Julie A Kneedler, RN
Corrective action completes audit cycle
How do you use the information obtained through an OR nursing audit to improve patient care? When you have completed an audit and determined the strengths and deficiencies, you must take action to correct the deficiencies. The action component of quality assurance guarantees that the quality is attained. As we have been developing quality assurance programs, we have focused on establishing standards of practice and developing measurement tools, both necessary before one can actually look at the quality of care given. AORN has developed Standards of Nursing Practice: Operating Room, published jointly with the American Nurses’ Association and available to our members. A recent survey by the
Julie A Kneedler, R N , EdD, is AORN assistant director of education1 continuing education. A leader of the AORN seminar, “Nursing audit: challenge to the OR nurse,” she received her BSN degree from Walla Walla College, College Place, Wash; her MSN degree from Loma Linda University, Loma Linda, Calif; and her EdD degree in adult continuing education from the University of Northern Colorado, Greeley .
AORN Standards of Nursing Practice Committee reveals that nurses are having problems implementing these standards, especially in the areas of nursing diagnosis, evaluation, and reassessment. To help members implement these standards, AORN is developing a seminar on the implementation of standards, which will be offered in fall 1978. AORN also sponsors seminars on nursing audit that focus on assisting nurses in the operating room to establish criteria for measuring the quality of patient care. In this article, I will go to the next step and discuss the corrective action that should be taken, what changes occur, and the resulting benefits to the hospital, nurse, and patient. “Quality” is defined as a characteristic or attribute denoting excellence or superiority. “Assurance” is defined as the act or actions that guarantee or give confidence. Combining those two terms and applying them to health care, the definition of “quality assurance” is a program to guarantee the excellence of health care. The quality assurance program has two major components. The first is securing measurements and ascertaining the degree to which standards are met. The second is the introduction of change based on information from the
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measurements. The end result of this should be improvement of patient care through the total effort of the hospital or nursing unit. Objectives of audit. Members of an audit committee should develop a statement of philosophy for nursing care in the operating room, write objectives to guide that care in the operating room, and look at determining the overall objectives in terms of improving the quality of nursing care. In determining its objectives, the audit committee may want to 0 identify strengths and weaknesses of nursing care given during the operative period 0 determine whether the nursing records or any records used by the nurses in the operating room reflect the quality of care given 0 determine if there are any problems that interfere with giving quality nursing care in the operating room 0 report findings and make recommendations to the appropriate administrative person (depending on whether the operating room is responsible to nursing or administration) 0 assess whether nursing care has improved when changes have been instituted. The audit committee has a responsibility to select auditors, to gather information, and to identify strengths and weaknesses of nursing care. Once that has been done, the findings should be reported to administrative personnel who must then take the responsibility for initiating corrective action. Some audit committees have encountered difficulties when the supervisor or administrative personnel’s priorities do not coincide with the findings of the audit committee. As a result, no action is taken. As it is developing objectives, the committee can 486
AORN nursing audit seminars
For operating room nurses interested in initiating an audit program in their OR suite or improving their current program, AORN offers information and guidance. AORN has developed an operating room nursing audit tool and guidelines, Nursing Audit: Challenge to the Operating Room Nurse. It also offers two-day seminars in various parts of the country to enable OR nurses to gain a more in-depth knowledge of what nursing audit involves and to discuss with colleagues their progress and problems. At a recent nursing audit seminar in Kansas City, Mo, about 40 OR nurses learned what OR nursing audit involves, how to measure patient care, what tools to use, and how to overcome obstacles. Under the direction of seminar leader Julie Kneedler, the participants had an opportunity to experiment with writing standards and measure criteria, which proved to be more difficult than one might think.
How do you write criteria to measure patient care in the OR? Seminar participants attempt to write both process and outcome standards and criteria, then discuss how successful they have been.
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involve the supervisor or the director of the operating room. Through this involvement, the supervisor knows what the committee is doing and has some idea of what her responsibilities are in the evaluation process. She will probably support the committee and follow through with corrective action. As a result of established objectives, the audit committee will be able t o gather information that can be used for a variety of purposes. These could include accounting for the level of care provided, making comparisons that will determine effective changes made in care practices, determine differences in care provided, determine the extent to which objectives of the program have been attained, and provide a basis for planning for improvement. The most important reason for evaluating patient care is to secure information that can lead to improvement of the quality of care. Strengths and deficiencies identified. Once the audit is completed, the audit committee must analyze the findings. When comparisons between the criteria and actual practice reveal a difference, this is considered a variation and can be either a strength or a weakness. Many times the audit committee or supervisor focuses on correcting only the deficiencies and not capitalizing on the strengths. The staff members should have the benefit of knowing that there has been an improvement in care provided or that the care they have been giving was good in the beginning. Identifying strong positive areas of care increases staff morale and job satisfaction. It also keeps staff alert to its responsibilities for caring, comforting, and personalizing care. Those strengths that consistently show up when reauditing should be analyzed and possibly dropped from the criteria or replaced
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by different or more discriminating criteria. Deficiencies may be in areas such as inadequacy of practice or performance, lack of documentation, and lack of knowledge. For example, an audit tool might be developed on transportation of patients to and from surgery. A deficiency may occur under inadequacy of practice or performance if appropriate personnel were not available when the patient was transferred from the unit bed to the OR gurney. In terms of lack of documentation, the deficiency would be that the method of transportation and identification of patient was not recorded on the patient’s chart. In the area of knowledge, the deficiency might be that the orderlies were not oriented to the transportation procedure and therefore did not know how to carry it out. Other areas where deficiencies frequently occur in relation to the operating room are in the psychosocial aspects of patient c a r e for instance, assisting the patient to cope with his anxiety, establishing rapport and meeting his need to be recognized as an individual patient, and protecting his right to privacy by preventing undue exposure during preparation on the operating table. When deficiencies appear, some judgment needs to be made regarding the importance of the deficiency in terms of the response or end result to the patient and also in terms of improving nursing care. Courses of Corrective action. Courses of corrective action are continuing education, inservice, peer pressure, administrative changes, environmental changes, research, self-initiated change, and reward or punitive action. Continuing education consists of planned learning experiences designed to promote the clinical competency of the nurse in the operating room. These
AORN Journal, September 1977, Vol26, No 3
A participant's hard work is re warded when seminar leader Julie Kneedler confirms that the criteria developed are workable. Photographs by Elinor S Schrader
experiences can take place within the operating room, hospital, or community. The emphasis is on expanding knowledge, skills, and attitudes for the enhancement of nursing practice. To illustrate how continuing education becomes a corrective action, we can envision a deficiency such as incomplete development of a nursing care plan for patients coming to the operating room. It may be that the OR staff has not previously been involved in doing preoperative assessments and developing a plan of care; therefore, it is not familiar with the components of a care plan. The nurses do not understand why it is necessary, what the benefits are, or how to use the nursing process to complete it. To assist the staff, a continuing education program with a series of meetings might be given in the hospital or some of the staff might go to a workshop on de-
veloping OR nursing care plans. These kinds of educational offerings are one avenue whereby the nurse gains additional knowledge and skills for improving her practice, which in the end benefits the patient. Inservice meetings are defined as planned instructional or training programs provided by the employing agency in the employment setting and designed to increase competence in a specific area. Inservice education is one aspect of continuing education, but the terms are not interchangeable. If the audit committee has identified a deficiency relative to positioning the patient on the operating table, it would be appropriate to plan a n inservice meeting for the entire staff where positioning is discussed and may even be demonstrated. Inservice is a n effective course of action. It has been shown that after initial audit inservice
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Courses of action Continuing education Inservice Peer pressure Administrative changes Environmental changes Research Self-initiated change Reward or punitive action
programs have focused on correcting deficiencies, a second audit shows a higher percentage of compliance to established criteria. This applies to deficiencies relative to safety measures, patient interviews, charting, and nursing care plans. Peer pressure results when a pressure group applies subtle force in an effort to provide group conformity. A peer is a person of the same rankone who is equal to another in abilities and qualifications. AORN defines “peer” as a registered nurse with the same role expectations and job description. Any discrepancies or deficiencies identified through audit are brought to the peer group, which assumes responsibility for determining actions to be taken and identifies changes required. If this peer group has cohesiveness, homogeneity, easy communication, and formal status to create group pressure, all individuals work together as a unit to improve patient care. Let’s relate this to the situation in the recovery room immediately postoperatively where the nurse has accompanied the patient and anesthesiologist. The anesthesiologist is busy giving his report to the recovery room nurse. The OR nurse is in a hurry or may be somewhat shy and doesn’t want to interrupt or take an assertive role. Consequently, she leaves without communicating. When the deficiency is revealed in inservice meeting that not all nurses are com490
municating essential data to recovery room personnel, a discussion ensues. The group decides they must all be more assertive and have an obligation to the patient. They decide that on a day-to-day basis they will observe each other and give positive or negative feedback on whether or not they communicate essential data to the recovery room nurse. This, then, becomes the method of validation by group members that should result in 100% compliance when the next audit is taken. Administrative changes refer to those actions that change existing policies, procedures, philosophies, staffing patterns, or other components of the administrative structure of the hospital. For instance, one of the weaknesses identified in an audit was in the procedure for skin preparation of patients having abdominal hysterectomies. The audit criteria stated that the skin preparation should be according to written procedure. The auditor noted that nurses were not following the procedure in that they were adding a step and doing a vaginal preparation. When this was brought back to the OR nurses, the action taken was to review the literature and substantiate their belief that because the surgery necessitates entering the vaginal cavity, a preparation should be done. This was documented through the literature, and the corrective action was a change in the written procedure. Environmental change constitutes any structural changes in the physical surroundings. An outcome of the audit may indicate that quality care could be improved if a sink is installed in an isolation room so nurses and physicians can readily wash their hands. Or more specifically in terms of the operating room, the audit may point out the need to provide a holding area
AORN Journal, S e p t d e r 1977, Vol26, N o 3
T
he OR staff needs to know what was done well.
for patients. On arrival in the holding area, the patient receives immediate preoperative care such as preoperative shave and medication, assessment relative to emotional status, and information regarding the surgical procedure. This results in more favorable outcomes t o the patient. Research becomes a corrective action when it provides documentation of rationale for decision making that can be translated into practice. As the basis for nursing practice continues to be explored, findings must be applied to the clinical setting. An example for the operating room is the current research by AORN-WICHE (Western Interstate Commission for Higher Education) on nursing activities and patient outcomes. When published, those nursing activities defined and studied in the project can be used by operating room audit committees as a basis for audit tool development. All research with implications for improving the quality of care should be considered. Research does not always have to be empirical in nature but may be instituted by nurses in the OR to test a hypothesis or hunch they may have in relation to the deficiencies that have been revealed by audit. Many operating room supervisors have encouraged their staff to participate in miniexploratory studies to determine the effectiveness of positioning, disposable drapes, and skin disinfectants.
Self-initiated change is a mechanism used by the individual nurse to make appropriate changes in her or his own performance resulting in improvement of patient care. Weaknesses or deficiencies brought out by the audit are presented to the entire group to identify a course of action. Once a course is chosen and the group implements the changes, each individual can assume additional personal responsibility for gaining knowledge and skills at a more advanced level, which will complement and strengthen the group’s action and result in a higher quality of care. Let’s look at the situation regarding positioning in the example under inservice as a course of action. One area of deficiency in positioning was that patients were unduly exposed. During the inservice meeting, all staff was made aware of the deficiency and an explanation was given of the need to protect the patient’s privacy. Shortly thereafter, one staff member attended a seminar on human sexuality. During the seminar, her consciousness was raised regarding the needs of different types of patients having specific types of surgery. As she projected herself into the role of the patient and gained a greater understanding of human response, there was a change in her behavior resulting in a keen sense of responsibility to keep the patient covered whenever possible.
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From audit, to action, to ahange This is how the OR nursing audit resulted in
action and change at one hospital. The audit topic was “Transportationof patient to and from surgery.”The scope of the audit criteria included the span of time the patient was taken from the unit to the OR and back to the unit after surgery. Prior to developing the audit criteria for this topic, a policy and procedure existed that served as guidelines for the department. The initial audit was done and results returned to the operating room supervisor. The results revealed that the existing policy was unrealistic,that the audit tool was confusing for the auditors, that nurses were not communicating certain specific information to the recovery room nurses prior to the patient being transported to the recovery room, that appropriate personnel were not always present on the unit to assist with transfer of the patient from bed to gurney, and that there was inadequate staffing in recovery room Reward or punitive action. Reward simply means to acknowledge positively the strengths identified from the audit. This course of action is often taken for granted. When reviewing the audit analysis as a prerequisite for determining a course of action, it is imperative to look at both strengths and weaknesses. The operating room staff needs to know what was done well. Personnel need to know that patient care is improving and the specific areas of audit show improvement. One purpose of auditing is to measure or evaluate nursing care as well as patient outcomes. Nurses respond to positive feedback regarding their activities. They need to be recognized, shown appreciation, and encouraged. This will result in even greater effort on their part. This can be done by seeking out individuals and giving them positive feedback, presenting strengths to the entire staff at inser-
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resulting in the patient’scondition not being communicated to the family. Corrective action was taken. 1. The policy and procedure for transportation was changed, and the portions of the policy that were unrealistic deleted. 2. The audit tool was changed. Criteria that could not be realistically observed were deleted. The tool was arranged into four distinct categories: (a) transportation of patient from unit to operating room, (b) admission of patient to operating room, (c) transportation of patient from operating room to recovery room, (d) transporting patient from recovety room back to unit. Additional information was added regarding the patient’s diagnosis, type of surgery, patient’s room number, and time the patient was picked up. 3. A staff inservice meeting was held to discuss the deficiencies such as “not vice meetings, or posting positive results on a bulletin board. Punitive action or discipline is the last course of action and should be so considered when trying to correct deficiencies. However, when all else fails, this may be the only recourse left. This course of action could be as simple as going directly to the individual who continuously fails to chart accurately or adequately in an effort to determine why he or she has not changed his or her behavior, or it may go to the extreme of discharge or termination of an employee. Changes. Once a course of action is identified and implementation begins, i t becomes equally important to assure that some change occurs. Those changes that occur should be documented and reported back to the OR staff. As a result of auditing nursing care in the operating room, these changes have been reported.
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communicating to recovery room.” In addition, this meeting focused on the need for documentation, accountability of the nurse, and legal implications. 4. The problem of inadequate personnel to assist on unit with the patient was discussed.
5. Staff in recovery room was increased to assist with patient care and to communicate with the family. 6. An inservice was held for the transportation orderlies to reiterate policy and procedure for transportation.
After changes had been implemented, another audit was done. The corrective actions made a difference. In all categories, the percent of compliance on the second audit was much higher. In addition to the reaudit showing an improvement of patient care, there were other rewarding benefits. The auditors for the reaudit were from other units in the hospital. Once they participated
1. New operating room records or nurse’s notes have been developed to document nursing care given. Some specifics incorporated are (a) positioning of patient, (b) emotional tenor of patient, (c) monitoring devices, (d) observations, (el cultures taken, (0 implants, (g) fluids, (h) tourniquet, (i) needle and sponge counts, and (j) skin and bone graft and donor sites. Guidelines have been developed to help the staff document care that will be meaningful when an audit is performed. 2. Tools have been established to use as guidelines for preoperative assessments. These tools encompass (a) social history, (b) mental status, (c) sensory perception, (d) regulatory mechanisms, (el motor status, (0 nutrition, ( g ) skin and appendages, (h) physical and emotional comfort, (i) reproductive, and (j) teachindlearning needs.
as auditors, their level of consciousness was raised regarding the care that must be given. In turn, these auditors communicated to their units the criteria on the OR audit. The portion concerning transporting the patient from the unit to the OR was actually evaluating staff on the unit. Through their involvement, staff nurses were more cooperative with transportation orderlies when patients were taken from units. It was rewarding to see these changes in attitudes take place. The administrative staff has been provided with data that will assist in planning for staffing variations such as lunch and change of shift. This not only involves recovery room staff but transportation orderlies and personnel on the nursing units. Another need that has been evident is for a holding area. This unit is being constructed, and the audit was one factor that made this a reality. Other benefits have been derived, but these give an example of what can happen when the audit results are followed through and changes implemented.
3. Flow sheets and preoperative preparation sheets have been developed to assist the nurse in documenting nursing care and patient outcomes. 4. Changes have been made in policies and procedures. 5 . Operating room nurses have been able to delineate their role and functions relative to patients in the operating room. 6. Hospitals have built new additions to the physical facility such as patient holding areas and anesthesia storage areas. 7. Staf‘fing patterns have been increased or varied to correct inadequate staffing. 8. Administration has taken on a greater responsibility for providing in-house inservice programs aimed at improving deficiencies identified by the audit. 9. Staff morale has improved be-
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cause of staffs involvement in the audit process, either by serving on the committee or being an auditor. 10. Patients have responded positively to the increased awareness and sensitivity of nurses to their behavior and/or reactions due to the surgical experience. 11. Nurses have taken on a sense of responsibility for self-regulation by being committed to the concept of peer review, and they are influencing supervisors to implement a systematic review in their ORs. 12. Operating room nurses are using the nursing process to a greater extent and developing skills in performing the functions of nursing. The foregoing changes are not a n exhaustive list but convey the fact that, through the process of audit and identification of appropriate courses of action, changes not only can occur but do occur. As operating room nurses, we are on the threshold of identifying those nursing actions that are critical in the operating room and result in positive patient outcomes. Benefits of audit. Some overall benefits resulting from the audit must be compared with the initial objectives. The patient is the focal point of any evaluation of measure conducted in an operating room. However, the benefits are more far reaching than many anticipate. Audits benefit operating rooms by emphasizing the need for a workable philosophy and objectives that reflect the kind of nursing care the staff believes should be given. Establishing standards of practice is essential to the audit process and must reflect nursing practice in the operating room. Nurses in the operating room are beginning t o identify nursing actions requiring independent nursing judgments as well as dependent functions. They are
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becoming increasingly involved as members of the health care team on a collegial basis. The use of the nursing process in the preoperative period has been incorporated into the nurse’s daily routine, and nursing care plans are being used as mechanisms for providing continuity of patient care. Documentation of care given is beginning to emerge on the patient’s chart, and communications are improving between the operating room staff and unit staff. The incentive for improving patient care exists in the operating room, and nurses are making every effort to be involved in providing higher quality patient care. Equipment is being checked more regularly and defects reported. Inservice or staff meetings are being held regularly; whereas in the past, they were very sporadic. The staff as a unit is participating in the decision making regarding the best approach to solving problems in relation to audit weaknesses. The monitoring function of quality assurance programs, in other words the assurance, is a crucial service. This can only be accomplished by completing the entire cycle of the evaluation process. The cycle begins by identifying professional values and determining the level of care patients in the operating room should receive through written standards of practice. It is further accomplished through development of an audit tool with discriminating criteria that demonstrate the strengths and weaknesses of care given to patients. Based on strengths and weaknesses, a course of action should be chosen that will result in improved patient care. Benefits derived from the entire process will be far reaching and encompass aspects of the hospital, administrative and environmental structure, nursing activities, and outcomes of patients. 0
AORN Journal, September 1977, Vol26, No 3
Corrective action completes audit cycle
How do you use the information obtained through an OR nursing audit to improve patient care? When you have completed an audit and determined the strengths and deficiencies, you must take action to correct the deficiencies. The action component of quality assurance guarantees that the quality is attained. As we have been developing quality assurance programs, we have focused on establishing standards of practice and developing measurement tools, both necessary before one can actually look at the quality of care given. AORN has developed Standards of Nursing Practice: Operating Room, published jointly with the American Nurses’ Association and available to our members. A recent survey by the
Julie A Kneedler, R N , EdD, is AORN assistant director of education1 continuing education. A leader of the AORN seminar, “Nursing audit: challenge to the OR nurse,” she received her BSN degree from Walla Walla College, College Place, Wash; her MSN degree from Loma Linda University, Loma Linda, Calif; and her EdD degree in adult continuing education from the University of Northern Colorado, Greeley .
AORN Standards of Nursing Practice Committee reveals that nurses are having problems implementing these standards, especially in the areas of nursing diagnosis, evaluation, and reassessment. To help members implement these standards, AORN is developing a seminar on the implementation of standards, which will be offered in fall 1978. AORN also sponsors seminars on nursing audit that focus on assisting nurses in the operating room to establish criteria for measuring the quality of patient care. In this article, I will go to the next step and discuss the corrective action that should be taken, what changes occur, and the resulting benefits to the hospital, nurse, and patient. “Quality” is defined as a characteristic or attribute denoting excellence or superiority. “Assurance” is defined as the act or actions that guarantee or give confidence. Combining those two terms and applying them to health care, the definition of “quality assurance” is a program to guarantee the excellence of health care. The quality assurance program has two major components. The first is securing measurements and ascertaining the degree to which standards are met. The second is the introduction of change based on information from the
AORN Journal, September 1977, Vol26, No 3
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measurements. The end result of this should be improvement of patient care through the total effort of the hospital or nursing unit. Objectives of audit. Members of an audit committee should develop a statement of philosophy for nursing care in the operating room, write objectives to guide that care in the operating room, and look at determining the overall objectives in terms of improving the quality of nursing care. In determining its objectives, the audit committee may want to 0 identify strengths and weaknesses of nursing care given during the operative period 0 determine whether the nursing records or any records used by the nurses in the operating room reflect the quality of care given 0 determine if there are any problems that interfere with giving quality nursing care in the operating room 0 report findings and make recommendations to the appropriate administrative person (depending on whether the operating room is responsible to nursing or administration) 0 assess whether nursing care has improved when changes have been instituted. The audit committee has a responsibility to select auditors, to gather information, and to identify strengths and weaknesses of nursing care. Once that has been done, the findings should be reported to administrative personnel who must then take the responsibility for initiating corrective action. Some audit committees have encountered difficulties when the supervisor or administrative personnel’s priorities do not coincide with the findings of the audit committee. As a result, no action is taken. As it is developing objectives, the committee can 486
AORN nursing audit seminars
For operating room nurses interested in initiating an audit program in their OR suite or improving their current program, AORN offers information and guidance. AORN has developed an operating room nursing audit tool and guidelines, Nursing Audit: Challenge to the Operating Room Nurse. It also offers two-day seminars in various parts of the country to enable OR nurses to gain a more in-depth knowledge of what nursing audit involves and to discuss with colleagues their progress and problems. At a recent nursing audit seminar in Kansas City, Mo, about 40 OR nurses learned what OR nursing audit involves, how to measure patient care, what tools to use, and how to overcome obstacles. Under the direction of seminar leader Julie Kneedler, the participants had an opportunity to experiment with writing standards and measure criteria, which proved to be more difficult than one might think.
How do you write criteria to measure patient care in the OR? Seminar participants attempt to write both process and outcome standards and criteria, then discuss how successful they have been.
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involve the supervisor or the director of the operating room. Through this involvement, the supervisor knows what the committee is doing and has some idea of what her responsibilities are in the evaluation process. She will probably support the committee and follow through with corrective action. As a result of established objectives, the audit committee will be able t o gather information that can be used for a variety of purposes. These could include accounting for the level of care provided, making comparisons that will determine effective changes made in care practices, determine differences in care provided, determine the extent to which objectives of the program have been attained, and provide a basis for planning for improvement. The most important reason for evaluating patient care is to secure information that can lead to improvement of the quality of care. Strengths and deficiencies identified. Once the audit is completed, the audit committee must analyze the findings. When comparisons between the criteria and actual practice reveal a difference, this is considered a variation and can be either a strength or a weakness. Many times the audit committee or supervisor focuses on correcting only the deficiencies and not capitalizing on the strengths. The staff members should have the benefit of knowing that there has been an improvement in care provided or that the care they have been giving was good in the beginning. Identifying strong positive areas of care increases staff morale and job satisfaction. It also keeps staff alert to its responsibilities for caring, comforting, and personalizing care. Those strengths that consistently show up when reauditing should be analyzed and possibly dropped from the criteria or replaced
488
by different or more discriminating criteria. Deficiencies may be in areas such as inadequacy of practice or performance, lack of documentation, and lack of knowledge. For example, an audit tool might be developed on transportation of patients to and from surgery. A deficiency may occur under inadequacy of practice or performance if appropriate personnel were not available when the patient was transferred from the unit bed to the OR gurney. In terms of lack of documentation, the deficiency would be that the method of transportation and identification of patient was not recorded on the patient’s chart. In the area of knowledge, the deficiency might be that the orderlies were not oriented to the transportation procedure and therefore did not know how to carry it out. Other areas where deficiencies frequently occur in relation to the operating room are in the psychosocial aspects of patient c a r e for instance, assisting the patient to cope with his anxiety, establishing rapport and meeting his need to be recognized as an individual patient, and protecting his right to privacy by preventing undue exposure during preparation on the operating table. When deficiencies appear, some judgment needs to be made regarding the importance of the deficiency in terms of the response or end result to the patient and also in terms of improving nursing care. Courses of Corrective action. Courses of corrective action are continuing education, inservice, peer pressure, administrative changes, environmental changes, research, self-initiated change, and reward or punitive action. Continuing education consists of planned learning experiences designed to promote the clinical competency of the nurse in the operating room. These
AORN Journal, September 1977, Vol26, No 3
A participant's hard work is re warded when seminar leader Julie Kneedler confirms that the criteria developed are workable. Photographs by Elinor S Schrader
experiences can take place within the operating room, hospital, or community. The emphasis is on expanding knowledge, skills, and attitudes for the enhancement of nursing practice. To illustrate how continuing education becomes a corrective action, we can envision a deficiency such as incomplete development of a nursing care plan for patients coming to the operating room. It may be that the OR staff has not previously been involved in doing preoperative assessments and developing a plan of care; therefore, it is not familiar with the components of a care plan. The nurses do not understand why it is necessary, what the benefits are, or how to use the nursing process to complete it. To assist the staff, a continuing education program with a series of meetings might be given in the hospital or some of the staff might go to a workshop on de-
veloping OR nursing care plans. These kinds of educational offerings are one avenue whereby the nurse gains additional knowledge and skills for improving her practice, which in the end benefits the patient. Inservice meetings are defined as planned instructional or training programs provided by the employing agency in the employment setting and designed to increase competence in a specific area. Inservice education is one aspect of continuing education, but the terms are not interchangeable. If the audit committee has identified a deficiency relative to positioning the patient on the operating table, it would be appropriate to plan a n inservice meeting for the entire staff where positioning is discussed and may even be demonstrated. Inservice is a n effective course of action. It has been shown that after initial audit inservice
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Courses of action Continuing education Inservice Peer pressure Administrative changes Environmental changes Research Self-initiated change Reward or punitive action
programs have focused on correcting deficiencies, a second audit shows a higher percentage of compliance to established criteria. This applies to deficiencies relative to safety measures, patient interviews, charting, and nursing care plans. Peer pressure results when a pressure group applies subtle force in an effort to provide group conformity. A peer is a person of the same rankone who is equal to another in abilities and qualifications. AORN defines “peer” as a registered nurse with the same role expectations and job description. Any discrepancies or deficiencies identified through audit are brought to the peer group, which assumes responsibility for determining actions to be taken and identifies changes required. If this peer group has cohesiveness, homogeneity, easy communication, and formal status to create group pressure, all individuals work together as a unit to improve patient care. Let’s relate this to the situation in the recovery room immediately postoperatively where the nurse has accompanied the patient and anesthesiologist. The anesthesiologist is busy giving his report to the recovery room nurse. The OR nurse is in a hurry or may be somewhat shy and doesn’t want to interrupt or take an assertive role. Consequently, she leaves without communicating. When the deficiency is revealed in inservice meeting that not all nurses are com490
municating essential data to recovery room personnel, a discussion ensues. The group decides they must all be more assertive and have an obligation to the patient. They decide that on a day-to-day basis they will observe each other and give positive or negative feedback on whether or not they communicate essential data to the recovery room nurse. This, then, becomes the method of validation by group members that should result in 100% compliance when the next audit is taken. Administrative changes refer to those actions that change existing policies, procedures, philosophies, staffing patterns, or other components of the administrative structure of the hospital. For instance, one of the weaknesses identified in an audit was in the procedure for skin preparation of patients having abdominal hysterectomies. The audit criteria stated that the skin preparation should be according to written procedure. The auditor noted that nurses were not following the procedure in that they were adding a step and doing a vaginal preparation. When this was brought back to the OR nurses, the action taken was to review the literature and substantiate their belief that because the surgery necessitates entering the vaginal cavity, a preparation should be done. This was documented through the literature, and the corrective action was a change in the written procedure. Environmental change constitutes any structural changes in the physical surroundings. An outcome of the audit may indicate that quality care could be improved if a sink is installed in an isolation room so nurses and physicians can readily wash their hands. Or more specifically in terms of the operating room, the audit may point out the need to provide a holding area
AORN Journal, S e p t d e r 1977, Vol26, N o 3
T
he OR staff needs to know what was done well.
for patients. On arrival in the holding area, the patient receives immediate preoperative care such as preoperative shave and medication, assessment relative to emotional status, and information regarding the surgical procedure. This results in more favorable outcomes t o the patient. Research becomes a corrective action when it provides documentation of rationale for decision making that can be translated into practice. As the basis for nursing practice continues to be explored, findings must be applied to the clinical setting. An example for the operating room is the current research by AORN-WICHE (Western Interstate Commission for Higher Education) on nursing activities and patient outcomes. When published, those nursing activities defined and studied in the project can be used by operating room audit committees as a basis for audit tool development. All research with implications for improving the quality of care should be considered. Research does not always have to be empirical in nature but may be instituted by nurses in the OR to test a hypothesis or hunch they may have in relation to the deficiencies that have been revealed by audit. Many operating room supervisors have encouraged their staff to participate in miniexploratory studies to determine the effectiveness of positioning, disposable drapes, and skin disinfectants.
Self-initiated change is a mechanism used by the individual nurse to make appropriate changes in her or his own performance resulting in improvement of patient care. Weaknesses or deficiencies brought out by the audit are presented to the entire group to identify a course of action. Once a course is chosen and the group implements the changes, each individual can assume additional personal responsibility for gaining knowledge and skills at a more advanced level, which will complement and strengthen the group’s action and result in a higher quality of care. Let’s look at the situation regarding positioning in the example under inservice as a course of action. One area of deficiency in positioning was that patients were unduly exposed. During the inservice meeting, all staff was made aware of the deficiency and an explanation was given of the need to protect the patient’s privacy. Shortly thereafter, one staff member attended a seminar on human sexuality. During the seminar, her consciousness was raised regarding the needs of different types of patients having specific types of surgery. As she projected herself into the role of the patient and gained a greater understanding of human response, there was a change in her behavior resulting in a keen sense of responsibility to keep the patient covered whenever possible.
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From audit, to action, to ahange This is how the OR nursing audit resulted in
action and change at one hospital. The audit topic was “Transportationof patient to and from surgery.”The scope of the audit criteria included the span of time the patient was taken from the unit to the OR and back to the unit after surgery. Prior to developing the audit criteria for this topic, a policy and procedure existed that served as guidelines for the department. The initial audit was done and results returned to the operating room supervisor. The results revealed that the existing policy was unrealistic,that the audit tool was confusing for the auditors, that nurses were not communicating certain specific information to the recovery room nurses prior to the patient being transported to the recovery room, that appropriate personnel were not always present on the unit to assist with transfer of the patient from bed to gurney, and that there was inadequate staffing in recovery room Reward or punitive action. Reward simply means to acknowledge positively the strengths identified from the audit. This course of action is often taken for granted. When reviewing the audit analysis as a prerequisite for determining a course of action, it is imperative to look at both strengths and weaknesses. The operating room staff needs to know what was done well. Personnel need to know that patient care is improving and the specific areas of audit show improvement. One purpose of auditing is to measure or evaluate nursing care as well as patient outcomes. Nurses respond to positive feedback regarding their activities. They need to be recognized, shown appreciation, and encouraged. This will result in even greater effort on their part. This can be done by seeking out individuals and giving them positive feedback, presenting strengths to the entire staff at inser-
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resulting in the patient’scondition not being communicated to the family. Corrective action was taken. 1. The policy and procedure for transportation was changed, and the portions of the policy that were unrealistic deleted. 2. The audit tool was changed. Criteria that could not be realistically observed were deleted. The tool was arranged into four distinct categories: (a) transportation of patient from unit to operating room, (b) admission of patient to operating room, (c) transportation of patient from operating room to recovery room, (d) transporting patient from recovety room back to unit. Additional information was added regarding the patient’s diagnosis, type of surgery, patient’s room number, and time the patient was picked up. 3. A staff inservice meeting was held to discuss the deficiencies such as “not vice meetings, or posting positive results on a bulletin board. Punitive action or discipline is the last course of action and should be so considered when trying to correct deficiencies. However, when all else fails, this may be the only recourse left. This course of action could be as simple as going directly to the individual who continuously fails to chart accurately or adequately in an effort to determine why he or she has not changed his or her behavior, or it may go to the extreme of discharge or termination of an employee. Changes. Once a course of action is identified and implementation begins, i t becomes equally important to assure that some change occurs. Those changes that occur should be documented and reported back to the OR staff. As a result of auditing nursing care in the operating room, these changes have been reported.
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communicating to recovery room.” In addition, this meeting focused on the need for documentation, accountability of the nurse, and legal implications. 4. The problem of inadequate personnel to assist on unit with the patient was discussed.
5. Staff in recovery room was increased to assist with patient care and to communicate with the family. 6. An inservice was held for the transportation orderlies to reiterate policy and procedure for transportation.
After changes had been implemented, another audit was done. The corrective actions made a difference. In all categories, the percent of compliance on the second audit was much higher. In addition to the reaudit showing an improvement of patient care, there were other rewarding benefits. The auditors for the reaudit were from other units in the hospital. Once they participated
1. New operating room records or nurse’s notes have been developed to document nursing care given. Some specifics incorporated are (a) positioning of patient, (b) emotional tenor of patient, (c) monitoring devices, (d) observations, (el cultures taken, (0 implants, (g) fluids, (h) tourniquet, (i) needle and sponge counts, and (j) skin and bone graft and donor sites. Guidelines have been developed to help the staff document care that will be meaningful when an audit is performed. 2. Tools have been established to use as guidelines for preoperative assessments. These tools encompass (a) social history, (b) mental status, (c) sensory perception, (d) regulatory mechanisms, (el motor status, (0 nutrition, ( g ) skin and appendages, (h) physical and emotional comfort, (i) reproductive, and (j) teachindlearning needs.
as auditors, their level of consciousness was raised regarding the care that must be given. In turn, these auditors communicated to their units the criteria on the OR audit. The portion concerning transporting the patient from the unit to the OR was actually evaluating staff on the unit. Through their involvement, staff nurses were more cooperative with transportation orderlies when patients were taken from units. It was rewarding to see these changes in attitudes take place. The administrative staff has been provided with data that will assist in planning for staffing variations such as lunch and change of shift. This not only involves recovery room staff but transportation orderlies and personnel on the nursing units. Another need that has been evident is for a holding area. This unit is being constructed, and the audit was one factor that made this a reality. Other benefits have been derived, but these give an example of what can happen when the audit results are followed through and changes implemented.
3. Flow sheets and preoperative preparation sheets have been developed to assist the nurse in documenting nursing care and patient outcomes. 4. Changes have been made in policies and procedures. 5 . Operating room nurses have been able to delineate their role and functions relative to patients in the operating room. 6. Hospitals have built new additions to the physical facility such as patient holding areas and anesthesia storage areas. 7. Staf‘fing patterns have been increased or varied to correct inadequate staffing. 8. Administration has taken on a greater responsibility for providing in-house inservice programs aimed at improving deficiencies identified by the audit. 9. Staff morale has improved be-
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cause of staffs involvement in the audit process, either by serving on the committee or being an auditor. 10. Patients have responded positively to the increased awareness and sensitivity of nurses to their behavior and/or reactions due to the surgical experience. 11. Nurses have taken on a sense of responsibility for self-regulation by being committed to the concept of peer review, and they are influencing supervisors to implement a systematic review in their ORs. 12. Operating room nurses are using the nursing process to a greater extent and developing skills in performing the functions of nursing. The foregoing changes are not a n exhaustive list but convey the fact that, through the process of audit and identification of appropriate courses of action, changes not only can occur but do occur. As operating room nurses, we are on the threshold of identifying those nursing actions that are critical in the operating room and result in positive patient outcomes. Benefits of audit. Some overall benefits resulting from the audit must be compared with the initial objectives. The patient is the focal point of any evaluation of measure conducted in an operating room. However, the benefits are more far reaching than many anticipate. Audits benefit operating rooms by emphasizing the need for a workable philosophy and objectives that reflect the kind of nursing care the staff believes should be given. Establishing standards of practice is essential to the audit process and must reflect nursing practice in the operating room. Nurses in the operating room are beginning t o identify nursing actions requiring independent nursing judgments as well as dependent functions. They are
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becoming increasingly involved as members of the health care team on a collegial basis. The use of the nursing process in the preoperative period has been incorporated into the nurse’s daily routine, and nursing care plans are being used as mechanisms for providing continuity of patient care. Documentation of care given is beginning to emerge on the patient’s chart, and communications are improving between the operating room staff and unit staff. The incentive for improving patient care exists in the operating room, and nurses are making every effort to be involved in providing higher quality patient care. Equipment is being checked more regularly and defects reported. Inservice or staff meetings are being held regularly; whereas in the past, they were very sporadic. The staff as a unit is participating in the decision making regarding the best approach to solving problems in relation to audit weaknesses. The monitoring function of quality assurance programs, in other words the assurance, is a crucial service. This can only be accomplished by completing the entire cycle of the evaluation process. The cycle begins by identifying professional values and determining the level of care patients in the operating room should receive through written standards of practice. It is further accomplished through development of an audit tool with discriminating criteria that demonstrate the strengths and weaknesses of care given to patients. Based on strengths and weaknesses, a course of action should be chosen that will result in improved patient care. Benefits derived from the entire process will be far reaching and encompass aspects of the hospital, administrative and environmental structure, nursing activities, and outcomes of patients. 0
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