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Circling the wagons - Health Policy Issues

AORN Journal, July, 2002 by Frederick P. Franko

Three presenters offered their unique perspectives on the perioperative arena in the education session "Circling the Wagons: Staffing the Perioperative Setting" at the 2002 AORN Congress in Anaheim, Calif. The session examined the issue of the RN as a circulating nurse in the face of a growing nursing shortage. It also provided a broader view of where perioperative nursing and health care may go in the near future.

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The presentation was an appropriate follow-up to the previous day's session "Staffing Today's OR: What Works," which examined determining safe staffing levels and benchmarking data. Judith Pins, RN, BSN, MHRD, MBA, and Judy Swanson, RN, BS, provided an overview for attendees on how to determine safe staffing levels and what they should look for in benchmarking data. In contrast, the presenters in the "Circling the Wagons" session spoke about their own experiences with stress, trends, and strategies when dealing with staffing issues.

WHAT IS IN PLACE NOW?

One of AORN's legislative priorities is to "ensure that state laws require RNs in the circulator role." (1) This priority helps AORN's Department of Government Affairs direct legislative and regulatory efforts. Fred Franko, AORN's state legislative coordinator and session moderator, opened the "Circling the Wagons" session by reviewing AORN's legislative priorities and the current laws and regulations that influence the perioperative work environment.

An important federal regulation pertaining to the perioperative arena is contained in the conditions for participation of hospitals receiving Medicare and Medicaid reimbursement through the Centers for Medicare and Medicaid Services (CMS). These conditions state that ORs must be supervised by an experienced RN or doctor of medicine or osteopathy. They further state that qualified RNs may perform circulating duties in the OR, and licensed practical nurses and surgical technologists may assist in circulatory duties under the supervision of a qualified RN. (2) In December 1997, CMS proposed a rule change removing the prescriptive language and replacing it with broad language that essentially would say surgical procedures can be performed only by practitioners with appropriate clinical privileges. AORN has fought to retain the prescriptive language, and CMS has not released any final rules.

State laws and regulations govern the profession of nursing. Perioperative nurses should familiarize themselves with their state laws and regulations, particularly those that define their practice and guide staffing in the OR. Presently, at least 25 states have regulations pertaining to the circulating role, and some are more prescriptive than others. For example, the regulations in Alaska say, "A registered nurse must be present to circulate for each surgical procedure." (3) In Massachusetts, however, the regulations for staffing the OR are outlined in the "Incorporation of Medicare Conditions of Participation in Hospitals." If the Medicare conditions of participation change, then the requirements for staffing the OR in Massachusetts will change.

A MEMBER OF THE TEAM

The first presenter in the "Circling the Wagons" session was Jill Anderson, RN, CNOR, a perioperative nurse for 11 years and currently a staff nurse with Mission Hospital Regional Medical Center, Mission Viejo, Calif. Anderson initially spoke about what drew her to the OR, which was the idea of fit (eg, fitting in the family, fitting with the team). She described the sense of family in the OR, which she saw as a team of players who work well together.

It was not long, however, before Anderson's ideal of the OR as a family working together was tested. The OR supervisor in her hospital left, followed by other staff members. People moved on, and the team broke apart. The hospital started using traveling nurses, which it continues to do today, 11 years later. Anderson soon realized that one key to achieving the ideal of a team or family working together was developing good working relationships with coworkers and managers. This ideal did not just happen; it was the result of team members communicating with each other. Ongoing communication helps retain a collegial atmosphere for current staff members and provides a way to integrate temporary staff members into the team.

Taking care of yourself, said Anderson, is critical for taking care of your patients. Conversely, not taking care of yourself increases the risk to your patients. These two concepts, communication as a means of working well together and taking care of yourself, have the ultimate objective of providing optimal care to patients.

A BROADER PERSPECTIVE

Staffing in the perioperative setting is a balancing act of meeting the needs of staff members, surgeons, and patients. All this must be taken into account within the context of the organizational mission of the health care facility. As nursing director of perioperative services for Children's Hospital of Philadelphia, Brenda McKonly, RN, MS, MBA, CNOR, understands staffing issues in the OR from a broader perspective. McKonly is responsible for the OR, postanesthesia care unit (PACU), day surgery unit, cardiothoracic OR, cardiac catherization laboratory, and three off-site surgery units.

Health Care Industry

Circling the wagons - Health Policy Issues

AORN Journal, July, 2002 by Frederick P. Franko

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