The critical "nurse" in the circulating nurse role - registered versus unlicensed supervision - Statistical Data Included

AORN Journal, May, 2001 by Kimberly Matson

Almost 100 years ago, state boards of nursing began to be formed to protect the public's health. Today, these boards establish standards for safe nursing care and issue licenses to individuals to practice nursing, all in an effort to ensure patient safety.(1) In concert with this, in October 2000, the AORN Board of Directors amended the Association's legislative priorities. AORN now is striving to ensure the supervisory presence of the professional RN in the perioperative arena, promote AORN's position that "every surgical patient deserves a perioperative nurse," and ensure that state laws require an RN to be in the circulator role.

WHAT IS A CIRCULATING NURSE?

A circulating nurse is an RN who "circulates" throughout the OR and is responsible for coordinating procedures and ensuring the patient's safety and comfort. Registered nurses are trained to provide total patient care, perform patient assessments, and understand how to prioritize and plan care. The individual in the circulating role must have these skills because he or she can be held legally responsible for any problems that arise in the OR.(2)

The circulating nurse's duties are performed outside the sterile field. The circulating nurse is responsible for managing the nursing care of the patient and coordinating the needs of surgical team members and other care providers needed for each procedure. Using critical thinking skills, the circulating nurse observes the procedure from a broad perspective and helps team members create and maintain a safe and comfortable environment for the patient. The circulating nurse assesses the patient's condition before, during, and after the procedure to ensure optimal patient outcomes.(3)

The circulating nurse is educated in every aspect of the nursing process (ie, assessment, identification of nursing diagnoses, planning, implementation, evaluation). Accordingly, the circulating nurse performs a preoperative patient assessment, develops and implements an individualized plan of care, and continuously evaluates patient outcomes during the intraoperative phase.(4)

NURSING SHORTAGE

The need for public protection through regulation has never been greater due in large part to the nursing shortage. Faced with a shortage of qualified nurses, hospital administrators and OR managers are pressured to hire less qualified personnel to meet their staffing needs. Failure to maintain standards of practice can lead to increased errors, increased risk for patient harm, and a lack of public confidence.(5) In response to the nursing shortage, the National Council of State Boards of Nursing wants to ensure that unlicensed assistive personnel (UAP) are used appropriately and that licensed nurses practice according to their state or territorial nurse practice acts.(6)

The issue of UAP in the circulating role is controversial. In some instances, an institution may loosely interpret the Health Care Financing Administration (HCFA) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) rules, which require an RN to be "immediately available."(7) Based on their interpretations, these institutions may have an RN supervise several ORs simultaneously and have UAP function in the scrub and circulator roles.(7)

Yet, problems can arise. If an RN is needed to abate a crisis in one OR, he or she no longer is "immediately available" in the other ORs. In addition, the circulating nurse performs certain tasks (eg, mixing medications, assessing patients, documenting care) that should not be delegated to UAP. Finally, a surgical patient's condition may become critical without warning. The circulating nurse must adapt to changes and revise the patient's care plan based on new assessments. This cannot be accomplished unless the circulating nurse is present during the entire procedure.(8)

One of the most forceful arguments is that in 20 states it is illegal for anyone but an RN to circulate. Although UAP may possess the technical skills to circulate, they do not have the ability to apply the nursing process to perioperative patient care.(9) To ensure patient safety, an RN must fill the role of the circulator.

FEDERAL REGULATION BY HCFA

There is no federal statute governing the circulating role; however, HCFA does have conditions of participation for hospitals and ambulatory surgical centers that provide reimbursable services for Medicare and Medicaid patients. The current HCFA role governing surgical services, [sections] 482.51, states that

* ORs must be supervised by an experienced RN or a doctor of medicine or osteopathy;

* licensed practical nurses (LPNs) and surgical technologists may serve in the scrub role under the supervision of a RN;

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