The Advanced Practice Nurse : An Essential Par t of the Perioperative Leadership Team Victoria M. Steelman, PhD, RN, CNOR, FAAN KEYWORDS  Advanced practice  Evidence-based practice  Leadership  Perioperative nursing       Leadership Clinical practice Education Consultation Management Research The leadership subrole includes collaboration and coordination with nursing and other disciplines to promote a culture of safety and positive patient outcomes. Clinical practice involves advanced assessment skills, complex physiologic monitoring, and independent judgment. Education is provided for patients, family, personnel, other disciplines, and the public. Consultation is an adjunct to education, providing guidance for the care of individual patients, groups of patients, and a safe environment of care. Management involves defining clinical practice, responding to regulatory requirements, and implementing complex changes. The research subrole involves evidence-based practice and collaborating with others in the conduct of research. In some perioperative settings, nurse practitioners are being employed to assess patient conditions and prescribe necessary preoperative medication and medical equipment.4 Nurse practitioners are autonomous, independent, licensed professionals with a scope of practice defined by the state board of nursing. They have prescriptive authority and document in the medical record, including in progress notes and order forms. Within this role, the APN provides care to Department of Nursing, The University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 6509 JCP, Iowa City, IA 52242, USA E-mail address: victoria-steelman@uiowa.edu Perioperative Nursing Clinics 4 (2009) 51–55 doi:10.1016/j.cpen.2008.10.002 1556-7931/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved. periopnursing.theclinics.com The advanced practice nurse (APN) has a vital role in the perioperative leadership team. This person through advanced education coupled with clinical expertise has the background to positively influence the quality of patient care, improve staff safety, and implement evidence-based interdisciplinary changes. APNs include nurse practitioners, nurse anesthetists, nurse midwives, and clinical nurse specialists. Of these, nurse anesthetists and clinical nurse specialists are found more often in perioperative settings. Nurse anesthetists provide direct patient care to one patient at a time. Clinical nurse specialists are more likely to provide indirect care and be part of the perioperative leadership team. The discussion herein focuses on the leadership role of the clinical nurse specialist. The American Nurses’ Association defines the APN as ‘‘The specialist in nursing practice is a nurse who through study and supervised practice at the graduate level (master’s or doctorate) has become expert in a defined area of knowledge and practice in a selected clinical area of nursing.’’1 In 2004, The American Association of Colleges of Nursing published a position statement advocating for the Doctor of Nursing Practice degree, based on a standardized core curriculum, to be the minimum educational preparation for APNs.2 The Association of periOperative Registered Nurses has described perioperative advanced practice nursing and identified different facets of the role as follows:3 52 Steelman individual patients on a patient-to-patient basis. Some nurse practitioners combine advanced practice skills with those of a registered nurse first assistant and provide care to patients preoperatively, intraoperatively, and postoperatively. Clinical nurse specialists, although educated to perform all five subroles described for APNs, are more likely to distribute their workload within one or two of the subroles. They commonly provide indirect patient care and participate as an active member of the perioperative leadership team. This latter role is discussed herein. THE ADVANCED PRACTICE PERIOPERATIVE NURSE IN A LEADERSHIP ROLE Individual APNs in leadership positions operationalize their roles differently, dedicating varying percentages of their work time to different subroles. This role division is based on the strengths of the APN and the priorities identified in collaboration with administration in the clinical practice setting. Some APNs focus more on patient care or education, whereas others focus on managerial responsibilities or evidence-based practice. The subroles are not mutually exclusive, and clinical practice, education, consultation, and management are ways in which the APN demonstrates leadership. The primary objective of the role, regardless of the time distribution between the subroles, is improving the quality of patient care. Leadership through evidence-based practice might be considered a conceptual model to describe advanced practice nursing through which the other subroles are operationalized (Fig. 1). In this way, clinical practice, education, consultation, and management are based on the best evidence available, promoting excellence in nursing practice. CLINICAL PRACTICE AND EDUCATION Traditionally, perioperative APNs serving as clinical nurse specialists have focused primarily on Leadership Evidence-based Practice Clinical Practice Education Consultation Management Fig. 1. Leadership in advanced practice nursing through evidence-based practice. the subrole of education. The APN builds upon his or her clinical expertise and understanding of the evidence guiding practice to educate new and existing staff members. Because new graduate nurses usually have little or no experience in the operating room, orientation of new nurses can be labor intensive and comprise a large percentage of the APN’s workload. This work is an essential contribution to the leadership team. Orientation offers an opportunity to set the stage for high-quality patient care by teaching best practices based on available evidence and instilling a value of inquiry. For example, educating about risk factors for retained sponges increases compliance with surgical counts and the attention to detail required. Likewise, educating about the risks of perioperative hypothermia increases the likelihood that evidence-based measures will be used effectively to promote normothermia. This education is beyond teaching the actual procedures and extends to the rationale and evidence to support these practices. It sets the expectation for high-quality care provided within the perioperative setting. Competency testing is also a part of the education subrole, promoting patient safety by ensuring that staff members are able to perform high risk, high volume, or problem prone job responsibilities in a safe manner. Examples of aspects of patient care that an APN may include in competency testing are listed in Box 1. Competency testing assists the manager with performance appraisal by providing objective data about an individual’s ability to perform. The manager can then design performance improvement programs for areas of concern. Ongoing staff development efforts usually focus on safety, including the correct use of new equipment and changes in established procedures. Some examples may include a new fluid warmer or ultrasonic dissector. The APN minimizes the risk of injury to patients by educating personnel about how to safely use equipment. Continuing education programs provide an opportunity to teach the rationale for practices in more depth, to enhance understanding, and to further develop the skills of personnel. A course preparing nurses for certification is an example of how an APN may develop staff to a higher level of performance than basic competency. Some APNs provide guest lectures to academic programs to inspire student nurses to consider perioperative nursing as a specialty. Others serve as preceptors, teaching student nurses and graduate students. This activity provides an excellent opportunity to role model professional nursing practice and facilitates recruitment of nurses. The Advanced Practice Nurse Box 1 Aspects of patient care included in competency testing Age-specific care Blood salvage Care of the morbidly obese patient Chemotherapy precautions Definitive care Documentation Electrosurgery precautions Personnel safety Ergonomics Prevention of exposures to blood-borne pathogens Prevention of sharps injuries Chemical hazards Smoke evacuation Laser safety Latex precautions Malignant hyperthermia Pneumatic tourniquet safety decision making. Consultations are often made on an individual patient basis or to support decision making for a group of patients. Individual patient consultations include a broad range of clinical issues. Staff nurses often need to make immediate decisions about patient care and have little or no time in which to find and review a policy or search for the best evidence to guide practice. The APN is ideally suited to provide these immediate consultations to maintain the efficiency of the perioperative patient flow while supporting high-quality patient care. Some examples drawn from the log of a perioperative APN are listed in Box 2. These consultations demonstrate the leadership role of the APN in complex decision making as well as providing an opportunity for ‘‘just in time’’ education and mentoring of personnel. Consultations may also be made to other departments, including anesthesia, labor and delivery, the cardiac catheterization laboratory, interventional radiology, intensive care unit, urology suite, digestive disease suite, preoperative areas, and postoperative areas. These consultations may address infection control, safety, the environment of care, or follow-up on adverse events. With more invasive procedures performed in areas outside of the traditional operating room, Radiation safety Sterilization Surgical counts Transmissible infection precautions Box 2 Clinical issues addressed by consultation with an APN Allergy to skin preparation agents The perioperative APN may also provide education to patients and family through one-on-one education or by developing educational material. The patient experience in the operating room can be explained better by someone actively involved in patient care. The perioperative APN may work with others to develop a video for preoperative education or written postoperative instructions. Through collaboration with staff members from other patient care areas, programs can be designed to meet the needs of different patient populations and their family members. The perioperative APN is also called upon to provide outreach education to the public. This education may range from tours of the operating room to presentations to local schools to adult education about perioperative services. In this way, the APN serves as a liaison from the facility to promote health education and the image of the facility. CONSULTATION The perioperative APN serves as a resource person to staff members, offering support for complex Complex positioning Dropped cranial bone flap management Emergency management Family communication Forensic evidence management Incorrect counts Informed consent issues Heating, air conditioning, and ventilation issues Latex allergy Malignant hyperthermia Methylmethacrylate precautions Preoperative fasting Prevention of hypothermia Sterilization issues Supplies opened for extended times Tissue banking Transmissible infections Visitors in the operating room 53 54 Steelman these extradepartmental consultations are increasingly important for the health care facility. Helping other departments develop policies and procedures for conducting surgical procedures in their areas is one way in which the APN acts as a clinical leader and consultant. Consultations provide an opportunity to collaborate with other departments, ensure the same standard of care for patients undergoing surgery outside of the operating room, and improve patient outcomes. MANAGEMENT AND PROGRAM DEVELOPMENT Many perioperative APNs focus a large portion of their workload on managerial responsibilities, including review of standards and regulations, preparation for accreditation surveys, development of new programs or overseeing existing programs, developing policies and procedures, serving on hospital-wide committees, completing short-term projects, and implementing interdisciplinary changes. During recent years, the number of accreditation or review surveys in health care facilities has increased dramatically. Facilities are seeking overall accreditation (eg, Joint Commission) and for designation as a center of excellence (eg, bariatrics). The Food and Drug Administration surveys tissue banks. Other surveys are performed to determine reimbursement (eg, Centers for Medicare and Medicaid, Occupational Safety and Health Administration) or to investigate patient or staff complaints. The perioperative APN is often called upon to prepare for, coordinate, or respond to survey findings, taking a leadership role in implementing change. In recent years, more health care facilities are seeking Magnet status through the Magnet Recognition Program, developed by the American Nurses Credentialing Center. This program recognizes health care organizations that provide nursing excellence. Evaluation of the facility is based on quality indicators and standards of nursing practice. APNs are often called upon to provide documentation required to demonstrate that the facility is meeting these quality indicators, or to implement changes to support the Magnet journey. In addition to accreditation and regulatory compliance, other examples of programs that the perioperative APN may develop, oversee, or dedicate a portion of his or her workload to include bariatrics, conscious sedation, fast track patient care, staff recognition, organ transplants, pain management, quality management, risk management, robotics, skin care, and tissue bank and trauma services. Managerial projects are usually short term in nature and folded into the workload of the perioperative APN. Examples of managerial projects that an APN may lead include communication and hand offs, continuum of care development, family communication and support, fire safety, national patient safety goals, patient satisfaction, policy revision, product evaluation and product recalls, prevention of wrong site surgery, public relations events, root cause analysis, skin integrity, staff recognition events, and surgeon satisfaction. In the current rapidly changing health care arena, the managerial role of the APN is also changing. New initiatives provide additional opportunities to make positive changes for patients and personnel. RESEARCH AND EVIDENCE-BASED PRACTICE Perhaps the most challenging and rewarding subrole of the perioperative APN is that of evidence-based practice and research. There is increasing demand by professional organizations, accrediting agencies, and consumer groups to base patient care on the best evidence available. To meet this expectation, evidence-based practice might be considered a conceptual framework for advanced practice leadership and integrated into each of the subroles described, including clinical practice, education, consultation, and managerial activities (Fig. 1). The APN may be a leader in the integration of evidence-based changes. One major national evidence-based initiative is the Surgical Care Improvement Project. The Joint Commission, Centers for Medicare and Medicaid, and Institute for Health care Improvement support this collaborative effort to reduce the incidence of surgical complications by 25% by the year 2010.5 Perioperative APNs are often called up to implement or evaluate compliance with the infection prevention measures (eg, elimination of razor use; appropriate selection, timing, and discontinuation of prophylactic antibiotics) and the targeted interventions to prevent venous thromboembolism. These changes are complex and interdisciplinary. The skills of the APN as a change agent are called upon to maximize the success of implementation of these improvements. Other evidence-based practice changes may be implemented by the APN in response to new knowledge gained from peer review literature. For example, two chlorhexidine gluconate showers have been found to decolonize patients from Staphylococcus aureus.6 Implementing these preoperative showers has been recommended by the Association of periOperative Registered The Advanced Practice Nurse Nurses.7 A second example is implementation of a clinical practice guideline, such as the American Society of Anesthesiologists guidelines for preoperative fasting.8 Implementation of these changes is complex and requires interdisciplinary collaboration. The APN may serve as the leader in the practice change or a change agent. APNs also serve as mentors for staff nurses completing evidence-based practice changes. This mentoring extends the work of the APN, implements an opinion leader in the clinical area, and develops the skills of the staff nurse. An example is implementation of an alcohol and chlorhexidine gluconate surgical hand antisepsis. Mentoring a staff nurse to champion this alternative provides the support needed to be successful. Stebral has described an APN-mentored evidence-based practice change to double gloving that resulted in an initial reduction in sharps injuries by 23.5%.9 Other evidence-based practice changes are initiated by APNs in response to clinical problems or adverse events. A review of the research on risk factors for retained sponges and instruments identified the need for additional measures to prevent retained objects in morbidly obese patients and major trauma patients undergoing laparotomy. This change required the skills of the APN to present the evidence and influence the opinions of other disciplines and implement a positive change to improve patient safety. At times, a clinical question arises that requires the conduct of research to answer. This need may best be addressed through a joint effort between the APN and a researcher with advanced education in the conduct of research. The APN may identify the question or work with a staff nurse to articulate the question. Once raised, it may be taken to a researcher, who will need a partner in the clinical setting. This partner may be the APN, who serves as an investigator on the research team. An example is the question ‘‘What is the best support surface to prevent intraoperatively acquired pressure ulcers?’’ APN Cecil King investigated this in collaboration with a researcher.10 The team found that gel pads are not always the best alternative to disperse intraoperative pressure. It is essential to base perioperative nursing practice on the best evidence available. The advanced education of the APN supports the questioning of practice, the search for the best evidence available, and implementing complex multidisciplinary changes. SUMMARY The APN provides a valuable service to the perioperative leadership team. While managers are busy with day-to-day operations, managing issues with personnel, physicians, and supplies, the APN can focus on long-term objectives such as staff development, clinical decision making, managerial programs and projects, and implementing best practices based on available evidence. This latter contribution will make the APN an indispensable member of the perioperative leadership team in the future. Evidence-based practice can be used as a framework to guide all of the leadership work of an APN. Education should incorporate evidence-based practice. Consultations should include an explanation based on evidence. Managerial programs and projects should be initiated incorporating available evidence. By using evidence-based practice as a framework, the perioperative leadership team can improve patient care and enhance patient outcomes while providing a safe work environment and improving staff satisfaction. REFERENCES 1. American Nurses Association. Scope and standards of advanced practice registered nursing. Washington (DC): American Nurses Publishing; 1996. 2. American Association of Colleges of Nursing. AACN position statement on the practice doctorate in nursing. October, 2004. 3. Association of Perioperative Registered Nurses. AORN position statement: perioperative advanced practice nurse. Denver (CO): Association of Perioperative Registered Nurses; 2007. p. 403. 4. Guido B. The role of a nurse practitioner in an ambulatory surgery unit. AORN J 2004;79:606–15. 5. Institute for Healthcare Improvement. Surgical Care Improvement Project. 2007. 6. Pottinger JM, Stark SE, Steelman VM. Skin preparation. Periop Nurs Clin 2006;1:203–10. 7. Recommended practices for preoperative patient skin antisepsis. In: AORN, editor. Perioperative standards and recommended practices. 2008 edition. Denver (CO): Association of periOperative Registered Nurses; 2008. p. 537–55. 8. American Society of Anesthesiologists Task Force on Preoperative Fasting. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy adults undergoing elective procedures. Anesthesiology 1999;90:896–905. 9. Stebral LL, Steelman VM. Double gloving for surgical procedures: an evidence-based practice project. Periop Nurs Clin 2006;1:251–60. 10. King C, Bridges E. Comparison of pressure relief properties of operating room surfaces. Periop Nurs Clin 2006;1:261–6. 55