Evidence for the professional standards

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ACORN apologises for the delay.

I recently spoke with ANMF about my workplace, we used to have the techs taking the patients out to recovery with the anaesthetist. I was told it’s an ACORN standard that a nurse escorts the patient to recovery with the anaesthetist and have tried to implement this in our department. Many are pushing back saying “no and give me proof we have to” I’m hoping you can help clarify this. This is the only place I have worked that a nurse doesn’t come out.

ACORN’s current Anaesethtic nurse nursing role standard states at 5.8 that “the anaesethtic nurse has a duty to provide a detailed handover with supporting documentation to the post-anaesthetic care nurse including details on multi-modal pain management, regular medications and intravenous therapy.” p14 of the ACORN Standards for Perioperative Nursing in Australia (16th edition)

This may assist you in local practice and you should ensure that your objections to deviation are noted and that the perioperative management appreciates the risk implications of not following ACORN’s recommendations. It is also important that you read the caveats at the top of this page regarding the extent to which organisations and individuals shoud comply with ACORN standards. You may also find additional information via ANZCA or ACPAN.

 

I would like to find out if a midwife can start a C- Section in an emergency if the scrub and scout nurse is still in transit. If giving a quick demo on how to prep and drape? What is the correct department I can find out from?

With regard to who can safely act as an instrument nurse from a technical point I would refer you to the current ACORN standard Instrument Nurse page 31 of the current 15th edition of the Standards for Perioperative Nursing in Australia as follows:

‘Nursing practice is regulated in Australia. Instrument nurses are required to meet current regulatory requirements for registration by the Nursing and Midwifery Board of Australia (NMBA). Instrument nurses are expected to provide safe and ethical nursing care within their scope of practice as well as act professionally and be accountable for their own practice. The instrument nurse has a duty to provide comprehensive patient care in line with current NMBA professional codes and guidelines including NMBA standards for practice, codes of ethics, codes of professional conduct and guides to professional boundaries. Where this role is undertaken by an enrolled nurse (EN), the EN must perform in the role of the instrument nurse strictly within the limits of their competence and must work under the supervision of an experienced registered nurse (RN)’ 

With regard to the legal issues I suggest you discuss this with senior nursing management within your health service organisation and possibly seek legal counsel. There may be jurisdictional-specific guidelines that either support or limit this practice.

In terms of scope of practice and professional obligations you should also consult the relevant Nursing and Midwifery Board of Australia Guidance including but not limited to:

Nursing and Midwifery Board of Australia (NMBA).Registered nurse standards for practice [Internet]. Canberra: NMBA; 2016 [cited 2020 March 26] Available from:https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx
 
Nursing and Midwifery Board of Australia (NMBA). Enrolled nurse standards for practice [Internet]. Canberra: NMBA; 2016 [cited 2020 March 26] Available from: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/enrolled-nurse-standards-for-practice.aspx
 
Nursing and Midwifery Board of Australia (NMBA). Nurse practitioner standards for practice. Canberra: NMBA; 2014 [cited 2020 March 29]. Available from: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/nurse-practitioner-standards-of-practice.aspx

Nursing and Midwifery Board of Australia (NMBA). Code of conduct for nurses [Internet]. Canberra: NMBA; 2018 [cited 2020 March 26]. Available from: www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx.
 
International Council of Nurses. The ICN Code of Ethics for Nurses. Geneva:ICN, 2012. [cited 2020 March 26]. Available from: https://www.icn.ch/sites/default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf
 
Nursing and Midwifery Board of Australia (NMBA). Registration standard: Continuing professional development.  [Internet]. Canberra: NMBA; 2016/ [cited 2020 March 26] Available from: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/nurse-practitioner-standards-of-practice.aspx
 
Nursing and Midwifery Board of Australia (NMBA). Professional codes and guidelines [Internet]. Canberra: NMBA; 2008 [cited 2017 December 7]. Available from: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/nurse-practitioner-standards-of-practice.aspx 
 
Nursing and Midwifery Board of Australia (NMBA). Professional standards [Internet]. Canberra: NMBA; 2020 [cited 2020 March 28]. Available from:https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/nurse-practitioner-standards-of-practice.aspx
 
Nursing and Midwifery Board of Australia (NMBA). Recency of practice standards [Internet]. Canberra: NMBA; 2016 [cited 2020 March 28] .https://www.nursingmidwiferyboard.gov.au/Registration-Standards/Recency-of-practice.aspx
 
Nursing and Midwifery Board of Australia (NMBA). Decision-making framework for nursing and midwifery. [Internet]. Canberra: NMBA; 2020 [cited 2020 March 28]. Available from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Frameworks.aspx

Could you please advise of ACORN's position on Perioperative Nurses that do not have certification as a Surgical Assistant being utilised as a such?

Volume 2 of the recently released ACORN Standards for Perioperative Nursing in Australia 16th edition includes two specific and distinct standards:

Perioperative nurse surgeon’s assistant page 47 and 
Perioperative nurses as surgical assistants page 54
 
In particular note the Purpose of the second standard which on page 54 states:
 
The purpose of this statement is to provide direction for the role and responsibilities of perioperative nurses who are requested to undertake the role of surgical assistant and who have not embarked on an educational course nor qualified as a Perioperative Nurse Surgeon’s Assistant (PNSA), in order to provide safe, high quality perioperative care to surgical patients. 
 
ACORN recommends that perioperative nurses who are requested to undertake the role of surgical assistant be able to refuse should they feel unable to fulfil the role adequately and that the role of surgical assistant be a discrete role and not combined with that of instrument nurse.
 
It is ACORN’s recommendation that informed consent be obtained from the patient prior to the perioperative nurse undertaking the surgical assistant role. ACORN also recommends that perioperative nurses be encouraged to become qualified as a PNSA. 
This statement is consistent with and supported by the Nursing and Midwifery Board of Australia (NMBA) Registered nurse standards for practice, in particular Standard 6, point 6.2 which specifies that nurses are required to practise only within their scope of practice.

My NUM has asked that I update our PACU discharge criteria. from what I have read in ACORN standards and ANZCA statements on post-anaesthesia care units is that a set discharge criteria should be met, but I am struggling to actually identify what this criteria should be and base it on the most up to date evidence. I've been trying to promote preventing inadvertent perioperative hypothermia, so I've added ensuring normothermia to our criteria, but it would be great have some standardized evidence for all other acceptable parameters

 

Your question is welcomed albeit not directly or easily answered by a simple response given that local requirements, staffing and service profiles differ. In this instance I would recommend you carefully review the ACORN Standard “Management of the Post Anaesthesia Care Unit” which places the responsibility for research translation on the Nurse Manager. 

Looking at the ACORN Post Anaesthesia Care Unit nurse there are 3 references which could potentially help you. They are as listed below, pease note that the National Safety and Quality Standards have been updated and a second edition now replaces the first. If you are unable to source the other two research papers I may be able to access them from ACORN archives but it would not be particularly easy. 

Phillips N, Street M, Kent B, Haessler E, Caddedu M. Post-anaesthetic discharge scoring criteria: Key findings from a systematic review. Int J Evid Based Healthc 2013;11(4): 275–284. 

Australian Commission on Safety and Quality in Health Care (ACSQHC). National safety and quality health service standards [Internet]. Sydney, ACSQHC, 2012 [cited 2016 February 15]. Available from: https://www.safetyandquality.gov.au/standards/nsqhs-standards

Siddiqui N, Arzola C, Iqbal M, Sritharan K, Guerina L, Chung F et al. Deficits in information transfer between anaesthesiologist and Post Anaesthesia Care Unit staff: An analysis of patient handover. Eur J Anaesthesiol 2012;29(9):438–445. 

Why is the Role of the PACU nurse Statement 2 - 2.3 not duplicated into the roles of the Anaesthetic; Circulating and Instrument nurse? Are they not also expected to participate in continuous improvement eg policy; safety; education - research etc?

 

Thank you for your interest in and questioning of this anomaly. For your reassurance please know that ACORN’s view is that all perioperative staff participate in continuous improvement regardless of whether it is specifically stated or assumed by implication. As you would appreciate all nurses have mandatory obligations under the Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017.

Thank you for your interest in and questioning of this anomaly. For your reassurance please know that ACORN’s view is that all perioperative staff participate in continuous improvement regardless of whether it is specifically stated or assumed by implication. As you would appreciate all nurses have mandatory obligations under the Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017.
https://www.safetyandquality.gov.au/publications-and-resources/resource-library/national-safety-and-quality-health-service-standards-second-edition

ACORN is currently reviewing every existing standard as we prepare for release of the 16th edition of the ACORN Standards for Perioperative Nursing in Australia. I am grateful for your query on this and I will try to address it in the revision standards relating to it.

ACORN is grateful for your query on this and will try to address it in the revision standards relating to it.


Could you tell me how I can find out about safe nursing within recovery units. What are the competencies that recovery nurses need to complete? Do nurses titrate inotropes in recovery? do they take responsibility for cardiac monitoring? should they? who can I ask about these things? 

The ACORN Standards for Perioperative Nursing in Australia now in their 16th edition include several standards relating to specific nursing roles. The role of the PACU nurse is well described in the Post Anaesethesia Care Unit nurse standar which is located from pages 57-62 of the second Volume of the current ACORN Standards. To access the ACORN Standards you will need an e-subscription. Many Australian hospitals and universities with nursing courses have purchased subscriptions. More details about access are available at Standards


Hi There Trying to update old competencies and need clarity as to what standards the following relate to: S1; S2; S3; S5; S7; S12; S17; S19; S65; NR1; PS4; PS6; PS7; PS10. The current standards no longer have these headings. Thank you for your assistance in this matter.

Please be advised that consistent with the contemporary national nursing frameworks ACORN has in effect rescinded its previously published Competency Standards including the 2008 published ACORN Competency Resource Package. ACORN is currently considering alternative approaches to perioperative nurse roles and activities as part of its Roadmap Project https://www.acorn.org.au/roadmap-project In the interim the nursing roles included in the current 16th edition of the ACORN Standards remain current. Please continue to refer to them.


Operating Theatres are concerned that management are changing the night shift allocation from 5 nurses to 4 (including in-charge). It will be expected that the circulating nurse in theatre will also hold the in-charge phone- receiving all the phone calls including urgent calls, scheduling patients, locating supplies for other wards and completing other in-charge duties whilst in theatre scouting for cases. The nursing staff are concerned that this will compromise patient safety as the circulating nurse can be interrupted and distracted whilst assisting the instrument nurse. Could you please indicate whether the ACORN standards address this issue? Do the ACORN Standards have any policies pertaining to the role of the in-charge?

You will appreciate that one of ACORN’s key purposes is to set, promote and continually review national ‘best practice’ standards for perioperative services or nursing. The ACORN Standards indicate how health service organisations may achieve that. However Please understand that 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. Although ACORN works directly with its members to develop perioperative nursing standards, ACORN is not responsible for enforcing, regulating or certifying compliance with those standards.

With regard to perioperative staffing please refer to the Staffing for safety standard requirements. ACORN's view is that safe and effective care in the perioperative setting is achieved by providing adequate numbers of appropriately qualified and experienced nurses and  staffing requirements are not static and require at least annual review. There may also be specific jurisdictional requirements depending on state or territory awards and legislation.


I’m trying to obtain the standards for minimum nursing staffing during general anaesthetic procedures in a free standing Day Care Unit. Particularly in regard to staff qualifications and whereabouts during procedures.

Please understand that 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. Although ACORN works directly with its members to develop perioperative nursing standards, ACORN is not responsible for enforcing, regulating or certifying compliance with those standards.

The ACORN Standards for Perioperative Nursing in Australia are developed through a rigorous review of the best available research and other evidence in Australia and abroad. Individual standards, guidelines and position statements are best-practice at the time of revision. Please refer to the revision history at the end of each individual document for the last revision date.


I would like to know ACORN's position on the use of uncertified AINs and orderlies being utilised as a prop nurse. ie: accepting patients into theatre receiving handover and the checking in of preoperative patients. Also the use of AINs performing admissions and discharges.

With regard to the scope of practice for an enrolled nurse I would recommend you reviewing the recommendations as described in the Enrolled nurse standard The  16th edition published in 2020 supersedes all previous editions of the ACORN Standards.

Regarding the role of Ancillary workers please review ACORN’s position statement, Ancillary workers in the ACORN Standards for Perioperative Nursing in Australia.


I have been a passionate  POSM for 20 plus years and have previously queried the staffing of 1 RN and I EN in the circulating and instrument nurse roles. If there is an RN in anaesthetic role I am unsure why we could not have 2 ENs in the circulating and instrument roles if both competent and potentially endorsed as well.

The ACORN Staffing for safety standard is always contentious. Different stakeholders impacted by it all require different things from it ie. registered general nurses want it to make sure their role is secured, enrolled nurses with endorsement want it to secure their role, management want it not to be onerous on the health service organisation etc. As you can appreciate it is unlikely that ACORN will ever please everyone. The current Staffing for safety standard was written by current practicing perioperative experts from various levels of practice including management. It is also worth noting that where national, state or territory government directives exist in regard to perioperative staffing they take precedence over ACORN’s standard.


Can you please clarify educator staff requirements for the perioperative department? Standards say 1 x FTE Nurse Educator for every 6 operating theatres. Can you please clarify if that includes recovery, CSSD, endoscopy and ancillary staff (e.g. theatre orderlies, reception) as well as scrub/scouts and anaesthetic RNs?

The new and subsequent Staffing for safety standard is less detailed and prescriptive than earlier versions in terms of recommended number of staff. This interim decision is on the advice of the National Leadership Group of ACORN’s Roadmap Project who have advised that nurse staffing is beyond ACORN’s scope and it should more naturally be determined by negotiation between the relevant health service organisations, regulatory authorities and nursing national and state industrial organisations.  

ACORN will keep its members informed as these discussions progress. Your question is a good example of how a one-size-fits-all approach to perioperative staffing is not flexible enough to meet specific needs of individual health service organisations. Please be reassured that the current ACORN staffing standard has at its core an agreement that staffing should be sufficient to not compromise the health or safety of patients or staff.


I have a question that I would like clarified. The hospital I'm working at is a small country facility and they are saying that they are going to have 2 anaesthetic nurses working on call and 1 scrub nurse. I have argued that they must have a scrub and a scout on call if they require an extra anaesthetic nurse they should have 4 people on call not 3. Can you please clarify this for me? Or should I address this with the union?

Your question does not stipulate whether the arrangements you are suggesting are general or specific to the current COVID-19 outbreak. ACORN appreciates that in these difficult times patient management may require novel approaches. Regardless ACORN always maintains a view that perioperative nursing staff should be of sufficient number, skill, qualification and experience to maintain high levels of patient safety and quality of care and to ensure staff are able to practise safely.

You will appreciate that one of ACORN’s key purposes is to set, promote and continually review national ‘best practice’ standards for perioperative services or nursing. The ACORN Standards indicate how health service organisations may achieve that. However please understand that 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. Although ACORN works directly with its members to develop perioperative nursing standards, ACORN is not responsible for enforcing, regulating or certifying compliance with those standards.

With regard to perioperative staffing please refer to the Staffing for safety Standard. Specific points to note are that “that safe and effective care in the perioperative setting is achieved by providing adequate numbers of appropriately qualified and experienced nurses” and  “staff requirements are not static” and require at least annual review. There may also be specific jurisdictional requirements depending on state or territory awards and legislation.