2 Perianesthesia nursing as A specialty

Sarah M.I. Cartwright, BA, RN, CAPA , Susan M. Andrews, BAN, MA, RN, CAPA

Perianesthesia nursing is a diverse field that encompasses patient care in a variety of settings. Recognition of perianesthesia nursing as a critical care specialty is well established. The main goal of the perianesthesia nurse is to provide competent, efficient care to patients and their families who are experiencing an anesthetic event. This care can be given in a traditional care setting, such as the hospital setting, or in a nontraditional care environment, such as a physician’s office. Where there is an opportunity for a patient to experience anesthesia—from moderate sedation to general anesthesia—there is an opportunity for a perianesthesia nurse to provide care.

Recent history has been witness to a number of significant factors that have influenced the practice of perianesthesia nursing. Among these factors are the emphasis on cost containment in health care; declining reimbursement for medical services; the aging and increased acuity level of the population; advances in technology; advances in pharmaceutical therapy; and fast-tracking of patients through the postanesthesia recovery process.

The American Society of PeriAnesthesia Nurses (ASPAN) is the professional organization that represents the professional interests of perianesthesia nurses and sets the clinical standards of care in this specialty in the United States and its territories. In an effort to define the role of the perianesthesia nurse, ASPAN has published a formal Scope of Practice document (Box 2-1) that addresses the core, dimensions, boundaries, and intersections of perianesthesia nursing practice.¹ The members and governing bodies partner to establish practice standards, guidelines, and evidenced-based practices to promote safe patient care. These standards encourage competent practice through their use, as vetted through peer review processes and member representation. The guidelines define practice issues such as evaluation of patient condition, practice statements for staffing patterns, use of unlicensed care personnel, and overflow of intensive care patients. ASPAN also partners with other nursing professional organizations to establish professional nursing standards advocating for safe conditions for both the patient and the caregiver.¹

BOX 2-1 Scope of Practice: Perianesthesia Nursing

The American Society of PeriAnesthesia Nurses (ASPAN), the professional organization for the specialty of perianesthesia nursing, is responsible for the defining and establishing of the scope of perianesthesia nursing. In doing so, ASPAN recognizes the role of the American Nurses Association (ANA) in defining the scope of practice for the nursing profession as a whole.

ASPAN supports the ANA Social Policy Statement 2003.¹^,² This statement charges specialty nursing organizations with definition of their individual scope of practice and identification of the characteristics within their unique specialty areas.

Evolving professional and societal demands have necessitated a statement clarifying the scope of perianesthesia nursing practice. Given rapid changes in health care delivery, trends, and technologies, the task of definition of this scope is complex. This document allows for flexibility in response to emerging issues and technologies in health care delivery and the practice of perianesthesia nursing.

The Scope of Perianesthesia Nursing Practice involves the age-specific assessment, diagnosis, intervention, and evaluation of individuals within the perianesthesia continuum. Those individuals have had or will have sedation/analgesia and/or anesthesia for surgical, diagnostic, or therapeutic procedures. Our practice is systematic, integrative, and holistic and involves critical thinking, clinical decision making and inquiry. ASPAN strives to promote an environment in which the perianesthesia nurse can deliver quality care among a diverse population within a multidisciplinary healthcare team.

This scope of practice includes, but is not limited to:

• Preanesthesia Level of Care

• Preadmission

• Day of Surgery/Procedure

• Postanesthesia Levels of Care

• Phase I

• Phase II

• Extended Observation

The delivery of care includes, but is not limited to, the following environments:

• Hospitals

• Ambulatory Surgery Units/Centers

• Procedural Areas (e.g., Cardiology, ECT, GI/Endoscopy, Interventional and Diagnostic Radiology, Oncology, Pain Management, etc.)

• Obstetrical Units

• Office Based Settings

This specialty of perianesthesia nursing encompasses the care of the patient and family/significant other along the perianesthesia continuum of care—Preanesthesia, Postanesthesia Phase I, Phase II, and Extended Observation. Characteristics unique to perianesthesia practice are:

Postanesthesia phase

Postanesthesia phase I

The nursing roles in this phase focus on providing postanesthesia nursing in the immediate postanesthesia period, transitioning to Phase II, the in-patient setting, or to an intensive care setting for continued care. Basic life-sustaining needs are of the highest priority. Constant vigilance is required during this phase.

Postanesthesia phase II

The nursing roles in this phase focus on preparation for care in the home or an extended care environment.

Extended care

The nursing roles in this phase focus on providing care when extended observation/intervention after discharge from Phase I or Phase II is required.

Perianesthesia nursing roles include those of patient care, research, administration, management, education, consultation, and advocacy. The specialty practice of perianesthesia nursing is defined through the implementation of specific role functions that are delineated in documents including ASPAN’s Perianesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing³ and the Standards of Perianesthesia Nursing Practice.⁴ The scope of perianesthesia nursing practice is also regulated by policies and procedures dictated by the hospital/facility, state and federal regulatory agencies, and national accreditation bodies.

Professional behaviors inherent in perianesthesia practice are the acquisition and application of a specialized body of knowledge and skills, accountability and responsibility, communication, autonomy, and collaborative relationships with others. Resources to support this defined body of knowledge and nursing practice include ASPAN’s Perianesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing,³ Standards of Perianesthesia Nursing Practice,⁴ and Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting.⁵ Certification in perianesthesia nursing (Certified Post Anesthesia Nurse: CPAN^® and Certified Ambulatory Perianesthesia Nurse: CAPA^®) is recognized by ASPAN as it validates the defined body of knowledge for perianesthesia nursing practice.

ASPAN interacts with other professional groups to advance the delivery of quality care. These include but may not be limited to:

• Ambulatory Surgery Center Association (ACS)

• American Association of Anesthesia Assistants (AAAA)

• American Association of Clinical Directors (AACD)

• American Association of Colleges of Nursing (AACN)

• American Association of Critical Care Nurses (AACN)

• American Association of Nurse Anesthetists (AANA)

• American Board of Perianesthesia Nursing Certification (ABPANC)

• American Nurses Association (ANA)

• American Society of Anesthesiologists (ASA)

• American Society of Pain Management Nurses (ASPMN)

• American Society of Plastic Surgical Nurses (ASPSN)

• Anesthesia Patient Safety Foundation (APSF)

• Association of periOperative Registered Nurses (AORN)

• Association of Radiologic and Imaging Nurses (ARIN)

• Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

• British Anaesthetic & Recovery Nurses Association (BARNA)

• Council of Surgical and Perioperative Safety (CSPS)

• Irish Anaesthetic and Recovery Nurses Association (IARNA)

• National Association of Clinical Nurse Specialists (NACNS)

• National Association of Perianesthesia Nurses of Canada (NAPANc)

• National League for Nursing (NLN)

• National Student Nurses Association (NSNA)

• Nursing Organizations Alliance (NOA)

• Society for Ambulatory Anesthesia (SAMBA)

• Society for Perioperative Assessment and Quality Improvement (SPAQI)

• Society of Gastroenterology Nurses and Associates (SGNA)

• Society of Office Based Anesthesia (SOBA)

This Scope of Perianesthesia Nursing Practice document defines the specialty practice of perianesthesia nursing. The intent of this document is to conceptualize practice and provide education to practitioners, educators, researchers, and administrators, and to inform other health professions, legislators and the public about perianesthesia nursing’s participation in and contribution to health care.

ECT, Electroconvulsive therapy; GI, gastrointestinal.

From The American Society of PeriAnesthesia Nurses: Perianesthesia nursing standards and practice recommendations 2010–2012, Cherry Hill, NJ, 2010, ASPAN. Reprinted with permission.

Perianesthesia nursing is practiced in multiple modalities, both inpatient and outpatient, within the hospital setting and in free-standing practice settings (Box 2-2). The continued emphasis on cost containment has stimulated the regionalization of health care and the development of tertiary care centers in major cities, while primary care has increasingly moved to ambulatory settings.² As a consequence, perianesthesia nursing is practiced in a variety of traditional and nontraditional settings, from the physician’s office to recovery care centers to highly specialized postanesthesia care units (PACUs) in dedicated medical centers, such as eye institutes and surgical hospitals as well as practice sites that include dental clinics, ambulatory surgery centers, office-based procedure areas, endoscopy suites, and pain management centers.

BOX 2-2 Perianesthesia Practice Settings