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By Kelly M. Pyrek
Sharon A. McNamara, RN, MS, CNOR, director ofsurgical services at Wake Med in Raleigh, N.C., has her sights set on anambitious agenda for the presidency she is about to assume at this yearsAssociation of periOperative Registered Nurses (AORN) Congress this month.
Her sweeping slate of issues to be addressed for 2005-2006 is reflected inthe theme of her presidency, which she says is diversity: patient, practiceand practitioner. Not only will McNamara continue the efforts establishedunder outgoing AORN president Bill Duffy, but she brings to the table anambitious agenda of her own. One of our biggest issues is the generationaldifferences 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 AORNmembership so that they can drive the profession of perioperative nursing,McNamara explains. The boomers and traditionalists are approaching retirementage within the next five to 10 years, so we must groom our successors.
McNamara plans to address the issue of younger nurse recruitment anddevelopment through a formal mentoring program. She acknowledges, We needmembers of the X and Y generation in leadership roles, but were not going tofind them through chapter meetings, we are realizing. The chapter model has served our traditionalists and boomers very well, andit isnt going to go away in the near future, but we do need other ways ofattracting the younger generation to nursing and to our organization. I believe the mentoring program is one way we can do that; its also a waywe 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 AORNsleadership meeting.
In the same vein, McNamara is examining AORNs various committees and taskforces to identify ways to introduce members of the younger generation to theorganization. I have made sure we have an X or Y generation person on everyAORN task force and committee, and we are also looking at our specialty assemblymodel and restructuring that to better meet the needs of all members. We see itas a way young people will enter the organization; they will come in through thespecialties rather than the generalist portal.
McNamara predicts that legislative issues will again be an important issueduring her term. One of the key issues, she says, is advocating for the presenceof perioperative registered nurse circulators. There are about 19 states thatdo not have prescriptive language either in regulation or legislation, but onlyin AORNs review only nine have significantly strong language or require a 1:1RN circulator to OR ratio. We are looking at getting legislation and regulationin every state to have one perioperative RN circulator to every patient, ourtarget nurse-to-patient ratio in which we believe very strongly. Well beworking 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 ofjoint and back problems, and much of that has to do with the kind of work thatwe do; we must learn how to do our work in a safer fashion. I hope that we willbe able to come out with a tray weight that will be acceptable to regulatoryagencies. No one has come up with that yet, but I think we need to set thestandard soon and move on. We have AORN representatives working with the Occupational Safety and HealthAdministration (OSHA), but they have not been able to come to consensus on thisissue, however. There are also vendors and manufacturers of trays who think itshould be one thing or another, and we cant agree. I am hoping with somecollaboration we will be able to come to a conclusion.
One of the most important issues that will receive McNamaras time andattention is the continuation of AORNs Patient Safety First campaign, whichadvocates for correct-site surgery, among other important tenets. McNamara is assembling a task force that will look at just response toerrors in the perioperative environment and will create a no-blame culturein the operating room (OR). She plans to invite representatives from theAmerican College of Surgeons and the American Society of Anesthesiology toparticipate in the task force because, she says, being a team is the only waywe will be able to work through this. McNamara says that the patient safetycouncil, comprised of seven organizations including AORN, represents all parties nurses, surgeons, anesthesiologists, nurse anesthetists, surgicaltechnologists, physician assistants and risk managers is working on a numberof initiatives to support mutual patient-safety goals, as well as to look atissues such as retained objects during surgery. Everyone in this council is soinvested in this process, McNamara enthuses. Before now, everyone was working in their own littleboxes, but coming together as a team and assembling all of the stakeholders, itreflects what we do every day to take care of patients.
AORNs Presidential Commission on Patient Safety has been working with theJoint Commission on the Accreditation of Healthcare Organizations (JCAHO) on itspatient-safety goals, with an eye specifically toward safe medication practicesin the perioperative environment, related to pediatrics. I understand thereis going to be some very interesting research coming out on pediatric medicationerrors, McNamara predicts, that will make people understand how importantthis topic is. McNamara adds that AORN is also recommending to JCAHO to addpositioning as part of its checklist for correct-site surgery. They speak toit in the guideline but not in the position statement or the actual goal, so wehave put in a recommendation to have that included. It will be interesting tosee if they go to the surgeon marking the site.
McNamara points to her recent two-day marathon of visits to hospitals inCalifornia. 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, andthis is pretty much what we are hearing across the country. Because theguideline does not say must mark the site, and even though the intent ofJoint Commission is that they do, its not happening. Thats an area I thinkwe are going to have to work collaboratively with Joint Commission.
Its a timely issue, and McNamara says awareness of this recommendationwill 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 ofthe pre-surgery time out, and having the whole team participate in it,McNamara emphasizes. Were also going to coordinate that with a statelobbying day where AORN state coordinators will contact representatives at theirstate capitols to ensure that the legislators understand what an impact we havemade in educating the hospital staff, as well as the patient, about correct-siteissues.
While on the topic of government affairs, McNamara refers to SenateResolution 40, the resolution introduced to the Senate last year by Sen. Mary Landrieu of Louisiana, in support of National Time Out Day. Theresolution stalled due in part to an end-of-year logjam of legislation as wellas issues related to Election Day, but McNamara says, It is our hope thatSen. Landrieu will bring it forward again; if it hasnt passed by June, wellreturn our attention to it, but I hope it will get moving faster than that. Iwas a little disappointed that it didnt go right through, seeing as there areno funding issues connected to it. It is politically correct in every way youlook at it. Its best for our patients and for the staff ... its good foreveryone.
Also on the legislative agenda is keeping watch over the continuing push forMedicare reimbursement for the services provided by certified registered firstassistants (CRNFAs). In December 2004, the Medicare Payment Advisory Commission(MedPAC) released a mandated report to Congress regarding its study of Part BMedicare reimbursement for CRNFAs. Law and regulation do not include criteriafor determining which non-physician providers (NPPs) should qualify for separatepayment. In the absence of explicit criteria, MedPAC in the past has notrecommended the inclusion of additional groups to the list of separately payableNPPs because of concerns about licensure and duplicate payments. CRNFAs wouldnot automatically disqualify from consideration on the basis of licensure, asdid other groups MedPAC has looked at, and they are similar to some of thegroups allowed to bill separately in education and experience. If Congresschooses to add CRNFAs to the list of NPPs eligible for separate payment underMedicare Part B for assistant as surgery services, any additional paymentsshould be offset from existing payments so that the effect of this change wouldbe 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 corecurriculum, our competencies, and our standardized language.
But because CRNFAs are not in the state nurse practice acts or in anylegislative piece, the issue comes up repeatedly. AORN has astute CRNFAs to helpout, to work with boards of nursing or in the legislative/regulatory arena.Regarding reimbursement, we have the MedPac study and will continue to apply itto our 2005 legislative action items.
Back in practice, McNamara agrees that perioperative nursing must address anystigmas that have pigeonholed it as an unrewarding or uninteresting nursingspecialty. To a certain extent, we hear from new nurses that their instructortold them, Dont go to the OR. I think its due in part to instructorswho havent actually been to ORs, and to do so would be going out of theircomfort zones; they are certainly not going to volunteer to take students into atotally foreign environment to them. Its an issue we will have to address inall of nursing, to have competent faculty in nursing schools. McNamararelates a recent example of a private-sector entity stepping up to the plate tohelp the educational system. Here in North Carolina, at Wake Med, our juniorcollege was not going to accept 100 students because they didnt have enoughinstructors. Our CEO made it possible for 12 Wake Med bachelors preparednurses to work with students on their required clinicals. We are hoping thatthese nurses will want to come to Wake Med and work when they graduate. Its acreative way to collaborate with faculty to allow us to bring enough nurses intothe educational system and get them educated. I think we are going to have tostart looking at more of those creative ways to recruit and keep nurses anddevelop partnerships between hospitals and colleges.
For this NovembersPerioperative Nurses Week, McNamara is continuing with an academic theme. Thisyear, were going to celebrate Take Your Perioperative Nurse to SchoolWeek, turning the tables so that nurses can reach out to youths in school. Itsthe right time to explain perioperative nursing to them, because if we waituntil they are old enough to go to nursing school, it might be too late to reachthem. I want perioperative nurses to visit their local schools and talk to aclass, telling them how important our role is in healthcare. Its a great wayto start getting kids to consider nursing as a career. Those who are in it loveit, 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 isnt realistic, the goal should be to show nursing facultywhat medical-surgical skills, of which there are many, that are learned in theOR. McNamara adds, The OR is an excellent clinical rotation for students;they can learn skills that are required by them in their curriculum, such asaseptic technique, and, of course, anatomy and physiology ...where better to see anatomy than what you can see in the OR? The medsurgskills they can pick up in one day in the OR are more than they get in a weekelsewhere out on the floor.
McNamara says that AORN is reviewing its core competencies, and scrutinizingthem for their relevance for everyone from novice nurses to veteran experts. Shesays that AORNs perioperative 101 course, which will be available online, iswhat McNamara calls orientation in a box for hospitals. McNamara explainsthat AORN will move forward with its perioperative nursing data sets which willprovide standardized measurements of core competencies.
Not only is AORN addressing core competencies, it is recognizing that anincreasing number of perioperative nurses are working in healthcare settingsdistinct from the hospital environment. Regulatory agencies are starting tolook at the settings such as physicians offices, where surgery is notregulated, McNamara says. As we start to see more errors coming to theforefront, including serious errors, adverse events and even loss of life, itsgetting peoples attention. In our membership campaign we are going to startreaching out to these other practice arenas. Whether its in a hospital cathlab, a physicians office, or an ambulatory surgery center, we should all belooking 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 canhelp its members make is that with the infection control community. Infectioncontrol is an extremely important piece of what perioperative nurses do, sheadds. One of the task forces I am putting into place is looking at thepotential for future epidemics such as SARS and avian flu. Events like thisrequire 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 sureto share time at in-services to educate everyone. The key is gettingpractitioners to interact with each other. I think the relationship has beenthere all along, but its just a matter of crossing borders, because everyonehas been a little hesitant to do so. I think that now, we are seeing moreinclusion than exclusion, with people getting out of their cocoons and seeingthe big picture. For example, we are seeing hepatitis C rates among healthcareworkers escalate even though we have personal protective equipment, containmentof sharps, and safe zones, but how many people are using them? So itscritical that risk management, infection control and the OR become very close toaddress these issues.
Sharon A. McNamara, RN, MS, CNOR, incoming president of theAssociation of periOperative Registered Nurses (AORN), has been a perioperativenurse 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 Directorsliaison to a number of Specialty Assemblies and State Councils. She is a memberof Capital AORN, a local chapter in Raleigh, N.C.; she was a long-standingmember of AORN of Western New York State. She is a member of the North CarolinaCouncil of OR Nurses and was a member of the New York State Council.
McNamara earned her associate in nursing degree from TrocaireCollege in Buffalo, N.Y.; her bachelor of science in nursing degree from DaemanCollege in Buffalo, N.Y.; and her master of science in nursing degree from DYouvilleCollege in Buffalo, N.Y. In her election statement, McNamara notes, Recruitment isone of nursings long-term issues; the most critical short-term issue isretention of perioperative nurses in our worksites and in AORN. Generational,cultural, and gender diversity offer unique opportunities to grow and enrich ourranks.
McNamara adds, Partnering with other professionalassociations 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 achievinghigher degrees to fill vacant nursing faculty positions, and adequatereimbursement.
AORN is the professional organization of perioperativeregistered nurses that supports registered nurses in achieving optimal outcomesfor patients undergoing operative and other invasive procedures. AORN is the global leader in promoting excellence inperioperative nursing practice. AORN is composed of approximately 40,000perioperative 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 invasiveprocedures.