The RN in the circulator role—a proactive approach - Health Policy Issues

AORN Journal, March, 2004 by Frederick P. Franko

Ensuring that there is a perioperative RN in the circulator role in the OR is one of AORN's top legislative priorities. Every patient deserves a perioperative RN during their surgical experience. AORN President Betty Shultz, RN, CNOR, reiterated this point in her presentation at the 2003 AORN Congress in Chicago. (1) Advocating for the RN in the role of circulating nurse in the OR is not new, but AORN has renewed its level of commitment to achieve this objective in all 50 states.

AORN's legislative priority specifically states,

   AORN maintains that every surgical
   patient deserves a perioperative
   registered nurse and works to
   ensure the supervisory presence of
   the professional RN in the perioperative
   arena with laws and regulations,
   both at the state and federal
   level, requiring a registered nurse in
   the circulatory role. (2)

AORN's underlying principles provide a foundation that helps serve as a guide in public policy issues perioperative nurses face and will face in the future. This underlying foundation emphasizes the care of patients and the work and commitment that goes into providing the best care for patients. The desired result is a positive patient outcome. AORN's "Statement on perioperative patient care quality" says, "it is the responsibility of the registered professional nurse to ensure high-quality nursing care to patients undergoing surgery." (3) AORN's mission statement reads "AORN supports registered nurses in achieving optimal outcomes for patients undergoing operative and other invasive procedures." (4) Having an RN in the OR is one way to help ensure that high quality nursing care is provided.

THE CIRCULATING ROLE

Perioperative RNs are fundamental members of the surgical team, working in collaboration with other health care providers, including the surgeon, anesthesia care provider, surgical assistant, and assistive personnel. Perioperative RNs provide nursing care to surgical patients preoperatively, intraoperatively, and postoperatively. Stated simply, perioperative nursing activities should be performed by a registered professional nurse.

Circulating during surgery is a perioperative nursing function. AOKN's support for laws and regulations requiring RNs in the circulator role, goes to the heart of AORN's mission statement and strategic direction. The long-range objective is to have meaningful laws or regulations in all 50 states. Currently, 27 states have some form of regulatory language requiring an RN in the circulator role, and 39 states have regulations requiring some level of supervision by RNs in the OR.

To realize the best outcomes for patients, AORN works to ensure that only qualified individuals are practicing nursing care and medicine in the perioperative arena. This requires individuals qualified by education and experience relevant to their respective roles. Providing perioperative nursing care requires specific nursing education and experiential learning. The circulating RN possesses the unique education and experience to monitor and evaluate the quality of nursing care in the perioperative arena. To provide optimal care, the RN makes use of nursing judgment, critical thinking skills, and interpersonal communication skills.

LAWS AND REGULATIONS

In December 1997, the Centers for Medicare and Medicaid Services (CMS)--then known as the Health Care Financing Administration--proposed changing conditions of participation for hospitals and ambulatory surgical centers that receive reimbursement for Medicare and Medicaid patients. (5) The proposed rule change would have removed the prescriptive language governing surgical services in the Code of Federal Regulations and replaced it with new language, that "surgical procedures be performed only by practitioners with appropriate clinical privileges." (6)

AORN and its members were active in efforts to stop the change in the months and years immediately following its publication. At this time, there is no indication that CMS will try to move forward with the proposed rule change.

The following are the main elements of [section] 482.51 Condition of participation: Surgical services, that currently are in effect.

* The OR must be supervised by an experienced RN or doctor of medicine or osteopathy.

* Licensed practical nurses (LPNs) and surgical technologists may serve as scrub persons under the supervision of an RN.

* Qualified RNs may perform circulator duties in the OR. In accordance with applicable state laws and approved medical staff policies and procedures, LPNs and surgical technologists may assist in circulator duties under the supervision of a qualified RN who is immediately available to respond to emergencies.

* Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service must maintain a roster of practitioners specifying the surgical privileges of each practitioner. (7)

STATE REGULATION

At this time, most of AORN's attention is focused at the state level. State governments regulate the professions and oversee the licensing of hospitals, ambulatory centers, and physician's offices (Table 1). Currently,