The evolving role of advanced practice nurses in surgery

AORN Journal,  May, 1998  by Denise M. Hodson

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UNLICENSED ASSISTIVE PERSONNEL

The driving force of health care reform has been cost management. Financial imperatives have prompted opportunities for unlicensed assistive personnel (UAP), especially within the surgical environment; however, initial cost-effective measures do not always equate to long-term quality care or cost savings. An extensive critique of studies related to UAP from 1975 to 1997 supports this phenomenon and prompts questioning of the statistical significance of data supporting the UAP role.(17) Data relating to UAP education was disturbing: Only 26% of hospitals required UAP to have high school diplomas, and only 65% of UAP positions required any education preparation.

The studies presented a clear picture of excessive nonproductive time associated with the use of UAP. No conclusions were reached regarding productivity or patient care costs related to the use of UAP because of lack of methodology. Documentation of patient satisfaction and quality effects related to UAP also were hard to demonstrate. Many of the UAP studies represented poor methodological rigor and four repetitive deficits: sampling, unknown psychometric instrument properties, failure to control confounding and extraneous variables, and incomplete reporting of statistical analysis.(18) The studies did not generalize information to a specific UAP group.

CERTIFIED SURGICAL TECHNOLOGIES

Certified surgical technologists (CSTs) now are striving to gain registration as a profession. AORN is opposed to the state licensure of CSTs because CSTs would be removed from the direct supervision of professional nurses who are trained to make decisions regarding patient care needs and to evaluate patient care processes and outcomes.(19) Public safety is not enhanced by a class of providers who are not accountable to another profession (eg, surgeons, nurses) through delegated tasks. Education for CSTs does not include the nursing process, judgment about patient needs, or evaluation of patient outcomes.(20) Registered nurse first assistants are challenged with researching and documenting the education, utilization, and outcomes related to the use of CSTs as assistants in surgery. Rigorous comparative research studies are necessary to further solidify the necessity for professional nurses in the assistant role. Additional nursing outcome data related to complications, cost savings, decreased surgical length of stay, and patient and physician satisfaction also will solidify job security for surgical APNs.

This article will explore the latest research to differentiate between expanded and advanced nursing practice, discuss the expanded knowledge bases for RNFAs, and offer a conceptual mo&I for acute care nursing practice with applications to the surgical arena. Literature will be reviewed that provides evidence that surgical APNs in collaborative practice have the potential to create innovative solutions for improving quality of care, decreasing costs, and improving surgical outcomes.(21) Advanced practice nursing will be discussed on a macro level to enhance surgical practitioners' and administrators' awareness of the APN role evolution, domains of practice, education, and necessity for evaluative research.