Standards FAQs

ACORN Standards subscriptions are intended only for the use of the individual or organisation subscriber. Any sharing of ACORN Standards log in information or content is a violation of ACORN's licence with you or your organisation. 

Can I still use previous versions of the ACORN Standards?

The ACORN Standards 2026 supersedes any previous versions of the ACORN Standards.

The only exceptions are the standards listed below, which are yet to be updated and included in The ACORN Standards 2026 edition:

• Loan sets and trial re-usable medical devices
• New equipment and instrumentation
• Planning and design of the perioperative environment
• Reprocessing re-usable medical devices
• Staffing for safety

The standards above, which are still valid from the 16^th edition, can be found at https://www.acorn.org.au/acorn-standards-16th-edition and, for ACORN members, fellows and affiliate members, in the Member Jungle app.

The content included in each new edition of the ACORN Standards is determined through a rigorous and collaborative governance process. Dedicated workstream teams lead the review and development of individual standards, drawing on current evidence, clinical practice developments, and stakeholder feedback. Their work is supported and overseen by the ACORN Research Committee, which ensures the standards remain evidence-informed, contemporary, and aligned with professional practice expectations. Subject matter experts from across perioperative nursing and related disciplines are engaged throughout the process to provide specialist knowledge and practical insight.

 

The Editor-in-Chief and Managing Editor coordinate the editorial development, consistency, and quality assurance of the publication, ensuring all content meets ACORN’s professional and publication standards. Once the review and editorial processes are complete, the final edition of the ACORN Standards is formally approved by the ACORN Board of Directors prior to publication.

The ACORN Standards can be accessed via the ACORN website or through organisational IP authentication, providing a streamlined and seamless user experience. Access is no longer provided through the Member Jungle app.

 

As an online resource, the ACORN Standards are designed to be searched by topic rather than read sequentially as a traditional publication. To search the Standards, select the search icon located in the upper left-hand corner of any page and enter relevant keywords (for example, ‘gloves’). Search results can also be refined by page or case sensitivity.

Users may also browse individual standards by opening the sidebar menu and selecting a standard from the alphabetical listing within each volume. However, using the search function is recommended, as the optimised search tool quickly identifies all relevant content across the Standards, helping ensure no related information is overlooked.

 

Recommended technical requirements to read the ACORN Standards

The ACORN Standards require an internet connection and one of the following web browsers:

• Microsoft Internet Explorer 8.0 or higher
• Mozilla Firefox
• Google Chrome
• Apple Safari

The ACORN Standards 2026 are also compatible with Android and iOS smartphones and mobile devices.

The 2026 edition of the ACORN Standards is no longer separated into individual and organisational volumes. Instead, the Standards are published in two comprehensive volumes:

• Standards for Safe and Quality Care in the Perioperative Environment (SSQCPE)
• Professional Practice Standards for Perioperative Nurses (PPSPN).

 

Access to The ACORN Standards 2026 is included as a member benefit through financial membership with a local state or territory perioperative association, ACORN affiliate membership, or ACORN fellowship. No separate individual subscription purchase is required.

Access for organisations is available through a 12-month organisational subscription, with pricing options based on the number of users and organisational requirements.

Government organisations and universities should contact ACORN directly at [email protected] to discuss pricing and arrange organisational access to the Standards.

 

The ACORN members login page information provides details to reset your ACORN username and/or password. Please follow the steps exactly as written.

Click the 'Forgot your password' or 'Forgot your username' link, whichever applies. You will be prompted to provide additional unique information including the email address associated with your ACORN membership account. You will receive an email containing instructions on resetting your password or username.

 

Help! I’m still having trouble logging in

First, we recommend clearing your browser’s cookies, saved passwords, and data from automatically filled forms, then trying to log in again.

If you still have login issues, please email  [email protected]

One month prior to when your subscription is set to expire, you should receive a renewal notice by email from ACORN. Please respond to renew your subscription. If you have not renewed, ACORN will send a further reminder one week prior to your subscription's expiration date.

If you have questions about renewal, please email [email protected]

Yes, you can print up to 5 pages of the ACORN Standards. Each printed page will be watermarked with IP address, date and time for version control.

Please note: The re-use or distribution of the ACORN Standards or content without the express written permission of ACORN is a violation of Australian copyright law. Sharing of the ACORN Standards e-subscriptions is not authorised.

All content within the ACORN Standards, including text, tables and figures, is protected by Australian copyright law and remains the copyright of the Australian College of Perioperative Nurses Ltd unless otherwise stated. Re-use of any material beyond personal study, education, or other uses permitted under the Copyright Act 1968 requires prior written permission from ACORN. Permission requests are assessed on a case-by-case basis.

To request permission to reproduce or use content from the ACORN Standards, please complete the Standards feedback form and provide details of the intended use.

Recommended citation for ‘Standards for safe and quality care in the perioperative environment’ volume:

Australian College of Perioperative Nurses Ltd (ACORN). The ACORN Standards: Standards for safe and quality care in the perioperative environment (SSQCPE) – 2026. Adelaide: ACORN; 2026.

 

Recommended citation for ‘Professional practice standards for perioperative nurses’ volume:

Australian College of Perioperative Nurses Ltd (ACORN). The ACORN Standards: Professional practice standards for perioperative nurses (PPSPN) – 2026. Adelaide: ACORN; 2026.

I think I’ve found an error in the ACORN Standards. What should I do?

If you notice an inaccuracy in the ACORN Standards, we would be grateful if you would share it with us.

Submit your standards feedback

 

I have ideas for improving the ACORN Standards. Whom do I contact?

We would love to hear your ideas and innovations! 

Submit your standards idea

 

I want to provide feedback about the ASIP tool.

To provide feedback on the new ACORN Standards Implementation Planner (ASIP) tool, please click on the button below.

ASIP tool feedback

No FAQs relating to this role at this time.

No FAQs relating to this role at this time.

Can a NP become a PNSA without any further training?

No. A NP cannot automatically assume the role of a PNSA without meeting the specific requirements of that role.

Although NPs are endorsed under the Nursing and Midwifery Board of Australia as advanced practice nurses with an expanded and autonomous scope of practice, the PNSA role is a specialised perioperative competency-based role that is defined by procedure-specific skills, credentialing processes, and local clinical governance requirements. These requirements are distinct from NP endorsement and are not transferable by virtue of NP status alone.

To practise as a PNSA, a clinician must demonstrate competence in perioperative surgical assistance within a defined scope of practice, supported by relevant perioperative experience, structured education or training, supervised practice, and formal credentialing in accordance with organisational and ACORN expectations. This ensures that the practitioner is specifically prepared for the technical, procedural, and team-based demands of intraoperative surgical assistance.

While an NP may have highly developed clinical knowledge and advanced assessment and decision-making skills, these do not replace the need for PNSA-specific competency development, particularly in relation to operative assistance, sterile field practice, and surgeon collaboration within the perioperative environment.

In summary, NP endorsement and PNSA credentialing represent different advanced practice pathways. An NP wishing to work as a PNSA must complete the required perioperative-specific training, competency assessment, and credentialing process before undertaking the role.

 Can ENs work as an anaesthesia nurse?

Yes, provided they meet the requirements of both the standards set out by the Nursing and Midwifery Board of Australia Standards, ACORN (PPSPNs) and ANZCA PS08 Assistant to the anaesthetist's core competencies.

‘This role may be undertaken by both registered nurses (RNs) and enrolled nurses (ENs).

ENs appointed to this role must be authorised to administer medicines in accordance with their registration status. ENs are permitted to administer medicines unless their registration carries a notation stating either:

• ‘Does not hold Board-approved qualification in administration of medicines’

or

• ‘May only practise in the area of mothercraft nursing’.

ENs who administer medicines must demonstrate the competence and confidence required to do so safely, regardless of when they obtained their medication administration qualification. A named and accessible RN with current anaesthesia competency must be available at all times when an EN is administering medications in this role.

All ENs must practise under the supervision of a suitably qualified anaesthesia RN, in accordance with the NMBA Enrolled nurse standards for practice and supervision requirements.’

 

Further information can be found in the PPSPNs regarding governance, overview of activities, knowledge and skills, education and professional development, delegation and supervision, and professional accountability.

It is important to consult the HSO policies and procedures around the enrolled nurse’s scope of practice and medication handling and administration for local variances, requirements or limitations.

 

Anaesthesia nurses and the surgical count

(See Management of accountable items section of FAQ page)

 

Is the insertion of a laryngeal mask airway (LMA) within an anaesthesia nurse's scope?

It is not a routine task, but it may be permitted with appropriate education, demonstrated competency, and formal HSO authorisation under supervision.

No FAQs relating to this role at this time.

What roles are included under the umbrella term ‘Day Procedure Service (DPS) nurse’, and why?

The term Day Procedure Service (DPS) nurse is an umbrella descriptor that encompasses nursing care delivered across the full perioperative journey for patients undergoing day surgery or same-day admission procedures. It reflects the fact that, depending on the health service organisation (HSO) model, staffing structure, and patient flow, nurses may work across one or more phases of care rather than in a single fixed role.

Under this umbrella term, DPS nursing practice may include responsibilities aligned with several perioperative phases: pre-admission, admission, post-anaesthesia care (Stage 2 recovery), and discharge and follow-up. Pre-admission activities may include health screening, risk assessment, patient education, and procedural preparation. On admission, the DPS nurse undertakes clinical assessment, documentation review, and confirmation of the care plan. In Stage 2 recovery, the focus is on monitoring recovery, managing symptoms such as pain and nausea, assessing return to baseline cognition, and determining discharge readiness. The role may also extend to post-discharge follow-up to support continuity of care and early identification of complications.

This broad scope exists because DPS services are designed to be flexible and patient-flow driven. Nurses may move between phases within a shift or have clearly defined phase-specific responsibilities depending on local service design and skill mix. Where practice is confined to a specific perioperative phase, nurses are expected to refer to the relevant ACORN PPSPN standards (e.g. anaesthesia nurse, circulating and instrument nurse, or PACU nurse standards).

The DPS nurse role may be undertaken by both registered nurses (RNs) and enrolled nurses (ENs), with practice requirements, supervision, and medication administration responsibilities determined by NMBA standards and organisational governance frameworks.

Can instrument nurses assist with fundal pressure during a caesarean section?

This appears to be above the role of the instrument nurse’s standard practice and would therefore require additional education and training in surgical assistance (e.g., Perioperative Nurse Surgeon’s Assistant). Within the intraoperative technique section of the RANZCOG Clinical Guidance Statement attached (page 7) it states that the pressure exerted is to be done by the surgical assistant or, accoucheur.

 

Can an instrument nurse fire a surgical stapler?

Typically, no. Assisting with surgical interventions like activating staplers is the role of a surgeon or a Perioperative Nurse Surgeon’s Assistant (PNSA).

Do you need a post graduate degree to be a perioperative nurse educator?

While holding a postgraduate degree is not a mandatory requirement for a perioperative nurse educator in Australia, it is strongly recommended to pursue postgraduate studies in both perioperative nursing and education to enhance effectiveness in the educator role. Several tertiary education institutions offer postgraduate programs in these fields, and it is advisable for perioperative nurse educators to undertake such qualifications.

It is also important to note that, in certain health service organisations, the position description for a perioperative nurse educator may specify the requirement of postgraduate qualifications to meet the role's responsibilities.

How does the perioperative manager support compliance with ACORN Standards?

The manager ensures system-level implementation of the ACORN Standards through policy development, staff education, audit feedback loops and integration of standards into daily clinical practice and governance structures. Inclusion of ACORN Standards in staff meeting agenda’s, quality improvement initiatives and annual education plan aligns with initial and ongoing education and training criteria incorporated within the ACORN Standards.

Why are there different pathways in the Standard for PNSAs?

The ACORN Standards recognise multiple pathways to becoming a PNSA to reflect both the historical development of the role and the evolution of formal education programs. The tertiary PNSA program (currently) delivered through La Trobe University represents a relatively recent advancement in the formalisation of surgical assistant education. However, the PNSA role has existed in practice well before the introduction of this higher education qualification, with many experienced perioperative nurses having undertaken surgical assistance roles through workplace-based training, mentorship, and competency development.

ACORN takes an inclusive and pragmatic approach within its Standards to ensure that nurses who were practising as PNSAs prior to the availability of formal tertiary qualifications are not disadvantaged or excluded. This acknowledges the legitimacy of prior learning, established clinical experience, and existing workforce contributions.

Moving forward, ACORN strongly supports the development and completion of formal tertiary qualifications in surgical assistance through recognised higher education providers, alongside clearly defined supervision requirements and demonstrated competency attainment. This combined approach ensures both recognition of experienced practitioners and the continued strengthening, standardisation, and safety of the PNSA workforce.

 

Is a PNSA and NP the same thing?

No. A PNSA and a NP are distinct advanced nursing roles, each defined by different regulatory frameworks, scopes of practice and models of clinical governance.

The PNSA is an advanced perioperative nursing role that functions within a clearly defined, procedure- and specialty-specific scope of practice. PNSAs work collaboratively as part of the multidisciplinary perioperative team, supporting surgeons, anaesthetists, perioperative nurses and allied health professionals across the continuum of care, from pre-admission assessment through to intraoperative assistance and post-operative recovery. The role is underpinned by structured credentialing, competency-based assessment, and local clinical governance arrangements to ensure safe, consistent and accountable practice within the perioperative environment.

In contrast, NPs are endorsed by the Nursing and Midwifery Board of Australia as autonomous advanced practice nurses with an expanded scope of practice that includes the ability to assess, diagnose, prescribe medications, and order diagnostic investigations within their authorised scope. NP practice is regulated through national endorsement requirements and is not limited to a single specialty environment.

While both roles are grounded in advanced nursing practice, clinical expertise, and accountability, they are not interchangeable. The PNSA role is focused on advanced perioperative surgical assistance within a defined procedural scope, whereas the NP role is a broader autonomous clinical role with legislated prescribing and diagnostic authority.

PNSAs are encouraged to engage in ongoing professional development to maintain and extend their perioperative expertise. For some clinicians, this may include further study and progression towards Nurse Practitioner endorsement; however, this is not a requirement of the PNSA role.

In summary, both roles contribute significantly to safe, high-quality patient care, but they operate within different scopes, regulatory structures and models of clinical practice within the Australian healthcare system.

Can ENs work in PACU?

Yes, provided they meet the requirements of both the standards set out by the Nursing and Midwifery Board of Australia Standards and ACORN (PPSPNs).

‘This role may be undertaken by both registered nurses (RNs) and enrolled nurses (ENs).

ENs appointed to this role must be authorised to administer medicines in accordance with their registration status. ENs are permitted to administer medicines unless their registration carries a notation stating either:

• ‘Does not hold Board-approved qualification in administration of medicines’, or
• ‘May only practise in the area of mothercraft nursing’.

ENs who administer medicines must demonstrate the competence and confidence required to do so safely, regardless of when they obtained their medication administration qualification. A named and accessible RN with current PACU competency must be available at all times when an EN is administering medications in this role.

All ENs must practise under the supervision of a suitably qualified PACU RN, in accordance with the NMBA Enrolled Nurse Standards for Practice and supervision requirements.’

 

Further information can be found in the PPSPNs regarding governance, overview of activities, knowledge and skills, education and professional development, delegation and supervision, and professional accountability.

It is important to consult the HSO policies and procedures around the enrolled nurse’s scope of practice and medication handling and administration for local variances, requirements or limitations.

Bringing in baskets/trolleys of unopened stock for cases 'just in case'

While the ACORN Asepsis Standard does not contain a specific statement regarding the practice of bringing baskets or trolleys of unopened consumables into the operating room ‘just in case’, several infection prevention and environmental considerations should guide practice. These include whether the basket or trolley is cleaned between cases, how and where it is stored within the operating room, the potential for contamination of unopened stock, whether the items are intended for a single patient or multiple patients, and the type of procedure being performed, particularly procedures associated with increased environmental microbial dispersion.

Clinical judgement is required to determine what is appropriate for each procedure. It may be reasonable to bring a limited number of additional unopened items that are likely to be required for a single patient or procedure, particularly where rapid access may be necessary, and the items are identified on a surgeon preference list. However, bringing excessive consumables into the operating room, especially for potential use across multiple patients, is not considered best practice due to the increased risk of environmental contamination. In these circumstances, storage of additional stock outside the immediate operating room environment is preferable.

 

Food and beverages in the operating theatres

This is a highly contentious issue and one that ACORN receives many enquiries about. Food and drink should not be permitted in the operating suite or other restricted perioperative areas due to the risk of contamination and the potential for compromising patient safety. Surgical site infections and hospital-acquired infections are significant concerns in the perioperative environment, as food and beverages can introduce bacteria, pathogens, or foreign particles into critical aseptic areas, potentially increasing the risk of infection. The operating room must maintain its critical aseptic environment, and the presence of food could jeopardise the sterility of the area by contributing airborne particles or contaminating surfaces.

In addition to the infection risks, allowing food and beverages in restricted areas may also cause distractions amongst perioperative personnel, compromising their concentration and focus during critical surgical procedures. The removal of personal protective equipment, such as masks, for eating or drinking further undermines the integrity of critical aseptic conditions and exposes both staff and patients to potential allergens or sensitivities. Furthermore, food and drink remnants can attract vermin and insects, creating additional hazards in the sterile environment.

ACORN continues working with RACS and ANZCA to develop a united position on this based on patient safety and infection control principles, emphasising the need to restrict food and beverage consumption in operating suites and other restricted areas. Health service organisations are encouraged to implement clear policies regarding the storage and consumption of food in these environments, ensuring that designated areas outside the operating room are available for personnel to access hydration and nutrition. By maintaining these standards, healthcare providers can ensure optimal care while minimising the risks associated with contamination, distractions, and the potential for equipment damage.

Cardboard boxes in the perioperative environment

The use of corrugated or unsealed cardboard boxes is not recommended within the perioperative suite due to the high risk of contamination from external microbes, which can compromise sterile stock and instrumentation. It is unclear whether you are referring specifically to the operating room or other areas within the perioperative suite, such as sterile stockrooms or the PACU. As a general guideline, restricted areas like the operating room or sterile stock areas should be kept free from external contaminants to maintain sterility. This is why appropriate perioperative attire is required in these areas.

Cardboard boxes used for transporting stock or instruments from external environments are porous and can carry a variety of microbes. Therefore, they should be decanted or unpacked before entering restricted perioperative areas, as they cannot be adequately cleaned for such settings.

 

Perfume or aftershave in the perioperative environment

ACORN's standards are silent on this issue as the decision should be organisation-wide rather than perioperative-specific. There are multiple confined areas within health service organisations where staff and patients are in close proximity. Any policy should address aftershave as well as perfume. ACORN keeps a watching brief on emerging evidence or research, but in this case for now ACORN advises you to take it up with your organisation’s OH&S management, as it is a governance issue. If you or any others in your workforce are truly sensitive, then there may be good grounds from an occupational health perspective to discourage and/or ban staff from wearing perfume while at work.

 

Can UV light or other emerging cleaning technologies replace manual cleaning in the operating room?

No. Emerging technologies such as ultraviolet (UV) light systems, hydrogen peroxide vapour, visible-light disinfection and air purification systems must not replace manual cleaning processes in the operating room.

Current evidence indicates that while these technologies may reduce microbial bioburden on environmental surfaces, their ability to independently reduce surgical site infection rates remains inconclusive. They are also subject to important practical limitations, including incomplete surface coverage, safety requirements for staff, room preparation constraints, turnaround times between cases, and equipment operational considerations.

For these reasons, ACORN Standards state that manual cleaning remains the primary and essential method of perioperative environmental decontamination. Emerging technologies may only be used as adjuncts to manual cleaning, and only when incorporated into terminal cleaning processes following a formal, multidisciplinary risk assessment conducted by the health service organisation.

Any adoption of adjunct technologies must involve relevant stakeholders, including infection prevention and control teams, perioperative leadership, engineering and biomedical engineering teams, work health and safety representatives, and environmental or cleaning services. The risk assessment should consider microbial efficacy, staff and patient safety, compatibility with materials and equipment, cost, and the potential impact on infection prevention outcomes.

In practice, this means UV light or similar technologies may enhance existing cleaning processes but cannot replace manual cleaning or disinfection steps. Cleaning staff must be appropriately trained and authorised to use any approved technology, and all deviations, malfunctions or safety concerns must be reported in accordance with local escalation procedures.

Where implemented, health service organisations should continue to monitor effectiveness through audit, environmental testing, and infection surveillance, with protocols adjusted based on outcomes and governance review.

No FAQs relating to this role at this time.

What is the difference between a Laser Safety Officer (LSO) and a Laser Safety Operator?

A Laser Safety Officer (LSO) is an authorised and trained individual responsible for the governance and oversight of laser safety within the health service organisation. As defined in the ACORN glossary, the LSO is responsible for evaluating and controlling laser hazards, and for developing, implementing, monitoring and enforcing compliance with all aspects of a healthcare laser safety program. This includes system-level responsibilities such as risk management, policy development, staff training frameworks, incident review, and ensuring organisational compliance with relevant standards and legislation.

In contrast, a Laser Safety Operator refers to the clinician or staff member who directly operates or assists with the use of laser equipment during clinical procedures. The operator is responsible for following established laser safety protocols, using equipment in accordance with manufacturer instructions and organisational policies, and applying required safety measures such as PPE, controlled access, and procedural safeguards within the operating environment.

In summary, the LSO holds organisational governance and oversight responsibility for laser safety systems, while the Laser Safety Operator is responsible for safe application of laser equipment at the point of care in accordance with those systems and protocols.

No FAQs relating to this role at this time

Can a nurse sign off an instrument tray list by drawing a line through it rather than counting each item?

No. Best practice is to count and document instruments individually by name against the tray list contemporaneously to support safety and accurate record-keeping.

 

Why must at least one RN be involved in the management of accountable items (rather than two ENs)?

ACORN requires that at least one member of the intraoperative team responsible for the management of accountable items be a RN to ensure appropriate clinical accountability, delegation oversight, and escalation capability in a high-acuity perioperative environment.

The management of accountable items is a critical patient safety process linked to the prevention of retained surgical items, requiring ongoing clinical judgement and the ability to respond immediately to discrepancies. In line with NMBA Standards for Practice, the RN holds primary accountability for care, including delegation and supervision of ENs, and is therefore the practitioner with the required scope of responsibility to lead escalation and decision-making when required.

This requirement reflects differences in regulatory scope and accountability rather than capability. ENs are highly valued members of the perioperative team and contribute essential skills to safe surgical care. The standard ensures that within the accountable items process there is always an RN present to provide appropriate oversight, governance, and escalation support in the event of rapidly evolving clinical needs.

 

Can the anaesthesia nurse be the ‘RN’ involved in the surgical count?

While anaesthesia nurses may have knowledge of surgical count processes, their primary responsibility is the management and monitoring of anaesthesia care. ANZCA guidance and ACORN PPSPNs require the anaesthesia nurse to remain immediately available for anaesthesia-related responsibilities throughout the procedure. As the supervision and management of accountable items falls within the scope and expertise of the circulating and instrument nurse roles, the anaesthesia nurse is generally not considered the most appropriate RN to supervise or assume responsibility for the surgical count.

 

Do I have to conduct a mandatory count if accountable items cannot be retained due to the nature of the surgical procedure?

The clauses outlined in the Management of accountable items standard 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.

The primary objective of managing accountable items through the use of a count sheet is to prevent the unintended retention of surgical items within the patient. However, the count sheet serves several additional purposes, which may vary depending on the healthcare organisation's policies. These include:

• Documentation of the completed timeout process and identification of the personnel involved.
• Recording of perioperative staff participation, including attendance times and accountability signatures.
• Management of operating room session times for theatre utilisation.
• Documentation of medications administered, such as local anaesthesia
• Tracking of implantable items inserted or removed, such as infiltration catheters.
• Management of rebate and consignment codes, including reordering procedures.

The use of a count sheet may still be required even in cases where no accountable items are utilised during the procedure, to address the above-listed purposes. In such instances, the count sheet would indicate ‘No Count Required’. The specific requirements for count sheet usage are typically determined at the local level, often through explicit guidelines outlined in the institution's Accountable Items Policy.

Is it safe for perioperative personnel to manually lift or reposition patients during surgery, and what are the best practices for patient handling in the operating suite in Australia?

The safety of manually lifting or repositioning patients during surgery is a controversial issue in the Australian healthcare context, as it poses potential risks for both the patient and perioperative staff. Manual handling in the operating suite is often necessary when adjusting patients’ positions, but it can lead to musculoskeletal injuries for healthcare workers if proper techniques are not followed. Moreover, improper patient positioning can affect surgical outcomes or patient safety, especially during critical stages of the procedure.

Best practice guidelines in Australia, such as those provided by Safe Work Australia and health service organisations, recommend that mechanical aids, such as patient lifts, transfer boards, and slide sheets, be used whenever possible to reduce the need for manual lifting. These devices are designed to help staff safely reposition patients with minimal physical strain, reducing the risk of injury to both workers and patients.

When manual handling is unavoidable, it is essential that perioperative personnel receive training on safe lifting techniques and proper body mechanics. Healthcare workers should also work closely as a team, using coordinated movements to ensure patient safety and minimise strain. Australian healthcare institutions must ensure that policies are in place to support safe patient handling, following local workplace health and safety regulations. The debate around this issue often centres on whether manual handling can ever be fully eliminated from the operating suite, with many advocating for a greater reliance on mechanical aids to safeguard both patient and staff well-being.

Is it necessary to remove hair from the surgical site before surgery, and if so, what is the safest method?

Current evidence and international guidelines recommend that hair at the surgical site should not be removed routinely unless it is likely to interfere with the surgical procedure, wound closure, or application of dressings. Guidance from the World Health Organization, the National Institute for Health and Care Excellence, the Australian Commission on Safety and Quality in Health Care, and other infection prevention organisations consistently identifies preoperative shaving with a razor as a risk factor for surgical site infections due to skin abrasions and disruption of the skin barrier.

Where hair removal is clinically necessary, electric clippers with a single-use or disinfected reusable head are the preferred method. Clippers should be used as close as possible to the time of surgery and outside the operating room where feasible, to minimise environmental contamination and reduce the opportunity for microbial colonisation. The use of razors is not recommended. Chemical depilatory creams may be considered in selected cases; however, they should be used cautiously because of the potential for skin irritation or allergic reactions.

Recent literature and guideline updates emphasise that unnecessary hair removal does not reduce SSI risk and may in fact increase it. The focus should instead remain on effective skin antisepsis, appropriate surgical site preparation, and adherence to aseptic technique. Decisions regarding hair removal should therefore be guided by clinical necessity, patient factors, procedure type, and local policy, with the primary aim of minimising patient harm and reducing the risk of infection.

Disposable vs reusable scrub hats

The use of reusable cloth scrub hats in the perioperative environment remains an area of ongoing discussion, balancing infection prevention considerations with sustainability, workforce preference, and operational practicality. Current evidence does not demonstrate that reusable cloth hats independently increase the risk of surgical site infections (SSIs) when compared with disposable alternatives. Earlier concerns, including a previous statement from the Association of periOperative Registered Nurses (AORN) discouraging cloth hats, were later withdrawn due to insufficient evidence linking reusable headwear to increased SSI risk. Similarly, contemporary guidance from organisations including AORN and the European Operating Room Nurses Association (EORNA) does not provide strong evidence favouring disposable over reusable head coverings for SSI prevention.

There is increasing recognition that reusable scrub hats may offer environmental advantages by reducing single-use waste and may also support staff identification and team communication. However, the safe implementation of reusable headwear relies heavily on effective laundering and governance processes. Relevant guidance, including EORNA recommendations, Standards Australia textile and laundering standards, and principles outlined by organisations such as the Centers for Disease Control and Prevention (CDC), emphasises that reusable healthcare textiles must achieve an appropriate level of hygienic cleanliness. This requires consistent control of laundering parameters such as temperature, cycle duration, detergent use, and mechanical action.

The greatest area of concern relates not to the reusable hats themselves, but to variability in laundering practices, particularly where laundering occurs in domestic settings. Domestic washing machines may not reliably achieve temperatures of at least 60 °C, maintain sufficient cycle times, or provide adequate mechanical cleaning action. User practices such as overloading machines, using short or eco cycles, or washing at lower temperatures may further reduce microbial removal. Additional considerations apply where contamination with organisms such as MRSA or VRE is suspected, as enhanced decontamination processes, including higher temperatures, longer cycles, or disinfectant additives, may be required.

Healthcare service organisations also have responsibilities to ensure laundering processes are appropriate, validated, and auditable. This can be difficult when reusable scrub hats are laundered outside accredited or controlled healthcare laundry services, raising challenges related to monitoring, compliance, accountability, and assurance of hygienic outcomes. Professional laundering services remain the preferred option in many settings because they operate under validated infection prevention and textile processing standards.

While reusable cloth hats appear to be a reasonable and environmentally sustainable option that does not independently increase SSI risk, their safe adoption depends on robust organisational policies, clearly defined laundering processes, and appropriate oversight to ensure consistent hygiene standards are maintained.

 

Why are false nails, jewellery and other personal items restricted in perioperative areas?

Perioperative attire requirements are designed to support surgical asepsis and minimise the risk of microbial contamination in semi-restricted and restricted areas. Current evidence demonstrates that artificial nails, chipped nail polish, false eyelashes and visible jewellery can harbour microorganisms and contribute to contamination risks within the perioperative environment. Long natural nails, artificial nail enhancements and damaged nail polish create areas where bacteria and fungi can persist despite hand hygiene practices, increasing the potential risk of surgical site infection.

Jewellery such as rings, watches, bracelets, bangles and necklaces may also carry microorganisms, interfere with effective hand hygiene, increase glove perforation risk and pose physical safety hazards to both patients and staff. Similarly, false eyelashes present a contamination risk if detachment occurs within the perioperative environment.

To reduce these risks, perioperative staff are expected to maintain short, clean, healthy fingernails free from artificial enhancements, including acrylics, gels, overlays, extensions and encapsulated nail art. False eyelashes should not be worn in semi-restricted or restricted areas; however, where removal is not possible for clinical or personal reasons, protective face shields should be used to reduce contamination risk.

A ‘bare below the elbows’ approach is recommended to support effective hand hygiene and aseptic practice. Hand, wrist, forearm and neck jewellery should therefore be removed or fully contained within perioperative attire before entering semi-restricted or restricted areas. Small stud or sleeper earrings may be worn if fully covered by head coverings, while any piercings not fully enclosed should be securely taped. Jewellery retained for cultural or religious reasons may be worn only where it is completely contained within attire and does not compromise aseptic technique or safety.

Healthcare organisations are responsible for supporting compliance with perioperative attire standards through education, orientation, regular auditing, supervision and competency assessment processes.

 

Is the Post-Anaesthesia Care Unit (PACU) considered a semi-restricted or unrestricted area?

PACU is generally considered a semi-restricted area within the perioperative environment for the purposes of perioperative attire, although specific attire requirements may vary according to local health service organisation policy.

Perioperative zoning frameworks commonly describe three areas: unrestricted, semi-restricted and restricted. PACU is located within the perioperative environment and cares for patients who have just undergone invasive procedures and are physiologically vulnerable. It is also functionally linked to operating rooms, with shared staff movement, equipment and workflows. For these reasons, PACU is not typically regarded as an unrestricted area.

The ACORN ‘Perioperative attire’ Standard (2026) explicitly supports this classification. In its glossary, ACORN defines a semi-restricted area as:

Semi-restricted area: an area within the perioperative environment which non-perioperative personnel may enter temporarily without donning perioperative attire. However, perioperative personnel don perioperative attire when entering semi-restricted areas to facilitate easy movement into the restricted areas. Semi-restricted areas may include drop off points for receiving patients into the perioperative environment, post-anaesthesia care unit (Stage 1 recovery), storage areas for non-sterile stock, waste management areas and corridors leading to restricted areas.

The infection prevention rationale underpinning these recommendations is that perioperative personnel shed skin cells and hair that can carry microorganisms (notably Staphylococcus aureus), and that street clothing may be a source of organisms associated with surgical site infection. Correctly laundered perioperative attire is therefore required before entering restricted and semi-restricted areas of the perioperative environment.

Please note: This response is in relation to the immediate post-anaesthesia care unit perioperative attire requirements (stage 1 recovery). Stage 2 recovery is classified as an unrestricted area in the day procedure service unit.

Should patient-owned Medic Alert bracelets (including QR code bracelets) be worn into the operating room?

Patient-owned Medic Alert bracelets should not replace HSO-approved identification processes, and any allowance for their use in the perioperative environment must be governed, standardised, and formally embedded in organisational policy following multidisciplinary review.

The use of patient-owned Medic Alert bracelets, including QR code devices, is not supported within ACORN Standards, however they are addressed within the ACORN Perioperative Team Communication governance criteria with local governance discretion. Their use in the operating room requires a formal multidisciplinary risk assessment, including input from infection prevention and control specialists, perioperative clinicians, and health service governance representatives.

While these devices may provide useful supplementary information, they are not standardised within hospital patient identification systems and may present risks related to inconsistent recognition, information reliability, infection control, and variation in staff familiarity. Reliance on patient-owned identifiers can also conflict with the NSQHS Communicating for Safety Standard, which requires the use of reliable, organisation-wide patient identification processes.

Where a health service organisation permits external medical alert jewellery to be worn into the operating room, this must be explicitly defined within local policy and procedure, supported by risk assessment outcomes and clear guidance on how this information is verified, documented, and integrated into standard patient identification systems.

 

Digitally signed consent forms

ACORN is not within the scope to comment on the legal validity of specific documentation. However, for further guidance, refer to the Australian Government (Attorney-General’s Department) website, which provides detailed information on electronic signatures: Australian Government - Electronic Signatures. Although this page does not specifically address medical or procedural consent forms, it highlights that the Electronic Transactions Act 1999 (ETA) states that electronic signatures (often referred to as e-signatures) are legally equivalent to traditional paper or 'wet ink' signatures for most Commonwealth processes.

Additionally, the Royal Australasian College of Surgeons (RACS) position statement provides detailed information on the elements required for informed consent, beyond the signature itself: RACS Informed Consent Position Statement.

 

Acronyms and abbreviations on consent forms

Regarding the use of acronyms and abbreviations on surgical consent forms, it’s important to refer to your local policies and procedures, as many health service organisations have guidelines on approved abbreviations for clinical communication, often as part of their NSQHS National Standards accreditation. If no policy exists, it would be advisable to create one to reduce confusion, especially around procedure identification. For reference, I’ve attached the NSW Health Clinical Abbreviations list (Nov 2020), and Vic Health’s glossary of acronyms: Vic Health Glossary.

The ACORN SSQCPEs highlights the importance of clear communication in ensuring patient safety and correct procedure matching, emphasising the risks of using unknown abbreviations. Position statements from RACS and ANZCA on consent and documentation are also recommended for guidance.

Regarding informed consent documentation, the NSQHS National Standards provide detailed requirements, particularly in the 'Partnering with Consumers' and 'Communicating for Safety' Standards. These standards stress the use of standardised language and approved abbreviations to ensure clarity and reduce the risk of errors: Informed Consent Standard, Correct Identification & Procedure Matching.

Additionally, the Queensland Clinical Excellence Commission's guide advises against using abbreviations in consent forms to avoid misinterpretation. For example, fingers should be named (e.g., thumb, index) rather than numbered, and procedures should be written out fully (e.g., ‘Right’ instead of ‘R’ or ‘Rt’).

Further resources:

• Queensland Clinical Excellence Commission's ‘Guide to informed decision making in healthcare.’
• NSW Health Clinical Abbreviations List.
• Australian Commission on Safety and Quality in Healthcare’s guidelines on terminology, abbreviations, and symbols used in medical documentation.

If a patient reports feeling ‘comfortable’ but has a preoperative temperature below 36.0°C, should active warming still be initiated?

Yes. A patient’s subjective perception of being ‘comfortable’ is not a reliable indicator of core body temperature or thermoregulatory status. In the perioperative setting, even mild hypothermia (<36.0°C) can occur without the patient experiencing chills or discomfort, particularly in the preoperative phase where anxiety, ambient temperature and altered physiological responses may mask thermoregulatory cues.

Evidence consistently demonstrates that inadvertent perioperative hypothermia is associated with increased risks of surgical site infection, altered drug metabolism, coagulopathy, prolonged recovery times, and patient discomfort in the postoperative period. Importantly, patients often do not recognise or report hypothermia symptoms reliably, meaning objective temperature measurement is essential for clinical decision-making.

Where a preoperative temperature is below the recommended threshold, active warming strategies should be initiated in accordance with organisational protocols, regardless of patient-reported comfort. This situation also provides an important opportunity for patient education, allowing perioperative nurses to explain the role of normothermia in supporting optimal surgical outcomes, reducing complications and improving recovery trajectories.

Maintaining normothermia is therefore a proactive patient safety intervention rather than a comfort-based decision and should be guided by measured temperature and evidence-based perioperative warming practices.

Where should sharps bins be located in the operating theatre, and what is the safest way to manage them?

Concerns are sometimes raised regarding the placement and movement of sharps bins within the operating theatre environment, particularly when bins are relocated into the room or contain waste from previous patients. This includes questions about potential cross-contamination risks, exposure to biohazardous material, and the management of accountable items such as needles, scalpel blades and laparoscopic sharps.

The ACORN Standards, in alignment with the NHMRC Australian Guidelines for the Prevention and Control of Infection in Healthcare, state that single-use sharps must be disposed of immediately after use into puncture-resistant, leak-proof containers compliant with recognised standards such as AS 4031, AS/NZS 4261 or ISO 23907. While these guidelines do not require sharps bins to be permanently located inside the operating room, they must always be positioned as close as practicable to the point of use to support immediate and safe disposal.

ACORN acknowledges that sharps bins used in perioperative settings should be designed to minimise the risk of re-access and exposure to contaminated contents. Smaller anaesthetic sharps containers often incorporate safety features such as restricted access apertures or rotating lids to reduce handling risks. In laparoscopic surgery, where instrument-related sharps disposal presents additional logistical challenges, portable sharps containers positioned at the point of use are recommended, with secure closure mechanisms (e.g. foot-operated lids) to reduce the risk of sharps injury and environmental contamination.

Decisions regarding whether sharps bins are permanently located within the operating theatre should be guided by local policy, workflow design, and risk assessment. Regardless of placement, compliance with safe disposal practices, appropriate container design, and staff education remains essential to minimise sharps injuries and maintain a safe perioperative environment for both patients and staff.

Are warning stickers required for fresh specimens and suspected CJD cases, or is a biohazard bag sufficient?

Specimens with additional handling or infection prevention requirements must be clearly identifiable to all subsequent handlers, including clinical staff, pathology personnel, and transport services. This aligns with national expectations for effective communication of specimen-related and infection control risks.

Where additional risks are present, such as suspected or confirmed transmissible spongiform encephalopathy (e.g. CJD), there must be a reliable system in place to ensure appropriate identification and safe handling. This may be achieved through warning labels, dedicated alert specimen containers or other standardised identification systems approved by the HSO. The method used should ensure consistent recognition across all points of handling.

Similarly, fresh specimens requiring urgent or time-sensitive processing must be clearly identified so that pathology services and couriers can prioritise and manage transport appropriately. A biohazard bag alone is not sufficient to communicate these specific clinical or procedural requirements unless it is specifically designed and recognised within the HSO system for that purpose.

Ultimately, the chosen approach must be standardised within the organisation, clearly documented in local policy, and supported by staff education to ensure consistent application and effective communication of specimen-related risks.

Why shouldn't hand scrub and alcohol-based surgical hand rub be used sequentially?

Since 2020, the ACORN Standards have recommended that traditional surgical hand scrub and alcohol-based surgical hand rub (ABSHR) should not be used sequentially. The 2026 ACORN Standards continue this recommendation in alignment with World Health Organization guidance and evidence cited in the literature, including the work of Kampf and colleagues.

Historically, surgical hand preparation involved a timed antiseptic scrub with water prior to every procedure. However, contemporary waterless alcohol-based surgical hand rub formulations are designed to achieve both rapid antimicrobial activity and sustained reduction of resident skin flora when used according to the manufacturer’s instructions for use (IFU). Many formulations combine alcohol for immediate antimicrobial effect with chlorhexidine gluconate for persistent activity.

Using a traditional surgical hand scrub immediately before applying alcohol-based surgical hand rub is not recommended because residual moisture on the hands may dilute the alcohol formulation and reduce its antimicrobial effectiveness. Sequential use may also increase skin irritation, dryness and dermatitis risk, potentially affecting skin integrity and staff tolerance.

ACORN does not endorse specific products, recognising that organisations operate under varying procurement processes and local policies. Product selection should consider evidence-based efficacy, compatibility with surgical gloves and other protective equipment, staff sensitivities, safety, cost, and compliance with manufacturer IFUs. Perioperative staff should use surgical hand antisepsis products only as intended by the manufacturer and engage with suppliers regarding education, product limitations and appropriate use.

ACORN acknowledges that this recommendation represents a significant change from longstanding perioperative practice and that implementation may require local consultation, education and practice review. Further guidance is available in the ACORN Standard ‘Surgical hand antisepsis, gowning and gloving’, including the associated glossary of terms.

Is surgical smoke the same as surgical plume?

The terms surgical smoke and surgical plume are often used interchangeably in clinical practice; however, they are not strictly identical.

Surgical plume is the broader, more contemporary term and refers to all airborne contaminants generated during the use of energy-based surgical devices, including cutting, coagulation, vaporisation, ablation, cauterisation, and thermal desiccation of tissue. It encompasses both visible and invisible components, including ultrafine particles, gases, and biological material.

Surgical smoke typically refers to the visible component of this by-product, often the more easily seen smoke released during electrosurgical or laser procedures. In contrast, plume includes this visible smoke as well as the finer aerosolised particles and gaseous contaminants that may not be visible but still present occupational and patient safety risks.

In contemporary perioperative practice and safety literature, ‘surgical plume’ is generally preferred, as it more accurately reflects the full spectrum of airborne contaminants and associated health risks within the operating room environment.

What is the perioperative nurse’s role when media (photography, filming or external observers) are present in the operating room?

The presence of media in the operating room is a high-governance activity that requires strict organisational approval, clear patient consent processes, and adherence to health service policies, privacy legislation, and professional standards.

The perioperative nurse plays a key role in ensuring that any approved media activity does not compromise patient safety, infection prevention, or the integrity of the sterile environment. This includes verifying that appropriate consent has been obtained in accordance with organisational requirements, confirming that the presence of media personnel has been formally authorised, and ensuring that all individuals in the operating room comply with aseptic practice, attire standards, and restricted area protocols.

From a patient safety perspective, the perioperative nurse is responsible for maintaining situational awareness and ensuring that filming or photography does not interfere with clinical workflow, sterile fields, equipment movement, or communication within the surgical team. The nurse should also remain alert to any breaches of confidentiality or unintended capture of patient-identifiable information.

If any aspect of media presence is not clearly documented, not approved, or appears to compromise safety or privacy, the perioperative nurse has a professional responsibility to escalate concerns in line with health service governance and patient safety frameworks.

While media access may be permitted under strict conditions, the perioperative nurse’s primary role is to uphold patient safety, maintain asepsis, and ensure compliance with organisational policy and legal requirements throughout the perioperative procedure.

Is the Staffing for safety standard (2020) being updated?

Work has already commenced on the development of an updated version of the ‘Staffing for Safety’ standard. This review recognises the ongoing need for contemporary, evidence-informed guidance to support safe perioperative staffing models, including consideration of acuity, skill mix and local workforce context.

Until the updated standard is released, healthcare service organisations are encouraged to continue using the 2020 Staffing for Safety standard as the current reference point for perioperative staffing guidance.

The revised standard will continue to reflect the principle that staffing should be appropriate to patient acuity and complexity, ensuring safe, high-quality care and minimising risk to both patients and staff. Further updates will be communicated as the review progresses.

Best practices for reprocessing medical devices

It is important to always ensure the medical device IFU, and manufacturer guidelines are received and understood prior to use. ACORN does not recommend specific reprocessing equipment products but advocates for best practice principles to be followed. These include but are not limited to:

• Following manufacturer guidelines for cleaning, disinfecting, and sterilising each device.
• Using validated equipment that meets the standards for sterilisation.
• Training staff regularly on proper reprocessing techniques and infection control protocols.
• Documenting each reprocessing cycle to maintain traceability and accountability.
• Inspecting devices for damage before and after each reprocessing cycle to ensure their integrity.
• Ensuring proper storage of sterilised devices in a clean and dry environment.

 

How do you know if a medical device has been properly sterilised?

To ensure that a medical device has been properly sterilised:

• Use of biological indicators: These are vials containing spores that are exposed to the sterilisation process. A negative result confirms that the sterilisation cycle was effective.
• Chemical indicators: These are applied to the devices or sterilisation pack to confirm that the correct temperature, pressure, or chemical concentration was reached.
• Regular monitoring and validation of sterilisation equipment, including routine maintenance and testing, to ensure its proper function.

Auditors should be experienced perioperative nurses, ideally with three or more years of perioperative practice. Familiarity with the relevant ACORN Standard is essential, including its principles, rationale and performance criteria. Experience with audit or quality programs (e.g. infection prevention audits, Hand Hygiene Australia, WHS or accreditation frameworks such as ACHS) is highly beneficial.

Formal Excel skills are not required to conduct observations; however, data entry, analysis and ongoing audit management should be performed or overseen by someone proficient in Excel.

Audit duration varies depending on experience and familiarity with the tool. Initially, approximately one hour should be allocated per standard, including time to capture observations and complete documentation. With experience, audits become more efficient and may be completed more quickly, with some auditors able to integrate observations into routine workflow where appropriate.

Practice audits provide a snapshot of real-time clinical practice across multiple staff, shifts and contexts, allowing organisations to assess overall compliance with standards and identify system-wide trends.

Competency assessments evaluate an individual nurse’s ability to demonstrate knowledge and performance of required standards at a defined point in time. Audits therefore support quality improvement, while competency assessments support education and performance validation.

Yes. All perioperative staff should be aware that practice audits are part of routine quality activities. This may be supported through communication strategies such as posters or announcements outlining the audit period and purpose.

Initial awareness of auditing activity is expected, but discretion should be maintained to minimise behaviour change bias. Using unobtrusive methods (e.g. small note-taking tools rather than clipboards) can assist. Over time, staff typically become accustomed to audit presence, allowing more natural observation.

Each audit should aim to observe multiple nurses (ideally more than two or three where possible each separate audit) to ensure a representative snapshot of practice. Observing only one or a narrow group (e.g. only new or only experienced staff) should be avoided. Small departments should still aim for diversity across available staff.

For standards involving sequential procedural steps (e.g. surgical hand antisepsis technique), it is appropriate to observe one nurse continuously through the full sequence. However, across the full audit cycle (e.g. ten audits), different nurses should be observed to ensure representativeness.

Representative sampling requires observation across different staff, shifts, case types and clinical contexts. Non-routine or emergency procedures should be avoided. Audits should reflect the usual workforce mix, including a range of experience levels.

Each standard should be audited across ten separate and varied occasions to minimise bias and improve validity.

Each standard within a bundle should be audited on ten separate occasions. These should be spread across different days, lists and clinical situations to ensure a broad and reliable snapshot of practice. Condensing all audits into a short timeframe may result in non-representative findings.

Non-compliant practice should be recorded as observed. Patient and staff safety remains the priority during audits. Where unsafe practice is identified, immediate intervention may be required in line with organisational escalation processes. Auditors should also provide or escalate feedback to support corrective action where appropriate.

Only observed practice should be scored. If an action is not seen, it should generally remain unscored and re-assessed when next observed. In some cases, clarification may be sought (e.g. confirming a completed step or label check), but auditing should focus on actual observed practice rather than self-reported behaviour.

If required equipment is unavailable, resulting in deviation from the standard, the practice should still be scored as non-compliant (0). Auditors may document contextual factors (e.g. stock shortages) to support follow-up and quality improvement actions.

No. The Excel-based audit tool automatically excludes NA responses when calculating compliance rates. Manual adjustment is not required unless used for verification purposes.

Both alcohol-based hand rub (ABHR) and traditional surgical hand scrub (SHS) are acceptable when performed according to instructions for use. The method observed should be scored for compliance, while the alternative method should be marked as NA. The system will automatically exclude NA items from calculations.

The ACORN Practice Audit Tools are specifically designed to evaluate perioperative nursing practice against The ACORN Standards. While standards may reference multidisciplinary collaboration, the audit tools have been validated for nursing practice only and are not intended for use in assessing other professional groups.