An emerging role for nurse practitioners—preoperative assessment

AORN Journal, Nov, 2005 by Jennifer S. Barnett

Health care needs in US communities are increasing as is the demand for quality, cost-effective health care. (1) As a result, opportunities are arising for nurse practitioners (NPs) to move beyond their primary care role. As NPs continue to explore the full scope of advanced practice nursing, it is important that their contributions in specialty areas be recognized and documented.

Preoperative assessment is an area that presents an opportunity for merging medical and nursing models of care into a specialty role for NPs. This article reviews health-related literature regarding the role and impact of NPs in preoperative assessment and explores the potential for this emerging role to present an alternative to existing preoperative assessment models.

THE NP ROLE

Currently, there are 174,606 advanced practice nurses (APNs) in the United States. (2) Advanced practice nurses include certified nurse midwives, clinical nurse specialists (CNSs), certified RN anesthetists, and NPs. The role of the NP was conceived in 1965. (3) Since then, the NP role has developed and expanded; NPs comprise the largest group of APNs at 115,091, (2) specializing in family, pediatric, adult, geriatric, school, neonatal, psychiatric, women's health, and acute care practice. Nurse practitioners are licensed RNs who have completed master's-level education that includes advanced academic and practical training. Depending on state regulations, NPs are prepared to provide diagnoses, prescribe medicine, and write orders either independently of a physician or with some degree of physician involvement or delegation. (2,4) Nurse practitioners have demonstrated for decades that they can provide quality, cost-effective primary care. (5,6) As a result, the scope of practice for NPs has moved progressively toward increasing professional autonomy. (2) Increased autonomy has paved the way for NIPs to continue exploring specialty roles, such as perioperative care.

AORN defines a perioperative APN as

   ... a registered professional nurse
   who uses specialized knowledge and
   skills in the care of patients and families
   undergoing operative and other
   invasive procedures. (7(p225))

Perioperative care providers are familiar with some of the specialty roles APNs perform in surgical services. Registered nurse first assistants and their master's degree-prepared counterparts, NPs and CNSs, have assisted surgeons in the OR and coordinated patient care for years. Nurse anesthetists have the longest history, with the earliest formal nursing anesthesia training programs dating back to 1915. (8) Nurse anesthetists today have advanced nursing degrees and either work independently or in collaboration with an anesthesiologist. (9) In perioperative services, NPs are beginning to move into the role of preoperative assessment providers.

THE NP ROLE IN PREOPERATIVE ASSESSMENT

Hospital and surgery center personnel have experienced the benefits of conducting a preoperative evaluation before the day of a scheduled surgical procedure. The purpose of this encounter is to identify potential problems that contribute to surgical morbidity and develop a plan to return patients to presurgical levels of functioning as soon as possible. (10) Ideally, this assessment occurs before the day of surgery to allow time to address medical issues and patient education, order special laboratory tests or procedures, and refer the patient for consultations as needed. If these issues are not addressed until the day of surgery, they may result in surgical complications or delay or postpone the surgical procedure (Table 1). Preoperative assessment must be conducted by a skilled practitioner who is familiar with the requirements a patient must meet to undergo anesthesia and has an eye for efficient use of OR time. The practitioner must be able to collect, identify, and interpret important patient information that might otherwise be overlooked. (11)

Traditionally, preoperative assessments have been completed by a physician, an anesthesiologist, or by an RN in collaboration with an anesthesiologist under the supervision of either the nursing or anesthesia department. Nurse practitioners, however, are well-prepared to identify and address the complex needs of preoperative patients. The advanced training and education that NPs receive provides them with the skills to recognize and manage medical, educational, and emotional issues. Additionally, an NP is able to use an understanding of nursing and medical models to provide holistic care by creating collaborative relationships with perioperative team members. Making sure the patient is truly prepared for surgery creates a more positive perioperative experience for patients, their family members, and perioperative staff members.

Although NPs' advanced skills seem suited to the preoperative assessment role, it was not until the early 1990s that the role of NPs in preoperative assessment was documented in the literature. A review of health-related literature revealed six articles that varied in describing the role and highlighting the benefits of NPs in preoperative assessment. Following are summaries of six US hospitals' experiences of using NPs for preoperative assessment.