AORN Position Statement on Perioperative Registered Nurse Circulator Dedicated to Every Patient Undergoing an Operative or Other Invasive Procedure

Abstract

AORN JournalVolume 110, Issue 1 p. 82-85 From AORNFree Access AORN Position Statement on Perioperative Registered Nurse Circulator Dedicated to Every Patient Undergoing an Operative or Other Invasive Procedure First published: 27 June 2019 https://doi.org/10.1002/aorn.12741Citations: 4AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat POSITION STATEMENT AORN believes: At a minimum, one perioperative RN circulator should be dedicated to each patient undergoing an operative or other invasive procedure and should be present during that patient's entire intraoperative experience.1 Having a practice environment with a minimum of one perioperative RN circulator dedicated to each patient undergoing an operative or other invasive procedure for the duration of the procedure will provide for safe, quality patient care in the surgical arena. Facility policies and procedures should address those procedures when more than one RN circulator is required. For example, individual competency, patient acuity, patient monitoring (eg, during local or moderate sedation), complexity of technology (eg, laser, minimally invasive techniques), and trauma procedures. Patient care in the perioperative setting is dynamic in nature and depends on the clinical knowledge, judgment, and clinical-reasoning skills possessed by the perioperative RN. The perioperative RN circulator supervises and evaluates the activities of other team members while simultaneously executing immediate directives and interventions in urgent or emergent situations.2 The perioperative RN circulator delegates certain nursing tasks and functions, such as the scrub role to LPNs and surgical technologists; nursing interventions such as circulating duties that require independent, specialized nursing knowledge, skill or judgment cannot be delegated. The foundation of perioperative nursing practice is based on both the art and science of nursing, including scientific principles, best practices, and patient advocacy. A practice environment that acknowledges the unique education of an RN empowers perioperative nurses to provide the highest quality of patient care in the surgical arena. Scientific research and the identification of nursing quality indicators, such as those found in the language of the Perioperative Nursing Data Set (PNDS), are the best means to monitor the relationship between appropriate nurse staffing and patient outcomes in the surgical setting. Administrative and collegial support, as well as effective relationships with physicians and surgeons, contributes to the perioperative nurse's ability to provide safe, quality patient care. Furthermore, AORN affirms that research should be conducted to determine proper nurse staffing to sustain safe quality patient outcomes, supports continued collaboration with all organizations endeavoring to reduce and eliminate health care errors, and affirms that adequate staffing is an essential element of error prevention. RATIONALE The goal of perioperative nursing practice is to assist patients to achieve a level of wellness equal to or improved from the preoperative level, and to support the patients’ family members and significant others during the perioperative period. AORN is committed to the provision of safe perioperative nursing care by ensuring that every patient undergoing an operative or other invasive procedure is cared for by a minimum of one registered nurse (RN) in the circulating role for the duration of each procedure. The perioperative nurse is an RN who plans, coordinates, delivers, and evaluates nursing care for patients whose protective reflexes or self-care abilities are potentially compromised during operative or other invasive procedures. Although the perioperative RN works collaboratively with other perioperative professionals (eg, surgeons, anesthesia professionals, surgical technologists) to meet patient needs, the perioperative RN is accountable for the patient outcomes resulting from the nursing care provided during the operative or other invasive procedure. Using clinical knowledge, judgment, and clinical-reasoning skills based on scientific principles, the perioperative nurse plans and implements nursing care to address the physical, psychological, and spiritual responses of the patient having an operative or other invasive procedure. In conjunction with the escalating changes in health care, there is a continuous need to provide optimal nursing care that is high quality, safe, accessible, cost-effective, and affordable for patients undergoing operative or other invasive procedures in all settings. Evolving models of health care delivery are affecting perioperative nursing practice across diverse settings in which operative or other invasive procedures are performed. Past staff-reengineering attempts that were part of cost-savings initiatives have not demonstrated improvement, and may in fact have a deleterious effect on patient care outcomes. Health care systems have unsuccessfully attempted to replace RNs with allied health care providers and assistive personnel who lack the education and clinical-reasoning skills to provide quality patient outcomes. A variety of organizational factors in the perioperative setting must be considered. Nurse administrators who are accountable for the organization of perioperative services must ensure that adequate resources are available to promote a quality care environment.3 Studies have demonstrated that higher nurse-to-patient ratios are associated with lower mortality rates, fewer incidents of failure to rescue, shorter lengths of stay, fewer medication errors, and reduced incidences of pressure ulcers and pneumonia.4-8 Better outcomes are inversely proportional to cost. In other words, better outcomes equal lower costs for the health care system.9, 10 Improved patient outcomes have been demonstrated with improved staffing, enhanced work environment, and better-educated nurses.11 The aging of the population has resulted in patients who are more acutely ill on admission to health care facilities. Despite the decreased lengths of stay in acute care facilities, patients continually require more sophisticated care to maintain their health. This situation has been further complicated by an absence of standardized, mandatory public reporting of data that could objectively quantify the effects of altered staffing configurations. National adoption of the PNDS will enable nursing care to be documented in a standardized manner to allow for collection of reliable and valid clinical data on perioperative nurse–sensitive outcomes resulting from nursing interventions during operative or invasive procedures.12 To improve patient safety, health care systems and care models must provide appropriate perioperative nursing staff to meet patient needs, accounting for both patient acuity and social determinants of health for the patient population. The economic situation of the provider organization should not serve as the sole basis for determining services offered. Safety is valued as a top priority, even at the expense of productivity.13 One of the critical responsibilities of the RN circulator is serving as the patient's advocate. This requires that the RN circulator has the opportunity to receive a hand-over report on the patient's status and that time be allowed for the nurse to have a conversation with the patient to identify any physical, spiritual, or social needs of the patient before the initiation of the intraoperative period.14, 15 The Code of Federal Regulations “Conditions of participation for hospitals” (42 CFR §482) sets forth delivery and service standards for hospitals receiving Medicare reimbursement. Under these regulations, the health care organization must have adequate numbers of qualified RNs to provide nursing care, which includes circulating duties.16 The Centers for Medicare & Medicaid Services interpretive guidelines in §482.51(a)(3) state, “The circulating nurse must be an RN.” A licensed practical nurse or surgical technologist may assist an RN in carrying out circulating duties, in accordance with applicable state laws and medical staff–approved hospital policy, but the licensed practical nurse or surgical technologist must be under the supervision of the RN circulator who is in the operating suite and who is available to respond/intervene immediately and physically to provide necessary interventions in emergencies. The supervising RN would not be considered immediately available if the RN was located outside the operating suite or engaged in other activities or duties that prevent him or her from immediately intervening and assuming whatever circulating activities or duties were being provided by the licensed practical nurse or surgical technologist.16 In addition, several states have their own legislation or regulation requiring an RN as circulator.17, 18 Perioperative RNs should know and must comply with their individual state statutes, rules, and Board of Nursing guidance regarding the role of the RN as the circulator in the perioperative setting. The perioperative RN may delegate tasks and functions according to applicable law, regulations, and standards, taking into consideration the competencies of the ancillary personnel, but retains accountability for the outcome of perioperative nursing care.3 Delegation must be consistent with state laws and regulatory agency standards. Any nursing interventions—such as circulating duties—that require independent, specialized nursing knowledge, skill, or judgment cannot be delegated.16 If LPNs or surgical technologists are performing in the scrub role, they do so under the supervision of the RN circulator.16 Administrators, directors, and managers responsible for providing staff for perioperative services should refer to the AORN Position Statement: Perioperative Safe Staffing and On-Call Practices.1 Glossary Invasive procedure: The surgical entry into tissues, cavities, or organs, or the repair of major traumatic injuries. Perioperative nurse: A registered nurse who, using the nursing process, develops a plan of nursing care and then delivers that care to patients undergoing operative or other invasive procedures. The perioperative nurse has the requisite skills and knowledge to assess, diagnose, plan, intervene, and evaluate the outcomes of surgical interventions. The perioperative nurse addresses the physiological, psychological, socio-cultural, and spiritual responses of surgical patients during the perioperative period. RN circulator: A role performed by the perioperative registered nurse, without donning sterile attire, during the preoperative, intraoperative, and postoperative phases of surgical patient care. In collaboration with the entire perioperative team, the RN circulator uses the nursing process to provide and coordinate the nursing care of the patient undergoing operative or other invasive procedures. Social determinants of health: The conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.19 REFERENCES 1 AORN Position Statement: Perioperative Safe Staffing and On-Call Practices. AORN, Inc. https://www.aorn.org/guidelines/clinical-resources/position-statements;. Accessed November 2, 2018. 2Ritchie CR. Fundamental perioperative nursing: decompartmentalizing the scrub and circulator roles. Perioper Nurs Clin. 2009; 4(2): 167- 180. 3 Standards of perioperative nursing. https://www.aorn.org/guidelines/clinical-resources/aorn-standards. 4Kane RL, Shamliyan T, Mueller C, Duval S, Wilt TJ. Nurse staffing and quality of patient care. Evid Rep Technol Assess (Full Rep). 2007; 151: 1- 115. 5Thungjaroenkul P, Cummings GG, Embleton A. The impact of nurse staffing on hospital costs and patient length of stay: a systematic review. Nurs Econ. 2007; 25(5): 255- 265. 6McGillis Hall L, Doran D, Pink GH. Nurse staffing models, nursing hours, and patient safety outcomes. J Nurs Adm. 2004; 34(1): 41- 45. 7Newhouse RP, Johantgen M, Pronovost PJ, Johnson E. Perioperative nurses and patient outcomes—mortality, complications, and length of stay. AORN J. 2005; 81(3): 508- 528. 8Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014; 383(9931): 1824- 1830. 9Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med. 2011; 364(11): 1037- 1045. 10McHugh MD, Berez J, Small DS. Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing. Health Aff (Millwood). 2013; 32(10): 1740- 1747. 11Aiken L, Cimiotti J, Sloane D, Smith H, Flynn L, Neff D. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care. 2011; 49(12): 1047- 1053. 12 Introduction to the AORN Guidelines for Perioperative Practice. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2019: ix- xii. 13 AORN Position Statement: Creating a Practice Environment of Safety. Denver, CO: AORN, Inc. https://www.aorn.org/guidelines/clinical-resources/position-statements;. Accessed January 7, 2019. 14 Perioperative Efficiency Tool Kit. AORN, Inc. https://www.aorn.org/guidelines/clinical-resources/tool-kits/perioperative-efficiency-tool-kit. Accessed January 7, 2019. 15Malley A, Kenner C, Kim T, Blakeney B. The role of the nurse and the preoperative assessment in patient transitions. AORN J. 2015; 102(2): 181.e1- 181.e9. 16 Centers for Medicare & Medicaid Services. Conditions of participation for hospitals. 42 CFR §482 (2018). https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=d46609dadb6b9f2aa7ffc7ec5217c4e0&mc=true&n=pt42.5.482&r=PART&ty=HTML#se42.5.482_151. Accessed January 7, 2019. 17 My State: Think Perioperatively, Act Locally. AORN, Inc. https://www.aorn.org/government-affairs/my-state;. Accessed January 7, 2019. 18 RN Circulator. AORN, Inc. https://www.aorn.org/government-affairs/policy-agenda/rn-circulator;. Accessed January 7, 2019. 19 Social Determinants of Health. World Health Organization. https://www.who.int/social_determinants/en/. Accessed January 7, 2019. Publication History Original approved by the House of Delegates, March 2001, as AORN Statement on Nurse-to-Patient Ratios Revision approved by the House of Delegates: March 2007 Reaffirmed by the Board of Directors: August 2012 Revision approved by the House of Delegates: April 2014 Revision approved by the membership: March 2019 Sunset review: 2024 Citing Literature Volume110, Issue1July 2019Pages 82-85 ReferencesRelatedInformation