AORN Journal
Volume 91, Issue 4 , Pages 519-524, April 2010

Clinical Issues—April 2010

  • Robin Chard, RN, PhD, CNOR (Perioperative Nursing Specialist)

AORN Center for Nursing Practice

Article Outline

This Month 

Assessing perioperative RN competency

Key words: perioperative nurse competency, professional standards, best practices, scope of practice.

Transfer of care communication

Key words: transfer of care, continuum of care, hand-off communication, standardized communication.

 

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Assessing perioperative RN competency 

Question 

We are preparing to evaluate the competency of the RNs working in our perioperative department. Which areas of competency should we assess, and are there different evaluation methods? How often should competency be assessed, and what are the criteria for maintaining our records?

Answer 

An integrated assessment of knowledge, skill, experience, and attitude is needed to comprehensively evaluate competent nursing care performance. Competencies may be categorized according to

■educational preparation (eg, entry level, generalist);

■core or scope of practice (eg, registered nurse, clinical nurse specialist, advanced practice nurse);

■specialty (eg, oncology, perioperative, informatics); and

■societal focus (eg, culture, age).

The need for baseline and continuous competency assessment stems from several sources, including nurse practice acts, professional standards, external regulatory agency standards, and the internal expectations of the health care organization to provide safe, quality patient care.1 According to the American Nurses Association, “Registered nurses attain knowledge and competency that reflects current nursing practice.”2(p35) In most instances, regulatory agencies define minimal standards to protect the public, and health care facilities are accountable to the public by providing an environment that supports competent practice.3

There are several methods that can be used to assess and measure competence. It is important to differentiate between baseline and continuous competency assessment and evaluation. For example, baseline or initial competency assessment occurs at the time of hire or when a graduate nurse successfully passes the National Council Licensure Examination®. Continuous competency assessment evaluates the knowledge, skills, attitudes, and behaviors that reflect specific practice setting requirements.

Competencies may be divided into topics such as

■high-risk/high-volume procedures or high-risk/low-volume procedures,

■new initiatives and implemented practices, and

■problem-prone areas (eg, medication safety).

Criteria are identified via policies, standards of practice, and guidelines as sources of information to determine competent performance.1 The particular patient population, developmental stage, and age group should be identified for each competency. For example, being competent in sterile technique is relevant to all patient populations, age groups, and developmental stages, whereas being competent in pediatric advanced life support would be relevant only to the pediatric population.

The components of competency evaluation include assessing an RN's ability to act in his or her scope of practice, an evaluation of an RN's general knowledge, and an evaluation of an RN's career competency expertise in the specified area of practice.4 Competency evaluations should be based on best practices. Evaluation methods may include but are not limited to

■knowledge assessment tests,

■skills laboratories,

■review of written or visual materials,

■verbalization of the desired skill or knowledge,

■scenario-based training or controlled simulation, and

■demonstration or direct observation.

If an individual does not successfully meet a competency, a plan of action to assist him or her in meeting that competency should be put in place.

Context is crucial in deciding which method would best evaluate the competency. For example, a recent graduate may be able to list all of the signs and symptoms of anaphylactic shock in a written test but be unable to recognize those same signs and symptoms in an actual patient. Additional methods should be used to evaluate the critical thinking needed to identify and act on these signs and symptoms in a clinical practice setting. Simulation training using a model to mimic a real-life situation is gaining acceptance as a method of competency evaluation, especially in crisis scenarios.5, 6 An advantage of simulated practice is that it provides a nonthreatening environment in which practitioners can learn from their mistakes.7

The frequency of competency assessment and evaluation in the practice setting is determined by several factors, including regulatory requirements and health care institution guidelines. The Joint Commission's human resource standards include elements of performance related to staff member competence in several health care environments, including hospitals, ambulatory and office-based surgery settings, and critical access hospitals.8 For example, the Joint Commission requires that hospital and ambulatory setting competency assessments be performed and documented at least once every three years or more frequently if it is required by the health care organization's policy or state or federal law or regulation.8 It is important to document initial as well as ongoing assessments of competency.

The ultimate goal of competent performance and evaluation is patient safety. In today's health care systems, emerging technology and evidence-based practice have influenced how competency is assessed and evaluated. Models of nursing care (eg, the Synergy Model,9 Benner's Novice to Expert Model10) are an essential component of a competency framework. Perioperative nurses must be prepared to provide a high level of expert care while practicing in a changing environment and responding to patients' changing conditions.11 To provide the highest level of safe patient care, nurses should be prepared to accept the role of lifelong learner to maintain a competent evidence-based and professional practice.

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Transfer of care communication 

Question 

There are several communication methods to use when transferring a patient. Are there any that could be applied to all perioperative phases?

Answer 

A standardized communication method provides structured, organized pieces of valuable information without reliance on memory and eliminates workarounds and shortcuts.1 One familiar standardized communication mnemonic, developed by the US Department of Defense, is “I PASS the BATON,” which stands for introduction, patient, assessment, situation, safety concerns, background, actions, timing, ownership, next.2 It is intended to be used during patient hand offs and transitions in patient care. Table 1 shows types of content related to each word in the mnemonic that can be used in each perioperative phase. Following are specific examples related to the actions, timing, ownership, and next portions of the mnemonic.

■Actions—Previous actions or interventions.
■Preoperative: The anesthesia care provider inserts an arterial line in the patient's radial artery; the circulating nurse is prompted to check the insertion site and ensure that the proper monitoring equipment is available.

■Intraoperative: The anesthesia care provider inserts an epidural catheter for pain management; the postanesthesia care unit (PACU) nurse is prompted to request and have available a patient-controlled analgesia pump.

■Postoperative: The patient is undergoing continuous bladder irrigation; the receiving RN is prompted to order supplies and prepare to record intake and output.


■Timing—Any interventions that have a level of urgency or must be administered within a certain time frame.
■Preoperative: The preoperative nurse administers antibiotics on schedule.

■Intraoperative: The circulating nurse schedules the patient to have a repeat blood glucose test.

■Postoperative: The PACU nurse administers the patient's next scheduled pain management intervention.


■Ownership—Responsible health care providers and family members.

During all three phases, the health care providers review contact information for the patient's family members in the event that the family members need notification regarding the patient's status.
■Next—Any anticipated changes or next steps in patient's care plan.
■Preoperative: The patient is at risk for hypothermia; the preoperative nurse initiates warming measures.

■Intraoperative: Depending on the patient's condition, the circulating nurse prepares to transfer the patient to the PACU or the intensive care unit.

■Postoperative: Pending laboratory results may alter the patient's care; the PACU nurse determines whether there are standing orders for intervention.


TABLE 1. Application of the I PASS the BATON1 Perioperative Transfer of Patient Care Mnemonic
PreoperativeIntraoperativePostoperative
IIntroductionRN to patientOR RN to PACU RNPACU RN to receiving RN
PPatient
■Name

■Identifiers

■Verification of correct patient, site, and procedure, including site marking


■Name

■Identifiers

■Verification of correct patient, site, and procedure


■Name

■Identifiers

■Verification of correct patient, site, and procedure

AAssessment
■Vital signs (ie, temperature, pulse, respirations, blood pressure, pain level, arterial oxygen concentration)

■Relevant cultural, educational, and age-related needs

■Risk of hypothermia, deep vein thrombosis, difficult airway, and surgical site infection


■Wound dressing

■Blood loss

■Catheter and/or drains present

■Medications, including dose and time

■IV and irrigation fluids

■Thermal interventions

■Deep vein thrombosis prophylaxis

■Patient and family information

■Presence or absence of surgical complications


■Vital signs

■Hemodynamic status

■Airway and oxygenation status

■Urine output

■Presence or absence of surgical complications

■Wound dressing

■Medications, including dose and time

■IV fluids

SSituation
■Surgical site skin preparation

■Presence of implants (eg, sensory aids, hardware, pacemaker, implanted external device)

■IV access

■Preoperative medications

■Needed equipment or supplies


■Current status

■Unanticipated events

■Needed equipment or supplies

■Presence of implants


■Current status

■Any recent changes

■Responses to surgical procedure and anesthesia

■Needed equipment or supplies

SSafety concerns
■Important laboratory values

■Allergies

■Alerts (eg, fall precautions, isolation precautions)

■Skin assessment


■Important laboratory values

■Allergies

■Alerts

■Skin assessment

■Positioning concerns


■Important laboratory values

■Allergies

■Alerts

THE
BBackground
■History and physical examination

■Comorbidities

■Code status


■Past surgical procedures

■Code status


■Past surgical procedures

■Code status

AActions
■What actions, if any, were taken or are required; provide a brief rationale


■What actions, if any, were taken or are required; provide a brief rationale


■What actions, if any, were taken or are required; provide a brief rationale

TTiming
■Level of urgency

■Prioritization of actions


■Level of urgency

■Prioritization of actions


■Level of urgency

■Prioritization of actions

OOwnershipOR RNOR RNPACU RN
NNext
■Transfer from preoperative to intraoperative area

■Next steps in the patient care plan and any anticipated changes


■Transfer from intraoperative to postoperative area

■Next steps in the patient care plan and any anticipated changes


■Transfer from postoperative area to floor, unit, or home

■Next steps in the patient care plan and any anticipated changes

PACU = postanesthesia care unit.

1US Department of Defense. Department of Defense Patient Safety Program: Healthcare Communications Toolkit to Improve Transitions in Care. Falls Church, VA: TRICARE Management Activity; 2005.

Using a prevention strategy such as a standardized communication method has the potential to improve patient safety.3 It is incumbent on all perioperative nurses to endorse and implement best practices for communicating accurate patient information.

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Learner Evaluation. Continuing Education Program 

Clinical Issues 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below.

Purpose/Goal 

To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

1.Discuss practices that could jeopardize safety in the perioperative area.Low 1. 2. 3. 4. 5. High

2.Discuss common areas of concern that relate to perioperative best practices.Low 1. 2. 3. 4. 5. High

3.Describe implementation of evidence-based practice in relation to perioperative nursing care.Low 1. 2. 3. 4. 5. High

Content 


4.To what extent did this article increase your knowledge of the subject matter?Low 1. 2. 3. 4. 5. High

5.To what extent were your individual objectives met?Low 1. 2. 3. 4. 5. High

6.Will you be able to use the information from this article in your work setting?1. Yes 2. No

7.Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.How will you change your practice? (Select all that apply)
1.I will provide education to my team regarding why change is needed.

2.I will work with management to change/implement a policy and procedure.

3.I will plan an informational meeting with physicians to seek their input and acceptance of the need for change.

4.I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice.

5.Other:


7B.If you will not change your practice as a result of reading this article, why? (Select all that apply)
1.The content of the article is not relevant to my practice.

2.I do not have enough time to teach others about the purpose of the needed change.

3.I do not have management support to make a change.

4.Other:



8.Our accrediting body requires that we verify the time you needed to complete this 1.0 continuing education contact hour (60-minute) program:

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Event: #10013; Session: #4005 Fee: Members $5, Nonmembers $10

The deadline for this program is April 30, 2013.

Each applicant who successfully completes this program will be able to print a certificate of completion.

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References 

    Assessing perioperative RN competency
  1. Arcand LL, Newmann JA. Nursing competency assessment across the continuum of care. J Contin Educ Nurs. 2005;39(6):247–254
  2. American Nurses Association. Nursing: Scope and Standards of Practice. Washington, DC: American Nurses Association; 2004;
  3. American Nurses Association. Position Statement on Professional Role Competence. Washington, DC: American Nurses Association; 2008;
  4. Allen P, Lauchner K, Bridges RA, Francis-Johnson P, McBride SG, Olivarez A. Evaluating continuing competency: a challenge for nursing. J Contin Educ Nurs. 2008;39(2):81–85
  5. Paige JT, Kozmenko V, Yang T, et al. High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care. Surgery. 2009;145(2):138–146
  6. Powers KA, Rehrig ST, Irias N, et al. Simulated laparoscopic operating room crisis: an approach to enhance the surgical team performance. Surg Endosc. 2008;22(4):885–900
  7. Notarianni MA, Curry-Lourenco K, Barham P, Palmer K. Engaging learners across generations: the progressive professional development model. J Contin Educ Nurs. 2009;40(6):261–266
  8. Human resources. HR.01.06.01. In: Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook. Oakbrook Terrace, IL: Joint Commission; 2009;https://e-dition.jcrinc.comAccessed December 22, 2009
  9. In:  Curley MA editors. Synergy: The Unique Relationship Between Nurses and Patient, The AACN Synergy Model for Patient Care. Indianapolis, IN: Sigma Theta Tau International Honor Society of Nurses; 2007;
  10. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Upper Saddle River, NJ: Prentice-Hall; 2001;
  11. Perioperative Competencies, Job Descriptions, and Evaluation Tools for Inpatient and Ambulatory Settings. Denver, CO: AORN, Inc; 2010;
    Transfer of care communication
  1. Boston-Fleischhauer C. Enhancing healthcare process design with human factors engineering and reliability science, part 1: setting the context. J Nurs Adm. 2008;38(1):27
  2. US Department of Defense. Department of Defense Patient Safety Program: Healthcare Communications Toolkit to Improve Transitions in Care. Falls Church, VA: TRICARE Management Activity; 2005;
  3. Greenberg C, Regenbogen S, Studdert D, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204(4):533–540

  indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn.org/ce. The contact hours for this article expire April 30, 2013.

 Editor's note: National Council Licensure Examination (NCLEX) is a registered trademark of the National Council of State Boards of Nursing, Inc, Chicago, IL.

 The authors of this column have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.

PII: S0001-2092(10)00069-4

doi:10.1016/j.aorn.2010.01.010

AORN Journal
Volume 91, Issue 4 , Pages 519-524, April 2010

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