J A N U A R Y 1986, VOL. 43, NO I A O R N J O U R N A L

Perioperative Nursing Competencies THE PROCESS AND STUDY

Jean M. Reeder, RN; Patricia P. Kapsar, RN

s part of its continuing commitment to provide care to surgical patients, AORN A established statements of competency for

perioperative nursing. The Association believes that determining competency is a necessary outgrowth of its beliefs about nursing and patient care. In its philosophy of perioperative nursing, AORN states that, “Nursing is a caring art based on the creative application of knowledge, skills, and interpersonal competenci es... the ulitmate goal of such nursing is the provision of quality individualized patient care.”’

In 1978, the AORN House of Delegates accepted Project 25’s definition of perioperative nursing:

The perioperative role of the operating room nurse consists of nursing activities performed by the professional operating room nurse during the preoperative,

Jean M. Reeder, RN, MSN, is the staff development coordinator, OR nursing section, at Madigan Army Medical Center, Tacoma, Wash. She earned her MSN from the University of Maryland Baltimore, and her RSN from Arizona State University, Tempe.

Patricia I! Kapsar, RN, BA, is the director of surgical services at St Joseph Hospital Kirkwood Mo. She earned her RA in management from Webster University, St Louk, and her nursing diploma fiom SI Luke’s Hospital, St Louis.

The authors wish to acknowledge the work of the entire Ad HOC Committee to Operationalize &sic Competency Statements. This article is based on their collective accomplishmenu.

intraoperaiive, and postoperative phases of the patient’s surgical experience. Operating room nurses assume the perioperative role at a beginning level dependent on their expemhe and competency to praciice. As they gain knowledge and ski& they progress on a continuum to an advanced level of practice. Recognizing the need to remain current, in 1984

the Nursing Practice Committee was charged with rewriting and revising the 1978 Statement. As a result, the definition of perioperative nursing practice is:

The registered nurse specializing in perioperative nursing practice perform nursing activities in the preoperative, intraoperative, and postoperative phases of the patient’s surgical experience. Registered nurses enter perioperative nursing practice at a beginning level depending upon their expert fie and competency to practice. As they gain knowledge and skills, they progress on a continuum to an advanced level of ~ractice.~ Identifying competency is essential to providing

an understanding of the fundamental knowledge and skills necessary to fulfill the functions/ activities of a registered nurse in the operating room, as defmed in the AORI? Standards and Recommended Practices for Perioperative Nursing.

Buckground. In 198 1, through the original Ad Hoc Committee on Basic Competencies, 25 statements were approved as Basic Competencies for Perioperative Nursing. The statements were intended as guidelines for what a nurse who has

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Level

Associate degree Diploma BSN BWBA in other area MS in nursing MS/MA in other area Doctorate Missing data Total

Table 1 Highest Level of Education

Number

37 163 87 42 29 29

3 3

393

Percent

9.5 41.8 22.3 10.8 7.4 7.4 0.8

missing 100.0

been employed in the operating room for six months to one year can be reasonably expected to achieve. Originally, basic competency was defined as:

The knowledge, skills, and abilities necessary to furfil, at a minimum level, the professional role functions of the re@tered nurse in the operating room Basic compet- ency is expected to be attained within a specfie time span (six to twelve months). The knowledge, skills and abilities are common to all nursing practice and are used in providing care to the surgical patient and hh family/significant others regardless of the practice ~etting.~ Committee charge and process. Following

publication of the basic competency statements, there was concern among the users that some of the competency statements were difficult to implement because of the lack of ability to quantify the practice statements.' Because of this concern, in 1983 the AORN Board of Directors established an Ad Hoc Committee to Operationalize Basic Competency Statements. The Committee con- sisted of Patricia A. Hercules, chairperson; Patricia P. Kapsar; Julia A. Kneedler; Jean M. Reeder; and Rosemary A. Roth. Janice R. Allen was the staff consultant.

The Committee found that although the existing competency statements represented expected perioperative nursing behaviors, they did not reflect measurable criteria. As written, they were

difficult to implement in the practice setting. The Committee's work, therefore, was to revise and refine the existing statements so they were more precise, objective, and measurable.

The Committee decided to rewrite the state- ments in measurable terms and validate the revised statements in an appropriate study such as the one conducted by the original Committee. Allen H. Nelson, PhD, research consultant to AORN, was enlisted to assist the Committee with this task. A literature review was done to determine the currency of the existing statements.

The Committee also reviewed the existing AORN projects to determine how consistent they were in describing competency behaviors per- formed by the perioperative nurse. Specifically, the Committee examined the Job Analysis as developed by the National Certification Board for the purpose of test development. The methodology used for development of this job analysis was determined to be valid and reliable. The Committee decided that there should be consis- tency between the established competency statements and the job analysis. Thorough review of the two did, indeed, reflect that desired consistency. To avoid confusion, the Committee decided to delete any reference to time in the competency definition. Consequently, competency is redefined as the knowledge, skills, and abilities necessary to fulfill the functions/activities of a registered nurse in the operating room, as defined in the AORN Standarch and Recommended

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Setting

Government Public Not-for-profit Private Missing data Total

Table 2 Work Setting

Number

25 41

223 41 63

393

Percent

7.6 12.4 67.6 12.4

missing 100.0

Practices for Perioperative Nursing. The Committee revised the original 25

statements and developed a competency model (Competency Statements in Perioperative Nurs- ing). This model and its application is discussed in the accompanying article. The Committee, working as a panel of experts aided by previous works of the Association and personal experience, developed expected behaviors or nursing actions that could be used to measure achievement of the competency statements. With consultation provided by Dr Nelson, a survey tool was developed to validate the work of this Committee.

Survey Tool

sing the new definition of competency as the guideline, the survey tool was

To what extent do you agree that these competency statements are a part of perioperative nursing practice? To what extent do you agree that the expected behavior is indicative, understan- dably stated, and measurable?

Each participant was given the scale of four possible responses from completely disagree, slightly disagree, slightly agree, to completely agree.

A third open-ended response was elicted from the question, “How might you use these competencies and expected behaviors in your practice setting?”

Pilot survey. The tool was piloted by distributing it to 30 perioperative nurses chosen

U developed to ask:

by the Committee to equally represent manage- ment, education, and clinical practice in periop- erative nursing. The purpose of the pilot survey was to determine clarity of the tool and appropriateness of construction and length. With a 100% return, it was determined that the only changes needed were in syntax rather than in substance.

Method. Following pilot testing and syntax revision, the survey tool was tested using a stratified random sampling technique. The target population was perioperative nurses who worked in staff, education, and management positions. An equal number of AORN members and nonmembers were sought. Survey tools were mailed to 1,800 AORN members and nonmembers in each of those employment categories. A total of 393 usable survey responses were included in the analysis, for a 21.8% response rate. Frequencies and correlational statistics were used to analyze the data.

Results. Demographics. The respondents identified their primary function in perioperative nursing-I 57 had in-service or education positions, 127 were in management, 86 were staff nurses, eight were RN first assistants, 10 occupied other positions, and five were missing data.

The respondents averaged 16 years of expe- rience in OR nursing and ranged from one to 41 years.

Three hundred eighty-one (96.9%) were AORN members, and 153 (40%) were CNORs. Educa- tional levels varied among the respondents (Table 1 ).

The primary work setting for most of the

A O R N J O U R N A L JANUARY 1986, VOL. 43, NO I

Table 3 Career Ladders, Clinical Levels,

and Competency Statements

Missing Has Percent Has not Percent Cases Total Total

Career ladders 78 19.9 313 80.1 2 393 100.0% Clinical levels 117 30.0 273 70.0 3 393 100.0% Competencies 103 26.4 287 73.6 3 393 100.0%

respondents (341 or 88.1%) was a hospital operating room. Other settings were: in-hospital day surgery (4 or l%), freestanding day surgery (4 or 1%), ofice day surgery (2 or 0.5%), academics (22 or 5.7%), other (14 or 3.6%), and missing data (6 or % missing).

The kinds of facilities in which respondents worked is shown in Table 2. Respondents were asked if their institutions had career ladders, clinical levels, or competency statements (Table 3). The majority answered no to all three.

The Survey: Part I

espondents rated each competency to the extent that they agreed or disagreed that R it was part of perioperative nursing

practice. Each statement was rated from one (completely disagree) to four (completely agree). Table 4 shows the means and standard deviations for each competency statement.

Discussion of competency statements. The competency statements in Table 4 show a high level of agreement. Of the 18 competencies, No. I1 (assess the psychosocial health status of the patientjfamily) and No. VII (participate in patiedfamily teaching) had the lowest levels of agreement. In summary, respondents agreed with all of the revised competency statements as being part of perioperative nursing practice.

The Survey: Part 11

art I1 asked respondents to answer three questions about each expected behavior. It P asked, “To what extent was there agreement

that expected behaviors were: 1. Indicative-a behavior expected for this

competency, 2. Understandable-stated in a manner that

can be clearly interpreted, and 3. Measurable-a behavior that can be

documented through observation, interview, or record.”

Discussion of all 11 1 expected behaviors would be unmanageable for this article. Only general trends are highlighted. Table 5 gives mean ratings for a selected, expected behavior for each competency statement.

Discussion. One method of interpreting the results is to examine means in terms of those above 3.5, those between 3.0 and 3.5, and those below 3.0. Means above 3.5 usually correspond to about 90% or greater responses of “slightly” or “completely agree.” Those behaviors were deemed acceptable. Means between 3.0 and 3.5* generally correspond to somewhere between 80% and 90% agreement. Those items were discussed a second time and retained as well. Behaviors with means below 3.0** generally correspond to 80% or less agreement. These expected behaviors had means below 3.0 “screens for substance abuse” (1.14), “identifies patients philosophical and religious beliefs” (2.6), and “identifies patient’s cultural practices” (2.7). Those responses indicated that there was less agreement as to the nurse’s role in the areas. Still, after reconsideration, the Committee decided to retain those items in the final model.

The Committee believed that perioperative nurses should be able to screen for substance abuse if other physical and historical assessment data

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Table 4 Ratings of Competency Statements

Competency* Mean

1 2 3 4 5 6 7 8 9

10 I 1 12 13 14 15 16 17 18

3.75 , 3.43

3.70 3.72 3.75 3.80 3.58 3.94 3.94 3.94 3.93 3.71 3.87 3.95 3.92 3.73 3.82 3.78

* refer to complete list of competency statements

Standard Deviation

,602 .792 .643 .620 .602 ,479 .703 .372 .385 .36 1 .407 .594 .440 .352 .410 .599 .518 .578

indicate potential substance abuse. Likewise, there are circumstances when philosophical, religious beliefs, and cultural practices must be considered when developing a care plan. Patients who believe in the power of a healing crystal, request to wear a religious medal during surgery, or refuse blood products, depend on the nurse to support their rights and beliefs. Perioperative nurses may not plan for this without knowledge of special needs gained through a preoperative assessment.

Overall analysis of the means of expected behaviors indicated that most respondents were in agreement that a high majority of the expected behaviors were indicative, understandable, and measurable indicators of the competency statements.

In the analysis of the demographic variables of “primary function” and “highest level of education,” two slight trends were noted, but conclusions should not be made from these relationships. The mean responses of staff nurses were slightly lower than those of educators and

managers. Secondly, the means of nurses from associate degree and diploma nursing programs were slightly lower than the other respondents for the first competency statements that pertain to assessment. Correlations determined on selected competency behaviors were not statistically significant.

Committee members felt the initial staff nurse response of 21% was low and might not have represented this group of people surveyed. It was decided to conduct another small survey with a convienent and purposeful sample to minimize the effect of return bias. Therefore, respondents did not have an option to discard the survey tool.

Forty-five usable surveys were analyzed. Follow-up survey results indicated great consis- tency with competency ratings in the initial study. Items were rated slightly higher than those in the first survey. The trend was the same for the behavioral competency indicators, either the same or slightly greater than the initial sample. Similarly, the items rated slightly lower on the first sample

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Table 5 Mean Ratings for &kW, Expected Behaviors

Expected Competency + Behavior Indicatlve Understandable

1 14 2 7 3 1 4 1 5 6 6 1 7 4 8 3 9 2

10 1 11 1 12 3 13 5 14 4 15 5 16 2 17 2 18 4

* means between 3.0 and 3.5 ** means below 3.0 + refer to complete list of competencies

2.96** 2.%** 3.83 3.37* 3.81 3.97 3.38* 3.99 3.96 3.99 3.96 3.64 3.96 3.44* 3.96 3.44* 3.69 3.63

3.02* 2.98** 3.71 3.40* 3.67 3.93 3.43* 3.96 3.91 3.98 3.95 3.76 3.92 3.51 3.84 3.38* 3.66 3.63

Measurable

3.00* 2.96** 3.67 3.49* 3.67 3.96 3.35* 3.87 3.83 3.98 3.94 3.79 3.89 3.66 3.72 3.39* 3.64 3.63

were just as low on the second. The follow-up survey strengthened the original survey and added validity. It was then assumed that the results did reflect the population that was studied.

The Survey: Part I’

art 111 asked the question, “How might you use these competencies and expected P behaviors in your practice setting?” Content

analysis, a way to determine trends and key words in written responses or interviews, was used to briefly examine 20 randomly s e l d responses each from the educators, staff nurses, and managers. Key words and phrases are listed in Table 6.

Educators had varied concerns related to the competencies:

The concept of preoperative assessment

is not facilitated by any level of our OR manageme&.. What good is (all this) when census management and DRGs are the code of ethics for patient care?

It is useful for the ‘old’ OR nurses to see that the things they have been doing all along really are part of the nursing process. Staff nurses also had interesting comments:

My currenl employment never heard of competencies. The robot fashion of care has given me four months of fmtration- I’m terminating!

Idon ’I believe a nurses competency should be measured by the times a beeper is answered..call wives, girlj?ier&, the goy pro...!

I prefer to give nursing care rather than write about it.

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Table 6 Responses to “How might you use these competencies and

expected behaviors in your practice?”

Educators’ responses Frequency

Orientation Performance appraisal Perioperative nursing course for student nurses Personal performance improvement Evaluation Quality assurance activities Job descriptions Identification of in-service needs Explain role to others Set long-term goals

10 7 6 5 4 4 4 3 3 2

Staff nurses’ responses Frequency

Learn nursing diagnosis Evaluation Improve own practice Orientation Personal and departmental goals Clinical ladder Job performance criteria Integrate perioperative nursing with

Assessment Checklist of professional obligations No use for them

generic student knowledge

3 4 2 2 2 2 1

1 2 1 1

Managers’ responses Frequency

Performance evaluation Orientation Clinical practice In-service/continuing education Criterion-based performance appraisal Standards of practice Job description Quality assurance Policies and procedures

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Hire separate coordinators to do these duties.

Because of set patterns by the superviior of 32 years, i ts diffict to change. ..but we are. Managers also gave some feedback about the

Many of these are low prioriiy: psycho- social status, religion ... unless it would obvious!y guide the surgical care.

We must stop writing so much..(the nurse) must be with the patient doing all the things nurses do.

These represent the best in OR nurs- ing. ..in these days of cost containment and reduced staflng, nurses are not all0 wed the time to make nursing diagnoses, care plans, and participate in teaching.

competencies:

Recommendations for Further Study

ny research project uncovers more questions than it answers, and that can A point the way for further study. Future

studies might look at the competency behaviors that had means below 3.0. Other projects might focus on use of nursing diagnoses, evaluation of patient outcomes, and some of the specific competencies. Investigators might explore individ- ual competency statements and test ways to increase their use and compliance within practice settings.

Perioperative nursing is a dynamic specialty. The competencies may change with time. Revision and retesting would be appropriate in five years to remain a current indicator of perioperative nursing practice. 0

Notes 1. Association of Operating Room Nurses,

“Operating room nursing: perioperative role,” AORN Journal 27 (May 1978) 1161.

2. Ibid, 1165. 3. Association of Operating Room Nurses, “A

model for perioperative nursing practice,”AORN Journal41 (January 1985) 188-190.

4. Association of Operating Room Nurses, “Developing basic competencies for perioperative nursing,” AORN Journal 35 (April 1982) 871-881.

5. J M Reeder, “Intraoperative nursing activities,” AORN Journal 38 (November 1983) 795-810.

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If so, stop by the Journal office in the Costa Mesa Room during Congress. The editorial staff will help you get started. The majority of articles are written by OR nurses with experiences or expertise to share. At the office, you can pick up an intent-to-submit form and guidelines for authors.

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