JPN 321 Autumn 2019 PDF

Autumn 2019
Journal of Volume 32
Number 1
Perioperative Nursing Autumn 2019
NORTHERN TERRITORY PERIOPERATIVE

NURSES ASSOCIATION INC.
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Contents
Editorial3
President’s report 5
Clinical practice article – Improving antibiotic prescribing for surgical

prophylaxis – the role of nurses 7
Peer-reviewed article – The impact of improved surgical safety checklist

participation on OR efficiencies: A pretest–posttest
analysis 9
Peer-reviewed article – Perioperative nurses’ perceptions of cross-training:

A qualitative descriptive study 19
Journal Editor
Associate Professor Nicholas Ralph Peer-reviewed article – Innovations in postgraduate work integrated
journaleditor@acorn.org.au learning within the perioperative nursing
environment: A mixed method review 27
Journal of Perioperative Nursing:
The official journal of the Australian
Feature – Pressure injury risk assessment and prevention strategies in
College of Perioperative Nurses
operating room patients: Findings
ISSN 2209-1084 (print) from a study tour of novel practices in American hospitals 33
ISSN 2209-1092 (online/digital)
Grants and scholarships 39
Published quarterly by
ACORN
PO Box 899 Education report 45
Lyndoch SA 5351
www.acorn.org.au ACORN Standards update 47
Copy editor Eleanor Tan
ACORN noticeboard 49
Graphic design Savanah Design
Subscription enquiries Coming events 51

administrator@acorn.org.au
State reports 53
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Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au 1

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ACORN Editorial Associate Professor Nicholas Ralph
PhD, MClinPrac (Perioperative Nursing), RN
The Australian College of Perioperative School of Nursing & Midwifery,
Nurses (ACORN) is a registered
Australian company and health Preventing University of Southern Queensland
promotion charity. It exists to serve its
members, the perioperative profession, perioperative Jeffrey Gow
PhD, MEcon
the patient and the community to
promote the prevention and control of hypothermia is School of Commerce, University of
Southern Queensland
disease.
clinically feasible Jed Duff
ACORN’s vision is for Australian patients
to receive the safest and highest quality and cost effective PhD, BN
School of Nursing and Midwifery,
evidence-based perioperative care in University of Newcastle
the world. Inadvertent perioperative
hypothermia is associated with
serious adverse surgical outcomes blood loss, prolonged hospitalisation
ACORN Board of Directors
including increased infection rates, and thermal discomfort are just
Rebecca East a few examples of the serious
morbid cardiac events and surgical
President
bleeding1. Surgical patients are complications that are caused by
Trent Batchelor particularly at risk of hypothermia perioperative hypothermia. Enzymes
Director that regulate organ functions and
because of ‘anaesthetic-induced
Patricia Flood impairment of thermoregulatory process medications, for instance,
Director control’ and the ‘cool operating are very sensitive to the change in
Journal Committee Chair and Research body temperature and consequently
room’ temperature that create the
Committee Chair
perfect combination for developing hypothermia affects the
Karen Hay hypothermia post-surgery 1,2. pharmacodynamics of many drugs.
Director
Conference Committee Chair and Perioperative hypothermia develops Recent developments in
Professional advocacy and advisory in three characteristic phases:
liaison thermal care
1. a rapid decrease in core The United Kingdom National
Grace Loh
Director temperature in the first hour Institute for Health and Clinical
Hospital and University Collaboration due to core to peripheral Excellence (NICE) has published a
and Accreditation Committee Chair redistribution of body heat guideline ‘Perioperative hypothermia
Grants, Awards and Scholarships mediated by the use of volatile
Committee Chair (inadvertent): The management
anaesthetic agents of inadvertent perioperative
Paula Foran
2. a slow linear decrease in core hypothermia in adults’ detailing
Member Director
Membership and Local Associations temperature due to heat loss appropriate perioperative thermal
Liaison Committee Chair exceeding metabolic heat gain management to minimise the
occurrence of perioperative
Sophie Ehrlich 3. a plateau in temperature in which
Director hypothermia. The guideline is based
vasoconstriction decreases heat
Education Programs Committee Chair on a comprehensive systematic
loss from the skin3.
review including both meta-analysis
Donna Stevens
Director Perioperative hypothermia increases and cost-effectiveness analysis4.
Education Committee Chair the incidence of complications
Recommendations from the
following surgery. Reducing
Garry Stratton guideline include the requirement
Director the incidence of perioperative
for preoperative hypothermia risk
Finance, Audit and Risk Committee hypothermia through appropriate
assessment, regular temperature
Chair perioperative care can reduce
monitoring, and active and passive
the number and complexity of
warming strategies. However,
complications that arise. Sessler2
compliance with recommendations
investigated the complications that
in clinical practice is poor despite
arise from hypothermia by reviewing
their relative simplicity and cost-
the current literature and reported a
effectiveness. For example, results
dozen major health consequences.
from a large European multisite
Myocardial ischemia, coagulopathy or

observational study (n = 8083) with guidelines effective for With the release of this report
conducted prior to the NICE guideline reducing perioperative hypothermia. expected in the first half of 2019, we
development found that temperature They found that the total cost encourage all perioperative nurses
monitoring was not appropriately of perioperative hypothermia to to take heart in recognising the
undertaken in 81 per cent of the Australian health system is significant value they provide to the
patients5. Both the Australian and $1.26 billion and that preventing Australian health care system by
New Zealand College of Anaesthetists perioperative hypothermia has an delivering excellent perioperative
and the Royal Australasian College of annual net benefit of: care.
Surgeons clinical guidelines reflect
• $602 million to the Australian References
the recommendations of the NICE
health system
guideline3. 1. Sessler D. Perioperative
• approximately $7085 per patient for thermoregulation and heat balance.
In 2014 a thermal care bundle was Lancet 2016;387(10038):2655–2664.
major surgery (with an overnight
developed by a panel of Australian 2. Sessler D. Complications and treatment
stay) from reducing SSIs alone
expert clinicians and researchers to of mild hypothermia. Anesthesiology
improve the prevention, detection • approximately $6560 per patient for 2001;95(2):531–543.
and treatment of perioperative minor surgery (with an overnight 3. Australian and New Zealand College
stay) from reducing SSIs alone. of Anesthetists (ANZCA). Perioperative
hypothermia in adult surgical
normothermia: Clinical audit guide. ANZCA:
patients6,7. Implementing a thermal This report is of significance to all Sydney, 2013.
care bundle can help rapidly perioperative nurses in Australia as 4. National Collaborating Centre for Nursing
disseminate optimal clinical the prevention of hypothermia is and Supportive Care. The management of
guidelines for the management of often led by nurses and denotes the
inadvertent perioperative hypothermia
in adults: Prevention and management in
health care–associated illnesses value of high reliability nursing care. adults. Clinical practice guideline. NICE:
and risks. The bundle elements were Significantly, the authors recommend London, 2008.
selected from the NICE guideline on that: 5. Torossian A. Survey on intra-operative
the management of perioperative temperature management in Europe. Eur J
hypothermia in adults. • current best practice is adopted Anaesthesiol 2007;24(8):668–675.
ensuring that thermal care is 6. Duff J, Walker K, Edward K, Williams
Economics of preventing provided to ‘every patient, every R, Sutherland-Fraser S. Incidence of
perioperative inadvertent hypothermia
perioperative hypothermia time’
and compliance with evidence-based
In a report soon to be released, • a national multidisciplinary-based recommendations at four Australian
hospitals: A retrospective chart audit.
the authors will provide a detailed policy for preventing and managing
Journal of Perioperative Nursing
economic analysis on the cost- perioperative hypothermia is 2014;27(3):16–23.
effectiveness of preventing developed 7. Duff J, Walker K, Edward K, Ralph N,
inadvertent perioperative • a definitive clinical trial on Giandinoto J, Alexander K, Gow J, Stephenson
hypothermia in Australia. Using J. Effect of a thermal care bundle on the
perioperative hypothermia is prevention, detection and treatment of
rigorous up-to-date data, the conducted. perioperative inadvertent hypothermia. J
authors report findings based on a Clin Nurs 2018;27(5–6):1239–1249.
scenario of 80 per cent compliance
4 Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au

President’s report Rebecca East
President
With the start of 2019 already drifting well into the past as you
read this autumn ACORN journal I wonder if our new year’s
resolutions are still fresh in our minds?
I don’t tend to make new year’s units on how to manage fatigue. This be well rested and well supported.
resolutions but I have recently been standard indicates that it is not only We want to work with industry to
working on taking care of myself. The the responsibility of health care find ways of lightening our load and
year 2018 was a tough one – not only facilities to ensure that staff are well decreasing the occurrence of fatigue
was it tough for me personally but for rested and safe to attend to their in the perioperative environment.
many of my colleagues, family and shift, but it also indicates that it is The inaugural ACORN Leadership
friends. I think as I write we have all our own responsibility to ensure we Summit in Canberra this year will
been looking forward to a new start are safe to work during our shift1. allow our perioperative leaders
in 2019. to discuss these issues nationally
And so I have decided to make a
and allow ACORN to support them
Nursing fatigue and burnout is a promise to myself to take care of
in not only this issue but in wider
constantly growing issue not only myself in 2019 and beyond. Although
industry issues. The summit has
in perioperative units but in health our employers are responsible
limited numbers so if you are keen
care worldwide. Only recently, as I sat for providing us with a safe work
to join us in Canberra for the ACORN
quietly waiting to perform an after- environment, we too are responsible
Leadership Summit please make sure
hours case, I had a catch up with for ourselves and our colleagues.
to get your registration in soon!
a colleague. He was fatigued. The The year 2019 is shaping up to be
long weeks of call, after hours cases a fantastic year on so many levels While we work in the background to
and challenges that he consistently personally and professionally. build our voice in the industry, I ask
comes up against every day are However, I will not be able to reach you to promise that you will work on
wearing him thin. Not to mention the all of my goals without taking care of taking care of yourself too. We are
challenges he faces in the outside myself in the process. responsible for our own health, and
world, having a young family, sporting though I know it’s not always easy,
At our December board meeting the
commitments, and the list goes on. let’s be advocates for ourselves and
ACORN directors reminded ourselves
our colleagues. It will allow us to be
The literature recognises that fatigue what it is that we are here for. We
better advocates for our patients too.
in the perioperative environment now write down at the start of our
is increasing. I came away from the meetings our vision. ACORN’s vision Reference
late evening case questioning if I, as is for patients to receive the safest
1. Australian College of Perioperative Nurses
a colleague, was doing anything to and highest quality evidence-based Ltd (ACORN). Standards for Perioperative
improve my own environment, let perioperative care in the world. The Nursing in Australia 15th ed. Adelaide, South
alone that of my colleagues. ACORN board recognises that for this to Australia: ACORN; 2018.
has a standard to guide perioperative occur our perioperative staff need to
Change of director
Since the last issue of the journal we We welcome Trent Bacthelor as the
have had a change of director. South new South Australian director. Trent
Australian director, Di Hutt, has left is Perioperative Services Manager at
the board after four years – two as Burnside War Memorial Hospital. He
representative and two as director. attended the face-to-face meeting
Di was Chair of the Conference in Launceston in February where he
Committee that organised the met the other directors and, with
wonderful international conference them, participated in the ACORN
in Adelaide in 2018. We thank Di for Tasmania study day.
all the time and effort she has put
into ACORN.

save the date
6–7 September 2019

East Hotel, Canberra
acorn.org.au/summit2019
East Hotel
Canberra NSW
Clinical practice
Improving antibiotic prescribing Authors

Robert Herkes
for surgical prophylaxis – the MBBS FRACP FCICM

Chief Medical Officer, Australian
role of perioperative nurses

Commission on Safety and Quality in
Health Care, Sydney NSW Australia
Associate Professor Pat Nicholson
Surgical site infection is a potential The Australian Commission on
PhD, RN, FACORN
post-surgery risk that needs to Safety and Quality in Health Care School of Nursing and Midwifery, Centre
be managed effectively as part of (the Commission) coordinates the for Quality and Patient Safety Research,
good patient care. The discovery of Antimicrobial Use and Resistance Faculty of Health, Deakin University,
antibiotics in the 20th century and in Australia (AURA) Surveillance Geelong Vic Australia
their associated use as surgical System, which provides a range of
antibiotic prophylaxis, often AMR and antibiotic use surveillance particularly where the evidence base
with other interventions such as data. AURA also provides a platform for alternative practices is limited.
oxygenation, glycaemic control and for voluntary standardised audits
Process issues still account for many
surgical antisepsis, has minimised of surgical prophylaxis through the
variations from guidelines-based
this procedural burden. Hospital National Antimicrobial
practice. Improved standardisation
Prescribing Survey (NAPS).
However, the global increase in could bring practice more in line
antimicrobial resistance (AMR) Data from participating hospitals in with consistent and reliable delivery
is limiting the effectiveness of 2017 showed that 30.5 per cent of of antibiotic prophylaxis. There are
antibiotics currently available when surgical prophylaxis prescriptions many opportunities for improvement
treating infections and impacting for inpatients extended 24 hours including:
on the delivery of safe and effective beyond the time of surgery. This is
• consistency in documentation of
care for patients. As a result, many despite guidelines recommending
fixed antibiotic duration
infections are no longer responsive surgical prophylaxis durations of less
to first line antibiotic choices. The than 24 hours. Commonly, surgical • development of and adherence
overuse and misuse of antibiotics, antibiotic prophylaxis was found to to evidence or consensus-based
wherever this occurs, impacts be too broad or too narrow for the guidelines
the efficacy of surgical antibiotic organisms known to cause surgical
• optimising administration timing
prophylaxis. This, compounded by the site infections or to be inconsistent
for optimal concentration of
decreased antibiotic development with guidelines (with no indication
antibiotics during the surgical
pipeline, means that managing an of patient characteristics that would
procedure.
infection is no longer as simple as require variation), or the wrong dose
just selecting ‘another antibiotic’. was prescribed. The timing of prophylactic antibiotics
is crucial, and nurses working in
Due to AMR, complex infections are Variation in surgical antibiotic
the perioperative setting are well
now being treated with potentially prophylaxis prescription often occurs
placed to have a significant impact
more toxic, costly and complicated because of individual prophylaxis
on this aspect of surgical antibiotic
regimens than in the past. This preferences. Despite evidence to
prophylaxis. Optimal timing is
creates additional risks for patients, the contrary 1,2, the perception that
dependent on the pharmacokinetics
including potentially adverse adverse outcomes are reduced
of the antibiotic used to optimise
outcomes from the antibiotics used with longer and broader spectrum
tissue concentrations. Vancomycin
and increased length of hospital antibiotic intravenous courses still
(and antibiotics with a longer
stay due to a lack of oral therapeutic exists. Topical or deep surgical
half-life) should be commenced
choices. Patients with unnecessary site administration has also been
within 120 minutes of knife
exposure to long courses of antibiotic reported.
to skin; the infusion does not
prophylaxis are also at a higher risk
The increased health care–associated have to be completed prior to
of morbidity and mortality if they
complications of prolonged or the commencement of surgery.
develop an infection as it is more
novel intra-operative antibiotic use Vancomycin can cause red man
likely the organism will be resistant
(for example irrigations, pastes or syndrome when administered too
to commonly prescribed antibiotics.
washes) also need to be considered, quickly in an attempt to finish the
infusion prior to knife to skin.

The timing of antibiotic administration specialties) may also aid in more nurses with resources to assist
also requires logistic coordination of consistent administration practices3. in safe antimicrobial use. Go to
the patient’s journey from the ward to www.safetyandquality.gov.au/SAP
Under the National Safety and
the operating suite and from the Post to find out how you can improve
Quality Health Service (NSQHS)
Anaesthesia Care Unit back to the surgical antibiotic prophylaxis in your
Standards, every hospital is required
ward. Nurses can also support best organisation.
to have a local antimicrobial
practice by promoting documentation
stewardship program to optimise References
of the plan for surgical antibiotic
use of antimicrobials and improve
prophylaxis to avoid confusion 1. Harbarth S, Samore MH, Lichtenberg D,
the use of surgical antimicrobial
when the patient returns to the Carmeli Y. Prolonged antibiotic prophylaxis
prophylaxis within hospitals. Nurses after cardiovascular surgery and its effect
ward. Prolonged administration of
are extremely valuable in their on surgical site infections and antimicrobial
intravenous surgical prophylaxis can resistance. Circulation 2000;101(25):2916–
participation in multidisciplinary
also increase the risk of a cannula site 2921
efforts to facilitate audits and
infection. 2. Broom J, Broom A, Kirby E, Post JJ.
feedback procedures or drive
Improvisation versus guideline concordance
Simple changes such as promoting dedicated quality improvement in surgical antibiotic prophylaxis: A
the importance of correct surgical projects. The provision of safe and qualitative study. Infection 2018;46(4):
antimicrobial prophylaxis for every effective care to patients is the 541–548.
procedure could also increase ultimate goal. To achieve this, the 3. Charani E, Tarrant C, Moorthy K, Sevdalis
N, Brennan L, Homes AH. Understanding
consistent administration and risks and benefits of antimicrobial
antibiotic decision making in surgery – a
improve choice practices. Clarity use need to be balanced. qualitative analysis. Clin Microbiol Infect
regarding the lead in the choice of 2017;23(10):752–760.
The Commission is working with
antibiotic (anaesthetic and surgical
ACORN to provide perioperative
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Peer-reviewed article
Authors
Brigid M Gillespie
The impact of improved surgical
PhD, RN, FACORN
School of Nursing and Midwifery, Griffith safety checklist participation on
OR efficiencies: A pretest-post
University, Gold Coast, Queensland,
Australia. Gold Coast Hospital and Health
Service, Queensland, Australia.
National Centre of Research Excellence
in Nursing, Griffith University, Gold Coast, test analysis
Queensland, Australia.
Does improved use of a surgical safety checklist influence OR
Emma Harbeck
efficiency?
PhD, B Psych (Hons)
School of Nursing and Midwifery,
Griffith University, Mt Gravatt Campus,
Abstract
Queensland, Australia. Objective: To describe changes in day of surgery (DOS) cancellations
Joanne Lavin and procedural delays following introduction of a practice improvement
BN, RN intervention to improve team members’ participation in the surgical safety
Surgical and Procedural Services, checklist (SSC).
Gold Coast Hospital and Health
Service, Queensland, Australia. Methods: Pretest—posttest electronic audit of secondary data collected 12
Therese Gardiner months before and 12 months after implementation. A consecutive sample
BN, GcEN, RN of patients who underwent elective surgeries were included. Elective
Surgical and Procedural Services, Gold surgeries over two periods (November 2014 to September 2015, and November
Coast Hospital and Health Service, 2015 to October 2016) were included in the audit and data was collected
retrospectively. The practice improvement intervention coined ‘pass the baton’
Teresa K Withers was implemented over four weeks in October 2015.
MD, FRACS Neurosurgery
Surgical and Procedural Services, Gold Results: Across audit periods 33 017 surgical procedures (16 262 pretest and
Coast Hospital and Health Service, 16 755 posttest) were performed. DOS cancellations between phases totalled
Queensland, Australia. 826 with an increase of 112 in the posttest phase with the largest posttest
Andrea P Marshall increase being in suite cancellation (increase of 97). Across phases, there were
PhD, RN, FACN, FACCCN 1508 procedural delays (pretest n=737, posttest n =771), with the most frequent
School of Nursing and Midwifery, Griffith delay being due to staff availability (p=0.577). Pretest procedural delays
University, Gold Coast, Queensland,
averaged 38.7 minutes (SD 52.4) and posttest averaged 36.8 minutes (SD 43.2)
Australia. Gold Coast Hospital and Health
Service, Queensland, Australia. (p=0.428).
National Centre of Research Excellence Conclusions: These results suggest no change in clinical efficiencies when
in Nursing, Griffith University, Gold Coast,
the SSC is fully utilised. That is, increased participation in the checklist does
not increase delays in surgery. When considering ways to improve clinical
Corresponding author efficiency, hospital administrators need to consider skill mix, physical layout
Professor Brigid M Gillespie of the OR and additional staffing, factors not captured in routine clinical audit
b.gillespie@griffith.edu.au. data collected.
Authors’ contributions Introduction costliest departments in any hospital,

contributing to more than 40 per cent
BMG conceived of the study, assisted Perioperative services are typically
in participant recruitment and drafted of its total running costs1,3, with costs
comprised of three phases:
the manuscript. BMG and EH performed as high as USD $40 per minute1,2
preoperative, intra-operative, and
the quantitative analysis. AM and EH (2018 AUD estimates $55 per minute).
post-operative. As a department,
contributed to study conception and Therefore, efficient management of
assisted in interpretation. TG, JL and TKW perioperative services is one of the
the service is necessary to minimise
assisted in recruitment, participated in most dynamic and complex in a
increased costs. Loss of information
the study and assisted in interpretation. hospital system and generates up
during the patient journey through
All authors participated in the design and to 60 per cent of the total gross
coordination of the study and read and
the department may negatively affect
revenue1,2. Nevertheless, US estimates
approved the final manuscript. patient flow and reduce clinical
suggest that they are also one of the
efficiency.

‘Efficiency’ is broadly defined as Despite the WHO SSC having been included. Data for the month of
performance that leads to cost implemented in over 132 countries October 2015 was excluded as at
reduction without compromising world-wide9, compliance remains a this time the process improvement
quality. Thus, efficiency relates to challenge10–12. We hypothesised that a strategy was being implemented
both productivity and quality. In theory-based practice improvement across the OR department. Over a
the operating room (OR) context, intervention aimed at changing four-week period, key stakeholders
definitions of efficiency usually focus clinician behaviour would increase implemented a process improvement
on time, whereas reductions in time checklist participation and item strategy intended to increase staffs’
related to a level of output translates use and influence OR efficiencies participation in the safety checks of
into efficiency4,5. Efficiency in the relative to day of surgery (DOS) the WHO SSC.
OR depends on minimising wasted cancellations and procedural delays.
and unused time to meet projected We chose these efficiencies because Process improvement strategy
surgical targets1. Numerous factors communication processes may affect In October 2015, a process
influence OR efficiencies e.g. surgical them, particularly during the sign-in improvement intervention coined
scheduling accuracy, on time starts, and sign-out phases of the WHO SSC. ‘pass the baton’ (PTB) was rolled
minimising case cancellations and To date, few studies have evaluated out department-wide with the goal
case turnover times4. improvements in WHO SSC use of improving team participation in
relative to longitudinal changes in the locally modified WHO SSC. PTB
Research suggests that improved
these OR efficiencies. was nurse-led and developed with
service efficiency depends on the
synchronisation of interprofessional input from key stakeholders across
Method nursing, surgery and anaesthetics.
communications in the OR
department which has a resultant We conducted a pretest—posttest Process strategies to promote
impact on patient flow6,7. The intent audit of electronic secondary behaviour changes in WHO SSC
of the World Health Organization data to describe changes in the participation were delivered over
(WHO) surgical safety checklist numbers of procedural delays four weeks and included audit
(SSC) is to improve several ‘must and DOS cancellations following and feedback, opinion leaders and
do’ critical clinical tasks and hence implementation of an intervention change champions, reminders and
improve the fluency of processes, to improve participation in the prompts and formal and informal
team communications and WHO SSC. DOS cancellations and education. A process evaluation
operations throughout the patient’s delays, regardless of the underlying of these strategies is presented
perioperative journey. Although cause(s), negatively impact on elsewhere14. The phases in which it
not intended to directly improve use and consequently on costs13. was most difficult to maximise staff
OR efficiencies, the checklist acts Retrospective audits of an electronic participation were the sign-in and
as a memory aid for passing on database of surgical information sign-out phases. Therefore, the PTB
key information or actions that maintained by the hospital occurred intervention specifically involved the
may otherwise be overlooked over two 12-month periods. allocation of nursing staff to lead
or forgotten ensuring timely the sign-in and sign-out using a
Setting and sample deliberate call-and-response format.
and consistent communications
among surgical teams8. Thus, the The study setting was a 750-bed Implementing changes that address
SSC aids interdisciplinary team tertiary hospital in Queensland team-based delivery of care have
communications and coordination specialising in all surgeries except demonstrated not only increases
of clinical activities. The checklist transplantation. The department in OR efficiencies15–17 but also
divides the operation up into has 18 commissioned ORs and improvements in patient safety 18,19.
three phases – the period before performs approximately 16 000
Data collection and coding
anaesthetic induction (sign-in), the surgeries per year. A consecutive
period after induction and before sample of patients undergoing Electronic data from the ORMIS
surgical incision (timeout), and the elective surgeries during the periods database of operative times inclusive
period during and immediately November 2014 to September 2015 of in-suite to out of OR times
after wound closure but before and November 2015 to October (i.e. in-suite, in anaesthetic, in OR,
transferring the patient out of the OR 2016, and drawn from the Operating procedure start, procedure finish,
(sign-out)8. Room Information Management out of OR), procedural delays (type
System (ORMIS) database was and reason), surgical specialty, and

month and year were extracted We recoded DOS cancellations and were usually out of the control of
for cases of elective surgeries. The procedural delays according to their health care professionals and not
original ORMIS data files were given primary origin, i.e. whether they influenced by process improvements
to the lead author as an encrypted were related to the organisation/ associated with the use of the
Excel file. In the original database, department or to the patient. In WHO SSC. For instance, in relation
DOS cancellations and delays had the analysis, we excluded DOS to DOS cancellations ‘failure to
multiple codes for similar types and cancellations and procedural delays attend surgery’, ‘patient cancelled
reasons. that were patient-related as these booking’ and ‘unfit for surgery’ were
Table 1: OR efficacy indicators, their definitions and measures (where applicable)
OR efficiency
indicator Definition Measurement
First case on time Difference between actual time the patient enters OR and the Time recorded in ORMIS.
start4 scheduled time for the session.
Procedural delay4 Total delays from late starts (first case ‘In OR’ time is after the Coded according to the
scheduled session start time) and prolonged change-over times primary reason/origin.
(change-over time more than 15 minutes).
Categorical variable,
Reasons for delays relate to the availability of bed, equipment or numbers summed in
documents; staffing; and previous case over-run. each category.
In OR time5 Time the patient enters the OR, often referred to as ‘wheels in’ to Time recorded in ORMIS.
OR.
Procedure start The earlier time of either the specific positioning of the patient Time recorded in ORMIS.
time2 for surgery or commencement of the skin preparation.
In OR time (‘wheels Time the patient enters the OR from either the induction room or Measured in minutes.
in’) to procedure main reception area until the time the patient is either positioned
start time4,5 or has been prepped and draped for surgery. This period includes
anaesthetic induction process.
Procedure finish Time when all the instruments and sponge counts are completed Time recorded in ORMIS.
time5 and verified as correct, all post-operative radiological studies
to be done in the OR are completed, all dressings and drains
are secured, and the surgeon(s) have completed all procedure-
related activities on the patient.
Out of OR time5 Time the patient leaves the OR, often referred to as ‘wheels out’ Time recorded in ORMIS.
of OR.
Procedure finish Time from application of the final incision dressing, to when the Measured in minutes.
time to out of OR patient leaves the OR for transfer to the PACU.
time (‘wheels out’)4,5
Elective day Unanticipated cancellation of elective surgery due to either Coded according to the
of surgery patient or hospital-initiated factors. primary reason/origin.
cancellation4
Categorical variable,
numbers summed in
each category.
Note: OR = operating room, ORMIS = Operating Room Management Information System, PACU = Post Anaesthesia Care Unit
References:
4. NSW Agency for Clinical Innovation (ACI). Operating theatre efficiency guidelines: A guide to the efficient management of operating
theatres in New South Wales hospitals. ACI: Chatswood NSW, 2014; 1–82.
5. Healthcare Improvement Unit Queensland Health. Operating theatre efficiency. Brisbane: Queensland Health, 2017;1–82.

excluded in the analysis. In terms of Table 2: DOS cancellations pre- and post-implementation
procedural delays, ‘patient condition’,
‘disaster plan activity’, and ‘radiology
Nov 2015 – Oct 2016

Oct 2014 – Sep 2015
unavailable’ were also excluded from
the analysis. DOS cancellations were
implementation
implementation
recoded according to type (within
24 hours or in-suite) and reason
(bed/equipment/documentation
Post-
n (%)
n (%)
unavailable, staff unavailable, list
Pre-
re-arranged). Procedural delays χ2 (p value)
were recoded relative to their Number of hospital
primary origin: bed, equipment or 16 262 (49.3) 16 755 (50.7)
cases
documentation unavailable; staff
unavailable or list re-arranged. Table Cancellation type 4.7 (0.030)
1 details the OR efficiency indicators Cancelled within 24
that guided this study, their 184 (51.5) 206 (43.9)
hours
definitions and measurement (where
applicable). Cancelled ‘in suite’ 173 (48.5) 263 (56.1)
Analysis Total DOS cancellations 357 469

We cleaned and analysed the data Total cancellations 826
using the Statistical Package for
Social Sciences (SPSS; V.24, IBM, Cancellation reason 1.2 (0.560)
NY, New York, USA), and checked
a random sample of 20 per cent Bed/equip/
for accuracy. Descriptive statistics documentation 258 (72.3) 332 (70.8)
using absolute (n) and relative unavailable
frequencies (per cent) or means Staff unavailable 31 (8.7) 35 (7.5)
and standard deviations (SD) were
used appropriate to the level of data. List re-arranged 68 (19.0) 102 (21.7)
For categorical data, comparisons
between phases relative to type Speciality 15.2 (0.076)
and reason for DOS cancellation
Obstetrics and
and procedural delay, and surgical 25 (7.0) 55 (11.7)
gynaecology
specialty were analysed using the Chi
squared (χ2) statistic. Independent Max facial/ENT/
61 (17.1) 67 (14.3)
sample t-tests were used to compare plastics^
overall time differences (in minutes) Orthopaedics 51 (14.3) 99 (21.1)
for each surgical specialty over
pretest and posttest phases. We used Urology 32 (9.0) 39 (8.3)
95 per cent confidence intervals (CI)
and considered p-values of < 0.05 General 36 (10.1) 45 (9.6)
significant.
Neurosurgery 36 (10.1) 43 (9.2)
Ethics
Ophthalmic 23 (6.4) 24 (5.1)
Ethics approval was given by Griffith
University (NRS/06/14/HREC) and Paediatrics 2 (0.6) 4 (0.9)
the Gold Coast University (HREC/13/
QGC/154) Human Research Ethics Cardiothoracic 56 (15.7) 60 (12.8)
committees. Following ethics
approval for the main study, we Vascular 35 (9.8) 33 (7.0)
sought permission to obtain
Note: ^ covers facio/maxillary, ear, nose and throat, dentistry and plastic surgery.

de-identified ORMIS data from the most predominant reason for DOS Overall, the mean procedural delay
director-general, Queensland Health, cancellation. Over each audit period, (in minutes) pretest was 38.7 minutes
as required by the Public Health Act the highest number of cancellations (SD 52.4), and posttest was 36.8
(2005). occurred in orthopaedic surgery minutes (SD 43.2). These results
(n =150/826, 34.9 per cent; pretest were not significant (t=0.79, df 1506,
Results n=51/357, 14.2 per cent; posttest p=0.428).
Over audit periods, 33 017 surgical n=99/469, 21.1 per cent) and the
Table 3 displays the pretest–posttest
procedures were performed (16 262 fewest in paediatric surgery (n =6/826,
results relative to times from in OR
pretest, 16 755 posttest), representing 0.72 per cent; pretest n=2/357, 0.56 per
to procedure start and procedure
an increase of 493 in the posttest cent; posttest n=4/469, 0.85 per cent).
finish to out of OR. Relative to in
period. Table 2 shows results for Figure 1 illustrates longitudinally OR to procedure start, there were
DOS cancellations according to the frequencies of procedural significant pretest–posttest time
type and reason for cancellation. delays relative to bed, equipment or differences (minutes) in two out of
DOS cancellations between phases documentation availability; staffing ten specialties (maxillary facial/ENT/
totalled 826, representing an availability, and prior case over-runs plastics, paediatrics). In relation
increase of 112 in the posttest phase. for each month over pretest and to procedure finish to out of OR
However, there were significant posttest phases. Across phases, there times, there were significant pretest–
(p=0.029) differences between phases were 1508 procedural delays (pretest posttest time differences (minutes) in
relative to each type of cancellation n=737, posttest n =771), with the four out of ten specialties (obstetrics
(i.e. within 24 hours compared to most frequent delays being related and gynaecology, maxillary
in-suite). Across phases, a lack of bed, to staff availability; however, this facial/ENT/plastics, paediatrics,
equipment or documentation was the was not significant (χ2 =1.10 p=0.577). cardiothoracic).
Pre-implementation phase Post-implementation phase Delay code

45 Bed, equipment or
documentation unavailable
number of recorded procedural delays
Staff unavailable
40
Prior case ran overtime
35
30
25
20
15
10
0
Oc
No 201
De 201
Ja 201
Fe 201
M 201
Ap 201
M 201
Ju 201
Ju 015
Au 015
Se 201
No 201
De 201
Ja 201
Fe 201
M 201
Ap 201
M 201
Ju 201
Ju 016
Au 016
Se 201
Oc 201
ar 5
ay 5
ar 6
ay 6
n 4
n 5
n 5
l2
n 6
l2
b 5
b 6
p 5
p 6
g
g
r 5
r 6
t
t2 6
c 4
c 5
v 4
v 5
2
01
6
Month
Figure 1: Types of delays relative to bed/equipment/documentation, staffing and prior case over-runs in pre-
and post-implementation periods over month

Table 3: Pretest–posttest results for times from in OR to procedure start and procedure finish to out of OR
implementation
implementation
95% confidence
interval of the
Post-
difference
Pre-
Mean Std error

Speciality n n t df difference difference Lower Upper
Time from in OR to
procedure start
Obstetrics and 1838 1882 0.18 3718 0:00:04 0:00:26 -0:00:46 0:00:55
gynaecology
Max facial/ENT/ 1931 1948 -4.36 3705.3 -0:02:38 0:00:36 -0:03:50 -0:01:27
plastics^
Orthopaedics 1971 2185 0.28 4154 0:00:06 0:00:23 -0:00:39 0:00:52
Urology 2451 2461 -0.69 4910 -0:00:12 0:00:18 -0:00:49 0:00:23
General 1152 1140 -1.46 2290 -0:01:03 0:00:43 -0:02:29 0:00:21
Neurology 359 392 1.96 683.7 0:02:55 0:01:29 -0:00:00 0:05:50
Ophthalmic 1913 1977 -0.92 3888 -0:00:13 0:00:15 -0:00:43 0:00:15
Paediatrics 400 429 -5.27 711.5 -0:04:09 0:00:47 -0:05:42 -0:02:36
Cardiothoracic 384 384 0.32 766 0:00:39 0:02:05 -0:03:26 0:04:46
Vascular 392 363 -0.54 753 -0:00:46 0:01:26 -0:03:35 0:02:03
Time from procedure
finish to out of OR
Obstetrics and 1838 1882 -2.44 3608.7 -0:01:39 0:00:40 -0:02:59 -0:00:19
gynaecology
Max facial/ENT/ 1933 1951 -3.35 3547.0 -0:04:55 0:01:28 -0:07:48 -0:02:02
plastics^
Orthopaedics 1972 2185 -2.17 3997.0 -0:01:39 0:00:46 -0:03:10 -0:00:09
Urology 2452 2462 1.42 4874.1 0:00:48 0:00:34 -0:00:18 0:01:55
General 1152 1141 -0.24 2291 -0:00:20 0:01:27 -0:03:11 0:02:30
Neurology 359 393 1.14 750 0:03:13 0:02:50 -0:02:20 0:08:47
Ophthalmic 1913 1977 1.99 3870.6 0:00:50 0:00:25 0:00:00 0:01:39
Paediatrics 400 429 -4.37 801.3 -0:02:44 0:00:37 -0:03:58 -0:01:30
Cardiothoracic 384 385 2.05 605.2 0:05:10 0:02:31 0:00:13 0:10:08
Vascular 392 364 -0.19 754 -0:00:30 0:02:35 -0:05:35 0:04:35
Notes:
Time difference is displayed in h:mm:ss.
Some degrees of freedom (df) have decimals because Levene’s test was violated so ‘equal variances not assumed’ data used.
^ covers facio/maxillary, ear, nose and throat, dentistry and plastic surgery.

Figure 2 depicts longitudinally the Discussion improvements in using the checklist
pretest and posttest means (in do not translate into increased
Few studies have used longitudinal
minutes) for all specialties combined efficiencies. Still, our results suggest
efficiency indicators to measure
relative to time from in OR to that increased participation in the
the impact of theory-based process
procedure start. The results vary WHO SSC does not negatively impact
improvement strategies on DOS
across both phases but there is a on OR efficiency. That is, active team
cancellations and procedural delays
notable spike in the posttest period participation does not increase
across an entire OR department.
for the months of December and the time taken to complete clinical
The benefit of the checklist on
March. Figure 3 shows longitudinally, activities. Many staff were concerned
patient outcomes, safety related
the pretest and posttest means that implementation of PTB needed
practices and clinical processes
(in minutes) for all specialties extra time and would reduce their
are well researched20–23. There
combined relative to time from ability to complete elective case
were no significant differences
procedure finish to out of OR. In the lists on time25. Previous research
in clinical efficiencies despite
pre-implementation phase there suggests that improvements in
observed improvements in
were drops in February, June and interdisciplinary communication
checklist items coverage and
September. reduces procedural delays7,26,27.
participation post-implementation
Nonetheless, some of these studies
of PTB (acknowledging that the
used self-reported survey data
SCC was not fully utilised)24. Clearly,
or had short follow-up periods26,27.
Pre-implementation phase Post-implementation phase

00:20:30
00:20:00
Mean time from in OR to procedure start (minutes)
00:19:30
00:19:00
00:18:30
00:18:00
00:17:30
00:17:00
00:16:30
00:16:00
00:15:30
Oc
No 14
De 14
Ja 14
Fe 15
M 15
Ap 15
M 15
Ju
Ju 15
Au 15
Se 15
No 15
De 15
Ja 15
Fe 16
M 16
Ap 16
M 16
Ju
Ju 16
Au 16
Se 16
Oc 16
ar
ay
ar
ay
n
n
n 5
l2
n 6
l2
b
b
p
p
g
g
r2
r2
t2
t2
c
c
v
v
20
20
20
20
20
20
0
0
20
20
20
20
20
20
20
20
20
20
20
20
0
01
0
0
1
Month (Error bars +1–2 Std error)
Figure 2: Time from in OR to procedure start (in minutes) pre- and post-implementation periods over month

Pre-implementation phase Post-implementation phase
00:18:00
00:17:00
Mean time from procedure finish to out of OR (minutes)
00:16:00
00:15:00
00:14:00
00:13:00
00:12:00
00:11:00
00:10:00
00:09:00
Oc
No 14
De 14
Ja 14
Fe 15
M 15
Ap 15
M 15
Ju
Ju 15
Au 15
Se 15
No 15
De 15
Ja 15
Fe 16
M 16
Ap 16
M 16
Ju
Ju 16
Au 16
Se 16
Oc 16
ar
ay
ar
ay
n
n
n 5
l2
n 6
l2
b
b
p
p
g
g
r2
r2
t2
t2
c
c
v
v
20
20
20
20
20
20
0
0
20
20
20
20
20
20
20
20
20
20
20
20
0
01
0
0
1
6
Month (Error bars +1–2 Std error)
Figure 3: Time from procedure finish to out of OR (in minutes) in pre- and post-implementation periods over
month
Therefore their findings need to at the study hospital. Priority is members are communicating the
be considered relative to these always given to emergency Caesarean necessary pre-checks and lessening
limitations. sections (categories 2–4), resulting the risk of unnecessary or prolonged
in the cancellation and rescheduling anaesthesia time thereby increasing
Our results indicate increases
of DOS elective (booked) C-sections. patient safety.
across most specialties for total DOS
Second, maxillary facial/ENT/plastics
cancellations (Table 2). The increase The duration of procedural delays
and orthopaedic cases involving
in ‘ in-suite’ cancellations during actually decreased despite an
implantable prosthetic components
the posttest period suggest that increase in the number of surgical
(e.g. total hip/knee replacement
clinical/case-related discrepancies procedures performed during the
surgeries) relies on having the
may not have been identified until posttest period. The results of other
appropriate range and sizes of
after the patient was received into research in this area also suggests
prosthetics available. The check-in
the department. The main reason modest to moderate improvements
phase of the WHO SCC has an item
for DOS cancellation related to in procedural delays following
covering equipment and instrument
bed or equipment availability. teamwork initiatives17,25,26. For instance,
availability. It may be that increased Wolf et al.26 and Nundy et al.27
We suggest there are a couple of
communication at this time identified reported reductions of 13 per cent
contributing factors. Firstly, for
a problem with availability and to 31 per cent in procedural delays
obstetric procedures, the availability
averted a situation when patients following the implementation of
of a ‘dedicated’ emergency obstetric
were anaesthetised without having briefings and debriefings. Clearly,
theatre during weekdays (8.00 am to
the equipment on hand. Plausibly improvements in communication,
5.00 pm) is not always guaranteed
this may demonstrate that team teamwork and planning are the

drivers behind how checklist Implementation of PTB aimed where clinical activities take priority,
briefings reduce procedural delays27. to simplify the checking process potentially reducing the accuracy of
Paradoxically in our study, four out through addressing behavioural and these data. Thirdly, these analyses
of ten specialties showed increases contextual factors that contributed are based on selected factors
in time delays (Table 3). Generally, to limited use of the SSC14,24. Yet to identified at the departmental
procedures in these specialties had achieve sustainable improvements in level, thus patient-related factors
shorter operative times, were less efficiencies, structural interventions were not included and may have
technically complex and involved such as parallel processing, physical contributed to OR efficiencies.
younger patient cohorts. layout of the OR and additional Nonetheless, these factors were
staffing should be considered. At largely outside the control of
Our results suggest that staff
the intervention hospital, the the department or organisation,
availability was the most common
layout of the new state-of-the-art hence their exclusion. Fourthly,
cause of procedural delays across
OR department (commissioned departmental factors (e.g. staff
both periods (Figure 1). This result
in September 2013), which was turnover and training requirements,
is somewhat concerning. This type
spread out along two long corridors, increased workload and the
of delay is potentially disruptive to
impacted on workflow and therefore addition of new procedures) could
workflow and impinges on the quality
patient care because of the distance not be accounted for. Such factors
and work environment of surgery.
needed to travel to fetch equipment may also influence performance
Staffing issues are often associated
and instruments. In relation to but could not be captured in the
with safety because improved
staffing, with the appropriate skill audit data. Finally, while PTB was
efficiency and capacity mean that
mix it is possible to perform work implemented department-wide, not
more operations are performed
tasks in parallel to increase efficiency all teams consistently participated.
during the daytime when back up
and maximise the work capacity of Prior to analysis, it was impossible
personnel are readily available. Fewer
members29. The hospital site in this to delineate particular cases (and
surgeries are performed at night
study is a teaching facility so relies exclude them) where there was
when skeleton teams who may be
on a trainee workforce with varying patchy or limited use of PTB. Despite
unfamiliar with each other are more
degrees of clinical experience and these limitations, these longitudinal
likely to work together26,27. Changes
expertise; therefore, it is not always analyses showed trends relative to
to staffing over time are inevitable in
feasible to undertake clinical tasks the types of delays that occurred (i.e.
any health care setting. Over the two-
in this manner. Workforce issues bed, equipment or documentation
year audit period there were changes
can have a profound bearing on availability; staff availability, case
in staffing with seasonal influxes or
performance of OR efficiencies. over-run) and seasonal variations
attrition of staff occurring throughout
However, relative to clinical in wheels-in and wheels-out times
the year. Further, increases in the
performance metrics, factors such across surgical specialties. Thus,
number and complexity of surgical
as workforce and physical layout are these results may help to identify
cases in the posttest period meant
unable to be captured. areas of process efficiency and areas
that staff workloads necessarily
increased leading to additional staff Limitations for improvement.
being hired. Many of these new staff
We acknowledge some limitations, Implications for perioperative
needed training and upskilling in
so there are caveats in the nursing
unfamiliar surgical specialties and so
were often on a steep learning curve. interpretation of these results. Firstly, Our study shows no change in
the use of a single hospital site may health services performance
Saving time (as a measure of limit the extent to which results can when the surgical safety checklist
efficiency) in the OR does not be generalised. Secondly, ORMIS is fully utilised. The primary
necessarily lead to increased data may be subject to errors in intent of the checklist is to
efficiency28. PTB was implemented as coding, leading to misclassification. improve team performance vis-
a driver to enable change in practice Where there were discrepancies, the à-vis communication among
and process when executing the lead author followed up with coding surgical teams rather than clinical
checklist14,24. Yet strategies that target staff to clarify. Also, the accuracy efficiencies. Contrary to long-held
changes in practice (i.e. those that of the times entered depends on beliefs, performing the checks as
are behavioural in nature) are not the ability of staff to enter these a team-based activity does not
in themselves sufficient to achieve times in the ORMIS system as they decrease clinical efficiencies. Clearly
improvements in clinical efficiencies. occur. Clearly there will be occasions

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Implementation of the surgical safety M, Fairweather N, Slater K. Effect of
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11. Rydenfält C, Johansson G, Odenrick P,
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Authors
Mellisa S Platt
Perioperative nurses’
MN(Periop)
Perioperative Flow Manager, Operating perceptions of cross-training:
A qualitative descriptive study
Theatres, St John of God Murdoch
Hospital, Western Australia
Tracey Coventry
PhD
Postgraduate Coordinator and Senior Abstract
Lecturer, University of Notre Dame,
Western Australia Purpose: To investigate the perceptions of perioperative nurses regarding the
use and impact of cross-training in the perioperative department.
Leanne Monterosso
PhD, MN, RN Participants and setting: Scrub and scout perioperative nurses (n=8) who had
Professor Clinical Nursing, University of completed a one-day recovery room cross-training program in a large tertiary
Notre Dame, Western Australia
private health care organisation in Western Australia.
Corresponding author Method: One-to-one, semi-structured interviews of perioperative scrub–scout
Mellisa S Platt nurses.
MN(Periop)
Perioperative Flow Manager Operating Findings: The participants perceived the positive aspects of cross-training
Theatres, St John of God Murdoch were teamwork, professional satisfaction and added value to patient care.
Hospital, Western Australia The aspects that inhibited participants from learning or taking part in the
mellisa.sara@yahoo.com.au cross-training program were staffing issues, lack of confidence and burnout.
Conclusion: Cross-training supported effective staffing and quality patient
care; however, training needs to be protected from disruption to ensure
participants develop confidence and competence in the new areas
contributing to workforce satisfaction, retention and patient safety.
Keywords Cross-training, perioperative nursing, teamwork, professional
satisfaction, professional development, program development
Perioperative nurse work hours to perioperative nursing, cross-

are increasing in the context of training has been described as an
reduced staff numbers and increased approach to facilitate management
workload1. In this context, challenges and utilisation of staff6. Nurses with
can arise with organisational staff a diverse perioperative skillset can
retention and turnover2. In addition, be deployed in multiple roles in
replacement of an ageing population recognition of dynamic team needs
of experienced perioperative nurses and the provision of more effective,
may be difficult2,3,4. Development of collaborative and efficient team
strategies to potentially increase support7.
efficiency and reduce nursing
Cross-training facilitates the
shortages is essential for the
professional development of
sustainable delivery of health care in
perioperative nurses in the roles
Australia1,2.
and responsibilities of the scrub,
Cross-training is one such scout, recovery or anaesthetic
educational strategy aimed at nursing roles6. In aviation, cross-
improving teamwork and quality training was observed to support
patient care. First described by Volpe effective teamwork and improved
et al.5, cross-training is a method communication between team
used to educate and train individuals members and consequently their
across multiple role responsibilities performance5. In nursing, cross-
to improve teamwork and work flow. training has been shown to improve
Originating in aviation and adapted staff–patient ratios, decrease

overtime through the ability to share conditions that involved cross- moving trained staff from areas of
staff across units, and increase trained teams and those that did low to high activity to support the
staff satisfaction by fostering a not. The results indicated those workload6. However, there is limited
greater sense of teamwork8. Masson who were exposed to cross-training understanding of team members’
and Fain9 highlight how cross- demonstrated more effective perceptions of cross-training and its
training programs were effective teamwork communication and influence on staff retention. Following
in developing staff member’s performance5. A study by Masson the redevelopment of a large private
capabilities and had the potential and Fain9 indicated cross-training tertiary health care organisation in
to assist with managing low staffing facilitated staff members’ ability to Western Australia (WA), the number
levels. manage low staffing levels by the of operating rooms increased
movement of nurses throughout from ten to sixteen. This planned
In Australia, the literature on nurses’
the perioperative process. Inman expansion of services required the
perceptions of cross-training in
et al.13 suggested that cross-training recruitment of additional scrub–
tertiary hospitals is limited. A
reduced the need for nursing scout, anaesthetic and recovery room
research project conducted in
overtime hours and agency staff. nurses to the existing pool of nursing
rural Queensland explored the
Cross-training may achieve this by staff. The highly specialised nature
role of perioperative nurses (n=12)
supporting a more flexible workforce of pre-, intra- and post-operative
and described their common
that uses cross-trained nurses in all patient care occurs in isolation to
experiences10. Cross-trained nurses
perioperative areas during the shift other nursing specialty areas6. This
were expected to perform in all
to accommodate for high and low requirement for specially trained
aspects of the perioperative process
patient activity and to compensate staff and associated perioperative
from admission through to recovery.
for staffing shortages. Similarly, staff shortages leads to challenges in
Although most staff enjoyed the
Kuthan14 concluded that cross- managing safe staffing levels13,15.
challenge and holistic approach of
training allowed for more efficient
cross-training, they also indicated Staffing issues caused by absence
distribution of staff by sharing nurses
the practice impacted their ability from sickness and leave, is affected
across areas of need throughout the
to deliver care. This multi-skill by the lack of suitably skilled
working day.
training was deemed necessary as perioperative nurses available to
rural nurses were often required Nurse retention and absenteeism work at short notice. This leads
to perform duties perceived as remain major concerns for the health to an over-reliance on agency or
outside their scope of practice when care industry. Although the positive casual nurses or the expectation
adequate staff and services were influence of cross-training on for permanent perioperative
not available and as a result of high teamwork, team functioning and staff nurses to work overtime. These
staffing levels in comparison to low utilisation has been demonstrated, staffing difficulties significantly
patient numbers10. there is a lack of data surrounding impact teamwork through poor
nurse satisfaction and the emotional communication, low morale and
Teamwork is vital for the delivery
impact of cross-training. A quality negative effects on the ability to work
of safe and effective care and must
improvement project by Ballou et al.6 as cohesive teams and thus provide
be embedded in an organisation’s
showed cross-training contributed to safe care13,14.
culture and workforce training.
greater work satisfaction in teamwork
Solutions for improving teamwork A report on future health workforce
and that nurses who engaged in
highlight the importance of cohesion requirements identified nursing
challenging and innovative roles
and adaptability as necessary as a significant area of concern
demonstrated greater adaptability
for improvement11,12. These two primarily related to low retention
and flexibility. Thus, the significance
skills are directly related to cross- and recruitment rates and an ageing
of this study was to explore the
training. Volpe et al.5 described nursing workforce2. The impact of
perceptions of cross-trained
cross-training as a mechanism to staff attrition and absenteeism on
perioperative nurses and the impact
provide each team member with the health care industry directly
on staff satisfaction and teamwork
insight into another team member’s affects patient safety, productivity
within a large tertiary private health
responsibilities. This quantitative and workload16. The perioperative
care organisation.
research explored the effects of area consists of numerous sub-
cross-training on team functioning Perioperative cross-training has been specialties that require intensive
in aviation students (n=122) who reported to improve staff shortages training and the negative effect
were randomly assigned to training and maldistribution of nurses by of staff absenteeism is keenly

felt17. Absenteeism can result in
Theme 1: Theme 2:
obstructed perioperative patient
Enablers of cross-training Barriers to cross-training
flow between areas, ineffective
communication, poor teamwork, staff Sub-themes: Sub-themes:
dissatisfaction and an increased • teamwork • staffing issues
risk of documentation and clinical
• professional development and • comfort zone and confidence
errors18. Such concerns associated
satisfaction • burnout
with nursing shortages and
maldistribution of nurses have led • added value to patient care
to the implementation of innovative
strategies such as cross-training to Data collection Findings
manage these situations16.
Semi-structured, one-to-one All participants were female; half
In response to these issues, a one- interviews were conducted at a (50%, n=4) were aged between 40 and
day cross-training program was mutually convenient time and 49 years of age. Experience in the
developed by the organisation’s location. Each participant received perioperative specialty was equally
education department in an information sheet and written divided between 11 to 30 years (50%,
collaboration with the perioperative consent form. Interviews were n=4) and 0 to 10 years (50%, n=4). Two
nurse educator. The program digitally recorded and transcribed overarching themes were identified:
content was based on the National verbatim by a transcription service. ‘enablers of cross-training’ and
Safety and Quality Health Service ‘barriers to cross-training’.
(NSQHS)19 and the Australian College Data analysis
of Perioperative Nurses (ACORN)20 Theme 1: Enablers
The qualitative data analysis process
standards and organisational policies was guided by the six phases of This theme represented the
and incorporated theoretical learning thematic analysis described by perceived benefits and positive
with supporting literature and Braun and Clarke21. Analysis began outcomes of cross-training. The
supernumerary time in the recovery with familiarisation of transcripts participants’ viewpoints centred on
room. The purpose of this study was and review for accuracy, which the positive training aspects and
to investigate the perceptions of allowed for data immersion to the subsequent influence on the
perioperative nurses regarding the search for meanings and patterns. work environment. The following
use and impact of cross-training in The transcripts were categorised subthemes were identified:
the perioperative department. using NVivo 10 software22 where a • teamwork
‘bottom-up’ approach was used to • professional development and
Methods
identify themes. Once organised into satisfaction
A qualitative descriptive design was meaningful groups, the overarching • added value to patient care.
used to describe the attitudes and themes were identified with their
beliefs of perioperative nursing associated sub-themes and named Subtheme 1.1: Teamwork
staff in relation to their experience to illustrate the analysis21.
The positive impact of teamwork was
of cross-training. Semi-structured
Limitations explained by one of the participants:
interviews were used to elicit
‘Each department’s not isolated;
descriptions from perioperative This study was limited to a small they’re definitely interconnected’.
nurses who had attended the cross- cohort of participants in one hospital Participants described how cross-
training program. within a large, tertiary private health training led to a sense of unity
care organisation in WA. It is possible between the recovery and scrub–
Setting and sample
that differences between public scout departments as individuals
The study was undertaken in the and private tertiary perioperative were ‘able to tell what the other
perioperative department of a departments may affect the team members need and how you
large tertiary, private health care relevance of findings. can help them’. Furthermore, cross-
organisation in WA. A purposive training programs were viewed as
sample of perioperative nurses (n=8) encouraging mutual collegial support:
was selected from a cohort of 30 ‘So, we could relieve each other
nurses who had participated in the for tea, lunch… so that helps with
recovery cross-training program. workflow’.

The program also enabled Subtheme 1.3: Added value to Theme 2: Barriers to cross-training
participants to develop a greater patient care
The barriers were represented by
understanding of their team
Participants considered their the perceived factors that inhibited
members: ‘You can sympathise
contribution to patient safety participants from learning or taking
with them because you know’. It
and quality care as a personal part in the cross-training program.
was evident that participants felt
responsibility to improve their The subthemes were:
there had been an improvement in
own clinical skills. One participant
teamwork as a result of engaging • staffing issues
explained: ‘Although it is good to
in the cross-training program. This
have experts in specialties, it is • comfort zone and confidence
was summarised by one participant:
everyone’s responsibility to learn all
‘Because we know, we are able to • burnout.
aspects of the perioperative process
help each other’ and ‘I am a more
and have an awareness of every part Subtheme 2.1: Staffing issues
versatile team member’.
of the chain’. When participants were
Staffing issues were frequently
Subtheme 1.2: Professional trained, they believed they were able
described by the participants. The
development and satisfaction to play a greater role in ensuring
insufficient staffing levels during
their patients remained safe. This
Participants who engaged in the training impacted the length and
was emphasised by one participant:
cross-training program recognised quality of their experience. Some
‘the more skills you have, the better
they had a learning deficit in the participants reported that as a result
and more confident you are in your
area of recovery. Thus, the expansion other colleagues were not able to
work and the more you can do, the
of new knowledge and skills to participate in the program. One
more you care for the patient and the
fulfil responsibility to professional participant was emphatic: ‘If the
patient has better outcomes’.
development was a key goal: ‘It gives staffing isn’t right then you might
me a greater understanding and also Participants commented on how get pulled from the program’. This
able to educate and inform other cross-training provided a holistic aspect had a significant influence on
colleagues about those specialties view of the patients’ journey participants’ learning and negatively
as well’. Participants believed they specifically through the intra- impacted their confidence at the
had increased their capability operative and post-operative completion of the program: ‘The
and flexibility to meet standards processes. As a result, participants content was good, but I still don’t feel
for practice: ‘I am a more versatile were able to seek improved confident to be put into recovery’.
team member, able to educate my outcomes for the patient. One
The length of the program and
colleagues and keep up my skill mix’. participant shared that she was
limited exposure to a variety of
able to ‘take into consideration
Cross-training also provided a sense patients was influenced by available
the patient on the table when you
of professional satisfaction at the staff, which affected participant’s
see them in recovery’ which gave
completion of the program. It was consolidation of theory to practice.
a ‘greater understanding of the
evident that participants felt proud One participant commented: ‘The
outcomes of what you’re doing’. Also,
of their initiative, new skills and main complaint for people is that
participants highlighted how their
confidence in another area of nursing. they haven’t been allocated the
clinical handover to recovery room
This was best explained by one correct amount of time in there to
nurses had changed, because they
participant: ‘I can do recovery, I feel consolidate, then those people don’t
were more aware of what information
like I have more job satisfaction than feel comfortable to go back or just
was required in order to provide
just being a scrub–scout’ and another won’t go back’. This lack of time to
the best care for the patient. One
stated on completion of the program consolidate learning reduced their
participant noted: ‘I do cater my
‘I could provide better quality patient desire to use their skills in recovery.
handover for recovery, because I now
care and felt more personally and This was succinctly summarised by
know what they need to know’ and
professionally fulfilled … knowledge, one participant: ‘The time allocated
another participant suggested that
it’s rewarding’. to supernumerary wasn’t enough, so
she gained a ‘broader understanding
the experience wasn’t worth a lot and
of the care required for the patient’.
I feel more apprehensive about being
in recovery than before’.

Subtheme 2.2: Comfort zone and emphasised this concern: ‘If you in recruitment and education of
confidence finish early and then you’re straight perioperative nursing staff. Brooks,
into recovery and then that’s really Hinck, Johnson, Kelly and Doerner
The desire to stay in a familiar
busy, too, then people will probably suggested the implementation
environment was a key factor in the
get tired’. Other participants were of a cross-training plan ensured
reluctance of nurses to engage in
concerned that those who had done registered nurses were able to
cross-training. This was articulated
the training would be expected to adapt to the growth of the service16.
by a participant: ‘They have been in
work longer than others. This was Similarly, Delaney25 recognised cross-
their roles for a long time, they know
highlighted by another participant: training as a strategy that extended
what they’re doing and they’re good
‘By doing the program, it might mean the capacity of nursing staff and was
at it, and getting out of your comfort
that you will end up going into influential in reducing the health
zone is uncomfortable’. Confidence
recovery all the time, and those who care organisation’s costs.
was directly linked to this key factor
haven’t done the course get to go
along with the time allocated to Flexibility is a highly desirable
home’. Another stated how being
program learning and consolidation. trait of perioperative nurses10,26. By
moved around impacted on time off
Despite the desire to work in recovery, expanding each nurse’s scope of
from work: ‘It’s about efficiency and
the time assigned to program practice, expertise is fully utilised
moving the staff round, I think people
content was insufficient to build their and able to ebb and flow around
will get quite exhausted that they’re
confidence and comfort as noted by health service provision and
just busy … whereas that downtime is
this participant: ‘I found the content financial limitations25,27,28. In the
sometimes important for people’.
good, and I think it has helped, but intensive care environment cross-
I still do not feel confident to be Discussion training has served the needs of
put into recovery’. Furthermore, the organisation’s bed occupancy
participants identified the time Perioperative nursing is a by maintaining patient flow and
between training and working in multifaceted nursing specialty and retention of nurses8,29. Additionally,
recovery also had an influence on in the current health care climate cross-training reduces the use
confidence: ‘The longer the time of financial constraints, creative of costly agency nurses and thus
since being in recovery, it’s just and flexible staffing solutions supports retention of permanently
really daunting, I think the skill isn’t are necessary. The benefits of employed nurses13.
gone but the confidence with your perioperative nurses with additional
skills for specialised areas has Retention of nurses is frequently
skill is gone’. Another participant
been highlighted as a cost-effective associated with job satisfaction30
identified how staff were ambivalent
strategy 14,16. Cross-training addresses and consequences of cross-training
about learning another role: ‘Some
the requirements of each area were increased confidence and
don’t see the bigger picture of the
through allocation of staff to role satisfaction6,31. In addition,
entire department’ and a commonly
areas of deficit to ensure effective professional growth through
heard expression was ‘that’s not my
staff utilisation6. In addition, the additional study and practice
job’. One participant summarised
importance of proactive planning provided evidence necessary to
reluctance to move from comfort
for ongoing cost containment and pursue promotional opportunities32.
zones: ‘I think … when they don’t
retention of nursing staff occurs with In extending perioperative nurses’
know, everything is hard until you
a focus on patient-centred care. scope of practice across all
learn it’.
roles and areas, nurses gained a
The worldwide improvement in comprehensive view of the patient
Subtheme 2.3: Burnout
health outcomes and expansion of journey with specific support at
Participants were concerned that health services and technology are the point of care24,33. Kuthan et
after completing cross-training they related to decreasing mortality rates al.14 described the benefits of a
would be made to work in recovery leading to an ageing population23. patient-centred care model where
at the end of their operating list At the same time, health care nurses accompanied patients on
which would potentially lead to an services are operating in a fiscally their surgical journey and provided
increased workload. One participant constrained environment24. Tertiary specialty care from perioperative
noted: ‘If you get downtime, and hospitals are expanding their admission to discharge. Similarly,
then you’re moved to the next surgical services to meet community Bindon34 observed nurses who
busiest area, there’s probably a risk needs, with increased surgical continued to develop their ongoing
of burnout’. Another participant volume corresponding to increases competence were more able to

provide safe patient-centred process their initial fears were and produce confident nurses willing
care, therefore making a greater resolved with the growth of to work across all areas. Strategic
contribution to perioperative practice confidence. Additionally, the rewards implementation of cross-training
and excellence in nursing care. of meeting such a challenge ‘head programs in the perioperative
on’ were described as a deeper environment should also include
In supporting the immersion of
appreciation of the novice nurse, evaluation of pre- and post-training
nurses into other subspecialties,
being a role model, reshaping experiences to ensure effectiveness
cross-training increases familiarity
career prospects and inspiring of training and the positive impact
with colleagues with whom nurses
others. Similarly, Foley-Brinza and on staffing and delivery of quality
would otherwise have limited contact.
Brunges31 also noted that despite an patient care.
According to Volpe et al.5 one key
initial unwillingness, the result of
goal of cross-training was to gain Knowledge translation
cross-training was improved nursing
a solid appreciation for another’s
teamwork and culture. 1. Cross-training is a significant
tasks and responsibilities. This was
described as being ‘connected’ in However, the unfavorable aspects of strategy for addressing
addition to an acknowledgment of this new challenge, such as added perioperative workforce issues
each other’s contribution, leading stress compounded by increased and ensuring patient-centred care.
to more intimate teamwork. In turn, or heavy workloads when asked 2. Cross-training impacted positively
being connected fostered a more to cover absenteeism, can lead to on perioperative teamwork and
overall positive work culture. This burnout39. The unique perioperative job satisfaction reinforcing staff
connection is significant to effective environment has been identified as retention and quality patient care.
communication which subsequently potentially more hostile than other
impacts on positive patient and areas of nursing, due to the confined 3. Inadequate consolidation
nurse relationships14. space of an operating theatre, high of cross-training influenced
patient turnover and the intense successful transition to confident
Successful implementation of practice.
nature of work being performed,
cross-training requires role-specific
which is also more likely to add to
content and a well-constructed Conclusion
burnout40.
program, conversely, poor planning
This study on perioperative nurses’
and execution can lead to frustration Implications for perioperative perceptions of cross-training
and financial loss for nurses’ and nursing has affirmed the positive impact
organisations6,16. This study identified
The ACORN standards assert the on teamwork and professional
the lack of supernumerary time as
acquisition of new knowledge satisfaction and the delivery of
a barrier to successful completion
is required to provide a high holistic patient-centred care.
of the training. The benefits cannot
standard of safe patient care20. However, in order for cross-
be realised without employers’
All perioperative nurses have a training to be successful and
commitment to the release of
professional responsibility to increase nurses’ clinical confidence,
staff for training and support for
seek and engage in professional participants should have access
supernumerary time to allow for
development activities. Additionally, to the uninterrupted theory and
consolidation of practice35,36
perioperative education programs practical components of the program.
Nurses are known to resist allocation should be designed for specific The program was vital for skill
to unfamiliar areas37. Participants training needs20. Thus, programs such development and was considered
in this study expressed that cross- as cross-training should consider the an essential element in developing
training took them out of their impact on participant satisfaction, confidence and competence. If known
comfort zone – they viewed cross- confidence and competence, in barriers are addressed, cross-training
training as a challenging concept that addition to reducing workforce can potentially improve the active
was difficult to envisage and required issues, improving staff satisfaction engagement of perioperative nursing
a step into the unknown. Mouradijan and retention, and patient safety. staff and thus contribute to reduced
and Stengel38 reported when A specific focus should be on the workforce issues and improved
perioperative nurses were moved uninterrupted theory and practice patient safety and quality of care.
into a new area of perianaesthesia experience to consolidate learning
where after a structured training

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doi:10.1016/j.jopan.2016.04.019

NEW Practice Audit tools
The ACORN Practice Audit Tools (PATs) are customised spreadsheets to
record evidence of clinical practice during real-time observational audits of
perioperative nurses. There are 12 PATs, grouped into two ‘bundles’, which have
been developed for the following ACORN standards (listed sequentially):
Practice Audit Tools 1: Practice Audit Tools 2:

Asepsis and Staff and patient safety
clinical care 6. Documentation (from Professional practice)
1. Perioperative attire 7. Surgical safety
2. Asepsis and Infection 8. Medication safety

prevention 9. Management of sharps in the perioperative
3. Surgical hand antisepsis, environment
gowning and gloving 10. Safe patient positioning in the perioperative
4. Preoperative patient environment and Safe manual handling
skin antisepsis 11. Management of accountable items used during
5. Specimen identification, surgery and procedures
collection and handling 12. Surgical plume and Electrosurgical equipment
(from Equipment and environment)
Now available online at

www.acorn.org.au/standards/practice-audit-tools-pats.
The ACORN Practice Audit Tools are designed to measure perioperative nurses’ compliance
and therefore the quality of perioperative nursing care against the nationally recognised
professional standards of practice, Standards for Perioperative Nursing in Australia
(15th edition). The collected evidence is a measure of the quality of care and provides a
mechanism to improve perioperative nursing practice and patient outcomes.
Authors
Kylie P Russell
Innovations in postgraduate
PhD, MHSc(Ed), GCHRM, BN, RN
Associate Professor, School of Nursing work integrated learning within
the perioperative nursing
and Midwifery, University of Notre Dame,
Australia
environment: A mixed method

Tracey Coventry
PhD, MNursEd, RN, RM
Postgraduate Coordinator and senior
lecturer, University of Notre Dame,
Australia review
Corresponding author Abstract
Kylie P Russell Purpose: To determine the impact of the Graduate Diploma of Perioperative
PhD, MHSc(Ed), GCHRM, BN, RN Nursing on student learning and career progression.
Associate Professor, School of Nursing
and Midwifery, University of Notre Dame, Participants and setting: A validated mixed methods descriptive survey was
Australia sent to participants (n=67). Findings were analysed using descriptive statistics
kylie.russell@nd.edu.au and results were further investigated using a focus groups of 12 individuals.
Methods: Overall 96 per cent of graduates were satisfied with the program
and agreed that the program had improved their delivery of patient care
and enhanced their application of theoretical knowledge to clinical skills.
Three themes were identified from data from the focus groups: ‘learning’,
‘empowerment’ and ‘opportunity’. Qualitative findings confirmed program
satisfaction among participants who valued the learning experience.
Conclusion: The Graduate Diploma of Perioperative Nursing provides a
unique opportunity for nurses in Western Australia to engage in a workplace-
supported program to consolidate their specialised practice. With significant
cutbacks occurring in nursing education across both the private and public
health care sectors, the profession should advocate for the role of work
integrated learning as a strategy to support nurses’ development in a complex
and changing health workplace.
Introduction reducing potential supernumerary

clinical placements for postgraduate
Within nursing academia and
students.
the health services there is
ongoing discussion and concern The Graduate Diploma of
about the practice-to-theory Perioperative Nursing delivered at an
gap in undergraduate1 and Australian university aims to meet
postgraduate speciality practice the needs of both theory and clinical
programs. Postgraduate programs practice with an understanding
providing specialist clinical that supernumerary positions are
practice cannot validate clinical limited. The program, rather than
and professional competence in requiring clinical placement, instead
their learning outcomes without uses a model of work integrated
student engagement in the clinical learning, as previously reported3.
environment. However, providing With increased pressure on health
workplace learning opportunities services to practice with efficient
for postgraduate programs remains staffing levels and reduced access
limited2. Entry to practice registered to staff learning and development,
nurse placements are limited and senior nurses advocating for the
remain the priority for universities program have requested further
and the profession, therefore data to support the impact of the

program on participants. This data Table 1: Response rate WIL survey by year (n=21)
will assist when budget requests are
made concerning student numbers, 2013 2014 2015 2016 2017
access to program resources such Number 4 4 4 4 5
as support to attend face-to-face
staff development programs, rotation
through a variety of theatres survey, a response rate of 22 (33 per ‘not very satisfied’ and ‘not at all
(which impacts on orientation and cent) was obtained. Table 1 shows the satisfied’.
supernumerary time) and availability number of respondents from each of
A high percentage of participants
of senior staff to provide assessment the five years from 2013 to 2017 (one
were satisfied with the program with
and feedback concerning new nurses’ respondent did not identify which
96 per cent articulating they were
practice. year they studied.)
either very satisfied or somewhat
Of the 33 per cent of participants that satisfied. Particular aspects of the
Study design
replied, 86 per cent had already been program and the percentage of
The research aim was to determine working in the perioperative suite participants who responded that they
the impact of the Graduate Diploma prior to program commencement, were satisfied are as follows:
of Perioperative Nursing on student 9 per cent had a student clinical • the study days (100 per cent)
learning and career progression. A placement as their only experience,
concurrent mixed method design and 5 per cent had no previous • staff development support
as described by Creswell4 was used experience. (90 per cent)
for this study. This involved the • online academic content
Demographic details highlighted a
collection and analysis of qualitative (96 per cent)
range of ages of the participants, as
and quantitative data separately.
outlined in Table 2. • WIL (96 per cent).
A validated mixed method descriptive
Table 2: Age of participants The impact of the program on
work integrated learning (WIL) survey
participant’s knowledge, skills and
was sent to graduates from the
abilities was measured with a five-
previous five years (n=67). Potential Age Number
point Likert scale of ‘strongly agree’,
participants were encouraged 21–25 3 ‘agree’, ‘neither agree nor disagree’,
to forward the information to
26–30 5 ‘disagree’ and ‘strongly disagree’. The
colleagues as some of the contact
data indicated that participants:
information held by the university 31–35 4
may not have been current (referred • agreed that the program had
36–40 4
to as a Snowballing technique5). Data improved their delivery of patient
analysis for the survey data involved 41–45 4 care (96 per cent)
the use of descriptive statistics. 46–50 2 • agreed that the program had
To provide further depth to the improved their application of
survey findings, graduates of the Quantitative findings theoretical knowledge to clinical
2017 program (n=12) participated skills (96 per cent).
The adapted WIL survey indicated
in a focus group (n=11). The focus Additionally, participants agreed that
that 39 per cent of the participants
group technique was used as a the following aspects were improved
had gained a promotion since
strategy to validate and explain the by the program (percentage of
completing the program with a
survey themes identified. Focus participants shown in brackets):
further 55 per cent of the remaining
groups provided an opportunity for
61 per cent having had the • perioperative practice
participants to share their stories,
opportunity to act in senior positions. (100 per cent)
opinions and thoughts about the
given topic6. Responses to questions relating • critical thinking (81 per cent)
to the program were rated on a • reflective practice (84 per cent)
Findings five-point Likert scale, with the five
points equivalent to ‘very satisfied’, • evidence-based practice
Of the potential 67 participants
‘somewhat satisfied’, ‘neutral’, (100 per cent)
meeting the inclusion criteria for
phase one of the study, the online • independent learning (96 per cent)

Nearly all participants (96 per cent) ‘Case study assignment good in tertiary and secondary centres. Due
agreed that academic support outlining pre-, intra-, and post- to the introduction of centralised
provided by the university had operative care required for optimal staff systems, hospitals in the
impact on their knowledge, skills and patient care in perioperative public system found this process
abilities and 55 per cent stated that setting.’ increasingly challenging resulting
they were interested in further study. in its cessation. Participants felt
‘I’ve actually read more policies and
strongly about the placement
Qualitative findings standards in this year than I did
removal, and believed that it should
in my previous working… so I think
The qualitative findings supported be brought back into the program.
it makes you actually go and look
the quantitative data that overall things up and see what it actually ‘I think the course should be
participants enjoyed the program says.’ reverted back to allow students
and felt that it provided a unique to be rotated around each host
opportunity to learn and consolidate As a result of these learning
hospital, I found that beneficial
the knowledge, skills and attitudes opportunities, participants
in gaining more experience
for perioperative nursing. Three described how they had increased
through spending time in different
themes were identified from the their knowledge and skills for
hospitals’ specialty areas’.
data, ‘learning’, ‘empowerment’ and perioperative nursing practice and
‘opportunity’. how this directly related to improved Empowerment
consideration of practice:
Learning The extension of knowledge and
‘Ability to learn new skills/ skills empowered students to
In the online survey and in the focus information that has helped me to question practice and seek new
groups participants made open- advance’. ways of providing care. There was
ended comments that the online a consensus that practice in many
‘My learning helped me to be
platform and study days provided a cases is routine:
less task-orientated and more
positive place to engage in learning.
evidence-based in my nursing ‘I also find people do stuff in
The study days in particular brought
and I feel that it has enabled me theatre that they’ve done for years,
together all of the students from
to be a better periop nurse and that’s just because they do it that
across the various health care sites.
has refocused my purpose on the way.’
This allowed opportunities to share
patient’s wellbeing’.
experiences, stories and ways of At times students found it frustrating
practicing. ‘You’re always thinking about all the when staff could offer no evidence-
little things that you’re doing that based practice reason for their
Participants felt that there were
maybe you didn’t think of before’. teaching and direction of care:
varied learning opportunities
provided in the program. These There were some comments related ‘There’s no backing behind what
different sources of information to the academic requirements of they do.’
supported understanding and the completing a graduate diploma and
ability to apply information to learning the skills of referencing The knowledge gained from the
different scenarios. Statements of and academic writing. However, program and the requirement to
support by the participants included: despite these extra requirements, review national and international
participants appreciated that the best practice standards and
‘Study days and hands on practice publications provided students
national standards of education
with equipment’. with a greater sense of confidence
must be met for the qualification
‘Rotating through specialities has of a graduate diploma. One to question practice and make
given me the skills and ability to program change that participants recommendations for practice.
operate in all fields.’ felt impacted significantly on ‘You’ve got confidence, and you
This application of learning was student learning was the removal understand the process behind
supported through the assessment of inter-hospital placements. Until why things come about… you can
tasks. Assessments promoted 2013 students were required to speak up about things, because
learning through the application of undertake a rotation outside of you know that you’ve read about it.’
perioperative practice, as highlighted their health service; in particular,
by participant comments: students crossed between public
and private health services and

Opportunity understanding of the ‘real’ world of Limitations
the chosen profession7,8.
Completion of the program was There may have been a number of
seen to provide an advantage when Findings of this study suggest potential participants who did not
applying for promotional positions that the Graduate Diploma of receive their invitation to partake
or being allocated increased Perioperative Nursing provides in the study due to changes in the
responsibility within the health a unique opportunity to support contact details of some students
service. Participants in the surveys perioperative nurses in their since enrolment and despite the
outlined promotions within their unit, professional practice. The results researchers encouraging participants
opportunities to act in senior roles, from the research data have to share the recruitment email with
and being asked to join committees indicated that participants found other program participants that
and take on extra responsibilities. the program to be of benefit to their they knew. This study relates only
professional knowledge and practice to the work integrated program the
‘I think looking at other people
and that career promotions and Graduate Diploma of Perioperative
who have done the course over
opportunities had been linked to the Nursing provided through an
the past few years … who are
program. Australian university. The findings
now acting CNs, or even if they’re
of this study do not translate to
not acting CNs, they’ve taken on Despite these benefits, the
other WIL programs provided by the
responsibilities, or are facilitators application of WIL in postgraduate
university or other universities.
for the students that come through, nursing education remains relatively
so it’s kind of... either they’re more untapped7,8. Cutbacks in learning Recommendations
driven, which led them to do the and development departments
course, but has also led them to get and reduced access to professional The study findings have provided
promotions, or whether the course development time have significantly evidence to support the perceived
helped them in the interviews to hindered their introduction benefits of the Graduate Diploma
get those positions. I think... there and continuation. In particular, of Perioperative Nursing, and in
is a connection between taking on postgraduate levels of education particular WIL. The use of the WIL
more duties and having done it.’ in nursing in Australia are at risk of model of education in postgraduate
falling behind comparable nations. nursing education should be
Further to this opportunity was the considered further by schools of
A recent report conducted by the
networking that occurred across nursing to support the ongoing
Victorian Government Department
health services and across year learning needs of registered nurses.
of Health9 clearly cited postgraduate
groups. An informal alumni had Specialised nursing clinical practice
education as a priority to nurses
developed: cannot be taught and learnt from the
and that the greatest barrier was
‘I think a lot of the people that have cost. The paper suggested removing classroom without the opportunity to
done the course previously are postgraduate education from the apply theory to practice. Departments
quite proud of it as well, and that academic setting and aligning it of health should be encouraged
I found a lot of people that had with professional colleges as is the to work with the education sector
done it, they’d go, ‘Oh, how are you case for postgraduate specialty to consider further opportunities
going?... How are you finding this?’ medical education. Such colleges for postgraduate WIL to meet the
and they’re willing to give their work in a similar arrangement to demanding needs of the profession.
support.’ the perioperative course, aligning
education within the hospital Conclusion
Discussion system and so reducing costs. This The Graduate Diploma of
Work integrated learning (WIL) model, which is also used by the Perioperative Nursing provides a
describes the collaboration between perioperative program under the unique opportunity for nurses in
higher education institutions and banner of WIL, can provide an Australia to engage in a workplace
industry to provide workplace alternative solution that continues to supported program to consolidate
learning. Workplace learning engage with the university sector. their specialised practice. With
supports the application of theory significant cutbacks in nursing
to practice which develops the education across both the private
essential skills, experience and an and public health care sectors, the
profession should advocate for the
role of WIL as a strategy to support

nurse’s development in a complex participants agreed that the program 4. Creswell J. Research design: Qualitative,
quantitative, and mixed methods
and changing health workplace. was of benefit to their professional
approaches. 4th ed. Los Angeles: Sage, 2014.
Nurses can ill afford to ignore their practice and offered opportunities for
5. Schneider Z, Whitehead D, LoBiondo-Wood
responsibility to lifelong learning learning and promotion; however, all G, Haber J. Nursing and midwifery research:
and professional development in the agreed that the program needed to Methods and appraisal for evidence-based
rapidly advancing health industry. incorporate rotations across health practice. 5th ed. Chatswood: Elsevier, 2016.
However, increasing costs associated service sites as previously included. 6. Polit D, Beck C. Essentials of nursing
with academic education remains a research: Appraising evidence for nursing
significant barrier to engagement in References practice. 9th ed. Philadelphia, PA: Wolters
Kluwer, 2018.
further education. 1. Ralph N, Birks M, Cross W, Chapman Y.
7. Drysdale M, McBeath M, Johansson
‘Settling for less’: Designing undergraduate
The findings of this study suggest K, Dressler S, Zaitseva E. Psychological
nursing curricula in the context of national
attributes and work-integrated learning: An
that the participants engaged with accreditation. Collegian 2017;24(2):117–124.
international study. Higher education, skills
the program content and delivery 2. Department of Health. Nursing and and work-based learning 2016;6(1):20–34.
and had been able to apply their midwifery education [Internet]. Canberra:
8. Johnston M, Bishop R. Noongar Dandjoo:
Department of Health; 2013.
learning to practice. Of the 22 A work-integrated learning case study. Asia
3. Russell K, Coventry T. Innovations in Pacific Media Educator 2012;22(2):165–77.
participants that participated in the
postgraduate work integrated learning
WIL survey all indicated that they 9. Darcy associates. Review of postgraduate
within the perioperative nursing
nursing and midwifery education in Victoria.
planned to stay in nursing with only environment: A Western Australian
St Kilda, Vic: Darcy Associates; 2015.
one unsure about their future in experience. Journal of Perioperative Nursing
2017;29(4): 15–19.
perioperative nursing. Further to this,

th
N E W 1 5
edition
Standards for Perioperative

Nursing in Australia
The ACORN Standards for Perioperative Nursing in Australia
constitutes the specialty knowledge of the perioperative
nursing community in Australia and represents the accepted
standard for professional practice.
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Feature
Pressure injury risk assessment Authors

Lauren Goudas
and prevention strategies MN, BN

Nurse consultant
in operating room patients –

Clinical nurse, Royal Adelaide Hospital
Steven Bruni
findings from a study tour of

MClinPract, BN
novel practices in American Corresponding author

Lauren Goudas
hospitals MN, BN
Lauren.Goudas@sa.gov.au
Introduction
Hospital-acquired pressure injuries representation of pressure injury would be futile, identifying all
(HAPIs) lead to complications such development in the OR. Facilities in patients as ‘at risk’ without much
as increased pain, increased bed the USA are now attributing pressure variability 19. In this case, staff will be
days, re-admissions, multiple surgical injuries that appear 72 hours after unlikely to implement extraordinary
interventions, possible disfigurement, surgery to the care the patient interventions during this phase.
decreased quality of life, increased received in the OR11. Furthermore, the Braden Scale
health care cost and mortality 1-5. does not require a skin inspection
There are several factors specific
However, HAPIs are preventable to be undertaken20. This leads to
to the OR which increase the risk
and financial penalties have been an ineffective assessment of the
for pressure injury development
imposed in some parts of the world pressure injury risk for OR patients.
such as poor positioning, major
as a strategy for ensuring hospitals
trauma/surgery, pharmacological Project background
comply with standards of practice to
side-effects, impaired regulation of
prevent them from occurring1. In the Being awarded a 2017–2018 South
body temperature, extracorporeal
United States of America, the Centers Australian premier’s nursing and
circulation, reduced perfusion,
for Medicare and Medicaid Services midwifery scholarship allowed the
ineffective communication of patient
developed guidelines that deny authors to undertake a study tour to
risk, operations over three hours
reimbursement for care required the USA to investigate pressure injury
in length and the patient being
due to HAPIs across hospitals in the risk assessment and prevention
immobile and unable to feel pain2,7,12–17.
United States of America2. In the strategies used there and to see what
Importantly, for every 30 minutes
Australian context, pressure injury could be adapted to use in Australia.
past a four-hour procedure the
has been identified as a hospital-
risk of pressure injury development The purpose of the study tour was to
acquired complication with the
increases by approximately 33 per investigate how several key hospitals
potential to affect an organisation’s
cent11. in the USA are using new tools to
revenue6. In Queensland, public
hospitals attract significant penalties Some Australian health services assess perioperative patients for
for failing to prevent pressure recommend the use of guidelines pressure injury risk. Additionally, we
injuries with fines ranging from for preventing HAPIs and include aimed to explore what preventative
$30 000 and $50 000 for Stage 3 and administering the Braden Scale when interventions are being used for
Stage 4 HAPIs, respectively 1. there is ‘more than four hours of patients identified as being at risk
complete immobility such as during of developing a pressure injury and
Research indicates that pressure to discover how these practices have
surgery’17. However, research indicates
injuries from the operating room been implemented.
that the Braden Scale has poor
(OR) can appear from 48 to 72 hours
predictive validity for critically ill The USA was chosen as a leader in
after surgery, thus the incidence of
patients18. Additionally, in their article, HAPI prevention largely due to their
pressure injury following surgery is
Byers, Carta and Mayrovitz19 explain implementation of two assessment
likely to be under-reported7–10. It can
that using the Braden Scale following tools, the Munro Pressure Ulcer Risk
therefore be difficult to gain a true
induction of a general anaesthetic

Assessment Scale For Perioperative Preoperatively the Munro Scale communication and feedback across
Patients (Munro scale) and Scott assesses mobility, nutritional state, all departments.
triggers which have been repeatedly BMI, recent weight loss, age and
validated and used across numerous co-morbidities. Intra-operatively it Preoperative
hospitals in the USA. Both tools assesses physical status, ASA score, Co-morbidities current
specifically assess for pressure injury anaesthesia, body temperature, C
status
risk in the perioperative population, hypotension, moisture, surface/
M Mobility
allowing the surgical team to motion and position. In the Post
appropriately plan and effectively Anaesthesia Care Unit the Munro U Under age of 60
communicate interventions to scale assesses the length of N Nutrition
prevent pressure injuries. At this procedure and blood loss. The total
stage there is little evidence of the cumulative scores deems a R Recent weight loss
comparing these new tools to the patient low, moderate or high risk. O Over weight (BMI)
Braden or other widely used scales; One of the standout benefits of the
Intra-operative
however, this can be attributed to the Munro scale is its cumulative nature
relative infancy of these tools. Both that facilitates communication and Systolic BP
S
tools are part of the Perioperative handover between the preoperative, Surface
Pressure Injury Toolkit produced intra-operative and post-operative
C Core temperature
by the Association of PeriOperative departments and through to the
Registered Nurses (AORN)21. inpatient wards. It requires nurses ASA
A
to say who they have handed over Anesthesia type
We visited seven hospitals across
the information to, which was quite
four states in the USA and met Laying position
interesting, and requires signatures
world renowned researchers and
of who completed the assessment Laying moisture
leaders in the field of pressure injury L
and who is receiving the patient. Post-operative
prevention as well as individuals
who are affiliated with AORN and Additionally, the mnemonic of LOS periop
the National Pressure Ulcer Advisory CMUNRO SCALE® can be used to
E EBL
Panel (NPUAP). heighten awareness and is a great
transition to the Munro assessment
Project findings tool. The CMUNRO SCALE® mnemonic Summary of the CMUNRO SCALE
was developed for nurses to become Reprinted with permission. Copyright ©
The Munro scale
accustomed to the perioperative 2011, Cassendra A. Munro. All rights
In California we visited Providence risk factors evaluated by the Munro reserved.
Saint John’s Health Center, Santa scale. The difference between the
Monica, and were hosted by CMUNRO SCALE® mnemonic and Scott Triggers tool
Cassendra Munro, MSN, RN, CNOR. the Munro scale assessment tool In Memphis, Tennessee we were
Cassendra is the Magnet and is that the latter has calculations hosted by Susan Scott, BSN, RN, WOC,
professional practice manager and for a level of risk which results in a and visited Methodist University
the founder of the Munro scale. cumulative score and is predictive Hospital, St Jude Children’s Research
The Munro scale encompasses in nature. Cassendra demonstrated Hospital, Memphis VA Medical Center,
assessment of patient risk, with a that the mnemonic could be put on a Le Bonheur Children’s Hospital
risk level scored for each phase lanyard by nurses for quick and easy and University of Tennessee Health
of surgery (pre-, intra- and post- access. Cassendra stated that she Science Center. Susan is the safety
operative)22. The Munro scale believes the use of the mnemonic quality improvement educator at the
has undergone three rounds of heightens awareness of contributors University of Tennessee (Medicine)
Delphi research and is currently to pressure injury, increasing and the founder of Scott Triggers.
implemented in seven sites across prevention and management,
increases wound consults, increases The Scott Triggers tool evaluates
the USA. It is currently undergoing
communication and improves skin four evidence-based predictors of
revision and the next version is due
assessments. Cassendra reiterated perioperative pressure injuries. The
soon.
to us the importance of ‘closing the tool is used preoperatively to assess
loop’ so enhancing and facilitating for a patient’s risk of pressure injury.

Aerial view of St Jude Children’s Research Hospital, Memphis, Tennessee (foreground right)
It asks four questions which require the incidence of pressure injuries is ticked, indicating a pressure injury
a yes or no answer. This tool takes decreased from 3.37 per cent to 0.89 risk is present.
into account a patient’s age (>62 per cent and the facility reduced
The circulating nurse in the OR then
years), serum albumin level or BMI costs by US$1 364 000 for a one-year
answers yes or no to the following
(albumin level < 3.5g/l or BMI < 19 or period by using the Scott Triggers
questions:
> 40), ASA score (>3) and estimated Tool (Susan Scott, pers. comm. NPUAP
surgery time (surgery greater than conference 2 November 2016). • Is surgery anticipated to be over
three hours). Two or more ‘yes’ two hours?
At the Methodist University Hospital
answers constitute a high risk • Is the patient’s ASA score three or
in Memphis a ‘START Procedural
patient and a set of evidence-based higher?
Briefing Confirmation Card’ is used
interventions in the form of an OR
pre-, intra- and post-operatively. If either of the above are answered
skin bundle or perioperative toolkit
START is an acronym for S=Supplies/ with yes, the patient is considered
should be implemented. For example,
equipment; T=Track history, allergies at high risk for pressure injury. This
practices such as relieve, reduce and
and patient notes; A=Assess fire and START card brings pressure injury
redistribute are promoted as well as
skin risk; R=Medication; and T=Time to the forefront of perioperative
interventions such as offloading the
out and tell the facts (fire score, nurses’ minds. Interestingly, the
heels.
skin risk and allergies stated). The START card assesses a patient’s fire
Scott Triggers® has been validated preoperative nurse completes a risk. A notable benefit of START is
in over 7000 surgical patients in Braden assessment for a patient and it encourages communication and
Houston, USA (Susan Scott, pers. documents the score on START. If a collaboration among team members
comm. email 8 July 2016) In one study, Braden score is below 16 a ‘yes’ box

Reprinted with permission. Copyright © Susan M. Scott, Scott Triggers PLLC.

along the perioperative journey,
ultimately improving continuity of
patient care.
A few other key points we discovered
were that at St Jude Children’s
Research Hospital the anaesthetist
generally moves the patient’s head
every hour or so as well as using gel
or foam head rings for the paediatric
population. A lot of the hospitals
also used disposable OR sheets
to help wick away moisture during
surgery. Circulators would prep with
a chloraprep swabstick to minimise
pooling of fluids.
Information sharing
In Indiana we were hosted by
Eskenazi Health’s Director infection
prevention, Debra Fawcett, PhD, RN.
At Eskenazi Health, we were fortunate
Memphis VA Medical Centre, Memphis, Tennessee
enough to meet with members of
the Indianapolis Coalition for Patient
Safety. The coalition provides a of the PI would be forwarded to the appropriately. Jeff, the registered
forum for Indianapolis hospitals OR leadership team as a learning nurse who we were buddied with said,
to share information about ‘best opportunity. This certainly helped to ‘this made life easy because nurses
practices’ and work together to solve close the loop and to discover if the didn’t have to go through lots of lists
patient safety issues. This was a fine pressure injury was correlated with of words but could just see where you
example of various organisations and the surgical position or devices used want to make a note, click and type’.
professionals coming together for the throughout surgery. It was beneficial It became apparent that a recurrent
ultimate goal of patient safety. to see how communication enabled theme at all facilities was that a lot
a great culture of improving patient of HAPIs were device-related from
Other important points we learnt
safety in a non-punitive way. An items such as endotracheal tubes
is that off-loading the heels is
emphasis on communication was and intravenous access devices. This
important but there are still
evident at every hospital we visited. reiterated the importance of the
questions about what to off-load the
fundamentals of care and highlighted
heels with as you do not want to use Electronic documentation the importance of education for all
something which will ‘bottom out’ or
In Boston, Massachusetts, we visited staff who take part in positioning the
simply relocate the same pressure
Beth Israel Deaconess Medical Centre patient in the OR.
to a different area on the leg. Also, if
using prophylactic dressings, e.g. to and were hosted by Clinical manager Another key point discussed was
the sacrum, frequent skin inspections perioperative education, Charlotte ensuring a comprehensive skin
must still take place. Several wound Guglielmi, MA, BSN, RN, CNOR. assessment pre- and post-procedure
care ostomy nurses explained these In Boston pressure injury risk had and that that findings from these
dressings do not prevent pressure been incorporated into electronic are written down. In Boston they
injuries but may decrease friction or documentation, which appeared had a saying, ‘if it isn’t written down,
shear. efficient and effective. There were you own it’. This suggests that if a
two graphics of a patient shown from PI does occur, OR staff must be able
While at Eskenazi Health we learnt
the front and the back. Nurses could to defend their actions toward its
that if a patient developed a hospital
easily click on the point where they prevention or it will be assumed
acquired PI, a root cause analysis
applied padding or noted a problem to have started in the OR. All the
would be conducted. If the patient
and then make a note to indicate hospitals we visited performed skin
had recent surgery, the occurrence
checks pre- and post-operatively

and some facilities used ‘four eyes’ Acknowledgements 9. Ralph N. Editorial: Fundamentals of missed
care – Implications for the perioperative
meaning two nurses perform the skin
We would like to acknowledge the environment. Journal of Perioperative
assessment together. Nursing 2018;31(3):3–4.
many dedicated and inspiring nurses
10. Wang I, Walker R, Gillespie BM. Pressure
Discussion who made our study tour possible
injury prevention for surgery: Results from
and such a success. We met many a prospective, observational study in a
By undertaking this study tour to trailblazers in the nursing field and tertiary hospital. Journal of Perioperative
the USA, we equipped ourselves became acquainted with world- Nursing 2018:;31( 3):25–28.
with the knowledge and experience renowned sites. We are extremely 11. Sammon MA (ed). Reducing hospital-
to implement a pressure injury risk grateful for the immense sharing acquired pressure ulcers in the
assessment tool for surgical patients. of time and knowledge from each
cardiovascular OR and ICU population.
World Union for Wound Healing Societies
While some risk factors cannot be site to assist us in achieving our Symposium; Florence, 2016.
modified, such as the length of a objectives for our study tour. A 12. Coleman S, Nixon J, Keen J, Wilson L,
procedure, the risk of a PI developing special thank you to Lisa Spruce at McGinnis E, Dealey C et al. A new pressure
can be reduced by ensuring care AORN and Deborah Fawcett who were ulcer conceptual framework. J Adv Nurs
provided is based on best-evidence instrumental in recommending sites
2014;70(10):2222–2234.
practices and risk is communicated and individuals for us to visit. Our
13. Fred C, Ford S, Wagner D, Vanbrackle L.
to subsequent care givers. Intra-operatively acquired pressure ulcers
study tour was a truly inspiring and and perioperative normothermia: A look at
The opportunity to see new memorable experience. relationships. AORN J 2012;96(3):251–260.
developments in the field of 14. National Pressure Ulcer Advisory Panel,
pressure injury risk assessment and References European Ulcer Advisory Panel, Pan Pacific
Pressure Injury Alliance. Prevention
prevention in the USA has enabled 1. Miles SJ, Fulbrook P, Nowicki T, Franks C.
and treatment of pressure ulcers: Quick
us to increase our knowledge Decreasing pressure injury prevalence in
reference guide. Perth, Western Australia:
an Australian general hospital: A 10-year
exponentially and also benchmark review. Wound practice and research
Cambridge Media, 2014.
our current practices. We believe, 2013;21(4):148–156. 15. Clarke S, Clark-Burg KG, Pavlos E. Clinical
based on what we have learnt from handover of immediate post-operative
2. Association of PeriOperative Registered
patients: A literature review. Journal
our study tour, that we can create a Nurses (AORN). AORN Position statement on
of Perioperative Nursing 2018:31(2):29–
perioperative pressure injury toolkit perioperative pressure ulcer prevention in
35. 2018;31(2):29–35.
the care of the surgical patient. Denver, CO:
containing pertinent evidence-based AORN; 2016. 16. Bingham, Sharon; Walsh, Kenneth; and Ford,
recommendations for pressure Karen. Reshaping perioperative nursing
3. Australian Wound Management Association.
injury prevention. Such a toolkit has practice to get the job done: A constructivist
Pan Pacific clinical practice guideline for the
grounded theory study. Journal of
potential for transferability across prevention and management of pressure
Perioperative Nursing 2018;31(1):19–29.
other clinical settings that provide injury. Osborne Park, WA: Cambridge Media,
2012. 17. SA Health. Pressure injury prevention and
surgical care. We foresee many management guideline. Adelaide: SA Health,
4. McErlean B. South Australian pressure
benefits of an assessment tool and 2013.
ulcer point prevalence survey report 2007.
toolkit including reduction in delayed Adelaide, Australia; 2007. 18. Cho I, Noh M. Braden Scale: evaluation of
discharges, fewer bed days lost and clinical usefulness in an intensive care unit.
5. Nguyen K-H, Chaboyer W, Whitty JA. Pressure
J Adv Nurs 2010;66(2):293–302.
decreased cost associated with injury in Australian public hospitals: A
19. Byers PH, Carta SG, Mayrovity HN. Pressure
pressure injuries as well as increased cost-of-illness study. Aust Health Rev
2015;39(3):329–336. ulcer research issues in surgical patients.
positive outcomes for patients, Adv Skin Wound Care 2000;13(3):115–121.
6. Australian Commission on Safety and
families and the wider community. 20. British Columbia Provincial Nursing
Quality in Health Care (ACSQHC). Indicators
of safety and quality: Hospital-acquired Skin and Wound Committee (BCPNSWC).
However, before implementing a new
complications [Internet]. Sydney: ACSQHC Guideline: Braden scale for predicting
pressure injury risk assessment tool pressure ulcer risk in adults and children.
[cited 2019 March 6]. Available from: www.
in the OR we would need to do some safetyandquality.gov.au/our-work/indicators. Vancouver: BCPNSWC; 2014.
groundwork including gap analysis. 7. Black J, Fawcett D, Scott S. Ten top tips: 21. Association of PeriOperative Registered
Careful consideration of the needs preventing pressure ulcers in the surgical Nurses (AORN). Prevention of Perioperative
Pressure Injury Toolkit – AORN. Denver CO:
of our health network will indicate patient. Int Wounds J 2014;5(4):14–18.
AORN; 2019.
which risk assessment tool should 8. Shaw LF, Chang P-C, Lee J-F, Kung H-Y, Tung
T-H. Incidence and predicted risk factors 22. Mathias JM. Fine-tuning the Munro Scale for
be implemented. This would follow pressure ulcers. OR Manager 2015;31(6):4–5.
of pressure ulcers in surgical patients:
the release of the revised and latest Experience at a medical center in Taipei,
version of the Munro scale. Taiwan. BioMed Res Int 2014(2):416896.

Grants and scholarships
Grants and scholarships Grace Loh

ACORN Director
Chair of Grants, Awards and Scholarships
Education grant, Committee
November 2018
We would also like to share a little
We had only one application for of what Australian perioperative
this award and it was awarded to nurses are doing overseas while
Catherine Smith who has been volunteering and sharing their
Bravura Laser Safety Officer an active member for more than knowledge and skills.
(LSO) education scholarship, 15 years with ACORN Queensland.
Catherine is a nurse practitioner Australian perioperative nurses are:
November 2018
and has been actively involved with • performing cleft lip and palate
If you work with lasers in your PNAQ committees and also served on surgery in the Philippines with
workplace this course will broaden several Standards review committees. Helping Children Smile
your knowledge and improve your Catherine attended the Obesity Week
expertise and competence in laser International Conference in Nashville • providing urgently needed cardiac
safety. The scholarship is open every USA. We look forward to hearing surgery in developing countries
six months and equates to eight all about the latest developments with Open Heart International
hours of continuing professional in obesity care, treatment and • providing perioperative nursing
development (CPD) for members. prevention from Catherine. care aboard the Mercy ship in
We are very grateful to our partners
Africa
at Bravura for sponsoring this International Volunteer
scholarship. • providing educational programs
and Teaching Grant,
and symposiums for doctors and
A brief summary of our ACORN November 2018
nurses to enhance their skills in hip
members who have been awarded We had numerous applications for and knee arthroplasty and trauma
this scholarship follows: this grant and would like to thank all with Australasian Nepalese Medical
• Jincy Paulose (SAPNA), scrub and our applicants. The recipient of this and Dental Association (ANDMA).
circulating nurse working with award is Nicole Dunne who will be
lasers in urology who would like to working in West Africa aboard the
be the trained LSO in her facility. Mercy Ship.
• Caroline du Preez (SAPNA), staff

development nurse who will
share her knowledge and ensure
compliance with standards.
• Sarah Bird (ACORN Tasmania) who
works across scrub and circulating
and educator roles. She will use the
scholarship to ensure laser safety
in the perioperative environment.
• Suzanne Hadlow (NSW OTA) is the
laser operator and is also on the
radiation safety committee and
work, health and safety committee
of her hospital. It will assist her to
be actively involved in developing
policies and procedures for safe
patient care.
Scenes from the Africa Mercy – the largest non-military hospital ship in the world

Hospitals and day surgeries around the
country are using this DVD or e-Video
to educate their staff on the procedure
for surgical hand antisepsis, gowning
and gloving. Is yours?
Arm your team with the knowledge

of and access to the most current
evidence-based practice.
Surgical hand
Surgical hand
antisepsis, antisepsis, gowning
and gloving
gowning and
gloving
DVD e-Subscription Bundle

Easy hands-on access to The online video is perfect DVD and e-Subscription for
ACORN’s evidence-based for facilities to share among ultimate convenience.
protocols and procedures. multiple users.
Available online at acorn.org.au/education/education-shop.

ACORN members receive a heavily reduced price.
“The latest edition of the ACORN Surgical hand antisepsis, gowning and gloving DVD offers
evidence-based and peer-reviewed guidelines for perioperative staff, and other members of the
team, to standardise perioperative practice and promote patient and worker safety. The 2nd
edition is available in two formats to suit you and your facility’s needs.”
Rebecca East, ACORN President 2018–2020
AUSTRALIAN COLLEGE OF T: +61 1300 781 924 F: +61 1300 781 934 E: administrator@acorn.org.au
PERIOPERATIVE NURSES PO Box 899 Lyndoch SA 5351 ABN 64 071 142 768 www.acorn.org.au
ACORN grant report
International volunteering with Ross McIlwraith

RN, MACORN
Mercy Ships in Guinea West

Africa 2018
Ross McIlwraith received an ACORN International volunteer and teaching grant in 2018.
In the period September to November coffee and a piece of cake. Thanks aimed at improving crop quality and
2018, I was given the opportunity to to a series of well-timed events the production.
be part of the international volunteer hospital where I work, Burnside War
The ship I volunteered aboard, the
program with the ship, Africa Mercy – Memorial Hospital, gave me extended
Africa Mercy, is a former train ferry
the largest non-military hospital ship leave from my position as clinical
from Denmark which has been
in the world. nurse coordinator of a busy five-
converted into a hospital ship with
theatre perioperative suite to travel
My interest in volunteering with the four wards, five operating theatres
to Guinea in west Africa in late 2018.
organisation started after reading an and a crew of four hundred people
And so I was able to start my journey
article published in a nursing journal from thirty nationalities. Mercy Ships
to volunteer with Mercy Ships in the
twenty years ago about the original dock in each country for around
West African nation of Guinea.
Mercy Ship, the Anastasis, and its ten months. In that time, volunteer
journey around the South Pacific Overview staff provide an average of five to six
providing free surgery to islanders. I thousand surgical treatments.
felt inspired reading it, as I felt my Approximately thirty percent of
the global burden of disease is Onboard mentoring programs
perioperative skills could be used
comprised of surgical conditions. also upskill local health care
to support the Mercy Ships initiative,
However, five billion people lack professionals and introduces doctors
but a young family and developing
access to surgery, with complex to the World Health Organization
nursing career kept me from fully
factors acting as barriers1. An surgical safety checklist3. This safety
realising that dream.
estimated five billion people lack checklist was an integral part of the
Fast forward twenty years and I access to surgery. Up to 81 million theatre routine on board and was
found myself in a unique position people face financial ruin to get it2. performed with every patient. Data
to once again consider volunteering demonstrated that the use of the
abroad the Africa Mercy. There were Mercy Ships is a Christian not- checklist has drastically reduced
a few planetary alignments needed for-profit organisation which surgical compactions and mortality.
and a number of hoops to jump provides international humanitarian
resourcing and aid in third world The ship also liaises and works
through to enable me to spend the
countries. Its mission is to provide alongside the African national
three months on board the ship as
free surgery in low- to medium- governments to identify and provide
a scrub–scout nurse and general
income nations. Its main function support for local health care needs.
dogsbody. Earlier in the year when
is to facilitate free surgery, training Mentoring programs are offered to
I was still wondering how I would
and mentoring to national African surgeons and anaesthetists, as well
finance my trip, I had received an
surgeons, nurses and allied health as programs to develop areas such as
email from ACORN asking if I would
care professionals. Thanks to this sustainable agricultural practices for
be interested in applying for an
vision, thousands of people are farmers to increase the nutritional
international overseas volunteer
able to receive quality surgical care value of their crops.
grant, two of which are offered each
year. With some help from my state so enabling them to once again The ship is a first world hospital
perioperative organisation SAPNA, become productive members of operating in a third world
I sent off my application. About a their local community while likewise environment helping to raise
month before my travel date, I was freeing their carers. Mercy Ships also practices to better practices when
informed that I had received the provides mentoring programs and best practices are realistically
grant which paid for my international courses in sterilisation, neonatal and unachievable. An example of a
flights and three courses of rabies adult resuscitation to local health positive outcome of this during my
vaccinations, with eleven dollars care workers, as well as courses in twelve-week stay in the OR was the
left over for a couple of cups of sustainable practices to local farmers low number of cleft palate and lip

surgeries performed. I was expecting decontamination and sterilising were born on the first of January – a
more than the six repairs that were rooms and a sterile instrument bit like race horses. Often people
done during my service. When I asked storage area. My first week coincided from the same regional area would
about the low numbers, I was told with the beginning of the surgery have the same name. Ibrahim Dialo
that during the last visit the ship timetable for the stay in Guinea. I was a favourite, with two or three
had made to Guinea, the staff had was privileged to be on the team Ibrahim Dialos often on the same
performed about one hundred and performing the first surgery. surgical list.
thirty of the same repairs. Apparently
Challenges The actual surgeries were
the volunteer surgeons on board
straightforward as most surgical
had done such a good job of training The ship is crewed by a multinational techniques were standard; however,
and upskilling the local Guinean staff. America provides the largest the surgical skin preparation was
surgeons that in spite of working with contingent of volunteers, followed complex due to the nature of
few resources, the local surgeons by Britain, but I’m proud to say Guinean lifestyle. The challenge was
had successfully learned the surgical Australians and New Zealanders to effectively reduce the skin flora
technique for cleft repairs. make up the third highest level to acceptable levels for surgery. All
of volunteers on board, with patients had a preoperative shower
Journey Canadian, Dutch, Swiss, German prior to coming the theatre. Such
After an overnight flight from Adelaide and a smattering of other European was the level of bio burden and
via Dubai I arrived in Conakry, Guinea nationalities making up the rest. the persistence of the coconut oil
on Sunday 26 August 2018. After Communication was pivotal to life favoured by patients as skin lotion
completing the necessary paperwork in the OR4, but strangely my biggest that skin was washed three times
and receiving my new photo ID, I language challenge was not the five with betadine preparation followed
found that the Aussie contingent on or so Guinean languages, including by another three times with skin
board already knew of my arrival, and French, that were spoken but rather sterilant.
I received my first invitation to share the English spoken by everyone
Tim Tams that night. else. Some international staff spoke Due to the coarse nature of body hair
English in a fast, confident way but and the coconut oil, surgical clipping
Orientation started the following was also a slow process. The limited
I often found myself asking them to
day when I learned how to put a size of the medical waste incinerator
repeat themselves as I found both
lifejacket on in case we had to also meant that only surgical drapes
accents and word usage hard to
abandon ship, as per maritime law. and gowns contaminated directly
grasp at times. The day crew, local
Seeing the ship was docked for ten with body fluids were disposed of by
Guineans who were employed as
months, I thought the chances of incineration. Contaminated parts of
translators and orderlies, were
that happening was remote. Once gowns and drapes were cut out like
excellent. Line (pronounced ‘Lyn’),
a fortnight the whole crew would paper dollies with the rest put in to
one of the female translators, spoke
participate in a mock fire drill. As general waste.
five languages and kept us amused
a member of the perioperative
by wearing bunny ears on ‘Crazy After surgery, all items of a surgical
team I was exempt from having to
scrubs’ Fridays. The patients all loved nature were rendered unusable, as it
actually ‘abandon ship’ but instead
Line. had been found from previous trips
formally discussed how we would
evacuate our anaesthetised patients Time is different in Africa. For most that the ship’s surgical waste was
if the need arose. Instead of the patients, daily time falls into one of being scavenged and sold at local
wooden fire doors I had been used two categories: before noon, or after markets to people needing surgery
to in Australia, the ship had steel noon. This required imagination at the local hospitals who couldn’t
containment doors, which sealed off and problem-solving skills when afford to buy equipment, as was
all horizontal movement between the performing the pre-operative required, from the medical supply
zones. Any evacuation would have to checklist, especially when discussing shops.
be up the stairs to the gangplank and fasting times. ‘When did you eat Another quirky challenge was the
onto the dock. last?’ I would ask. ‘A while ago,’ would expectation of the American surgeon
come the reply. Patient identifiers being gowned and gloved by the
The perioperative department
were another challenge as a large scrub nurse. This was a cultural
consisted of five operating
number of Guineans were not sure of issue that after my initial surprise I
rooms, a four-bed PACU, small
their birth date. It seemed that many modified into my own scrub routine,

while stifling the question as to why minimal cost using cheap intraocular have the opportunities that we have
couldn’t they dress themselves? lenses from India or China. in first world nations.
The working days were long but I was Reconstructive plastics for burns, Acknowledgements
able to observe and be involved with thyroidectomy, inguinal hernia
maxillofacial tumours that I have repairs and lipoma removals are the Thank you to both the SAPNA
only seen twice in Australia. On Africa most common surgeries. As I was due and ACORN for their support and
Mercy, two such tumours are treated to leave, the hospital was preparing encouragement in my volunteering
every day. The paediatric orthopaedic to take on women with vesicovaginal with Mercy Ships organisation.
surgery, performed for bandy and fistula caused by prolonged
bowlegs, knock-knees and the like, obstructed labours without access to
References
were a result mostly of rickets and Caesarian section. 1. Meara JG, Leather AJ, Hagander LE, Alkire
BC, Alonso N, Ameh EH et al. Global surgery
other deformities that result from
During my twelve weeks on board 2030: Evidence and solutions for achieving
nutritional deficiencies. health, welfare, and economic development.
there were one thousand two
Lancet 2015;386(9993):569–624.
Cataracts were plentiful, as Guinea hundred procedures performed.
2. Lin BM, White M, Glover A, Wamah GP, Trotti
is close to the equator with a Every surgery is a win-win situation
DL, Randall K et al. Barriers to surgical care
consequently high level of ultraviolet as it gives people their life back, with and health outcomes: A prospective study
radiation and most Guineans the added benefit of often releasing on the relation between wealth, sex, and
cannot afford simple protection like their carer as well to re-enter the postoperative complications in the Republic
of Congo. World J Surg 2017;41(1):14–23.
sunglasses or even hats, so often work force.
3. White M, Peterschmidt J, Callahan J,
develop cataracts quite early. The
Would I do it again? Absolutely. Fitzgerald JE, Close KL. (2017). Interval follow
ophthalmologists on board use an up of a 4-day pilot program to implement
Would I recommend the experience
older technique minimal incision the WHO surgical safety checklist at
to other perioperative nurses?
cataract surgery (MICS) to manually a Congolese hospital. Global Health
Without a doubt. It is a great way 2017;13(1):42. doi:10.1186/s12992-017-0266-0.
extract the cataract in lieu of a
to pass on valuable experience and 4. Brown MA. Perioperative nursing and
phaco machine. This technique is
clinical skills to those who do not communication challenges aboard the
transferable to the local surgeons at Africa Mercy. AORN J 2018;108:321–324.
doi:10.1002/aorn.12357.
Introducing ACORN Professional Standards Officer

The ACORN board is pleased to welcome Cathryn Murphy as our new Professional Standards Officer.
As Professional Standards Officer, Cath will manage ACORN’s Standards for Perioperative Nursing
in Australia, Practice Audit Tools (PATs) and our new publication, Professional Standards to be
released in the latter part of 2019.
Cath’s career over several decades has covered senior infection prevention positions in clinical,
government and non-government settings and professional associations both in Australia, her
home country, and internationally. She is an Honorary Adjunct Associate Professor at Bond
University on the Gold Coast, Australia.
Career highlights for Cath include working in the USA at the Centers for Disease Control and
Cathryn Murphy Prevention (CDC), consulting for the World Health Organization and serving as the elected
PhD, MPH, RN, CIC president of Associations for Professionals in Infection Control and Epidemiology (APIC) in 2010.
In 2016, Cath became the first non–North American to be awarded APIC’s esteemed Carole de Mille Award for lifetime
excellence in and dedication to the field of infection prevention. She is currently an Australasian College for Infection
Prevention and Control (ACIPC) Credentialled Infection Control Professional (Expert), holds the US CIC (Certification in
infection prevention and control) and is a fellow of APIC and also the Society for Healthcare Epidemiology of America (SHEA).

save
the
date
acorn.org.au/conference2020
Education
Education report Paula Foran

PhD, MACN, FACORN
Although we are already three months into the year, this is my Education Officer (Webinars)
ACORN Member Director
first opportunity to wish you all a happy and prosperous 2019.
With the start of a new year comes the opportunity to re-evaluate
our perioperative practice and ‘recharge our batteries’ to provide
our patients with the best perioperative care possible. What
better way to do this than to ensure we are all up to date with our
educational needs by keeping up with the ACORN webinars.
Practice Audit Tools (PATS) comes to hand, the webinars are in one drug may sensitise a person
revised and updated when required. to another drug, promoting allergic
Another two webinars have been
I had the personal pleasure of reactions2.
delivered since my last report. By
presenting this webinar, which
popular demand, the first webinar Two years later in 2009, research
provided revision on anaphylaxis,
was the third in the series on our conducted by Florvaag and Johansson
but also incorporated some new
perioperative Practice Audit Tools in 20093 indicated that the rate of
information from the Australian and
(PATS), titled ‘Audit results: What anaphylaxis to NMBAs in Norway
New Zealand Anaesthetic Allergy
now? Using your audit results to was much higher than in Sweden.
Group (ANZAAG) 2016 guidelines
improve performance’. As the researchers already had
as well as findings from the 6th
evidence of the connection between
The first webinar in the PAT series National Audit Program (NAP 6) from
QAI epitopes and neuromuscular
was, ‘ACORN practice audits: Do you the Royal College of Anaesthetists
blockers, they searched the homes
see what I see?’ which explained the which focused on anaphylaxis and
of residents in both countries to
layout of the audit tool and the steps presented information about the
try and identify sources of tertiary
in conducting a practice audit. The pholcodine hypothesis.
or quaternary ammonium ion
second, ‘ACORN practice audits: Does
Pholcodine hypothesis epitopes3. Surprisingly, a cough
it all add up?’ clarified how to enter
syrup containing pholcodine
the audit data into the Excel spread The pholcodine hypothesis was (PHO) emerged as the most likely
sheets and generate results, and born from research conducted in candidate3. Cough mixture containing
discussed specific data collecting Scandinavia. As many of you know, PHO was not available in Sweden
issues with the Surgical hand I love research but I think this but was widely available in Norway4,5.
antisepsis, gowning and gloving PAT. research is so vitally important, The researchers postulated that the
innovative and exciting that even the substituted ammonium ion structure
This third webinar further explained
most uninterested reader may be of PHO was resulting in sensitisation
what the audit results mean,
hooked on this particular research and an increased anaphylaxis
discussed what you can do with
journey! reaction rate to NMBAs observed
these results, gave suggestions on
giving feedback to staff, provided Neuromuscular blocking agents in Norway relative to Sweden5. This
some examples from clinical practice (NMBAs) have always been high on information led to the withdrawal of
on how audit results can be used the list of perioperative substances cough mixture containing pholcodine
to improve performance and gave a that may cause anaphylaxis, taking from the Norwegian market3.
preview of the next round of ACORN second place (33 per cent) to This also sparked great interest
PATs – Bundle 2: Staff and patient antibiotics (46 per cent) in the recent and examination of pholcodine-
safety. It may be beneficial to you, NAP 6 findings1. NMBAs contain containing drugs in other countries3.
although it is not essential, to watch quaternary ammonium ion (QAI) Thus, the pholcodine hypothesis was
these webinars in sequence to get epitopes which may be bound by born.
the most from them. immunoglobulin E (IgE) antibodies, Six years after removing PHO from
causing anaphylaxis. These epitopes the market in 2007, ‘the Norwegian
Perioperative anaphylaxis
are common chemicals found in population has gradually become
This webinar was an updated version pholcodine and several other drugs. signiﬁcantly less IgE-sensitised and
of the original webinar that was first In 2007, researchers reported that clinically more tolerant to NMBA’6.
recorded in 2016. As new information previous exposure to QAI epitopes

It should however be noted that by a lack of mandatory reporting of References
pholcodine is not the only drug that serious anaphylactic reactions7.
1. Royal College of Anaesthetists. Anaesthesia,
contains QAIs, thus when removal of surgery and life-threatening allergic
McAleer et al.7 suggest that while
cough mixture with pholcodine was reactions. Report and findings of the Royal
anaesthesia in Australia and College of Anaesthetists’ 6th national audit
discussed in Europe, the European
New Zealand is safer than ever project: Perioperative anaphylaxis. London:
Medicines Association concluded
before the target for primary NIAA Health Services Research Centre Royal
that ‘the benefits of pholcodine- College of Anaesthetists, 2018.
anaesthesia mortality should be
containing medicines continue to 2. Harboe T, Johansson SGO, Florvaag E.
zero. The removal of PHO from cough
outweigh their risks’ and declined Pholcodine exposure raises serum IgE
mixtures, or at least restricting it to in patients with previous anaphylaxis to
to introduce a ban on them7. This
prescription-only rather than over neuromuscular blocking agents. Allergy
is despite research findings to
the counter purchases, would not 2007;62:1445–1450.
suggest that there was no real
cause disadvantage to consumers 3. Florvaag E, Johansson S. The pholcodine
evidence that over the counter cough story. Immunol allergy clin North Am
but could further reduce preventable
medicines containing pholcodine are 2009;29(3):419–427.
anaesthesia-related harm to
effective in treating an acute cough8. 4. Florvaag E, Johansson S. The pholcodine
Australian and New Zealand patients
Australian authors suggest that this case. Cough medicines, IgE sensitisation,
undergoing anaesthesia7. Personally, I and anaphylaxis: a devious connection.
ruling ignores the principle that in
now check the label carefully on any World Allergy Organ J 2012;5:73–78.
the absence of proven efficacy for a
cough mixture bottle and prefer the 5. Florvaag E, Johansson S, Irgens A, de Pater G.
product ‘first do no harm’.
non-pholcodine option for my family IgE sensitization to the cough suppressant
pholcodine and the effects of its withdrawal
Great interest has been shown in and myself. The debate continues!
from the Norwegian market. Allergy
Australia and New Zealand where 2011;66(7):955–960.
alternatives to pholcodine (such as The ACORN roadshow
6. De Pater G, Florvaag E, Johansson S, Irgens A,
dextromethorphan) are available The ACORN roadshow continues to Petersen M, Guttormsen A. Six years without
for use in cough mixture without travel around Australia having last pholcodine; Norwegians are signiﬁcantly
less IgE-sensitized and clinically more
the associated risk7. ANZAAG and visited Launceston in Tasmania in
tolerant to neuromuscular blocking agents.
Australian and New Zealand College February. Please look out for the Allergy 2017;72(5):813–819.
of Anaesthetists (ANZCA) groups ACORN team at your local association 7. McAleer P, McNicol L, Rose M. Perioperative
have approached the relevant meetings and feel free to make anaphylaxis: Progress, prevention and
bodies in Australia and New Zealand, yourself know to us. We would love to pholcodine policy. Anaesth Intensive Care
namely Therapeutic Goods and 2017;45(2):147–150.
get to know you all better.
Medsafe, regarding ways to protect 8. Smith SM, Schroeder K, Fahey T. Over-
In conclusion, I hope autumn brings the-counter (OTC) medications for acute
consumers from the possible risk of cough in children and adults in ambulatory
good health to you and your patients
pholcodine use, but thus far have not settings. Cochrane Database Syst Rev
and that you continue to enjoy your
been successful in a mandatory or CD001831 2012:8.
learning.
voluntary removal7. The argument in
Australia has been hindered, in part,

Standards
From great to greater Cathryn Murphy

PhD, MPH, RN, CIC
ACORN members may be aware that in late December 2018 ACORN Professional Standards Officer
recruited and appointed me to the newly established position of

Professional Standards Officer (PSO). It is a bold move by ACORN’s
leadership and one which will hopefully solidify and expand on
the remarkable evolution of ACORN’s Standards for Perioperative
nursing in Australia (the Standards) and further their uptake by
Australian perioperative nurses.
When entering any new role it is single leader. Their outputs must For organisations to thrive, they must
important to fully understand the also survive multiple life-cycles2. For be nimble, connected and adaptive.
people who have contributed to companies, this is achieved by always Transition is constant, and it always
that point and the processes and ensuring their employees share in involves ‘ending something, exploring
protocols that are in place. Such their success. For associations, this opportunities, and embracing the
understanding is particularly manifests as members experiencing new’3. ACORN leadership’s investment
important before making changes. a keen sense of identity with their in a permanent part-time position
My early review suggests that organisation and subscribing to its for the new PSO role reflects ACORN’s
contributions from volunteers, core values and a sense of shared ability to adapt.
perioperative experts, academics purpose. The PSO role encompasses
and clinicians at every stage of the As the Standards continues to promoting the Standards to more
perioperative career path have to evolve some additional aspects perioperative nurses and health care
date resulted in a comprehensive, identified by Collins will likely come facilities as well as overseeing the
high-quality, evidence-based set of into play, particularly a ‘relentless development, review and revision
practice standards1. drive for progress’2. Progress is of individual standards and the
Importantly the ACORN Standards almost always only possible through biennial publication of the book
must always support ACORN’s vision change. For many, however, change as a whole. The Standard’s value,
which is for Australian patients to can be threatening, destabilising applicability and contribution to
receive the safest and highest quality and often painful. Change for the safer perioperative care and working
evidence-based perioperative care sake of change is never good. In conditions rely entirely upon ongoing
in the world. Please be reassured contrast, thoughtful, well-planned, contributions from ACORN members
that any proposed changes to the strategically executed change can and the continued oversight of the
Standards will always be evaluated lead to greater efficiencies; improved Standards Committee. To that end
for alignment with ACORN’s vision. processes; consistent, high-quality member submissions-of-interest
Changes will also take member outputs and sustainable practices. to be involved with the Standards
proposals, feedback and commentary and lodged with ACORN in 2018 are
Perhaps Collins’ most profound
into account. They will, as always, currently being reviewed and those
recommendation is his warning
be subject to the relevant guiding members should anticipate hearing
to organisations seeking growth
public policy and legislation. As soon from ACORN regarding the
to ‘preserve the core and stimulate
well they will also be responsive to outcome of that review.
progress’. He further explains
emerging biological, research and that a visionary organisation Keeping input fresh and sharing the
technological developments. is characterised by its ability opportunities associated with and
In his seminal research on during the change process to workload involved in maintaining the
organisational culture, survival balance ‘continuity and change, biennial publication of an updated
and prosperity, published in three conservatism and progressiveness, edition of the Standards are important.
best-selling books, Jim Collins stability and revolution, predictability As a result, from time to time members
identifies a series of fundamental and chaos, heritage and renewal, with particular skills, knowledge,
principles underpinning successful fundamentals and craziness’2. I would qualifications and expertise may also
organisations that both survived hope for minimal revolution, chaos be called upon to contribute.
and thrived. One important and craziness as together we ensure Making the Standards available and
recommendation Collins makes the progression of the ACORN accessible in formats and timeframes
is that for long-term prosperity Standards. that maximise their utility and uptake
organisations must ensure that is one of ACORN’s goals. Just over a
success reaches far beyond any quarter (28 per cent) of members

who participated in a recent survey concerted marketing and promotion leadership and management, all
reported dissatisfaction with access efforts. Members may help these contribute to taking ACORN from
to the Standards. In response, the efforts by sharing their own great to greater.
ACORN board and leadership have experiences of using the Standards
addressed the difficulties associated to drive safer perioperative practice. References
with the security system that has Members sharing their experiences 1. Osborne S. Making evidence-based
previously underpinned web-based with other members also supports perioperative practices stick: An
PDF editions of the Standards. As member development and the introduction to an implementation science
a result, in March or April 2019, development of ACORN as an approach. Journal of Perioperative Nursing
Standard’s subscribers will enjoy organisation. Over the next few 2017;30(4):53–55.
easier access as a new platform is months stay tuned for some new
2. Collins J. Building companies to last
launched via the freshly designed ways of facilitating that exchange.
[Internet]. Jim Collins; 1995. Available from:
ACORN website. Protecting the Although it has been more than www.jimcollins.com/article_topics/articles/
investment ACORN and its members twenty years since I last worked as building-companies.html#articletop.
have made in the Standards will a perioperative nurse, my career
also become more secure as 3. Winter G. The three habits of nimble, agile
in infection control has given me
ACORN adopts new systems of PDF companies [Internet]. Human Resources
many opportunities to work with
securement, encryption and rights Director Australia; 2013: Available from:
professional associations in their
management. www.hcamag.com/hr-resources/hr-
strategic planning, leadership and
strategy/the-three-habits-of-nimble-agile-
Ensuring the Standards offer good delivery of member services and
companies-181290.aspx.
value and are affordable to members products. Those experiences will
and subscribers is another ACORN underpin what I bring to the PSO Bibliography
goal. Finding the balance between role with ACORN, and I look forward
1. Collins JC. Good to Great: Why Some
affordability for members and to making new relationships and
Companies Make the Leap... and Others
subscribers and cost effectiveness sharing new insights with ACORN’s
Don’t. New York, NY: Collins; 2009.
for ACORN to produce the Standards membership. For any members
is a little more difficult; however, as it hoping for support, growth and 2. Collins JC. Built to last: Successful Habits
has always done, ACORN will remain progression along their perioperative of Visionary Companies. London: Random
sensitive to these drivers. career pathway through volunteer House Business, 2005.
Growing the audience for the service to ACORN’s Standards please 3. Collins JC. How the Mighty Fall: And Why
Standards is critical to their know you are welcome, and I look Some Companies Never Give In. Harper
sustainability. It will require forward to working with you and Collins: New York, 2012.
for you, as we, along with ACORN
ACORN would like to thank Sonya Osborne

for her work as Standards Editor
In 2012 ACORN appointed Associate Professor Sonya Osborne, PhD, to the inaugural
position of Standards Editor. Over the next seven years, Sonya devoted herself to
bettering the Standards, always ensuring that their development and review was
timely, evidence-based and, most importantly, useful to and easily understood by
perioperative nurses. Sonya’s ability to attract many of ACORN’s most highly qualified
and experienced members to revise existing standards and develop new ones was
masterful. Additionally, she and her volunteer teams mentored and encouraged
subsequent generations of ACORN volunteers with compassion and understanding.
ACORN’s standards for practice have evolved continuously since their origin in 1977
Associate Professor Sonya Osborne
and under Sonya’s guidance the Standards were re-invented and re-aligned with PhD, MN, GradCert Nursing
ACORN’s organisational vision. Sonya’s work with the Standards reminds us, yet again, (Perioperative),
of the importance of ACORN’s member contributions. Thank you Sonya for your GradCert (Higher Educ), BSN,
vision, your leadership and your commitment. May your legacy in the Standards be BSPsychology,
RN, Centaur Fellow, MACN, MACORN
something of which you will always be proud.
Standards Editor 2012–2018

ACORN noticeboard
International volunteer and teaching grant Education grant
As an ACORN member you may be eligible to apply for All ACORN members are eligible to apply for a grant
a grant to assist with travel costs for teaching or doing of up to $2000 to attend education events. Often
voluntary work overseas. members from rural and remote areas apply for
assistance to offset costs associated with travel.
The next round of applications for this grant close on
31 May 2019. Applications for this grant may be submitted at any
time.
Successful applicants will be notified by 31 July 2019.
Applications will be assessed quarterly, from
The application form is available on the Grants and
15 February, 17 May, 16 August and 15 November.
awards page of the ACORN website.
Applicants will be notified of the outcome at the end of
March, June, September and December.
Bravura Laser Safety Officer (LSO) For more details and to download the application form
education scholarship for this grant please visit the Grants and awards page
of the ACORN website.
Bravura is offering a scholarship for one ACORN
member from each state to complete a course in basic
laser safety training (surgical and operating suite).
Notice of Annual General Meeting
The next round of applications for this grant close on
The Annual General Meeting of the College will be held
31 May 2019.
1:00–1:30
Successful applicants will be notified by 31 July 2019.
Saturday 4 May
For more details and to download the scholarship
The Ville Resort-Casino
application please visit the Grants and awards page of
Sir Leslie Thiess Drive
the ACORN website.
Townsville
Queensland
Call for abstracts

The NTPNA biennial conference is fast approaching.
27th and 28th September 2019

Are you considering attending our conference in Darwin?
Do you have knowledge or experience that you believe would benefit the
perioperative community?
If so we would love to hear from you.
The conference theme is ‘Deadly Territory’ this could be your territory or ours!
We are currently calling for abstracts for presentations over the two days.
Presenters will receive a reduced registration fee for the entire conference.
If you have any questions or would like to discuss presenting at the conference Call for abstracts
please do not hesitate to email the NTPNA at education@ntpna.org. closes 28 June 2019

Transform
your Nursing
ACORN members
career continue
to benefit in 2019
Hundreds of ACORN members
ACORNhave benefittedScholarships
Member since 2016 with fee-waived study
through the University of Tasmania (UTAS).
Study with one of Australia’s leading providers of online postgraduate nursing
These UTAS scholarships willWith
education. continue at 50courses
more specialisation per cent
than anyof HECS
other fees
Australian in 2019.
university,
we offer you more choice and more flexibility to pursue your goals.
Applications for Semester 2, 2019
Our postgraduate arecourses
nursing now are
open.
flexible,Ifpart
you timeare planning
and 100% to study
online, and
have been designed for practicing nurses to specialise in a particular field of
further, don’t miss out. UTAS may not continue this fee-waived study beyond 2019.
healthcare.
For further information

As avisit our
member website:
of ACORN, you can study specialisations in perioperative nursing
or anaesthetics and recovery nursing, and study without tuition fees*.
www.acorn.org.au/education/utas-member-benefit.
Applications are now open for study in 2018.
utas.edu.au/health/acorn
Photo credit: Paul Redding Photographer, with thanks to the Hobart Private Hospital
*Conditions apply, see the website for details. CRICOS Provider Code: 00586B
Coming events
6–10 April AORN Surgical Conference & Expo Nashville, USA www.aorn.org.au
ACORN Queensland Conference – www.acornqld.org.au/

1–4 May Townsville
Agents of Change events/2019-state-conference
4 May ACORN Annual General Meeting Townsville www.acorn.org.au
The Hague, www.eorna.eu/EORNACongress-

16–19 May 9th EORNA Congress
Netherlands 2019-website-isopen_a557.html
Crowne Plaza
17–18 May NSW OTA conference ota3@bigpond.com
Terrigal
1–2 June Trauma Tasmania Symposium Hobart www.traumatasmania.com.au
9 August IFPN Board meeting and AGM York, U.K. www.ifpn.org.uk/events.phtml

2019
Melbourne
16–17 August VPNG conference Convention and enquiries@vpng.org.au
Exhibition Centre
ACORN 2019 Perioperative East Hotel,

6–7 September www.acorn.org.au/summit2019
Leadership Summit Canberra
27–28 September NTPNA conference Darwin education@ntpna.org
www.nzno.org.nz/groups/
colleges_sections/colleges/
17–19 October NZPO conference Hamilton, N.Z.
perioperative_nurses_college/
conferences_events
University of Notre
26 October ACORN WA conference enquiries@acornwa.org.au
Dame
ACORN 2020 International Sydney, New South

2020
28–30 May www.acorn.org.au/conference2020

Conference Wales

Member benefit
For a number of years, members have asked if ACORN can assist to provide
members with professional indemnity insurance (PII).
We are pleased to offer this benefit to our members through our partnership
with Guild Insurance.
Who is Guild Insurance? What does Guild Insurance cover me for?

Guild Insurance has been providing PII for Australian Guild’s Combined Liability Insurance policy, an all-in-one
Allied Health professionals for over 54 years. They liabilities product, includes the following key elements:
currently partner with and provide insurance for nine
AHPRA-registered professions. 1. Professional indemnity: broad cover for financial loss
caused in connection with your nursing.
Why do I need PII?
2. Public Liability: cover for accidents that cause injury or
Even though you may have cover provided to you by
property damage because of you performing your job.
your employer, when it comes to the ability to have your
own legal representation or zero excess should you
3. Products liability: protects you against liability for
need to make a claim, having your own individual Guild
damages caused by goods sold or supplied by you in
Insurance policy could be the difference between a slight
your role.
inconvenience or, in some cases, a $20 000 out-of-pocket
expense.
How can I find out more?
Guild’s combined liabilities insurance policy provides
Visit our website www.acorn.org.au/membership/
cover for not only the cost of defending a claim but also
professional-indemnity-insurance
the cost of damages you incurred when responding
to the allegation. The costs of representation can be Should you have questions about the options for
very high, no matter how minor the outcome of an professional indemnity insurance, what it covers
investigation or enquiry may be. It could be enough to and costs, please contact Guild Insurance directly
severely disrupt your livelihood, or cripple you financially. on 1800 810 213.
Important notes
Insurance issued by Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233791, is subject to terms,
conditions and exclusions.
Please refer to the policy wording and policy schedule for details.
Guild Insurance supports ACORN through the payment of referral fees. These referral fees will be used for member
education and services.
AUSTRALIAN COLLEGE OF T: +61 1300 781 924 F: +61 1300 781 934 E: administrator@acorn.org.au
PERIOPERATIVE NURSES PO Box 899 Lyndoch SA 5351 ABN 64 071 142 768 www.acorn.org.au
State reports
New South Wales Northern Territory
Karen Hay Allanah Hazelgrove Sophie Ehrlich Dorcas Shih

ACORN Director NSW OTA President ACORN Director NTPNA President
PO Box 212, Croydon, NSW 2132 PO Box 43203, Casuarina, NT 0811

T: (02) 9799 9835, F: (02) 9799 1867 secretary@ntpna.org
E: info@ ota.org.au, www.ota.org.au
Sadly, I must begin by announcing that Sr Mary Gabriel (Pat At the beginning of December 2018, NTPNA hosted an end of year
Solomon), an esteemed member of the NSW OTA and our first celebration party to which all members and non-members were
president, passed away early this year. Pat was a founding invited. We had a great time celebrating the great achievements and
member of the association and will always be remembered fellowship of 2018 and the tremendous opportunities for networking
for her dedication to perioperative nursing and education, with our fellow non-members and medical staff. Such opportunities
and for her beautiful smile. In recent years Pat travelled to the enable us to promote NTPNA and are a chance for others to
OTA conference on several occasions to present to delegates get to know more about NTPNA and how we can help with their
and share her knowledge and stories of the perioperative perioperative education.
environment. It was a true privilege to be present when ACORN
The year ahead brings a very exciting time for NTPNA. We are full
President Sarah Bird awarded her an honorary fellowship of
steam ahead preparing for our biennial conference in September. We
ACORN. Pat will be sadly missed by all who knew her.
are also very excited about the ACORN leadership summit that will
The Crown Plaza Terrigal is the place to be in May when our be held in Canberra, also in September. We look forward to learning
annual conference will be held. The executive committee are more about leadership in perioperative nursing.
busy preparing for the conference and the program is almost
With some great conferences ahead, NTPNA hopes our members
complete. We would love to see you there – it is the perfect
will make use of the scholarships available to attend some of
opportunity for you learn something new, network with other
these great educational opportunities. If anyone has any questions
perioperative nurses and discover new ideas at the trade
about the scholarships or grants that are available, please email us
exhibition. Registrations will be open soon so keep an eye on
at education@ntpna.org. We are more than happy to answer any
your emails and the NSW OTA website.
questions.
Providing education for our members is the number one priority Dorcas Shih
for our association. Each year the state executive presents three NTPNA President
professional education days and the seven zones hold two days
each, amounting to a total of 17 professional education days
across NSW and the ACT. We are very excited to announce that in
July we are holding a professional education day in collaboration
with ACORN. The day will be held on the 6th July in Sydney. More
information will be available shortly.
We have recently joined with the Clinical Excellence Commission
to review ‘Policy Directive 2013_054 Accountable Items’. Shortly
you will be receiving information about how you can assist in
this process. It is the best opportunity we have to influence
government policy directly related to our day-to-day work.
Allanah Hazelgrove
NSW OTA President

Queensland South Australia
Donna Stevens Elaine Loots Trent Batchelor Darren Gray

ACORN Director ACORN Queensland ACORN Director SAPNA President
President
GPO Box 2518, Brisbane, QLD 4001 PO Box 149, O’Halloran Hill, SA 5158
T: 0409 876 363, F: 07 3314 7062 T: 0424 974 660
www.acornqld.org.au www.sapna.org.au
What an amazing and busy first three months of my time as During 2018 we saw many changes to the SAPNA committee.
president. Firstly, I need to make a correction from the previous Cathy Ebel our president resigned from her post. As president-
journal report – it was Evelyn Kang who was the winner of the ACORN elect I have been caretaking in that role until the 2018 AGM and
Queensland research grant. Well done Evelyn and congratulations! subsequent committee elections.
The Queensland ACORN board has been very busy. Our new The SAPNA committee has been busy over the past year
constitution was registered by the Office of Fair Trade on the 10 ensuring that the key qualities of our mission – care, vision and
January 2019. The board then met on 20 January in Brisbane for a excellence – have been a part of every activity and event we have
strategic planning session – please take a look at the website to see held or planned through 2018.
our new vision, mission and purpose statements. At the commencement of the year our president led the
We welcome back to the board Joy Jensen who is returning in the committee in a strategic planning event looking at the year
role of treasurer. A big thank you also to Damien Knight for his ahead and beyond. At this meeting we were able to lay the
efforts in this role. foundations for the future direction of the organisation to
ensure that our prime objectives are met. Throughout the year
Did you know that ACORN Queensland are on Facebook, LinkedIn,
the committee has referred back to this plan to ensure that our
Twitter and Instagram? On Facebook, ACORN QLD will be replaced by
relevance to perioperative nursing remains strong.
ACORN QLD: Australian College of Perioperative Nurses Queensland
with the associated closed group being Members of ACORN QLD In 2018 we saw ACORN come to Adelaide to hold the national
Nurses. On Linkedin the group is ACORN QLD (Perioperative Nurses conference. It was great to catch up with so many of you at
Association of QLD), on Twitter the handle is ‘ACORN QLD@AcornQld’ this event and participate in such an informative and thought-
while on Instagram it’s ACORN QLD acorn_qld. Please join us on provoking program. The year ahead is shaping up to be as good if
these platforms and give us your comments and input. not better than 2018. Our state conference will be at a new venue
so watch out for exciting developments and announcements
You will soon be receiving an email from us if you have not already
concerning this.
done so. Please respond to let us know what education we can
deliver to you at a venue nearby. Alternatively, email Anndrea I wish to thank all past and present members of the SAPNA
Steinhardt (Education Officer) at education@acornqld.org.au. committee for their time and commitment to our members.
Without the time that each and every committee member puts in
Have you registered for our ‘Agents of change’ conference in
as a volunteer, SAPNA would not be able to provide its members
Townsville on 2–4 May 2019? It is still not too late to do so if you
with the high quality of educational sessions that we do. I also
haven’t. We look forward to seeing you there.
wish to acknowledge our entire member base which is growing
Are you interested in getting involved with ACORN Queensland? If so, year on year. Without your continued membership renewal and
please contact me at president@acornqld.org.au. support SAPNA could not ensure that perioperative nurses have
It is with great sadness that we report the loss of Wenda Young. a voice in health care both locally and nationally.
We express our condolences to her family and wish them long life. I look forward to serving you all again in 2019 and networking
Please refer to the tribute on page 56. with you at our educational events.
‘Be sure you put your feet in the right place, then stand firm.’ Darren Gray
SAPNA President
Abraham Lincoln
Elaine Loots
ACORN Queensland President

Tasmania Victoria
Garry Stratton Leanne Glennie Patricia Flood Jane Thomas

ACORN Director ACORN Tasmania ACORN Director VPNG President
President PO Box 593, East Melbourne, VIC 8002
PO Box 513, Kings Meadow, TAS 7249 Tel: 1300 721 169, Fax: 1300 721 170
www.acorn.org.au/tasmania enquiries@vpng.org.au, www.vpng.org.au
First up, we have had great success with our transition to our new At the VPNG strategic planning day last year we reviewed the
webpage for new (we have 15 who have joined) and current members subcommittees and the portfolios within each subcommittee in 2019.
to access. The Conference Subcommittee has organised a regional study day
On 17 November 2018 we held our first educational session via video- in Traralgon for 16 March as well as the State Conference at the
link between Royal Hobart Hospital and Mersey Hospital. This was a Melbourne Convention and Exhibition Centre in Melbourne on Friday
great success as we were able to have our three speakers give verbal and Saturday 16 and 17 August. The conference will have the trade
and visual presentations to both sites. exhibition over two days which will include education workshops
and a session specifically for perioperative nurse unit managers and
I would also like to express our sincere gratitude to Mary Condon-
procurement officers.
Williams, Director of nursing, and Paul Ashby, Business manager,
from Royal Hobart Hospital for very kindly allowing us to hold our The Education Subcommittee organise a variety of educational events,
educational session in their meeting room and for assisting with the scholarships and grants. The Sr Mary Felix and June Allen scholarship
refreshments for the day. for postgraduate studies in perioperative nursing, the Marea Fennell
scholarship for postgraduate studies in management or education
Work is still underway for the development of a new members pack
and the Mary Barry Medtronic education grant are all available again
to be established along with the opportunity to include some ACORN
in 2019.
Tasmania merchandise available for purchase from our webpage. All
proceeds from these transactions will go towards helping us provide The first of our two ‘Introduction to perioperative nursing’ courses
outstanding educational sessions to our members on a more regular was held in February at Wangaratta. It was a fantastic two days
basis throughout the year. and a very big thank you to everyone from the region who assisted
in the lead up to the event, presented sessions and assisted with
We have our first ACORN Tasmania champion, Ricarda Bakker. I
workshops over the two days. The second of these courses will be
am still hoping that more members will become ACORN Tasmania
held in the latter half of the year.
Champions and actively engage with their workplaces to promote
our organisation and distribute notices about ACORN Tasmania In addition, the Education Subcommittee have organised the second
events. If you are interested in becoming a champion, then of our co-hosted education events. Matrix Surgical and VPNG will
please forward your details and a brief background summary to hold a bariatric surgery education day on Saturday 11 May 2019.
acorntasmaniapresident@gmail.com. Following on the successful management seminar in 2018 we will
Members of the ACORN Board of Directors attended our education also be hosting a perioperative education seminar later in 2019.
session in Launceston on Saturday 16 February. This was also linked Information on all the education events, scholarships and grants can
by video to Hobart and North West Hospitals. I attended the session be found at www.vpng.org.au.
and was able to personally welcome members and discuss how we
aim to continue the success of ACORN Tasmania. The Communication Subcommittee are involved in promoting
events via social media, managing the VPNG website, producing
Finally, we are currently organising our ACORN Tasmania Conference the quarterly ‘Snippets’ newsletter,and facilitating for hospital
to be held over one and a half days on Friday and Saturday 1 and 2 representatives. Please contact enquiries@vpng.org.au if you have
November 2019. The theme will be ‘And now for something a little bit job vacancies, trade products or a perioperative education event you
different’ – keep an eye out for flyers with more details coming soon. wish to advertise or if you want to become a hospital representative.
Leanne Glennie
As a group of volunteers, the VPNG Committee work hard to continue
ACORN Tasmania President
to provide educational opportunities for perioperative nurses in
Victoria. I want to thank them very much for their valuable time that
they all put in.
Jane Thomas
VPNG President

Western Australia
In memorium
Wenda Young 1949–2018
It is with deep sadness that we
report on the recent passing of
one of our ACORN Queensland
Life Members, Wenda Young.
Grace Loh Caroline Dufton In 1966 at the age of 17, Wenda
ACORN Director ACORN WA President
Lesley Gay Young, born in
PO Box 990, Victoria Park, WA 6979 Warwick, Queensland, was
enquiries@acornwa.org.au
accepted for nursing training
www.acornwa.org.au WESTERN AUSTRALIA
at Glen Innes Base Hospital in New South Wales.
Following her graduation in 1969, Wenda completed
Great news, our name has changed! As of 7 January 2019 we are now
officially ACORN WA. her midwifery certificate at the Toowoomba Base
Hospital, then spent the next six months working
We have a new executive member on our committee who has
taken the position of education coordinator. Please welcome
in Tara (Western Downs Region of Queensland)
Victor Asirvatham who is employed in the perioperative services at before moving to the Princess Alexandra Hospital
Armadale Hospital. He is keen to get to work with the committee to in Brisbane in November 1971.
provide workshops and a conference for this year.
In 1975 Wendy accepted a position at the
The conference this year will be held at the University of Notre Dame Dalby Hospital for two years before joining the
on Saturday 26 October, so please save the date. We thank you for
Australian Inland Mission to staff their hospital
your evaluations and the many ideas you have given us for future
at Oodnadatta, South Australia, in early 1977. In
workshops and speakers for the next conference. A retreat seems
to be a popular theme, with emphasis not only on education but 1978 she moved back to Queensland to work at
also on perioperative nurses’ wellbeing, so we will be looking into Birdsville AIM Hospital for a further year. From
providing a mix of topics with a focus on relaxation. If you have any April 1979, Wenda nursed at the Warwick Base
thoughts about a venue for a retreat, for example somewhere down Hospital before transferring back to Toowoomba
south, please email with your ideas. Base Hospital in late 1981 where she specialised
Val Di Giusto, our student committee member, is now a qualified in ‘operating theatre’ work. Wenda then spent
registered nurse, and we are putting her great organisational skills to the next 14 years as a scrub nurse at St Vincent’s
good use by giving her the position of conference convenor on the Hospital Toowoomba, followed by 18 years at St
committee. We can look forward to a well-planned conference this year.
Andrews Hospital Toowoomba until her retirement
At the end of last year I had the pleasure of attending the Notre in 2014.
Dame awards ceremony where our award for the highest achieving
student in the NS208 undergraduate perioperative course and Wendy took an active interest in her professional
practicum went to Eloise Ebert. associations, joining the PNAQ (Perioperative
Congratulations also to Val Di Giusto who won a special Nurses Association of Queensland) in 1985 and
commendation award for work in the emergency and critical care going on to hold the position of Downs and South
area as well as the Doreen McCarthy best Effort Award. Well done on West secretary from 1996 to 2008. Wenda went on
your achievements. to be awarded life membership of PNAQ for her
The committee are all looking forward to seeing you at our lifelong dedication to perioperative nursing and
workshops and conference this year. even after retirement continued to support and be
Caroline Dufton part of her local association.
ACORN Western Australia President
RIP Wenda. You will be sadly missed.

ACORN wishes to acknowlege our corporate partners
Would you like to become a corporate partner and further assist with the education of nurses?
Details can be downloaded from www.acorn.org.au or by contacting the ACORN office on 1300 781 924
or email at administrator@acorn.org.au
Journal of Perioperative Nursing in Australia Volume 29 Number 2 Winter 2016 acorn.org.au 51
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Autumn 2019

NORTHERN TERRITORY PERIOPERATIVE

Clinical practice article – Improving antibiotic prescribing for surgical

Peer-reviewed article – The impact of improved surgical safety checklist

Peer-reviewed article – Perioperative nurses’ perceptions of cross-training:

Subscription enquiries Coming events 51

Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au 1

Preps alone are not enough.

Use an incise drape.

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6–7 September 2019

Improving antibiotic prescribing Authors

for surgical prophylaxis – the MBBS FRACP FCICM

role of perioperative nurses

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in the running to win the complete set

NORTHERN TERRITORY PERIOPERATIVE

Make sure personnel and practices depicted

in your photos meet current practice

The photos must be high resolution, i.e.

8 Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au

Authors’ contributions Introduction costliest departments in any hospital,

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Table 1: OR efficacy indicators, their definitions and measures (where applicable)

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Nov 2015 – Oct 2016

Analysis Total DOS cancellations 357 469

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Pre-implementation phase Post-implementation phase Delay code

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Mean Std error

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Pre-implementation phase Post-implementation phase

Month (Error bars +1–2 Std error)

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Perioperative nurse work hours to perioperative nursing, cross-

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Practice Audit Tools 1: Practice Audit Tools 2:

1. Perioperative attire 7. Surgical safety

2. Asepsis and Infection 8. Medication safety

Now available online at

environment: A mixed method

Introduction reducing potential supernumerary

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Standards for Perioperative

Pressure injury risk assessment Authors

and prevention strategies MN, BN

Subscription enquiries Coming events 51