Learns corner because part of the procedure is taking a long time.
effectively through lectures and explanation. Student deferral vehicle: “My clinical instructor will give me a
• The educator presents lectures on specific topics and uses deficiency grade if I sit and change the level of sterility of the
multimedia to reinforce the discussion. PowerPoint presen- front of my gown.”
tations enhance the lecture and can be printed for the stu- 3. Event: Preceptor instructs the student to offer a towel from the
dents to use in following along. Embedded video is useful open and biologically contaminated back table to a person who
and links to websites provide variety, plans to enter the working sterile field. Student deferral vehicle:
7. Logical-mathematical: Prefers to investigate and solve problems. “My clinical instructor will give me a deficiency grade if I offer
Conceptual thinking precedes detailing with these learners. a towel from my working back table.”
• The educator can use several testing formats to challenge the Learners are not expected to assume responsibilities for which
learners. Tables set up with instruments for identification they are not fully prepared, but they should be taught to politely
by category or classification give students the opportunity speak up when something is not right for the benefit of the team
to determine how each item is used in a particular specialty. and the patient. Only through continued study and experience
An interesting twist to this method involves intentionally can individuals qualify as team members in the perioperative
omitting a particularly necessary item from the field; the environment.
students have to reconstruct the steps of the procedure to The new perioperative nurse in a hospital orientation program,
figure out which item is missing. who will be functioning in interchangeable scrub and circulating
Each facility should clearly define the role of the perioperative roles, may learn the scrub role first in the learning sequence so
learner of each discipline. Activities of new perioperative nurses as to learn the art of anticipation of surgeon and patient needs
and surgical technology students are not the same. The periopera- during a surgical procedure. This is the closest vantage point by
tive nurse is involved with more direct patient care and decision which participation enables the perioperative nurse to be familiar-
making through physical assessment. The student surgical technol- ized with the surgical process. An educator, preceptor, or other
ogist is concerned primarily with preparing and maintaining the qualified staff member scrubs in as support and gradually allows
the new perioperative nurse to take over more of the work in the typing words in all caps. The slide color scheme and design can be
sterile field. One of the primary behavioral objectives is to gain selected from predesigned templates or customized per presenta-
knowledge and skill in sterile technique. Performing the scrub tion. Colors such as blue and green are easier on the eyes than
role allows repetition of tasks performed within the sterile field reds, oranges, and bright yellows. Time between slide changes
and better prepares the perioperative nurse to supervise surgical should permit questions or examples.
technologists. Positive reinforcement helps the learner build confidence and
The second component of the perioperative nurse’s learning competence. The educator should not punish a learner for making
sequence is the circulating role. A registered nurse preceptor is honest errors during supervised learning. Degradation and dam-
assigned to teach the new nurse the coordination of the scrub and age to self-esteem are barriers to learning. The learner should not
circulating roles. Standard routines are taught under the super- be required to perform any function for which he or she has not
vision of an experienced perioperative nurse with comparable had adequate training or guided practice. The educator should
knowledge, skill, and educational preparation. Guidance and help maintain a list of procedures in which the learner has participated
from the clinical educator and other experienced staff members and has demonstrated increasing levels of competence. Whether
help the new perioperative nurse pull it all together. Surgeons and the learner is in a school-sponsored OR education program or a
other staff members contribute to the learning process. departmental orientation program, the duration of the program
Personality traits, such as emotional maturity, social skills, and should be sufficient to afford opportunities for adequate experi-
psychologic characteristics, are continually assessed by the educa- ence to facilitate success. The AORN position statement on basic
tor.4 A moody, easily angered, and negative person can be very dif- orientation recommends a period of 40 hours in each specialty as
ficult to deal with as a future team member. The learner who does part of the orientation process.
not possess assertive skills for dealing with stressful events cannot Check-off sheets can help to track experiential progress during
function effectively in a team environment. Subjective responses the education process. Figure 1-1 shows an example of a basic
to all activities should remain on a professional level if the team is check-off sheet for the evaluation of knowledge and skill in the
to function efficiently. The perioperative nurse in training should scrub role. Figure 1-2 shows an example of a basic check-off sheet
be evaluated on a periodic basis to assess for increased compe- for evaluation of knowledge and skill in the circulating nurse’s
tency levels. role. This sheet can be modified to apply to specialties as needed.
The Association of Surgical Technologists (AST) and AORN have
Perioperative Educator developed skills checklists available through the organizations.
Experience in the perioperative clinical setting should be planned Behavioral Objectives

and supervised by an experienced perioperative nurse educator.
The term educator is used throughout this text to refer to the per- The learner takes an active role in the teaching/learning process
son responsible for planning, implementing, and evaluating the by helping identify behavioral objectives. Effective and organized
learner’s experiences in the classroom and clinical perioperative educational experiences are identified and based on these objec-
setting. Other teaching personnel at the clinical site include peri- tives. The identified behavioral objectives are attained through
operative nurse preceptors. critical-thinking exercises. Skill in questioning and encourage-
The educator should consider the effect on the learner who is ment in making discoveries allow the learner to use critical think-
seeing the perioperative environment for the first time. The OR ing as a learning tool.
can appear cold, large, and overwhelming. A tour of the facil- Evaluation of the learner’s progress is measured by how suc-
ity before beginning the program can help decrease the learner’s cessfully the learner has met the behavioral objectives. Behavioral
anxiety. objectives are identified and written in behavioral terms and based
A structured curriculum uses behavioral objectives, written on standards of expected performance and accepted standards of
guidelines, and relevant assignments for feedback to ensure that patient care. In 1956, Benjamin Bloom described the measure-
learning has occurred. Learner conferences are held at regular ment of cognitive learning. He detailed six levels of learning, rang-
intervals to discuss procedures and progress. AORN (The Asso- ing from simple recall to advanced abstract thinking.
ciation of periOperative Registered Nurses) offers perioperative Bloom’s taxonomy provides a framework for structuring cogni-
nursing coursework in their Periop 101 program purchased by tive and affective learning. Therefore the concepts to be learned
hospitals for training of new perioperative nurses. and the behavioral objectives to be met should form the foun-
Didactic presentations should be incorporated into the teaching dation on which all perioperative caregivers build their practice.
program to provide information concerning the theory and detail Each behavioral objective in Box 1-2 is measurable and is evalu-
of all performed actions in the perioperative environment. Pre- ated by performance standards.
sentations should be offered by knowledgeable presenters who are
well prepared to deliver information to the group. If PowerPoint Elements of Effective Instruction
multimedia are used, the educator should be sure to use accurate
and concise terminology when creating the slides. Handouts can The organization of the instructional material and the learning
be printed in several formats for distribution to the participants to experience are further enhanced by the way the program is pre-
use when following along with the talk or taking notes. Overload- sented. The elements of effective instruction are summarized as
ing each slide with wordiness and silly images causes confusion follows:
and wastes time. The key elements should be simply worded and • Set clear and concise behavioral objectives measurable in cog-
should not exceed six lines of text per slide. The educator should nitive terminology that describes knowledge, comprehension,
not read exactly from the slides, but explain while incorporating application, analysis, understanding, and evaluation.
the concept the slide imparts. Font style should be simple and font • Establish a learning environment that is controlled by the
size should be readable even at the back of the classroom. Avoid educator.
Meets Needs Improving Does Not Meet

Evaluation Comments
Standard Improvement Yes or No Standard
Reports for duty in a punctual manner
Wears OR attire properly:

Dons personal protective gear
Dons radiation badge as needed
Performs housekeeping duties:

Before first procedure of day
Between procedures
After last procedure of day
Sterile supplies:
Plans and gathers supplies
Checks integrity of packages
Checks sterility integrator
Checks dates on perishables
Places items on sterile surface:

Opening wrapper(s)
Peel packages
Solution dispensing
Scrubs for setup and procedure:

Hand and arm scrubbing
Hand hygiene with hand antiseptic
Gowning:
Gowns self correctly
Gowns others
Gloves:
Closed method
Open method
Changes contaminated glove
Gloves others
Sterile setup:
Drapes table and Mayo stand
Positions items in the field
Accountability:
Participates in timeout before
incision
Labels solutions and drugs
Reports amount of use
Practices safety
Maintains the sterile field
Responds appropriately to emergent
situations
Anticipates needs of surgeon:

Coordinates with circulator
Facilitates the first assistant
Passes instrumentation
Prepares and applies dressing
materials
Counts:
Sponges
Sharps
Instruments
Assembles instruments:
Attaches knife blades on handles
Loads or prepares suture
Tests drills and devices
Other
Disassembles the table:

Follows proper disposal of items
Follows decontamination procedures
Removes gown and gloves:

Gown off first
Glove-to-glove/skin-to-skin
• FIG. 1-1 Performance appraisal of the scrub role.

Meets Needs Improving Does Not Meet

Evaluation Comments
Standard Improvement Yes or No Standard
Reports for the duty in a punctual manner
Wears OR attire properly:

Dons personal protective gear
Dons radiation badge as needed
Performs housekeeping duties:

Before first procedure of day
Between procedures
After last procedure of day
Sterile supplies:
Plans and gathers supplies
Checks integrity of packages
Checks sterility integrator
Checks dates on perishables
Dispenses or transfers items to sterile surface as appropriate:

Opens wrapper(s) and peel packs
Opens closed container
Solution dispensing
Medication dispensing
Validates implant parameters and documents in the lot log
Practices aseptic technique:

Dons and removes sterile or nonsterile gloves as appropriate
for task
Hand hygiene with hand antiseptic
Gowning and gloving of others:

Ties gowns for sterile team members
Assists with contaminated glove removal
Provides additional gowns and gloves as needed
Accountability:
Gathers and checks solutions and drugs for use on the field
Documents amount of usage of drugs and solutions on the field
Practices safety for the patient and team
Monitors the sterile field and the members of the sterile team
Anticipates needs of patient, anesthesia provider, surgeon, and

other team members:
Coordinates with the scrub person
Obtains additional supplies and instrumentation as needed
Provides safe and competent direct patient care:

Patient advocate
Patient identification
Assists the anesthesia provider as needed during induction
Validates correct site protocol and time out procedures
Patient assessment
Responds appropriately to emergent situations
Supports psychosocial aspects of care
Positioning and prepping as appropriate
Monitoring physiologic and psychologic responses as appropriate
Cares for specimens
Patient teaching
Counts:
Sponges
Sharps
Instruments
Documents any other item added to the field intraoperatively
Attaches and activates surgical machinery and devices for the

sterile field:
Electrosurgery (ESU) cables, suction, power cords, and other
peripheral equipment
Activates, sets, and monitors peripheral equipment
Supervises and manages the room:

Plans and implements direct patient care using the nursing process
Directs the activities of learners
Communicates procedural progress to the control desk
Communicates with family members
Manages messages for the surgeon and first assistant
Prevents inappropriate traffic through the room
Documents procedural activities in patient record
Computer literacy
Uses patient electronic medical record responsibly
Maintains patient confidentiality
Manages patient charge items responsibly
• FIG. 1-2 Performance appraisal of the circulating nurse’s role.

• BOX 1-2 Behavioral Objectives for Perioperative experience. The learners gain knowledge by observing and work-
ing with members of the entire team. Everyone should be familiar
Team Members
with the level of the learners, the behavioral objectives, and the
• To identify the role and responsibility of each team member teaching roles that staff members are expected to assume. Learn-
• To define current standard terminology associated with perioperative ers also should be responsible for updating the staff about needed
patient care through use of the perioperative nursing data set (PNDS) experience and their current level of achievement.
• To compare and contrast knowledge of normal anatomy, physiology, and Hospitals or facilities offering the clinical perioperative setting
pathophysiology for educational programs have policies and procedures that are
• To discuss the interrelationships among physiologic, ethnocultural, and adaptations of national standards. All personnel, including faculty
psychosocial factors that affect a patient and family’s adaptation to the
members and learners, are expected to adhere to their content.
perioperative experience
• To identify the procedures necessary to prepare each patient as an
individual for the intended surgical procedure
PROS/CONS
• To demonstrate the ability to select appropriate instrumentation,
equipment, and supplies according to the individualized plan of care Perioperative Educator: Engaging the Learner
• To apply the principles of sterilization, disinfection, and aseptic and
sterile techniques in the preparation and use of all materials in
the perioperative environment to prevent transmission of biologic PROS
contamination • Health care facilities perform better when employees are engaged
• To identify the potential environmental hazards to the patient and team with what they are doing. Commitment is linked to job satisfaction
• To demonstrate knowledge of the basic actions and uses of anesthetic and better organizational performances.
agents, medications, fluid therapies, and electrolytes • Educators and managers must recognize the current culture of their
• To demonstrate knowledge and skill during the surgical procedure by department and find ways for improvement.
anticipating the needs of the patient and the team • Health care facilities require education on certain topics as part of
• To discuss the principles of wound management employee annual training. These competencies may be required
• To function as a team member by showing consideration for and yearly and are documented in the employee record.
cooperation with other perioperative caregivers • As part of continuing education, a facility may have a perioperative
• To communicate effectively with personnel on other patient care educator or manager who follows a structured curriculum according
divisions within the facility to the facility guidelines and policies.
• To develop the ability to perform safely and effectively during stressful • Scheduled regular in-services are planned when most employees
situations can be present; this usually occurs during the work day. Employees
who are not in attendance may need to reschedule with the
educator to cover the missed material.
• Provide variation in presenting material. Videotapes, DVDs, • Staff involvement during in-services increases when they are
recognized, part of decision making, on a unit council, involved in
audiodiscs, and photographs can be alternated with lectures
teamwork, in training, and recruited to assist.
and hands-on practice. Handling instruments and supplies in • A structured presentation keeps the group interested. When
a classroom is less intimidating than handling them in the peri- knowledge is linked with previous knowledge and preexisting
operative environment for the first time. cognitive structure, effective learning occurs.
• Encourage the exchange of questions and answers as an assess- • People retain information in different ways. Some positive ways to
ment tool. Learners often ask exactly what they need to know. engage staff during an in-service includes: vary the tone of your
The educator can determine areas of deficient knowledge. voice, include positive body language, practice presentation skills,
• Reinforce learning. After a skill has been taught in a didac- offer refreshments, tell a story, ask questions, role play, use fewer
tic manner, provide guided practice in the clinical laboratory words, and use technology.
before the task is actually performed in the perioperative envi- • Understanding information is easier through the use of images,
color, audiovisual, demonstration, and active participation.
ronment. Provide positive support for desired behaviors. Self-
• Employees may have preclass preparation such as an article to
assessment tools and performance evaluations provide feedback read, small group discussions, and simulation. Each employee may
about the learner’s progress. be required to demonstrate the simulation during the in-service.
• Summarize the learner’s accomplishments at regular intervals. This helps build confidence and competence through positive
Reviewing daily activities helps reinforce the learning process reinforcement.
by allowing the learner to associate the events of his or her • Use surveys and committees to engage staff; this encourages
experience with newly acquired knowledge. participation and a chance to be heard.
The educator should work closely with the perioperative nurse
manager. Classroom hours and clinical experience assignments are CONS
coordinated to provide the best experience for the learner. The • Low morale and poor job satisfaction lead to low participation in
nurse manager offers suggestions and coordination input for the educational activities. Workplace culture is hard to change and often
benefit of the learner and staff members. The educator identifies ingrained into the culture of the facility.
• Unprofessional behavior and bullying create bad employee attitudes
areas of needed experience for the learner. An effort is made to
and need to be redirected. Redirection may increase in-service
confer and coordinate any changes in the program with all person- participation, positivity, and a better learning environment.
nel in the department. The educator and the manager collaborate • People forget what was taught and done during boring in-services.
with the assigned preceptors as needed. These strategies foster a They get distracted easily. Use emotion because it is a strong
friendly and cooperative relationship among learners, educators, memory stimulus and can be more effective than reading data.
management, and preceptor staff. • Large groups tend to be less engaging. Break a large group into
All perioperative staff members indirectly assist in teach- smaller groups if possible because they are more productive.
ing the learners within the guidelines of the structured learning
Really Simple Syndication (RSS) feeds are subscription ser-

References
vices that provide information via computer or cell phone in
1. Brunges M, Foley-Brinza C: Projects for increasing job satisfaction and creat- the form of email. RSS data is small so it works well with smart
ing a healthy work environment, AORN Journal 100(6):670–681, 2014.
phones. A software RSS reader program is necessary to receive
2. Wolff M, Wagner MG, Poznanski S, et al.: Not another boring lecture: Engaging
learners with active learning techniques, J Emerg Med 48(1):85–93, 2015. and open RSS feeds. The readers are free on the Internet and are
3. Killu A, Sabbagh A: The art of presentation, J Am Coll Cardiol part of browser packages such as Internet Explorer or Firefox.
65(13):1373–1376, 2015. Collections of educational medical and nursing RSS feeds are
found at www.medworm.com.
5. Specialty online news groups can be subscribed to through
computerized email systems. Referred to as ListServ, these
groups are communication tools for day-to-day discussions
Media and Print Learning Resources with others who have comparable interests. They are available
Books, journals, videos, DVDs, slides, photographs, computers, as daily e-mail entries or as a weekly digest. Yahoo Groups
and audiovisual materials may supplement the lecture approach offers ListServes for special interest groups. Classes can estab-
to perioperative education. Larger teaching institutions may have lish their own ListServ at Yahoo with a classmate serving as a
live closed-circuit television and interactive telecommunication moderator. The specialty assemblies at aorn.org have member-
systems that permit educators and learners to communicate from ship blogs where members share ideas. The surgical technology
remote locations. Many audiovisual materials, such as videodiscs, website has educator and student blog sites to discuss topics of
audiotapes, and computer-assisted instruction, are self-contained interest for surgical technologists.
units for individual study. A bibliography in a text such as this or 6. Literary databases are found on select websites and in most
at the conclusion of a journal article provides references to broaden libraries. Examples of on-line literary databases include but are
the learner’s database. Accessibility to current medical and scien- not limited to the following:
tific literature is without limit. Other sources include websites on a. Cumulative Index to Nursing and Allied Health Literature
the Internet and educational services that provide contact hours (CINAHL) is a widely used index for nursing and allied
online. health. The database includes indexing by subject headings
The following are useful resources for acquiring and reinforcing from virtually all English-language nursing journals and allied
knowledge: health literature from January 1983, with bimonthly updates.
1. Library and literature file. Books and current periodicals are b. Medical Literature Analysis and Retrieval System Online
available for the learner’s reference in the medical library, (MEDLINE) is a computer-based reference system avail-
online, and in learning centers at local colleges. able at most libraries in the United States and Canada.
2. Educational literature and DVDs are available from surgical Many websites on the Internet offer free MEDLINE access.
supply and instrument manufacturers. Most manufacturers Biomedical journals, including nursing journals, are refer-
have their product literature and educational material online. enced. The file contains references dating from 1966 at the
All personnel who will be working with the item should review National Library of Medicine (www.nih.gov).
the literature that accompanies new equipment. Inservices are c. Medscape (www.medscape.com) is a free article subscrip-
commonly provided by clinical staff associated with the indus- tion service online. This site requires registration. The user
try. The purchasing agent is a good source for these types of selects an identification name and password. Many differ-
references. ent specialty services are represented in print with continu-
3. Computer database information systems are available in ing education credits.
most facilities or through personal Internet access providers The array of health-related educational materials is endless. The
for researching topics of interest for self-study or for supple- Internet, which is accessible 24 hours a day, has opened many
menting classroom presentations. Computer terminology is channels of information throughout the world. Many websites
defined at www.sharpened.net/glossary for new computer can be accessed in a multilingual mode, including Spanish, Ger-
users. Web browsers such as Microsoft’s Internet Explorer, man, French, and Japanese. Some websites offer full-text articles
Mozilla’s Firefox, Apple’s Safari, Opera, and Google’s Chrome that can be uploaded or printed. Some of the articles are in .zip
are used in searching the World Wide Web (WWW). Most or .pdf format that requires WinZip or Adobe Acrobat Reader to
of the search engines have an image-finding capability, which open the file into a readable and/or printable document. WinZip
is good because it allows students to associate the image with and Acrobat Reader are free programs that can be downloaded
a procedure. Search engines such as Bing and Google are and used repeatedly to open zipped or pdf files. Websites such
valuable tools for finding special-interest groups and profes- as www.download.com offer links to free file-opening software.
sional medical associations. Most health-related organiza- These programs are frequently preloaded onto the hard drive of
tions have a website full of information for professionals and new computer models.
patients. AORN Online can be accessed at www.aorn.org. The advancement of computer technology has made computer
AST has a website (www.ast.org) that provides information equipment small enough to fit in a backpack and economical
about surgical technology. Terms associated with the Inter- enough for the average household to own one computer and pos-
net and computer can be found at http://evolve.elsevier.com sibly two. Tablets and similar devices are good for reading eBooks.
/BerryKohn. Multiple books can be stored on one device.
4. Internet broadcasting in podcast format can be uploaded into an When researching scientific data on the Internet, it is advis-
iPod or MP3 player in audio or video format for remote viewing. able to review more than one website to support the accuracy of
Netcasts or webinars are online broadcasts for use on PCs the information. Caution is advised regarding providing personal
or Macs. Many of the topics are available via the Apple iTunes information such as credit card numbers over the Internet; secu-
store. Accounts can be set up with a credit card or PayPal. rity may be an issue.
Application of Theory to Practice Above all, perioperative experience teaches that no surgical proce-
dure is a minor event to the surgical patient! The only predictable
Learning is a process of discovery and mastery of skills. Perfor- element in the perioperative environment is the potential for an
mance-based learning to function competently in an area such as unpredictable occurrence. For practical use, hospitals may classify
the perioperative environment should take place on three levels: surgical procedures as major or minor; however, in reality no such
cognitive, psychomotor, and affective. The learner should under- distinction exists. Every procedure has a deep personal meaning
stand the scientific principles (cognitive learning) underlying the for each patient and his or her family, and the possibility of an
technical skills (psychomotor learning) and should appreciate the unfavorable outcome can never be completely excluded. All peri-
necessity of adhering to these principles (affective learning). In operative procedures carry an element of inherent risk. A relatively
simpler terms the learner should know why to do what (cogni- safe procedure can rapidly become catastrophic, even fatal, if the
tive); how (psychomotor); and when, where, and by whom (affec- patient:
tive). The learner should always have a rationale for each action. • Is unknowingly allergic or sensitive to a chemical, substance,
Learners and practicing perioperative caregivers should always medication, or anesthetic drug
know exactly why they are doing what they are doing—not just • Develops uncontrollable bleeding
blindly perform tasks. This approach enables an intelligent modi- • Has seizures
fication of the plan of care in the event of an emergency or other • Experiences cardiac arrest on the OR bed
untoward situation. In actual practice this knowledge may be criti- • Goes into irreversible shock (cardiogenic, hematologic, hypo-
cal for patient safety and attainment of favorable outcomes. volemic, neurogenic, toxic, or vasogenic)
Practice will give learners an opportunity to apply their knowl- • Develops a metabolic event such as malignant hyperthermia,
edge of the basic sciences. Theory becomes meaningful and valu- thyroid storm, hyperglycemia, or hypoglycemia
able only when put to practical use. Some knowledge is gained Although every precaution is taken to foresee and prevent
through observation, but skills are learned through actual hands- adverse reactions, such reactions do occur on occasion. No mat-
on experience in applying the theory learned in the classroom or ter how simple the procedure, an experienced, conscientious team
self-study laboratory. member is always acutely aware of potential problems and gives
In the perioperative environment the learner observes liv- undivided attention to the patient and procedure at all times.
ing anatomy; its alteration by congenital deformities, disease, or During the learning experience the learner will participate in
injury; and its restoration or reconstruction. Perioperative experi- or observe the preparation of supplies and equipment and learn
ence enables the learner to be a more understanding, observant, their intended use. With practical experience the learner will gain
and efficient person. In close teamwork with surgeons and anes- an appreciation for the precision of surgical instrumentation and
thesia providers the nurse and the surgical technologist participate equipment. Also, in helping to carry out a daily schedule of surgi-
in vital resuscitative measures and learn to care for anesthetized, cal procedures the learner will become aware of the interdepen-
unconscious, and/or critically ill patients. Learning to function dence of the various departments within the facility and how they
in life-threatening situations is critical to the patient’s welfare. In work together for the well-being of the patient. One of the most
addition, the learner discovers that emergencies such as cardiac valuable learning experiences in the perioperative environment is
arrest are easier to prevent than treat. By learning how theory the opportunity to see and become a part of real teamwork in
applies to clinical practice, the student gains valuable experience action. Chapter 25 explores and explains the coordinated roles of
that is applicable to any patient care situation. The learner should the circulating nurse and the scrub person.
strive to attain the following objectives:
• Appreciate what surgical intervention means to each patient.
• Recognize the importance of optimal physical and psychologic Expected Behaviors of Perioperative
preoperative patient preparation. Caregivers
• Validate the need for constant patient observation intraopera-
tively. Regardless of their respective roles, all perioperative caregivers are
• Determine the cause of postoperative pain and/or complica- expected to be competent and humane. A patient’s sense of secu-
tions. rity is grounded in how he or she perceives the behavior of the
• Differentiate between seemingly innocuous occurrences and team as a whole. This leaves a lasting impression that patients asso-
situations that, if left unrecognized and allowed to progress, ciate with their experiences in the perioperative environment. The
lead to injury of the patient or a team member or damage to behavior of the team reveals self-confidence (or diffidence), inter-
departmental equipment. est (or indifference), proficiency (or ineptitude), and authority (or
• Cope with all situations in a calm, efficient manner, and think indecision). In addition to possessing technical knowledge and
clearly and act quickly in an emergency. skill, personnel should display appropriate personal attributes and
• Attend to every detail, observe keenly, and anticipate the needs communication skills that inspire confidence and trust in patients
of the patient and team members. and other team members.
• Determine the importance of aseptic and sterile techniques,
and comprehensively and conscientiously apply knowledge to Personal Attributes
practice.
• Expect the unexpected. Situations or conditions can change at Personal attributes are manifest in the attitudes displayed by an
a moment’s notice. The student should use the “what if ” phi- individual while performing his or her duties. These inherent
losophy for planning patient care. Thinking ahead and antici- characteristics contribute to interrelatedness of the team and the
pating what to do “if ” the patient becomes critical benefit the final outcome for the patient. Although these concepts are intrin-
patient and the team by minimizing the element of surprise sic to the individual and are certainly open to interpretation, the
when unexpected events occur. main premise remains focused on providing safe and efficient
patient care through a team effort. Desirable personal attributes the patient—those in direct patient contact, and those in other
are listed in Table 1-3. departments whose services are essential and contribute indirectly
to patient care. Interdependence characterizes a team—without
the other members, the goals cannot be met.
Communication The team approach to patient care should be a coordinated
Communication is essential for exchanging information with effort that is performed with the cooperation of all caregivers.
another person. It is necessary for successful interpersonal rela- Team members should communicate and should have a shared
tionships and serves to clarify actions. Communication is pro- division of duties to perform specified tasks as a unified body. The
active when an idea or intent is relayed to another person and failure of any one member to perform his or her role can have
reactive when a response is received. Communication has taken a serious effect on the success of the entire team. Performing as
place when the receiver interprets the message in the manner a team requires that each member exert an effort to attain the
intended by the sender. Communication is effective only when common goals competently and safely. The actions of each team
the patient and caregivers understand one another. A key element member are important. No one individual can accomplish the
is to demonstrate appropriate body language to match the spoken goal without the cooperation of the rest of the team.
word. Pride in one’s work, and in the team as a whole, leads to per-
sonal satisfaction. High morale is facilitated by adequate staff ori-
entation, staff participation in departmental decision making and
Teamwork problem solving, the receipt of deserved praise, the opportunity
A team is a group of two or more people who recognize com- for continuing education, and motivation to reach and practice at
mon goals and coordinate their efforts to achieve them. Broadly the highest potential.
defined, the health care team includes all personnel relating to The common goal of the perioperative team is the effective
delivery of care in a safe, efficient, and timely manner. To function
efficiently, team members must communicate effectively. Prob-
TABLE lems such as a break in aseptic or sterile technique must be iden-
1-3 Attributes Expected in a Perioperative Caregiver tified and corrective actions taken. To fulfill expectations, team
members must be aware of each other’s needs for information.
Desirable Attribute Measurable Behaviors Efforts of other support services, such as radiology and pathology
Empathy Develop a sense of what the patient is departments, are coordinated with the needs of the surgeon.
feeling Mutual respect is the foundation of teamwork. It is also a right.
Respect is shown through collaboration, cooperation, and truth-
Conscientiousness No compromise in quality of care ful communication. Verbal abuse, disruptive behavior, and harass-
Efficiency Organized and properly prepared; time is ment are out of place in the professional environment. Behavior
not wasted duplicating steps that inhibits the performance of team members or threatens
patient safety should be factually documented and reported to
Sensitivity Genuine caring and perceptiveness for the
patient and the team superiors in the chain of command. The Joint Commission (TJC)
requires accredited facilities to establish leadership standards that
Open-mindedness Accepting of the ideas of others address disruptive and inappropriate behaviors as follows:
Flexible and adaptable Able to cope with changes in routine 1. Defines a code of conduct to distinguish between acceptable
and inappropriate behaviors in interpersonal relationships in
Supportive Nonjudgmental and sincere approach to the perioperative environment.
relationships 2. Creates and implements a process for managing behaviors that
Communicative Exchanges information in a professional undermine a culture of safety in the perioperative environment
manner Teamwork requires the commitment and effort of team mem-
bers to increase productivity, ensure quality performance, and
Listening Accepts and receives information in a
professional manner
participate in problem solving by communicating and cooperat-
ing with one another. A team approach is necessary for patient-
Even-temperedness Hostility and anger have no place in the centered care. Surgeons, assistants, anesthesia providers, patient
perioperative environment care staff, and staff of supporting services should coordinate their
Versatility Knowledgeable and can troubleshoot efforts. Each discipline contributes to successful outcomes of sur-
gical intervention by working together as a team. Several factors
Analytic Knowing how and why for each task contribute to these successful outcomes:
Creativity Able to innovate solutions 1. Interdepartmental communication is important for mutual
cooperation, consideration, and efficient collaboration.
Sense of humor Eases tension at appropriate times
a. Personnel on patient care divisions and physicians share
Manual dexterity Good hand-eye coordination pertinent information concerning patients. Collected data
are documented, thereby protecting the patient, the patient
Stamina Capable of standing for prolonged periods
care personnel, and the facility.
Good hygiene Body odors cause discomfort for the team b. Personnel work together in a congenial atmosphere with
Ethics Strong sense of truth, honor, and goodness
respect and appreciation for each other’s unique skills and
contributions. Team members benefit from the expertise of
Curiosity Desire to know and learn new things each other. Teamwork is at its finest in the perioperative
environment.
c. Personnel are considerate of each other and the patient. must be competent to fulfill this requirement independent of a
• The surgeon should inform the team of any anticipated preceptor.
potential deviation from his or her regular routine for
the scheduled procedure. An advance notice of changes Reality Shock
can help avoid delays in obtaining needed equipment.
• The perioperative team promotes a quiet atmosphere to Reality is a sense of actuality, a feeling that this is what the real
ensure the surgeon’s uninterrupted concentration. Inter- world is all about. Reality shock sets in as the transition takes place
ruptions during the procedure can cause the team to lose from being a beginning learner to becoming an employed gradu-
concentration and jeopardize the safety of the patient or ate professional nurse or surgical technologist. The familiar educa-
team members. tor and peer learners are not always present to give counsel, advice,
• The anesthesia provider and circulating nurse assist each and moral support. As professional caregivers attempt to adapt to
other with certain procedures such as medication admin- new demands, they need to remember the following:
istration and intubation. • Learning does not end with basic education. It is an ongoing
2. Adequate preparation and familiarity with the surgeon’s pref- process throughout an entire professional one’s career.
erences and the surgical procedure to be performed are fun- • Teaching at various levels is the responsibility of the entire
damental to teamwork. If the perioperative staff members are team. New information is developed and shared by the group
unfamiliar with the routine and equipment, the patient or a for the improvement of patient care practices.
team member may be at risk for injury. An adequately experi- • All caregivers were once novices (although some may have for-
enced and skilled team is essential for the effective performance gotten those novice days). They have experienced the feelings
of a safe, efficient procedure. and frustrations of being the newest staff member. The experi-
3. The patient has an unconditional right to the team’s complete enced caregiver should try to remember these feelings and offer
concentration and attention at all times. He or she is a unique encouragement to new personnel.
individual who is completely dependent on the perioperative • Patience is an asset while developing work habits and establish-
caregivers to work as a team. ing working relationships. Expectations of self and of others
Although the ideologic differences of personnel may at times be should be realistic. Feelings of excitement and anticipation and
a source of conflict, the care of the patient should be a priority the fear of failure or making mistakes are normal but should
over personality differences. Complex procedures, busy surgery be expressed appropriately. Disruptive behavior distracts the
schedules, or shortages of personnel should not interfere with the attention of the team from the patient.
delivery of efficient, individualized patient care. • Applying the principles and techniques already learned will
enable the caregiver to make sound judgments and appropriate
decisions in the perioperative environment.
Clinical Competence • It is important to ask questions and acknowledge not know-
On the basis of experience and performance, patient care person- ing how to do something. Seeking help promotes professional
nel can be categorized as novice, competent, proficient, or expert. growth.
The novice lacks experience but is expected to perform to the best Everyone wants and needs to become an accepted member of both
of his or her ability with assistance. Most employers provide a for- social and work groups. The entire perioperative team, including
mal orientation program for new patient care personnel. During the surgeon and anesthesia provider, is both a social group and
this orientation period, the necessary knowledge, skills, and abili- a work group. Ambivalent feelings may arise on entering these
ties should be developed to perform at a level of basic competency. groups. The pleasures of functioning as a team member may be
As experience is gained, proficiency expands from a minimal offset by uncertainty about the ability to perform well. Initial goals
competency to an advanced level of expertise. Competent prac- will be task- and skill-oriented as learning focuses on policies,
tice requires critical thinking skills and decision-making ability. procedures, and routines. Eventually insecurity will be replaced
Statements of clinical competency are established by professional with self-confidence. The display of confidence will increase trust,
organizations such as AORN and AST. Guidelines are published respect, and recognition from others, as well as the personal satis-
by each professional organization and made available to practitio- faction of accomplishment.
ners of all disciplines. Competencies are discussed in more detail
in Chapter 2. Dynamics of the Psychologic Climate:
Preceptors, Mentors, and Role Models
Realities of Clinical Practice
Learning to adapt to the variety of tasks and ever-changing
When a formal educational experience is completed, a learner or demands in the perioperative environment is difficult. Some
orientee is eager to apply his or her skills and knowledge in an anxiety is normal, especially in situations in which feelings of
employment setting. A transition from dependent learner to inde- insecurity are generated or a sense of intimidation pervades the
pendent practitioner evolves over time. The realities of the work environment. At times the demands of the job may seem to out-
environment and the emotional and ethical dilemmas of some weigh the personal resources of the caregiver. Confidence develops
situations are experienced as basic competencies are developed. as skills are learned.
The development of surgical conscience evolves as experience is An understanding of expected performance is perhaps the most
gained. Surgical conscience applies the standards of care to ethical important element in the transition from novice to independent
situations and makes decision making more concrete. practitioner. Personnel in the perioperative environment play vital
It can take 6 months to 1 year to feel confident as a functioning roles in the beginner’s development. There is a distinction among
perioperative team member. Many facilities require personnel to the roles of preceptor, mentor, and role model. A preceptor works
take calls for emergencies after business hours; therefore the staff with orientees and learners according to a prescribed task-oriented
lesson plan. The process offers minimal flexibility and little person- Many facilities have developed a zero tolerance policy for abu-
alization for individual needs. A mentor has more experience with sive behavior in the OR.
the personnel and the climate of the OR and can provide insight
into the social atmosphere of the department.5 A mentor develops Stress Reduction
a relatively personalized relationship with less experienced orien-
tees or learners and fosters a sense of nurturance for their growth Assertive behavior is a useful tool for conflict resolution. Shared
and assimilation into the department. A beginner should look for professional communication can keep the tension in the environ-
a mentor to help bridge the gap between novice and proficient ment at a minimum. The caregiver should keep his or her com-
levels. Beginners should also look for role models—those expe- posure at all times and maintain a professional and assertive (not
rienced staff members who are emulated and respected for their aggressive) attitude. Personal conflicts between team members
clinical competence—and pattern their emerging professional self should be dealt with privately.
after the behaviors of the role model. A personal relationship may Humor can be an effective method of reducing anxiety. It should
not evolve with a role model in the same way as with a mentor. be used appropriately to defuse tension. Laughing at oneself helps
The beginner should stick with the winners—those staff mem- to preserve self-esteem while learning from the experience.
bers who are reaping personal rewards and self-satisfaction from At the end of the work shift the caregiver should evaluate
their work ethic. Their enthusiasm will be contagious and start the the events of the day, the emotions evoked, and how they were
growth of an exciting career. The losers—staff members who have handled. What was done effectively? What coping skills may be
negative attitudes, complain, and do not make an effort to solve needed to improve or enhance positive attitudes and interpersonal
problems but instead create them—should be avoided. relationships in the work environment? Teamwork is essential in
the perioperative environment, with every team member obli-
gated to make a positive contribution.
Eustress versus Distress Stress is a reality that need not create a sense of self-defeat.
Physical and emotional stresses are part of daily life. Stress is the Regardless of the source of stress, the body responds, and the
nonspecific reaction of the body, physiologically and/or psycho- physiologic and psychologic effects can be subtle or intense. The
logically, to any demand. The demand may be pleasant or unpleas- determination of whether a stressor is good or bad depends on an
ant, conscious or unconscious. The intensity of the stressor will individual’s perception of the circumstances. Any event that cre-
dictate adaptation. An individual’s perception of a situation will ates a feeling of impending danger also creates the perception of
influence the reaction to it. loss of control. A major factor in stress management is maintain-
Stress is not only an essential part of life but also a useful stimu- ing control, which can be accomplished by learning to tune in to
lant. Positive stress, referred to as eustress, motivates an individual the balance between the body and the mind. The caregiver can
to be productive and efficient. It forces adaptation to the ever- learn to be prepared for life’s difficulties by understanding how
present changes in the perioperative environment. The response the perception of stress can affect decision making, self-expression,
should be quick (e.g., when a trauma victim arrives or a patient and subsistence in the world.
has a cardiac arrest). To expect the unexpected is part of periopera-
tive patient care. Eustress fosters a sense of achievement, satisfac- Listening to the Body
tion, and self-confidence.
Stress that becomes overwhelming and uncomfortable is The caregiver should develop a sense for how the body signals
referred to as distress. In the perioperative environment the exhaustion, hunger, illness, and/or physical pain. The body is a
behavior of others may be perceived as cause for distress. Poli- sensory barometer of the environmental effects on the caregiver,
cies, or a lack of them, can also be a source of distress if they are and ignoring physical signals decreases the ability of the body
in conflict with the caregiver’s expectations. Through adaptive to manage stress. Going without sleep or skipping meals creates
mechanisms, the caregiver can cope with the tensions, conflicts, physical stress that can be avoided. Sleep deprivation caused by
and demands of the perioperative environment in either a col- long hours on call can be as dangerous as overuse of alcohol or
laborative or a nonproductive manner. Even though perceived using illegal drugs. The biologic need for sleep cannot be denied
as distress, some conflict is necessary to stimulate a change in and is important for the health and safety of the individual and
work methods and solve organizational problems. Sometimes it the others in the environment. Decision making, reaction times,
takes dissatisfaction with a situation to spark positive change and memory, and generalized health are impaired by not getting
prevent stagnation. enough rest. Regular sleep of at least 6 hours per day and rest
Patient care personnel become distressed by the conduct periods, exercise, adequate dietary practices, and routine health
of other team members. For example, it is uncomfortable to checkups provide a sound basis for care of the body.
be harshly criticized by a surgeon in front of peers or patients.
However, much that is said is not personally directed. Often the Maintaining the Mind
surgeon is reacting to his or her distress regarding unanticipated
circumstances presented by the patient, team member, or equip- Mental relaxation can help the caregiver manage stress. Using
ment during the surgical procedure. The reactions of personnel meditation and mental imagery on a regular basis provides a
will be influenced by their attitudes, mood, cultural and reli- break from stressful routines and allows the mind to fortify
gious background, values and ethics, experiences, and concerns itself against the negative perceptions of a situation. Creating
of the moment. Outbursts of anger are never appropriate in time to clear confusing thoughts and align productive thinking
the OR. However, constant frustration and inner conflict create enables the body and the mind to support an emotional balance
the distresses that can lead to job dissatisfaction. Behaviors that and a sense of well-being. This positive interaction can become
place patients or personnel at risk, such as throwing objects, an influence in a stressful situation and serve as an example to
should be reported to the nurse manager and documented. coworkers.
References 4. Wesolowski MS, Casey GL, Berry SJ, Gannon J: The clinical nurse
leader in the perioperative setting: A preceptor experience, AORN J
1. Ball K, Doyle D, Oocumma NI: Nursing shortages in the OR: Solu- 100(1):30–41, 2014.
tions for new models of education, AORN J 101(1):115–136, 2014. 5. Posluszny L: Shaping undergraduate professional identities through
2. Steelman VM: Pursuing excellence through creative education, AORN mentoring and promoting the future of nursing, AORN J 100(6):566–
J 100(3):235–237, 2014. 569, 2014.
3. Frederick D, Bullying: mentoring, and patient care, AORN J
99(5):587–593, 2014.
2
Foundations of Perioperative Patient
Care Standards
CHAPTER OBJECTIVES Element Smallest unit of data that is known and can be described
and measured.
After studying this chapter the learner will be able to: Guidance statement Document based on empirical data that sug-
• Discuss how standardization influences patient care. gests processes for performance of clinical activities.
• Describe two professional sources of patient care standards. Guideline Document or concept based on empirical data that
• List three main aspects of accountability. guides clinical activities.
• Identify the components of the nursing process. Licensure Approval for practice granted by a governmental
agency for a predetermined period, after which the approval
process is repeated.
Nomenclature Specialized set of terms.
Nursing diagnosis Identification of patient problem, need, or
CHAPTER OUTLINE health consideration, which may be actual or at risk; based on
human response patterns according to NANDA International.
Surgical Conscience Nursing process Organizational framework for planning patient
Patient Rights care; this involves assessment, nursing diagnosis, outcome iden-
Accountability tification, planning, implementation, and evaluation of the plan.
Obligation Duty or promise.
Standardization of Patient Care
Outcome Effect of an intervention.
Recommended Practices PNDS Perioperative nursing data set. Standardized perioperative
Professionalism nursing language.
Professional Perioperative Nursing Position statement Document that describes a particular belief.
Evidence-Based Practice Profession Vocation in a specialty requiring specialized education
Nursing Process and knowledge.
Recommended practice Activities believed to be the optimal level
Standards of Perioperative Nursing Practice
of professional practice that are achievable.
Clinical Competency of the Perioperative Nurse Responsibility Social, moral, or legal duty.
Scope of Perioperative Nursing Practice Rights Power or possession of privilege.
Surgical Technology Standard Authoritative statement that describes accountability,
Standards of Practice for Surgical Technologists values, and priorities.
Taxonomy Orderly classification based on interrelationships.
Clinical Competency of the Surgical Technologist
Continual Performance Evaluation and Improvement
EVOLVE WEBSITE
http://evolve.elsevier.com/berrykohn
• Historical Perspective
KEY TERMS AND DEFINITIONS • Glossary
Accountability Answering for performance of a service or task.
Accreditation Method of professional evaluation and recognition
of an institution for meeting educational, practice, and national This chapter establishes the basis for perioperative patient care.
standard parameters. The opening section gives a glimpse of historic patient care and
Advocacy Active support of another person. progresses to modern perioperative practice.
Benchmark Point of reference that sets the evaluation point of
activities. Surgical Conscience
Competency statement Document based on empirical data that
define expected and measurable clinical activities. The essential elements of perioperative practice are caring, con-
Domain Set of knowledge that is specific and clearly identified. science, discipline, and technique. Optimal patient care requires
15
an inherent surgical conscience, selflessness, self-discipline, and anticipate events. Assistance in coping acknowledges the anxieties
the application of principles of asepsis and sterile technique. All and fears of the patient and family, regardless of how minimally
are inseparably related. invasive the procedure may seem. No procedure is minor to the
Florence Nightingale is credited with developing the environ- patient! Each patient reacts differently. The patient senses some
mental theory of patient care on which all perioperative patient relief in knowing that the caregiver has taken the time to identify
care is based (Box 2-1). According to her theory, the caregiver is needs specific to his or her care. The patient advocate is a caregiver
accountable for creating and maintaining the best possible envi- who acts in the following ways:
ronmental conditions to assist natural healing. She emphasized 1. Establishes rapport with the patient, family, or significant others
the need for prevention through education and teamwork. In her in a manner that conveys genuine concern and sincere caring
eyes the team consisted of not only the caregivers, but also the 2. Encourages the patient and family or significant others to
patient and family. She often approached her legislators with sug- express feelings and ask questions
gestions for bills and laws designed to protect patients and caregiv- 3. Helps relieve anxiety and apprehension by providing appropri-
ers. Her numerous letters and writings chronicle her work. ate factual information regarding what to expect
The concept of a surgical conscience is simply a surgical 4. Helps the patient to make informed decisions throughout the
Golden Rule: Do unto the patient as you would have others do perioperative experience
unto you (Box 2-2). The caregiver should consider each patient 5. Acts as a patient representative by communicating pertinent
as himself/herself or as a loved one. Once an individual develops information to other team members
a surgical conscience, it remains inherent thereafter. Nightingale 6. Oversees all activities throughout the perioperative experience
summarized what is, in essence, its meaning when she said, “The to ensure the safety and welfare of the patient
nurse should keep a high sense of duty in her own mind, must 7. Keeps the family informed of significant events throughout the
aim at perfection in her care, and must be consistent always in perioperative experience
herself.” 8. Protects the patient’s rights by compliance with advance direc-
tives for care (living will, durable power of attorney, or both).
Patient Rights Additional information about advance directives and durable
power of attorney can be found in Chapter 3.
As a consumer the patient purchases services to fulfill health care
needs and is entitled to certain rights. Access to health care is rec- Accountability
ognized as a right, not a privilege, of every human being.
Accountability means answering to someone for an obligatory
action. As both learners and caregivers, perioperative nurses and
Patient Advocacy surgical technologists are accountable to the following people/
A patient advocate recognizes the patient’s and the family’s need entities:
for information and assistance in coping with the surgical experi- • Patients receiving services
ence, regardless of the setting. As an advocate the perioperative • Employer
nurse can provide information discovered during patient assess- • Educational institution providing learning experiences
ment that identifies specific needs or health concerns requiring • Profession or vocation to uphold established standards of prac-
action. Advance preparation can help the patient and family tice
• Self and other team members
A lack of accountability for behavior in the perioperative
• BOX 2-1 Nightingale’s Environmental Theory environment may result in patient injury or dissatisfaction with
care. Health care providers have a legal and moral obligation to
Physical Psychologic Social Environment
Environment Environment identify and correct situations that threaten a patient’s safety and
well-being. Most incidents that could endanger the patient lead
Sanitation Communication Mortality data
Ventilation Advice Prevention of disease
to preventable legal actions. Prevention focuses on the responsible
Lighting Variety Education of caregiver performance of duty and continual performance improvement.
Noise Scientific knowledge base Nursing as distinct from The provision of safe care of the patient also protects caregivers
Odors Creativity medicine and the health care facility from liability. In addition, it upholds
Temperature Spirituality Accountability the reputation of the professions by maintaining the confidence of
Responsibility the consumer public. Failure of a caregiver to maintain account-
ability constitutes negligence. If negligence is established, any
caregiver can be held liable for his or her own acts of omission or
commission. Each person is responsible for his or her own negli-
gent acts.
• BOX 2-2 Elements of Surgical Conscience
A sense of moral obligation and responsibility
Self-regulation and control
Standardization of Patient Care
Honesty and integrity in professional practice Importance of Standardization
Personal commitment
Ethical value system Perioperative patient care personnel should be able to cope with
Admit and remedy errors all situations and give patients the best of their skills and knowl-
Sincere desire to do the right thing edge. Although the use of different techniques may achieve the
same results, each hospital establishes policies and procedures
CHAPTER 2 Foundations of Perioperative Patient Care Standards 17
for all personnel to follow based on standards, recommended sciences. They describe how the nursing process is used in
practices, and guidelines developed by professional organizations the perioperative setting. The Perioperative Nursing Data
and predicated on scientific research. These written policies, pro- Set (PNDS) provide a means to measure and collect perfor-
cedures, and guidelines help prevent confusion and foster coor- mance improvement data.
dination of activities. The guidelines, or guidance statements, c. Standards of Perioperative Professional Practice. These are
are intended to demonstrate a way to incorporate recommended process standards that describe a competent level of behav-
practices in everyday patient care. Uniformity and standardization ior for the professional role of the perioperative nurse. The
of procedures help personnel develop skill and efficiency for the activities relate to quality practice evaluation, continuing
following reasons: education, collegial relations, collaboration, ethical con-
• The main purpose is to ensure the safety and welfare of the duct, and use of resources, evidence-based research, and
patient and personnel. leadership.
• It is easier for the perioperative educator and preceptors to d. Quality and Performance Improvement Standards for Periop-
teach learners consistent methods of patient care. erative Nursing. These are process standards to assist in the
• Learning is easier if everyone performs procedures in the same development of methods to measure, assess, and improve
way. patient care.
• Deviations show a need for evaluation of the procedures or the e. Perioperative Patient Outcomes: Standards of Perioperative
staff. Do the procedures need revision? Care. These are outcome standards that reflect desired
• Consistent procedures provide an efficient check during prepa- observable patient outcomes during preoperative, intra-
ration for any surgical procedure. operative, and postoperative phases of patient care. They
• One person can take over for another at any time during the focus on patient and family responses to intervention dur-
surgical procedure, if necessary, and know exactly where to find ing surgical, diagnostic, or therapeutic intervention. Each
instruments and supplies. outcome has a unique identifier in the PNDS.
• Routine procedures establish habits that increase speed in 2. The Operating Room Nurses Association of Canada (ORNAC,
thought and action. Doing work in a certain way promotes a www.ornac.ca) has published the Recommended Standards for
high level of proficiency. Operating Room Nursing Practice and Quality Assurance Audit.
• Knowing the standards allows intelligent decision making 3. Association of Surgical Technologists Standards of Practice
when a patient’s condition requires modification of a routine. (AST, www.ast.org). These are process standards that provide
guidelines for safe and effective patient care in appropriate pre-
operative, intraoperative, and postoperative practice settings.
Professional Sources of Standards They include interpersonal skills, environmental safety, and
Standards of care are defined as those acts that a reasonably pru- application of principles of surgical technology.
dent person with comparable training and experience would 4. The Joint Commission (TJC) standards (www.jointcommissio
perform under the same or similar circumstances. Professional n.org). These standards, published in the Accreditation Manual
standards delineate activities related to performance, performance for Hospitals, are functional, performance-based standards that
improvement, continuing education, ethical behavior, responsi- focus on actual clinical care provided directly to patients and
bility, and accountability. on management of the health care organization providing ser-
Standards established by regulatory agencies are governed by vices. They relate to efficiency, effectiveness, safety, and timeli-
laws. Standards established by professional associations are volun- ness; appropriateness, continuity, and availability of care; and
tary. Standards of practice for perioperative patient care include patient satisfaction. TJC evaluates compliance with these stan-
professional and regulated standards. Several sources of periopera- dards and reviews clinical outcomes of care provided as funda-
tive patient care standards are identified in this list: mental criteria for accreditation. Selective clinical indicators
1. Standards of Perioperative Nursing. These standards, which serve as outcome measurements for the processes of patient
originated as American Nurses Association (ANA) standards care. Additional information about error reporting and moni-
of OR practice in 1975, were approved by ANA and AORN toring of patient care standards is found in Chapter 3.
(Association of periOperative Registered Nurses) and originally • TJC established National Patient Safety Goals (found in
published in 1981. Reviews and revisions are done annually as their entirety at www.jointcommission.org/patientsafety).
needed. • Improve the accuracy of patient identification by using at
These five sets of standards for an optimal level of periop- least two forms of patient identification.
erative nursing practice are published annually in the AORN • Improve the effectiveness between caregivers by using stan-
Guidelines for Perioperative Practice (formerly AORN Standards dardized patient “hand-off” reporting (change from one
and Recommended Practices). The scaffold of the standards is caregiver to another), verbal reflection, avoiding abbrevia-
premised in patient care quality and is primarily trifold—Struc- tions and symbols, and assuring timely communications.
ture, Process, and Outcome. These three components provide a • Improve the safety of using medications by identifying
means for the perioperative nurse to analyze and interpret care. potential “sound-alike” or “look-alike” drugs in the facility,
Reviews and revisions are done yearly as needed. labeling all drug containers and delivery devices on and off
a. Standards of Perioperative Administrative Nursing Practice. the field, decrease the risk of anticoagulation error.
These are structural standards that provide a framework for • Reduce the risk of health care–associated infections by
establishing administrative and organizational practices in a meticulous hand hygiene and by recording and reporting as
variety of settings. a sentinel event any unanticipated death or loss of function
b. Standards of Perioperative Clinical Practice. These are pro- associated with sepsis or health care–acquired infection.
cess standards based on problem-solving techniques using • Accurately and completely reconcile medications across the
principles and theories of biophysical and behavioral continuum of care by comparing patient current medication
regimen with medication orders during care in the facility. have no documentation about conditions “present on admis-
Patient and subsequent caregivers in and out of the facility sion” are immediately rejected without reimbursement.
are provided a complete list of current medications on dis- More information can be found at http://www.cms.gov/.
charge. As of October 2008, CMS will not reimburse the facility
• Reduce the patient’s risk for harm from falls by implement- for the following conditions:
ing a program of safe patient positioning and transport in 1) Pressure ulcers
the OR. Fall prevention programs should have an evalua- 2) Falls or trauma
tion process. 3) Vascular catheter–associated infection
• Encourage the patient’s participation in the safe delivery of 4) Retained foreign objects from surgery
care by defining and communicating the steps of care and 5) Certain surgical site infections (mediastinitis after car-
encouraging the patient and family to ask questions and diac surgery, bariatric gastrointestinal procedure, and
voice concerns for safe care. orthopedic procedures of spine, neck, shoulder, or
• Identification of potential safety risks in the patient popula- elbow)
tion relevant to patients with emotional or behavioral disor- 6) Air embolus
ders by prevention of self-harm or suicide. 7) Blood incompatibility
• Improve recognition and response to changes in the patient’s 8) Uncontrolled blood sugar
condition by ongoing assessment and immediate access to 9) Deep vein thrombosis (DVT) and pulmonary embolus
specially trained individuals when a patient’s condition has (PE) after knee or hip joint arthroplasty
changed. 10) Urinary catheter–associated infection
5. National Fire Protection Association (NFPA) standards (http:/ 11) Wrong site surgery
/safety.science.tamu.edu/nfpa.html). These standards apply to 12) Wrong patient surgery
environmental safety to reduce, to the extent possible, hazards 13) Wrong surgery performed on a patient
to patients and personnel. c. National Quality Forum (NQF): Serious reportable events
6. Association for the Advancement of Medical Instrumentation mirror the CMS “No Pay List” and the 45-page 2010
(AAMI) device standards (www.aami.org). These standards serious reportable events document can be viewed using
provide the industry with reference documents on accepted Acrobat Reader at www.premierinc.com/safety/topics/guid
levels of device safety and performance and test methods to elines/nqf.jsp.
determine conformance. AAMI standards have also been estab- The NFQ document details include, but are not limited to,
lished for sterilization, electrical safety, and patient monitoring the following events:
for health care providers in relation to evaluation, mainte- 1) Surgical events such as wrong site or wrong patient
nance, and use of medical devices and instrumentation. surgery
7. Clinically based risk-control standards. These standards are 2) Device or biologic material–associated deaths (equip-
written by medical specialty groups and professional liabil- ment and medication contamination)
ity underwriters. They establish appropriate benchmarks of 3) Patient protection event such as patient suicide
acceptable practices and outcomes specifically for controlling 4) Care management event such as wrong drug or blood
liability losses. They may be incorporated into the health care administration
facility’s risk management program. 5) Environmental event such as electrocution or falls
6) Criminal event such as assault or abduction
2. American National Standards Institute (ANSI) standards
Standards from Regulatory Bodies (www.ansi.org). These standards concern exposures to toxic
The standards set by these organizations are enforceable by law: materials and safe use of equipment such as lasers.
1. Federal Medicare Act and all subsequent amendments to this 3. U.S. Food and Drug Administration (FDA) performance
Social Security Act (http://www.cms.gov/). This legislation standards (www.fda.gov). Federal Medical Device Amend-
incorporates the provision that institutions participating in ments regulate the manufacture, labeling, sale, and use of
Medicare must maintain the level of patient care recognized as implantable medical devices and many products used in or on
the norm. Specific requirements are included. patients. The FDA also controls treatment protocols for use of
a. Health Insurance Portability and Accountability Act drugs. The manufacturer’s lot number and product description
(HIPAA, http://www.cms.gov/hipaageninfo/). The Depart- of implanted devices should be attached to or included in the
ment of Health and Human Services (HHS) set national patient’s chart.
standards for electronic health care transactions and 4. Agency for Health Care Research and Quality (AHRQ) clinical
national identifiers for providers, health plans, and employ- practice guidelines (www.ahcpr.gov). These standards include
ers. It also addresses the security and privacy of health data. indicators for performance measurement. They are based on
Many facilities require the employees to sign a confidenti- research and professional judgment regarding effectiveness and
ality agreement upon hire. Schools of nursing and surgi- appropriateness of medical care, including safety, efficacy, and
cal technology, clinical sites, and patient care training sites effectiveness of technology. This agency was created in provisions
require students to sign confidentiality agreements. Some of the Consolidated Omnibus Budget Reconciliation Act of 1989.
schools prohibit tape recording in class because of patient 5. Occupational Safety and Health Administration (OSHA)
and facility confidentiality issues. standards (www.osha.gov). These legally enforceable standards
b. Medicare’s “No Pay List”: Accuracy of documentation of include permissible levels of toxic substances in the environ-
conditions present on admission as differentiated from con- ment. Although explicitly developed to protect employees,
ditions acquired during hospitalization determines facility patients receive secondary benefits from control of hazards in
reimbursement for patient care. Claims for payment that the environment.
Sources of Standardization Data Within the with surrounding communities because of power failure
or flooding and cannot easily reroute patients to a safe
Health Care Facility receiving hospital.
Each patient care facility uses several sources from which to derive 6. Infection control manual. This manual contains the policies
standardization data. Efficient use of time and resources is the end and procedures designed to minimize the risk of infection
result. Establishing protocols and performance expectations that and control the spread of disease within the health care facil-
are specific to the needs of the facility benefits the patient, the ity. It includes state, local, federal, and professional standards
caregiver, and the facility. Many of the following documents may for the protection of the patient and the caregiver.
be found on the facilities’ intranet for employee use. 7. Perioperative policy and procedure manual. This manual, usu-
1. Facility-specific patient care standards. The patient care services ally a hardcover ringed binder, contains the policies pertaining
department establishes standards for appropriate patient care solely to the administration and operation of the periopera-
based on the standards developed by the ANA. Optimal tive environment or online in the hospital’s intranet. A copy is
standards of nursing practice guide the provision of patient accessible for reference in the manager’s office, at the control
care throughout the institution. Written policies and proce- desk, or in both places. The primary purpose of the periopera-
dures reflect these standards. Institutional standards are based tive policy and procedure manual is to detail why and how
on standards established at national levels by TJC, AORN, procedures should be specifically performed within the peri-
ANA, and other nursing organizations and governmental operative environment. It includes both supportive activities
agencies. Nurses should work within the limitations of the and practices that involve direct perioperative patient care.
nurse practice act of the state in which they are licensed and 8. Orientation manual. This manual is designed to acquaint
practice. Licensure is a legal requirement to practice nursing. personnel with the environment, policies, and procedures
Copies of facility-specific documents are available for review specific to performance and the position descriptions of all
from the nursing or hospital administration. personnel in the department.
2. Hospital policy and procedure manual. This manual contains 9. Instrument book. The individual instruments and trays
basic and general administrative and patient care policies that required for each surgical procedure are listed in a central
apply to all hospital personnel. A copy is retained on each processing computer or in a separate book kept in the instru-
patient care unit and in all departments of the hospital. ment processing area. Photographs or catalog illustrations
3. Safety plan manual. The potential hazards and identifiable help instrumentation personnel identify the vast number
situations that may cause injury to a caregiver or patient are of instruments and how they are compiled into sets. Flash-
described in the manual provided by the hospital safety com- cards and educational instrument textbooks are commercially
mittee. Plans for fire or disaster drills and evacuation routes available. A search engine with an image finder (e.g., Google
are outlined. or Bing) may be used to find specific instruments. Most
4. Safety data sheets (SDS). Also known as Material safety data instrument companies have online catalogs.
sheets (MSDS). These detailed sheets describe chemicals used 10. Surgeon’s preference cards/case cart sheet. A preference card
in the workplace and actions to take if they are spilled into is maintained in a computerized database or written note
the environment. Specific cleanup and disposal methods are card for each surgical procedure that each surgeon performs.
outlined. Most facilities require a yearly review of the SDS The surgeon’s specific preferences and any variance from the
process. Individual SDS for specific chemicals are online at procedures in the procedure book are listed on these cards.
www.msds.com. The cards are revised as procedures and personal prefer-
5. Disaster plan manual. This manual outlines the plans for both ences for new technology change. A set of these cards is kept
internal and external disasters. Both internal and external readily available in a central file or in a computer under the
disasters require rapid activation of all services within the surgeon’s name, and they are pulled for each day’s surgical
hospital. Personnel who are off duty will be called to the procedures. In preparing for each surgical procedure, nurses
facility and assigned as needed. Command centers and com- and surgical technologists consult both these cards and the
munications will be critical stations for the entire facility to procedure book. A surgical central supply department may
follow and respond. Triage protocol will be followed carefully use these cards to pack a case cart for each individual pro-
as defined by the facility. cedure. Box 2-3 shows sample case cart sheet components
a. An internal disaster is an event that happens within the incorporating the surgeon’s preference card.
facility (e.g., an explosion, a fire) and requires employee 11. Directories. Alphabetic listings of the location of supplies
assistance for control of the situation and evacuation of per- and equipment are maintained for the instrument room,
sonnel and patients. An evacuation plan should be part of general workroom, sterile supply room, and general periop-
this planning structure because in-process surgeries cannot erative storage areas. Regardless of where the storage areas are
be abruptly halted and simply carried out of the building. located, personnel should know the location of supplies and
b. An external disaster is an event that happens outside the equipment. Directories save time in trying to locate items.
confines of the facility (e.g., the World Trade Center ter-
rorist actions of September 11, 2001). An external disaster Recommended Practices
could also be a natural phenomenon such as an earthquake
or an accident (e.g., a train wreck). Recommended practices are optimum behavioral objectives for
c. A combined internal-external disaster such as Hurricane caregivers. They may not always be achievable, as standards are,
Katrina is complex and may have multiple stages of reso- because of limitations in a particular practice setting. Recom-
lution. Extremes of patient casualties may be brought in mended practices state what ideally can be done.
only to find the facility is to capacity in census. In some AORN guidelines for perioperative nursing concern sterile
circumstances the facility may be out of communication and aseptic techniques and other technical aspects of professional
• BOX 2-3 Sample Case Cart Sheet Components with follow policy and perform procedures correctly. The following
examples should be included in the perioperative department
Surgeon’s Preferences*
manual. These procedures are incorporated into discussions in
Surgeon: Suture: subsequent chapters.
Dr. Jared 3-0 Vicryl PS1
Gloves: Disposable supplies:
Size 8 Extra 4 × 4 sponges available Universal Protocol
Positioning: Patient: Universal Protocol is a standardized means for keeping a patient
Supine Martin Alexander
Instruments: Patient data: (e.g., age, sex, allergies)
safe in surgery. The World Health Organization (WHO) created
Soft tissue set 26 years old, male, no allergies a basic surgical safety checklist under the guidance of Dr. Atul
Special requests: Drapes: Gawande and a select team of anesthesiologists, surgeons, and reg-
Radio or CD player on low General custom pack istered nurses. The purpose of the checklist is to globally reduce
Procedure: 2 gowns surgical harms to patients in a manner that can be applied uni-
Excision lipoma right anterior Sponges: versally in high- and low-income countries. Initial multinational
thigh 2 packs Raytec studies of the checklist use demonstrated a one-third reduction in
Prep: Notes: surgical mortality and morbidity.
One-step iodophor Call family when procedure The initial 19 items require oral confirmation at three critical
Medications: completed points during perioperative patient care that include: (1) the “sign in”
1% lidocaine plain
Sterile saline 1000 mL
before induction of anesthesia, (2) “time out” before skin incision,
and (3) “sign out” before the patient leaves the OR. The universal
checklist provides a means for documentation of each step of care for
*Components of computer-generated case cart procedure supply sheet. These sheets are
generated at the time the procedure is scheduled using standardized surgeon’s preference cards
patients undergoing invasive and noninvasive surgical procedures.
and patient-specific needs. Items listed under each heading are examples only. AORN has incorporated the Joint Commission’s 2010 Patient Safety
Goals and Universal Protocol into the WHO Surgical Safety Check-
list to create a Comprehensive Surgical Checklist (Fig. 2-1).
practice are directed toward providing safety in the perioperative
environment. They are premised in principles of microbiology, Identifying the Patient
scientific literature, validated research, evidence-based prac-
tice, and experts’ opinions. Although compliance is voluntary, When a patient enters the facility a plastic identification wrist-
individual commitment, professional conscience, and the practice band is put on the patient in the admitting area. Care is taken to
setting should guide perioperative caregivers in using these recom- place the wristband in a location that does not interfere with the
mended practices. They represent an optimal level of practice and surgical site. To verify accuracy the patient should be asked for his
are achievable. or her birth date and to spell his or her name and pronounce it.
Guidelines and recommended practices of other agencies, The circulating nurse and anesthesia provider check the wristband
including the Association for the Advancement of Medical Instru- with the patient and surgeon, the patient’s chart, and the surgi-
mentation (AAMI), the Centers for Disease Control and Preven- cal schedule. The surgeon should visit with the patient before an
tion (CDC), the National Institute for Occupational Safety and anesthetic is administered. A parent, legal guardian, or individual
Health (NIOSH), Occupational Safety and Health Administra- with power of attorney can complete this identification process.
tion (OSHA), and the Environmental Protection Agency (EPA), TJC indicates that at least two methods should be used to identify
also are used for environmental, patient, and personnel safety. a patient as part of the patient safety goals.
Policies and Procedures Identifying the Surgical Site

Policies and procedures reflect variations in institutional envi- The surgical site indicated by the consent form should be verified
ronments and clinical situations. They are established to protect between the circulating nurse and the patient. Universal methods
employees, learners, and patients. They establish the facility’s stan- of surgical site verification include asking the patient to describe
dard of care. Policies should be consistent with regulatory and pro- what he or she understands about the planned procedure. If the
fessional standards of practice. Procedures define scope, purposes, procedure is on a particular side of the body, the patient should
and instructions to be carried out and by whom. They should be be asked to point to and clarify the site. The surgeon should mark
clearly written, current, dated, and reviewed periodically. Although the site with his or her initials in indelible ink that does not wash
policies and procedures vary from one institution to another, they off during intraoperative skin preparation. Marking with an X is
provide guidelines for patient care and safety in that specific physi- inappropriate and may be misunderstood.
cal facility. Learning and following policies and procedures are Before making the incision the entire team pauses for a “time
protective measures against potentially litigious actions. out” as the surgical site listed on the consent form is read aloud.
Many facilities document in the employee’s personnel file that The entire team confirms that this is correct information for the
policies and procedures were reviewed during orientation to the patient and that any scans or x-rays reflecting the same body part
employment setting. Employees are often asked to sign a nota- are displayed in the correct orientation. Allergies or sensitivi-
tion verifying knowledge of a new or revised policy or procedure ties are confirmed at this time. During the “Time out” process,
after its introduction. Some policies and procedures apply to all the availability of the correct implants or special equipment is
employees; others refer to a specific department. Because of the confirmed (Box 2-4).
potential legal implications, adherence to all policies and proce- The surgical site marking and identification process should
dures is mandatory. Personnel are evaluated on their ability to be standardized within the facility and written into policy to
COMPREHENSIVE SURGICAL CHECKLIST

Blue = World Health Organization (WHO) Green = The Joint Commission - Universal Protocol (JC) 2013 National Patient Safety Goals Orange = JC and WHO
PREPROCEDURE SIGN-IN TIME-OUT SIGN-OUT

CHECK-IN
In Holding Area Before Induction of Anesthesia Before Skin Incision Before the Patient Leaves the
OR
Patient/patient representative RN and anesthesia care provider Initiated by designated team RN confirms:
actively confirms with confirm: member
Registered Nurse (RN):
All other activities to be
suspended (unless a
life-threatening emergency)
Identity Yes Confirmation of: identity, Introduction of team members Name of operative procedure
Procedure and procedure site procedure, procedure site and Yes Completion of sponge, sharp, and
Yes consent(s) Yes instrument counts Yes N/A
Consent(s) Yes Site marked Yes N/A All: Specimens identified and labeled
Site marked Yes N/A by person performing the Confirmation of the following: Yes N/A
by person performing the procedure identity, procedure, incision site, Any equipment problems to be
procedure consent(s) Yes addressed? Yes N/A
Patient allergies Yes N/A Site is marked and visible
RN confirms presence of: Yes N/A To all team members:
Difficult airway or aspiration risk? What are the key concerns for
History and physical Yes No Relevant images properly labeled recovery and management of this
Yes (preparation confirmed) and displayed Yes N/A patient?
Preanesthesia assessment ___________________________
Yes Risk of blood loss (greater than Any equipment concerns? ___________________________
500 mL) ___________________________
Diagnostic and radiologic test Yes N/A Anticipated Critical Events ___________________________
results Yes N/A # of units available ______ Surgeon: ___________________________
States the following: ___________________________
Blood products Anesthesia safety check critical or nonroutine steps ___________________________
Yes N/A completed case duration ___________________________
Yes anticipated blood loss
Any special equipment, devices, June 2013
implants Briefing: Anesthesia provider:
Yes N/A All members of the team have Antibiotic prophylaxis within
discussed care plan and 1 hour before incision Yes
addressed concerns N/A
Include in Preprocedure
Yes Additional concerns?
check-in as per institutional
custom:
Scrub and circulating nurse:
Beta blocker medication
Sterilization indicators have
given (SCIP) Yes N/A
been confirmed
Venous thromboembolism
Additional concerns?
prophylaxis ordered (SCIP)
Yes N/A
Normothermia measures
(SCIP) Yes N/A
The Joint Commission does not stipulate which team member initiates any section of the checklist except for site marking.
The Joint Commission also does not stipulate where these activities occur. See the Universal Protocol for details on the
Joint Commission requirements.
• FIG. 2-1 AORN comprehensive surgical checklist. (Reprinted with permission from AORN.org.
Copyright © 2013, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.)
avoid wrong-site procedures. The time out process should be

• BOX 2-4 “Time Out” for Prevention of Wrong Site
documented in the patient’s record by the circulating nurse. More
Surgery information can be found at www.aorn.org in the official state-
• Correct patient? ments section and on the TJC website at www.thejointcommiss
• Correct position? ion.org. TJC has described factors that contribute to wrong site,
• Correct site? wrong patient, and wrong procedure surgery. They are as follows:
• Correct procedure? • Emergencies
• Correct equipment? • Morbid obesity
• Correct images? (scans or x-rays in proper orientation) • Physical deformity
• Correct implants? (as appropriate) • Unusual equipment or setup of the OR
• Multiple surgeons
• Multiple procedures The plan of care should include appropriate numbers of per-
• Unmarked patients sonnel for safe patient movement. Patients who are incapable of
• Unverified patients assisting with physical motion require a minimum of four people
• No checklist to ensure a safe move from one surface to another. There should
• No assessment be at least one person on either side of the patient, one at the foot,
• Staffing issues and one at the head to monitor the patient’s airway and physi-
• Distractions and disharmony among staff members ologic response. The person guiding the patient’s head, usually the
• Lack of information about the patient anesthesia provider, should be the one who counts “one—two—
• Organizational culture of the facility three” to pace the synchronized movement from one surface to
another.
The surgeon determines the appropriate surgical position in
Protecting Personal Property consultation with the anesthesia provider. The circulating nurse
Personnel in preoperative areas are responsible for removing valu- and first assistant help position the patient. A stretcher is kept
ables and prostheses before patients go to the OR. The circulating nearby at all times if a patient is placed in a prone position or
nurse is responsible for double-checking each patient and remov- any position other than supine. In the event of an emergency the
ing unnecessary items brought to the OR. Personal items such patient will need to be placed in a supine position for treatment
as religious medals, hearing aid(s), eyeglasses, dentures, and eye such as cardiopulmonary resuscitation (CPR).
prostheses are commonly permitted to remain with the patient Many patients receive a general anesthetic or heavy sedation
who is having local or regional anesthesia. The circulating nurse and are therefore unconscious or not in control of their protective
should inform the anesthesia provider and the surgeon of the pres- reflexes. Constant vigilance is essential to safeguard patients who
ence of such items and document them on the patient’s chart. are vulnerable and unable to protect themselves. Liability on the
Artificial extremities, undergarments, wigs, hairpins, wristwatches, part of the team would be difficult to dispute. Everyone in the
and rings should be removed. Jewelry could get lost, or a ring perioperative environment has a duty to monitor and protect the
might become stuck on the patient’s finger as a result of postop- patient at all times without exception.
erative swelling. In addition to the danger of losing or damaging
these items, some could cause pressure areas on the anesthetized Aseptic and Sterile Techniques
patient’s body.
Any item that is removed should be placed in a rigid container Infection is a serious postoperative complication that may become
and labeled with the patient’s name and identification number. life-threatening for the patient. Perioperative patient care team
The patient’s personal property should not be wrapped in a paper members must know and apply the principles of aseptic and
or linen towel that could inadvertently be discarded in a trash sterile techniques at all times. Established procedures for asep-
receptacle or laundry hamper. The container may be retained by tic technique, sterilization, and disinfection should be followed
the circulating nurse during the surgical procedure and sent with meticulously. An emergency situation in which asepsis becomes
the patient to the postoperative area. Alternatively, the circulating a secondary concern is a rare occurrence. Asepsis should not be
nurse may immediately ask a nursing assistant to return the con- compromised for the sake of convenience of the caregiver. Each
tainer to the patient care unit. This person should obtain a receipt team member should consider how personal preferences for care
for the patient’s personal property from the person receiving it. of self or a loved one should be applied to the care of patients.
The receipt is given to the circulating nurse to put in the patient’s Postoperative wound infection can originate in the OR from
chart along with a notation of the transaction in the nurses’ notes. a break in technique by any team member. Inappropriate reuse
Patients value their property. A caregiver can be held liable for lost of disposable items may be indefensible, as can use of an unster-
or damaged personal property. ile endoscope introduced into a sterile body cavity. An unsterile
scope can disrupt the mucous membrane and come into contact
with the patient’s vascular system. No area of the body is con-
Observing the Patient sidered “dirty.” Any area of the body is at risk when the vascular
Unattended patients may fall from a stretcher or the OR bed. Falls system is entered and should be worthy of sterile instrumenta-
are one of the most frequent causes of avoidable injuries. Side rails, tion. Microorganisms can be transferred via any access portal
restraints, and safety straps should be used to protect all patients, to the vascular system, including but not limited to the mouth,
children as well as adults. A small child could reach and insert a urethra, penis, vagina, rectum, and ear. Strict asepsis and sterile
tiny finger into an electrical socket. Patients should be observed at technique prevent many postoperative complications. The fol-
all times in the perioperative environment. lowing principle applies: When in doubt about something’s ste-
rility, consider it unsterile, hence the phrase, “When in doubt,
throw it out.”
Positioning the Patient
Care is taken when moving all patients to and from the OR bed. Accountability of Accurate Counts
The patient should be positioned to ensure adequate exposure of
the surgical site for the surgeon but not compromise any body The primary responsibility for accounting for all sponges, sharps,
system. The anesthesia provider should determine the physiologic and instruments before, during, and after every surgical procedure
safety of the patient’s body systems. Cardiopulmonary function- rests with the circulating nurse and scrub person. Laziness and a
ing should not be impaired. Adequate support of joints and limbs cavalier attitude surround the statement, “the incision is too small
should be provided during movement into the desired position. to lose anything.” Don’t be fooled by this cavalier statement. It can
Pressure areas should be adequately protected to prevent neuro- happen when least expected. There are several reasons to count
vascular damage. and be accountable for items used in a surgical procedure.
1. Patients have retained items from a surgical procedure regard-

CONS
less of the size or location of the surgical site. This is a serious
safety breach that is inexcusable. • Some organizations do not specify that everything needs to be
counted for every procedure. Every facility is responsible for their own
2. Instruments are costly and should not “vanish into thin air.” It
policies and procedures determining what items need to be counted
is a shame that some hospitals x-ray all the trash and have metal in every case.
detectors on the doors of the OR. Instruments stuck in wash- • Counting is a time consuming part of the surgical process because
ing machines cause damage to the mechanisms. Accountability it is done before the procedure, during the procedure, before closing
significantly decreases this loss. the wound, and after the procedure (final count).
3. Many instruments and devices have sharp tips or cutting • Some cases, such as orthopedic surgeries, have many trays with
surfaces. If an instrument is in the trash or laundry it can small parts that are designed to size custom implants. Because
become a source of injury to unsuspecting housekeepers or there are so many pieces they are not counted based on the
laundry workers. Gloves worn for cleaning do not protect from rationale that they will not be removed from their tray.
sharp objects. This can result in prolonged illness and inability • Accountability is the responsibility of the surgical team. Lack of
accountability can result in patient injury or poor surgical outcome.
to work.
• Deviations in the standard counting policies can result in a “never
Any item put into the patient should be documented as part of event,” which is a retained surgical item. Risk factors that contribute
the count and reconciled at the end of the procedure. The counts to retained items may include: error in the count, unexpected change
should proceed in an established manner each time. The surgeon in procedure, high body mass index, distractions, and change of
and first assistant facilitate the count of the items on the surgi- staff.
cal field before closure; however, it is not their job to perform
the actual counts. Because accountability for sponges, sharps, and References
instruments is recognized as essential to safe practice and the stan- 1. Recommended practices for medication safety: Perioperative stand-
dard of care, omission of appropriate counts or a facility’s lack ards and recommended practices, Denver, Co, 2013, AORN, Inc.
of established procedures for counting and accountability could 2. Hariharan D, Lobo DN: Retained surgical sponges, needles, and instru-
result in a serious threat of liability. There is no excuse for any ments, Ann R Coll Surg Engl 95(2):87–92, 2013.
retained foreign object if the entire team follows the systems for 3. AORN: Guidelines for perioperative practice, Denver, Co, 2015, The
Association.
accountability.
The circulating nurse should document in writing the out-
come of the final counts as correct or incorrect and any unusual
incidents concerning them, including the need for an x-ray to Facility policy and procedure should determine the disposition
look for a lost item. If an x-ray is taken, the name of the radi- of any tally sheets used in the counting process. The tally sheets are
ologist and the findings also should be documented. An inci- merely worksheets and have no particular value to the permanent
dent report should be filed on all counts that remain unresolved. record. Some facilities use a wipe-off grease board to tally sponge,
It is not necessary to indicate the actual number of sponges or needle, and instrument counts. Additional information about the
needles used on the OR record. The documentation of correct processes and rationale for counting and being accountable are
or incorrect counts is sufficient. Any questionable count should described in Chapter 25.
be documented as resolved or unresolved and to whom the event
was reported.
Using Equipment
All instruments, equipment, and appliances should be used and tested
according to the recommendations and instructions of the manu-
PROS/CONS facturer. Safety devices such as personal protective attire or smoke
evacuation apparatus should be employed as necessary. Electrical and
Counting and Accountability laser equipment also should pass inspection by the biomedical engi-
neering department and be tagged with a dated p reventive mainte-
PROS nance sticker. Electrical equipment should be properly grounded to
• Every health care organization should define a standardized count prevent electrical shock and burns. Equipment or devices that are
procedure that fits their facility. Count sheets may be used as part known or suspected to be faulty are not used.
of the standardized count procedure, but it is up to each facility to The facility should conduct appropriate training and compe-
determine the appropriate practices to implement. tency reviews for all equipment used in patient care. Personnel
• The circulating nurse and scrub person should do a count before who set up and operate facility-owned equipment may be found
any procedure in which any item from the sterile field could be negligent if a patient is injured. Great care is critical to prevent
retained. injury when using all equipment in the perioperative environ-
• Some facilities have policies where the only counted items are those ment. It is inappropriate to operate equipment or machinery for
that are small enough to be lost in a wound. Instruments may not be which the employee has had no training. All personnel should
counted for tiny incisions.
have adequate training on all equipment they are expected to
• Specific cases such as trauma may be exempt from the counting
process because priority is to save the patient’s life. operate during patient care in the OR. Records of such training
• Documentation must state the reason for skipping the count in should be on file within the department.
cases in which the count was void. An x-ray may be done after the
procedure to determine whether any item was retained. Preventing Skin Injury
• Facility standardization and counting protocols are put in place to
protect the patient and surgical staff. Skin injury may be caused by an electrical or thermal device,
chemical agent, sharp objects, or mechanical pressure. Pressure
necrosis is possible after any procedure and especially after proce-

dures lasting more than 2 hours. Patients who have been in hold-
ing areas or emergency departments may have pressure injury in
process before arriving at the OR. The circulating nurse should
assess the patient for skin injury.
A burn may occur from the use of a hot instrument taken
directly out of the autoclave, such as a mouth gag or a large retrac-
tor. The best practice is to avoid immediate-use sterilization and
obtain a wrapped, processed instrument from the instrument
room. If immediate sterilization must be used, the scrub person
should immerse the hot instrument in a basin of cool, sterile water
before handing it to the surgeon. The hot item should not be
placed in a damp towel and placed on the patient’s skin; the heat
from the item will transfer through the towel and cause a burn.
Prolonged contact of even moderate temperatures can cause tissue
damage. The patient under anesthesia has no protective reflexes to
warn of an impending injury. Thermal injury can happen when
any device or solution heated beyond 110° F (44° C) comes into
• FIG. 2-2 Labeled basin with solution and labeled delivery device.
contact with a patient’s tissues.
A patient may be burned during use of the electrosurgical
unit (ESU). Inadequate skin contact or improper placement of Dispensing with the needle in place can cause aerosolization of the
the patient return electrode can cause a deep tissue burn that drug, potentially causing airborne exposure of a sensitive person.
won’t manifest immediately in the OR by a superficial reaction. AORN has developed a medication toolkit for preventing
Redness of the skin on removal of the patient return electrode medication errors. Contact AORN at www.aorn.org for more
may be caused by the adhesive rather than a burn. In a thermal information about receiving this packet. Consider the “seven
injury the deep tissue necroses and sloughs from the bottom up, rights” of medication administration:
leaving a full-thickness wound that may be insensate because of • Right patient
nerve damage. The tip of the ESU pencil, endoscopic instru- • Right drug
ment, or suction cautery probe remains hot after it is applied to • Right dose
tissues for hemostasis. Unintended burns may occur if the hot • Right reason
tip touches other body parts or it is activated against a metal • Right time
retractor or instrument. Use of a dry sponge against an activated • Right route
tip causes ignition and fire. • Right documentation
Alcohol and other flammable solutions such as some one-step
alcohol-based prep chemicals can ignite, causing flash fires if the
solutions are pooled under the patient or allowed to saturate
Monitoring the Patient
drapes, especially in the presence of oxygen. Vapors, fumes, or The standard of care indicates that a registered nurse is responsi-
oxygen can accumulate under drapes and ignite if exposed to the ble for monitoring the cardiac and respiratory status of a patient
ESU pencil. A thermal burn also can occur from other types of receiving local anesthetic, with or without intravenous (IV)
electrical and laser equipment that is improperly used or main- conscious sedation, if an anesthesia provider is not present. The
tained. The caregiver should be aware that the effects of some nurse is expected to interpret the monitoring equipment, assess
types of lasers on tissue are not readily visible until tissue necrosis the patient, and initiate interventions promptly if the patient
takes place several days postoperatively. has an untoward reaction. Policies and procedures are delineated
by each facility for care of the patient receiving local anesthetic.
Administering Drugs The nurse who is monitoring the patient should not be assigned
circulating duties that would distract attention from the patient.
Any drug or solution used in the surgical site, such as an antibi- Nurses who monitor patients under moderate sedation should
otic or local anesthetic, is recorded in the perioperative note by the be ACLS certified. Patient monitoring is described in more
circulating nurse and surgeon. The drug is checked by a registered detail in Chapter 27.
nurse and the scrub person before it is transferred to the sterile
field. The sterile medication cup and syringes (if used) are clearly
labeled by the scrub person on the field immediately after the drug
Preparing Specimens
is dispensed (Fig. 2-2). The scrub person frequently has more than With very few exceptions, tissue and objects removed from a
one drug on the instrument table, and confusion could result if the patient are sent to the pathology department. The loss of a tissue
drugs are not properly marked. The scrub person repeats the name biopsy specimen could necessitate a second surgical procedure to
of the drug to the surgeon when passing it. Medications and medi- obtain another one. Incorrectly labeled specimens could result in
cation handling are described in more detail in Chapters 23 and 25. a mistaken diagnosis, with possible critical implications for two
The scrub person should not “spear” a vial held by the circulat- patients. The loss of a specimen could prevent determination of
ing nurse, because that action places the circulating nurse’s hand a diagnosis and subsequent initiation of definitive therapy. The
at risk for a needlestick injury. The drug should be drawn into pathology report becomes part of the patient’s permanent record
a syringe by the circulating nurse and dispensed into the sterile as added documentation of the diagnosis. Specimens from oppo-
medicine cup after removing the needle used to penetrate the vial. site sides of the body should be sent in separate marked containers.
Care for foreign bodies according to the policy of the facil- internal specialty assembly governance structure provides a chair-
ity. They may have legal significance and frequently are claimed man and other elected officials. A perioperative nurse may belong
by police, especially if the foreign body is a bullet or something to as many assemblies as desired.
implicated in a crime. A receipt from the person taking them Nursing in general is both a humanistic art and an applied
protects personnel and the facility. Chain of custody is a serious science. The art of professional nursing practice involves nursing
subject and these items are accounted for at all times. diagnoses and the treatment of human responses to health and ill-
Specimen handling can be hazardous for personnel. Best prac- ness in all patient care settings. The science behind the paradigm
tices indicate that a sterile container and lid of the appropriate size of nursing is based on theories about the nature of humankind,
on the sterile field is the safest way to prevent biologic exposure of health, and disease. Nursing education prepares nurses to translate
other team members. The scrub person should contain the speci- the art and science of nursing into relevant knowledge and skill.
men completely before handing the container off to the circulat- Professional nursing education is built on a solid base of general
ing nurse, who is wearing protective gloves. Dropping a specimen education in liberal arts, humanities, and natural and behavioral
into a cup being held by another is placing that person at risk for sciences. AORN Position Statements reflect that, in the future,
exposure. This is avoidable. Specific information about specimen minimal entry level into perioperative nursing should be the bac-
preparation is found in Chapter 22. calaureate degree.
A wise physician once said that the physician’s role is to cure
sometimes, to relieve often, and to comfort always. The same can
Patient Teaching be said for the perioperative nurse, who is a registered nurse who
The patient and/or significant others need to be informed about embodies all that “nurse” has traditionally meant to a patient—
treatment options and their roles in the process. The patient provider of safety and comfort, supporter, and confidante. The
has the right to make decisions and contribute to the develop- patient’s safety and welfare are entrusted to the perioperative OR
ment of the plan of care. The perioperative nurse can assist with nurse from the moment of arrival in the perioperative environ-
preoperative teaching of deep-breathing exercises for postopera- ment until departure and the transfer of responsibility for care to
tive recovery. Information should be provided verbally and in another professional health care team member. The perioperative
writing. The patient and/or significant others should respond nurse is legally accountable for the delivery of care to patients in the
appropriately in such a way as to signify understanding of the perioperative environment, including interventions that assist the
information. This is particularly important for ambulatory sur- patient in a conscious or unconscious state. The primary emphasis
gery patients who will go home under the care of others. Patient of the nurse’s responsibility is to the patient. The perioperative
teaching and demonstration of understanding is documented in nurse identifies the physiologic, psychologic, and sociologic needs
the chart. More information about patient teaching is located in of the patient; develops and implements an individualized plan of
Chapter 21. care that coordinates interventions; and evaluates outcomes of the
patient’s perioperative experience. The nurse is accountable and
Professionalism responsible for delegated patient care.
Professionals act responsibly in accord with their commitment Patient-Nurse Relationship

to public trust and service. Simply stated, the word profession
implies a combination and coordination of knowledge, skills, and To practice in a technologically complex environment, periop-
ideals that are communicated through activities based in higher erative nurses must be flexible and their skills must be diverse.
education. The characteristics of a profession include: Their roles incorporate both the technical and the behavioral
• It defines its own purposes and code of ethics. components of professional nursing. Competent fulfillment of
• It sets its own standards and conducts its own affairs; it is self- the perioperative nursing role is based on the knowledge and
regulated and has autonomy. application of the principles of biologic, physiologic, behavioral,
• Through research, it identifies and develops its own body of and social sciences. Perioperative nurses develop nursing diagno-
knowledge unique to its role. ses based on patients’ problems, needs, and health status. This is
• It requires critical thinking skills in clinical judgment, as well as essential information in the identification of expected outcomes
problem-solving and decision-making skills in the application and in the formulation of a perioperative plan of care.
of knowledge. The perioperative nurse shares a special humanized experi-
• It engages in self-evaluation and peer review to control and ence with the patient at a time of great stress and need in his or
alter its practices and accountabilities. her life. This relationship encompasses feelings, attitudes, and
behaviors, with mutual trust and understanding as vital compo-
Professional Perioperative Nursing nents. Effective interaction encompasses concern for the unique
personhood of both the patient and the nurse. The length of
Professional nursing is dedicated to the promotion of optimal time spent with the patient is not as important as the quality of
health for all human beings in their various environments. AORN the interaction. The level of the interaction may directly affect
is the leading organization for perioperative nursing and sets the patient’s perception of the delivery of care in the periopera-
the standard for professionalism. In the support of professional tive environment.
perioperative nursing in a wide variety of specialties, AORN has To achieve and maintain a viable cooperative relationship, the
formed specialty assemblies for specialized practice areas and pro- patient should be able to sense that the nurse unconditionally
fessional interests. The specialty assemblies do not have regular cares about his or her well-being. The nurse should remain aware
meetings, but offer online and newsletter participation. Several that personal interaction is often predicated on culture, attitudes,
times a year the specialty assemblies offer workshops. Assembly beliefs, and experiences. Knowledge of the effect of care on the
meetings are held at the annual AORN Congress. An abbreviated patient’s outcome enhances the attainment of the desired result.
Perioperative nursing care is a specialized combination of indi- • BOX 2-5 The Nursing Process
vidualized and standardized care. Individualized care, the art of
nursing, demonstrates genuine concern for the patient as a person Assessment
and is not purely technical. Standardized care, the science of nurs- • Identify the actual or potential problems, needs, and health status
ing, is derived from a body of scientific knowledge that has been considerations through appraisal of the physiologic, psychosocial,
developed through research and clinical practice. objective, subjective, cultural, and ethnic data related to the patient as
an individual. Assessment is based on functional health patterns.
Evidence-Based Practice • Document assessment data.
The medical model has used tradition or habit to determine the Nursing Diagnosis
foundations of practice. In the 1980s medicine adopted an evi- • Formulate prioritized actual or potential nursing diagnoses unique to
dence-based framework premised in research as a foundation for the patient. Human response patterns guide the development of nursing
patient care practices. Nursing has questioned the best methods diagnoses.
for performing patient care and has sought confirmation of the Identification of Outcomes
rationale that supports nursing actions. The development of a
• Develop measurable and attainable expected outcomes and mutual
systematic process involves research that yields evidence of best
goals in collaboration with the patient, significant others, and other
practices. The essential elements involve obtaining and evaluating health care providers.
evidence and considerations for implementing newly established • Identify realistic time frames in which fulfillment may be accomplished.
evidence in practice.
Caregivers should always question why they are doing a Planning
particular action and if it is truly effective. Behaviors should • Establish and prioritize a working set of interventions for the actual
continually be evaluated for usefulness as opposed to ritualism. problems, needs, and health status considerations.
Many practices may no longer be necessary and are not supported • Establish a contingency plan for the potential problems, needs, and
by evidence. The following questions should be systematically health status considerations that may become actual during the course
reviewed when researching for evidence-based practice: of the perioperative experience.
• Which practice area requires evidence? • Include the patient’s input for the construction of the individualized plan.
• What comprises evidence? • Document the plan of care in a retrievable manner.
• How can evidence be found? Implementation
• What is the value of individual increments of evidence?
• Share the plan with the perioperative team for continuity of care.
• Can the increments of evidence be combined into a unit of
• Activate the interventions in a systematic order of priority.
practice? • Discontinue any intervention that is ineffective.
• Can the unit of practice be implemented in patient care? • Document the implementation of the interventions and their
To set up a research project or a systematic review, the following effectiveness.
should be well established:
• Who will make up the population to be studied? Evaluation
• Which intervention will be studied? • Determine the effectiveness of the plan as the expected outcomes and
• How does one intervention compare with another? mutual goals are met.
• Which outcomes are preferred? • Reformulate the plan and implement new interventions as necessary.
• Has an Investigational Review Board (IRB) approved the • Document the effectiveness of the plan of care in an ongoing,
research project? systematic manner.
Nursing Process
Perioperative patient care requires developing a plan of care and iden- • BOX 2-6 Human Response Patterns According to
tifying expected outcomes through the nursing process (Box 2-5). NANDA International
The nursing process is a systematic approach to nursing practice
using problem-solving techniques. This six-part process provides a • Exchanging • Moving
systematic foundation for assessing the patient, establishing a nurs- • Communicating • Perceiving
ing diagnosis, identifying desired outcomes, planning interventions, • Relating • Knowing
• Valuing • Feeling
implementing care, and evaluating the success of the plan. Human • Choosing
response patterns to health and illness are vital elements in establish-
ing a nursing diagnosis (Box 2-6).
Integration of the Nursing Process into attainment of outcomes. The perioperative nurse is responsible
Perioperative Patient Care for continually assessing the patient by observing and acknowl-
edging parameters identified in Box 2-7. The system and the
The six components of the nursing process are integrated into structure had been traditionally complex until specific data ele-
the three phases of the patient’s perioperative experience: the ments of perioperative patient care were clearly stated in a stan-
preoperative phase, the intraoperative phase, and the postop- dardized manner.
erative phase. Throughout the entire perioperative period the AORN responded to this dilemma and has identified a
patient is continually assessed, the plan of care is modified, Perioperative Patient Focused Model that consists of three
implementation is effected, and the cycle is evaluated for the primary areas of nursing concern: nursing diagnosis, nursing
• BOX 2-7 Assessment Parameters Monitored the individual patient via standardized documentation by EHR or
paper documentation.
Throughout Perioperative Care by the
A data element is the smallest unit of descriptive information
Circulating Nurse available that retains its meaning. It allows the reader to conceptu-
• Physiologic alize without added descriptors. The Perioperative Nursing Data
• Medical diagnosis Set (PNDS, 3rd ed) published by AORN in 2010 includes 93
• Surgical site and procedure perioperative nursing diagnoses, 151 perioperative nursing inter-
• Results of diagnostic studies ventions, and 39 patient outcomes. The PNDS is described in
• Laboratory tests four domains specific to the perioperative nursing process. These
• Review of systems are as follows:
• Mobility, range of motion • Domain 1: (D1) Safety
• Prosthetics (internal or external)
• Domain 2: (D2) Physiologic responses
• Sensory impairments
• Allergies • Domain 3-A: (D3-A) Behavioral responses of patient and
• Skin condition family: Knowledge
• Nutritional and metabolic status • Domain 3-B: (D3-B) Behavioral responses of patient and
• Height and weight family: Rights and ethics
• Vital signs • Domain 4: (D4) Health system
• Elimination pattern (e.g., continence) The PNDS is important for capturing data in a systematic way
• Sleep, rest, exercise patterns that can be retrieved, measured, and evaluated by an information
• Medications system. Nursing diagnoses have been connected with implemen-
• Substance abuse tation of nursing interventions and with specific outcomes to fur-
• Psychosocial
ther validate the use of a standardized perioperative language. The
• Cognition (e.g., mental status)
• Cultural and religious beliefs standardized language has a letter and a number that are specific
• Perception of procedure to the nursing activity it describes within the particular domain as
• Expectations of care described. For example:
• Knowledge base (e.g., informed consent) • A—Assessment
• Readiness to learn • Im—Implementation
• Ability to understand and retain teaching • E—Evaluation
• Stress level (e.g., anxiety, fears) • O—Outcome
• Coping mechanisms The PNDS was officially recognized by the ANA’s Committee
• Support from family or significant others on Nursing Practice Information in 1999. The clinical relevance
• Attitude and motivation (e.g., health management)
of the PNDS is specific to perioperative patient care and provides
• Affective responses (e.g., ability to express feelings)
• Speech characteristics (e.g., language) a standardized language to validate the value of the role of the
• Nonverbal behavior professional perioperative nurse. The PNDS is clinically validated
nursing language that is useful for clinical practice, education, and
research. According to AORN, the advantages of PNDS usage
include but are not limited to the following:
interventions, and patient outcomes. These areas are reflected in • Providing a framework to standardize documentation (i.e.,
the model as domains that describe the perioperative patient’s AORN SYNTEGRITY)
interaction with the health care system, particularly surgery. • Providing a universal language for perioperative nursing
The primary domains concerning perioperative nurses and their practice and education
patients are patient safety, physiologic responses, and behavioral • Assisting in the measurement and evaluation of patient care
responses: (1) concerning the patient and the system; and (2) outcomes
concerning the nurse, ethics, and the patient’s rights and the • Providing a foundation for perioperative nursing research and
health care system. evaluation of patient outcomes
• Informing decisions about the relationship of staffing to patient
Perioperative Nursing Data Set outcomes
• Providing data about the contributions of nurses to patient
AORN developed the perioperative-specific nursing vocabulary outcomes in the perioperative arena
that defines and describes the perioperative patient’s experiences • Data can be gathered and tallied in a mechanized format and
from preadmission to discharge from care. The standardized are compatible with computerized information systems.
language of data elements identifies specific common components Consult AORN online at www.aorn.org for additional informa-
that are distinctly part of perioperative patient care. E lectronic tion about obtaining a copy of the PNDS. A discount is avail-
health records (EHR) represent perioperative nursing care in able to AORN members. Other nursing organizations with
a unified language that provides feedback in an evidence-based recognized forms of standardized language are listed online at
format. The AORN SYNTEGRITY framework was developed www.nursingworld.org.
to provide a consistent integration of perioperative documen-
tation incorporating PNDS into the perioperative record for Preoperative Phase
minimization of discrepancies and evidence of standards compli- The preoperative phase of the patient’s surgical experience begins
ance (Fig. 2-3). The PNDS is set into tables used by perioperative when the decision is made to undergo surgical intervention, and
information systems. Tables of PNDS values connect assessment it ends when the patient is transferred to the OR bed in the OR.
and nursing diagnoses, intervention, and outcome data directly to During this phase the perioperative nurse performs the assessment,
Guidelines & Regulatory

Standards
Recommended Practices Requirements
PAT Standardized Standardized

PNDS
Workflow Procedure List
All phases of perioperative patient care
AORN Syntegrity® Solution
PreOp Current Standardized

Electronic Perioperative
Health Content for
Record the EHR
Intraoperative
PostOp
The AORN Syntegrity® Solution is standardized content for perioperative

nursing documentation and surgical scheduling that is built into the current
Electronic Health Record.
• FIG. 2-3 AORN SYNTEGRITY™ Standardized Perioperative Framework. Nurses enter their docu-
mentation and AORN SYNTEGRITY™ framework provides a guide through a standardized language,
PNDS, with your current information system. (Reprinted with permission from AORN. Copyright © 2016,
AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.)
determines the nursing diagnoses, identifies potential outcomes, the immediate postoperative patient care division for progressive
and develops a plan of care. The nurse assesses the patient to iden- stages of self-care on a surgical unit before being discharged from
tify any actual or potential physiologic, psychosocial, and spiritual the hospital. The postoperative phase ends when the surgeon dis-
needs, problems, or other health status considerations. In col- continues follow-up care. Evaluation, the sixth component of the
laboration with the patient and/or significant others the nurse nursing process, is completed during this phase.
then determines the nursing diagnoses and identifies the expected
outcomes of the perioperative experience. The perioperative nurse Standards of Perioperative Nursing Practice
plans, prioritizes, and initiates the patient care necessary for the
attainment of the desired outcomes. A standard is an authoritative statement established and published
by a profession and by which the performance of practice can be
Intraoperative Phase measured. The standards of nursing practice establish parameters
The intraoperative phase begins with placement of the patient and competency levels against which the practice of the profession
on the OR bed and continues until the patient is admitted to is compared.
a postprocedure or postoperative area, such as the postanesthesia The ANA Standards of Clinical Nursing Practice reflect the
care unit (PACU). Implementation of the plan and evaluation of nursing process and state the interventions to be performed. These
care continue during this phase. The perioperative nurse either standards are a description of a competent level of practice com-
personally carries out the plan of care or supervises others in car- mon to all nurses and form the foundation of all decision making
rying out the plan with skill, safety, efficiency, and effectiveness. in the provision of care to all patients. The interpretive statements
Modification of the plan may be necessary during the procedure. that accompany each standard provide definitions of terms along
with the interventions and guidelines necessary to achieve these
Postoperative Phase standards. Criteria for the achievement of each standard are also
The postoperative phase begins with admission of the patient to a stated and remain consistent with current nursing practice.
postprocedure or postanesthesia area, which may be a PACU or an Nursing practice is based on theory and evidence-based practice.
intensive care unit (ICU). Patients admitted to the facility on an Nursing is constantly evolving with the development of new tech-
ambulatory 1-day-stay basis may return to the ambulatory unit. nology and research. The standards are written in behavioral terms
As indicated by his or her condition the patient will transfer from so nurses can measure to what degree each standard has been met.
The Standards of Perioperative Clinical Practice, originally pub- factors have an effect on a patient’s interpretation of illness and
lished in 1981, were revised in 2009 by the AORN Board of Direc- response to the interaction with the perioperative environment.
tors. The nursing activities inherent in each standard are incorporated Anticipatory apprehension, although normal to some degree, may
in the nursing process during the three phases of surgical care. diminish critical-thinking and decision-making abilities. Stress may
initiate an exaggerated response of normal coping mechanisms for
self-protection. Establishing a preoperative psychosocial baseline facil-
Standard I: Assessment itates prompt recognition of maladaptation to a perioperative event.
The perioperative nurse collects patient health data from which the
nursing diagnoses are derived. Data collection is continual and ongo- Documentation
ing. It may be gathered in the preoperative holding area, on the patient Pertinent information should be recorded in the patient’s chart or
care unit, in the clinic, or by a telephone call to the patient at home. EHR for use by the perioperative team. Data collection sets the
Information can be obtained from the patient’s chart, by consultation baseline for ongoing care in the perioperative environment and
with other members of the health care team (e.g., unit nurses, sur- into the remote postoperative care period.
geon, anesthesia provider), through interviews with the patient and/ Computer information systems can be used to establish a com-
or family or significant others, and by observation and physical assess- puterized patient database. Many facilities have incorporated the
ment. Data collection is a progressive and orderly process of gathering Internet to permit the patient access to his or her own medical
meaningful information pertinent to the planned surgical interven- record with a personalized logon and password. Use of the PNDS
tion. It includes but is not limited to the following parameters: allows the nurse to use standardized terminology that in turn per-
• Current medical diagnosis and therapy mits data collection about patient care. This is the foundation of
• Diagnostic studies and laboratory test results evidence-based practice. A printed copy of the patient care plan
• Physical status and physiologic responses, including allergies can be printed for the patient’s record. The nurse should review
and sensory or physical deficits the printed copy and date and sign it for the permanent record.
• Psychosocial status, including education level
• Spiritual needs, ethnic and cultural background, and lifestyle Standard II: Diagnosis
• Previous responses to illness, hospitalization, and surgery
• Patient’s understanding, perceptions, and expectations of the The perioperative nurse analyzes the assessment data in
procedure determining the nursing diagnoses. Nursing diagnoses are conclu-
Pertinent data collected through physiologic and psychosocial sions based on analysis and interpretation of the human response
assessment are documented. Box 2-7 lists the perioperative assess- patterns revealed by the assessment data. These are concise written
ment parameters. The basic elements of a nursing assessment are statements about a patient’s actual or potential problems, needs,
described in the sections that follow. or health status considerations amenable to nursing intervention.
• Subjective data: Include the patient’s perceptions and expec- A medical diagnosis defines problems on the basis of a patient’s
tations of the procedure and may be recorded in the form of pathologic condition(s). NANDA International has developed a
a direct quote. list of nursing diagnoses (www.nanda.org). This list, known as a
• Objective data: Include the nurse’s observations of the taxonomy, classifies human response patterns and standardizes
patient and the interpretation of baseline data. the nomenclature for describing them. It includes definitions and
defining characteristics for each diagnosis and leads the nurse to
Physiologic Assessment generate assessment data that link to outcomes. The PNDS has 93
The perioperative nurse performs a physical assessment of the nursing diagnoses specific to perioperative patients. A NANDA
patient. Techniques include inspection/observation, auscultation, nursing diagnosis has three components:
percussion, palpation, and olfaction. The assessment of major 1. Defining characteristics. Human responses to altered body
body systems establishes the baseline health status of the patient. processes and other contributing factors describe the acuity of
It provides a basis for planning appropriate patient care and pro- an actual or potential health status deviation. The nurse iden-
vides a database for postoperative evaluation. tifies the characteristics for which nursing interventions can
The perioperative nurse should also be familiar with labora- legally be used to maintain current health status or to reduce,
tory test norms so that critical deviations can be identified in eliminate, or prevent its alteration. These interventions are
all phases of perioperative care. Other important parameters for based on human response patterns:
planning perioperative care include knowledge of allergies, skin a. Problem. Any health care condition that requires diagnostic,
integrity, sensory or physical limitations, prosthetic devices, nutri- therapeutic, or educational action. Problems can be active
tional/metabolic status, and chronic illness. The routine use of (requiring immediate action) or inactive (having been
medications can affect or interact with anesthetic medications solved). Problem-oriented medical records are built on this
and postoperative recovery. A patient who smokes and who will premise. An ongoing list is maintained in a database and is
have general anesthesia needs to be taught coughing and deep- used throughout the managed care environment.
breathing exercises. The patient who is dependent on alcohol or b. Need. A lack of something essential for the maintenance of
other drugs can suffer postoperative physiologic and psychologic health that may be met through the plan of care. Needs may
manifestations of withdrawal. A chemically dependent person be actual (in existence at the time of assessment) or potential
who is recovering from an addiction may refuse preoperative seda- (anticipated to become actual during the length of stay [e.g.,
tion and postoperative narcotics for pain. deficient knowledge]). Many of these needs are met through
the intervention component of the plan of care.
Psychosocial Assessment c. Health status considerations. A personal habit, lifestyle, or influ-
The perioperative nurse performs a psychosocial assessment. Illness encing agent that if uncontrolled can lead to a decline in physi-
makes a person vulnerable, and individuals vary in their ability to ologic or psychologic well-being (e.g., occupational hazards,
cope with stressful situations. Culture, religion, and socioeconomic exposure to chemical agent or smoke, substance abuse).
• BOX 2-8 Gordon’s Functional Health Patterns of Expected perioperative outcomes are the desired and obtain-
able patient objectives after a surgical intervention. These out-
Observable Behaviors
comes occur within specified time frames and have specific criteria
• Health perception/health management for evaluation, as demonstrated in the 39 identified PNDS patient
• Nutritional/metabolic outcomes. They direct patient care to modify or maintain the
• Elimination patient’s baseline functional physical capabilities and behavioral
• Activity/exercise patterns. The patient’s rights and preferences are the cornerstones
• Sleep/rest for expected outcomes. They should be realistic, attainable, and
• Cognitive/perceptual consistent with medical regimen and patient outcome standards
• Self-perception/self-concept
for perioperative nursing.
• Role/relationship
• Sexuality/reproductive
• Coping/stress tolerance
Documentation
• Value/belief The results of care should be documented in standardized lan-
guage. Examples of PNDS outcomes are prefixed with the letter
Modified from Gordon M: Manual of nursing diagnosis, 1997-1998, St. Louis,
1997, Mosby.
O and the nomenclature and number from the PNDS list. Select
examples of PNDS documentation include the following:
• O30 The patient’s neurologic status is consistent with or
improved from baseline levels established preoperatively.
2. Signs (objective) and symptoms (subjective). Data obtained • O14 The patient’s respiratory status is consistent with or
during the assessment identify the defining characteristics of improved from baseline levels established preoperatively.
the patient’s actual or potential health problems. The patient’s • O13 The patient’s fluid and electrolyte balance is consistent with
functional health patterns are assessed (Box 2-8). Gordon has or improved from baseline levels established preoperatively.
suggested that there are 11 functional health patterns that
should be assessed. The domains include physiologic, psycho- Standard IV: Planning
logic, and sociologic aspects of observed behavior.
3. Etiology/related factors. The causes of problems may be related to The perioperative nurse develops a plan of care that prescribes
physiologic, psychosocial, spiritual, environmental, or other fac- interventions to attain the expected outcomes. Based on the
tors contributing to the patient’s health status. These causes define assessment data, nursing diagnoses, and identified expected out-
relevant risk factors to be considered in planning patient care. comes, the perioperative nurse devises a plan of care. The plan
should include a provision for all phases of patient care in the
Documentation perioperative environment. Strategic concepts to consider in
Use of the PNDS terminology helps perioperative nurses establish planning perioperative patient care include but are not limited
standard communication when documenting nursing diagnoses. to the following:
A common language facilitates continuity of patient care. • Participation of the patient and/or significant others in formu-
lation of the plan
• Medical diagnosis and effect of surgical intervention on the
Standard III: Outcome Identification patient’s physiology
The perioperative nurse identifies expected outcomes unique to • Psychosocial and spiritual needs of the patient and his or her
the patient. Each outcome can be affected by nursing care (also significant others
referred to as “nurse sensitive”1) and is specific to the individual, • Environmental safety, comfort, and well-being
the family, and the community. The Nursing Outcomes Classifi- • Provision of supplies, equipment, and technical expertise
cation (NOC) taxonomy is built on five levels: domains, classes, • Current best nursing practices
outcomes, indicators, and measures.2 The standardized termi- The plan of care should reflect current standards, facilitate
nology gives quantifiable language to the statement of outcomes the prescribed medical care, and work toward the attainment
and has numeric codes that can be used in nursing informatics of desired outcomes. The scope of the plan is determined by
systems. Each outcome is evidence based and was researched using assessment data. Any unusual data are considered for indi-
qualitative and quantitative methods in 10 midwestern centers in vidualized patient care. Alternative options or interventions,
the United States. not just routine procedures, are a necessary part of the plan.
The nurse measures the patient’s responses and uses a five- Regardless of format, the plan of care specifies the following
point Likert scale to tally the score. A numeric baseline range is parameters:
documented and the numeric target outcome is identified. This • Patient care necessary to achieve expected outcomes
method permits the use of the data in an information system and • Interventional priorities and sequence of care
empiric research. The 330 validated outcomes are closely linked • Availability of resources needed to implement the plan
and integral with 191 NANDA nursing diagnoses3 and can be • How, where, and by whom the care will be delivered
used across the care continuum in all branches of nursing, includ- • Specific modifications for individualized aspects of care
ing the perioperative care areas. • Methods for evaluating the effectiveness of the plan
1
Documentation
Terminology used in the Nursing Outcomes Classification (NOC) 3/e,
2004. Standardized patient care plans may be developed for patient pop-
2 NOC 5/e, 2013. ulations undergoing like procedures, with space provided to note
3 NANDA updates can be found under Diagnosis Development at www. any unique or unusual patient assessment data. These care plans
nanda.org. can be organized on preprinted forms to include the usual nursing
diagnoses and expected outcomes and may include, but are not the care given. This written documentation becomes part of the
limited to, the following: patient’s permanent record. The circulating nurse accountable for
• The patient will demonstrate understanding of the procedure. the patient’s care is responsible for the documentation either in
• The patient will be injury free. writing or through the EHR. The person completing the docu-
• The patient will remain normothermic. mentation should sign with a complete name and title. Interven-
• The patient will be infection free. tions contributing to patient comfort and safety are identified.
• The patient’s skin will remain intact. Activities other than direct patient care that are not recorded else-
• The patient will remain physiologically stable. where and may affect patient outcomes are included (e.g., how
• The patient will demonstrate psychologic comfort. tissue specimens were handled).
• The patient will return to normal activities of daily living. Writing nurses’ notes or progress notes on the patient’s chart
The format of the record may include checklists and spaces or completing an accurate intraoperative observation checklist
for specific patient data. This record accompanies the patient provides a profile of what has happened to the patient. The notes
throughout the perioperative environment and serves as a guide should contain what happened and why. Intraoperative records
for the perioperative team. Use of a standardized language, such not only have legal value but also are valuable to the postoperative
as the PNDS, is beneficial for precise communication. Dissemina- care team. The PNDS provides standardized language to describe
tion of the plan to all personnel involved in providing care to the 133 nursing interventions that are designated by the letter I and
patient is essential for continuity of care. The plan is modified as the nomenclature and number from the list. Select PNDS inter-
indicated by ongoing evaluation data. vention examples include:
• I4 Administers care to wound site
• I5 Administers electrolyte therapy as prescribed
Standard V: Implementation • I3 Administers care to invasive device sites
The perioperative nurse implements the direct and indirect inter- • I37 Evaluates for signs and symptoms of electrical injury
ventions identified in the plan of care. A taxonomy of nursing • I84 Manages specimen handling and disposition
interventions known as the Nursing Intervention Classification
(NIC) is the basis for the standardization of terminology.4 The Standard VI: Evaluation
NIC is linked to NANDA International and describes 514 evi-
dence-based interventions that are grouped into 30 classes. The The perioperative nurse evaluates the patient’s progress toward
seven domains of the NIC are Physiologic: Basic, Physiological: the attainment of outcomes with an actual outcome statement
Complex, Behavioral, Safety, Family, Health, and Community. as described in the PNDS. Evaluation is a continual process of
The standardized terminology of the NIC gives quantifiable lan- reassessing the patient and his or her responses to implementa-
guage to the nursing interventions and has numeric codes that can tion of the plan of care. Perioperative caregivers accommodate a
be used in nursing informatics systems. variety of intense situations within a short time. The perioperative
The plan of care is implemented throughout the perioperative team is always on the alert for, and prepared to respond to, the
care period by the entire team. Scientific principles provide the unexpected. The flexibility of the team is manifest in the quick
basis for patient care interventions that are consistent with the plan modifications to the plan of care during emergency situations.
for continuity of patient care in the perioperative environment. All components of the nursing process are performed con-
They are performed with safety, skill, efficiency, and effectiveness. currently during the intraoperative phase as changes occur in
The patient’s welfare and individual needs are paramount in the patient’s internal and external environments. The patient is
every facet of activity and must not be compromised. Seemingly observed during the surgical procedure and evaluated for responses
routine details are significant. For example, taking a defective to all interventions.
instrument out of circulation may prevent injury to the patient or Determination of patient responses and the realization of
team member. All preoperative preparations within the periopera- expected outcomes can be verified by direct observation of and/
tive environment provide for the physical safety of the patient and or conversation with the patient. The perioperative nurse observes
team in an aseptic, controlled manner. The circulating nurse also the patient’s responses to interventions during the immediate
provides emotional support to the patient before transfer to the preoperative and intraoperative phases of care in the periopera-
OR bed and during induction of anesthesia. tive environment. The perioperative nurse may accompany the
This text focuses primarily on direct and indirect interventions patient to the PACU or postprocedure area to determine the level
that perioperative and perianesthesia nurses and surgical technolo- of attainment of expected outcomes. The “hand-off” report should
gists perform to ensure achievement of expected patient outcomes. be standardized between the perioperative nurse and the postanes-
Implementation of safe and efficient patient care requires the thesia nurse. Ideally the perioperative nurse visits the patient post-
application of technical and professional knowledge, sound clini- operatively on the patient care division or phones an ambulatory
cal judgment, and a surgical conscience on the part of all team patient at home within 24 to 48 hours after discharge to complete
members. Nurses have a responsibility to monitor constantly the the assessment of outcomes.
physical and psychologic responses of patients to care. They control
environmental factors that affect outcomes of surgical intervention. Documentation
The patient’s permanent record should reflect the ongoing evalua-
Documentation tion of perioperative nursing care and its outcomes. This includes
All patient care interventions (both routine and individualized), a comparison of expected outcomes to the degree of outcome
observations of patient responses, and the resultant outcomes attainment as determined by the patient’s responses to nursing
delineated in the patient care plan are documented as evidence of interventions. Documentation using a standardized language pro-
vides legal evidence of results of the plan of care and revisions to
4 Nursing Intervention Classification (NIC) 6/e, 2013. the plan after reassessment of the patient. Examples of PNDS in
action include, but are not limited to, the following PNDS num- • Maintain asepsis
bered nursing diagnoses and outcome statements: • Monitor physiologic and psychologic status
• O31: Patient demonstrates knowledge of the expected • Manage aggregate patient needs
responses to the procedure • Supervise ancillary personnel
• O11: Patient has wound/tissue perfusion consistent with or • Validate and explore current and prospective practices
improved from baseline levels established preoperatively • Integrate and coordinate care across all disciplines
• O12: Patient is at or returning to normothermia at the conclu- • Collaborate and consult
sion of the immediate postoperative period These activities are incorporated into the scope of perioperative
• O2: Patient is free from injury from extraneous objects practice by managers, educators, practitioners, and researchers.
These practices take place in hospitals, clinics, educational facili-
ties, physicians’ offices, provider organizations, and industry.
Clinical Competency of the Perioperative
Nurse Surgical Technology
Using the framework of the nursing process, AORN published The activities of registered professional nurses are supple-
Competency Statements in Perioperative Nursing in 1986 mented and complemented by the services of allied technical
and revised them in 1992. These broadly written statements of health care personnel. The term allied health care personnel
expected competencies can be used to develop position descrip- refers to individuals who have been trained in a health care–
tions, generate performance appraisals, and organize orientation related science and have responsibility for the delivery of health
and staff development activities. They may serve as guidelines for care–related services but who are not graduates of schools of
the skills a nurse should reasonably expect to achieve to function medicine, osteopathy, dentistry, podiatry, or nursing. Approxi-
as a perioperative nurse in the perioperative environment. These mately two thirds of the health care workforce are designated
statements incorporate the many principles, procedures, and prac- as allied health professionals. Educational preparation may be
tices elaborated throughout this text for competent care of the offered in colleges, vocational-technical schools, hospital-based
surgical patient. programs, or military service schools. Technologists, techni-
• Assess the physiologic health status of the patient. cians, and therapists in more than 130 occupational categories
• Assess the psychosocial health status of the patient and family. work collaboratively with and under the direction of physicians
• Formulate nursing diagnoses based on health status data. and registered nurses.
• Establish the patient’s expected outcomes based on nursing The surgical technologist, or ST, is a member of the direct
diagnoses. patient care team and works intraoperatively with the surgeon
• Develop a plan of care that identifies patient care interventions and anesthesia provider under the direction of the circulating
to achieve expected outcomes. nurse. This team is referred to as the perioperative team. The sur-
• Implement patient care interventions according to the plan of gical technologist prepares instruments, supplies, and equipment
care. to maintain a safe and therapeutic surgical environment for the
• Evaluate the attainment of expected outcomes and effective- patient. The surgical technologist performs specific techniques
ness of patient care. and functions designed to exclude pathogenic microorganisms
• Participate in both patient and family teaching. from the surgical wound.
• Create and maintain a sterile field. A surgical technologist completes a 9-month certificate to
• Provide equipment and supplies based on patient needs. 2-year college degree intensive educational program. This pro-
• Perform sponge, sharps, and instrument counts. gram includes courses in anatomy and physiology, pathology, and
• Administer drugs and solutions as prescribed. microbiology as prerequisites to courses that involve the theory
• Physiologically monitor the patient during the surgical proce- and application of technology during surgical procedures and
dure and throughout the perioperative experience. for care of the perioperative environment. Other courses in the
• Monitor and control the environment. curriculum, such as pharmacology, help explain the underlying
• Respect the patient’s rights. basis for the technical tasks to be performed. Courses in psychol-
• Demonstrate accountability. ogy, ethics, and interpersonal communication are fundamental to
an appreciation of the humanities. According to the accrediting
Scope of Perioperative Nursing Practice body’s standards, a 9-month program should average 400 to 500
hours of didactic instruction and offer more than 500 hours of
Perioperative nurses care for patients throughout the continuum supervised clinical practice.
of the perioperative intervention. The patient’s needs are unique AST (Association of Surgical Technologists), NBSTSA
during this phase of care and require specific activities particular (National Board of Surgical Technology and Surgical Assisting),
to the realm of perioperative nursing. The professional nurses ren- and ARC-STSA (Accreditation Review Council on Education
der direct care or oversee the implementation of the plan of care in Surgical technology and Surgical Assisting) have taken the
through specialized activities that include but are not limited to position that an associate degree is the preferred educational
the following: level for entry into practice and that certification should be
• Educate staff and peers a condition of employment. This is documented in the 2005
• Emotionally support and reassure the patient and his or her combined meeting minutes and in the AST Recommended
family Standards of Practice.5
• Serve as patient advocate
• Control environment 5
AST, ARC-ST, and LCC-ST are located at 6 West Dry Creek Circle,
• Provide resources Littleton, CO 80120.
Standards of Practice for Surgical rights. The surgical technologist, like all members of the health
Technologists care team, is expected to perform as a patient advocate in all situa-
tions. This is an accountability subject and should be part of each
AST has developed standards of practice that provide g uidelines aspect of patient care.
for the development of performance descriptions and performance
evaluations. The quality of the surgical technologist’s practice may Standard VI
be judged by these standards. The six authoritative statements that
comprise the standards describe the scope of patient care and serve Every patient is entitled to the same application of aseptic tech-
as a guide on which to base clinical practice.6 nique within the physical facilities. Implementation of the indi-
vidualized plan of care for every patient includes the application
of aseptic or sterile technique at all times by all members of the
Standard I health care team. All patients are given the same dedication in
Teamwork is essential for perioperative patient care and is contin- their care.
gent on interpersonal skills. Communication is critical to the posi-
tive attainment of expected outcomes of care. All team members
should work together for the common good of the patient. For Clinical Competency of the Surgical
the benefit of the patient and the delivery of quality care, inter- Technologist
personal skills are demonstrated in all interactions with the health
care team, the patient and family, superiors, and peers. Personal The performance description developed by AST identifies per-
integrity and surgical conscience are integrated into every aspect formance objectives against which the surgical technologist may
of professional behavior. measure his or her level of competency. According to AST, the
surgical technologist can aspire to three levels based on education,
experience, and time in service. Each level requires the surgical
Standard II technologist to be certified and employed in the OR. The employ-
Preoperative planning and preparation for surgical intervention ment setting can be a clinic, private practice, or a facility, such as a
are individualized to meet the needs of each patient and his or hospital. These levels could be used to structure seniority, promo-
her surgeon. The surgical technologist collaborates with the pro- tions, and salaries. The certified surgical technologist (CST) levels
fessional registered nurse in the collection of data for use in the are as follows:
preparation of equipment and supplies needed for the surgical
procedure. The implementation of patient care identified in the Level I CST
plan of care is performed under the supervision of a professional
registered nurse. • Entry level as certified or a qualified applicant
• Graduated from an accredited program with a minimum of
125 cases in the scrub role
Standard III • Performs as first scrub in all assigned specialty cases
The preparation of the perioperative environment and all sup-
plies and equipment will ensure environmental safety for patients Level I Competencies
and personnel. The application of the plan of care includes wear- • Demonstrates knowledge and practice of basic patient care
ing appropriate attire, anticipating the needs of the patient and concepts
perioperative team, maintaining a safe work area, observing asep- • Demonstrates the application of the principles of asepsis in a
tic technique, and following all policies and procedures of the knowledgeable manner that provides for optimal patient care
institution. in the OR
• Demonstrates basic surgical case preparation skills
• Demonstrates the ability to perform in the role of first scrub on
Standard IV all basic surgical cases
Application of basic and current knowledge is necessary for • Demonstrates responsible behavior as a health care professional
a proficient performance of assigned functions. The surgical
technologist should maintain a current knowledge base of pro- Level II CST (Advanced)
cedures, equipment and supplies, emergency protocol for various
situations, and changes in scientific technology pertinent to his • Current CST
or her performance description objectives. It is the responsibility • A minimum of 5 consecutive years of full-time employment
of the surgical technologist to augment his or her knowledge base • Documentation of a minimum of 24 continuing education
by studying recent literature, attending inservice and continuing credits in a specialty area
education programs, and pursuing new learning experiences.
Level II Competencies
• Demonstrates all competencies required for CST level I
Standard V • Demonstrates advanced knowledge and practice of patient care
Each patient’s rights to privacy, dignity, safety, and comfort are techniques
respected and protected. Each member of the OR team has a • Demonstrates advanced knowledge of aseptic and surgical
moral and ethical duty to uphold strict observance of the patient’s technique
• Demonstrates advanced knowledge and practice of circulating
6 www.ast.org skills and tasks
• Demonstrates knowledge related to OR emergency situations purpose is to correct deficiencies and deviations from expected
• Demonstrates advanced organizational skills standards. Important aspects that have an effect on the qual-
• Demonstrates advanced knowledge in one or two specialty ity of patient care are identified, and a measurable indicator is
areas established for each aspect. Data sources and methods of data
• Demonstrates a professional attitude collection should be appropriate for each indicator. Sample size
and the frequency of data collection should be sufficient to
identify trends or patterns in the delivery of care. A sample
Level III CST (Specialist) size of 5% of the monitored patient population selected for
• Current CST study or 25 patients or events, whichever is greater, is usually
• Associate’s degree in surgical technology or related field, or a adequate to obtain reliable data.
minimum of 8 consecutive years of full-time employment Data are collected either concurrently or retrospectively and
• Documentation of a minimum of 24 continuing education are organized for evaluation. A concurrent study begins with a
credits in a specialty or management area current manifestation and links this effect to occurrences at the
• Documentation of a minimum of 20 continuing education same time (i.e., is related to care in progress). This type of study
credits in AST category 3 advanced practice focuses on a systematic series of actions that brings about an
outcome. Through concurrent observation, the implementa-
Level III Competencies tion component of the nursing process can be monitored during
• Demonstrates all competencies required for CST level II perioperative patient care to determine whether interventions
• Demonstrates superior knowledge and practice of patient care are consistent with established standards for care and recom-
techniques mended practices. The interventions performed should protect
• Demonstrates superior knowledge of aseptic and surgical tech- the welfare and safety of the patient and should meet his or her
nique identified physiologic and psychologic needs. The environment,
• Demonstrates advanced knowledge and practice of circulating including equipment or supplies used in the room, can also be
skills and tasks evaluated at this time.
• Demonstrates advanced knowledge related to OR emergency A retrospective study focuses on the end result of patient
situations care or on a measurable change in the actual state of the
• Demonstrates advanced organizational skills patient’s health as a result of care received. This evaluation of
• Demonstrates superior knowledge in one or two specialty areas outcomes usually occurs through review of patient records.
• Demonstrates a professional attitude The study begins with a current manifestation and links this
• Demonstrates leadership abilities effect to some occurrence in the past (i.e., care previously
given). Complications attributable to care in the periopera-
tive environment may be identified (e.g., nerve palsy from
Continual Performance Evaluation poor positioning, infiltration of an IV infusion, postoperative
and Improvement wound infection). The source of these complications may be
difficult to identify unless every detail of actual care given and
Nursing research and experience have shown that quality can- any unusual occurrences are recorded in the patient’s record.
not be ensured, only monitored and performance improved. Accurate and complete documentation is therefore essential for
TJC has adopted a definition of quality as “continual improve- meaningful retrospective studies.
ment” in patient care services to increase the probability of Any method that systematically monitors and evaluates the
expected patient outcomes and reduce the probability of unde- quality of patient care can enable perioperative nurses and sur-
sired outcomes. Outcomes can be defined, monitored, and gical technologists to take corrective action for improvement of
measured. Patient satisfaction is one outcome measurement performance. Quality improvement studies also assist in the coor-
that is critical in evaluating quality of performance. Satisfied dination of plans for patient care with surgeons, improve commu-
patients are more cooperative and receptive to therapy and nications with other departments, identify needs for revision of
teaching. policies and procedures, and reassess equipment, personnel, and
Each patient deserves the best possible care. Without the struc- other aspects of patient care.
ture provided by the nursing process, health care services would be
fragmented and accountability for the quality of services rendered Benchmarking
would be made difficult. Society demands the accountability of
those who provide patient care services. Patients are protected by Benchmarking is a term that is used to continually monitor
laws, standards, and recommended practices. Performance of care progress of a competitor to discover methods for performance
should comply with established policies and procedures of the improvement and how to implement them. According to TJC,
hospital or ambulatory care facility and with professional stan- when processes within the same facility are measured against
dards of practice. each other, this is referred to as internal benchmarking. Mea-
suring performance against an outside competitor is referred
to as competitive benchmarking. If another industry’s activi-
Performance Improvement Studies ties are used as the comparison, the reference is then made to
Most studies are designed to measure compliance with cur- functional benchmarking.
rent policies and procedures and identify the need for change When practices are benchmarked, the current level of attain-
in practice guidelines or education of staff. Both strengths ment is clearly identifiable and higher performance attributes can
and weaknesses in performance are identified. Ultimately the be viewed as the next step in professionalism.
Peer Review Bibliography

Peer review differs from other quality improvement programs AORN (Association of periOperative Registered Nurses): Guidelines for
in that it looks at the strengths and weaknesses of an individual perioperative practice, Denver, 2015, The Association.
practitioner’s performance rather than appraises the quality of AORN: Perioperative nursing data set: The perioperative nursing vocabu-
care rendered by a group of professionals to a group of patients. lary, ed 3, Denver, 2010, The Association.
An associate with the same role expectations and performance Morton P, et al.: Validation of the data elements for the health system
domain of the PNDS, AORN J 98(1):39–48, 2013.
description examines and evaluates the clinical practice of
Nightingale F: Notes on nursing: what it is, and what it is not, New York,
a peer. The individual is evaluated by written standards of 1969, Dover Publications.
performance, and the review should offer constructive criti- Spruce L: Back to basics: Implementing the surgical checklist, AORN J
cism of the performance observed. Through this framework, 100(5):465–476, 2014.
caregivers gain feedback for personal improvement or confir- Spruce L: Back to basics: Implementing evidence-based practice, AORN J
mation of personal achievement related to their effectiveness 101(1):106–114, e4, 2015.
of professional, technical, and interpersonal skills in providing Spruce L, et al.: Introducing AORN’s new model for evidence rating,
patient care. AORN J 99(2):243–255, 2014.
3
Legal, Regulatory, and Ethical Issues
CHAPTER OBJECTIVES Proximate cause An act of commission or omission by one or
more persons that caused a consequence to another.
After studying this chapter, the learner will be able to: Root cause analysis The baseline reason for the occurrence of
• Define negligence as it applies to caregivers. failure in a process or system.
• Discuss informed consent. Sentinel event An unexpected occurrence that involves physio-
• Describe the importance of patient care documentation. logic or psychologic injury or death. This occurrence signals the
• List several methods of documentation of patient care. need for appropriate reporting and documentation, immediate
• Identify three potential events that could lead to litigation. investigation, and response.
• Describe the role of TJC in the promotion of patient safety. Systems approach A global attitude of improvement and safety
that encompasses involvement of individuals and the organi-
zation at all levels. Adverse events are attributed not only to
individuals but also failure of the interaction of the individual
and the organization.
CHAPTER OUTLINE Tort Wrong committed by one person against another; civil action.
Legal Issues
Liability EVOLVE WEBSITE
TJC and Sentinel Events http://evolve.elsevier.com/berrykohn
Consent • Historical Perspective
Documentation of Perioperative Patient Care • Glossary

Legal Aspects of Drugs and Medical Devices
Ethical Issues Competent patient care is the best way to avoid a malpractice or
negligence claim. Unfortunately, even under the best of circum-
stances, a patient may be injured and recover monetary damages
KEY TERMS AND DEFINITIONS as compensation. Understanding how a liability action starts
and how it proceeds is important in the effort to avoid the many
Advance directive Document that indicates wishes concerning pitfalls that can lead to being named and successfully sued in a
health care and usually designates someone to make decisions lawsuit.
if the patient is unable to do so for self. Caregivers should consider that liability is not the only ratio-
Autonomy Self-government or independence. nale behind competent care. The main focus should be the desired
Causation Action directly or indirectly causing an injury. outcome for the patient and the exemplary delivery of care. Per-
Consent Voluntary, autonomous permission to proceed with an forming in a particular manner merely to avoid being sued is not
agreed-on course of action. an ethical practice.
Damages Compensation awarded to make restitution for an injury
or a wrong. Legal Issues
Defendant Person named as the object of a lawsuit.
Deposition Statement given under oath that is a documentation Inherent in professional practice is the duty to safeguard the
of fact used in a court of law. safety and rights of patients. The patient is at risk for harm
Iatrogenic Injury or illness caused by professional intervention of a during any surgical procedure. These factors also may present
health care provider. health care providers with ethical dilemmas complicated by legal
Indicator A measured increment of performance, process, system, issues. Respect for the patient’s autonomy and the patient’s right
or outcome. to make informed decisions about his or her own health care
Liability Legally responsible for personal actions. should be considered and balanced by the professional obliga-
Malpractice Substandard delivery of care that results in harm. tions of beneficence (the duty to benefit) and nonmaleficence
Near miss An event or situation that just by chance did not cause (not to harm).
patient injury. A very close call. Any caregiver can be named in a lawsuit. Being named in a
Negligence Careless performance of duty. suit does not mean that you have been successfully sued and does
Plaintiff Person who initiates a lawsuit. not always mean you are liable for anything. Attorneys frequently
36
CHAPTER 3 Legal, Regulatory, and Ethical Issues 37
name everyone involved with the patient in the suit as part of 2. Deviation from that duty by omission or commission
the fact-finding process for building the lawsuit. When in doubt 3. Direct causation of a personal injury or damage because of
about personal competency for a new or unfamiliar procedure or deviation of duty
piece of equipment, seek guidance from the clinical educator or 4. Damages to a patient or personal property caused by the devia-
immediate supervisor. tion from the standard of care
Regardless of who is in charge of the team, each team mem- Statutory laws (laws by legislation) and common laws (laws
ber is responsible for his or her own actions. When performing based on court decisions) differ from state to state. Courts differ at
duties within the scope of practice and according to facility pol- times in their interpretation of laws. Any caregiver who is in some
icy and procedure, the risk of being successfully sued in a mal- way thought to be responsible for injury to a patient may be sued.
practice or negligence suit is very limited. Honest mistakes can The nurse manager or clinical educator responsible for assigning
result in patient injury. If a suit is brought to court, a jury can duties to this individual may be included in the suit if delegation
evaluate a reasonable set of circumstances, facts, and testimony to and supervision are in question.
render a verdict in favor of the caregiver. The plaintiff does not Caregivers, such as nurses, technologists, and technicians,
always win. If the verdict is found in favor of the plaintiff, the are considered employees of the health care facility. The facility
damages awarded may be for compensatory award. Many states is almost always named in the suit as ultimately responsible for
have set limits on the amount of money that can be awarded by hiring, monitoring credentials, evaluating, and disciplining their
the court. employees.
The quality of health care is assessed through the outcome of The court may rule that a learner or an experienced practitioner
services rendered. If the outcome is unacceptable, patients tend to is liable for his or her own acts. A learner may be held responsible for
take grievances to court. The severity of an injury usually deter- independent actions in proportion to the amount and type of instruc-
mines whether a claim of merit will arise, but other contributing tion received and judged by the standard of other learners in training.
factors include a breakdown of rapport between the patient and An instructor can be named with the learner as partially liable.
the health care team members and unrealistic expectations about Medical care and professional liability have become institu-
the outcome of care. tional problems. The primary cause of professional liability claims
Causes for litigation lie in patients’ and their families’ belief is iatrogenic medical injury—an injury or other adverse outcome
that physicians and/or health care organizations have not pro- sustained by a patient as a result of treatment. Many incidents in
vided appropriate diagnosis, treatment, or results. Although the the perioperative environment have been causes for a lawsuit.
physician is professionally responsible for patient care, other
patient care personnel act as part of the health care team, car- Liability Prevention for the Facility and the Team
rying responsibility for their own actions. Medical and surgical
sales personnel and suppliers of equipment and drugs also are Complex technologies, acuity of hospitalized patients’ conditions,
indirectly involved in treatment and may be held responsible for short-stay procedures, diverse roles of providers, inadequacy of
product liability. staffing numbers, and other factors present challenges in manag-
ing risks of liability. Many surgeons restrict their practices to avoid
Liability patients who have complex diseases or who are at high risk of
uncertain outcomes. Others practice defensive medicine, order-
To be liable is to be legally bound and responsible for personal ing tests principally to protect themselves against possible litiga-
actions that adversely affect another person. Every patient care tion. Because lawyers have become increasingly sophisticated in
provider should always perform duties in accordance with stan- representing injured patients, all health care providers need to take
dards and practice guidelines established by federal statutes, measures to protect themselves from litigation. A preventive strat-
state practice acts, professional organizations, and regulatory egy includes the following:
agencies and those that are common practice throughout the • Become active within the professional organizations associated
community. Deviation from these standards and practices that with setting the standards for practice. Most organizations pro-
cause injury to a patient can result in liability for negligence or vide up-to-date education and resources for improvement of
malpractice. For this type of civil suit to be successful for the practice. Have a voice in shaping the future of the profession.
plaintiff, he or she has to prove that negligent care or malprac- • Remain current with continuing education. Become certified,
tice caused the injury. and maintain the credential.
Negligence is the failure to use the care or skills that any care- • Establish positive rapport with patients. Patients are less likely
giver in the same or a similar situation would be expected to use. to sue if they perceive that they were treated with respect, dig-
These acts of omission or commission that cause damage to a nity, and sincere concern. Patients have the right to accurate
patient may give rise to tort action, which is a civil lawsuit. information and good communication.
Malpractice is any professional misconduct, unreasonable lack • Comply with the legal statutes of the state and standards of
of skill or judgment, or illegal or immoral conduct. Malpractice accrediting agencies, professional associations, and the health
and negligence claims usually are settled in a civil court; how- care facility policies.
ever, depending on the severity of the injury and the extent of the • Adhere to the policies and procedures of the facility. Seek a
misconduct, they may be taken to criminal court. From the legal position on the policy and procedure committee to have a say
point of view of damages or fault, professional negligence is often in the formation and revision of facility practices.
synonymous with malpractice in a tort action. Factors contribut- • Document assessments, interventions, and evaluations of
ing to a successful lawsuit on behalf of the plaintiff have been patient care outcomes. Leave a paper trail that is easy to follow
called the “four D’s of malpractice”: for the reconstruction of the event in question.
1. Duty to deliver a standard of care directly proportional to the • Prevent injuries by adhering to policies and procedures. Short-
degree of specialty training received cuts can be hazardous to the patient and team members.
• If an injury occurs, control further injury or damage by report- surgeon does share some liability if he or she prohibits or prevents
ing problems and taking corrective action immediately. the team from accomplishing this task. If this is the case, the cir-
• Maintain good communications with other team members. culating nurse should clearly document the surgeon’s refusal to
• In addition to these strategies, the facility as the employer and permit counting in the medical record and report to the immedi-
the caregiver as the employee should take steps to avoid liabil- ate supervisor.
ity. The facility protects the patient, its personnel, and itself
by maintaining safe and well-defined policies and procedures Independent Contractor
based on national standards and recommended practices.
The employer may be held responsible for employees under the
master–servant rule. However, the current trend is to hold an
Liability Insurance individual responsible for his or her own acts under the principle
Formerly it was thought that patients did not sue nurses and of the independent contractor. For example, a private scrub per-
other patient care providers because they had no large assets. son, biomedical technologist, or first assistant may contract with
Unfortunately, this is no longer true. Increased autonomy several surgeons to provide services on a fee-for-service basis.
increases the risk for liability. Perioperative nurses make inde- These individuals are not directly employed by the facility but
pendent nursing decisions based on their assessments, and they are usually credentialed and given permission to work with the
can perform and/or delegate certain patient care interventions surgeon by the medical staff department. Some questions may
without a physician’s order. No matter how careful the caregiver arise concerning the level of responsibility of the facility for cre-
is, mistakes can happen. An unintentional wrong may cause dentialing someone who is accused of substandard practice. The
injury to a patient. facility will be named in the suit initially but may be dropped
Most facilities carry insurance that covers incidents that result at a later date.
in harm to a patient when policies and procedures are followed; In 2006 The Joint Commission (TJC) determined that the
however, they may not cover the employee who fails to follow the facility that permits independent contractors, such as private first
established protocol. In some instances the facility’s insurance may assistants, interns, residents, or other privately engaged personnel,
not adequately cover all of the expenses associated with a lawsuit, is responsible for specific standards associated with accountability.
such as a private attorney and lost wages during suspensions and These standards are as follows:
trial. • The contractor must be appropriately credentialed for the role.
The caregiver who accidentally caused the injury may be named • The contractor must be competent.
in the suit as an individual or as a codefendant. Carrying personal • The contractor must be providing care under the direct super-
liability insurance protects against a possible discrepancy with the vision of a licensed practitioner.
facility’s insurance coverage and provides the employee with the • The contractor may perform duties only within the scope of his
opportunity for representation by a personal attorney. or her intended role.
A professional liability policy can be individualized to meet the • The contractor must adhere to the policies and procedures of
practice of the insured. The policy costs are tax deductible and the facility.
the protection of personal assets and wages may well be worth • The contractor must be oriented to the facility’s emergency
the price of the coverage. Professional associations recommend evacuation procedures.
individual professional liability insurance and frequently offer dis- • The contractor must be current in immunizations and health
counts to members. screenings.
• The contractor must display appropriate identification at all
times.
Borrowed Servant Rule • The contractor must comply with all background checks, pos-
In the past the surgeon was considered the captain of the ship sibly including fingerprinting and drug testing.
in the perioperative environment and was liable for the negligent
acts of servants. In the early 1940s and 1950s, courts held that Doctrine of the Reasonable Man
this doctrine, based on the master–borrowed servant relationship,
was applicable by the mere presence of the surgeon. Once hav- A patient has the right to expect that all patient care personnel
ing entered the OR, the surgeon was considered to have complete will use knowledge, skill, and judgment in performing duties that
control over other team members. But courts now recognize that meet standards exercised by other reasonably prudent profession-
the surgeon does not have complete control over the acts of the als involved in similar circumstances.
perioperative patient care team at all times. Whenever a mishap occurs in patient care, the cause of the
Each member of the team has significant performance auton- event is compared with local and national standards of care.
omy. The surgeon usually is not held responsible when a periop- Experts are consulted by attorneys and the mishap is studied. The
erative caregiver fails to carry out a routine procedure as expected. results should show whether the same event performed by some-
Courts have decided that certain procedures do not need to be one else of the same or similar education and role would have
personally performed by the surgeon, such as counts or mixing had the same result under the same or similar circumstances. This
medications on the sterile field. According to the borrowed ser- is how the courts determine the reasonableness of a caregiver’s
vant rule, the surgeon is liable for acts of team members only actions. An example of this might be how drugs are administered.
when he or she has the right to control and supervise the way in The average nurse in average circumstances would check and
which a perioperative caregiver performs the specific task. A good recheck to be sure the right patient gets the right drug. A careless
example of this is counting sponges, sharps, and instruments. The nurse might omit checking the patient’s ID and administer the
facility, not the surgeon, establishes the mechanism by which the wrong drug. This would be considered unreasonable and would
employee team accounts for items used during a procedure. The be a source of liability.
Doctrine of Res Ipsa Loquitur Supreme Court found HealthTrust, Inc. liable for permitting a
surgical technologist to perform in the role of first assistant at
Translated from Latin, res ipsa loquitur means “the thing speaks for Crestwood Hospital in 1997 (Cantrell v. Crestwood). The surgical
itself.” Under this doctrine, the courts allow the patient’s injury technologist was holding a retractor during an open hip procedure
to stand as inference of negligence. The defendant has to prove on a pediatric patient and permanently injured the sciatic nerve.
that he or she did not act negligently. Before this doctrine can be Her leg is disfigured, and she has undergone multiple failed sur-
applied, three conditions must exist: geries to restore function. The surgeon was not found liable for the
1. The type of injury would not ordinarily occur without a negli- acts of the facility’s employee.
gent act.
2. The injury was caused by the conduct or instrumentality within
the exclusive control of the person or persons being sued.
Extension Doctrine
3. The injured person could not have contributed to negligence or If the surgeon goes beyond the limits to which the patient con-
voluntarily assumed risk. sented, liability for assault and battery may be charged. This
This doctrine applies to injuries sustained by the patient while doctrine implies that the patient’s explicit consent for a surgical
in the perioperative environment, such as a retained foreign object procedure serves as an implicit consent for any or all procedures
(e.g., sponge, towel, needle, other instrument), a fall, or a burn. deemed necessary to cope with unpredictable situations that
The defendant must prove that a breach did not occur and that he jeopardize the patient’s health. By medical necessity and sound
or she was not negligent. judgment, the surgeon may perform a different or an additional
surgical procedure when unexpected conditions are encountered
Doctrine of Respondeat Superior during the course of an authorized surgical procedure (e.g., find-
ing an abscess near the target organ or finding a tumor extended
An employer may be liable for an employee’s negligent conduct into adjacent structures).
under the respondeat superior master–servant employment rela- The surgeon may extend the surgical procedure to correct or
tionship. This implies that the master will answer for the acts of remove any abnormal or pathologic condition under the exten-
a servant. If a patient is injured as a result of an employee’s neg- sion doctrine. The court will determine whether the patient con-
ligent act within the scope of that employment, the employer is sented to a specific procedure or generally to surgical treatment
responsible to the injured patient. The patient may name both the of a health problem. The surgeon may not routinely remove the
facility and the employee in a civil suit, but the employee may be appendix or gallbladder during a tubal ligation.
dropped from the suit if he or she was following facility policy
and procedure and acting within the appropriate scope of practice.
A facility may have outdated practices or unsafe procedures.
Assault and Battery
One example might be the labeling of drugs on the sterile field. In legal terms, assault is an unlawful threat to harm another physi-
Instead of requiring the name and dose of the drug to be written cally. Battery is the carrying out of bodily harm, as by touching
on the sterile container and the syringe, the facility may permit without authorization or consent. Lack of informed consent to
the scrub person to place the cap of the syringe into the medicine perform a procedure is an important aspect of an assault-and-bat-
cup containing local anesthetic to signify the contents of both the tery charge. Informed consent must be obtained by the physician
syringe and cup. This is a practice that was in effect in some facili- and consent to perform a procedure must be given voluntarily
ties up to a few years ago. It is clearly an unsafe practice to require with full understanding of implications by the patient. The pur-
a scrub person to manage drugs on the sterile field in this manner. poses of a written, signed, and witnessed consent are to protect the
The facility would be found liable for this action if it required the surgeon, anesthesia provider, perioperative team members, and
employee to perform at this unacceptable level. facility from claims of unauthorized procedures and to protect the
patient from unsanctioned procedures. Consents are discussed in
Doctrine of Corporate Negligence detail later in this chapter.
Under the corporate negligence doctrine, the facility may be liable

not for the negligence of employees but for its own negligence in
Invasion of Privacy
failing to ensure that an acceptable level of care is provided. The The patient’s right to privacy exists by statutory or common law.
facility has a duty to provide services and is responsible for the The patient’s chart, medical record, videotapes, x-rays, and pho-
following: tographs are considered confidential information for use by phy-
• Screening and verifying qualifications of all staff members, sicians and other health care personnel directly concerned with
including medical staff, according to standards established by that patient’s care. The patient should give written consent for
TJC videotaping or photographing his or her surgical procedure for
• Monitoring and reviewing performance and competency of medical education or research. The patient has the right to refuse
staff members through established personnel appraisal and peer photographic consent.
review procedures The patient has the right to expect that all communications
• Maintaining a competent staff of physicians and other caregiv- and records pertaining to individualized care will be treated as
ers confidential and will not be misused. This includes the right to
• Revoking practice privileges of a physician and other caregivers privacy during interview, examination, and treatment. The sur-
when the administrators know or should have known that the gery schedule bearing the names of the patients should not be
individual is incompetent or impaired posted in a location where the public or other patients can read it.
Corporate negligence includes the use of personnel who are Some patients, such as celebrities, may request to be admitted
inadequately trained for the position they hold. The Alabama with an alias. Care is taken when identifying these patients so that
they will not be confused with other patients and receive the wrong a responsibility to a patient. A child or disoriented patient left
procedure. Community hospitals may be admitting people from alone or unguarded in a holding area, for example, may sustain
the surrounding neighborhood. The caregiver may be in a position injury by an electric shock from a nearby outlet or by some other
to learn private information about a neighbor. Maintaining the con- hazard within reach. The circulating nurse may be considered neg-
fidentiality of patient information is imperative. Every health care ligent by reason of abandonment for failure to monitor a patient
worker has a moral obligation to hold in confidence any personal in the OR. The circulating nurse should be in attendance during
or family affairs learned from patients. Many facilities have imple- induction of and emergence from anesthesia and throughout the
mented confidentiality agreements with all health care personnel on surgical procedure to assist as needed.
the premises. Schools for surgical personnel require students to sign
confidentiality agreements before going to a clinical site. TJC and Sentinel Events
Health Insurance Portability and Professional accountability requires professionals to monitor perfor-
mance as it applies to patient outcomes. The identification of an
Accountability Act undesired outcome may be the result of direct or indirect actions of
Health Insurance Portability and Accountability Act (HIPAA) was the caregiver. Such an outcome is referred to as a sentinel event—an
published in the Federal Register in 2003 and the final rule took unexpected event that involves a risk for or the occurrence of death
effect in April 2005. This act provides for confidentiality of health or serious physical or psychological injury. Serious injury specifically
data involved in research or transmitted and stored by electronic includes loss of limb or function. The term sentinel was selected to
or any other means. The release or disclosure of this protected represent the concept because the seriousness of the event requires
health information (referred to as PHI) requires patient authoriza- immediate investigation and response. These events have a signifi-
tion.4 HIPAA covers far more than PHI—it covers fingerprints, cant effect on patient outcomes; they should be evaluated for root
voice prints, and photographic images.* cause and a plan to prevent its occurrence should be prepared.
When a victim of crime or a perpetrator is in a health care
facility, both have the right to privacy. Caregivers may not speak Root Cause Analysis
to news media or any other person concerning either individual.
If a crime is discovered by a caregiver the information must be TJC developed and approved a list of sentinel events that should
reported to an appropriate supervisor. At no time is a caregiver to be voluntarily reported and other events that need not be reported
make a promise of secrecy to a suspected perpetrator. (Box 3-1). The TJC publication Conducting a Root Cause Analysis
The use of social media, such as Facebook, to discuss patient in Response to a Sentinel Event has been made available to institu-
information is a violation of patient confidentiality.4 Accessing tions as a guideline for investigating the causes of sentinel events.
patient records without authorization is grounds for dismissal The objective is to improve the system that has permitted the error
from employment. Both of these activities are violations of HIPAA to occur. Guidelines include a fill-in-the-blank questionnaire to
and are punishable by law. help track the cause of the event.
The guidelines suggested by TJC allow each facility flexibility
in determining the root causes for events specific to the environ-
Abandonment ment. Using flowcharts, the facility can identify one or more of
Abandonment consists of leaving the patient for any reason when these root causes. Each facility is encouraged but not required to
the patient’s condition is contingent on the presence of the care- report sentinel events to TJC. Other sources, such as the patient,
giver. If the caregiver leaves the room knowing there is a potential a family member, or the media, may generate the report. If TJC
need for care during his or her absence, even under the order of a becomes aware of an event, the facility is required to perform a
physician, the caregiver is liable for his or her own actions. root cause analysis and action plan or other approved protocol
In Czubinsky v. Doctor’s Hospital, the surgeon ordered the cir- within 45 days of the event. A TJC glossary of sentinel event ter-
culating nurse to leave the room to help him start another pro- minology can be viewed at www.TheJointCommission.org.
cedure. During the circulating nurse’s absence, the patient had a
cardiac arrest. The only team members on hand were the anesthe- Institutional Reporting of Sentinel Events
sia provider and the surgical technologist. At the trial, the circu-
lating nurse admitted to knowing that it was wrong to leave the The Patient Safety and Quality Improvement Act of 2005† encour-
patient because of his condition but left because of the surgeon’s ages a culture of safety in the health care system. TJC indicates that
insistence. The expert witness testified that the circulating nurse mistakes are minimized by designing systems that anticipate and pos-
should not have been ordered away from the patient to work in sibly prevent human error.‡ Each procedure has inherent safety risks
another room. The court decided that if adequate help for resusci- that are not always apparent. These tend to surface when systems
tation had been available in the OR during the patient’s crisis he thinking is not foremost in the procedure development process.
would not have suffered permanent brain damage, which occurred The 2005 act references data that show the incidence of report-
because of this breach of duty. According to the court, the circu- ing to be more accurate when done on a voluntary basis rather than
lating nurse had a duty to remain with the patient. when reporting is mandatory. Health care facilities have requested
If an event necessitates leaving a patient, it is important to protection for reporting information because to rework the system
transfer care to another caregiver of equal status and function. In the faults need to be known. This is the main way of studying prob-
uncontrollable circumstances, the perioperative manager should lems and finding solutions for improved performance. Many states
be consulted immediately. The patient must not be left unat-
tended. No one, not even a physician, may release a caregiver from † This act is an amendment to Title IX of the Public Health Service Act.
‡ Institute of Medicine: To err is human: building a safer health system, Wash-
* www.hhs.gov/ocr/privacy/. ington, DC, 1999, National Academy Press, pp 86–87.
• BOX 3-1 Reportable and Nonreportable Sentinel incorporate NPSGs’ language to prevent wrong patient, wrong
site, and wrong surgery events as part of Universal Protocol:
Events Identified by TJC
1. Ambulatory Health Care
Reportable 2. Critical Access Hospital
• Any event that results in the loss of life or limb (e.g., death, paralysis, 3. Hospital
coma) associated with a medication error 4. Office-Based Surgery
• Suicide of a patient within 72 hours of being in an around-the-clock care Patient safety is a serious concern when the patient’s protective
setting reflexes and cognition are impaired by preoperative medications
• Elopement or unauthorized departure of an individual from an around- and/or anesthetics. The focus of the applicable patient safety goals
the-clock care facility that results in suicide or homicide or permanent includes but is not limited to the following points:
loss of function 1. Adequate patient identification
• Abduction from a care facility 2. Accurate marking for surgical procedures
• Rape 3. Eliminating medication errors
• Discharge of an infant to the wrong family
4. Improving communication between caregivers
• Hemolytic transfusion reaction involving the administration of blood or
blood products having major blood group incompatibilities 5. Preventing health care–associated infections
• Surgery on the wrong patient or the wrong body part 6. Preventing injury from falls and pressure points
• Intrapartum maternal death related to the birth process 7. Safe and appropriate use of machinery alarms (e.g., electrosur-
• A perinatal death unrelated to a congenital condition in an infant gery, cardiac monitors)
weighing more than 2500 g
• Assault, homicide, or other crime resulting in patient death or a major “Never Events” and Reimbursement for Hospitals
permanent loss of function
• A fall that results in death or major permanent loss of function as a and Health Care Facilities
direct result of the injuries sustained The Centers for Medicare and Medicaid Services (CMS) took
• Hemolytic transfusion reaction involving incompatible blood
action to improve patient care and decrease errors and injury by
• A retained foreign object from surgery
denying payment for medical errors that result in serious harm
Nonreportable or death for patients. CMS no longer reimburses for care ren-
• Any near miss dered to patients to remedy the consequences of errors. Protection
• Full return of limb or bodily function by discharge or within 2 weeks of from “Never Events” is the goal of the 2009 CMS rule concerning
the initial loss of function denial of reimbursement for the following injuries acquired dur-
• Medication errors that do not result in death or the permanent loss of ing care:
function 1. Air embolism
• Any sentinel event that has not affected the recipient of care 2. Blood incompatibility
• A death or injury that follows discharge against medical advice (AMA) 3. Catheter-associated urinary tract infection
• Unsuccessful suicide attempts 4. Poor control of blood sugar
• Unintentionally retained foreign body without permanent loss of function 5. Deep vein thrombosis or pulmonary emboli after total knee
• Minor hemolysis with no clinical sequelae
or total hip surgery
TJC, The Joint Commission.
6. Falls or trauma while in care
7. Retained object from surgery
Adapted from The Joint Commission: Accreditation committee approves 8. Pressure sores
examples of voluntary reportable sentinel events, 4:1998.
9. Surgical site infection after certain orthopedic or bariatric
surgery
have adopted the National Quality Forum’s (NQF) list of 29 adverse 10. Surgical site infection after coronary artery bypass surgery
events as the foundation for mandatory adverse event reporting.§ In 11. Catheter-associated vascular (bloodborne) infection
2004, Minnesota was the first state to adopt the adverse events list Details concerning statistics and trends in CMS programs and
as mandatory to report. In the first year of mandatory reporting, rulings can be found at www.cms.gov.
surgical adverse events were the highest reported of all the categories
by early 2006. Other states have followed by implementing report-
ing systems and including additional categories of adverse events Consent
that are mandatory to report. For additional information about the General Consent
NQF adverse event list, go to www.qualityforum.org.
Most facilities require the patient or his or her legal guardian to
sign a general consent form on admission. This form authorizes
National Patient Safety Goals the attending physician and the staff to render standard day-to-
Universal Protocol is incorporated into the sixteen National day treatment or to perform generalized treatments and care as
Patient Safety Goals (NPSGs) implemented in July 2010 by TJC‫׀‬ the physician deems advisable. This general consent is relied on
(Fig. 3-1). The following Joint Commission accreditation statements only for activities performed in routine care. Physicians and nurses
should be knowledgeable about the statements on the form used
§ The full list of 29 adverse events as defined by the NQF is located on the
in their facility.
Minnesota Department of Health’s website: http://www.health.state.mn.us/ Each facility should have policies and procedures in place
patientsafety/ae/adverse27events.html. Accessed April 2015. about the authorization of general consent. Many facilities require
‫ ׀‬The complete list of National Patient Safety Goals can be viewed at www.jo the patient or appropriate guardian to sign the general consent
intcommission.org. document in the admission department before admission to the
Conduct a pre-procedure verification process
SpeakUP
TM
Address missing information or discrepancies before starting the procedure.
• Verify the correct procedure, for the correct patient, at the correct site.
• When possible, involve the patient in the verification process.
• Identify the items that must be available for the procedure.
• Use a standardized list to verify the availability of items for the procedure. (It is not necessary to
document that the list was used for each patient.) At a minimum, these items include:
relevant documentation
Examples: history and physical, signed consent form, preanesthesia assessment
labeled diagnostic and radiology test results that are properly displayed
Examples: radiology images and scans, pathology reports, biopsy reports
any required blood products, implants, devices, special equipment
• Match the items that are to be available in the procedure area to the patient.
Mark the procedure site

At a minimum, mark the site when there is more than one possible location for the
procedure and when performing the procedure in a different location could harm
the patient.
• The site does not need to be marked for bilateral structures.
Examples: tonsils, ovaries
• For spinal procedures: Mark the general spinal region on the skin. Special intraoperative imaging
techniques may be used to locate and mark the exact vertebral level.
• Mark the site before the procedure is performed.
• If possible, involve the patient in the site marking process.
• The site is marked by a licensed independent practitioner who is ultimately accountable for the
procedure and will be present when the procedure is performed.*
• Ultimately, the licensed independent practitioner is accountable for the procedure – even when
delegating site marking.
* In limited circumstances, site marking may be delegated to some medical residents,
physician assistants (P.A.), or advanced practice registered nurses (A.P.R.N.).
• The mark is unambiguous and is used consistently throughout the organization.
• The mark is made at or near the procedure site.
• The mark is sufficiently permanent to be visible after skin preparation and draping.
• Adhesive markers are not the sole means of marking the site.
• For patients who refuse site marking or when it is technically or anatomically impossible or impractical
to mark the site (see examples below): Use your organization’s written, alternative process to ensure
that the correct site is operated on. Examples of situations that involve alternative processes:
mucosal surfaces or perineum
minimal access procedures treating a lateralized internal organ, whether percutaneous
or through a natural orifice
interventional procedure cases for which the catheter or instrument insertion site is
not predetermined
Examples: cardiac catheterization, pacemaker insertion
teeth
premature infants, for whom the mark may cause a permanent tattoo
Perform a time-out
The procedure is not started until all questions or concerns are resolved.
• Conduct a time-out immediately before starting the invasive procedure or making the incision.
The • A designated member of the team starts the time-out.

• The time-out is standardized.
Universal
• The time-out involves the immediate members of the procedure team: the individual performing the
procedure, anesthesia providers, circulating nurse, operating room technician, and other active
participants who will be participating in the procedure from the beginning.
Protocol • All relevant members of the procedure team actively communicate during the time-out.
• During the time-out, the team members agree, at a minimum, on the following:
correct patient identity
for Preventing Wrong Site, correct site
Wrong Procedure, and procedure to be done
Wrong Person Surgery™ • When the same patient has two or more procedures: If the person performing the procedure
changes, another time-out needs to be performed before starting each procedure.
Guidance for health care professionals • Document the completion of the time-out. The organization determines the amount and type
of documentation.
This document has been adapted from the full Universal Protocol. For specific requirements
of the Universal Protocol, see The Joint Commission standards.
• FIG. 3-1 The Joint Commission poster for the Universal Protocol. (From The Joint Commission: Speak
up initiatives, available at www.jointcommission.org/speakup.aspx.)
facility. This is facilitated by the admissions clerk, who is a supplier of the drug or device and eventually filed with the FDA
nonmedical person. This in no way equals informed consent. (www.fda.gov). The patient is free to refuse or withdraw at any
Box 3-2 compares content examples of general consent to treat time from research performed under the auspices of the HHS. All
versus informed consent. parties involved with the procedure are bound by HIPAA and the
confidentiality implied therein. More information can be found
on the HHS website (www.hhs.gov).
Informed Consent
State statutes differ in their interpretation of the doctrine of Informed Consent for a Surgical Procedure
informed consent, but all recognize the physician’s duty to inform According to the American College of Surgeons, a reasonable
the patient of the risks, benefits, and alternatives of a procedure approach to informed consent should involve answering the fol-
and to obtain consent before treatment. Failure to do so may be lowing patient questions:
considered a breach of duty. Informed consent is a process—not a • What do you plan to do to me?
paper document that is signed. Explanations of the procedure, risks, • Why do you want to do this procedure?
benefits, and alternative therapy are made verbally to the patient’s • Are there any alternatives to this plan?
level of understanding.1 Some facilities have a special form that is • What things should I worry about?
used during this process. A surgeon or anesthesia provider may be • What are the greatest risks or the worst thing that could hap-
held liable for negligence if the patient can prove failure to disclose pen?
significant information that would have influenced a reasonable The patient has the right to waive an explanation of the nature
person’s decision to consent. Informed consent is a protective act and consequences of the procedure and has the right to refuse
for the patient and the treating physician and should be docu- treatment. When a patient signs a consent agreement, consent
mented appropriately. The circulating nurse, as patient advocate, is given only for the specific procedure indicated on the form.
should ensure that this process has taken place before permitting Additional procedures should be listed and signed separately—
the patient to be transferred to the OR.2 not added after the patient has already signed the form. Contents
The anesthesia provider also has a responsibility to inform the documented about informed consent should include but are not
patient of any potential for unfavorable reactions to any medi- limited to the following:
cation or anesthetic agent that may be given during the surgical • Who will be performing the procedure, including any resi-
procedure. The risks of anesthesia should be explained without dents, interns, or first assistants
causing the patient undue stress. If the surgeon intends or wants • Each surgical procedure to be performed, including secondary
to perform a procedure not specified on the consent form, the procedures
circulating nurse has the responsibility to inform the surgeon and/ • Any procedure for which an anesthetic is administered
or proper administrative authority of the discrepancy. • Procedures involving entrance into the body via an incision,
The surgeon may be approved by the U.S. Food and Drug puncture, or natural orifice
Administration (FDA) as a clinical investigator or by the Depart- • Any hazardous therapy, such as irradiation or chemotherapy
ment of Health and Human Services (HHS) as a researcher for • Other persons attending the performance of the procedure,
the controlled experimental use of new drugs, chemical agents, or such as students, sales personnel, or other observers
medical devices. Written consent based on an informed decision • Video recording or photography and the disposition of the
to participate in the research should be obtained from the patient recorded/photographed images
before any investigational item, drug, or procedure begins. The
surgeon completes an investigator’s report that is returned to the Responsibility for Informed Consent before
a Surgical Procedure
The surgeon is responsible for obtaining informed consent from
the patient, which should include the risks, benefits, and possible
• BOX 3-2 Examples and Comparison of Consent
complications of all proposed surgical procedures. The explana-
Form Contents tion should include a discussion of the removal and disposition of
General Consent to Treat Informed Consent body parts, the potential for disfigurement or disability, and what
Admission to facility Name of patient and legal guardian the patient may expect in the postoperative period. The preopera-
as appropriate tive discussion also should include advice to the patient regarding
Time and date admitted Name of facility medications, diet, bathing, smoking, and other factors that might
Admissions clerk name Specific procedures and who affect outcome and rehabilitation.
explained them The surgeon has the ultimate responsibility for obtaining
Mode of admission Specific practitioners and their informed consent for the procedure and should document this
roles activity in the patient’s permanent record according to facil-
Treating/admitting physician Risks of the procedure
ity policy and procedure. The patient or appropriate guardian
Person responsible for payment Alternatives to treatment
Contact persons for emergency Signatures: patient or legal
may be required to sign this record in the presence of a wit-
guardian, surgeon(s), and the ness. All consent documents become a permanent part of the
witness to the signatures patient’s medical record and accompany him or her throughout
Basic care assumptions (such as Date and time the process took place the perioperative environment. When checking the patient’s
dietary orders, activity orders, identity and chart on arrival in the OR, it is the duty of the
testing, examination by physician) circulating nurse and the anesthesia provider to be certain of
the following:
Data from Centers for Medicare and Medicaid Services, 2005, available at • The appropriate consents are on the chart and are properly
www.cms.gov. completed, dated, and signed.
• The information on the form is correct concerning the patient, • Mental state of signatory (i.e., not coerced, sedated, or con-
procedure, and personnel performing the procedure. fused) at the time of signing
Consent in Emergency Situations

Validation of Consent In a life-threatening emergency, the consent to treat and stabilize
The patient should personally sign the consent unless he or she is is not essential. Although every effort should be made to obtain
a minor, is unconscious or mentally incompetent, or is in a life- consent, the patient’s physical condition takes precedence over a
threatening situation. The next of kin, legal guardian, or other procedure permit. The patient’s state of consciousness may prevent
authorized person should sign for these patients. The physician him or her from verbalizing or signing a permit for treatment. Per-
gives explanations to the parent of a minor or to the legal guardian mission for a lifesaving procedure, especially for a minor, may be
of an incompetent adult. accepted from a legal guardian or responsible relative by telephone,
A consent document should contain the patient’s name in full, fax, or other written communication. If it is obtained by telephone,
the surgeon’s name, the specific procedure to be performed, the two nurses should monitor the call and sign the form, which is
signatures of the patient and authorized witness(es), and the date signed later by the parent or legal guardian on arrival at the facility.
of signatures. A signed consent is regarded as legally valid for as
long as the patient still consents to the same procedure. Institu- Right to Refuse a Surgical Procedure
tional policy may vary. The patient should reconcile the advantages and disadvantages of
The patient giving consent for treatment should be of legal the surgical intervention. Each patient is entitled to receive suf-
age and mentally competent. Except in life-threatening emer- ficient information from which to intelligently base a decision
gency situations, the patient should sign the consent form before regarding whether to proceed. The patient has the right to decide
premedication is given and before going to the OR or other pro- what will or will not be done to him or her. Only after making
cedural/interventional area. This may be done in the surgeon’s this decision is the patient asked to sign a written consent for a
office, in the facility’s admitting office, or on the patient care surgical procedure.
unit; it is done freely without coercion. If the patient is the The patient has a right to withdraw written consent at any time
following: before the surgical procedure. The surgeon is notified, and the
• A minor, a parent or legal guardian should sign. patient is not taken into the OR. The circulating nurse documents
• An emancipated minor, married, or independently earning a the situation in the patient’s record. The surgeon should explain
living, he or she may sign. the medical consequences of refusing the surgical procedure. If
• A minor who is the parent of an infant or child who is having therapeutically valid, alternative methods of medical management
a procedure, he or she may sign for his or her own child. should be offered. The surgical procedure is postponed until the
• Illiterate, he or she may sign with an X, after which the witness patient makes a final decision. The procedure may be canceled.
writes, “Patient’s mark.” Because illiteracy implies the inability The surgeon should document the patient’s refusal for surgical
to read and write, the patient should indicate an understanding treatment. For legal protection, the surgeon should also obtain
of a verbal explanation. from the patient, parent, or legal guardian a written refusal for
• Unconscious, a responsible relative or guardian should sign. the procedure or other treatment. The physician is required to
• Mentally incompetent, the legal guardian—who may be either inform the patient of the consequences of refusing diagnostic tests
an individual or an agency—should sign. A court order may be or therapeutic procedures.
necessary to legalize the procedure in the absence of the legal
guardian. Second Opinion
• An adult or an emancipated minor who is mentally incapaci- If the surgeon or patient has doubts about the necessity of a proce-
tated by alcohol or other chemical substance, the spouse or dure, another opinion should be sought from a qualified specialist
responsible relative of legal age may sign when the urgency of in the appropriate field of surgery. Consultation is a common and
the procedure does not allow time for the patient to regain desirable part of good surgical practice. A second opinion may be
mental competence. required by third-party payers (i.e., insurance carriers) or managed
Consent documents vary. Policies related to informed consent care services. This is particularly indicated if the surgical procedure
are developed by the medical staff and governing body in accor- involves extended disability. Policy may require special consulta-
dance with legal requirements. All personnel involved in the care tion or consent for procedures resulting in reproductive steriliza-
of patients should be familiar with these policies. tion or a pregnancy termination.
Witnessing a Consent
Advance Directives
A witness verifies that the consent was signed without coercion
after the surgeon explained the details of the procedure. The The Patient Self-Determination Act enacted by the U.S. Congress
patient’s or guardian’s signature should be witnessed by one or in December 1991 ensures the patient the opportunity to partici-
more authorized people. The witnesses may be physicians, nurses, pate in decision making before a procedure.¶ The law requires that
other facility employees, or family members as established by pol- patients be informed of their rights to make their own decisions
icy. Checking or witnessing the signature of the patient or other regarding their health care. This act applies to hospitals, nursing
authorized person does not constitute validation of informed homes, home health care agencies, hospice programs, and health
consent. The witness assumes no liability or responsibility for the maintenance organizations. It does not apply to freestanding
patient’s understanding. The witness signing a consent document ambulatory or office settings.
attests only to the following:
• Identification of the patient or legal substitute ¶ Patient
Self-Determination Act, Public Law 101-508, Federal Register 57,
• Voluntary signature, without coercion March 6, 1992.
Each patient has the right to determine the care received and • Stated factually. Documentation of objective data and services
to participate in the selection of delivery methods. The caregiver rendered should be very specific. Observations and actions
has the obligation to respect the patient’s wishes regarding that should be stated definitively, objectively, and concisely. Record
care. This right extends to the issue of refusing treatment. Policies what is seen, heard, felt, or smelled (i.e., the facts without
should be in place to provide for making patients aware of their judgment or opinion). Write quotes of the patient’s subjective
right of self-determination. expression.
The term advance directive encompasses durable power of • Stated in understandable terminology. Abbreviations may be
attorney and living wills. The living will concept allows the patient permissible only for very commonly accepted medical terms
to refuse treatment or nonessential measures to prolong life in a (e.g., T&A, D&C, TUR). Most institutions provide a stan-
hopeless situation. A durable power of attorney document desig- dard list of their accepted medical abbreviations for charting
nates the person authorized to make decisions in the event that the purposes.
patient is incapacitated. It allows the wishes of patients concerning • Dated (month, day, year), including the time (AM/PM) the
their care needs to be met if they become impaired and cannot note is written and the time action was performed as appropri-
make decisions. The durable power of attorney does not apply to ate for significant events or changes in the patient’s condition.
pediatric patients or to incompetent adults who are already under Late entries are documented as per facility policy. Computer-
legal guardianship. These patients already have decision makers ized entries are date stamped.
available to decide treatment options. • Signed with the full legal signature, title, and status of the
On admission to the facility, the patient is asked whether he writer, either in permanent ink or electronically.
or she has an advance directive or durable power of attorney. A • Corrected if an error is made. The date, time, and initials of
federal regulation requires that the institution be aware of whether the person making a correction should be noted next to the
such a document exists and enact it in the event of impaired cog- correction. A single line should be drawn through incorrect
nitive function of the patient. The perioperative team should be information on a paper document without obliterating it (the
made aware of its existence. A copy, not the original, is placed mistake should not be scribbled out or erased), and the correct
in the patient’s record. Advance directives may also indicate the information should then be entered. Correction fluid is not
patient’s preferences concerning organ donation. The family is acceptable. If an entire page must be recopied, the original is
still asked for consent before any procurement occurs after the attached to the new copy and not destroyed.
patient’s death. In some states, the family has the right to refuse Additional documentation in the patient’s record should
procurement regardless of the patient’s last wishes. include the following:
• Execution of the physician’s orders and the patient’s responses
Documentation of Perioperative Patient Care • Any teaching of the patient or family, including how he, she, or
they indicated understanding
Verbal communication between patients and health care providers • Any unusual event, such as a fall, spontaneous change in condi-
does not constitute legal documentation of care. Entries in the tion, or injury
record by nurses and physicians provide a history of the patient’s • All visitors, especially physicians
clinical course and responses to treatment. The record serves to • Any notification of physicians or supervisors
identify what was done. The broad assumption is that if some- The perioperative nurse should be alert to signs that a patient
thing is not documented, it was not done. The record serves as a does not clearly understand what is going to happen as a result of
means of communication among providers for continuity of care. surgical intervention. This should be documented and brought to
Policies and procedures should be in place for documentation. the attention of the surgeon. Significant observations should be
Each patient care facility is responsible for the following: recorded in the chart. For example, if a patient verbally withdraws
• Establishing, evaluating, and enforcing policies and procedures consent for a surgical procedure or expresses a fear of death in
for patient care documentation the OR, the perioperative nurse is responsible for communicating
• Interpreting and outlining standards for care documentation in this information to the surgeon and anesthesia provider and for
accordance with accreditation guidelines recording the patient’s statement.
• Protecting the privacy of patients by preventing unauthorized
access and use of documented patient care data and reports Benefits of Documentation to the Facility
• Creating forms and charting formats for personnel to use in
hard copy documentation There are many reasons for accurate documentation other than
• Selecting protocol for computerized archives of patient care those for legal application. Some facilities use the data for strate-
records and reports gic planning and growth of the organization. Benefits of accurate
• Providing a timely mechanism for retrieval of archived patient documentation to the facility include but are not limited to the
care records and reports for reference in a timely manner for following:
routine or emergency care • Legal permanent record
All interactions with patients should be documented in the • Billing and reimbursement
patient’s medical record in the appropriate format. Regardless of • Performance improvement
the format or the media used for the patient’s record, all entries • Measurement of clinical pathways
should be: • Budget and financial planning
• Documented on the appropriate form (e.g., code sheet, periop- • Staffing ratios
erative record, medication sheet, progress note). • Research protocol
• Written legibly in ink without erasures. The charting procedure • Utilization review
may be specific (e.g., all entries are to be made in black ink if • Risk management
paper charting is used). • Patient acuity and census
Standards and Methods for Documentation computer system.3 Passwords are changed at routine intervals.
of Patient Care Retrievable data recorded and accumulated in these electronic
files include patient care information, laboratory results, surgical
The standards for patient care documentation are established reports, admission and discharge summaries, and many highly
by the American Nurses Association (ANA) and TJC. The stan- sensitive details about a patient’s financial status. Many larger
dard of care requires that patient care documentation reflect the multihospital systems, such as the Cleveland Clinic, have utilized
application of the nursing process (assessment, nursing diagnosis, the Internet to permit multiple record access points for office-
outcome identification, planning, intervention, and evaluation) based physicians, surgeons, and the patient. All authorized users
during the entire length of stay, according to ANA and TJC. The have access to reports and health data as soon as they are entered
use of the Perioperative Nursing Data Set (PNDS) is the method of into the system.
choice for perioperative patient care documentation. The PNDS Nurses charged with the responsibility of accessing and con-
provides a standardized universal language for patient care docu- tributing to computerized patient data should be aware that secu-
mentation and is used by many surgical computer information rity and confidentiality must be protected. Failing to maintain the
system manufacturers. secrecy of passwords and failing to log off after use are common
problems identified with unauthorized access. Some systems have
Charting Modalities a built-in log-off feature if the workstation is left idle for a pro-
Many ways of recording patient care information have been used longed period. If this happens, the user has to reenter the system
over the years. Changes in technology have created more methods by logging back on.
of recording patient care; below is a list of examples.
• Narrative charting. Expository writing about significant events Perioperative Documentation
using third-person commentary, quotes, and standard abbre- Specific care given in the perioperative environment should be
viations. Entries are sequential, timed, dated, and signed. documented on the patient’s chart. Most facilities use a preprinted
• Block charting. Short commentary on activity that resembles form with a standardized plan of care. Space is provided to add
narrative charting covering a longer period of several hours or individualized patient needs and to document additional inter-
days. Entries are sequential, timed, dated, and signed. Some ventions. Data included in the record come from several patient
facilities use a checklist format. care areas.
• Focus charting. Specific documentation directed at a designated A comprehensive checklist is included with the chart to
aspect of the patient’s needs, status, or health considerations. assist the circulating nurse to determine whether all of the data
• Subjective-objective charting (subjective-objective assessment plan
[SOAP]). Multidisciplinary approach to documenting care
according to cues given by a patient with a specific set of signs
and symptoms. This approach uses direct quotes and assess- PROS/CONS
ment data. Computerized Documentation
• Problem-oriented charting (problem-oriented medical record
[POMR]). Approach using a problem list as the working ele-
ment from which care is planned. Working from the list, PROS
patient priorities are investigated, diagnosed, treated, mini- • Terminology is standardized.
mized, solved, or remain ongoing. As problems are solved, they • Abbreviations are standardized.
are stricken from the list. • Useful for accumulation of data from many sources.
• Computer-generated charting. Use of standardized care plans • Data retrieval is easier and efficient.
formulated in the computer and modified for the individual • Information is legible and in standard terminology.
patient. The computer time and date stamps the plan as it is • Uses standardized formats, flow charts, and graphs.
• All entries and printing are time and date stamped.
printed for the hard copy record. This form of charting requires • Can minimize error if physicians record orders online.
the caregiver’s signature. • Data can be transferred electronically between physician’s office
• Computer information systems, check-off forms, and flow sheets. and care facility.
Commonly used as shortcuts for record keeping. Unfor- • Record updating is more timely and ongoing.
tunately, it is easy to rely on the standardized data on these • Can save time, space, and resources.
preprinted records and inadvertently omit potentially impor- • Easier to retrieve archived charts from previous admissions.
tant individualized information. Most computerized patient • Health care organizations with multiple remote sites can transfer
records have secondary documentation fields to complete for patient data online.
individualized data capture.
CONS
Computerized Documentation • Can be confusing for inexperienced users.
Many facilities have been using computers for patient admitting, • Failure to log off can leave the system available to unauthorized use.
• Can be out of service for undetermined periods.
billing, scheduling, and human resource information for sev- • Needs periodic maintenance and software updates.
eral decades. Within the past few years, patient data have been • Backups of files are needed in case of failure.
recorded and stored electronically at the patient care unit level. • Paper records must be kept when the system is down.
Referred to as electronic health records or electronic medical records, • Impersonal interaction between patient and caregivers.
the documentation is transmitted electronically to multiple sites • Preoutlined care plans are less individualized.
including the OR, surgeon’s offices, and patient care areas. Only • Hardware and software can be costly to install.
select personnel are permitted to access this information and must • Potential for breach of security if files are transferred online.
log on using employee identification and passwords to enter the
initiating Universal Protocol are included on the chart (see Fig. PROS/CONS
3-1). Expected outcomes should be specified (e.g., the patient is
free from injury). The circulating nurse should document specific Patient Hand-Off or Handover
activities performed to achieve the expected outcomes. The per-
manent perioperative record should include but not be limited to PROS
the following:
• Preoperative history, physical (H&P) examination, laboratory • A hand-off is defined as a linear transmission of information from
one person to another.
reports, consent form(s), and other documents in the chart per • The Joint Commission recommends a standardized hand-off in their
policy. Any area on the patient’s body with redness or injury National Patient Safety Goals. It is called the Targeted Solutions Tool
before hands-on care begins must be documented as “present for Hand-off Communications.
on admission.” • AORN also has recommendations for transferring patient care
• Patient identification and verification of the surgical site, information.
intended surgical procedure, allergies, and nothing-by-mouth • Standardized protocols are recommended because the hand-off or
(NPO) status handover of patients to another health care provider is reported as a
• Significant intraoperative times, such as arrival in and depar- high-risk time associated with sentinel events.
ture from the OR, anesthesia start and finish, and incision and • Every facility should establish a format for standardized hand-off
closure protocols and policies. Standardized protocols provide critical patient
information necessary for safe patient transfer and reduction in
• Patient’s condition on transfer to and from the OR, as well as communication breakdown.
the method of transport to and from the OR, and by whom. • Many standardized models exist. An example of a standardized
Any change in the patient’s skin integrity, such as redness or documentation format is SBAR (Situation, Background, Assessment,
injury should be documented as “not present on admission.” and Recommendation).
• Level of consciousness or anxiety manifested by objective • Another popular documentation format is SHARED (Situation, History,
observation Assessment, Request, Evaluate, and Document).
• Patient position, and types of restraints and supports used for • Hand-off reporting improved when health care facilities established
maintaining the patient’s position on the OR bed and for pro- a format of standardized hand-off protocols. These protocols are
tecting pressure areas, and by whom written, verbal, and electronic methods of documentation and
• Personal property disposition, such as religious articles, hearing communication.
• Hand-off communication improved when personnel were educated
aid, spectacles, and dentures about the standardized protocols and policies. Positive education
• Skin condition and antimicrobials used for skin preparation, methods include: role playing, competency training, case studies,
and by whom anticipated patient needs, and simulation.
• Intravenous (IV) site, time started, type of needle or cannula, • Ways to improve hand-off include: reduce noise and distractions,
solutions administered IV (including blood products), and by take notes, use a checklist, improve listening skills, use standard
whom vocabulary, provide accurate documentation, document person
• Medication types and amounts (including local anesthetic taking hand-off report, ask questions, and read back information to
agents), irrigating solutions used and amounts, and given by verify.
whom
CONS
• Tourniquet cuff location, pressure, inflation duration, identifi-
cation of unit, and applied by whom • Communication breakdown has been documented as the root cause
• Estimated blood loss and urinary output, as appropriate of many sentinel events.
• Problems and errors related to poor hand-off include: room noise,
• Sponge, sharps, and instrument counts as correct or incorrect. rushing, errors on record, distractions, change of staff, lack of
If inconclusive, state steps taken in remedy of the situation and information, personnel physiologic problems, relationship barriers,
notification steps taken lack of experience, and number of personnel involved in the hand-off
• Surgical procedure performed, location of the incision process.
• Specific equipment used (e.g., laser), electrosurgical unit, dis- • More research is needed to identify an error-free transfer
persive and monitoring electrode(s), and prosthetic devices of information to improve patient outcomes. The current
implanted, if applicable, including the manufacturer and lot/ standardization protocols still have breakdowns in communication
serial number putting patients at risk for injury.
• Specimens and cultures sent to the laboratory
References
• Site and types of drains, catheters, and packing as applicable
• Wound classification is documented at the end of the proce- 1. Aggarwal R, Arora S, Darzi A, et al.: Effectiveness of interventions to im-
dure when all risks for infection have been identified prove patient handover in surgery: A systematic review, Surgery: Official
Journal of the Society of University Surgeons, Central Surgical
• Type of dressing applied Association, and the American Association of Endocrine Sur-
• Any unusual event or complication, and action performed geons 158(1):85–95, 2015.
• All personnel in the room and their roles, including physicians, 2. Mohorek M, Webb T: Establishing a conceptual framework for handoffs us-
visitors, sales personnel, students, and others as applicable ing communication theory, Journal of Surgical Education 72(3):402–
409, 2015.
3. AORN: Transfer of patient care information. Perioperative Stand-
Incident Report ards and Recommended Practices, Denver, Co, 2015, AORN, Inc.
When an accident or unusual incident occurs involving a patient,
employee, or property in the facility, the factual details should
be reported to the nurse manager and documented according
to institutional policy. Details should be objective, complete,
and accurate. They should be written as statements of facts with- safety, of drugs before making them commercially available. These
out interpretation or opinion. For example, it should be stated amendments established a mechanism for clinical investigation to
that the area of the patient’s skin under the inactive dispersive evaluate the efficacy of drugs. Depending on the nature of a drug,
electrode of the electrosurgical unit was mottled and red when clinical studies often require several years before the FDA approves
the electrode was removed, rather than that the patient’s skin commercial sale of a product.
appeared burned by the dispersive electrode. The details of The Medical Device Amendments of 1976 gave the FDA regu-
equipment used, including the serial number or asset tag iden- latory control over medical devices. A medical device is defined
tification of the generator and the lot number of the electrode, as any instrument, apparatus, or other similar or related article,
should be included. including any component, part, or accessory, promoted for a med-
The action performed as a result of any adverse event should ical purpose that does not rely on chemical action to achieve its
be described in detail. Any equipment in question should be intended purpose. Under this definition, sutures were reclassified
removed from service and tagged as “out of order” for repair as devices. All of the wound closure materials discussed in this
by the biomedical personnel of the facility. Any suspect device chapter are classified as devices.
should be inspected and reapproved for use according to insti- In 1988 the FDA reclassified many devices, including surgical
tutional policy before it is returned to service. All devices and attire, masks, gloves, and drapes, for control under FDA regu-
their identifying wrappers suspected of being defective should lations. Medical devices are classified and receive FDA approval
be secured for inspection by the facility’s risk management before they are marketed. They are classified into one of three
personnel. classifications:
Incident reports are completed per policy and retained by the • Class I devices are subject to general regulatory controls that
risk management department. They should be reviewed as part of ensure that they are as safe and effective as similar devices
the overall institution and departmental quality improvement and already being sold.
risk management programs. Incident reports are considered work • Class II devices must establish safety and effectiveness perfor-
products and constitute privileged information. They may serve mance standards for a new type of product.
to refresh an individual’s memory of events, however, for prepara- • Class III devices are usually life-sustaining or life-supporting
tion of defense in a lawsuit. The fact that an incident report was implants or external devices. The manufacturer must file for
completed should not be documented in the patient’s permanent premarket approval before the device is tested clinically to sub-
record. Examples of situations that require incident reporting are stantiate effectiveness.
included in Box 3-3. A mandatory device-reporting regulation was put into effect
in 1984. This regulation requires manufacturers and importers to
Legal Aspects of Drugs and Medical Devices report to the FDA any death or serious injury to a patient as a
result of the malfunction of a medical device. Through the Safe
In 1906 the U.S. government enacted the Pure Food and Drug Medical Devices Act of 1990, health care facilities are required
Act, with the U.S. Department of Agriculture as the enforcing to report directly to the FDA and to the manufacturer the prob-
agency, to ensure the introduction of safe and sanitary foods and ability that a device caused or contributed to a patient’s death,
drugs to the public. The Food, Drug, and Cosmetic Act of 1938 serious injury, or serious illness. Additional requirements for
extended the regulation to include cosmetics, drugs, and medical tracking certain permanently implantable devices became effec-
devices. The FDA, within the Department of Agriculture, became tive in 1993. Manufacturers are responsible for tracking devices
the enforcing agency with authority to implement a preclearance from the manufacturing facility through the chain of distribution
mechanism requiring drug manufacturers to provide evidence of (purchasers) to the end users (patients). Health care facilities that
safety before a new drug could be sold. Sutures were classified as implant and explant (remove) these devices must submit reports
drugs. to manufacturers promptly after devices are received, implanted,
The Kefauver-Harris Drug Amendments of 1962 added and/or explanted. The manufacturer must be able to provide to
strength to the new drug clearance procedures. Drug manufac- the FDA the following specific information:
turers must prove to the FDA the effectiveness, as well as the 1. Device
a. Lot, batch, model, and serial numbers or other identifica-
tion used by the manufacturer
• BOX 3-3 Unusual Situations That Require an b. Date(s) of receipt or acquisition within the chain of distri-
Incident Report bution
c. Name(s) of person(s) or supplier from whom the device was
• Falls or unexpectedly finding a patient, visitor, or other personnel lying received
on the floor 2. Patient
• Injury to patient, visitor, or other personnel a. Date of implantation
• Needlesticks
b. Name, address, and telephone number of the recipient
• Any fire or smoke event
• Possible theft or loss of an item patient
• Malfunctioning equipment c. Social Security number, if the patient’s permission is
• Intruder or unauthorized personnel obtained to release his or her Social Security number to the
• Medication error manufacturer
• Medication reaction 3. Physician(s) who prescribed, implanted, and/or explanted the
• Lost sponge or instrument during a procedure (incorrect and unresolved device
count) 4. End-of-life information about the device, as applicable
• Object retained within patient a. Date of explantation
b. Date of patient’s death
c. Date the device was returned to the distributor or manufac- • BOX 3-4 Moral Principles in Decision Making
turer
d. Date the device was permanently retired from use or dis- Autonomy: Self-determination implies freedom of choice and ability to
posed of make decisions to determine one’s own course of action. Decisions
Also in 1993 the FDA began the voluntary MedWatch program may be made in collaboration with others, based on reasonable and
to encourage physicians, nurses, pharmacists, and other health prudent information. Decisions should be acknowledged and respected
care professionals to report adverse events and defects or problems by others.
Beneficence: Duty to help others seek balance between what is good to
with regulated drugs and devices. The purpose of MedWatch is
do and what might produce harm to another or self.
to provide a nationwide standardized system for reporting to the Nonmaleficence: Duty to do no harm.
FDA any medical device or drug suspected of causing a patient’s Justice: Allocation of human, material, and technologic resources a person
death, life-threatening injury or illness, disability, prolonged hos- has a right to receive or claim (i.e., equality of care).
pitalization, congenital anomaly, and/or experience that required Veracity: Devotion to truthfulness (i.e., to give accurate information).
intervention to prevent permanent health impairment. Adverse Fidelity: Quality of faithfulness, based on trust and honesty, which protects
events can be reported online at https://www.accessdata.fda.gov/s rights of individuals (e.g., dignity, privacy).
cripts/medwatch/. Examples of reportable problems include latex Confidentiality: Respect for privileged information received from another
sensitivity, malfunction of drug infusion pumps, and failure of an person with disclosure only to appropriate others.
alarm during malfunction of a ventilator.
Surgeons who implant or use medical devices, and nurses, sur-
gical technologists, and others who handle them, must be ade-
quately instructed in the proper care and handling of all devices as evidenced by rulings about such issues as abortion, the right
to ensure patient safety. Most adverse events occur when devices to die with dignity, and living wills.
are misused, are defective, or malfunction. However, an adverse
patient reaction can occur when the device functions properly and
is used appropriately. The FDA is responsible for investigating a
Bioethical Situations
report of an adverse event or product problem and for taking cor- An ethical dilemma arises in the work situation when the choice
rective action. between two or more alternatives creates a conflict between an
individual’s value system and moral obligation to the patient,
Ethical Issues to the family or significant others, to the physician, or to the
employer and coworkers. Conflicts can be between rights, duties,
Professions have codes of conduct and documents that include and responsibilities.
value statements derived from moral concepts. The Code of Eth- Students and other caregivers should take the time to review
ics of the Association of Surgical Technologists (AST) provides the remaining pages in this chapter and make a personal determi-
guidance for surgical technologists. Nurses may refer to the Inter- nation about facing some of these situational ethics in practice.
national Code of Nursing Ethics and to a code established by their Personal moral–ethical conflicts can be avoided by having a pre-
own professional association, such as the ANA Code for Nurses or determined sense of action when faced with situations involving
the Code of Ethics for Nursing of the Canadian Nurses Associa- procedures such as abortion, reproductive sterilization, experi-
tion. In the statement of the nature and scope of nursing practice mentation, organ procurement, and end-of-life decisions. Actions
titled Nursing, a Social Policy Statement, developed by the ANA may be governed by religious or philosophic beliefs. Each care-
Congress of Practice in 1980, nurses committed to respect for giver should have the opportunity to abstain or participate accord-
human beings “unaltered by social, educational, economic, cul- ing to personal choice.
tural, racial, religious or other specific attributes of human beings Both legal and ethical considerations can cause conflicts.
receiving care, including nature and duration of disease and ill- Legally, a patient has the right to choose among treatment alterna-
ness.” The ethics of a profession establish the role and scope of tives or the right to refuse treatment. Philosophically, the patient’s
professional behavior and the nature of relationships with patients preference may be different from that of the health care provider.
and colleagues. The primary responsibility to the patient is to ensure delivery of
Universal moral principles guide ethical decision making safe care. This includes use of appropriate and available technol-
and activities in clinical practice (Box 3-4). These include the ogy, but only if this is the patient’s choice, with informed consent
following: freely given, or is known to be the patient’s wish. Conversely, the
• Values are operational beliefs an individual chooses as the basis patient and the caregiver may be forced to face court-ordered pro-
for behavior. They may change over time. They may create con- cedures or treatments. This may impose the need to assist in a sur-
flicts when value systems are not compatible with the expecta- gical intervention such as a cesarean section on a woman who has
tions of others. Values reflect ethics. Ethics refer to standards or moral or religious objections to this form of treatment but who
principles of moral judgment and action. Ethics as a philoso- has been ordered by the court to have the procedure performed
phy defines a systematic method of differentiating right from for the benefit of the unborn fetus.
wrong within a specific belief system. This example is extreme, but the courts are constantly working
• Professional and societal codes and standards offer guidelines to define the rights of the unborn. In the issue of viability versus
in this determination. Ethics and law are closely related. Legal possible death, the court usually supports measures necessary to
doctrines often interpret ethical concepts. sustain life. The caregiver who participates in a court-ordered pro-
• The Bill of Rights of the Constitution of the United States cedure is protected by law, provided that the performance of his or
establishes individual rights based on moral principles that her duties meets the standards of care.
respect human worth and dignity. The courts have upheld the Caregivers should decide for themselves the appropriate course
right to individual autonomy in making health care decisions, of action when dealing with an ethical dilemma. By developing a
personal philosophy and by understanding both professional and in the OR in the form of embryonic tissue, and the implantation
institutional philosophies, the caregiver may better answer many may take place in the OR. Fetal tissue lacks lymphocytes that can
personal ethical questions such as the following: cause graft-versus-host response. Advantages of fetal tissue include
• When does life begin? rapid proliferation of cells, quick reversal of the host’s condition,
• When does it end? and differentiation in response to cues of the host tissue. Studies
• What is my perception of quality of life between conception have shown promise in the treatment of diabetes mellitus, Parkin-
and death? son’s disease, and certain blood disorders and that the fetal tissue
• What is my role in health care? used in the treatment of Parkinson’s disease continues to prolif-
• What is my role as patient advocate? erate and function for many years after transplant. Tissue from
• What are my moral rights in relation to my personal beliefs and spontaneous abortion and ectopic pregnancy has generally under-
values and those of others? gone pathologic degradation and is not suitable for this use. The
• Where are the dividing lines between a patient’s personal rights use of fetal tissue and organs is subject to state law.
to privacy and confidentiality and a legal or ethical duty of
disclosure? HIV and Other Infections
A few of the ethical dilemmas facing physicians and periopera- The prevalence of human immunodeficiency virus (HIV) infec-
tive personnel are mentioned for personal consideration. It should tion, with or without acquired immunodeficiency syndrome
also be noted that some of these issues are regulated by state stat- (AIDS), has created a catastrophic health problem with many
utes or federal court decisions. All caregivers should be familiar inherent emotional issues. Unlike other communicable diseases,
with statutes in the state in which they practice, particularly those HIV infection is a fatal illness with no known cure at this time,
regarding participation and the right to refrain on the basis of although some drug therapies may slow its progression. Its mode
personal beliefs. The right to refuse to participate may be covered of transmission and methods of prevention are known. Therefore
by a law but not at the expense of a patient’s safety and welfare. personal biases and prejudices should not discriminate against the
The patient cannot be harmed by acts of commission or omission. infected patient. However, underlying attitudes about homosexu-
ality and IV drug abuse may subconsciously influence the care
Reproductive Sterilization of such patients. Are HIV-positive patients any different from
Voluntary reproductive sterilization as a contraceptive method patients with hemophilia or those who became infected through a
may be contrary to the moral, ethical, or religious beliefs of a care- contaminated blood transfusion? Should the infant with HIV be
giver. Consent is required to perform reproductive sterilization. treated any differently from an infant with a congenital anomaly?
Some facilities require consent from a patient’s spouse. Does the diagnosis make a difference to the health care provider
and to the quality of care that the patient receives? Should it?
Abortion Knowing that HIV infection is transmitted by blood and body
Legalized abortion allows for induced termination of pregnancy. secretions, conscientious application of standard precautions for
In the 1973 decision of Roe v. Wade, the U.S. Supreme Court infection control should provide protection against occupational
ruled that any licensed physician can terminate pregnancy during exposure to HIV, hepatitis, tuberculosis, and other communicable
the first trimester with the woman’s consent. During the second or resistant infections. The ANA Code for Nurses emphasizes that
trimester, the Court requires a state statute that regulates abortion care is given regardless of the nature of health problems.
on the basis of preservation and protection of maternal health. Other ethical questions concern screening and the reporting
During the third trimester, legal abortion should consider mean- of test results versus confidentiality. Do the same considerations
ingful life for the fetus outside the womb and endangerment to apply to team members as to patients? What constitutes valid rea-
the mother’s life and health. By selective abortion, one or more sons for restricting or terminating employment on the basis of
fertilized ova may be aborted so that others may mature properly health status? This question has broader implications than just the
in a multiple pregnancy, which is perhaps a result of fertility drugs. issue of being seropositive for HIV. No state mandates by law that
In facilities where abortions and other reproductive procedures a health care worker can refuse to provide care for a patient with
are performed, employees have the right to refrain from participation HIV infection. Risks versus benefits to self, patients, and team
because of their moral, ethical, or religious beliefs except in an emer- members, plus potential litigation as a result of actions, should
gency that threatens the life of the mother. These beliefs should be be evaluated in making ethical decisions. Confidentiality, privacy,
made known to the employer in writing. Some states have a protec- and informed consent are human rights that should be protected,
tive statute for employees and employers regulating good-faith efforts but the right to health care should be protected also.
to accommodate employees’ beliefs. In other states, laws protect an Both AORN and AST have published statements encouraging
employee from being forced by an employer to assist in abortions. health care facilities to provide policies and procedures to ensure
the safety of patients and personnel. These organizations believe
Human Experimentation that providers have a right to know the HIV or other infectious
Procedures still in developmental stages are performed in clini- status of patients but that caregivers do not have the right to dis-
cal research–oriented facilities with the patient’s informed con- criminate against HIV-positive patients. They should follow the
sent. Those willing to be pioneers in human experimentation have Centers for Disease Control and Prevention guidelines in caring
given or will give hope to many patients with poor prognoses. A for all patients to prevent transmission of infection.
caregiver should decide if he or she wants to participate in experi-
mental surgery. Quality of Life
Surgeons often must make critical decisions before or during sur-
Fetal Tissue and Stem Cell Research gical interventions regarding the quality of patients’ lives after
Experimentation with human tissues may be of moral concern surgical procedures. Palliative procedures may relieve pain. Thera-
to some individuals. The acquisition of the tissues may take place peutic procedures may be disfiguring. Life-support systems may
sustain vital functions. Life-sustaining therapy may prolong the A patient who has a standing DNR order may require a procedure
dying process. Many questions arise regarding care of terminally to decrease pain or palliate uncomfortable symptoms. Before going
ill, severely debilitated or injured, and comatose patients.5,6 What to the OR, the DNR order should be reaffirmed with the patient,
will be the outcome in terms of mental or physical competence? guardian, or person who has durable power of attorney. The status of
When should cardiopulmonary resuscitation be initiated or dis- the DNR order must be clarified before the patient goes to the OR. In
continued? Physicians decide, but all team members are affected an emergency, if there is doubt about the validity of the DNR order
by the decisions. or a question concerning reconsideration of the order, the caregiver
Patients with advance directives have made many of these dif- should participate in resuscitation.6 If there is any question about the
ficult decisions while in a lucid mental state. This saves the family patient changing his or her mind, a second chance may not be an
or legal guardians the anguish of making the decision during times option during an emergency situation. If the patient or legal guardian
of duress. This helps provide some closure and a small sense of is specifically clear about upholding the DNR order in the OR, the
satisfaction that the loved one’s wishes were known and followed. team has the responsibility to follow the patient’s wishes. A caregiver
who has a moral objection to upholding a DNR order may request
Euthanasia reassignment through the nurse manager of the department.
How is euthanasia defined? Is mercy killing ethical, legal, or jus- The issue of discontinuation of life-sustaining measures
tified? Does the patient, family or guardian, physicians, or courts becomes more difficult in a comatose, mentally incompetent
have the right to decide to abandon heroic measures to sustain patient who has not executed an advance directive. Family mem-
life? The patient who is aware of the options and whose decision- bers, in consultation with physicians, may request DNR orders.
making capacity is intact has the right of self-determination. Caregivers are obligated to follow DNR orders.7
OR personnel develop the plan of care guided by an advance
directive. Organ Donation and Transplantation
Euthanasia is derived from the Greek words meaning “good or As a result of the Uniform Anatomical Gift Act of 1968, many
merciful death.” Both active euthanasia and passive euthanasia are adults carry cards stating that at death they wish to donate
intentional acts that cause death, but the methods are different. their body organs or parts for transplantation, therapy, medical
An act of direct intervention that causes death is active euthana- research, or education. Most states include this information on a
sia. Withholding or withdrawing life-prolonging or life-sustaining driver’s license. If this legal authority is not available, some states
measures is passive euthanasia. Death is caused by the underlying have a required request law. In the event of legally defined brain
disease process, trauma, or physiologic dysfunction. This concept death, the caregivers are required by this law to ask the family if
differs from physician-assisted suicide. Suicide involves the person they wish to allow organ retrieval for transplantation.
causing his or her own demise. Transplant surgeons rely on the perioperative patient care teams
The idea of euthanasia seems to violate traditional principles of who procure donor organs, eyes, bone, and skin. Organ transplan-
medicine to preserve life, but our modern technologies can pro- tation has complicated the issue of time of death. Perfusion of oxy-
long life without preserving quality. Quality of life can be inter- genated blood through tissues must be sustained by artificial means
preted as life that has a meaningful value. Most human beings during procurement of vital organs with functional viability. Brain
value having cognitive abilities, physical capabilities, or both, and death must be clearly established before procurement can proceed.
living free of undue pain and suffering. This raises the ethical ques- Legally, death has occurred when an individual has sustained
tion of whether physicians should do what they technologically either irreversible cessation of circulation and respiratory func-
can do. tions or irreversible cessation of all functions of the entire brain,
including the brainstem. Therefore the accepted definition of
Right to Die irreversible coma for potential donors includes unresponsiveness,
Courts have determined that patients have a constitutional right no spontaneous movements of respiration, no reflexes, and a flat
to privacy in choosing to die with dignity or a common law right electroencephalogram.
to withhold consent and refuse treatment. A mentally competent When brain death is determined by two physicians who are
adult older than the age of 18 years can execute a living will, an not part of the transplant team, the donor will be taken to the
advance directive, directing physicians and other health care pro- OR with artificial support systems functioning to perfuse organs.
viders not to use extraordinary measures to prolong life. Most Some caregivers have moral questions about assisting with removal
physicians designate “extraordinary” measures as those that are of viable organs from seemingly living bodies. When the heart is
optional, such as mechanical respiration, hydration, nutrition, removed, cardiopulmonary support is discontinued and the anes-
medication, or a combination of these, and that sustain life. If it thesia personnel leave the room. This is a difficult time for the
is the expressed wish of the patient, the physician writes do-not- remaining team who may still have the assignment of procuring
resuscitate (DNR) orders.7 nonperfused tissues, such as skin, bone, or eyes.
A living will relieves family members of decision making when Perioperative caregivers who believe that donation of organs
the patient becomes terminally ill, incompetent, or comatose. No and body parts is a gift of love find it easier and ethically accept-
laws or court precedents deal specifically with the issue of DNR able to participate in procurement procedures. Family members
orders in the perioperative environment. Institutional policy of donors have been encouraged by surgical team members not
should address this matter. Theoretically, a patient can attempt to to focus on their grief, but rather to focus on the gifts of life they
sue for compensation for expenses under a negligence or battery are giving unselfishly to the recipients. This does not mean that
charge. In general, courts are reluctant to hold health care work- the donor’s family will not go through the grieving process. They
ers liable for acts performed to maintain life. In Anderson v. St. will need support. Caregivers learn to cope with feelings associ-
Francis, defibrillation was performed despite a DNR order. The ated with the procurement of donor organs in a manner similar to
court found that sustaining life was not considered an injury and dealing with the sudden death of any patient in the perioperative
rejected the compensatory claim. environment.
Death and Dying • Deal with the patient’s death by identifying personally with
Intellectually, we know that death is inevitable. Death can be the loss. Empathy is a positive emotion. Working through the
a difficult burden for caregivers to bear because our education, grieving process brings a sense of closure to the relationship.
experience, and philosophy are dedicated to survival. Regardless • Some facilities provide support groups to help staff members
of religious or cultural beliefs, death is a mystery, a passage from and bereaved families deal with death.
the known to the unknown. Perhaps partially for this reason, the • Arrange a visit with the hospital chaplain, clergy, or rabbi.
death of a patient in the OR is an unsettling experience, especially
if it is unexpected. References
One of the most difficult aspects of a death in the OR for the
team members is the period after the actual event. The surgeon 1. Schrems BM: Informed consent, vulnerability and the risks of group-
goes to inform the family. The assistants and anesthesia provider specific attribution, Nurs Ethics 21(7):29–843, 2014.
leave the room. Often the perioperative team is left alone with the 2. Malnick S, Malnick S: Informed consent should not be obtained un-
patient’s body. The patient should be prepared so that the family der duress, Gastrointest Endosc 80(5):914, 2014.
can view the body in an area adjoining the perioperative environ- 3. Keller DL: A response to the call to action to improve EHR documen-
tation, Am J Med 127(12):e21, 2014.
ment, where they can have privacy in expressing their feelings. The 4. Bagley JE, et al.: Health care students who frequently use Facebook
perioperative nurse may be expected to accompany the family and are unaware of the risks for violating HIPAA standards: A pilot study,
to lend support during the viewing. A chaplain or other clergy J Diagn Med Sonog 30(3):114–120, 2014.
should be called if desired by the family. Specific departmental 5. McCabe MS, Coyle N: Ethical and legal issues in palliative care, Se-
policies should be developed to assist the caregiver with this dif- min Oncol Nurs 30(4):287–295, 2014.
ficult aspect of patient care. Coping strategies that can help team 6. Goel A, et al.: End-of-life care attitudes, values, and practices among
members may include the following: health care workers, Am J Hosp Palliat Care 31(2):139–147, 2014.
• Realize that everyone involved is part of a team effort. 7. Byrne SM, et al.: Reconsidering do-not-resuscitate orders in the peri-
• Believe in a power greater than the skills of the team. operative setting, J Perianesthes Nurs 29(5):354–360, 2014.
• Share feelings with others. It is helpful for perioperative patient
care team members to talk with each other about what hap- Bibliography
pened. Encourage each other to share feelings associated with
the loss. Crying is acceptable behavior. AORN (Association of periOperative Registered Nurses): Guidelines for
perioperative practice, Denver, CO, 2015, The Association.
S E C TI ON 2 The Perioperative Patient Care Team
4
The Perioperative Patient Care Team
and Professional Credentialing
CHAPTER OBJECTIVES of the public. The laws that define the scope of practice govern-
ing a registered professional are called practice acts.
After studying this chapter, the learner will be able to: Nonsterile team Intraoperative caregivers who provide direct care
• Define the concept of the sterile team. from the periphery of the sterile field and environment; do not
• Define the concept of the nonsterile team. wear sterile attire (i.e., radiology technician, anesthesia tech-
• Describe the role of the circulating nurse. nologist).
• Describe the role of the scrub person. Perianesthesia nurse RN who renders care in the preoperative and
• Describe the credentialing process for perioperative nurses. postoperative environment. Member of the nonsterile team.
• Describe the credentialing process for surgical technologists. Registration Establishing a record of name, address, and qualifi-
cations of a professional with a state authority. This does not
establish standards of practice, does not require a certain entry
level, and does not provide for continued competency verifica-
CHAPTER OUTLINE tion or continued education.
Scrub person Member of the sterile team who passes instruments
Dependence of the Patient on the Qualified Team
and facilitates the surgical procedure. Is a surgical technologist
Credentialing of Qualified Caregivers (ST), registered nurse (RN), or licensed practical or vocational
Perioperative Patient Care Team nurse (LPN/LVN).
Sterile team Intraoperative caregivers who provide direct care
KEY TERMS AND DEFINITIONS within the sterile field; wear sterile attire (i.e., surgeon, first assis-
tant, scrub person).
Anesthesia provider Member of the nonsterile team who admin- Surgeon Physician (e.g., MD, DO, DDS, DPM) who performs the
isters anesthetics during the surgical procedure; may be a physi- surgical procedure.
cian (MD, DO), anesthesia assistant (AA), or a specially trained Surgical assistant Member of the sterile team who provides
and certified registered nurse anesthetist (CRNA). exposure and hemostasis during a surgical procedure. Is a physi-
Certification A method of professional evaluation and recognition cian, registered nurse first assistant (RNFA), surgical assistant
of an individual for meeting educational, practice, and national (SA), physician assistant (PA), or certified surgical technologist
standard parameters that range above minimal competency. specially trained and certified as a first assistant (CST/CFA).
Circulating nurse Perioperative Registered Nurse (RN) member of the
nonsterile team who directs and coordinates the activities of the
intraoperative environment during the surgical procedure. Role EVOLVE WEBSITE
involves patient assessment, planning, and critical thinking skills. http://evolve.elsevier.com/berrykohn
Credentials Validation of professional recognition, such as licen- • Historical Perspective
sure or certification. • Glossary
Delegation A registered nurse or physician can assign and super-
vise tasks performed by an LPN/LVN, ST, or other UAP (unli-
censed assistive personnel), provided the tasks are not intended
for a licensed individual’s scope of practice and are within the
capabilities of the person being assigned the tasks. Dependence of the Patient
Licensure Governmental regulation of approval to practice in on the Qualified Team
a specific profession to provide specific services. Practicing
without a license is illegal and punishable by law. Some license The perioperative team works to promote the best interests of
renewals include attainment of continued education in the pro- the patient every single minute. For the welfare and safety of the
fession. Licensure is designed to ensure minimal competency of patient, the entire team must work efficiently as a functioning single
the licensee for the benefit of protecting the safety and welfare unit. The members should be thoroughly familiar with procedures,
53
54 SECTION 2 The Perioperative Patient Care Team
setups, equipment, and policies and should be able to cope with examination in another state. Some states require licensure for some
the unpredictable. Their qualifications must be beyond reproach. categories of allied health occupations, such as physical therapists.
They should have a high morale, mutual understanding, trust, Licensure is not offered on an indefinite basis. Applicants apply
cooperation, and consideration. Anyone who cannot function for renewal at specific time intervals determined by each state.
wholeheartedly as a qualified team member has no place in the OR. Many states require proof of continuing education for nurses and
All OR personnel should have the proven knowledge, skill, com- physicians as a prerequisite for eligibility of relicensure.
petency, and ability to perform at an optimal level at all times. The Registration is a method of state regulation of practice param-
validation of clinical competence is an important aspect of provid- eters and designation for disciplinary action. Perioperative nurses
ing safe patient care. Once each member of the team has passed are registered as well as licensed.
the novice stage, other criteria demonstrate and document the
knowledge and skills gained through experience and continuing Certification
education. Aligning professionally with local, state, and nationally
recognized organizations that establish the standards of practice A nongovernmental private organization can award a credential
provides an opportunity for growth. Credentialing and certification that attests to level of knowledge above minimal competency of an
may include completing a course of instruction or meeting certain individual who meets predetermined qualifications. Certification
criteria and passing an examination. Other measurements of com- may be defined as documented validation of an individual’s pro-
petence include performance evaluations in a clinical setting. fessional achievement of knowledge and skill in identified stan-
dards. To be certified is to demonstrate the attainment of more
Credentialing of Qualified Caregivers than minimal competency; it is a statement of certification-level
knowledge. Certification is an additional form of a credential.2
Credentialing refers to the processes of accreditation, licensure, Certification is granted for a limited time. To retain this cre-
and certification of institutions, agencies, and individuals. These dential, an individual must complete the recertification process
processes establish quality, identity, protection, and control for the established by the certifying body. For recertification, some cer-
competency-based education and performance of professional and tifying organizations require a specified number of clinical hours,
allied technical health care personnel. Credentialing also protects continuing education contact hours, a written examination, or a
the public from fraudulent practitioners. combination of these in a portfolio format. Maintaining certifica-
tion by going through this process demonstrates a high level of
motivation and commitment.
Accreditation of Schools and Facilities Physicians, nurses, and allied health care personnel may be cer-
An accrediting body of a voluntary organization evaluates and sanc- tified by their professional specialty association as competent in
tions an educational program or an institution as meeting predeter- knowledge and skills to practice. Applicants take an examination
mined standards and/or essential criteria. The National League for that tests knowledge in the area of specialization.
Nursing accredits schools of nursing. Surgical technology programs
are accredited by the Commission on Accreditation of Allied Health Perioperative Patient Care Team
Education Programs (CAAHEP) after a satisfactory review and rec-
ommendation by the Accreditation Review Council on Education in The perioperative patient care team is like a symphony orches-
Surgical Technology and Surgical Assisting (ARC/STSA).1 tra, with each person an integral entity in unison and harmony
The United States Government Department of Education has with professional colleagues to accomplish the expected outcomes.
been accepted by the National Board of Surgical Technology and Communication using a comprehensive surgical checklist can pro-
Surgical Assisting (NBSTSA) as an accepted accrediting body. vide a seamless interface between patient care areas and minimize
The Accrediting Bureau of Health Education Schools (ABHES) the risk of error (see Fig. 2-1). Preoperatively, the perianesthesia
accredits many colleges and vocational settings in the United nurse initiates the use of the comprehensive surgical checklist and
States. Certifying and licensing bodies require graduation from performs the preoperative assessment. The surgeon should mark
an accredited program before eligibility criteria are met to take the surgical site with indelible ink marker. The patient is trans-
professional certification or licensing examinations. ferred to the care of the surgical team and information concerning
The Joint Commission (TJC) accredits hospitals and ambula- the patient’s condition is communicated verbally and in writing.
tory care centers. Other professional organizations offer accredita- In the OR, the patient is surrounded by the surgeon, the sur-
tion for special-interest groups. gical assistant, the scrub person, the anesthesia provider, and the
circulating nurse. Before the procedure begins the OR team takes
a “timeout” and reaffirms the correct patient is having the correct
Licensure and Registration surgery on the correct body part. The patient may participate if
A license to practice is granted to professionals by a governmental awake. The circulating nurse documents this collaboration.
agency, such as the state board of nursing or medicine. Licensure Postoperatively, the perianesthesia nurse receives information
implies a certain amount of appropriate independence in actions. from the circulating nurse and the anesthesia provider concerning
On completion of a formal academic education, nurses and physi- the surgical procedure and the patient’s condition in the form of a
cians who successfully pass a state examination receive a license to “hand-off” report. The patient remains in the postanesthesia care
practice in that state. To maintain this license, they must register unit (PACU) until his or her physiologic status is deemed stable
with the state as required by law; hence the term registered nurse. by the anesthesia provider.
Licensed practical/licensed vocational nurses (LPN/LVNs) also These individuals, each with specific functions to perform, form
are licensed. the perioperative patient care team. (More information is available
Most states grant a license by reciprocity or endorsement to at www.aspan.org; the role of the perianesthesia nurse is described
applicants who wish to practice in their state but who took the in more detail in the postoperative section in Chapter 30.)
CHAPTER 4 The Perioperative Patient Care Team and Professional Credentialing 55
U.S. Medicare and Medicaid regulations Title 42, Public Adequate communication between the surgeon and the anesthesia
Health, describe conditions for participation of individuals in provider is the patient’s greatest safeguard. The anesthesia provider
surgical services departments. In Chapter IV, Part 482, Section is an indispensable member of the perioperative team. Functioning
482.51, the regulation states that the OR must be supervised by as a guardian of the patient’s physiology throughout the entire care
an experienced registered nurse (RN) and that the circulator must period, the anesthesia provider manages the patient’s medication,
be an RN. It further states that an LPN/LVN and surgical tech- vital signs, and generalized well-being. Throughout this text the
nologists may serve as scrub nurses or assist with circulating duties term anesthesia provider is used to refer to the person responsible
under the supervision of the qualified RN (a copy of the Center for inducing and maintaining anesthesia at the required levels and
for Medicare and Medicaid Services [CMS] regulation is available managing untoward physiologic reactions throughout the surgical
at www.aorn.org). procedure. Medically delegated functions of an anesthetic nature
are performed under the overall supervision of a responsible physi-
cian or in accordance with state regulations and individual written
Nonsterile and Sterile Team Members guidelines approved within the health care facility.
The perioperative team is subdivided according to the functions An anesthesiologist is an MD or DO, preferably certified by the
of its members: American Board of Anesthesiology, who specializes in administer-
1. The nonsterile team ing anesthetics to produce various states of anesthesia. To become
a. Anesthesia provider eligible for certification, physicians complete a 2-year anesthesia
b. Circulating nurse residency program after successful completion of medical school.
c. Perianesthesia nurse The term anesthetist refers to a qualified RN, anesthesiologist assis-
d. Others (e.g., students, sales representatives, laboratory or tant (AA), dentist, or physician who administers anesthetics.
radiography personnel) An RN is required to have a minimum of a bachelor’s degree
2. The sterile team in nursing or science for entrance into a school of nurse anesthe-
a. Surgeon sia. To become a certified registered nurse anesthetist (CRNA), a
b. First assistant (second assistant if needed) graduate of an accredited nurse anesthesia program (a minimum
c. Scrub person of 2 years) is required to have a master’s degree in nursing and pass
The team also may include biomedical technicians, specialty the certification examination of the Council on Certification of
technicians, and others who may be needed to set up and operate Nurse Anesthetists. Nurse anesthetists are recertified every 2 years.
specialized equipment or monitoring devices during the surgical An AA is a master’s prepared nonphysician, non-nurse anesthe-
procedure. Specialty technicians are usually considered separately tist who administers anesthesia under the direction of an anesthe-
from the main sterile and nonsterile team members. They may not siologist. The AA’s education consists of a baccalaureate in biologic
enter the sterile field. science and 2 additional years of specialty training in biophysical
Sterile team members perform a surgical scrub on their hands science. More information on the AA degree is available online at
and arms, don a sterile gown and gloves, and enter the sterile www.anesthetist.org.
field. The sterile field is the area of the OR that immediately Some anesthesia providers prefer to specialize in one area, such
surrounds and is specially prepared for each individual patient. as cardiothoracic or obstetric anesthesia. The latter involves the
To establish and maintain a sterile field, all items needed for the simultaneous care of two patients—the mother and the neonate.
surgical procedure are sterile and handled in a sterile manner. In some settings, anesthesia providers participate in teaching and
Only sterile items and personnel dressed in sterile attire may research as well as in clinical practice.
enter the sterile field. Anesthesia providers are not confined to the perioperative envi-
Nonsterile team members do not enter the sterile field; they ronment, but this is their primary arena. In addition to providing
function outside and around it. They assume responsibility for anesthesia during surgical procedures, anesthesia providers over-
maintaining sterile and aseptic techniques during the surgical see the PACU until each patient has regained control of his or
procedure. They handle supplies and equipment that are not her vital reflexes. They also participate in the hospital’s program
considered sterile. Following the principles of aseptic technique, of cardiopulmonary resuscitation as teachers and team mem-
they keep the sterile team supplied, provide direct patient care, bers. They are consultants or managers for problems of acute and
and handle situations that may arise during the perioperative care chronic respiratory insufficiency that require respiratory therapy,
period. as well as for a variety of other fluid, electrolyte, and metabolic
disturbances that require intravenous therapy through a central
Nonsterile Team Members venous catheter. In the intensive care unit (ICU) or emergency
Perianesthesia Team. The perianesthesia team consists of department, their advice may be sought regarding the total care of
RNs and specially trained patient care assistants who care for the unconscious, critically ill, or injured patients with acute circula-
patient in the presurgical and postsurgical areas. In some facili- tory disorders or neurologic deficits. Anesthesia providers also are
ties this incorporates an ambulatory or interventional surgery integral staff members of pain therapy clinics.
suite. Circulating Nurse. The circulating nurse is a qualified
Preoperatively, the perianesthesia nurse assesses the patient and RN. The circulating nurse is vital to the smooth flow of events
documents the findings on the comprehensive surgical checklist before, during, and after the surgical procedure. Physical
that will accompany the patient throughout the surgical experi- and psychological demands of the circulating nurse’s role are
ence. Some perianesthesia RNs specialize in the care of the patient described in Box 4-1.
before the surgical procedure and others specialize in the care of The patient’s medical record is required to identify who pro-
the patient postoperatively. vided circulating duties. The circulating nurse’s role as the patient’s
Anesthesia Provider. Anesthesia and surgery are two distinct advocate and protector is critical and extends throughout the entire
but inseparable disciplines; they are two parts of one medical entity. perioperative environment. A qualified surgical technologist (ST)
• BOX 4-1 Physical and Psychological Attributes of A qualified perioperative nurse should be available at all times to
respond to emergencies in the perioperative environment accord-
the Circulating Nurse’s Role
ing to the CMS regulations. “Immediately available” has been
1. Visual acuity with or without correction is critical to precise observation interpreted to imply that one RN can supervise an unspecified
of the environment, patient, and team, and for reading small print. number of contiguous rooms and be immediately available to assist
Protective eyewear is required at all times when in proximity to the in each of these rooms at any given moment. The RN who is called
surgical field or when at risk for a splash/aerosol exposure. Bright to a room to manage a crisis is not immediately available to any
lights or dim lights are commonly used throughout the surgical other patient who may be in need. The circulating nurse would be
procedure, and people with photosensitivity or susceptibility to light- abandoning one patient to tend to another. This is highly unsafe
mediated eye irritation will find the OR environment problematic. Visual
and places the nurse and the facility at risk for liability.
accuracy is imperative.
2. Manual dexterity and accuracy of motion are required for fast action The circulating nurse is vital to the provision of care that
during emergencies. Inability to coordinate body motions could cause includes, but is not limited to, the following:
injury to the patient, team, or self. Physical ability to maneuver around 1. Applying the nursing process to directing and coordinating all
the periphery of the sterile field without causing contamination or activities related to the care and support of the patient in the
disruption of the surgical procedure is critical. OR. Nursing diagnosis and decision-making skills are essential
3. Eye-hand coordination is essential for safe and efficient delivery of in assessing, planning, implementing, and evaluating the plan
sterile items to the field. Eye-hand coordination is imperative for the of care before, during, and after a surgical intervention. This is
safety and preservation of the sterile field. the professional perioperative role of the RN circulating nurse.
4. Ability to concentrate and remain alert during long procedures. 2. Creating and maintaining a safe and comfortable environment
Thinking on one’s feet is a hallmark of the circulating nurse.
for the patient by implementing the principles of asepsis. The
Multitasking is essential because the coordination of the room, patient
care, team, documentation, and anticipation demands clear thinking. circulating nurse demonstrates a strong sense of surgical con-
5. Ability to lift instrument trays of at least 20 pounds and assist with science. Any break in technique by anyone in the room should
moving large incapacitated patients using proper body mechanics. be recognized and corrected instantly. Although sterile tech-
6. Auditory acuity in both ears with or without amplification is critical for nique is the responsibility of everyone in the room, the circu-
hearing and understanding commands while machinery is running. lating nurse is on the alert to catch any breaks that others may
Voices are kept low during surgery, especially when the patient is not have seen. By standing farther away from the sterile field
awake. Hearing correctly is imperative. than others, the circulating nurse is better able to observe the
7. Ability to quickly anticipate and discern commands and needs of the entire field and the sterile team members.
team. Must be able to differentiate and prioritize the needs of the 3. Providing assistance to any member of the OR team in any
surgical team and the anesthesia provider efficiently and to be able to
manner for which the circulating nurse is qualified. This role
offer appropriate alternatives in extraordinary circumstances.
8. The ability to speak, understand, and document clearly using requires current knowledge of the legal implications of surgical
the English language is critical to safe patient care. Appropriate intervention. The circulating nurse knows the organization of
terminology and use of approved standard accepted abbreviations are the work and the relative importance of the factors involved
essential to communication in the OR. in accomplishing it. An effective circulating nurse ensures that
9. Communication is essential between the team, anesthesia provider, the sterile team is supplied with every item necessary to per-
control desk, family waiting room, labs, and perianesthesia care areas. form the surgical procedure efficiently. The circulating nurse
The circulating nurse coordinates pertinent information among all must know all supplies, instruments, and equipment; be able
areas concerning the care of the perioperative patient. to obtain them quickly; and guard against inadvertent hazards
10. The ability to remain calm and function quickly, safely, and precisely in their use and care. He or she must be competent to direct
during an emergency. Must be able to make decisions and problem
the scrub person.
solve effectively without loss of emotional control.
11. Mental clarity. Use of medications or substances that alter alertness 4. Identifying any potential environmental danger or stressful
and attentiveness are not acceptable in the OR. Lack of sleep can situation involving the patient, other team members, or both.
affect thought processes. This role requires constant flexibility to meet the unexpected
12. Accountability. Takes responsibility for independent actions. and to act in an efficient, rational manner at all times.
Admits error and remedies the situation when breaches in technique or 5. Maintaining the communication link between events and
contamination occurs. team members in the sterile field and people who are not in
the OR but are concerned with the outcome of the surgical
procedure. The latter includes the patient’s family or signifi-
cant others plus other personnel in the perioperative environ-
or LPN/LVN may assist with circulating duties under the supervi- ment and in other departments of the hospital. The ability
sion of the RN.* The surgeon is in charge at the operating bed, to recognize and effectively communicate situations involving
but relies on the circulating nurse to monitor and coordinate all the patient and/or other team members is a vital link in the
activities within the room and to manage the care required for each continuity of patient care.
patient. The RN should be continuously knowledgeable about the 6. Directing the activities of all learners. The circulating nurse
status of the patient. To some extent, the circulating nurse controls must have the supervisory capability and teaching skills nec-
the physical and emotional atmosphere in the room, which allows essary to ensure maintenance of a safe and therapeutic envi-
other team members to concentrate on tasks without distraction. ronment for the patient. Kindly given assistance builds up the
As of 2014, the laws in 39 states specify that one RN circu- learner’s confidence. In this capacity the circulating nurse acts
lates in each room (hospital and ambulatory centers combined). as a supervisor, adviser, and teacher.
CNOR: The Certified Perioperative Nurse. A periopera-
* 42 CFR § 428.51: Federal position on the RN circulator according to the tive nurse who has been in clinical perioperative practice for 24
CMS. months and who has successfully passed a national examination
is certified by the Competency & Credentialing Institute (CCI; • BOX 4-2 CNOR Eligibility Criteria
www.cc-institute.org) as a certified perioperative nurse, which is
designated as CNOR. Box 4-2 describes the required eligibility • Licensed RN in state of practice and currently employed full or part
for CNOR certification and Table 4-1 describes the criteria for time in administrative, teaching, research, or general staff capacity in
CNOR recertification. Contact hours can be logged and stored perioperative nursing.
on the CCI website. Retired CNOR nurses can accept an emeritus • Bachelor of science in nursing not required for CNOR.
status to retain the credential. They are signified by (E) after the • Two years of perioperative nursing experience.
main credential of CNOR (e.g., CNOR(E)). Roles Eligible for Certification
Several nursing specialty organizations, such as the National
• Staff nurse
Association of Orthopaedic Nurses (www.orthonurse.org) and the
• Surgical services administrative nurse manager
American Society of Plastic Surgery Nurses (www.aspsn.org), offer • Surgical services nursing coordinator
certification examinations through their certifying bodies as an • Assistant surgical services supervisor
additional credentialing tool.3 • Surgical services director
• Surgical services information technology specialist
Sterile Team Members • Surgical services budget and finance manager
Surgeon. The surgeon must have the knowledge, skill, and • Surgical services central processing manager
judgment required to successfully perform the intended surgical • Surgical services materials manager
procedure and any deviations necessitated by unforeseen difficul- • Surgical services quality assurance coordinator/auditor
ties. The American College of Surgeons has stated the principles of • Surgical services head nurse
• Surgical services assistant head nurse
patient care that dictate ethical surgical practice. Protection of the
• Surgical services team leader
patient and quality care are preeminent in these principles. The • Surgical services charge nurse
surgeon’s responsibilities include preoperative diagnosis and care, • Perioperative educator or staff development director (whether teaching
selection and performance of the surgical procedure, and postop- registered nurses, student nurses, or surgical technologists)
erative management of care. • Private RN scrub nurse
The care of many surgical patients is so complex that consider- • RN first assistant
ably more than technical skill is required of a surgeon. The sur- • Perioperative administrative supervisor
geon cannot predict that a surgical procedure will be simple and • Medical-surgical instructor in perioperative nursing
uncomplicated. The surgeon must be prepared for the unexpected • Perioperative clinical nurse specialist or nurse clinician
by having knowledge of the fundamentals of the basic sciences • Full-time student who meets applicant status requirements
• Perioperative nurse consultant
and by having the ability to apply this knowledge to the diagnosis
• Individual who handles the perioperative role in a noninvasive/invasive
and management of the patient before, during, and after surgi- procedure setting, such as a radiology suite, a cardiac cath laboratory,
cal intervention. The surgeon assumes full responsibility for all an office surgery setting, or an endoscopy suite
medical acts of judgment and for the management of the surgical • Clinical education consultant (who provides inservice programs to OR
patient. staff)
A surgeon is a licensed MD, DO, oral surgeon (doctor of den- • Case manager
tal surgery [DDS] or doctor of dental medicine [DMD]), or doc-
tor of podiatric medicine (a podiatrist [DPM]) who is specially Roles Ineligible for Certification
trained and qualified by knowledge and experience to perform • Nurse anesthetist (eligible only if functioning as a perioperative nurse)
surgical procedures. After earning a bachelor’s degree, all physi- • PACU nurse or manager (eligible only if relieving in the OR as needed or
cians complete the equivalent of 4 years of medical school. To has responsibility for OR/surgical services)
become a surgeon, a physician completes at least 2 years of general • Emergency department nurse
• OR labor and delivery nurse (eligible only if surgical procedures such as
surgical residency training before completing additional years of
cesarean sections are done in delivery room)
postgraduate education in a surgical specialty. The surgical resi- • RN sales representative (eligible only if performing the role of
dency provides the physician with education and experience in the perioperative nurse part time or the role of perioperative educator, i.e.,
preoperative evaluation, intraoperative treatment, and postopera- providing inservice programs)
tive care of patients. Consultation and supervision are available • Director or assistant director of nursing service (eligible only if directly
from faculty and attending surgeons. responsible for the OR)
By virtue of their postgraduate surgical education, most sur- • RN hospital administrator/assistant administrator (eligible only if directly
geons practice within a specific surgical specialty. Highly trained responsible for OR/surgical services)
and qualified surgeons limit themselves to their specialty, except • Nurse in surgical care or surgical rehabilitation units
perhaps in emergency situations. • ICU or coronary care unit nurse
• Infection control nurse/nurse epidemiologist (eligible only if directly
Qualification for surgical practice involves certification by a
responsible for OR/surgical services)
surgical specialty board approved by the American Board of Medi- • Veterinary OR nurse
cal Specialists. Ten American specialty boards grant certification • Cardiopulmonary perfusionist (eligible only if performing the role of
for surgical practice. All 10 boards governing the surgical special- perioperative nurse)
ties require at least 3 years of approved formal residency train- • Nurse with inactive licensure and/or graduate nurse status
ing, and most set the minimum at 4 or 5 years. Any physician
who aspires to become a board-certified surgeon must meet these
requirements.
Surgical procedures may be performed by physicians who do surgical privileges for more than 5 years in a hospital approved
not meet the previously discussed criteria. These physicians include by TJC, where most of their surgical practice is conducted; those
those who received an MD degree before 1968 and who have had who render surgical care in an emergency or in an area of limited
TABLE
4-1 CNOR Recertification
Examination for Portfolio

Recertification Contact Hour Method (Include Reflection Form and Documentation of Events)
Previously certified 125 approved contact hours in 5 years. One year is Documentation of applied learning to professional activities within the
during previous January 1 to December 31 of same year. previous 5-year certification period
5-year period 75 contact hours continuing education; must be Professional resumé for previous 5 years
specific to perioperative nursing Select 4 of the following activities from the previous 5 years
62.5 contact hours may be earned via CME (con- Educational presentations
tinuing medical education) Academic courses completed or taught
(1 CME = 1 contact hour) Continued education (35 contact hours)
Must be part of academic credit toward a bacca- Professional writing
laureate degree or higher. Grade of C or better. Standards application
(1 semester hour = 15 contact hours) Patient-centered care
(1 quarter hour = 10 contact hours) Precepting-mentoring-coaching
Risk mitigation/management
Evidence-based practice/research
Contributions to:
• Professional organization
• Institution (committees)
A discount applies for AORN members. Consult www.cc-institute.org for more information and recertification applications.
population where a surgical specialist is not available; and those evaluated: anticipated blood loss, anesthesia time for the patient,
who by reason of education, training, and experience are eligible fatigue factors affecting the OR team, and the potential for com-
for but have not yet obtained certification. plications. This role is critical to the well-being of the patient.
A surgeon must become a member of the medical staff and All first assistants must be granted privileges to practice by the
be granted surgical privileges in each facility in which he or she medical staff department in the facility of employment or practice.
wishes to practice. Standards for admission to staff membership Detailed information about the role and duties of the first assis-
and the retention of that membership are clearly delineated in the tant can be found in Chapter 5.
bylaws formulated by the medical staff and are approved by the For many simple procedures, it is unreasonable to insist that
governing body of the hospital. The credentials committee has a second surgeon assist a competent surgeon. Reimbursement is
the primary responsibility for thoroughly investigating not only generally not provided for simple cases. The surgeon should evalu-
the training of an applicant but also his or her integrity, techni- ate all factors to determine his or her need for assistance during
cal competence, and professional judgment. In making its recom- the surgical procedure and consider that some insurance providers
mendations, this committee can limit a surgeon’s privileges as it do not reimburse for a physician first assistant. However, the assis-
sees fit, which ensures that each surgeon performs only those ser- tance of another qualified surgeon is usually necessary for proce-
vices for which he or she has been deemed competent. dures requiring considerable judgment or technical skill and those
Patients are entitled to protection and the assurance that a requiring more than one sterile team. The hazards of a surgical
surgeon’s surgical privileges are limited to those for which he or procedure may depend more on the condition of the patient than
she has been trained and competence has been demonstrated. The on the complexity of the procedure itself. The surgeon should be
patient’s choice of and confidence in a surgeon, as well as adher- able to provide rationale for his or her decision if challenged or if
ence to instructions and advice, are factors in the outcome of sur- not in compliance with medical staff bylaws. More information
gical intervention. A discerning patient will check the surgeon’s can be found at www.facs.org. Lists of specific surgeries requiring
qualifications before surgery. MD/DO or other assistants are located on this website.
A competent surgeon is a physician who realistically appreci- Scrub Person. The scrub person is a patient care staff member
ates his or her own cognitive skills and personal characteristics and of the sterile team. The scrub role may be filled by an RN, LPN/
can intervene effectively in a patient’s illness or injury. Appropri- LVN, or an ST. The term scrub person is used throughout this text
ate clinical skills (e.g., data gathering, decision making, problem to designate this role and to elaborate on the specific technical and
solving) and appropriate personal characteristics (e.g., humanistic behavioral functions of the individual performing on the sterile
concern, accountability, compassionate interpersonal behavior) team in this capacity.
are important attributes of a surgeon. The scrub person should not simultaneously function in the
First Assistant. Under the direction of the surgeon, a quali- role of first or second assistant. Performing additional tasks takes
fied first assistant helps maintain visibility of the surgical site, the scrub person’s attention away from the primary responsibili-
controls bleeding, closes wounds, and applies dressings. The first ties of maintaining the sterile field and facilitating the surgical
assistant handles and manipulates tissues and uses instruments to procedure. Holding retractors, for example, can cause permanent
provide hemostasis. The role of and need for a first assistant will injury to a patient if inappropriately positioned, maintained in
vary with the type of procedure or surgical specialty, the condition alignment, or placed in contact with electrocautery inadvertently.
of the patient, and the type of surgical facility. In determining The scrub person is responsible for establishing and maintaining
this need, the characteristics of the surgical procedure should be the integrity, safety, and efficiency of the sterile field throughout
• BOX 4-3 Physical and Psychological Attributes • BOX 4-4 Eligibility for Certification by Examination
of the Scrub Person’s Role for Surgical Technologists
1. Visual acuity with or without correction is critical to threading small • CST may recertify by examination every 4 years
needles and reading small print. Protective eyewear is required at • Graduate of a CAAHEP-accredited surgical technology program
all times when at the surgical field. Bright lights or dim lights are • Graduate of an ABHES from the U.S. Department of Health and Human
commonly used throughout the surgical procedure, and people with Services. For additional information, visit www.abhes.org
photosensitivity or susceptibility to light-mediated eye irritation will find • Graduate of an accredited Alternative Accelerated Delivery program
the OR environment problematic. Visual accuracy is imperative. attached to an accredited school of surgical technology
2. Manual dexterity and accuracy of motion is required for fast action • No minimum practice hour requirement (accredited programs have
during emergencies. Inability to coordinate body motions could cause minimum case number ratings for new graduates)
injury to the patient, team, or self. Manual dexterity is imperative. Consult www.nbstsa.org for additional information.
3. Eye-hand coordination and alertness are essential for safe handling of
instruments during surgery. Eye-hand coordination is imperative for the
efficiency of the procedure.
4. Ability to delay nutritional intake for prolonged periods during long provides services and assists with patient care under the supervi-
procedures. sion of an RN at all times.
5. Ability to stand in a confined space for prolonged periods. Some facilities permit RNs or STs privately employed by sur-
6. Ability to lift instrument trays of at least 20 pounds and assist with geons to come into the OR to perform the scrub role for their
moving large incapacitated patients using proper body mechanics. employers. These private scrub persons should adhere to all hos-
7. Auditory acuity in both ears with or without amplification is critical for
pital policies and procedures and to approved, written guidelines
hearing and understanding commands while machinery is running.
Voices are kept low during surgery, especially when the patient is for the functions they may fulfill. They are not covered under the
awake. Hearing correctly is imperative. facility’s liability insurance and should carry their own policy as
8. Ability to quickly anticipate and discern commands and needs of the independent contractors. There is no such thing as working under
team. Must be able to differentiate between instruments and supplies someone else’s license such as a physician or a registered nurse.
efficiently and to offer appropriate alternatives in extraordinary Each person is responsible for personal liability. Further discussion
circumstances. of independent practitioners can be found in Chapter 3.
9. The ability to speak, understand, and document clearly using Private scrub persons can create liability for the facility because
the English language is critical to safe patient care. Appropriate the facility will be held liable by virtue of permitting them to work
terminology and use of approved standard accepted abbreviations are within the facility. They should not perform first-assisting or be
essential to communication in the OR.
considered first assistants unless they are appropriately educated
10. The ability to remain calm and function quickly, safely, and precisely
during an emergency. Must be able to make decisions and problem and credentialed in the role. Several states have addressed who
solve effectively without loss of emotional control. may and may not first assist in surgery.
11. Mental clarity. Use of medications or substances that alter alertness CST: The Certified Surgical Technologist. STs who have com-
and attentiveness are not acceptable in the OR. Lack of sleep can affect pleted an accredited surgical technology program and success-
thought processes. fully passed an examination attesting to their theoretic knowledge
12. Accountability. Takes responsibility for independent actions. are certified by the NBSTSA, the main certifying body for STs.
Admits error and remedies the situation when breaches in technique or These individuals are entitled to use the designator CST after their
contamination occurs. names as a credential. Box 4-4 describes eligibility for taking the
CST examination.
As of 2010, graduates of accredited surgical technology pro-
the surgical procedure. Knowledge of and experience with asep- grams are required to take the NBSTSA certification examina-
tic and sterile techniques qualify the scrub person to prepare and tion as a graduation requirement. Application for the certification
arrange instruments and supplies and to facilitate the surgical examination may be made as soon as 30 days before graduation
procedure by providing the required sterile instruments and sup- for the graduating class to apply as a group. Certification fees are
plies. The scrub person must anticipate, plan for, and respond to discounted for Association of Surgical Technologists (AST) mem-
the needs of the surgeon and other team members by constantly bers. Special packages are available from AST that include mem-
watching the sterile field. Manual dexterity and physical stamina bership and registration for the examination. The results of the
are required. Other important assets include a stable tempera- examination provide data for measuring an accredited program’s
ment, an ability to work under pressure, a keen sense of responsi- effectiveness.
bility, and a concern for accuracy in performing all duties. Box 4-3 As of 2013, seven states require the CST credential for employ-
describes the physical and psychological attributes required of the ment. These states are New York, New Jersey, South Carolina,
scrub person in the sterile scrub role. Tennessee, Indiana, Massachusetts, and Texas. STs, who were
Two scrub persons may join the team in teaching situations employed before the date of the CST requirement are permitted
or during extremely complicated or hazardous surgical proce- to remain in the role of scrub person. Military and federal gov-
dures. One scrub person may pass instruments and supplies to ernment employees are exempt. The CSTs are permitted to func-
the surgeon while the other prepares the supplies. Two scrub tion under the direction of the RN circulator and may not suture,
persons should be assigned if two complete teams are working administer medication, or apply wound dressings according to the
simultaneously. laws governing CST role activities. Refer to the laws governing
An experienced preceptor may join the team to teach, guide, CST practice in the individual state of employment.
and assist the learner function as a scrub person. When unex- Certification for the CST is valid for 4 years. The CST must be
pected, unusual, or emergency situations arise, specific instruc- renewed to remain active. It can be renewed by retaking the CST
tions and guidance are received from the surgeon or RN. The ST examination or attainment of 60 approved continuing education
• BOX 4-5 Calculating Approved Continuing References

Education (CE) Credits for CST
1. Pehotsky C, et al.: Effects of an educational program on perceived
Lecture value and barriers to certification, J PeriAnesthesia Nurs 29(5):e45,
2014.
1 CE = 50-60 minutes of lecture
2. Hickey J, et al.: Credentialing: The need for a national research agen-
0.5 CE = 30 minutes of lecture
da, Nurs Outlook 62(2):119–127, 2014.
Add 0.25 CE for every 15 minutes over the first 30 minutes of lecture
3. Boyle DK, et al.: The relationship between direct-care RN specialty
certification and surgical patient outcomes, AORN J 100(5):511–528,
Independent Study Article
2014.
2000 typed words = 1 CE
Bibliography
AORN (Association of periOperative Registered Nurses): Guidelines for
(CE) credits. Recertification fees are discounted for AST mem- perioperative practice, Denver, 2015, The Association.
bers. Calculations for accruing CE credits can be found in Box Association of surgical technologists: Core curriculum for surgical technology,
4-5. Providers of CE credits must apply to AST for approval of the ed 5, Englewood, CO, 2002, The Association.
offering. Continuing education forms are available for download
from www.ast.org.

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What are some of the roles and responsibilities of surgical team members?

What are some of the roles and responsibilities of surgical team members?

What are the eligibility requirements for certification as a surgical technologist?

What are the eligibility requirements for certification as a surgical technologist?

S E C TI ON 1 Fundamentals of Theory and Practice

The Art and Science of Surgery Perioperative Learner

Experience in the perioperative clinical setting should be planned Behavioral Objectives

Meets Needs Improving Does Not Meet

Reports for duty in a punctual manner

Wears OR attire properly:

Performs housekeeping duties:

Places items on sterile surface:

Scrubs for setup and procedure:

Anticipates needs of surgeon:

Disassembles the table:

Removes gown and gloves:

• FIG. 1-1 Performance appraisal of the scrub role.

Meets Needs Improving Does Not Meet

Reports for the duty in a punctual manner

Wears OR attire properly:

Performs housekeeping duties:

Dispenses or transfers items to sterile surface as appropriate:

Validates implant parameters and documents in the lot log

Practices aseptic technique:

Gowning and gloving of others:

Anticipates needs of patient, anesthesia provider, surgeon, and

Provides safe and competent direct patient care:

Attaches and activates surgical machinery and devices for the

Supervises and manages the room:

• FIG. 1-2 Performance appraisal of the circulating nurse’s role.

Really Simple Syndication (RSS) feeds are subscription ser-

Policies and Procedures Identifying the Surgical Site

COMPREHENSIVE SURGICAL CHECKLIST

PREPROCEDURE SIGN-IN TIME-OUT SIGN-OUT

avoid wrong-site procedures. The time out process should be

1. Patients have retained items from a surgical procedure regard-

necrosis is possible after any procedure and especially after proce-

Professionals act responsibly in accord with their commitment Patient-Nurse Relationship

Guidelines & Regulatory

PAT Standardized Standardized

AORN Syntegrity® Solution

PreOp Current Standardized

The AORN Syntegrity® Solution is standardized content for perioperative

Peer Review Bibliography

Under the corporate negligence doctrine, the facility may be liable

Conduct a pre-procedure verification process

Mark the procedure site

The • A designated member of the team starts the time-out.

Consent in Emergency Situations

Examination for Portfolio

• BOX 4-5 Calculating Approved Continuing References

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1. Patients have retained items from a surgical procedure regard-

• BOX 4-5 Calculating Approved Continuing References