Welcome to the ACORN Practice Audit Tools frequently asked questions (FAQs) page. ACORN will be pleased to assist you with questions from members and non-members regarding the use of the Practice Audit Tools. Below are some common questions. If your question is not answered below or you would like to report an issue, please click here.
1. What skills do I need to undertake the ACORN practice audits?
Auditors will need to be experienced perioperative nurses – ideally this would mean three or more years’ nursing experience in a perioperative setting. Auditors will also need to be familiar with the specific ACORN standard being audited, including the specific principles, rationales for practice and the individual performance criteria. Experience or training with other audit programs will be very helpful for auditors (e.g. Infection Control audits, Hand Hygiene Australia, WH&S audits, ACHS etc). Auditors will not need to be experienced excel users for data collection. It is essential however, that an experienced excel user is responsible for excel data entry, analysis of results and ongoing management of the audit program.
2. How much time do I need to undertake the ACORN practice audits?
The time taken to audit one standard will depend upon many things and will change over time as you become more experienced and efficient. At the beginning you should schedule one hour to conduct an audit (including time to prepare, conduct, record). Allocate another time to return to the PAT if there are some practices you did not observe in the time. You will get faster and more efficient with experience. For example, you may feel skilled enough to audit more than one standard during an observation period. Eventually, you may feel skilled enough to conduct audits while you are going about your other work.
3. How do these ACORN practice audits differ from competency assessments?
Practice audits are designed to take a random snapshot of the practice of many nurses within your workplace at various times and in different situations. The result of the audit will tell you whether, in general, the nurses in your workplace practice according to the standards. Audits are the measurement tools in quality improvement. Competency assessments are designed to focus on a single nurse's practice at an agreed point in time. The result of the competency assessment will tell you whether this one nurse knows how to practice according to the standards when asked to do so. Assessments are measurement tools in training and education.
4. Should I tell the nurses that they are being audited?
All staff, including nurses, medical officers and ancillary staff, should be aware that practice audits are being conducted. We recommend that you display reminder posters as part of your audit program. These posters should inform the staff of the time period during which the nursing practice audits will be conducted (i.e. dates of the month).
5. How do I conduct the ACORN practice audits without being noticed?
At the beginning, the nurses may notice when you are observing their practice. Aim to be discrete when using the audit tool – carrying a piece of paper is more discrete than a clipboard. Eventually, your colleagues will become used to this and you will be able to observe without being noticed as much.
6. How many nurses should I observe during an audit?
Remember the audit is designed to be a random snapshot of many nurses' practice within your workplace, so you should try to observe more than
two or three nurses whenever that is possible. This will be more of a challenge for small departments with only one or two rooms. Avoid audits that observe only new nurses or only experienced nurses. With each audit, consider whether you are observing a range of nursing experience and consider whether this reflects the usual mix of nursing experience in your workplace. Your set of ten audits should be representative of the diversity of your workplace.
7. When should I focus on one nurse during an audit?
Some standards include practices which must be performed in the correct sequence of procedural steps – for example, complete stages of surgical hand antisepsis technique from the sink to the gown trolley and/or from the gown trolley to the instrument table. You should focus on one single nurse when observing these practices. It is very important to observe different nurses for each of the ten audits with this standard to ensure that your results are representative of the diversity at your workplace.
8. How do I ensure my audit results are representative of my workplace?
Non-routine or emergency procedures are not appropriate times to conduct the practice audit. Observe more than two or three nurses whenever that is possible. Avoid audits that observe only new nurses or only experienced nurses. With each audit, consider whether you are observing a range of nursing experience and consider whether this reflects the usual mix of nursing experience in your workplace. Your set of ten audits should be representative of the diversity at your workplace. An exception is when standards include practices which must be performed in the correct sequence of procedural steps – for example, the complete surgical scrubbing technique from the sink to the instrument table. You may focus on one nurse when observing these sequential practices. It is very important to observe different nurses for each of the ten audits with this standard to ensure that your results are representative of the diversity at your workplace.
9. How many ACORN practice audits need to be completed for each standard in the bundle?
Each standard should be audited on ten separate and diverse occasions. You should try to provide a wide snapshot of nurses' practice within your workplace in many different surgical lists, clinical situations and teams. Consider the results you get when you conduct ten audits in one week compared with ten audits in one month – the first example will provide you with a narrow snapshot of practices (not representative and potentially biased) while the second example will provide you with a wider snapshot of practices and is likely to represent more of the diversity in your workplace.
10. What should I do when I observe non-compliant practice doing an audit?
Score practices as non-compliant as and when you observe them. Patient and staff safety are paramount at all times and practice audits are no different in this respect. You should be prepared to speak up if you observe practices that compromise patient or staff safety. Consider whether non-compliant practices are likely to compromise patient or staff safety. It may require immediate intervention or it may require corrective instruction. For example, you may observe a nurse at the scrub sink without protective eyewear. You could observe until the nurse approaches the instrument trolley and prepares for direct patient care. If the nurse has not yet corrected their practice and the circulating nurse has not noticed and provided assistance, you should intervene. You would then score the practice as non-compliant.
11. How do I score a practice that was performed during an audit, if I did not observe it myself?
A general rule of observational audits is that you cannot audit practices that you do not observe. In most instances, it is preferable for you to not score the practice and wait until you can observe the practice – in this way you will score it based on the nurse's real practice (i.e. what the nurse actually does), not on what the nurse's knowledge (i.e. what the nurse knows or their ideal practice). In some instances, you might be able to ask nurses what they did when you were not looking; however, it would not be acceptable to ask nurses what they did before you arrived in the room for the audit. For example, you might ask how the nurse poured the prep solution into the unsighted bowl, or you might read the specimen label yourself and check if the nurse has completed it correctly. Another example would be to ask the nurse about the previous scrub techniques and agents to audit whether the nurse has been compliant with scrub duration and has been consistent with the use of agents.
12. If essential equipment is unavailable for the nurses' use, do I score that as NA (not applicable) or zero (non-compliant)?
When a nurse's practice deviates from the accepted standard it is considered non-compliant and scored as zero (0). Generally, this score is not influenced by the reason for the nurse's non-compliance. As auditor, you could make a note of the reason so that management can take action. For example, 'plastic aprons not available'. This may explain to management why the nurses practice was non-compliant for the month that the equipment was out of stock.
13. Why is the compliance rate higher than 100 per cent?
The excel formulas in the PATs (the yellow cells) have been created to assist with these calculations. The most likely reason for a compliance rate higher than 100 per cent is that you have made an error calculating the scores marked NA. Generally, entering NA will account for any practice that was not required, i.e. not applicable – NA. Check that you have added up all of the NAs and then check and confirm your calculations for the applicable criteria (AC) i.e. the denominator.
NB: The surgical hand antisepsis (SHA) gowning and gloving PAT contains an exception to the NA rule. For this standard, you should observe ONLY one technique for SHA during each audit and should use zero (0) for the criteria in the technique you did not observe. See also Instruction, FAQ 14, Scenario 6 and Scenario 7.
14. There are two possible techniques for surgical hand antisepsis – how do I score the 'unused criteria'?
Whenever the nurse performs surgical hand antisepsis, they will use EITHER the traditional surgical hand scrub (SHS) with running water, OR they will use the waterless technique with alcohol-based hand rub (ABHR). Both of these techniques are acceptable and, when performed correctly, they are considered compliant practice. Therefore, the criteria for the observed technique should be scored 1 when the nurse's practice is compliant. The criteria for the other technique (the technique you did not observe), should be scored zero. This is the only exception to the NA rule (the reason for this exception is related to the excel formulas). See also Instructions, FAQ 13, Scenario 6 and Scenario 7.
15. Why are the ACORN PATs designed to audit only the nurses’ practice and not any other members of the perioperative team?
The intention of the ACORN PAT Project is to look for evidence of Australian perioperative nurses’ compliance with their national standards – the ACORN Standards for Perioperative Nursing in Australia. While individual standards might refer to the multidisciplinary team and might describe what members of the multidisciplinary team should be doing, the focus of the ACORN Standards is the nurses’ roles. So the ACORN PATs are specifically designed as audit tools for perioperative nursing staff only – they have not been validated for use as audit tools for other professions.