Incoming AORN President Sets Ambitious Agenda for Perioperative Nurses

By Kelly M. Pyrek

Sharon A. McNamara, RN, MS, CNOR, director of surgical services at Wake Med in Raleigh, N.C., has her sights set on an ambitious agenda for the presidency she is about to assume at this year’s Association of periOperative Registered Nurses (AORN) Congress this month.

Her sweeping slate of issues to be addressed for 2005-2006 is reflected in the theme of her presidency, which she says is “diversity: patient, practice and practitioner.” Not only will McNamara continue the efforts established under outgoing AORN president Bill Duffy, but she brings to the table an ambitious agenda of her own. “One of our biggest issues is the generational differences that are out there, and getting the X and Y generation into nursing, first of all, but getting them into perioperative nursing, and then into AORN membership so that they can drive the profession of perioperative nursing,” McNamara explains. “The boomers and traditionalists are approaching retirement age within the next five to 10 years, so we must groom our successors.”

McNamara plans to address the issue of younger nurse recruitment and development through a formal mentoring program. She acknowledges, “We need members of the X and Y generation in leadership roles, but we’re not going to find them through chapter meetings, we are realizing. The chapter model has served our traditionalists and boomers very well, and it isn’t going to go away in the near future, but we do need other ways of attracting the younger generation to nursing and to our organization. I believe the mentoring program is one way we can do that; it’s also a way we can use the wisdom and the knowledge of our boomers and our traditionalists.” McNamara says the mentoring program is scheduled to launch in July at AORN’s leadership meeting.

In the same vein, McNamara is examining AORN’s various committees and task forces to identify ways to introduce members of the younger generation to the organization. “I have made sure we have an X or Y generation person on every AORN task force and committee, and we are also looking at our specialty assembly model and restructuring that to better meet the needs of all members. We see it as a way young people will enter the organization; they will come in through the specialties rather than the generalist portal.”

McNamara predicts that legislative issues will again be an important issue during her term. One of the key issues, she says, is advocating for the presence of perioperative registered nurse circulators. “There are about 19 states that do not have prescriptive language either in regulation or legislation, but only in AORN’s review only nine have significantly strong language or require a 1:1 RN circulator to OR ratio. We are looking at getting legislation and regulation in every state to have one perioperative RN circulator to every patient, our target nurse-to-patient ratio in which we believe very strongly. We’ll be working on that very aggressively this year.”

Another issue is that of ergonomics in the perioperative setting. McNamara says, “We have an aging population of nurses who have lots of joint and back problems, and much of that has to do with the kind of work that we do; we must learn how to do our work in a safer fashion. I hope that we will be able to come out with a tray weight that will be acceptable to regulatory agencies. No one has come up with that yet, but I think we need to set the standard soon and move on. We have AORN representatives working with the Occupational Safety and Health Administration (OSHA), but they have not been able to come to consensus on this issue, however. There are also vendors and manufacturers of trays who think it should be one thing or another, and we can’t agree. I am hoping with some collaboration we will be able to come to a conclusion.”

One of the most important issues that will receive McNamara’s time and attention is the continuation of AORN’s Patient Safety First campaign, which advocates for correct-site surgery, among other important tenets. McNamara is assembling a task force that will look at “just response to errors in the perioperative environment” and will create a “no-blame culture” in the operating room (OR). She plans to invite representatives from the American College of Surgeons and the American Society of Anesthesiology to participate in the task force because, she says, “being a team is the only way we will be able to work through this.” McNamara says that the patient safety council, comprised of seven organizations including AORN, represents all parties — nurses, surgeons, anesthesiologists, nurse anesthetists, surgical technologists, physician assistants and risk managers — is working on a number of initiatives to support mutual patient-safety goals, as well as to look at issues such as retained objects during surgery. “Everyone in this council is so invested in this process,” McNamara enthuses. “Before now, everyone was working in their own little boxes, but coming together as a team and assembling all of the stakeholders, it reflects what we do every day to take care of patients.”

AORN’s Presidential Commission on Patient Safety has been working with the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) on its patient-safety goals, with an eye specifically toward safe medication practices in the perioperative environment, related to pediatrics. “I understand there is going to be some very interesting research coming out on pediatric medication errors,” McNamara predicts, “that will make people understand how important this topic is.” McNamara adds that AORN is also recommending to JCAHO to add positioning as part of its checklist for correct-site surgery. “They speak to it in the guideline but not in the position statement or the actual goal, so we have put in a recommendation to have that included. It will be interesting to see if they go to the surgeon marking the site.”

McNamara points to her recent two-day marathon of visits to hospitals in California. “I visited seven hospitals in two days and spoke at two chapters; at only one of the seven hospitals were the surgeons marking the operative site. The nurses and the patients were marking the site at the other hospitals, and this is pretty much what we are hearing across the country. Because the guideline does not say ‘must mark the site,’ and even though the intent of Joint Commission is that they do, it’s not happening. That’s an area I think we are going to have to work collaboratively with Joint Commission.”

It’s a timely issue, and McNamara says awareness of this recommendation will be raised concurrently with the celebration of “National Time Out Day,” which will be held on June 23 this year. “We must reinforce the importance of the pre-surgery time out, and having the whole team participate in it,” McNamara emphasizes. “We’re also going to coordinate that with a state lobbying day where AORN state coordinators will contact representatives at their state capitols to ensure that the legislators understand what an impact we have made in educating the hospital staff, as well as the patient, about correct-site issues.”

While on the topic of government affairs, McNamara refers to Senate Resolution 40, the resolution introduced to the Senate last year by Sen. Mary Landrieu of Louisiana, in support of National Time Out Day. The resolution stalled due in part to an end-of-year logjam of legislation as well as issues related to Election Day, but McNamara says, “It is our hope that Sen. Landrieu will bring it forward again; if it hasn’t passed by June, we’ll return our attention to it, but I hope it will get moving faster than that. I was a little disappointed that it didn’t go right through, seeing as there are no funding issues connected to it. It is politically correct in every way you look at it. It’s best for our patients and for the staff ... it’s good for everyone.”

Also on the legislative agenda is keeping watch over the continuing push for Medicare reimbursement for the services provided by certified registered first assistants (CRNFAs). In December 2004, the Medicare Payment Advisory Commission (MedPAC) released a mandated report to Congress regarding its study of Part B Medicare reimbursement for CRNFAs. Law and regulation do not include criteria for determining which non-physician providers (NPPs) should qualify for separate payment. In the absence of explicit criteria, MedPAC in the past has not recommended the inclusion of additional groups to the list of separately payable NPPs because of concerns about licensure and duplicate payments. CRNFAs would not automatically disqualify from consideration on the basis of licensure, as did other groups MedPAC has looked at, and they are similar to some of the groups allowed to bill separately in education and experience. If Congress chooses to add CRNFAs to the list of NPPs eligible for separate payment under Medicare Part B for assistant as surgery services, any additional payments should be offset from existing payments so that the effect of this change would be budget neutral.

“States are debating what CRNFAs can do within their scope of practice; this issue comes up every year,” McNamara says. “We look to our core curriculum, our competencies, and our standardized language.

But because CRNFAs are not in the state nurse practice acts or in any legislative piece, the issue comes up repeatedly. AORN has astute CRNFAs to help out, to work with boards of nursing or in the legislative/regulatory arena. Regarding reimbursement, we have the MedPac study and will continue to apply it to our 2005 legislative action items.”

Back in practice, McNamara agrees that perioperative nursing must address any stigmas that have pigeonholed it as an unrewarding or uninteresting nursing specialty. “To a certain extent, we hear from new nurses that their instructor told them, ‘Don’t go to the OR.’ I think it’s due in part to instructors who haven’t actually been to ORs, and to do so would be going out of their comfort zones; they are certainly not going to volunteer to take students into a totally foreign environment to them. It’s an issue we will have to address in all of nursing, to have competent faculty in nursing schools.” McNamara relates a recent example of a private-sector entity stepping up to the plate to help the educational system. “Here in North Carolina, at Wake Med, our junior college was not going to accept 100 students because they didn’t have enough instructors. Our CEO made it possible for 12 Wake Med bachelor’s prepared nurses to work with students on their required clinicals. We are hoping that these nurses will want to come to Wake Med and work when they graduate. It’s a creative way to collaborate with faculty to allow us to bring enough nurses into the educational system and get them educated. I think we are going to have to start looking at more of those creative ways to recruit and keep nurses and develop partnerships between hospitals and colleges.”

For this November’s Perioperative Nurses Week, McNamara is continuing with an academic theme. “This year, we’re going to celebrate ‘Take Your Perioperative Nurse to School Week,’ turning the tables so that nurses can reach out to youths in school. It’s the right time to explain perioperative nursing to them, because if we wait until they are old enough to go to nursing school, it might be too late to reach them. I want perioperative nurses to visit their local schools and talk to a class, telling them how important our role is in healthcare. It’s a great way to start getting kids to consider nursing as a career. Those who are in it love it, and all we need to do is go out and let people know that.”

McNamara says it is essential to “put the OR back into the curriculum,” but if that isn’t realistic, the goal should be to “show nursing faculty what medical-surgical skills, of which there are many, that are learned in the OR.” McNamara adds, “The OR is an excellent clinical rotation for students; they can learn skills that are required by them in their curriculum, such as aseptic technique, and, of course, anatomy and physiology ...where better to see anatomy than what you can see in the OR? The medsurg skills they can pick up in one day in the OR are more than they get in a week elsewhere out on the floor.”

McNamara says that AORN is reviewing its core competencies, and scrutinizing them for their relevance for everyone from novice nurses to veteran experts. She says that AORN’s perioperative 101 course, which will be available online, is what McNamara calls “orientation in a box for hospitals.” McNamara explains that AORN will move forward with its perioperative nursing data sets which will provide standardized measurements of core competencies.

Not only is AORN addressing core competencies, it is recognizing that an increasing number of perioperative nurses are working in healthcare settings distinct from the hospital environment. “Regulatory agencies are starting to look at the settings such as physician’s offices, where surgery is not regulated,” McNamara says. “As we start to see more errors coming to the forefront, including serious errors, adverse events and even loss of life, it’s getting people’s attention. In our membership campaign we are going to start reaching out to these other practice arenas. Whether it’s in a hospital cath lab, a physician’s office, or an ambulatory surgery center, we should all be looking at our practices and the basis for them — they are very much the same. AORN will be reaching out more to offsite practices, such as eye centers, plastic surgery centers, ASCs, because we need to draw in those nurses so they, too, know what the standard of practice is. It should be the same no matter what physical setting they are working in; patient care and patient safety should be at the same high standard.”

McNamara acknowledges that one of the most important connections AORN can help its members make is that with the infection control community. “Infection control is an extremely important piece of what perioperative nurses do,” she adds. “One of the task forces I am putting into place is looking at the potential for future epidemics such as SARS and avian flu. Events like this require collaboration between the OR, infection control, and risk management. Risk managers have been able to go to the OR during Perioperative Nurses Week, and see what the OR does. The same with infection control and the OR — be sure to share time at in-services to educate everyone. The key is getting practitioners to interact with each other. I think the relationship has been there all along, but it’s just a matter of crossing borders, because everyone has been a little hesitant to do so. I think that now, we are seeing more inclusion than exclusion, with people getting out of their cocoons and seeing the big picture. For example, we are seeing hepatitis C rates among healthcare workers escalate even though we have personal protective equipment, containment of sharps, and safe zones, but how many people are using them? So it’s critical that risk management, infection control and the OR become very close to address these issues.”

Sharon A. McNamara, RN, MS, CNOR, incoming president of the Association of periOperative Registered Nurses (AORN), has been a perioperative nurse and a member of AORN for 26 years. She has served AORN in a number of volunteer positions, including National Secretary; member of the Finance and Audit Committee; member of the Executive Committee; and Board of Directors liaison to a number of Specialty Assemblies and State Councils. She is a member of Capital AORN, a local chapter in Raleigh, N.C.; she was a long-standing member of AORN of Western New York State. She is a member of the North Carolina Council of OR Nurses and was a member of the New York State Council.

McNamara earned her associate in nursing degree from Trocaire College in Buffalo, N.Y.; her bachelor of science in nursing degree from Daeman College in Buffalo, N.Y.; and her master of science in nursing degree from D’Youville College in Buffalo, N.Y. In her election statement, McNamara notes, “Recruitment is one of nursing’s long-term issues; the most critical short-term issue is retention of perioperative nurses in our worksites and in AORN. Generational, cultural, and gender diversity offer unique opportunities to grow and enrich our ranks.”

McNamara adds, “Partnering with other professional associations and industry is a core value that has mutual beneficial advantages. We will need to lobby aggressively for safety regulations, monies for minorities to attend nursing programs and finance nurses in achieving higher degrees to fill vacant nursing faculty positions, and adequate reimbursement.”

AORN is the professional organization of perioperative registered nurses that supports registered nurses in achieving optimal outcomes for patients undergoing operative and other invasive procedures. AORN is the global leader in promoting excellence in perioperative nursing practice. AORN is composed of approximately 40,000 perioperative registered nurses in the United States and abroad. Perioperative nurses are defined as those who provide, manage, teach, and study the care of patients undergoing operative or other invasive procedures.