CHAPTER 2 Foundations of Perioperative Patient Care Standards 29

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).
30 SECTION 1 Fundamentals of Theory and Practice

• 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 Terminology
Documentation
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
 CHAPTER 2 Foundations of Perioperative Patient Care Standards 31

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
32 SECTION 1 Fundamentals of Theory and Practice

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.
 CHAPTER 2 Foundations of Perioperative Patient Care Standards 33

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
34 SECTION 1 Fundamentals of Theory and Practice

• 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.