ACORN Standards Applied to Practice (ASAP)
When will The New ACORN Standards be released?
The Standards were launched on Saturday 18 March 2023 in Adelaide. The Standards for Individuals and Standards for Organisations are now live.
Do you have questions or feedback about the Standards?
Watch the Standards Launch
What has changed?
A lot has changed with The New ACORN Standards!
There is an exciting new format providing guidance for both clinicians and hospital administrators. The guidance set out in The New ACORN Standards allows perioperative practitioners to not only implement the standards but to be able to audit compliance, thereby demonstrating outstanding perioperative practice.
If you haven’t already, take a look at the Webinar: End of year Standards update as this goes through the structure and inclusions and exclusion within The New ACORN Standards.
Watch the Webinar: The history and future of the ACORN Standards below which looks back on the rich history of the ACORN Standards and the exciting future of these essential Standards for Perioperative Nursing in Australia, plus a sneak peek at The New ACORN Standards.
What is going to happen to the guidelines and position statements?
Currently, all ACORN position statements and guidelines can be found in the 16th edition of Standards for Perioperative Nursing in Australia. This will not be the case for the new standards. Current position statements and guidelines will be available for members on the website and through the Member Jungle app when updated.
Not all the current standards are included in the new Standards, why?
While ACORN has been working hard on updating the Standards, there are a few key standards which have not, as yet, been updated. Important work is being conducted at various state and national levels within government and professional organisations, which will impact new standards. It is essential that ACORN ensures that The New ACORN Standards contains the latest, most up-to-date and correct information. That is the reason behind pausing the release of Reprocessing re-usable medical devices, Staffing for safety, Visitors to the perioperative environment, Perioperative nurse surgeon's assistant, Loan sets and trial re-usable medical devices, New equipment and instrumentation, Professional development and Performance review. Once that work has been completed, then ACORN will be in a position to update and release the before-mentioned standards.
Standards still valid from 16th edition
Yes the can, but they need to ensure that they meet the requirements of both the Nursing and Midwifery Board of Australia Standards and ACORN’s PPSPN Standards.
The role of Post Anaesthetic Care Unit Nurse is suitable for an Enrolled Nurse provided they are working within their scope of practice, have the adequate level of post-diploma education and are either directly or indirectly supervised by a Registered Nurse who also has the appropriate postgraduate education in PACU nursing. This includes being able to fulfil all activities inherent to the PACU nurse role.
Further information can be found on pages 91 and 94:
“This role is suitable for both registered nurses (RNs) and enrolled nurses (ENs). ENs need to be able to administer medicines in this role which they can do unless they have the notation ‘Does not hold Board-approved qualification in administration of medicines’ or ‘May only practice in the area of mothercraft nursing’ on their registration. ENs administering medications must have the competence and confidence to administer medications safely, regardless of when the initial education occurred.5 When undertaking the role of PACU nurse the EN must have access at all times to a named and accessible RN for assistance and support.1 This RN must be a suitably qualified and experience PACU nurse.
4. Education and professional development
4.1 The PACU nurse shall hold current registration as an RN or EN with Australian Health Practitioner Regulation Agency (Ahpra).
4.2 RNs and ENs should undertake further education and professional development activities to develop more in-depth knowledge to competently fulfil the role of PACU nurse. Further education can be at the postgraduate and post diploma level.
4.3 The PACU nurse shall demonstrate currency and competency in:
4.3.1 basic and advanced life support 4.3.2 anaesthetic and surgical emergencies
4.3.3 mandatory competencies determined by the HSO.
4.4 The PACU nurse shall use critical reflection to identify learning needs and actively participate in internal and external education to meet those learning needs.
4.5 The PACU nurse maintains a portfolio of evidence of ongoing education.
4.6 The PACU nurse undertakes an annual appraisal to assist in identifying learning needs, professional goals, achievement of key knowledge and skills and accomplishment of education activities and/or mandatory competencies.
4.7 The PACU nurse actively participates in education activities within the perioperative unit including supervision and education of novice and inexperienced perioperative nurses.”
ACORN receives several enquiries every year about staffing within Australian perioperative units. ACORN has set standards for staffing since 1977, and each new iteration of the ACORN standards has continued to affirm the need for staff-to-patient ratios. There is a clear correlation between patient safety and appropriate staffing levels. (1) It is vital that perioperative units are staffed in line with ACORN’s Staffing for Safety Standard.
The Operating Room
Each operating theatre and/or procedure room must be staffed with a minimum of 3.5 nurses. This is regardless of the patient's acuity, procedure, surgery, or anaesthetic. Of those 3.5 nurses, each operating theatre will be allocated an anaesthetic nurse, circulating nurse and instrument nurse. The 0.5 should be a nurse who can provide meal relief and assistance to the other nursing staff in the operating theatre. (2)
Additional staff may be required in lists with a high turnaround and complex technology when large amounts of data entry/documentation are required, patients are complex or deteriorating, and simultaneous procedures are being performed. (2)
At all times and regardless of the patient load, two nurses must be allocated to PACU, one of which must be a competent and trained Registered PACU nurse. Additionally, there is to be an additional nurse allocated to PACU to manage patient flow and staff allocations. (2)
The ratios of nurses to patients:
One-to-one for an uncomplicated unconscious patient (one nurse: one patient)
Two-to-one for a complex or deteriorating patient or during arrival to PACU (two nurses: one patient)
One-to-two for patients who are stable and conscious (one nurse: two patients) (2)
Additional work time
Staffing models must allow perioperative nurses indirect patient care time to conduct other significant activities contributing to the effective, efficient, and safe running of the perioperative unit. Perioperative nurses must be given time to fulfil the various duties associated with their portfolios, such as engaging in quality and safety improvements projects, procuring and repairing instruments and equipment and rostering. Additionally, perioperative nurses need to be able to attend and provide education and engage in research. (2)
Additional Non-nursing staff
The ACORN Staffing for Safety Standard also recognises the need for non-nursing staff to support the running of the perioperative unit. These may include but are not limited to logistics and material managers and quality, risk and safety officers. (2)
- Nick N, Paula F. The effects of staffing practices on safety and quality of perioperative nursing care - an integrative review. Journal of perioperative nursing. 2021;34(1):15-22.
- Australian College of Perioperative Nurses (ACORN). Perioperative Nursing in Australia 16th ed: Volume 2 – Professional Standards. Adelaide: ACORN; 2020.
Do you have questions about accountable items? Here are answers to the most common questions.
Q1: What is an accountable item?
Accountable items are instruments and other items which, by their nature, are at risk of being retained in the patient and require additional risk management. Accountable items include, but are not limited to, instruments, sharps, absorbent items or other potentially retain able material.
The ACORN Standards p.14
Q2: Who can develop the local policies for accountable items?
When developing policies health service organisations (HSOs) should use a multidisciplinary perioperative management team. The clauses under criterion 1 from the ACORN Standards outline the role of the multidisciplinary management team and the processes and information which should be included in HSO policies.
The multidisciplinary perioperative management committee has a duty to develop a policy/guideline which:
clearly defines those types of surgery/procedures requiring the management of accountable items
clearly defines items to be included in mandatory counts
clearly identifies any local variations to the management of accountable items.
ensures the timely review of all processes.
The ACORN Standards p. 15
Q3: Do I have to conduct a mandatory count if accountable items cannot be retained due to the nature of the surgical procedure?
The clauses above allow for local variations to policies and procedures while also allowing perioperative personnel and HSOs to comply with standards. If consumable and absorbent items and instruments are identified as accountable items which are subject to a mandatory count, then unless stated in the local policy, they will need to be counted. However, exceptions can be made for particular procedures, and HSOs may clearly define in their policies which procedures are subject to mandatory counts. For example, the policy may require a minimum of four mandatory counts of all accountable items to be conducted for a caesarean section while stating that accountable items used during cataract surgery are not subject to a mandatory count.
Q4: What about instruments for procedures where instruments could not be retained such as cataract surgery?
Instruments, while being accountable items which are sometimes subject to a mandatory count, are also subject to traceability processes. So although instruments, including microscope handles used during cataract surgery, may not need to be counted as accountable items, there needs to be a clear process in place for tracking the items from point of use through to cleaning, repacking, sterilising and re-using. This must be clearly documented; and this is why there is a need for instrument tray lists and counting of instruments when they don’t necessarily meet the definition of an accountable item. Clause 3.1.3 of the ACORN ‘Reprocessing re-usable medical devices’ standard states:
… documentation [of all the activities involved in each stage of the reprocessing cycle] must be maintained for the required timeframe and include tracking and traceability of processes and re-usable medical devices from point of use, through the reprocessing cycle then back to the patient. Documenting responsibility at each stage is mandated as part of the quality cycle.
The ACORN Standards p.279
- Australian College of Perioperative Nurses Ltd (ACORN). Standards for Perioperative Nursing in Australia 16th ed: Volume 1 – Clinical Standards. Adelaide: ACORN; 2020.
This month we received an interesting enquiry that relates to the Accountable items standard.
Are we allowed to use Raytec® as packing when it comes to bleeding issues during laparoscopic procedures?
Are we allowed to open the Raytec® and allow the surgeon to use it laparoscopic to control the bleeding?
Retained surgical items (RSI) are instruments or consumables which are inadvertently left within a patient’s body cavity or surgical wound after surgery. RSI are a cause of morbidity and mortality in surgical patients worldwide.1,2
As Raytec® – or to use the generic term ‘swabs’ – are at risk of being retained during surgery they would be classed as accountable items.3 It is vital that accountable items are managed in a way which prevents inadvertent retention.
In ACORN’s Standards for Perioperative Nursing in Australia, standard statements 4 and 5 of the Accountable items standard provides guidance for the management of accountable items, in general, and swabs, in particular.
Standard statement 4:
A minimum of two (2) surgical/procedural counts shall be performed whenever accountable items are used and documented on the APD. Where a body cavity is entered, an additional count of accountable items shall be performed on closure of each cavity. This includes minimally invasive surgical procedures.3, p.16
Standard statement 5, criteria 5.2:
All absorbent accountable items that are used during surgery/procedures shall be handled in a manner that reduces the risk of the item being retained …
5.2.1 shall be x-ray detectable
5.2.2 shall never be cut
5.2.3 are not used as dressings on wounds
5.2.4 are not used for wrapping articles for sterilisation, under any circumstances
5.2.5 green gauze swabs shall only be used for anaesthetic purposes.3, p.17
The standard does not specifically cover the use of swabs during laparoscopic procedures. However, swabs can be used during any surgical procedure as long as they are managed in accordance with the Accountable items standard. If the use of swabs were to make it less likely that the surgical count is accurate and more likely that an item is inadvertently retained, then Raytec® should not be used in that manner.
To read more on accountable items please refer to ‘Accountable items’ on page 14 of volume 1 (Clinical Standards) of Standards for Perioperative Nursing in Australia.
- Weston M, Chiodo C. Preventing retained surgical items. AORN J 2022;115(6):569–75.
- Gluncic V, Lukic A, Candido K. Retained surgical items: Implications for anesthesiology practice. J Clin Anesth 2019;58:83.
- Australian College of Perioperative Nurses Ltd (ACORN). Standards for perioperative nursing in Australia 16th ed. Adelaide, South Australia: ACORN; 2020.
ACORN receives numerous queries from members about practice standards and clinical issues. This month we are sharing a question, and the answer ACORN provided, about anaesthetic nurses and the surgical count. Perhaps this will clarify a clinical issue you may have within your perioperative unit.
- Accountable items
- Staffing for safety
A perioperative unit in Victoria which conducts a lot of oral and dental surgery.
Dental technicians are allocated to the theatre in the roles of circulating and instrument assistants in lieu of enrolled or registered nurses. As a result, the anaesthetic nurse is responsible for the count. Anaesthetic nurses are conducting the first and final count after intubation and prior to extubation.
What is best practice in this situation?
There are two standards to apply in this situation, Accountable items and Staffing for safety.
The Accountable items standard states there must be two nurses responsible for the count.
During surgery and procedures two (2) nurses perform the surgical/procedural count, one of whom shall be an RN. Whenever possible, the same two nurses should be present and responsible for all counts during the surgery/procedure to ensure continuity of care.
Standards for Perioperative Nursing in Australia 16th edition, Volume 1 – Clinical Standards, page 15.
Therefore, best practice is to have two nurses responsible for the count one of whom must be a registered nurse. It is not best practice for a dental technician to be responsible for the count and an anaesthetic nurse cannot be solely responsible for conducting the count.
The Staffing for safety standard also provides guidance in this situation. This standard states:
Excluding any appropriately authorised, educated and skilled technicians, the minimum number of nursing staff per session per OR per procedure should be 3.5 nurses who collectively meet the skills and qualifications needed to fulfil the following roles:
- anaesthetic nurse – an appropriately authorised, educated and skilled anaesthetic nurse, who may be a registered nurse or an enrolled nurse under the supervision of an experienced anaesthetic registered nurse
- instrument nurse –a registered general nurse, or an enrolled nurse performing within the limits of their competence and under the direct or indirect supervision of a registered general nurse
- circulating nurse –another registered general nurse or an enrolled nurse
- a 0.5 registered general nurse to provide adequate assistance, support and relief, including meal breaks, to all nursing staff in the OR.
Standards for Perioperative Nursing in Australia 16th edition, Volume 2 – Professional Standards, page 140.
As per the Staffing for safety standard, best practice is to have three nurses allocated to the theatre in which dental procedures are taking place in addition to the dental technicians. There should also be another 0.5 nurse allocation to support and relieve staff in that theatre.
ACORN’s Standards for Perioperative Nursing in Australia provides guidance in addition to any state or territory legislation in existence. In Victoria, the Safe Patient Care Act 2015, which governs the minimum safe staffing level for hospitals covered by the Nurse and Midwives Enterprise Agreement 2012–2016, should also be reviewed to answer any queries about staffing in a perioperative unit.
As everyone is eagerly awaiting the new SSQCPE and PPSPN standards I can assure you all that I am working hard on getting these ready for release. We recently had drafts of the new Accountable items standard and Patient positioning and manual handling standard out for public comment. Thank you to those who provided feedback, your input from the clinical environment is invaluable. If you didn’t get a chance to have your say with these first two, please keep an eye on your emails or check the Open for public comment page on our website. The next SSQCPE to be sent out for public comment will be the Surgical plume standard and I look forward to your feedback and comments.
I hope everyone enjoyed Day 2 of the ACORN Virtual Conference Series held on 21st May. Thanks to those who attended my presentation ‘PATs and standards enacting change at the coal face’. I just want to reiterate a few points from my presentation for those who were not able to attend.
- ACORN’s Practice Audit Tools (PATs) can be an invaluable tool to help perioperative units identify if they are complying to standards.
- The PATs are very useful for identify the specific areas of the standards which you need to improve.
- ACORN has 12 PATs available for individuals and organisations to use to improve quality and safety within the perioperative environment.
When using the PATs, once you have conducted your audits and identified the areas which need to be improved, return to the standards and use their guidance to develop your actions for making quality changes within your perioperative unit. A lot of the time this will involve education, sometimes this may involve changing attitudes as well. It is very important to develop and maintain a culture that is positive about change and quality improvement within the perioperative setting. As a result our perioperative patients will receive the safe high-level care we are all stiving to provide.
In 2020, ACORN received 16 formal submissions requesting ACORN’s recommendations on either staffing numbers, ratios or mix. In 2021, ACORN received nine more questions seeking the same clarification. These questions accounted for 19 per cent of all questions submitted in that two-year period.
Astute readers will have noticed that the Staffing for safety standard in the current (16th) edition of Standards for Perioperative Nursing in Australia (the ACORN Standards) makes no mention or recommendations about staffing numbers, ratios or mix. The ACORN Standards does, however, include a note in the Staffing for safety standard that reads as follows.
Historically, ACORN has set minimum numbers of perioperative staff according to specific perioperative care settings and the specific phase of perioperative care. Nevertheless, ACORN receives constant enquiries regarding local variation in perioperative staffing. Because of different industrial awards, employment contracts and various local issues, it is generally not possible to determine, based on evidence, an exact figure for the number of perioperative nursing staff required. Rather, ACORN recommends that at every stage of perioperative care the number and skills of the nurses attending the patient shall be appropriate for the acuity of the patient and sufficient to ensure quality care is delivered with minimal risk to patients and staff.
During the Roadmap Project, the National Leadership Group (NLG) undertook healthy and informed discussion regarding perioperative staffing. They instructed ACORN not to include a Staffing standard in the 2022 Professional Practice Standards for Perioperative Nurses (PPSPNs). The NLG reminded ACORN that inclusion of a Staffing standard will, as it has done previously, detract from widespread jurisdictional adoption of the broader ACORN standards. The NLG also recognised that in some jurisdictions, such as Queensland, the ACORN Staffing for safety standard is relied on as a primary piece of perioperative governance.
The NLG instructed ACORN to begin, from mid-2022 onwards, exploring options for including a perioperative staffing recommendation in relevant industrial instruments. The NLG recognised that it would be desirable for ACORN to continue to produce a Staffing guideline as a stand-alone document that would then support easier adoption into industrial instruments. NLG members agreed that one of the challenges is the limited evidence that is available to support a staffing standard.
Readers of the 2022 ACORN Standards should not be surprised to find that the PPSPNs contain no recommendations specifying staffing numbers, ratios or mix. Instead, they can be reassured that, as instructed, ACORN’s leadership and Board of Directors will be giving further consideration to how to best engage with relevant national industrial and professional bodies to define and address shortages in perioperative nurse staffing. In the interim ACORN asks that members resist the urge to submit questions to ACORN regarding perioperative staffing and also stop referring to the, now rescinded, previous ACORN staffing recommendations that were published prior to the 16th edition. For more information you are encouraged and welcome to visit https://www.acorn.org.au/professionalfaqs
The purpose of this month’s ASAP is to update ACORN members and standards’ subscribers on the significant perioperative-related changes to national public policy that happened in 2021.
A core element of ACORN’s standards and guidance is that they must align with the relevant, related national public policies. These public policies include national standards such as those published by the Australian Commission on Safety and Quality in Health Care (ACSQHC), the National Health and Medical Research Council (NHMRC), the Department of Health and Standards Australia.
The end of a year is typically a time to pause and take stock of the events of the year and to plan for the coming year; hence this update on relevant public policy.
In May 2021 the ACSQHC released updated versions of the eight mandatory 2017 National Safety and Quality Health Service (NSQHS) Standards (2nd edition). Each of the eight standards apply to perioperative nursing in the public and private hospitals and day procedure services where surgery is performed.
In addition to the NSOHS Standards in 2021 the ACSQHC released the following new or revised clinical care standards:
- Acute anaphylaxis clinical care standard (new)
- Cataract clinical care standard (new)
- Delirium clinical care standard (revised)
- Management of peripheral intravenous catheters clinical care standard (new).
With the release of each new or revised clinical care standard the ACSQHC makes suites of tools and resources freely available. ACSQHC's intention is that these tools and resources will assist health service organisations with local implementation and understanding of a specific clinical standard.
In 2021, the NHMRC amended the Australian Guidelines for the Prevention and Control of Infection in Healthcare four times. The April and July amendments relate to use and management of sharps, safety engineered devices and medication vials, and cleaning and personal protective equipment as part of standard or transmission-based precautions. These updates are relevant to all Australian perioperative nurses. The ACSQHC produced various resources for their implementation in 2021 and to assist with Australia’s COVID-19 response. The resources will assist organisations to conform to the NHMRC’s guidelines.
In June 2021 the federal Department of Health updated recommendations to protect health care workers from COVID-19 infection. The updated recommendations address face and eye protection and are critical for perioperative nurses working in settings and situations where COVID-19 transmission risk is suspected or confirmed.
As a nominating organisation, ACORN participates in Standards Australia committees for HE-023 Processing of medical and surgical instruments, HE-003 Medical electrical equipment and HE-011 Safe management of sharps and health care related wastes. Participation in these committees provides ACORN with opportunities to represent its members and to influence and receive early notice of changes to some Australian Standards that relate to perioperative nursing. In early 2021, Standards Australia published AS 3825:2020 Procedures and devices for the removal, containment and disposal of scalpel blades from scalpel handles. Standards Australia has also drafted a new standard for reprocessing re-usable medical devices which will replace AS4187. ACORN members are encouraged to review and make comments on this draft during its public comment phase which runs until 24 January 2022. You will need to log in and select the DR AS 5369:2021 Reprocessing of reusable medical devices and other devices in health and non-health related facilities from a list of drafts currently open for public comment. The site also provides a user guide with information on current standards development projects, committees and more.
Please be reassured that the New ACORN Standards, which ACORN will release in May 2022, will be based on the most recent versions of all Australian health-related public policy.
In my capacity as ACORN’s Standards Manager, I strongly encourage you all to familiarise yourselves with the new and revised national standards, guidelines and their companion implementation tools. Perhaps they should be at the top of your summer holiday reading list as they are mine.
Happy holidays and many thanks to those of you contributing to, improving and conforming to the ACORN standards.
ACORN Standards Manager
For several years ACORN has grappled with finding the best way to make the ACORN Standards available to members, other Australian perioperative nurses and stakeholders in a format that maximises their usability while still retaining ACORN’s rights and intellectual property (IP).
ACORN is aware that, historically, many users have disregarded the copyright law that applies to the ACORN Standards by photocopying hard copies or creating digital copies of some or all of the standards and then sharing copies with colleagues. Some subscribers who purchased a single-user subscription have shared their log-in details with non-subscribers, which is a breach of the licence agreement they accept each time they access the Standards.
In 2020 these breaches of copyright and IP were key reasons ACORN stopped publishing hard copies of the ACORN Standards. The only way the current 16th edition can be accessed is through a secure website. There is no capacity for subscribers to print any pages of the 16th edition. Since the release of the 2020 ACORN Standards, ACORN has received feedback from several members advising that the current security constraints that protect the Standards limit their use by perioperative nurses.
In particular, subscribers highlight their inability to access the Standards when they are offline which is often the case for rural members and educators. Other subscriber concerns include the need for educators and students to have hard copy printouts from specific chapters so they can make notes specific to their learning needs. Perioperative managers also have a need to append specific sections of the ACORN standards to business case submissions. These various subscriber issues are important and highlighted the need for ACORN to re-think how it secures and manages its digital rights in relation to the ACORN Standards and associated digital implementation tools. To that end, the National Leadership Group of ACORN’s Roadmap Project recommended that ACORN, while continuing to not print hard copies, undertake a review of available licence options for subscribers to the new 2022 ACORN Standards.
ACORN intends to undertake a pilot test, early in November 2021, with a small group representing the different subscriber types to determine the merit or not of introducing some or all of the following licence options for the 2022 ACORN Standards:
- print prevention/restriction
- screenshot prevention
- expiration by date
- expiration by use
- text edit prevention
- copy prevention/restriction
- save prevention
- page-level view and print restrictions
- page-level searching.
The new ACORN Standards will be released in May 2022. It is hoped that the pilot test and user feedback received during the pilot will enable ACORN to ensure that the new ACORN Standards will be easy to use and widely adopted by the Australian perioperative nurse workforce in every setting where surgical procedures are performed.
From early April through to mid-September 2021, ACORN provided drafts of its ten new Professional Practice Standards for Perioperative Nurses (PPSPNs) to stakeholders and members for public consultation. Over that consultation period, ACORN received almost 350 public submissions.
ACORN reviewed each submission individually and, where appropriate, ACORN made suggested changes, additions and deletions to each draft standard. Where themes emerged from multiple respondents, the draft standards were reviewed comprehensively and, in some cases, substantially revised. Once all of the public comments were analysed, ACORN's Standards Manager discussed them with the Roadmap Project’s National Leadership Group (NLG) and the NLG considered re-worked versions of the standards. Subject to those considerations and NLG recommendations, the NLG approved a final version of each PPSPN. ACORN's Publications and Communications Officer is now editing each PPSPN before submission to the ACORN board for final approval. ACORN is optimistic that the board will review these drafts as one of their final activities for 2021.
ACORN's efforts to seek member and stakeholder feedback on its standards are now firmly established. The respondents provided valuable insights that may have otherwise been missed, despite the input from multiple stakeholder representatives involved in the drafting and the twelve steps followed by ACORN in developing each PPSPN.
This report permits discussion of just a few of these issues. Perhaps they are some you may have otherwise not considered. Alternatively, if you were one of the almost 350 respondents, please accept ACORN's appreciation for having raised essential issues that have resulted in a set of robust, future-proofed PPSPNs.
Differences in the conditions and roles of perioperative nursing staff in the various surgical and procedural settings was a key theme. In rural settings and in the private sector, respondents reported their roles often included substantial overlap compared to their peers in large, metropolitan, public health service organisations (HSO). There were also often differences between jurisdictional legislation and guidelines regarding specific activities performed by perioperative nurses.
These examples highlight the important need for users of ACORN's standards to understand that the ACORN standards provide broad, over-arching statements that each HSO must apply when developing and monitoring their HSO-specific policies, guidelines and expectations of nurses working in the various roles included in the new PPSPNs.
Many respondents commented on ACORN's silence in the new PPSPNs regarding educational requirements. This silence is deliberate and reflects the requirement that it is the Nursing Midwifery Board of Australia's role to set educational requirements for Australian nurses. ACORN also respects that there is likely variation in jurisdictional awards and other requirements regarding nurses' education. ACORN members are correct in assuming that, in principle, ACORN supports the post-graduate education of all perioperative nurses but has no absolute or delegated authority to set such requirements.
A third area that respondents focussed on was the requirement in each PPSPN that ‘regardless of operational reporting structure, the X nurse is always accountable to a nurse for their professional practice’. ACORN suspects that respondents may have misinterpreted the intent of this statement. For clarification ACORN recognises that operational reporting structures and relationships differ between HSOs. In some cases, nurses may report operationally to doctors or non-clinical managers. The intent of the statement is that regardless of operational structures, nurses should always be the ones who decide what is or is not professional nursing practice and whether a nursing standard is being met. Based on member feedback, it is likely that in the introductory section to the PPSPNs, ACORN will further explain the issues discussed above.
As the new PPSPNs move closer to their scheduled release in May 2022, ACORN remains grateful for the varied and vital feedback our members and stakeholders provided in the respective consultation procedures. Your views matter and because of them ACORN believes your new 2022 ACORN standards will be the best ever. Thank you.
At its most recent meeting, the National Leadership Group (NLG) of the Roadmap Project (RMP) agreed that, for the first time, the ACORN standards will be published in two separate publications. So, in May 2022, we look forward to members' responses to the first edition of the Professional Practice Standards for Perioperative Nurses (PPSPN) and, similarly, the first edition of the Standards for Safe and Quality Care in the Perioperative Environment (SSQCPE). Together, they will be the New ACORN Standards collection.
The NLG's decision to separate the professional standards from the safety and quality standards was deliberate and strategic. The NLG firmly believes that this will improve the usability of the PPSPNS and the SSQCPEs for members and subscribers. The NLG also respects the rich history of ACORN’s practice standards, published since 1977, and emphatically instructed ACORN to retain the overarching title of ‘ACORN Standards’. The choice to include ‘New’ in the title of the collection symbolises an important and progressive milestone in the life of the ACORN Standards – the point where ACORN’s members formally differentiate and articulate the clinical practices that ensure perioperative safety and quality and the professional practices that are expected from perioperative nurses.
The RMP ends on the 30 September 2021. Much work has been done in recent weeks to prepare the final drafts the ten PPSPNs and work is ongoing to incorporate the high-level evidence reports into early drafts of the nine safety and quality topics that will comprise the SSQCPEs.
ACORN eagerly awaits members' and subscribers' responses to the new structure of the PPSPNs and SSQCPEs. Feedback for the draft standards that have already been made available for public and member comment has been overwhelmingly supportive. In response to member requests ACORN is evaluating the possibility of adding a cross reference to the PPSPNs and SSQCPE which would enable users to quickly locate elements of interest across the entire collection. In addition, ACORN staff are also considering a new layout and revised features. These may include a map of the changes, revised crosswalks of how the PPSPNs and SSQCPEs relate to the National Safety and Quality Health Service Standards, the Nursing and Midwifery Board of Australia Registration Standards and the Standards Australia standards that apply to the perioperative setting.
Development of the ACORN standards is a massive, complex, taxing but rewarding multi-year project. It requires the efforts of many, most of whom contribute voluntarily. As the sun sets on the RMP, ACORN remains so very grateful to all who have helped shape the 2022 New ACORN Standards. They will look and be different. The ACORN Standards are, and always will be, ACORN members’ standards and it is ACORN's hope that the New ACORN Standards will be embraced by perioperative nurses all over Australia.
So far in 2021, about a quarter of all clinical questions posed to ACORN relate to the surgical count. Most often questions are about who can be involved, who must be involved and what items should be included.
The primary purpose of ACORN's standard ‘Accountable items’ is to prevent unintentional retention of surgical instruments and equipment. Retained surgical items (RSI) is a serious and unresolved global preventable complication of surgery.
Domestically, this is a significant problem and Australia's 2012 to 2013 rate for a foreign body left in during procedure was 8.6 per 100 000 separations1. This was higher than the Organisation for Economic Co-operation and Development (OECD) average at the time which was 5.7 for the comparison year. Australian state and territory reports from 2012 to 20182 indicate that every year in Australian there are between 22 and 34 cases of instruments or other material retained after surgery requiring re-operation or further surgical procedure.
In 2019 Cockburn, Davis and Osborne published a seminal paper detailing how Australian cases of unintentionally retained surgical items have historically been dealt with legally3. Cockburn's work highlights the small proportion of RSIs that are resolved through the judicial system. The assertion being that most RSI cases are resolved prior to litigation. This accounts for the ‘disappearing’ nature of RSI outcomes. Most importantly the authors emphasise the current shared responsibility and accountability of the operating team, surgeons and nurses. They also highlight the current inadequacy of counting and documentation of accountable items in preventing RSIs3. This assertion is supported by another seminal Australian paper by Hibbert and colleagues4 in which the authors assert that count discrepancies are not fully protective with one study suggesting that counts only detected 77 per cent of RSIs4. Additionally, Hibbert reports that if a count is incorrect the risk of an RSI increases 20-fold4.
The count-related queries posed to ACORN in the last two years almost always seek clarification on who has responsibility for the count. Often the asker is also seeking ACORN's position on minor deviations from the process detailed in the current Accountable items standard, particularly alternative staffing requirements or possible exclusions of specific items from the count process. In every response ACORN reiterates the requirements of the standard. ACORN's responses are based on the premise that perioperative nurses should never make decisions that increases the risk of RSI or reduce the ability of any perioperative team member to provide safe, high quality care. Within ACORN's response and in the Accountable items standard ACORN notes that where contradictory recommendations exist in additional national or jurisdictional directives, including legislation, public policy or guidelines, those recommendations take precedence. ACORN’s responses routinely include the caveat ‘the ACORN Standards for Perioperative Nursing in Australia are voluntary documents that set out specifications, procedures and guidelines that aim to ensure products, services and systems used in perioperative nursing are safe, consistent and reliable’.
Given the ongoing risk of RSI in Australia ACORN's recommendation is that all perioperative nurses familiarise themselves with ACORN's Accountable items standard, participate in a gap-analysis to determine if local changes are needed and periodically monitor their own and their colleagues' practice in relation to accountable items and RSI prevention. We also recommend the papers published by Cockburn3 and Hibbert4.
More information is also available at Clinical FAQs under the Accountable items option.
- Australian institute of Health and Welfare (AIHW). OECD health-care quality indicators for Australia 2015: 6.1 Foreign body left in during procedure rate [Internet]. Canberra AIHW; 2016 [updated 2017 October 5, cited 2021 June 21]. Available from: https://www.aihw.gov.au/reports/international-comparisons/oecd-health-care-quality-indicators-2015/contents/table-of-contents.
- Australian Institute of Health and Welfare (AIHW). Health system: Safety, Sentinel events, Retained instruments or other material after surgery requiring re-operation or further surgical procedure [Internet]. Canberra AIHW; [updated 2021 March 25, cited 2021 June 21]. Available from: https://www.aihw.gov.au/reports-data/australias-health-performance/australias-health-performance-framework/national/all-australia/safety/safety/2_2_3?tab=2.2.3|Table&filter=2.2.3|2|Number&filter=2.2.3|4|2017–18&filter=2.2.3|1|Retained%20instruments%20or%20other%20material%20after%20surgery%20requiring%20re-operation%20or%20further%20surgical%20procedure.
- Cockburn T, Davis J, Osborne S. Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. J Law Med 2019;26(4):841–848.
- Hibbert PD, Thomas MJW, Deakin A, Runciman WB, Carson-Stevens A, Braithwaite J. A qualitative content analysis of retained surgical items: Learning from root cause analysis investigations. Int J Qual Health Care 2020;32(3):184–199.
The Roadmap Project’s Clinical Workstream Team (WST) has extensively reviewed the contents of Volume 1 of the current 2020 ACORN Standards with the aim of making future ACORN clinical standards simple, easily located and narrowly focussed.
The Clinical WST members provide a broad base and after thorough consideration and robust discussion, ten topics were identified for inclusion:
- Accountable items
- Chlorhexidine and latex sensitivity
- Electrosurgical equipment
- Fire safety specific to the perioperative setting
- Infection prevention – this will include all of the following individual standards combined into a single standard
- Cleaning and maintaining the perioperative environment
- Disposal of surgically removed human tissue and explanted items
- Perioperative attire
- Preoperative patient skin antisepsis
- Sharps and preventing sharps-related injury
- Surgical hand antisepsis, gowning and gloving
- Laser safety
- Patient positioning and manual handling
- Specimen identification, collection and handling
- Surgical plume
- Surgical safety
In December 2020, the Clinical WST made its recommendations to the Roadmap Project’s National Leadership Group (NLG). The NLG carefully considered and discussed the WST's recommendations for clinical standard topics and how those standards relate to other primary safety and quality standards. In March 2021, the NLG accepted the ten topics outlined above to form the Standards for Safe and Quality Care in the Perioperative Environment (SSQCPE) in the 2022 ACORN Standards.
The Clinical WST have diligently met their intent that ACORN not duplicate, contradict or ignore higher-ordered public policy. In their review, the WST considered the current and future need for each existing clinical standard. They also identified what alternative pieces of public policy relate to the topics included in each existing 2020 clinical ACORN standard. Particularly, they took note of the authority and remit of the organisations and agencies authoring or promulgating these alternative directives. The WST's goal was to appropriately rationalise and substantiate the need for ACORN to retain, or not retain, specific clinical standards. The WST recognised that some clinical standards were now superfluous or redundant and have recommended ACORN retire those standards.
The standards, guidelines and position statements in Volume 1: Clinical Standards of the 16th edition of the ACORN Standards remain current until the release of the 2022 ACORN Standards. ACORN is reviewing the topics not carrying over to the 2022 edition, which will only contain standards, and will work with its leadership and members to determine which of those superfluous topics will be reviewed and republished separately as a guideline or position statement and which will be retired.
Redeveloping ACORN's clinical standards is a complex and fast-paced process. Please keep an eye on this page, the Roadmap Project webpage and ACORN social media accounts for updates and opportunities to review and contribute to these ten standards
Recently ACORN launched a public comment process to gain feedback on drafts of new and revised ACORN standards. The first standard open for review is the Professional Practice Standards for Perioperative Nurses (PPSPN) - Registered Nurse draft. Feedback can be submitted on this draft until midnight on 4 May 2021 after which ACORN will consider, review and respond to every piece of feedback. ACORN will use the feedback to produce a final draft which will then be progressed for approval and release.
ACORN developed this new public comment process in response to a report commissioned by the ACORN board in 2019. The report detailed de-identified stakeholder consultation responses about the pros and cons of ACORN’s standard-setting process as it was then. Some respondents expressed concern that the ACORN standard-setting process was not sufficiently transparent because it was largely conducted ‘in-house.’ The report also stated that
‘Several respondents said that the ACORN Standards would be more widely accepted if the College consulted more widely in their development. While the standard-setting process includes a “review draft” process for internal and external stakeholders, several respondents said that ACORN does not systematically expose its draft standards to members, related nursing and medical colleges or health care consumers. They say that feedback should be actively sought and incorporated into the Standards before they are published if they are to be accepted and observed by all operating theatre personnel.’
ACORN's overall response to the report included the establishment of the Roadmap Project (RMP) and major review, redesign and overhaul of the ACORN Standards and each aspect and process of their development and release.
Public comment on draft standards
As part of the RMP's priority work ACORN has recently launched an online review system whereby ACORN members, subscribers and stakeholders can access and provide feedback on pre-publication drafts of all future ACORN Standards.
ACORN's preferred method for receiving feedback on draft standards is by online survey. The survey for the draft currently open for comment is taking respondents around eight minutes to complete. The survey contains questions about the relevant consultation documents that are available to be downloaded on the ACORN website.
ACORN is unable to take written feedback into consideration as it is difficult to analyse and requires resources beyond those which ACORN has. If feedback includes a suggested change or alternate or additional recommendations ACORN requests that alternate phrasing is suggested and evidence cited to support each suggested change. A rationale for each suggestion is also welcomed. Suggestions that do not include alternate phrasing, a rationale or a full cited reference will not be considered. Comments received after the published closing date will not be considered in the final review.
ACORN looks forward to feedback on the feedback system and of course on each standard posted between now and the next scheduled release of the ACORN Standards in May 2022. We hope that this new system, along with the future initiatives from the RMP, will serve ACORN members and subscribers well and to their satisfaction.
Recently ACORN received an enquiry requesting additional insights regarding changes made by Standards Australia to AS/NZS 3825:1998 Procedures and devices for the removal and disposal of scalpel blades from scalpel handles. In late 2020, Standards Australia updated and republished AS/NZS 3825:1998 as AS 3825:2020 Procedures and devices for the removal, containment and disposal of scalpel blades from scalpel handles. The enquiry recognised that ACORN was a Nominating Organisation with a representative involved in reviewing the AS 3825 standard.
Standards Australia standards are developed and revised by Technical Committees (TCs) made up of representatives from organisations that represent the views of a particular interest group. Organisations that nominate a representative for a TC are referred to as Nominating Organisations (NOs). ACORN is a valued NO. It regularly provides representatives sourced from ACORN’s expert members to work with Standards Australia and representatives from other NOs as members of specific TCs. Under Standards Australia’s governance for standards development, all NO representatives are obligated to provide periodic updates to their respective NO. These updates ensure the NO representatives contribute from a broad base rather than from a personal or single facility perspective. This is important for ACORN as our members represent a diverse array of practice settings and perioperative roles.
Additionally, Standards Australia always has a period of public comment on every draft standard they develop. While ACORN acknowledges that its representative to a TC has an obligation to draw ACORN’s attention to pending changes, it is ultimately up to organisations such as ACORN and the local state and territory perioperative nursing associations (local associations or LAs) to keep abreast of Standards Australia’s work. Therefore, ACORN keeps a watching brief on publicly available information and updates published by Standards Australia. Further detail about Standards Australia’s public comments process and their governance structure around standards development is accessible on the Standards Australia website.
When considering new or updated standards from Standards Australia, one must also appreciate that ACORN is only one of many organisations represented on any TC. The Standards Australia drafting process always requires consensus before finalising any drafts. That consensus does not have to be unanimous; instead, it may be by majority. While the workings of committees are not in the public domain, it is not unreasonable to suppose that sometimes NOs hold minority views different to the majority of other stakeholders.
ACORN members seeking to understand and accept the recommendations included in various Standards Australia standards should find that the recommendations are generally consistent with the principles in other high-level public policies and directives e.g. the current Australian Guidelines for the Prevention and Control of Infection and the National Safety and Quality Health Service Standards. Standards Australia routinely seeks alignment with these and other equivalently powered directives.
Similarly, ACORN seeks to align ACORN standards with Australian and international standards. The two volumes of the current 16th edition of Standards for Perioperative Nursing in Australia (the ACORN Standards) both include a table of Australian and international standards cited within the respective volumes. ACORN included these tables for two reasons. Firstly, their inclusion reassures readers that ACORN has thoroughly interrogated public policy and directives related to each individual ACORN standard. Secondly, the details included in the table assist readers who are keen to review the existing Australian and international standards that have been cited.
ACORN is aware of only one downside of citing Australian and international standards – the need to review and revise ACORN standards in response to any changes or updates to the Australian and international standards in the period between each current and subsequent edition of the ACORN Standards. Such changes almost always require ACORN to make minor amendments to its standards and this is much more easily done on electronic, rather than hard copy, editions of the ACORN Standards.
It is hoped that this brief update clarifies how ACORN members are represented in Standards Australia standard-setting and how ACORN evaluates and incorporates specific Standards Australia standards into the ACORN Standards.
Volume 1 of the current 16th edition of Standards for Perioperative Nursing in Australia (the ACORN Standards) includes recommendations on a wide range of clinical practices. Historically each set of clinical practice recommendations was classified and structured as either a standard, guideline or position statement. Collectively those standards, guidelines and position statements formed approximately half of the entire suite of ACORN Standards. The next edition of the ACORN Standards will only include standards. Therefore an essential part of ACORN’s Roadmap Project currently being undertaken by the Clinical Workstream Team (WST) is making recommendations about which of the 16th edition's current clinical topics will remain as revised, updated standards.
ACORN will deal with the clinical topics not being retained in one of three ways. They may be reclassified as an ACORN guideline, reclassified as an ACORN position statement or rescinded. All reclassified topics will be subject to revision and updating before ACORN progressively republishes them. They will sit separate from the ACORN Standards and serve an entirely different purpose. ACORN will communicate that purpose as each guideline or position statement is published.
ACORN’s Roadmap Project has delegated responsibility for making recommendations about which clinical topics ACORN must include in the next edition of the ACORN Standards to the Clinical WST. To do this task well and thoroughly, team members have considered how they and their colleagues routinely use the ACORN Standards and, through a series of meetings, surveys, and email discussions the team has recommended improvements ACORN could make to increase the useability of future ACORN Standards.
The Clinical WST identified two key issues early in their discussion:
- the high degree of repetition, and possibly even contradiction, in the overall content of the Standards
- the absence of an index in the previous and current edition of the ACORN Standards.
To address the first issue the team has now provided a list of standards it recommends be revised and published in the next edition of the ACORN Standards. As well, the team has recommended the preferred future for the residual current standards, guidelines and position statements. Pending approval by the Roadmap Project’s National Leadership Group (NLG), some will be revised and retained as standards while others will be reclassified, revised and republished as guidelines or position statements. The team recognised that some topics, currently included in the ACORN Standards, are covered elsewhere as standards published by another reputable agency or organisation and has recommended that ACORN rescinds standards, guidelines and position statements about these topics.
In relation to the second issue, the team identified that perioperative staff may need to immediately know or confirm ACORN's recommendations contained in a specific standard; therefore, the team strongly recommended that ACORN consider developing an index for the next version of the ACORN Standards. As this brief report goes to press, ACORN is exploring possible options for integrating an index.
ACORN continues to seek ways to improve and simplify the ACORN Standards. ACORN remains committed to providing Australian perioperative nurses and organisations with standards that are clear, free from repetition or contradiction and reflective of their evolution over the last four decades. ACORN can only achieve these goals by the direct involvement of committed members and experts such as the members of the Clinical WST and the NLG. Together with the NLG, the Clinical WST and ACORN look forward to sharing more details about the next edition closer to its publication. In the interim, please keep up to date with the standards via ACORN's Standards webpage.
Recently, a member asked for ACORN's advice about the requirements for consent with paediatric patients. Specifically, when a child comes to theatre does the parent that signed the consent form have to be present? Or can it be the other parent who may not have consented for the surgery?
A great place to start to learn more about consent is ‘Informed consent in health care’ a fact sheet for clinicians published by the Australian Commission on Safety and Quality in Health care (ACSQHC). The fact sheet highlights:
- there is case law in Australia about informed consent
- each state and territory also has guardianship and/or medical treatment legislation about capacity and consent
- this legislation is different in each state and territory, and can be complex.
Fact sheet: Informed consent in health care, ACQSHC 2020, p.2
ACORN encourages all members practicing in Australia to refer to the Commission's fact sheet which is available at: https://www.safetyandquality.gov.au/publications-and-resources/resource-library/informed-consent-fact-sheet-clinicians.
ACORN last published competency standards in 2014 as part of the ACORN Standards for Perioperative Nursing. Following substantial changes in national recommendations from the Nursing and Midwifery Board of Australia (NMBA), the ACORN Board of Directors agreed that ACORN should no longer publish competency standards. The subsequent 2016, 2018 and 2020 editions of Standards for Perioperative Nursing in Australia (the ACORN Standards) do not include competency standards. This, and the lack of competencies published on ACORN’s website, signal that ACORN has rescinded the 2014 ACORN competency standards. ACORN recommends that they not be used in terms of contemporary practice.
It is worth noting, as it had a direct impact on the relevance of ACORN’s competency standards, that the NMBA replaced the National competency standards for the registered nurse (2010) and the National competency standards for the enrolled nurse (2002) with Registered nurse standards for practice (2016) and Enrolled nurse standards for practice (2016). The NMBA also published the Nurse practitioner standards for practice in 2014. See www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx.
The NMBA has openly removed the term 'competency' from its standards because ‘Research suggested that confusion existed between the use of the term “competency-based assessment” in the vocational education and training (VET) sector and use of the term “competency” in other settings.’
For their respective nursing registration – enrolled nurse (EN), registered nurse (RN) or nurse practitioner (NP) – the NMBA standards for practice are the core practice standards that provide the framework for assessing nursing practice. They reflect the respective roles ‘in the current health environment, remaining broad and principle-based, to ensure they are sufficiently dynamic and applicable for a range of practice settings’.
The 2020 ACORN Standards stipulate that surgical hand scrub and alcohol-based surgical hand rub should not be used sequentially. Of all the recommendations included in the ACORN Clinical Standards this issue is one of the most commonly questioned. It's time we made it simpler to implement so please read on to learn more about this recommendation, where it comes from, what it means and how you can follow it clinically.
ACORN does not make recommendations regarding specific products as we appreciate that different jurisdictions and organisations have various procurement procedures in place including tenders with specific manufacturers and distributors. Important issues such as staff tolerance to the active ingredients in a solution used for surgical hand antisepsis should also influence what's used. Organisations should take care in selecting hand hygiene solutions as sensitivities may develop. Clinicians should also follow all manufacturer instructions for use (IFU) and only use the solution how and for what it was intended.
Both iodine and Chlorhexidine (CHG) are excellent antiseptics, the main benefit for CHG is its persistence. CHG should be in combination with alcohol so that both immediate kill is achieved (by the alcohol) and persistence is attained (by the CHG).
Members of the surgical team should perform a surgical hand scrub using an antiseptic surgical solution (surgical hand scrub) before the first and every subsequent surgical procedure of the day1.
Traditionally, surgical team members have performed a presurgical hand preparation (‘scrub’) using a surgical hand preparation and water. Recent formulations of waterless, alcohol-based antiseptic hand rub, when used according to IFUs, no longer require the preliminary scrub using a surgical hand preparation and water. The waterless, alcohol-based antiseptic hand rub alone should be sufficient to eliminate transient flora and reduce resident skin flora on the user's hands.
The 2020 ACORN Standards stipulate that surgical hand scrub and alcohol-based surgical hand rub should not be used sequentially as using surgical hand scrub and washing may result in moist hands and moisture may dilute the antimicrobial properties of the surgical hand rub. Surgical hand scrub may also enhance skin irritation and dryness. This recommendation is based on World Health Organization guidelines2 which cite a seminal paper by Kampf3.
Applying this recommendation requires a necessary change in long-held practice. Perioperative nursing often involves following highly ritualised behaviours and so ACORN appreciates this change may be difficult. ACORN also recognises that differences in recommendations, procurement and supply may exist and these need to be considered by perioperative staff at a local decision-making level. Also staff sensitivities; compatibility of hand hygiene solutions with other protections, such as surgical gloves; pricing; safety and IFUs also rightly influence purchasing decisions and practice.
ACORN encourages perioperative staff to engage with hand hygiene suppliers regarding IFUs, benefits, limitations and educational materials associated with their specific hand hygiene formulations. Also please refer to ACORN standard ‘Surgical hand antisepsis’, including its glossary of important terms.
- National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare [Internet]. Canberra: NHMRC; 2019 [cited 2020 March 24]. Available from: https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019.
- World Health Organization. Guidelines on hand hygiene in health care. First global patient safety challenge: Clean care is safe care. Geneva: WHO; 2009.
- G Kampf, H Löffler. Dermatological aspects of a successful introduction and continuation of alcohol-based hand rubs for hygienic hand disinfection. J Hosp Infect 2003;55(1):1–7. DOI: 10.1016/S0195-6701(03)00223-8.