Perioperative nursing

According to the Association of periOperative Registered Nurses (AORN), the goal of perioperative nursing practice is “to assist patients and their designated support person(s) with achieving a level of wellness equal to or greater than that which they had before their operative or other invasive procedures.”¹ At the core of the Perioperative Patient Focused Model is the patient surrounded by the four domains of “patient safety, physiological responses, behavioral responses of the patient and support person(s), and the health system in which the perioperative care is delivered.” ¹ Perioperative care is delivered by a nurse during the preoperative, intraoperative, and postoperative phases of the patient’s surgical experience in a variety of environments, including hospital surgical suites, outpatient centers, catheterization suites, endoscopy units, radiation departments, clinics, physician offices, and other sites. The model for competency for perioperative nurses is evidenced through perioperative assessment, diagnosis, outcome identification, planning, implementation, and evaluation. “Standards, knowledge, judgment, and skills based on scientific principles”¹ serve as the solid foundation for perioperative practice. The perioperative nurse, therefore, has the requisite skills and knowledge to use the nursing process to design, coordinate, and deliver care to patients to meet their specific needs when their protective reflexes or self-care abilities are potentially compromised because of an operative or invasive procedure.¹ The care of the surgical patient continues through the transportation to the PACU, where this care is transferred to the perianesthesia nurse.

Perianesthesia nursing

According to the American Society of PeriAnesthesia Nurses position statement on perianesthesia safety, characteristics of the culture of safety are identified by activities representing communication, advocacy, competency, efficiency, timeliness, and teamwork.² When a patient’s care is safely transferred to another provider, these six characteristics are also present. Appropriate communication requires “ensuring a complete and systematic approach to hand-off processes and transfer of care and developing and using effective listening skills.”² Advocacy mandates protecting the patient from injury and implementing best practices. This requires a complete understanding of the patient’s condition and status by actively participating in the hand-off process. Competency involves clinical judgment and critical thinking as the care of the surgical patient is transferred to the perianesthesia nurse postoperatively. Patient hand-offs must be timely so that efficiently of care is encouraged. Finally, teamwork is vital so that the promise of safety can be guaranteed to the recovering patient.

According to the American Society of PeriAnesthesia Nurses, the scope of perianesthesia nursing practice involves “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.” The practice “is systematic, integrative, and holistic and involves critical thinking, clinical decision making, and inquiry. The 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 Care.”³

“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.”³

The perianesthesia nurse has a responsibility to the patient to provide quality care and safety. The American Society of PeriAnesthesia Nurses (ASPAN) Perianesthesia Standards for Ethical Practice state that the perianesthesia nurse “communicates pertinent information as the patient progresses through the continuum of perianesthesia care.”³ The nurse also has the professional responsibility to collaborate “with appropriate healthcare providers as needed to ensure optimum care.” ³

According to the ASPAN Practice Recommendation 2, “components of initial, ongoing, and discharge assessment and management” provides recommendations for the different phases of perianesthesia patient care. For example, when the patient’s care is transferred from the perioperative nurse to the perianesthesia nurse in phase 1, the integration of the information about the patient should include³:

The perioperative nurse or the anesthesia provider should remain in the PACU until the PACU nurse accepts the responsibility of the nursing care of the patient. Patient safety is compromised when a patient is transferred to the PACU and abandoned by the transporting surgical team members before the perianesthesia nurse is able to assume the responsibility for that patient’s care.

Communication between perioperative and perianesthesia nurses

Whether nurses describe their practices or roles as perioperative or perianesthesia, the basic foundation of nursing practice remains the same: high-quality care for the surgical patient. Therefore nurses who provide care during surgical procedures that involve sedation, analgesia, or anesthetics must work closely with nurses who provide care after the procedure to foster continuity, quality services, and desired patient outcomes.

Safe transportation of the surgical patient must be incorporated into the overall patient plan of care. The perioperative nurse must establish a safe environment for the transportation of the surgical patient with use of transportation safety devices, plans for special patient needs during transfer (e.g., oxygen needs), and active participation in the safe transportation of the patient. The patient’s individual needs are determined so that the patient can be transferred without injury and without alteration in the patient’s condition, such as changes in temperature, respirations, tissue perfusion, discomfort, or pain.

The transportation and transference of care of the surgical patient involves planning, collaboration, and communication between the perioperative and perianesthesia registered nurses. Communication between perioperative and perianesthesia nurses is essential for patient safety and appropriate and consistent nursing care. Both AORN and ASPAN have written recommendations on proper and accepted hand-off procedures.

AORN recommended practices for transfer of patient care information

AORN has published a recommended practice that specifically addresses the transfer of patient care information. This recommended practice provides guidance for perioperative nurses who are responsible for accurately transferring patient information to succeeding healthcare professionals, including perianesthesia nurses. AORN has also created a hand-off tool kit available to all AORN members that provides a companion resource to the recommended practices that are described as follows.¹

• Recommended practice I: “A transfer of patient information process should be developed, standardized, and based upon the best available and most current evidence.” ¹ Reliability and accuracy of information is improved when standardization is enforced to prevent communication breakdowns. Everyone on the multidisciplinary team (perioperative nurses, perianesthesia nurses, anesthesia providers, surgeons, and others) should be involved with creating a format and process upon which a standardized transfer policy can be created. Written and verbal formats are both included in a successful patient transfer. When nurses use both verbal (like face-to-face interaction) and a standardized written form, data loss is minimal.⁴ Actual transfers should be made in an environment that has minimal interruptions and extraneous sounds.

• Recommended practice II: “Patients, families, and significant others should have an active role in transfer of patient information processes whenever possible.” ¹ When families or support persons are kept informed about an impending patient transfer from surgery to PACU, anxiety is reduced and realistic expectations are promoted.

• Recommended practice III: “Personnel should receive education, training, and competency validation on effective communication skills and processes for the transfer of patient information.” ¹ Because communication problems are often the cause of sentinel events, effective communication techniques and skills are mandatory.

• Recommended practice IV: “The perioperative registered nurse should document the process for the transfer of patient information using a standardized documentation format, and the document should be recorded and retained in a manner consistent with the health care organization’s policies and procedures.” ¹ A standardized documentation tool promotes timely and accurate patient information and continuity of care.

• Recommended practice V: “Policies and procedures for standardized transfer of patient information processes should be developed, reviewed periodically, readily available in the practice setting, and reflect the rules and recommendations from regulatory and accreditation bodies.” ¹ Policies and procedures guide practices within a health care facility, should emanate from evidence-based practices, and may often be used as the basis to validate competencies of practice.

• Recommended practice VI: “A quality management program should be implemented to evaluate and monitor the processes for the transfer of patient information. Components should include patient, process, and structural (e.g., format) outcome indicators. A fundamental precept of AORN is that it is the responsibility of professional perioperative registered nurses to provide safe, high-quality nursing care to patients undergoing operative and invasive procedures.” ¹ Quality review activities help to identify communication problems, practice issues, and practices that may need improvement. Evaluation efforts of transfer activities should be ongoing to ensure patient safety and compliance with evidence-based practices.

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