Chapter 12 Professional development and future roles and practice
Entry to the perioperative environment
There are two divisions of nurse in the Australian health care system. The first division is the registered nurse (RN) (Division 1 in Victoria and Western Australia), who, since the mid 1980s, is university prepared at the bachelor degree level. The second division is the enrolled nurse (EN, or RN Division 2, Victoria and Western Australia, hereafter referred to as EN), who is vocationally prepared at Certificate IV or diploma level. The EN provides care to patients in a model of delegation and supervision by the RN. The Australian perioperative nursing workforce includes both RNs and ENs, who do not require specialist qualifications to gain entry to this practice environment, even though perioperative nursing is recognised as an area of specialty nursing practice (Australian Health Workforce Advisory Committee [AHWAC], 2006).
Continuing education providers, such as technical and further education (TAFE) institutions, and the College of Nursing (formerly the NSW College of Nursing) offer short, introductory programs in perioperative nursing for both RNs and ENs, which do not require employment in a perioperative setting. Courses such as these can only provide an overview of the perioperative specialty; however, participation in them can demonstrate to potential employers the nurse’s interest in perioperative nursing care and their desire to enter the specialty. In New Zealand, District Health Boards (DHBs) are funded to support nursing entry to practice (NETP) programs for newly graduated RNs (NZ Ministry of Health, 2006).
The registered nurse
Like many specialty areas of nursing practice that were once part of hospital-based training, perioperative nursing is no longer a core component of the undergraduate curriculum in Australia (AHWAC, 2006) or New Zealand (P. Hames, personal communication, 2007). Consequently, the newly qualified RN may have little knowledge or experience in the care of the unconscious patient during general anaesthesia and surgery, the principles of aseptic technique or the management of a patient’s recovery from anaesthesia and surgery. An undergraduate curriculum that does not offer perioperative experience affects graduates as well as perioperative nurse managers. For example:
The international experience is similar in as much as the current perioperative recruitment issues in the United States have been linked to the loss of perioperative nursing from the undergraduate curriculum in the 1980s (Gutierrez et al., 1989; Happell, 2000; Jones & Sorrell, 1989). This is compounded by the ageing of the nursing workforce (Australian Institute of Health & Welfare [AIHW], 2005).
Opportunities for undergraduates
For undergraduate nurses in Australia and New Zealand, entry to the perioperative environment may be possible during a rotation or clinical placement on a surgical ward. Astute perioperative managers and educators will encourage these short, observational visits during undergraduate clinical placements (P. Hames, personal communication, 2007) as a means of attracting nurses to consider the specialty on graduation (NSW Operating Theatre Association, 2007).
In recent years, universities in Australia (e.g. University of Technology, Sydney) have begun to offer the perioperative specialty as an elective in second or third year nursing curricula, while others offer it as a core subject (e.g. Notre Dame University). The Australian Catholic University (ACU) has offered a perioperative elective in the final year nursing practicum since 2005, when 25 students were enrolled. This number has increased almost four-fold in the 2 years since, with 95 students enrolled in 2007 (Frotjold et al., 2007).
This growing interest in perioperative nursing at the undergraduate level echoes the findings of a US study (Gutierrez et al., 1989) and supports the inclusion of the perioperative specialty in the nursing curriculum in Australia. Effective collaborations between nursing faculties and operating suites have many benefits for potential employers. The ACU students’ evaluations of the perioperative elective indicate the program’s success as a recruitment strategy; 88% of students indicated that they would consider employment in the operating suite on graduation as a direct result of their positive experiences during the clinical placement. Indeed, the hospitals participating in the ACU elective have reported an increasing number of graduates recruited to the perioperative specialty since the inception of the undergraduate elective (Frotjold et al., 2007).
Clearly, undergraduate programs with outcomes such as this can have a positive impact on the graduate workforce. This is borne out by recent research in the United Kingdom (Andrews et al., 2002), which investigated the impact of clinical placements on 650 past and present nursing students. The research was carried out in two large, metropolitan universities, using questionnaires, focus groups and interviews. A key finding from the research was that the organisations that provided a supportive learning environment for the nursing students during their clinical placements became the nurses’ preferred employers on graduation. The authors concluded that employers will attract and retain more nurses by creating a positive workplace—one in which learning is encouraged and supported (Andrews et al., 2002).
Opportunities for graduates
The shorter, 3–4 month rotation of most new graduates to the operating suite provides time beyond orientation for the nurse to explore the practice of a single perioperative role only. By the end of a 4-month rotation in anaesthetics, for example, the new graduate nurse should be able to manage the care, within a limited range of elective patients, at induction and emergence from anaesthesia with minimal direction and support. Similarly, the new graduate circulating and instrument nurse should have developed the knowledge and skills to prepare the environment, patient and equipment for a limited range of elective procedures under the guidance of an experienced nurse. During the short rotation, neither of these nurses would have developed the knowledge or skills of the other roles; however, they should have developed an understanding of the relationship between the nursing roles and the teamwork required to provide effective patient care in the perioperative environment. Longer rotations, such as the ‘dedicated stream’ models, do allow movement within the full range of perioperative roles.
The enrolled nurse
The educational preparation of the EN in Australia has undergone intensive review in recent years in response to the National Review of Nursing Education (Australian Department of Education, Science and Training [DEST], 2002). A key recommendation was the development of a national qualification that would incorporate the EN competencies of the Australian and Nursing Council (ANC), now known as the Australian Nursing and Midwifery Council (ANMC). This has culminated in the development of the Health Training Package HLT07 (Certificate IV, Diploma and Advanced Diploma in Enrolled Nursing/ Division 2 Nursing), which is available for delivery across Australia (Community Services & Health Industry Skills Council [CS&HISC], 2007). New Zealand does not have an EN category; the entry level for all nurses is registration via a 3-year bachelor degree program (NZ Ministry of Health, 2007).
ENs may work in the anaesthetic nurse role with or without a post-enrolment qualification, such as the Certificate IV in Anaesthetic Technology (CS&HISC, 2007). Those ENs who posses this qualification are able to function in the role of anaesthetic technician. A smaller number of perioperative ENs may work in the circulating and instrument nurse role; however, there are fewer post-enrolment qualifications for this specialised role, which has most often been performed by the RN within Australian jurisdictions (NSW Health, 2007b). As opportunities increase for advanced practice roles for RNs, so too, will opportunities increase for ENs. This is explored further under advanced practice on pages 301–302.
Orientation and clinical programs
Without exposure to the perioperative environment, the majority of nursing graduates, be they RNs or ENs, will have received little theory or clinical practice in the care of the perioperative patient during their initial education. Operating suites that do attract graduates to specialty practice must, therefore, provide comprehensive orientation and clinical programs to equip these new recruits for a role in the perioperative environment. Table 12-1 lists activities that are appropriate for inclusion in an orientation program.
Table 12-1 Sample content of a 5-day orientation program
| Perioperative roles |
|---|
| 1. Medicolegal principles and policy |
| 2. Patient and environmental safety |
| 3. Principles of asepsis and infection control |
South Eastern Sydney Illawarra Area Health Service (2006)
The Association of periOperative Registered Nurses (AORN) in the United States offers the ‘Perioperative Curriculum 101’, which was first developed in 1999 and is now available as an online educational resource (AORN, 2007). Members of the Perioperative Nurses College (PNC) of the New Zealand Nurses Organisation (PNCNZNO) are able to purchase a perioperative education manual, which has been approved by the New Zealand Nurses Organisation (Marenzi, 2006). A key goal of the PNC is the establishment of a national perioperative education program and, to this end, the College structure includes an education subcommittee.
Currently, there is no equivalent program offered by the Australian College of Operating Room Nurses (ACORN). Orientation to specialty practice, therefore, is provided by individual healthcare facilities in Australia (ACORN, 2007) and, in some cases, centralised orientation and clinical programs are provided across an organisation or health service. The duration of these programs ranges from a few days orientation to 6-month or 12-month extended clinical programs. These extended programs may supplement the content of new graduate RN rotations, or they may provide an alternative pathway to specialty practice as part of an organisational recruitment strategy (South Eastern Sydney Illawarra Area Health Services, 2007).
In addition to a structured orientation, extended programs offer a theoretical framework of regular study days, as well as supported clinical practice and assessment. Extended programs may also be recognised for subject credit in tertiary-level graduate programs. This relationship exists between Deakin University and Barwon Health in Victoria, Adelaide University and the Royal Adelaide Hospital in South Australia and, in New South Wales, the ACU and St Vincent’s Hospital, as well as the Wollongong University and Wollongong Hospital, to name just a few examples.
Ongoing professional development
Progress along the nursing career pathway requires a commitment to ongoing education and professional development. This commitment is even more important in specialty areas such as perioperative nursing, where technology, health policy and nursing practice are continually developing and changing (Senate Community Affairs References Committee, 2002). The knowledge and skills that the beginning RN or EN develops during the orientation period are the foundation upon which specialty practice is built. Ongoing perioperative nursing practice requires the acquisition of further qualifications and/or work experience. The role that training and education plays in the elevation of the profession’s status is explored on page 293.
Formal development
Australian and New Zealand universities and colleges provide a range of postgraduate programs for perioperative nurses, including graduate certificates, graduate diplomas, masters and doctoral programs. Historically, hospital-based certificates were the mainstay of professional development courses for perioperative nurses (AHWAC, 2006). Even though certificates were available for anaesthetic and postanaesthesia recovery unit (PARU) nurses, there were many more for instrument and circulating nurses. These certificates were routinely of 12 months’ duration, during which time the students were required to rotate through the major surgical specialties, as well anaesthetics and PARU.
Since the transition of nursing education to the tertiary sector in the mid 1980s, these certificates have disappeared from hospitals; however, some have re-emerged (in somewhat smaller numbers) as graduate certificate courses in the tertiary sector. There are some notable exceptions as a few facilities continue to offer hospital-based programs, including the Fremantle Hospital in Western Australia, the Queen Elizabeth Hospital in South Australia, and the Liverpool Hospital in New South Wales (AHWAC, 2006). In New Zealand, the DHBs fund postgraduate nursing studies based on local need, as well as providing clinical learning placements (NZ Ministry of Health, 2007).
In a survey of Australian course coordinators in 2005, the Australian Health Workforce Advisory Committee (AHWAC, 2006) identified 16 providers of postgraduate programs for perioperative nurses. This figure included the three hospitals mentioned above, 12 universities and the College of Nursing. At the time, students enrolled in perioperative specialisations outnumbered anaesthetic and PARU students by 3:1, echoing the trend seen in hospital-based certificates (AHWAC, 2006).
Informal or continuing education
In 2002, the Senate Inquiry into Nursing reported that continuing education for perioperative nurses was:
… essential for the ongoing maintenance of professional expertise and therefore professional standards. With the rapid development of new technologies in the operating room environment, nurses need access to professional development programs on a regular basis (Senate Community Affairs References Committee, 2002, p 192).
The Senate Inquiry made a number of suggestions, including the need for more opportunities for specialist nurses, in particular, to maintain knowledge and skills. At much the same time, another review into the nursing profession was underway in Australia. Not surprisingly, similar themes emerged. The National Review of Nursing Education also recommended that nurses undertake lifelong learning as a means of maintaining competence (Australian DEST, 2002).
Professional portfolios can be used to record these activities and will, more importantly, provide an effective mechanism for the nurse to reflect on practice. In fact, self-reflection is vital because it ensures that the individual nurse’s portfolio is more than a list of activities completed, but rather it enables the nurse to demonstrate what has been achieved through participation in the activities (McMullan et al., 2003).
A commitment to lifelong learning is not simply valued by the nursing profession; nursing and midwifery registering authorities have begun to stipulate continuing education hours as a requirement for annual licence renewal (ANMC, 2006a; National Nursing and Nursing Education Taskforce [N3ET], 2006). The ANMC’s position is articulated in its Continuing Competence Framework (ANMC, 2007b). This framework comprises the elements of:
The professional portfolio is recognised here as one of the best methods for nurses to document their maintenance of competence (ANMC, 2007b; Davies & Hamlin, 2003). Certainly, then, the professional portfolio can serve many purposes for the perioperative nurse.
Perioperative nurses as professionals
The division of labour is also a division of knowledge, with consequential implications of reciprocal dependence and vulnerability between participants (Dingwall & Lewis, 1983, p 12).
In Australia in the 1880s, assisting surgeons during operations was fundamental to the work of all nurses because they attended operations in the home, hospital ward and operating suite. Initially, all nurses were trained to meet the skill requirements of this role: to prepare patients, the environment, the necessary equipment and dressings, and then assist patients to recover from their operation. As with any occupation, it was important for nursing to gain recognition as a profession because it carried with it status and security; furthermore, as with any occupation, professional status provides a basis for protection from occupational competition (Freidson, 1983).
As medical specialties developed, nursing specialties emerged alongside to meet gaps in skills and knowledge. Training was important in elevating nursing’s professional status (Bessant & Bessant, 1991). Freidson (1994) argued that the division of labour is specialisation and that (former) operating suite nursing is an example of a dynamic nursing specialty that continues to evolve into super-specialty areas of skills and knowledge that are not constrained by geographical boundaries. For example, within perioperative nursing, nurses may specialise and work exclusively in areas such as cardiothoracic surgery or neurosurgery, or they move into day surgery settings and work across the continuum of ambulatory patient care.
As nursing evolved from a service to a trained practice, and scientific and technological advances developed in medicine, nurses were measured not only by their character but increasingly by their technical skills and knowledge, which gave them portability to practice in the hospital or to work privately. Perioperative nurses, as with other specialist nurses, are identified not only by the geographical locus of work (in this case operating suites, perioperative units, outpatient clinics and day surgery units) but also by their specialist skills and knowledge. That is, their specialist skills and knowledge admit them into a world of specialist practice as a professional and differentiate them from generalist nurses (Heartfield, 2006).
There has been much debate among nurses (and others) about whether nursing has achieved professional status (Schwirian, 1998). Although there is no universally accepted definition, the term ‘profession’ refers to an occupation that controls its own boundaries of work, is organised by a set of institutions and is informed by a particular ideology of expertise and service. While the line between nursing and domestic service could hardly be drawn in the mid-19th century (Rosenberg, 1987) and the term ‘quintessential domestic scientists’ was used to describe nurses at this time (Bashford, 2000), operating room nurses made sense of germ theory and incorporated this knowledge into their practice to make it more scientific. As anaesthesia advanced and the complexity of surgery increased, so too did the range of the nurse’s skills, and an occupational gap was created for a worker with specialised knowledge and skills to care for patients, but mainly to assist surgeons during operations. Technical virtuosity was inextricably related to status for institutions as well as individuals (Rosenberg, 1987).
Control over the labour market is one of the defining characteristics of a profession and this may be achieved by giving credentials to members of the profession (Leicht & Fennell, 2001). Individually, most nurses have limited control over their work, and the role of the perioperative nurse is constantly being renegotiated by policy makers, nurses and employers. Because of this renegotiation, specialist nurses are never secure in their role. The renegotiation is played out in the contest for physical and professional space in the operating room, where medical and nursing hierarchies are often reinforced (Lingard et al., 2002).
Professional associations
The role of professional associations
Professional associations may be defined as those whose primary purposes are to protect, enhance and advance the common interests of the organisation, and their professional and non-professional members. They operate at local, state, national and international levels, and perform a number of functions, including gaining support through political lobbying, providing education, and developing standards for practice, care-givers, resources and the environment. These activities may also include establishing and enforcing a code of ethics, stimulating and promoting the professional development of practitioners, and ensuring members’ financial and general welfare (Brooks & Berman Brown, 2002). For nurses, they also provide an opportunity to develop a bigger picture of nursing and health care overall (Frank, 2005).
From a sociological perspective, professional organisations are a convenient way of mobilising practitioners’ allegiance to the profession (Freidson, 1983, 1994). The nursing profession is no exception and the role of one of the earliest Australian organisations, the Australasian Trained Nurses’ Association, which was formed in 1899, was to protect the public from ignorant and incompetent nurses, to improve and standardise general nurse training and to promote the professionalisation of trained nurses (Hamlin, 2005).
In Australia and New Zealand, more than 60 professional nursing organisations represent clinical, managerial, educational, research-based and industrial interests. Most have small membership numbers, and this proliferation of organisations can be counterproductive to the overall aims and goals of nursing. In Australia, the two most significant national nursing organisations are the Royal College of Nursing, Australia (RCNA), which is affiliated with the International Council of Nurses (ICN), and the Australian Nurses Federation (ANF), which is an industrial body. Both have state branches or chapters. Many of the state and national specialist organisations are part of a coalition, the National Nursing Organisations (NNO). Formed in 1991, the NNO acts as a lobby group and provides a forum for discussion about future directions in nursing. Importantly, recent work conducted by an NNO workgroup and funded through the National Nursing and Nursing Education Taskforce (NNO, 2006), resulted in the publication of a toolkit on governance standards for nursing and midwifery organisations. The toolkit is in the process of being implemented by several national specialist nursing organisations and should result in an improvement in the governance of them, and better accountability to members.
However, specialist organisations, such as those of interest to perioperative nurses, generally better meet the interests of their membership because they are focused largely on the specialty of interest (Hamlin, 2005). Contemporary nurses must be committed to lifelong learning in order to maintain their nursing registration and to practise safely. Although few of the specialist professional organisations offer formal education programs, they meet a need for ongoing development in the specialist nursing community by providing continuing education for their members. This is through their national, state or regional member groups, which organise study days, seminars and conferences, and via publication of journals and newsletters. These activities also provide opportunities for networking with specialist colleagues. Perioperative organisations are examined in closer detail below.
Perioperative nursing associations
As well as writing standards for practice and conducting conferences and educational meetings, most specialist nursing organisations, including perioperative associations, publish journals or newsletters and have established websites. The opportunities provided by professional associations include:
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