PeriAnesthesia Nursing Core

Curriculum, 4e (April 9,
2020)_(032360918X)_(Elsevier) Aspan
Visit to download the full and correct content document:
https://ebookmass.com/product/perianesthesia-nursing-core-curriculum-4e-april-9-20
20_032360918x_elsevier-aspan/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

PeriAnesthesia Nursing Core Curriculum E-Book:

Preprocedure, Phase I and Phase II PACU Nursing – Ebook
PDF Version

https://ebookmass.com/product/perianesthesia-nursing-core-
curriculum-e-book-preprocedure-phase-i-and-phase-ii-pacu-nursing-
ebook-pdf-version/

Core Curriculum for Forensic Nursing First Edition,

(Ebook PDF)

https://ebookmass.com/product/core-curriculum-for-forensic-
nursing-first-edition-ebook-pdf/

Core Curriculum for Maternal Newborn Nursing E Book 5th

Edition, (Ebook PDF)

https://ebookmass.com/product/core-curriculum-for-maternal-
newborn-nursing-e-book-5th-edition-ebook-pdf/

Core Curriculum for Neonatal Intensive Care Nursing 6th

Edition M. Terese Verklan

https://ebookmass.com/product/core-curriculum-for-neonatal-
intensive-care-nursing-6th-edition-m-terese-verklan/
WOCN Core Curriculum: Ostomy Management (Wound, Ostomy
and Continence Nurses Societyu00ae Core Curriculum) 1st
Edition, (Ebook PDF)

https://ebookmass.com/product/wocn-core-curriculum-ostomy-
management-wound-ostomy-and-continence-nurses-society-core-
curriculum-1st-edition-ebook-pdf/

AACN Core Curriculum for High Acuity, Progressive and

Critical Care Nursing E Book 7th Edition, (Ebook PDF)

https://ebookmass.com/product/aacn-core-curriculum-for-high-
acuity-progressive-and-critical-care-nursing-e-book-7th-edition-
ebook-pdf/

AACN Core Curriculum for Progressive and Critical Care

Nursing, 8e (May 19, 2022)_(0323778089)_(Elsevier) Aacn

https://ebookmass.com/product/aacn-core-curriculum-for-
progressive-and-critical-care-
nursing-8e-may-19-2022_0323778089_elsevier-aacn/

Core Curriculum for Transplant Nurses 2nd Edition,

(Ebook PDF)

https://ebookmass.com/product/core-curriculum-for-transplant-
nurses-2nd-edition-ebook-pdf/

Drain’s Perianesthesia Nursing: A Critical Care

Approach 7th Edition Edition Jan Odom-Forren

https://ebookmass.com/product/drains-perianesthesia-nursing-a-
critical-care-approach-7th-edition-edition-jan-odom-forren/
f » ASPAN
* American Society o PcnAncrthcsia Nuraes

PeriAnesthesia
Nursing
Core Curriculum

EDITORS

Lois Schick
FJ .SEV1ER
Pamela E . Windle
 SECTION ONE SECTION FIVE
Professional Competencies System Competencies

Evolution of Perianesthesia Care, 1

1  18 Respiratory, 333
Standards, Legal Issues, and Practice Settings, 10
2  19 Cardiovascular, 387
Safety, Quality Improvement, and Regulatory and
3  20 Neurological, 446
Accrediting Agencies, 26 21 Endocrine, 499
Research and Evidence-­Based Practice, 40
4  22 Gastrointestinal, 517
23 General Surgery, 537
SECTION TWO
Preoperative Assessment Competencies 24 Hematology, 566
25 Renal/Genitourinary, 580
Preoperative Evaluation, 51
5 
26 Obstetrics and Gynecology, 613
Preexisting Medical Conditions, 70
6 
27 Ophthalmology, 660
Transcultural Nursing and Alternative Therapies, 88
7 
28 Oral/Maxillofacial/Dental, 675
The Developmentally and Physically Challenged
8 
29 Orthopedics and Podiatry, 686
Patient, 113
30 Otorhinolaryngology, 723
SECTION THREE 31 Peripheral Vascular Disease, 744
Life Span Competencies 32 Plastic and Reconstruction, 770

The Pediatric Patient, 138

9  33 Bariatrics, 795

10 The Adolescent Patient, 181 34 Trauma, 817

11 The Adult Patient, 194 35 Interventional Radiology and Special

Procedures, 833
12 The Geriatric Patient, 205
36 Perianesthesia Complications, 843
SECTION FOUR
Perianesthesia Competencies SECTION SIX
Education and Discharge Competencies
13 Fluid, Electrolyte, and Acid-­Base Balance, 220
37 Postoperative/Postprocedure Assessment, 859
14 Anesthesia, Moderate Sedation/Analgesia, 238
38 Discharge Criteria, Education, and Postprocedure
15 Thermoregulation, 287
Care, 896
16 Postoperative/Postdischarge Nausea and
Appendix A: Certification of Perianesthesia Nurses:
Vomiting, 301
The CPAN and CAPA Certification Programs, 908
17 Pain and Comfort, 312
Appendix B: Testing Concepts and Strategies, 914
 Fourth Edition

PeriAnesthesia
Nursing
Core Curriculum
Preprocedure, Phase I and Phase II PACU Nursing
EDITORS
Lois Schick MN, MBA, RN, CPAN, CAPA, FASPAN
Perianesthesia Nurse Consultant
Per Diem Staff Nurse II, PACU
Lutheran Medical Center
Wheat Ridge, Colorado

Pamela E. Windle DNP, RN, NE-BC, CPAN, CAPA, FAAN, FASPAN

Perianesthesia Nurse Consultant
Nursing Program Manager
Harris Health System
Houston, Texas
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043

PERIANESTHESIA NURSING CORE CURRICULUM: PREPROCEDURE, ISBN: 978-­0-­323-­60918-­0

PHASE I AND PHASE II PACU NURSING, FOURTH EDITION

Copyright © 2021 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notice

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or con-
tributors for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in
the material herein.

Previous editions copyrighted 2016, 2010, 2004.

Library of Congress Control Number: 2020931431

Senior Content Strategist: Sandra Clark

Senior Content Development Manager: Lisa Newton
Senior Content Development Specialist: Laura Selkirk
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Doug Turner
Designer: Amy Buxton

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

I would like to dedicate the fourth edition of the Core Curriculum to my family
and friends, including my co-­workers at Lutheran Medical Center in Wheat Ridge,
Colorado, and all the contributing authors to this edition. A special thank you is
extended to co-­editor Pam Windle and all nursing colleagues whom I have
encountered and have had the opportunity to share nursing stories. Without the
support and encouragement of others, including family, it would have been dif-
ficult to update the material in this edition and to meet deadlines. You will note
some changes in the fourth edition of the ASPAN PeriAnesthesia Nursing Core
Curriculum: Preprocedure, Phase I, and Phase II PACU Nursing, including the
formatting, font size, and new punctuation based on Doland’s Medical Dictionary.
It has been an experience of new changes, challenges, and opportunities. Thank
you!
Lois Schick

I dedicate this book to all perianesthesia nurses, especially my former staff in

the Post Anesthesia Care Unit (PACU), Day Surgery Center, CV Preop/PACU,
Surgical Observation Unit and Endoscopy departments at St. Luke’s Medical
Center, Houston, Texas, who for over 20 years consistently showed commitment
in their daily practices, shared their knowledge, and provided me with their ex-
pertise and insights. Working with them to provide the best postoperative care
management for all types of patients has been a great privilege and an honor.
To David, my husband, my two children, Cynthia and Michael, my son-in-law,
Jeremy, and my granddaughter, Natalia, for their understanding of my dedication
and love of my career, and for their support and patience throughout this en-
deavor, as well as to my brothers Junior, Alan, Peter, and Philip, and sisters Elsie,
Jane, Tina, and Brenda, and especially to my loving parents, Mary and Lorenzo,
who believed in me! Thank you all!
Pamela E. Windle
CONTRIBUTORS

Maria Liza Anicoche, MSN, RN, ACNS-­BC, Amy Dooley, MS, BSN, RN, CPAN, CAPA
CPAN, CAPA Clinical Educator
NCIII, PACU PACU, Ambulatory Surgery, Pre-­Operative Center
Johns Hopkins Hospital Lahey Hospital and Medical Center
Baltimore, Maryland Burlington, Massachusetts
ASPAN Past President 2019-2020
Krista Paternostro Bower, MPA, CAE
Cherry Hill, New Jersey
Chief Executive Officer, Administration
American Board of Perianesthesia Nursing Certification, Inc. Susan Fetzer, PhD, MBA, MSN, BA, BSN, RN
New York, New York Professor Emeritus
College of Health and Human Services
Courtney Brown, PhD, RN, CRNA
University of New Hampshire
Associate Director Didactic Education
Durham, New Hampshire
Nurse Anesthesia Program
Director of Research
Wake Forest School of Medicine
Southern New Hampshire Medical Center
Winston-­Salem, North Carolina
Nashua, New Hampshire
Matthew Byrne, PhD, RN, CNE
Barbara Godden, MHS, BA, BSN, RN, CPAN, CAPA
Adjunct Professor, Nursing
Staff Nurse, PACU
Saint Catherine University
Sky Ridge Medical Center
Saint Paul, Minnesota
Lone Tree, Colorado
Shelly L. Cannon, MSN, BSN, APRN, AGCNS-BC, Editor, Breathline
CPAN, RN-BC ASPAN
CNS Pain Management Cherry Hill, New Jersey
PACU, ERAS Coordinator
Valerie Aarne Grossman, BSN, RN, MALS, NE-­BC
Lutheran Medical Center
Nurse Manager, Medical Imaging
Wheat Ridge, Colorado
Highland Hospital (University of Rochester affiliate)
Sarah Marie Independence Cartwright, DNP, MSN-PH, Rochester, New York
BAM, RN-BC, CAPA
Vallire D. Hooper, PhD, RN, CPAN, FAAN
Integrated Clinical Practice Strategist
Nurse Scientist Scholar
Anesthesiology and Perioperative Medicine
Nursing Practice, Education, and Research
Augusta University
Mission Health
Augusta, Georgia
Asheville, North Carolina
Theresa L. Clifford, MSN, RN, CPAN, CAPA,
Seema S. Hussain, MS, BSN, RN
FASPAN
Nurse Educator
Manager Perioperative Services
Nursing Professional Practice
Mercy Hospital
MedStar Washington Hospital Center
Portland, Maine
Washington, District of Columbia
ASPAN Nurse Liaison for Special Projects
ASPAN Past President 2009–2010 Deborah Johnson-­Sasso, MHA, BSN, RN
Cherry Hill, New Jersey Service Line Director
Cardiovascular and Critical Care
Audrey E. Cook, MS, RN, CPAN, CAPA
Lutheran Medical Center
Perianesthesia
Wheat Ridge, Colorado
Children’s National Hospital
Washington, District of Columbia H. Lynn Kane, MSN, MBA, RN, CCRN
Clinical Nurse Specialist, Nursing
Amy Dempsey, MSN, BSN, RNC
Thomas Jefferson University Hospital, Methodist Division
Obstetrics Clinical Practice Specialist
Philadelphia, Pennsylvania
Women and Children’s Center
Lutheran Medical Center
Wheat Ridge, Colorado

v
vi Contributors

Dina A. Krenzischek, PhD, RN, CPAN, CFRE, FAAN, Nancy O’Malley, MA, BSN, RN, CPAN, CAPA
FASPAN Staff RN, ECT PACU
Director of Nursing Professional Services Porter Adventist Hospital
Mercy Medical Center Denver, Colorado
Owings Mills, Maryland
Jan Odom-­Forren, PhD, RN, CPAN, FAAN, FASPAN
ASPAN Past President 2004-2005
Associate Professor, College of Nursing
Cherry Hill, New Jersey
University of Kentucky
Maureen Lisberger, BS, RN, AD, CCRN, CPAN, CAPA Lexington, Kentucky
PACU Nurse Perianesthesia Nursing Consultant
Center for Pain Management Louisville, Kentucky
Presbyterian St. Luke’s Medical Center ASPAN Past President 1992-1993
Denver, Colorado Cherry Hill, New Jersey
Myrna Eileen Mamaril, MS, BSN, DNP, RN, NEA-BC, CPAN, Sohrab Alexander Sardual, MBA, BSN, RN, NE-BC
CAPA, FAAN, FASPAN Assistant Clinical Director
Clinical Nurse Specialist Pediatric ICU
Perioperative Services Texas Children’s Hospital
Johns Hopkins Hospital Houston, Texas
Baltimore, Maryland
Lois Schick, MN, MBA, RN, CPAN, CAPA, FASPAN
ASPAN Past President 1999-2000
Perianesthesia Nurse Consultant
Cherry Hill, New Jersey
Per Diem Staff Nurse II, PACU
Rex A. Marley, MS, CRNA, RRT Lutheran Medical Center
Nurse Anesthetist Wheat Ridge, Colorado
Independent Contractor ASPAN Past President 2008-2009
Anesthesiology Cherry Hill, New Jersey
Fort Collins, Colorado
Linda Wilson, PhD, RN, CPAN, CAPA, NPD-BC, CNE,
Rae Marshall, MS, RN, CPAN CNEcl, CHSE-­A, FASPAN, ANEF, FAAN
Educator, PeriAnesthesia Assistant Dean for Simulation and Continuing Education
Centura Health Porter Adventist Hospital College of Nursing and Health Professions
Denver, Colorado Drexel University
Philadelphia, Pennsylvania
Maureen Frances McLaughlin, MS, ACNS-­BC, CPAN,
ASPAN Past President 2002-2003
CAPA
Cherry Hill, New Jersey
Quality Nurse Anesthesiology
Lahey Hospital and Medical Center Pamela E. Windle, DNP, RN, NE-­BC, CPAN, CAPA,
Burlington, Massachusetts FAAN, FASPAN
Perianesthesia Nurse Consultant
Kim A. Noble, PhD, RN, ACCNS-AG, CPAN, FASPAN
Nursing Program Manager
Assistant Professor, School of Nursing
Harris Health System
Widener University
Houston, Texas
Chester, Pennsylvania
ASPAN Past President 2006-2007
Staff Nurse
Cherry Hill, New Jersey
Jeanes Hospital
Philadelphia, Pennsylvania Vicki G. Yfantis, MSN, RN, CRNP, CPAN
President 2017–2020
Denise O’Brien, DNP, RN, ACNS-­BC, CPAN, CAPA,
American Board of Perianesthesia Nursing Certification, Inc.
FCNS, FAAN, FASPAN
New York, New York
Perianesthesia Clinical Nurse Specialist
Clinical Nurse Manager
Department of Operating Rooms/PACU
Pre-Op, PACU, Pre-Surgical Testing
Adjunct Clinical Instructor
Suburban Hospital
School of Nursing
Bethesda, Maryland
University of Michigan Hospitals and Health Centers
Ann Arbor, Michigan
ASPAN Past President 1994-1995
Cherry Hill, New Jersey
REVIEWERS

Sylvia J. Baker, MSN, RN, CPAN, FASPAN Allan Schwartz, DDS, CRNA
Clinical Education Specialist President
Mercy Health Sedation Consult, LLC
Rockford, Illinois Columbia, Missouri
Associate Professor
William Mark Enlow, DNP, NP, CRNA, DCC
Department of Periodontics the Center for Advanced Dental
Nurse Anesthetist
Education
Department of Anesthesia Services
St. Louis University
Samaritan Medical Center
St. Louis, Missouri
Watertown, New York
Sarah A. Sheets, MSN, CRNA
Teresa Passig, BSN, RN, CPAN, CAPA, CCRN, CPHQ
Fort Collins, Colorado
Regulatory Consultant
Orlando Health
Orlando, Florida

vii
FOREWORD
The American Society of PeriAnesthesia Nurses (ASPAN)
is pleased to offer the fourth edition of the PeriAnesthesia
Nursing Core Curriculum. While professional practice and
nursing knowledge are embedded in day-­to-­day practice,
leadership in the development of care delivery models and
constant collaboration in medicine have driven the need to
update this essential text. This edition provides subject
matter encompassed in the wide range of perianesthesia
practice and has been created by clinical experts in peri-
anesthesia nursing.
The core tenets in this curriculum are intended to pro-
vide guidance to cover the spectrum of perianesthesia
nursing, from preoperative or preprocedural assessments
and planning to day-­of-­surgery or procedure care, through
Phase I, Phase II and Extended Levels of Care to include
Enhanced Recovery After Surgery (ERAS). In addition,
these concepts of practice are intended to offer guidance
regardless of the location of that care. This includes the
acute care setting, ambulatory or free-­standing facilities,
and office-­based practices, to name a few. New topics are
integrated throughout the text to reflect a growing body of
evidence and to address emerging trends in care. New fea-
tures in this edition include combining chapters and
streamlining content to create a more concise book.
Education and discharge competences have been revised to
address changes in ambulatory settings and patient dis-
charge practices. Updated new content will include ERAS
in multiple chapters, transgender care, Do Not Resuscitate/
Do Not Attempt Resuscitation/Do Not Intubate (DNR/
DNAR/DNI) and the impact of the latest technology on
perianesthesia nurses.
ASPAN’s compelling vision is to be recognized as the
leading organization for evidence-­ based perianesthesia
nursing practice. The depth and value this edition will bring
toward that goal is immense. As a core curriculum, it will
provide guidance for nurses seeking certification, a map for
creating unit-­based competencies, a reference for clinical
orientation of new staff and new perianesthesia nurses, and
a resource for the fundamentals and standards of practice.
ASPAN offers this text as a comprehensive review for
the assessment and care of patients of all ages presenting
with a wide variety of medical findings, surgeries, and pro-
cedures in all phases and settings of perianesthesia care.
The American Society of PeriAnesthesia Nurses
(ASPAN)
ix
P R E FA C E
The specialty of perianesthesia nursing is performed in a
variety of settings. Once practiced only in the “recovery
room,” nurses now care for perioperative and postproce-
dure patients in an array of surroundings—hospital-­based
and freestanding. Perianesthesia nursing encompasses car-
ing for patients during the preanesthesia level of care (pre-
admission and day of surgery/procedure), in postanesthesia
levels of care (Phase I, Phase II and Extended Care), ambu-
latory care settings, extended observation settings, and
special procedure areas (e.g., endoscopy, radiology, cardio-
vascular, oncology), obstetric units, pain management
services, and physician or dental offices. Nurses caring for
perianesthesia patients need to possess a variety of skills
and expertise. Patients undergoing operative and invasive
procedures come to the facility either as a planned event or
as an emergency. Being able to assess the patient, develop
an individualized plan of care, implement the plan, and
evaluate the results requires proficiency in perianesthesia
nursing based on safety and evidenced-­based practices.
This book is divided into the following sections to
address competencies:
• Professional Competencies
• Preoperative Assessment Competencies
• Life Span Competencies
• Perianesthesia Competencies
• System Competencies
• Education and Discharge Competencies
This text is also a resource for nurses preparing to take
either the Certified Post Anesthesia Nurse (CPAN) or the
Certified Ambulatory PeriAnesthesia Nurse (CAPA) certi-
fication examination. Certification in one’s specialty is a
way to promote quality of care to the general public, the
nursing profession, and the individual nurse. When a nurse
achieves certification in his or her specialty, this demon-
strates commitment to his or her nursing career, provides
tremendous personal satisfaction, and provides opportuni-
ties for career advancement.
The text uses an outline format to delineate areas of peri-
anesthesia nursing practice. The text is not designed to be a
complete study guide. The nurse must identify his or her
own areas of strength and weakness, seek out additional
resources, and develop an individualized study plan that will
meet his or her needs. This book can be utilized as:
• A study guide for nurses new to the perianesthesia
setting
• Development of an orientation plan for the PACU
• Development of perianesthesia nursing competencies
• A reference guide for student nurses rotating through
the PACU
The chapter authors are experts in their fields of prac-
tice, and many of them are certified in their specialties. The
information presented in this text is as accurate and cur-
rent as possible. Each chapter has been reviewed to ensure
accuracy. The development of this core curriculum was
sponsored by and supported by the American Society of
PeriAnesthesia Nurses (ASPAN).
Lois Schick and Pamela E. Windle
xi
ACKNOWLEDGMENTS
The fourth edition of the Core Curriculum has been
updated by combining chapters of like subjects to reflect
evidence-­based practice. Revisions were made to the surgi-
cal specialties chapters to combine care concepts. In this
edition, from inception to its final reality, we encountered
numerous challenges but none so monumental that they
could not be overcome. We wish to thank the previous
authors and our current authors who contributed chapters,
as well as the reviewers who provided insightful sugges-
tions and recommendations for updating each chapter in
this edition. The time, energy, and dedication the authors
and reviewers contributed is a reflection of their devotion
to our nursing specialty.
Our sincere appreciation goes to Laura Selkirk, Senior
Content Development Specialist at Elsevier, for her dedica-
tion in assisting us and each chapter author with any
desired changes in their manuscript. She was always there
with encouragement and words of kindness, keeping us on
track to get the project done on time and to print, which is
greatly appreciated. We extend our gratitude to the numer-
ous other members of Elsevier’s team and thank them for
bringing this project to fruition and to Doug Turner for
getting the final proofs ready in a timely manner.
We could not have accomplished the rewrite of this
book without the opportunity provided by the American
Society of PeriAnesthesia Nurses (ASPAN) to recognize
the continued need for an updated evidenced-­based core
curriculum. This text will assist the perianesthesia nurse in
enhancing his or her knowledge and skills in preparation
for taking their certification examination(s) and for pro-
viding comprehensive care to patients and families.
I continue to appreciate all the support given to me over
the years from my eleven older siblings and their families
particularly sisters Jean Newton, Lavonne Hougen, Henry
Schick, and nurse friend Roma Schweinefus, who have
always been there to encourage and support me in all my
life endeavors and during my nursing career. Thank you to
the ASPAN Board of Directors for the opportunity to co-­
edit the fourth edition of the Core Curriculum. I am
indebted to co-­editor Pam Windle and to Laura Selkirk and
Doug Turner at Elsevier for their expertise and support
during this time of writing.
Lois Schick
To all perianesthesia nurses, especially to my former
staff in the PACU, Day Surgery Center, CV Preop/PACU,
Endoscopy departments and Surgical Observation Unit at
CHI St. Luke’s Medical Center, Houston, Texas, who for
the past 20 years have consistently shown commitment in
their daily practices, shared their knowledge, and pro-
vided me with their expertise. Working with them has
been a great privilege and an honor. And to all the peri-
anesthesia staff at Harris Health System and to all the
TAPAN members whom I’ve mentored throughout the
years, thank you!
A special thanks to my husband David, for his patience
throughout this endeavor, and for his support and under-
standing of my dedication and love of my career. To my
2 children, Cynthia and Michael, Jeremy and Natalia, my
brothers Junior, Alan, Peter, and Philip, and my sisters
Elsie, Jane, Tina, and Brenda, and especially to my loving
parents, Mary and Lorenzo, for their continual support and
encouragement. Thank you also to my best friend and
mentor, Lois Schick, for her continued assistance as co-­
editor, to Laura Selkirk and Doug Turner at Elsevier, who
are always there for us. Lastly, to ASPAN, thank you for this
wonderful opportunity and to all the authors for your con-
tributions to this book! Thank you all!
Pamela E. Windle
xiii
CONTENTS

SECTION ONE 16 Postoperative/Postdischarge Nausea and

Professional Competencies Vomiting, 301
Jan Odom-­Forren
Evolution of Perianesthesia Care, 1
1 
17 Pain and Comfort, 312
Jan Odom-­Forren and Theresa L. Clifford Linda Wilson and H. Lynn Kane
Standards, Legal Issues, and Practice
2 
Settings, 10 SECTION FIVE
Barbara Godden System Competencies
Safety, Quality Improvement, and Regulatory and
3 
Accrediting Agencies, 26 18 Respiratory, 333
Rex A. Marley
Dina A. Krenzischek
Research and Evidence-­Based Practice, 40
4  19 Cardiovascular, 387
Deborah Johnson-­Sasso
Susan Fetzer
20 Neurological, 446
SECTION TWO Pamela E. Windle
Preoperative Assessment Competencies 21 Endocrine, 499
Matthew Byrne
Preoperative Evaluation, 51
5  22 Gastrointestinal, 517
Sarah Marie Independence Cartwright Denise O’Brien
Preexisting Medical Conditions, 70
6  23 General Surgery, 537
Lois Schick Maria Liza Anicoche and Myrna Eileen Mamaril
Transcultural Nursing and Alternative
7  24 Hematology, 566
Therapies, 88 Pamela E. Windle and Sohrab Alexander Sardual
Myrna Eileen Mamaril
25 Renal/Genitourinary, 580
The Developmentally and Physically Challenged
8  Kim A. Noble
Patient, 113 26 Obstetrics and Gynecology, 613
Theresa L. Clifford
Amy Dempsey

SECTION THREE 27 Ophthalmology, 660

Seema S. Hussain
Life Span Competencies
28 Oral/Maxillofacial/Dental, 675
The Pediatric Patient, 138
9  Denise O’Brien
Myrna Eileen Mamaril 29 Orthopedics and Podiatry, 686
10 The Adolescent Patient, 181 Shelly L. Cannon
Pamela E. Windle and Lois Schick 30 Otorhinolaryngology, 723
11 The Adult Patient, 194 Rae Marshall
Lois Schick 31 Peripheral Vascular Disease, 744
12 The Geriatric Patient, 205 Maureen Lisberger
Pamela E. Windle and Myrna Eileen Mamaril 32 Plastic and Reconstruction, 770
Theresa L. Clifford
SECTION FOUR 33 Bariatrics, 795
Perianesthesia Competencies Kim A. Noble

13 Fluid, Electrolyte, and Acid-­Base Balance, 220 34 Trauma, 817

Myrna Eileen Mamaril
Kim A. Noble
14 Anesthesia, Moderate Sedation/Analgesia, 238 35 Interventional Radiology and Special
Courtney Brown Procedures, 833
Amy Dooley and Valerie Aarne Grossman
15 Thermoregulation, 287
Vallire D. Hooper 36 Perianesthesia Complications, 843
Lois Schick

xv
xvi Contents

SECTION SIX Appendix A: Certification of Perianesthesia Nurses:

Education and Discharge Competencies The CPAN and CAPA Certification Programs, 908
Krista Paternostro Bower and Vasso G. Yfantis
37 Postoperative/Postprocedure Assessment, 859
Appendix B: Testing Concepts and Strategies, 914
Maureen Frances McLaughlin
Nancy O’Malley
38 Discharge Criteria, Education, and Postprocedure
Care, 896
Audrey E. Cook
SECTION ONE
Professional Competencies
Evolution of Perianesthesia Care
OBJECTIVES
At the conclusion of this chapter, the reader will be
able to do the following:
1. Describe three of the earliest recovery rooms.
2. Name the decade when recovery rooms became
commonplace.
3. Name the one historical event that contributed most to
the advent of recovery rooms.
4. Name three advances in medical technology that led to
an increase in ambulatory surgeries.
5. List three reasons for consumer acceptance of
ambulatory surgery.
6. Describe the development of the American Society of
PeriAnesthesia Nurses (ASPAN), formerly known as the
American Society of Post Anesthesia Nurses.
7. Describe three benefits brought to perianesthesia
nursing by ASPAN.
I. Early Beginnings
A. Early beginnings of recovery room and ambulatory
surgery
1. Trephining of the skull and amputations identified
in the year 3500 BC, as evidenced by cave drawings
2. New Castle Infirmary, New Castle, England (1751):
rooms reserved for dangerously ill or major surgery
patients
3. Florence Nightingale, London, England (1863):
separate rooms for patients to recover from imme-
diate effects of anesthesia
4. Ambulatory surgeries performed at Glasgow Royal
Hospital for Sick Children in Scotland from 1898
to 1908
a. Surgeries were performed on 8988 children
b. Surgeries included orthopedic problems, cleft lip
and cleft palate, spina bifida, skull fracture, her-
nias, and others
c. None of the children required hospital
admission
CHAPTER 1
Jan Odom-­Forren and Theresa L. Clifford
5. Information from Glasgow Hospital presented at a
meeting of the British Medical Association in 1909
6. Twentieth century
a. First general anesthesia in ambulatory surgery at
Sioux City, Iowa, in 1918
b. 1920s and 1930s: complexity of surgeries
increased
c. 1923: Johns Hopkins Hospital, Baltimore,
Maryland, three-­bed neurosurgical recovery
unit opened by Dandy and Firor
d. World War II: recovery units created to provide
adequate level of nursing care during nursing
shortage
e. 1942: Mayo Clinic, Rochester, Minnesota
f. 1944: New York Hospital
g. 1945: Ochsner Clinic, New Orleans, Louisiana
h. 1940s and 1950s: early ambulation after surgery
came into acceptance
B. Value of recovery room demonstrated in improving
surgical care
1. Anesthesia Study Commission of the Philadelphia
County Medical Society report (1947) stated that
one-­third of preventable postsurgical deaths during
an 11-­year period could have been eliminated by
improved postoperative nursing care
2. The Operating Room Committee for New York
Hospital (1949) stated that adequate recovery room
service was necessary for any hospital that provided
surgical services
II. Acceptance and Decline of
Recovery Rooms
A. Impact of changing technology on patient care
1. 1950s: more knowledge of common postanesthesia
complications
2. 1950s and 1960s: growth of surgical intensive care
and postoperative respiratory support
3. Expanding complex surgical procedures
1
 2 SECTION ONE • Professional Competencies
4. Expanding technology led to outpatient complex
surgeries
Section
a. Microscopic surgeries abounded
One
b. New lasers were developed (yttrium argon gas,
argon, and carbon dioxide)
c. New laparoscopic instruments facilitated
shorter, less-­invasive laparoscopic procedures
d. More endoscopic procedures performed as out-
patient procedures
e. Video equipment and computer-­assisted surger-
ies now performed
f. Fiber optics led to advances in ophthalmic sur-
geries, most performed in outpatient settings
5. Change in anesthesia techniques and medications
6. 1970s: recovery rooms managed routine postanes-
thesia patients, including ambulatory, routine, and
critically ill patients receiving respiratory and cir-
culatory support
7. Many diagnostic procedures done in ambulatory
settings
a. X-­ray procedures
b. Laboratory tests
c. Physical therapy
d. Cardiopulmonary tests
e. Pain blocks
B. Recovery rooms lose viability and identity
1. Staffing: shortage of skilled personnel
2. No organized body of knowledge pertinent to
postanesthesia
a. Staff performance evaluated on the basis of trial
and error
b. No territorial restrictions: sometimes considered
an extension of the operating room
c. No established standards of care
III. Ambulatory Surgery Focus
A. Ambulatory surgery programs established
1. The nation’s first ambulatory surgery program
opened at Butterworth Hospital in Grand Rapids,
Michigan, in 1961, and staff performed 879 ambu-
latory surgeries between 1963 and 1964
2. A formal ambulatory surgery program began at the
University of California, Los Angeles in 1962
3. In 1968, the Dudley Street Ambulatory Surgery
Center opened in Providence, Rhode Island
4. The nation’s first freestanding surgery facility was
opened in 1970, by Dr. Wallace Reed and Dr. John
Ford in Phoenix, Arizona
a. In 1971, the American Medical Association
endorsed the use of surgicenters
b. In 1974, the Society for the Advancement of
Freestanding Ambulatory Surgery was formed,
which was the precursor for the current Federated
Ambulatory Surgery Association (FASA)
5. The American Society for Outpatient Surgeons
(now known as American Association of
Ambulatory Surgery Centers) was formed in 1978,
leading to surgery being performed in doctors’
offices
a. The 1980s brought a shortage of inpatient hospi-
tal beds
b. In 1980, the Omnibus Budget Reconciliation Act
authorized reimbursement for outpatient
surgery
c. In 1981, the American College of Surgeons
(ACS) approved the concept of ambulatory sur-
gery units (ASUs) as preadmission units for
scheduled inpatients
d. In 1983, Porterfield and Franklin advocated for
office outpatient surgery
e. The Society for Ambulatory Anesthesia was
formed in 1984
B. The ambulatory surgery concept proliferated in the
1980s
1. Hospital-­affiliated ambulatory surgery accounted
for 9.8 million operations (45%) performed within
hospital settings by 1987
2. By 1988, there were 984 Medicare-­participating
freestanding ambulatory surgery centers in the
United States
3. By 1988, the 984 freestanding outpatient surgery
centers performed more than 1.5 million surgical
operations
4. The list of approved procedures that can be con-
ducted in surgery centers was expanded in 1987, by
the Health Care Financing Administration (HCFA),
now known as the Centers for Medicare and
Medicaid Services
5. In 1989, HCFA revised the payment schedule for
outpatient surgeries performed on Medicare
patients
C. Freestanding recovery sites
1. In 1979, the first freestanding recovery care center
opened in Phoenix, Arizona
a. Patients were transported directly to the recovery
care center from hospital postanesthesia care units
(PACUs), from ASUs, and from physicians’ offices
b. Some patients were transferred there from hospi-
tals on their second or third postoperative day
2. The limits of stay for recovery care centers are
defined by each state regulation
3. In the 1980s, the concept of 23-­hour units led to
guest services being developed for patients living
more than 1 hour away from the site where the sur-
gery was to be performed (hospital hotels; medical
motels)
a. Freestanding medical motels are considered a
comfortable, affordable, and convenient place to
recuperate
b. Patients are cared for by family members
 CHAPTER 1 • Evolution of Perianesthesia Care 3

Table 1.1
Characteristics of Ambulatory and Inpatient Surgeries.

One
Section
One
CHARACTERISTICS AMBULATORY SURGERIES INPATIENT SURGERIES

Section
Amount Percent Amount Percent
Total visits/stays for surgeries 9.9 million 57.8 7.2 million 42.2
Visits/stays per 100,000 population 5600 — 4100 —
Total number of surgeries 11.5 million 52.7 10.3 million 47.3
Average number of surgeries per visit/stay 1.2 — 1.4 —
Adapted from Steiner CA, Karaca Z, Moore BJ, et al: Surgeries in hospital-­based ambulatory surgery and hospital inpatient settings, 2014: Statistical brief #223, Agency for
Healthcare Research and Quality, 2017, revised February 2018.

c. Home health nurses make visits, or a nurse is
stationed onsite
4. Data from the National Center for Health Statistics
Data Center, 1996
a. An estimated 31.5 million surgical and nonsur-
gical procedures were performed during 20.8
million ambulatory visits in 1996
b. An estimated 17.5 million (84%) of the ambula-
tory surgery visits were in hospitals, and 3.3 mil-
lion (16%) were in freestanding centers in 1996
c. In 2000, 63% of all surgeries were performed in
outpatient settings
5. In 2005, there were more than 4200 ambulatory
surgery centers, which provided more than 12 mil-
lion surgeries annually
6. Nearly 64% of all surgeries in the United States are
performed in the ambulatory setting, including
approximately 22 million surgeries (Table 1.1)
D. Economics of ambulatory surgery
1. Cost control, a primary force in the development of
ambulatory surgery
a. In 1988, 58% of surgery centers contracted with
health maintenance organizations, and 52% with
preferred provider organizations
b. In 1990, the American Hospital Association
reported that more than 50% of all hospital-­
based surgical procedures were done on an out-
patient basis
c. In the 1990s, 23 home observation units (recov-
ery centers) were established in the United States
d. The percentage of outpatient procedures
approved for payment under Medicare increased
(1) In 1982, 450 procedures were approved
(2) By the early 1990s, 2500 procedures were
approved
(3) On July 1, 2003, 282 more approved proce-
dures were added
e. Third-­party payers require many surgeries to be
performed in an ambulatory setting, to avoid the
cost of hospitalization
f. Many freestanding centers have contractual
arrangements with managed care plans, rehabili-
tation centers, and nursing homes
g. Outpatient facilities eliminate the costs of cafete-
ria, laundry, and the need for 24-­hour staffing
h. Outpatient procedures eliminate unnecessary
lab, x-­ray, and electrocardiogram services
i. Patients recovering in 23-­hour units are con-
sidered nonhospitalized for purposes of reim-
bursement by Medicare and third-­party
payers
E. Legislation encouraged growth of ambulatory centers
1. Relaxation of legislation began to occur in the
1980s
2. By 1987, the Omnibus Budget Reconciliation Act
provided for less reimbursement to hospitals, pro-
viding rates equal to those for ambulatory surgery
centers
3. The Omnibus Budget Reconciliation Act of 1989
again increased the reimbursement rates for
assigned surgical procedures in ambulatory centers
4. Ambulatory centers became certified by accepted
certifying agencies
F. Consumer acceptance of ambulatory surgery
1. Awareness
a. Increased marketing led to increased consumer
awareness
b. Greater awareness led to greater demand for
surgery in ambulatory settings
c. Consumers saw more physician involvement in
ambulatory settings
d. Patient consumers felt more involved and took
part in decisions
e. Few problems were seen with quality of care
2. Convenience
a. Flexible hours
b. Early admission and same-­day discharge
c. Less time lost from work
d. Units easily accessible
3. Wellness philosophy well accepted
a. Patients could walk to the operating room
b. Patients could recover on stretchers or in
recliners
c. Parents could remain with children during
induction; parents and sometimes families could
be present postoperatively
 4 SECTION ONE • Professional Competencies
d. Patients were able to keep dentures, eyeglasses,
and hearing aids with them
Section
e. Patients felt more involved in decision making
One
for their care
f. Family visitation encouraged in phase I PACUs
4. Reimbursement
a. Reimbursement provided by Medicare for out-
patient procedures for the elderly made ambula-
tory surgery a viable alternative
b. Employers were paying less, and consumers
found ambulatory settings less expensive,
making outpatient surgery an attractive
option
IV. Emergence of Organized
Recovery Room Groups
A. The need to identify a special body of knowledge and
skills required for practice
1. Groups form to develop educational opportunities
a. Nineteen groups were organized in the United
States
b. The Florida Society of Anesthesiologists initi-
ated a yearly seminar in 1969
(1) Attended by nurses from United States and
Canada
(2) Dr. Frank McKechnie: supporter of recovery
room nurses
2. Series of seminars sponsored by American Society
of Anesthesiologists (ASA) in the 1970s
a. Supported by solid attendance and strong inter-
est from nurses in the specialty
b. Interest shown in development of recovery room
nursing organization
B. Local and state organizations form a national group
1. Regional nursing representatives met with ASA
Care Team to organize a national postanesthesia
nurses’ association
2. Goals established
a. Education for postanesthesia nurses
b. Recognition of postanesthesia nursing as a
specialty
3. 1979: steering committee formed
a. Selection of name: American Society of Post
Anesthesia Nurses (ASPAN)
b. Preparation of bylaws
c. Incorporation
d. First ASPAN president: Ina Pipkin, RN, from
Seattle, Washington
4. First meeting of board of directors held October
1980, in Orlando, Florida
5. April 1982: charter for component status granted to
Alabama and Florida
V. First years (October 1980 to
April 1982)
A. Financial development
1. ASA grant for legal expenses
2. Membership dues
B. Internal organization developed
1. Committees appointed
2. Newsletter, Breathline, begun in 1981
3. Membership increased
a. First national conference planned
b. Regional educational meetings held
VI. ASPAN Developments
A. Publications
1. 1981: Breathline (ASPAN’s newsletter)
2. 1983: Guidelines for Standards of Care
3. 1984: Post Anesthesia Nursing Review for
Certification
4. 1986: Standards of Nursing Practice
5. 1986: Journal of Post Anesthesia Nursing (JoPAN)
6. 1986: Redi-­Ref, ed 1
7. 1990: Fifty Years of Progress in Post Anesthesia
Nursing 1940–1990
8. 1991: Standards of Post Anesthesia Nursing Practice
9. 1991: Core Curriculum for Post Anesthesia Nursing
Practice, ed 2
10. 1992: Standards of Post Anesthesia Nursing Practice
11. 1992: ASPAN Resource Manual
12. 1993: Postanesthesia and Ambulatory Surgery
Nursing Update (Saunders, publisher)
13. 1994: Pediatrics added to Redi-­Ref
14. 1994: ASPAN Resource Manual published in collab-
oration with American Board of Post Anesthesia
Nursing
15. 1994: Ambulatory Post Anesthesia Nursing Outline:
Content for Certification
16. 1995: Core Curriculum for Post Anesthesia Nursing
Practice, ed 3
17. 1995: Standards of Perianesthesia Nursing Practice
18. 1996: Certification Review for Perianesthesia
Nursing
19. 1996: Research Primer
20. 1997: Competency Based Orientation and
Credentialing Program, ed 1
21. 1998: Redi-­Ref, ed 2
22. 1998: Standards of Perianesthesia Nursing
Practice—new additions
a. Guidelines for preadmission phase
(1) Preadmission
(2) Day of surgery/procedure

b. Guidelines for phase III (addresses ongoing care
for those patients requiring extended observa-
tions/interventions after transfer/discharge from
phase I or phase II)
c. 1998 Position statements approved:
(1) “Minimum Staffing in Phase I PACU”
(2) “Registered Nurse Use of Unlicensed
Assistive Personnel”
(3) “Intensive Care Unit (ICU) Overflow
Patients”
23. 1999: Core Curriculum for Ambulatory
Perianesthesia Nursing Practice
24. 1999: Core Curriculum for Perianesthesia Nursing
Practice, ed 4
25. 1999 Position statements
a. “Fast Tracking”
b. “Pain Management”
c. “On Call/Work Schedule”
26. 2000 Standards included a “Joint Position
Statement on ICU Overflow Patients,” developed by
ASPAN, American Association of Critical Care
Nurses (AACN), and ASA’s Anesthesia Care Team
Committee and Committee on Critical Care
Medicine and Trauma Medicine
27. 2001: Competency Based Orientation and
Credentialing Program for the Unlicensed Assistive
Personnel in the Perianesthesia Setting, ed 1
28. 2002: Standards included position statement on the
“Nursing Shortage”
29. 2003: Competency Based Orientation and
Credentialing Program, ed 2
30. 2003: Prevention of Unplanned Perioperative
Hypothermia Guidelines
31. 2003: Pain and Comfort Clinical Practice Guidelines
and Resource Manual
32. 2003 Position Statements approved included:
a. “Medical/Surgical Overflow Patients in the
PACU and Ambulatory Care Unit”
b. “Visitation in Phase I Level of Care”
c. “Smallpox Vaccination Programs”
33. 2003: Breathline approved for online access
34. 2004: Redi-­Ref, ed 3
35. 2004: PeriAnesthesia Nursing Core Curriculum:
Preoperative, Phase I and Phase II PACU Nursing,
ed 1
36. August 2005: ASPAN’s Evidence-­Based Practice
Model introduced
37. 2006: Evidence-­Based Clinical Practice Guideline for
the Prevention and/or Management of PONV/PDNV
38. 2006–2008 Standards of PeriAnesthesia Nursing
Practice—new additions
a. “The Joint Commission Universal Protocol for
Preventing Wrong Site, Wrong Procedure,
Wrong Person Surgery”
b. Position statements approved:
CHAPTER 1 • Evolution of Perianesthesia Care 5
(1) “Safe Medication Administration”
(2) “Cultural Diversity and Sensitivity in
One
Section
Perianesthesia Nursing Practice”
One
(3) “Perianesthesia Safety”
Section
39. December 2007: ASPAN’s Safety Model introduced,
“Perianesthesia Nursing’s Essential Role in Safe
Practice,” published in Journal of PeriAnesthesia
Nursing (JoPAN)
40. 2007: Competency Based Orientation and
Credentialing Program for the Unlicensed Assistive
Personnel in the Perianesthesia Setting, ed 2
41. February 2008: ASPAN’s Perianesthesia Data
Elements (PDE) Model introduced
42. 2008–2010 Standards of PeriAnesthesia Nursing Practice
a. “Smallpox Vaccination Program” position state-
ment retired
b. Position statements approved:
(1) “The Geriatric Patient”
(2) “Advocacy”
43. 2009: A Competency Based Orientation and
Credentialing Program for the Registered Nurse in
the PeriAnesthesia Setting, ed 2
44. 2009: ASPAN PDE
45. 2009: ASPAN Safety Toolkit
46. 2009: Evidence-­Based Clinical Practice Guideline
for the Promotion of Perioperative Normothermia
47. 2009: Additional position statements
a. “The Pediatric Patient”
b. “The Workplace Violence”
48. 2009: “Go Green” initiatives
a. Breathline—only available online
b. ASPAN educational syllabus—only available online
49. 2010: ASPAN Bylaws and Representative Assembly
Standard Procedures (updated version)
50. 2010: 2010 Redi-­Ref for Perianesthesia
Practices, ed 4
51. 2010–2012 ASPAN Standards
a. Name changes to include practice
recommendations
b. Position statement approved:
(1) “Substance Abuse in Perianesthesia Practice”
52. 2012–2014 ASPAN Standards
a. Format and name changed to include interpre-
tive statements
b. Approved “Principles of Perianesthesia Safe
Practice”
c. New Practice Recommendations:
(1) “Obstructive Sleep Apnea in the Adult
Patient”
53. 2013: Additional position statement
a. “Social Media and Perianesthesia Practice”
54. 2015–2017: ASPAN Standards
a. Additional practice recommendation:
(1) “The Prevention of Unwanted Sedation in
the Adult Patient”
 6 SECTION ONE • Professional Competencies
b. Additional position statements:
(1) “Care of the Perinatal Patient”
Section
(2) “Nurse of the Future: Minimum Bachelor of
One
Science in Nursing (BSN) Requirement for
Practice”
55. 2014: A Competency Based Orientation and
Credentialing Program for the Registered Nurse in
the PeriAnesthesia Setting, 2014 ed.
56. 2015: 2015 Redi-­Ref for Perianesthesia Practices, ed
5 12. 2006 Shining Star Award created to recognize
57. 2016: A Competency Based Orientation and
Credentialing Program for the Registered Nurse
Caring for the Pediatric Patient in the
PeriAnesthesia Setting, 2016 ed.
58. 2016: PeriAnesthesia Nursing Core Curriculum:
Preprocedure, Phase I and Phase II PACU Nursing,
ed 3
59. 2017: A Competency Based Orientation and
Credentialing Program for the Unlicensed Assistive
Personnel in the PeriAnesthesia Setting, 2017 ed
60. 2017–2018: ASPAN Standards
a. Additional position statements:
(1) “Alarm Management”
(2) “Acuity Based Staffing for Phase I”
(3) “Air Quality and Occupational Hazard
Exposure Prevention”
61. 2017: Certification Review for PeriAnesthesia
Nursing, ed 4
62. 2019–2020: ASPAN Standards
a. Additional position statements:
(1) “Opioid Stewardship in Perianesthesia
Practice”
(2) “Gender Diversity”
(3) “Certified postanesthesia nurse (CPAN) and
certified ambulatory postanesthesia nurse
(CAPA) Perianesthesia Nursing
Certification”
(4) “Marijuana”
B. Certification
1. 1985: American Board of Post Anesthesia Nursing
Certification (ABPANC) established (see Appendix A)
2. Certification examination developed to recognize
knowledge and skill of practitioners
3. November 1986: certification examination first
administered, 172 nurses certified
4. Annual CPAN and CAPA recognition day at
national conference
5. 1991: certification examination expanded to
include ambulatory surgery nurses who work in
preoperative and phase II areas
6. 1993–1994: separate certification examinations
under development for phase I PACU nurses and
ambulatory postanesthesia nurses—CPAN and
CAPA designations
7. November 1994: CAPA examination first
administered
8. 1996: name changed to American Board of
PeriAnesthesia Nursing Certification (ABPANC)
9. 1998: 4191 CPANs, 1183 CPANs, and 100 with dual
certification
10. 2003: 3921 CPANs, 1730 CPANs, and 202 with dual
certification
11. 2006 Advocacy Award created to recognize publicly
the CPAN and/or CAPA certified nurse who exem-
plifies leadership as a patient advocate
ASPAN components for supporting and encourag-
ing certification at the local level
13. 2008: 5371 CPANs, 3210 CAPAs, and 297 with dual
certification
14. 2008: the American Nurses Credentialing Center
(ANCC) and the American Nurses Association
(ANA) designated March 19 as National Certified
Nurses Day
15. 2009: Computer-­based testing for CPAN and CAPA
underway
16. 2013: 6670 CPANs, 4302 CAPAs, and 494 with dual
certification
17. 2014: 6958 CPANs, 4542 CAPAs, and 550 with dual
certification
18. 2017–2018: 7439 CPANs, 5141 CAPAs, and 676
with dual certification
19. Spring 2019: 6977 CPANs, 4866 CAPAs, 808 with
dual certification
C. Education
1. 1982: national conference and annual educational
program started
2. Regional core curriculum workshops (2-­day pro-
gram available)
3. Regional ambulatory surgery workshops
4. Regional interpersonal and leadership skills
workshops
5. ASPAN videotapes, overviews of postanesthesia
nursing
6. 1993: national ASPAN Lecture Series established
7. 1993: joint ASPAN/Association of periOperative
Registered Nurses (AORN) Ambulatory Surgery
Symposium
8. 1994: cosponsored Governmental Affairs
Workshop with American Association of Nurse
Anesthetists (AANA), AORN, and the American
Veterans Association of Nurse Anesthetists
9. September 1994: sponsored first Volunteer
Leadership Institute in Richmond, Virginia
10. 1997: patient education videos on general anesthe-
sia, conscious sedation, and regional anesthesia
developed
11. Continuing education articles available in JoPAN
12. 1998: Consensus Conference for Perioperative
Normothermia held in Bethesda, Maryland
13. 2001: Consensus Conference for Pain and Comfort
held in Nashville, Tennessee

14. 2008: second consensus meeting for normothermia
guidelines held in St. Louis, Missouri
15. 2011: on-­demand programming initiated
D. Specialty representation
1. Member of National Federation for Specialty
Nursing Organizations (NFSNO) since June 1983
a. 1990: Federation presidents invited for Nurses
Day Luncheon given by Barbara Bush at the
White House with ASPAN President
attending
2. Member of National Organization Liaison Forum
(NOLF)
3. Established official liaison with ASA
4. Official liaisons with following organizations
a. Society of Gastroenterology Nurses and
Associates
b. Society of Critical Care Medicine
c. FASA
5. Increased networking with the following
a. AANA
b. AORN
c. AACN
6. 1992: organizational affiliate of ANA
7. 1994–1996: ASPAN elected to NFSNO Executive
Board
8. 1994: ASPAN elected to NOLF Board
9. 1994: ASPAN represented at AORN Perioperative
World Conference in Adelaide, Australia
10. Nursing Summit held in Chicago—a coalition of all
nursing leadership to discuss Nursing’s Agenda for
Healthcare Reform
11. September 2000: ASPAN started the first
Component Development Institute, focusing on
leadership, education, research, clinical practice,
and advocacy
12. Fall 2002: ASPAN president represented at the 10th
Congress of the Cuban Nursing Society and the
first Colloquium on Natural and Traditional
Medicine in Havana, Cuba
13. 2003: NOLF and NFSNO combine to form new
organization of the Alliance: Nursing Organizations
Alliance (NOA)
14. 2003: ASPAN begins partnership with the British
Anaesthetic and Recovery Nurses Association
(BARNA), and seven ASPAN delegates attended
the BARNA Conference
15. 2004: ASPAN collaborates with the AANA,
American Association of Surgical Physician
Assistants, ACS, ASA, AORN, and the
Association of Surgical Technologists to form the
Council on Surgical and Perioperative Safety
(CSPS), dedicated to promote a culture of patient
safety and a caring perioperative workplace
environment
16. July 2006: ASPAN represented at the Nursing
Terminology Summit, Nashville, Tennessee
CHAPTER 1 • Evolution of Perianesthesia Care 7
17. September 2006: ASPAN represented at the first
summit of the newly formed Society for
One
Section
Perioperative Assessment and Quality Improvement
One
18. October 2006: ASPAN president is invited to attend
Section
the ACS in Chicago
19. October 2007: ASPAN president participated in the
Irish Anaesthetic and Recovery Nurses Association
Conference and began a partnership in Waterford,
Ireland
20. October 2011: Inaugural International Conference
for PeriAnesthesia Nurses held in Toronto, Canada
21. September 2013: International Conference for
PeriAnesthesia Nurses held in Dublin, Ireland
22. September 2015: International Collaboration of
PeriAnaesthesia Nurses held in Copenhagen, Denmark
23. November 2017: International Collaboration of
PeriAnaesthesia Nurses held in Sydney, Australia
24. November 2019: International Collaboration of
PeriAnaesthesia Nurses held in Cancun, Mexico
E. Other highlights
1. 1983: members encouraged to change name from
recovery room to PACU
2. 1989: postanesthesia nurse awareness week
established
3. 1989: definition of immediate postanesthesia nurs-
ing expanded to include preoperative and phase II
areas to incorporate ambulatory nurses working in
those areas
4. 1989: presidential award established
5. 1989: AACN formally recognized postanesthesia
nursing as a critical care specialty
6. 1991: clinical excellence and outstanding achieve-
ment awards established
7. 1991: ASPAN becomes an ANA approver and pro-
vider of continuing education
8. 1992–1993: research committee offers grants and
conducts the first Delphi study to establish postan-
esthesia and ambulatory surgery nursing priorities
9. 1993: ASPAN Foundation established with first
board of trustees
10. 1993: organizational task force appointed to look at
size and structure of ASPAN Board, dues structure,
and membership voting
11. 1994: approved concept of specialty practice groups
12. 1994: Ontario, Canada, becomes ASPAN’s first
affiliate member
13. 1994: online communication by means of the inter-
net, between officers and national office
14. 1995: change of ASPAN’s name to American Society
of PeriAnesthesia Nurses approved, effective July 1,
1996
15. 1995: funds for first scholarship awards donated by
the ASPAN Foundation
16. 1996: one dues structure initiated (one payment
includes national and component membership)
17. 1996: ASPAN website created (www.aspan.org)
 8 SECTION ONE • Professional Competencies
18. 1996: Journal of Post Anesthesia Nursing name
changed to Journal of PeriAnesthesia Nursing
Section
19. April 10, 1997: newly structured board of directors
One
met for first time in Denver, Colorado, after the
ASPAN Conference
20. 1997: ASPAN Foundation receives seat, and
ASPAN member attends AANA Foundation
Research Scholars Program
21. April 21, 1998: first meeting of the ASPAN
Representative Assembly at National Conference in
Philadelphia
22. 2006–2007: ASPAN Safe Staffing Group conducted
a multidisciplinary meeting and developed an
ASPAN Fatigue Checklist as a guide for members
23. 2007: ASPAN Research Committee conducted the
second Delphi study for ASPAN members’ research
priorities
24. 2009: ASPAN joined social media with a Facebook
page, Twitter, LinkedIn, and Pinterest
25. 2013: ASPAN introduces Standards to digital
libraries
26. 2018: Established the Fellows of the American
Society of PeriAnesthesia Nurses (FASPAN) pro-
gram with 17 inaugural inductees
27. Membership highlights
a. 1998: ASPAN membership is more than 10,000
with 40 components
b. 2008: ASPAN membership is 13,403
c. 2013: ASPAN membership is 15,458
d. 2018: ASPAN membership is 14,032
e. 2019: ASPAN membership as of August is 14,138
F. Specialty interest groups
1. Preoperative Assessment, chartered 1996–1997
2. Management, chartered 1998–1999
3. Pain Management, chartered 1999–2000
4. Publications, chartered 2002–2003
5. Pediatric, chartered 2003–2004
6. Geriatric, chartered 2004–2005, retired 2018
7. Advanced Degree, chartered 2004–2005
8. Perianesthesia Nurse Educator, chartered
2007–2008
9. Informatics, chartered 2009–2010
G. Past presidents of ASPAN and national conference
themes
1. Ina Pipkin, 1982; First National Conference
2. Hallie Ennis, 1983; Nurses in Action
3. Jeanne Maher, 1984; New Horizons
4. Marilyn Glaser, 1985; Caring, Sharing, and All That
Jazz
5. Clara Conn, 1986; Spirit of 86
6. Meg Danielson Alexander, 1987; ASPAN Directions
for Change
7. Jean Sutton, 1988; Challenge of Excellence
8. Anne Allen, 1989; Magic of Caring
9. Deborah Johnson, 1990; Sailing into the Future
10. Debby Niehaus, 1991; Bridging Knowledge and
Growth
11. Cindy Smith, 1992; In Session
12. Jan Odom-­Forren, 1993; Goldmine of Knowledge
13. Dolly Ireland, 1994; Reaching for Excellence
14. Denise O’Brien, 1995; Champions of Caring
15. Lois Roberts, 1996; Proud Past, Bright Future
16. Terry McLean, 1997; Attaining New Heights,
Change and Transition
17. Lisa Jeran, 1998; Professional Growth through
Knowledge and Fitness
18. Maureen Iacono, 1999; New Milestones in a New
Millennium
19. Myrna Mamaril, 2000; Creating Visions for the Future
20. Nancy Saufl, 2001; Making the Connection through
Teaching, Touch, and Technology
21. Susan Shelander, 2002; Transforming Vision into
Reality, Our Journey, Our Legacy
22. Linda Wilson, 2003; Reach Beyond the Horizon—
Make Dreams a Reality
23. Sandra Barnes, 2004; Circles of Influence—
Shaping Tomorrow’s Definition of Perianesthesia
Nursing
24. Dina Krenzischek, 2005; Vision in Action—Values,
Power, Unity, Passion
25. Meg Beturne, 2006; Perianesthesia Nursing
Diversity—Touch the World That Touches You
26. Pamela Windle, 2007; Soaring on the Magical
Journey to Excellence
27. Susan Fossum, 2008; Be the Voice—Advocacy
through Education, Practice, Research, and
Legislative Involvement
28. Lois Schick, 2009; Dreams Create Lasting Legacies
29. Theresa Clifford, 2010; Roots of Knowledge, Seeds
of Transformation
30. Kim Kraft, 2011; Reinvest in Your Potential
31. Christine Price, 2012; Beacons of Change, Focusing
on the Future
32. Susan Carter, 2013; Towering Opportunities,
Endless Possibilities
33. Twilla Shrout, 2014; Dealing with Challenges:
Winning with Power, Practice, Purpose
34. Jacque Crosson, 2015; Igniting Professionalism:
Excellence in Practice, Leadership and
Collaboration
35. Armi Holcomb, 2016; Renew Perianesthesia
Passion: Inspire Excellence
36. Katrina Bickerstaff, 2017; Energizing Generations:
The Race to Distinction!
37. Susan Russell, 2018; Detecting Greatness: The
Proof is in Our Practice
38. Regina Hoefner-­Notz, 2019; Leading With
Knowledge; Serving With Heart
39. Amy Dooley, 2020. Celebrate Strengths, Elevate
Practice
 CHAPTER 1 • Evolution of Perianesthesia Care 9

Bibliography Fetzer SJ: Practice characteristics of the dual certificant: CPAN/

CAPA, J Perianesth Nurs 12(4):240–244, 1997.

One
Section
Frost E, editor: Post anesthesia care unit: current practices, ed 2, St.
American Society of Post Anesthesia Nurses: Fifty years of prog-

One
Louis, 1990, Mosby.
ress in post anesthesia nursing 1940–1990, Richmond, 1990,
Krenzischek D, Clifford TL, Windle PE, et al.: Patient safety: peri-

Section
The Society.
anesthesia nursing’s essential role in safe practice, J Perianesth
American Society of Post Anesthesia Nurses: ASPAN resource
Nurs 22(6):385–392, 2007.
manual, Richmond, 1992, The Society.
Litwack K: Post anesthesia care nursing, ed 2, St. Louis, 1995,
Barone CP, Pablo CS, Barone GW: A history of the PACU, J
Mosby.
Perianesth Nurs 19(4):237–241, 2003.
Luczun ME: Postanesthesia nursing: past, present, and future, J
Bendixen H, Kinney J: History of intensive care: American
Post Anesth Nurs 5(4):282–285, 1990.
College of Surgeons. In Kinney JM, Bendixen HH, Powers Jr
Mamaril ME, Ross JM, Krenzischek D, et al.: The ASPAN’s EBP
SR, editors: Manual of surgical intensive care, Philadelphia,
conceptual model: framework for perianesthesia practice and
1977, WB Saunders, pp 3–35.
research, J Perianesth Nurs 21(3):157–167, 2006.
Burden N: Outpatient surgery: a view through history, J Perianesth
Niebuhr BH, Muenzen P: Foundation for newly revised CPAN
Nurs 20(6):435–437, 2005.
and CAPA certification examinations, J Perianesth Nurs
Burden N: PACU nursing: our today, our tomorrows, J Post
16(3):163–173, 2001.
Anesth Nurs 3(4):222–228, 1988.
Odom-­Forren J: Drain’s Perianesthesia Nursing: a critical care
Burden N, Quinn D, O’Brien D, et al.: Ambulatory surgical nurs-
approach, ed 7, St. Louis, 2018, Elsevier.
ing, ed 2, Philadelphia, 2000, Saunders.
Russo A, Elixhauser A, Steiner C, Wier L: Hospital-­based ambula-
Clifford TL, Windle PE, Wilson L: ASPAN perianesthesia data
tory surgery, 2007. Washington, DC, 2010, Agency for
elements: the model, J Perianesth Nurs 23(1):49–52, 2008.
Healthcare Research and Quality.
Cullen KA, Hall MJ, Golosinskiy A: Ambulatory surgery in the
Ruth H, Haugen F, Grove DD: Anesthesia study commission, J
United States, 2006, Hyattsville, 2009, National Center for
Am Med Assoc 135(14):881–884, 1947.
Health Statistics.
Schneider M: Trends in postanesthesia nursing, J Post Anesth
DeFazio-­Quinn D, editor: Ambulatory surgical nursing core cur-
Nurs 2(3):183–188, 1987.
riculum, Philadelphia, 1999, Saunders.
Wetchler BV: Anesthesia for ambulatory surgery, ed 2, Philadelphia,
Dunn F, Shupp M: The recovery room: a wartime economy, Am J
1990, Lippincott.
Nurs 43(3):279–281, 1943.
Feeley TW, Macario A: The postanesthesia care unit. In ed 6, Miller
R, editor: Anesthesia. New York, 2004, Churchill Livingstone.
CHAPTER 2
Standards, Legal Issues, and
Practice Settings
Barbara Godden
OBJECTIVES
At the conclusion of this chapter, the reader will be
able to do the following:
1. Describe the importance of standards as they relate
to perianesthesia nursing practice.
2. Discuss the contents of the American Society of
PeriAnesthesia Nurses (ASPAN) Perianesthesia
Nursing Standards, Practice Recommendations and
Interpretive Statements.
3. Define the scope of practice for perianesthesia
nursing.
4. Describe the preanesthesia phase of care.
5. Explain the three phases of postanesthesia care.
6. List three inpatient and three outpatient settings
where perianesthesia nursing care is delivered.
7. Define competency-­based practice.
8. Identify important ethical principles.
9. List the steps for ethical decision making.
10. Identify five common causes of nursing liability.
11. Describe the four elements of negligence.
12. Discuss phases of litigation that can occur with a
malpractice suit.
13. Differentiate between a policy and a procedure.
14. Name three agencies or organizations that influence
perianesthesia policies and procedures.
15. Identify policies and procedures that define practice
in perianesthesia nursing settings.
I. Definition of Standard
A. Established by authority, custom, or general consent
B. Model for quality or quantity
C. Standardized for everyone
D. Determined by what a reasonably prudent nurse act-
ing under the same circumstance would do
E. Describes the responsibilities for which the nursing
profession is accountable
F. Provides direction for professional nursing practice
10
G. Framework for the evaluation of care
H. Minimal requirements that define an acceptable level
of care
II. Evolution of Nursing
Standards
A. Before 1950
1. Florence Nightingale
2. Her early treatments were used as standards
B. Code of Ethics published by the American Nurses
Association (ANA) in 1950
1. Nursing care without prejudice
2. Confidential care
3. Safe care
C. Standards of professional nursing practice
1. Pertain to general or specialty practice
2. First generic nursing standards in 1973 by the ANA
Congress for Nursing Practice
3. Specialty standards followed beginning in 1974
III. Sources of Standards
A. Accrediting organizations
1. Centers for Medicare and Medicaid Services (CMS)
2. The Joint Commission (TJC)
3. Healthcare Facilities Accreditation Program
(HFAP)
4. Det Norske Veritas (DNV)
5. Center for Improvement in Healthcare Quality
(CIHQ)
6. National Committee for Quality Assurance
(NCQA)
7. Accreditation Association for Ambulatory Health
Care (AAAHC)
8. American Association for the Accreditation of
Ambulatory Surgical Facilities (AAAASF)
B. State Nurse Practice Act and Board of Nursing Rules
C. Federal agency guidelines and regulations
 CHAPTER 2 •
1. Agency for Healthcare Research and Quality
(AHRQ)
2. Occupational Safety and Health Administration
(OSHA)
D. American Nurses Association (ANA)
1. Magnet Environments for Professional Nursing
Practice
E. ASPAN or other national specialty organizations
F. Hospital or ambulatory surgery facility rules and
procedures
G. State Board of Nursing
H. Nursing texts and articles
I. Common practice
J. Determined by expert witnesses for judicial system
1. Essential in professional negligence cases
IV. Standard Criteria
A. Standard: authoritative statement articulated and dis-
seminated by the profession by which the quality of
practice, service, or education can be judged
B. Rationale: delineates the importance to perianesthesia
practice
C. Outcome: measures the results of activity (per TJC,
care should meet the same standards of practice wher-
ever the care is provided)
D. Criteria: describes principles and actual activities used
in implementing practices to meet the standard
V. ANA Standards of Nursing
Practice
A. Original standards published in 1973—updated as
changes in practice occur
B. Applies to all registered nurses (RNs) in clinical
practice
C. Standards of practice: describe a competent level of
nursing care
1. Assessment: collect pertinent patient health
information
2. Diagnosis: analyze assessment data to determine
nursing diagnosis
3. Outcomes identification: identify individualized
expected patient outcomes
4. Planning: develop a plan of care specific for the
patient
5. Implementation: implement the identified plan
6. Evaluation: evaluate progress toward outcomes
D. Standards of professional performance: describe a
competent level of behavior in the professional role
1. Quality of practice: enhances quality and effective-
ness of nursing practice
2. Education: acquires knowledge and competency
related to current practice
Standards, Legal Issues, and Practice Settings 11
3. Professional practice evaluation: evaluates one’s
own nursing practice
Section
4. Collegiality: interacts with professional peers and
One
colleagues
5. Collaboration: collaborates with patient, family, and
others
6. Ethics: integrates ethics into all aspects of
performance
7. Research: integrates and disseminates research
findings into practice
8. Resource utilization: considers factors related to
safety, effectiveness, cost, and impact on practice
9. Leadership: provides leadership in the practice
setting
VI. Agency for Healthcare
Research and Quality (AHRQ)
A. Established in 1989
B. Goals to enhance the quality, appropriateness, and
effectiveness of health care and to ensure efficient
implementation and evaluation
C. Standard of practice: patients will receive care accord-
ing to the standard
D. Guideline: to guide practitioners, patients, and con-
sumers in health care decisions
E. First guidelines in 1992: Acute Pain Management
goals:
1. Reduce the incidence and severity of patients’ acute
postoperative or post-­traumatic pain
2. Educate patients about the need to communicate
unrelieved pain
3. Implement proactive and multimodal interventions
4. Enhance patient comfort and satisfaction
5. Contribute to fewer postoperative complications
and shorter lengths of stay
VII. 2019–2020 Perianesthesia
Nursing Standards, Practice
Recommendations, and
Interpretive Statements
A. ASPAN history of standards (see Chapter 1 for addi-
tional information)
1. 1983: Guidelines for Standards of Care published
2. 1986: Standards of Nursing Practice published
3. 1989: definition expanded to include preoperative
and phase II areas
4. 1991: Standards of Post Anesthesia Nursing
Practice published; included data for initial, ongo-
ing, and discharge assessment for phase I and
phase II
5. 1992: Standards of Post Anesthesia Nursing
Practice published
 12 SECTION ONE • Professional Competencies

6. 1995: Standards of Perianesthesia Nursing Practice (2) Endoscopy/gastrointestinal (GI) procedures

published; included preanesthesia, preprocedural, (3) Cardiac catheterization lab
Section

phase I and phase II postanesthesia information (4) Electroconvulsive therapy (ECT)

One

7. 1998: Standards of Perianesthesia Nursing Practice, (5) Pain management clinic

revised; included the addition of postanesthesia (6) Oncology
phase III for patients requiring extended 2. Outpatient settings
observation a. Ambulatory surgery unit
8. 2000–2010: Standards of Perianesthesia Nursing (1) Hospital based
Practice, revised every 2 years (2) Free-­standing center
9. 2010–2012: Perianesthesia Nursing Standards and b. Areas where procedural sedation/analgesia is
Practice Recommendations; some resources required
changed to be entitled Practice Recommendations (1) Interventional and diagnostic radiology
10. 2012–2014 Perianesthesia Nursing Standards, (2) Endoscopy/GI procedures
Practice Recommendations and Interpretive (3) Cardiac catheterization
Statements; Interpretive statements added for fre- (4) ECT
quently asked questions (5) Pain management clinic
11. 2015–2017 Perianesthesia Nursing Standards, (6) Oncology
Practice Recommendations and Interpretive (7) Urgent care centers
Statements, revised and updated c. Office-­based settings
12. 2017–2018 Perianesthesia Nursing Standards, (1) Dental
Practice Recommendations and Interpretive (2) Dermatology
Statements, revised and updated (3) Ophthalmology
13. 2019–2020 Perianesthesia Nursing Standards, (4) Plastic surgery
Practice Recommendations and Interpretive D. Perianesthesia nursing encompasses the following
Statements, revised and updated continuum of care:
B. Scope of perianesthesia nursing practice 1. Preanesthesia phase
1. Cultural, developmental, and age-­specific assess- a. Preadmission: preparation, interviewing, assess-
ment, diagnosis, intervention, and evaluation of ment, identification of potential or actual prob-
individuals within the perianesthesia continuum lems, and education
2. Nursing practice is systematic, integrative, and b. Day of surgery/procedure: assessment, valida-
holistic and includes: tion of existing information; coordination of
a. Nursing process care (sometimes patients need radiology proce-
b. Critical thinking dure before going to the OR), preparation and
c. Clinical decision making completion of required documents, reinforce-
d. Inquiry ment of preoperative teaching, and review of
3. The scope of practice includes, but is not limited to, discharge instructions
the following: 2. Postanesthesia phase I: immediate postanesthesia
a. Preanesthesia level of care period; basic life-­sustaining needs, constant vigi-
(1) Preadmission lance and monitoring, safe handoff
(2) Day of surgery/procedure 3. Postanesthesia phase II: prepare the patient/signifi-
b. Postanesthesia levels of care cant other for home or extended care environment,
(1) Phase I discharge teaching
(2) Phase II 4. Extended care (formerly phase III): provide ongoing
(3) Extended care care for patients requiring extended observation/
C. Perianesthesia nursing practice occurs in, but may not intervention after discharge from phase I or phase II
be limited to, the following environments: 5. Care of the patient and family/significant other
1. Hospital settings (inpatients and outpatients) along the perianesthesia continuum
a. Preadmission assessment/testing unit a. Physical
b. Preoperative/preprocedural holding area b. Psychological
c. Postanesthesia care unit c. Educational
d. Same-­day surgery units d. Cultural
e. Extended observation e. Spiritual
f. Obstetrical units E. Perianesthesia nursing practice is based on knowledge
g. Emergency department of:
h. Special procedure areas 1. Physiological and psychological responses
(1) Interventional and diagnostic radiology 2. Vulnerability of patients subjected to the following:
 CHAPTER 2 •
a. Sedation/analgesia
b. Anesthetic agents and techniques
c. Specific surgical or procedural interventions
3. Principles of age-­specific medical-­surgical nursing
and critical care nursing
4. Evidence-­based practice (EBP)
F. Perianesthesia nursing roles encompass:
1. Clinical practice
2. Education
3. Research
4. Management
5. Administration
6. Consultation
7. Advocacy
G. The scope of perianesthesia nursing practice is regu-
lated by:
1. Hospital or facility policies and procedures
2. State and federal regulatory agencies
3. National accreditation organizations
4. Professional nursing organizations
H. Perianesthesia nursing interacts with other profes-
sional groups to advance the delivery of quality care.
These groups include, but may not be limited to, the
following:
1. Alliance for Nursing Informatics (ANI)
2. Ambulatory Surgery Center Association (ASCA)
3. American Academy of Ambulatory Care Nursing
(AAACN)
4. American Academy of Anesthesiologists Assistants
(AAAA)
5. American Association of Colleges of Nursing
(AACN)
6. American Association of Critical Care Nurses
(AACN)
7. American Association of Neuroscience Nurses
(AANN)
8. American Association of Nurse Anesthetists
(AANA)
9. American Association of Nurse Practitioners
(AANP)
10. American Board of PeriAnesthesia Nursing
Certification (ABPANC)
11. American College of Surgeons—John A, Hartford
Foundation (ACS-­JAHF) Geriatric Program
12. American College of Surgeons (ACS)
13. American Medical Informatics Association (AMIA)
14. American Nurses Association (ANA)
15. American Nursing Informatics Association (ANIA)
16. American Organization of Nurse Executives
(AONE)
17. American Society for Pain Management Nursing
(ASPMN)
18. American Society of Anesthesiologists (ASA)
19. American Society of Plastic Surgical Nurses
(ASPSN)
20. Americans for Nursing Shortage Relief (ANSR)
Standards, Legal Issues, and Practice Settings 13
21. Anesthesia Patient Safety Foundation (APSF)
22. Association for Radiologic & Imaging Nursing
Section
(ARIN)
One
23. Association for Vascular Access (AVA)
24. Association of Anesthesia Clinical Directors
(AACD)
25. Association of periOperative Registered Nurses
(AORN)
26. Association of Women’s Health, Obstetric and
Neonatal Nurses ((AWHONN)
27. British Anaesthetic and Recovery Nurses
Association (BARNA)
28. Council on Surgical and Perioperative Safety
(CSPS)
29. Enhanced Recovery After Surgery (ERAS)
30. International Collaboration of PeriAnaesthesia
Nurses (ICPAN)
31. Irish Anaesthetic and Recovery Nurses Association
(IARNA)
32. National Association of Clinical Nurse Specialists
(NACNS)
33. National Association of PeriAnesthesia Nurses of
Canada (NAPANc)
34. National League for Nursing (NLN)
35. Nursing Community Forum
36. Nursing Organizations Alliance (NOA)
37. Pain Action Alliance to Implement a National
Strategy (PAINS)
38. Society for Ambulatory Anesthesia (SAMBA)
39. Society for Office Based Anesthesia (SOBA)
40. Society for Perioperative Assessment and Quality
Improvement (SPAQI)
41. Society of Anesthesia and Sleep Medicine (SASM)
42. Society of Gastroenterology Nurses and Associates
(SGNA)
43. Society of Pediatric Nurses (SPN)
44. Surgical Pain Consortium (SPC)
45. The Joint Commission (TJC)
I. Perianesthesia Principles for Ethical Practice
1. Specific context in which to apply the ANA Code of
Ethics
2. Moral commitment to uphold values and ethical
obligations related to perianesthesia nursing
3. Strive to ensure:
a. Competency
(1) Maintains personal accountability
(2) Participates in professional continuing
education
(3) Adheres to ASPAN’s standards
(4) Complies with institutional policies and
procedures
(5) Accepts responsibility/accountability
(6) Participates in performance improvement
(7) Uses competency-­based orientation
(8) Participates in periodic performance
reviews
 14 SECTION ONE • Professional Competencies
(9) Remains current on new products/equip-
ment/procedures
Section
(10) Incorporates research and evidence into
One
practice
b. Responsibility to patients
(1) Practices with compassion and respect
(2) Provides quality care to all patients
(3) Ensures patient safety
(4) Introduces self and explains procedures
(5) Maintains patient confidentiality and
privacy
(6) Participates in perianesthesia teaching
(7) Answers questions honestly and accurately
(8) Communicates pertinent information
(9) Respects advance directives
(10) Provides communication aids
(11) Advocates for spiritual comfort
(12) Respects patient’s decisions
(13) Advocates for patient welfare
(14) Delegates tasks appropriately
(15) Provides multimodal pain management
and other comfort measures
(16) Includes the patient’s family and/or sup-
port system in the plan of care
(17) Ensures that all patients are cared for by a
competent perianesthesia RN
(18) Adheres to policies regarding social media
and electronic devices
c. Professional responsibility
(1) Provides comparable level of care regard-
less of physical setting
(2) Collaborates with appropriate healthcare
providers
(3) Maintains accurate, objective patient
records
(4) Safeguards confidentiality of verbal,
written, and electronic patient infor-
mation
(5) Participates in activities that contribute to
the ongoing development of the perianes-
thesia nursing profession
(6) Promotes certification for perianesthesia
nursing
(7) Acts as a mentor/preceptor
(8) Demonstrates stewardship through respon-
sible management of resources
(9) Maintains an awareness of changing peri-
anesthesia practice issues
(10) Engages in activities that promote care of
self
(11) Recognizes need for work-­life integration
(12) Follows policies, procedures, and laws to
protect the patient from incompetent,
unethical, or illegal practice and report
appropriately
(13) Maintains professional boundaries
d. Collegiality
(1) Maintains respectful, civil, and cooperative
workplace environment
(2) Engages in multidisciplinary collaboration
to improve patient outcomes
(3) Demonstrates and promotes cultural sensitivity
e. Research
(1) Identifies problems to be considered for
research
(2) Obtains appropriate Institutional Review
Board (IRB) approvals
(3) Protects the rights of all research partici-
pants and staff
(4) Protects patient confidentiality
(5) Uses research and evidence to change and
support clinical practice
(6) Promotes dissemination of research findings
f. Advocacy
(1) Promotes advocacy and awareness
(2) Promotes coalition building within the nurs-
ing community
(3) Maintains commitment to activism and
advocacy for the profession, perianesthesia
practice, and patients
(4) Provides ongoing education and informa-
tion on current political events involving
healthcare policy
(5) Advances the position and image of peri-
anesthesia nursing through public outreach
and education
(6) Promotes principles of nursing advocacy
involving collaboration with other profes-
sional organizations and regulatory agencies
J. Principles of Safe Perianesthesia Practice
1. Define the principles and scope of perianesthesia safety
2. Provide guidelines for best practices
3. Supported by an environment of caring
4. Guided by research and evidence-­based practices
5. Characteristics of a culture of safety defined by the
Institute of Healthcare Improvement (IHI)
a. Active leadership
(1) Influences members to engage in activities that
result in enhanced performance and outcomes
(2) Creates a supportive environment for staff
to express concerns.
b. Psychological safety
(1) Staff believe concerns and opinions will be
received openly and treated with respect
c. Accountability
(1) Supports a just culture where staff are
accountable but treated fairly in adverse events
d. Teamwork and communication
(1) Behaviors for effective groups include time
management, evaluation, structured com-
munication, and active multidisciplinary
risk management
 CHAPTER 2 •
e. Negotiation and conflict management
(1) Requires collaborative efforts to resolve con-
flict and identify solutions
f. Transparency
(1) Patient safety problems are identified and
examined as opportunities to learn from
problems and improve systems
g. Reliability
(1) Develops system supports to optimize
strengths and support weakness to produce
consistent and dependable outcomes
h. Improvement and measurement
(1) Seeks opportunities to implement best
practices
i. Continuous learning
(1) Focuses on proactive learning and
improvement
K. Standards of perianesthesia nursing practice
1. Standard I: Patient Rights and Responsibilities
2. Standard II: Environment of Care
3. Standard III: Staffing and Personnel Management
4. Standard IV: Quality Improvement
5. Standard V: Research and Clinical Inquiry
6. Standard VI: Nursing Process
L. Practice Recommendations
1. Patient Classification/Staffing Recommendations
2. Components of Assessment and Management for
the Perianesthesia Patient
3. Equipment for Preanesthesia/Day of Surgery Phase,
PACU Phase I, Phase II, and Extended Care
4. Competencies for the Perianesthesia Registered
Nurse
5. Competencies of Perianesthesia Support Staff
6. Safe Transfer of Care: Handoff and Transportation
7. The Role of the Registered Nurse in the
Management of Patients Undergoing Procedural
Sedation
8. Fast Tracking/Bypassing Phase I
9. Family Presence in the Perianesthesia Setting
10. Obstructive Sleep Apnea in the Adult Patient
11. The Prevention of Unwanted Sedation in the Adult
Patient
M. ASPAN Position Statements
1. A Position Statement on the Perianesthesia Patient
with a Do-­Not-­Resuscitate Advance Directive
2. A Position Statement on a Healthy Work Schedule
3. A Position Statement on Overflow Patients
4. A Position Statement on Safe Medication
Administration
5. A Position Statement on the Older Adult
6. A Position Statement on the Pediatric Patient
7. A Position Statement on Workplace Violence in the
Perianesthesia Setting
8. A Position Statement on Substance Use Disorders
in Perianesthesia Practice
Standards, Legal Issues, and Practice Settings 15
9. A Position Statement on Workflow Interruptions,
Technology, Social Media, and Perianesthesia
Section
Practice
One
10. A Position Statement on Care of the Perinatal
Patient
11. A Position Statement on the Nurse of the Future:
Minimum BSN Requirement for Practice
12. A Position Statement on Alarm Management
13. A Position Statement on Acuity-­Based Staffing for
Phase I
14. A Position Statement on Air Quality and
Occupational Hazard Exposure Prevention
15. A Position Statement on Opioid Stewardship in
Perianesthesia Practice
16. A Position Statement on Gender Diversity
17. A Position Statement on CPAN and CAPA
Perianesthesia Nursing Certification
18. A Position Statement on Marijuana
N. ASPAN Resources
1. Appraisal and Synthesis of Evidence Using Joanna
Briggs Institute (JBI)
2. American Society of Anesthesiologists (ASA)
Standards:
a. Statement on Routine Preoperative Laboratory
and Diagnostic Screening
b. Basic Standards for Preanesthesia Care
c. Standards for Postanesthesia Care
d. Standards for Basic Anesthetic Monitoring
e. Statement on Nonoperating Room
Anesthetizing Locations
3. Association for Radiologic & Imaging Nursing
(ARIN) Clinical Practice Guideline: Handoff
Communication Concerning Patients
Undergoing a Radiological Procedure with
General Anesthesia
4. Perianesthesia Orientation Timeline
O. Practice Resources—available at:
http://www.aspan.org/Clinical-­Practice/Practice-­
Resources
1. Society for Ambulatory Anesthesia
a. Consensus Guidelines for the Management of
Postoperative Nausea and Vomiting
b. Consensus Guidelines for the Management
of Postoperative Nausea and Vomiting: An
Executive Summary for Perianesthesia
Nurses
2. American Society for Pain Management Nursing
a. Registered Nurse Management and Monitoring
of Analgesia by Catheter Techniques: Position
Statement
P. Clinical Practice Guidelines—available at:
http://www.aspan.org/Clinical-­Practice/Clinical-­
Guidelines
1. Normothermia
2. Pain and Comfort
 16 SECTION ONE • Professional Competencies

18. Postoperative education and teaching

VIII. Competency-­Based 19. Discharge readiness phase I and phase II
Section

Practice 20. Medical imaging/interventional radiology

One

21. Legal issues and clinical documentation

A. Comprehensive guide to competency and skill devel-
opment for the perianesthesia nurse
B. May be used to orient the new perianesthesia nurse
C. May be used for annual skills renewal and annual
updates for the perianesthesia nurse
D. Provides the perianesthesia nurse a framework of
essential performance criteria, thus establishing basic
competencies needed to practice in diverse perianes-
thesia settings
E. Guidelines for using unlicensed assistive personnel
(UAP) in the perianesthesia setting
1. Value of using competent UAP in perianesthesia
settings
2. Foremost concern is to promote a safe environment
for the perianesthesia patient
3. Perianesthesia nursing profession defines and
supervises the education, training, and utilization
of UAPs involved in direct patient care
4. Perianesthesia RN is responsible for and account-
able for the provision of nursing practice
5. Perianesthesia RN supervises and determines
appropriate utilization of any UAP involved in
direct patient care
6. Purpose of the UAP is to assist the professional peri-
anesthesia nurse to provide nursing care for the patient
F. Competencies for the RN in the perianesthesia setting
1. Mentoring: beyond orientation
2. Teamwork and collaboration
3. Critical thinking
4. Safety
5. Preanesthesia care
a. Preanesthesia testing
b. Preprocedural teaching
c. Preanesthesia history and assessment
d. Day of surgery preparation
6. Airway management
7. Circulation
8. Neurological
9. Renal
10. Moderate sedation and analgesia
11. Anesthesia agents and adjuncts
a. General inhalation agents
b. Muscle relaxants
c. Regional anesthesia
d. Intravenous and oral agents
12. Perianesthesia fluid management and resuscitation
13. Pain and comfort management
14. Nausea and vomiting
15. Malignant hyperthermia
16. Hypothermia
17. Geriatric competencies
22. Transcultural nursing/diversity care
23. EBP in the perianesthesia setting
G. Competency-­based orientation for the perianesthesia
support staff in the perianesthesia setting
1. Introduction
2. Patient rights, confidentiality, and communication
skills
3. Basic infection prevention and control practices
4. Preoperative testing
5. Basic life support
6. Airway management
7. Care of the patient requiring monitoring
8. Care of the patient receiving intravenous fluids
9. Pain assessment and management
10. Care of the patient requiring comfort measures
11. Care of the patient with nausea and vomiting
12. Care of the patient requiring oral or nasal suctioning
13. Care of the patient requiring oral intake
14. Care of the patient with catheters and drains
15. Care of the patient with hypothermia
16. Care of the patient with malignant hyperthermia
17. Care of the patient with seizure disorder
18. Care of the patient requiring anti-­embolism devices
19. Assisting with ambulation
20. Safe transport of the perianesthesia patient
To obtain a copy of the 2019–2020 Perianesthesia Nursing
Standards, Practice Recommendations and Interpretive
Statements; A Competency-­ Based Orientation and
Credentialing Program for the Registered Nurse in the
Perianesthesia Setting 2019; A Competency-­Based Orientation
and Credentialing Program for the Registered Nurse Caring
for the Pediatric Patient in the Perianesthesia Setting 2016;
and/or A Competency-­Based Orientation and Credentialing
Program for the Unlicensed Assistive Personnel in the
Perianesthesia Setting 2017, contact ASPAN at 90 Frontage
Road, Cherry Hill, NJ 08034-­1424; at 1-­877-­737-­9696 (toll-­
free); or at www.aspan.org → Resources → ASPAN Publications
IX. Ethical Issues
A. Ethics
1. The principle related to moral actions and values
2. Concerned with motives and attitudes and their
relation to the good of the individual
B. Professional responsibilities and duties
1. Duty of veracity: a duty to tell the truth
2. Rule of confidentiality: a duty to control disclosure
of personal information about patients to others
3. Health Insurance Portability and Accountability
Act of 1996 (HIPAA)
 CHAPTER 2 •
a. Major goal is to ensure proper protection of
individuals’ health information
b. Major purpose is to limit the circumstances in
which an individual’s protected health informa-
tion may be disclosed
4. Duty of advocacy: nurse supports the best interests
of the individual patient
5. Accountability: answerable to others for one’s
actions
6. Duty of fidelity: obligation to be faithful to com-
mitments to self and others
C. Ethical theories
1. Utilitarianism: defines good as happiness or
pleasure
a. Greatest good for the greatest number of people
b. The end justifies the means
2. Deontology: system of ethical decision making
based on moral obligation or commitment to
others
a. Emphasis on the dignity of human beings
3. Principalism: incorporates various existing ethical
principles and attempts to resolve conflicts by
applying one or more of them
D. Ethical principles
1. Beneficence: views the primary goal of health care
as doing good for patients
2. Nonmaleficence: requirement that health care pro-
viders prevent or do no harm to their patients
3. Autonomy: freedom of action as chosen by an
individual
4. Justice: duty to be fair to all people
E. Ethical decision making: goal is to determine right
from wrong in certain situations in which the lines are
unclear
1. Decision-­making process
a. Obtain as much information as possible
b. State the problem or dilemma as clearly as
possible
c. List all possible choices of action
d. Evaluate the consequences of each choice
e. Make a decision
2. Moral model
a. Massage the dilemma
b. Outline the options
c. Resolve the dilemma
d. Act by applying chosen option
e. Look back and evaluate entire process
F. Relationship of law and ethics
1. Legal system is founded on rules and regulations
that are formal and binding; ethical values are sub-
ject to philosophical, moral, and individual
interpretation
2. Legal right may or may not be ethical
3. Moral right may or may not be a legal right
4. Law influences ethical decision making, and ethics
can influence legal decision making
Standards, Legal Issues, and Practice Settings 17
G. Perianesthesia Standards for Ethical Practice, included
in the 2019–2020 Perianesthesia Nursing Standards,
Section
Practice Recommendations and Interpretive
One
Statements
H. American Nurses Association (ANA) Code of Ethics
for Nurses with Interpretive Statements 2015
1. The nurse practices with compassion and respect
2. The nurse’s primary commitment is to the patient
3. The nurse advocates for, and protects the rights,
health, and safety of the patient
4. The nurse is accountable for individual nursing
practice
5. The nurse owes the same duties to self as to others
6. The nurse participates in maintaining and improv-
ing the ethical environment of the work setting and
conditions of employment for safe, quality care
7. The nurse participates in the advancement of the pro-
fession through research, standards, and health policy
8. The nurse collaborates with other health profes-
sionals and the public to promote health
9. The profession of nursing is responsible for articu-
lating nursing values, for maintaining the integrity
of the profession, and for integrating social justice
principles into healthcare policy
I. Nurse staffing versus the nursing shortage
1. American Nurses Association: advocates for safe
staffing requirements
2. U.S. Congress: introduction of safe staffing legisla-
tion bills
3. The Joint Commission -­publication: Health Care at
the Crossroads -­Strategies for Addressing the
Evolving Nursing Crisis
X. Legal Concepts
A. Sources of law
1. Constitutional—system of laws for governance of a
nation; may be federal or state
2. Statutory—made by the legislative branch of the
government
3. Administrative—laws enacted by administrative
agencies charged with implementing particular
legislation
4. Judicial—laws made by the courts that interpret
legal issues that are in dispute
B. Types of law
1. Common law: derived from principles rather than
rules and regulations
2. Civil law: based on rules and regulations
a. Administered through courts as damages or
money compensation
b. Most important area is tort law, which involves
compensation to those wrongfully injured
3. Criminal law: conduct that is offensive or harmful
to society as a whole
 18 SECTION ONE • Professional Competencies
4. Substantive law: concerns the wrong, harm, or duty
that caused the lawsuit
Section
5. Procedural law: concerns the process and rights of
One
the individual charged with violating substantive law
C. Legal definitions (Box 2.1)
D. Negligence law
1. Tort law: a civil wrong that allows the injured party
to seek reparation; concerns any action or omission
that harms someone
a. Negligence
b. Malpractice
c. Assault and battery
d. Invasion of privacy
e. False imprisonment
f. Defamation
2. Essential elements of professional negligence
(malpractice)
a. Duty: once you, as a nurse, undertake the care
of a patient, you are under a duty to act in
accordance with the standard of care (e.g., you
establish a duty to the patient when you take
report on a patient in the postanesthesia care
unit and accept that patient into your care)
b. Breach of duty—failure to act in accordance
with the standard of care
(1) May be an act of omission (e.g., a failure to
administer a medication that was ordered)
BOX 2.1
Legal Terminology
Assault: An attempt or threat that causes a person to
fear physical touch or injury
Battery: The unauthorized touching of an individual’s
body, any extension of it, or anything attached to it in
an offensive or injurious manner
Defendant: Person or entity against whom plaintiff’s
allegations are made
Expert witness: A person who serves to educate the
court and jury about the subject under consideration,
including the appropriate standard of care
Malpractice (professional negligence): A type of neg-
ligence that involves a standard of care that can be
reasonably expected from professionals (e.g., attor-
neys, nurses, physicians, and accountants); failure to
act as a reasonably prudent nurse would act under
similar circumstances
Negligence: Deviation from the standard of care that
a reasonable person would use in a certain set of
circumstances
Plaintiff: The person or party who brings the lawsuit
and alleges harm
Standard of care: The care and judgment exercised
by a reasonable, prudent person (nurse) under the
same or similar circumstances
(2) May be an act of commission (e.g., adminis-
tration of a medication to which the patient
had an allergy)
c. Causation: plaintiff must prove that the breach
of duty was the cause of damages (e.g., the
administration of the medication to which the
patient had an allergy caused an anaphylactic
shock, resulting in the patient’s death)
(1) Most difficult element to prove
d. Damages—actual loss or damages must be
established (e.g., death, nerve damage, or
fracture)
e. Plaintiff must prove all four elements of negli-
gence for the cause of action to succeed
3. Employer liability
a. Respondent superior—“let the master speak”—
employer is vicariously liable for negligent acts
of employee if the act occurred during an
employment relationship and within part of the
employee’s job responsibilities
b. The corporate liability-­health care delivery sys-
tem can be sued when it breaches any direct
duty to the patient
4. Res ipsa loquitur —“the thing speaks for itself ”—a
rule of evidence that allows a supposition of negli-
gence on the part of the defendant (e.g., permanent
loss of neuromuscular control of arm after routine
hysterectomy)
a. Defendant must be solely in control at the
time injury occurred, and injury would not
have occurred if defendant had exercised due
care
b. Plaintiff must have done nothing to contribute
to negligence (e.g., foreign object left inside
patient after surgery)
5. Intentional torts—intent is necessary, and there
must be a willful action against the injured person
a. Assault: an action that causes apprehension or
unwarranted touching (e.g., threatening a
patient)
b. Battery: unauthorized touching of one person by
another (e.g., lack of consent for treatment)
c. Invasion of privacy: patient’s right to privacy is
recognized
(1) Releasing private patient information to a
third party
(2) Unauthorized entry into a patient’s medical
record
(3) Unauthorized observation of a procedure
(4) Taking pictures of patients without consent
d. Defamation: wrongful injury to another’s
reputation
(1) Libel (written form)
(2) Slander (spoken form)
e. False imprisonment: unjustifiable detention of a
person without a legal warrant
 CHAPTER 2 •
(1) Not allowing a patient to go who wants to
leave against medical advice
(2) Inappropriately restraining a patient
6. Unintentional torts—result from the defendant’s
negligence
a. Negligence
(1) Foreign object left in patient after surgery
(2) Failure to observe a patient as ordered
(3) Failure to report a change in patient
condition
(4) Failure to report witnessed negligence
(5) Failure to keep side rails up
(6) Failure to provide discharge teaching
7. Standards of care: minimal requirements that define
an acceptable level of care (see section III. Sources of
Standards at the beginning of the chapter.)
XI. Liability Issues
A. Possible causes of nursing liability for the perianesthe-
sia nurse
1. Failure to adequately assess or monitor a patient
a. Nurse must possess competency to assess and/or
monitor patient
b. Assessment and monitoring of patient are actu-
ally performed
c. If assessment and monitoring reveal reportable
condition, nurse must notify physician
d. Nurse must continue to assess and monitor to
evaluate effectiveness of intervention
2. Errors in the use of equipment
3. Failure to provide language access in health care
settings: Title VI and Beyond
4. Errors in medication or treatment
a. Failure to follow eight rights:
(1) Right drug
(2) Right dose
(3) Right patient (two identifiers)
(4) Right route
(5) Right time
(6) Right reason
(7) Right documentation
(8) Right response
5. Failure to communicate
a. To another nurse
b. Confirmation of physician orders
c. Changes in patient condition to a physician
6. Patient falls
7. Operating-­room errors (e.g., sponges/instruments
left inside patient)
8. Mix-­ups during patient transfers and/or before sur-
gery (e.g., wrong surgery on patient, failure to com-
municate change of order of patients’ surgeries)
9. Failure to report or act on deviations from accepted
practice
Standards, Legal Issues, and Practice Settings 19
a. Nurses expected to exercise independent judg-
ment and object when physician’s orders are
Section
inappropriate
One
b. Report facts to manager or otherwise follow
chain of command
10. Failure to follow a physician’s order promptly and
accurately
11. Failure to follow institutional or facility procedures
12. Failure to properly teach patient or caregiver accu-
rate and appropriate discharge instructions
a. Should receive discharge instructions before
admission or surgery
b. Use preprinted discharge instructions
c. Give verbal and written instructions
13. Premature discharge for the ambulatory surgery
patient
14. Failure to ensure the presence of an informed care-
giver (responsible adult)
15. Failure to assess the ambulatory surgery patient on
admission (e.g., nothing by mouth status, any signs
or symptoms that might affect reaction to anesthe-
sia or surgery, medication use that day)
B. Prevention of liability
1. Documentation
a. Accurate and comprehensive documentation
b. Purposes of documentation
(1) To communicate the patient’s condition to
other health professionals
(2) To assess for improvements that might be
needed by risk management and quality
management
(3) To obtain data for research
(4) To obtain reimbursement from the govern-
ment and insurance
(5) As a legal record
(6) To use as data for quality-­of-­care review
c. Nurses’ notes, the first place an attorney will look
(1) Electronically entered/written with time and
date and in chronological order
(2) Contains most detailed information regard-
ing the patient
d. Documentation guidelines
(1) Chart accurately
(a) It is very difficult to prove that some-
thing was done if it is not charted
(b) However, deliberate inaccuracies can
totally destroy defense and expose nurse
to criminal charges of fraud
(c) Adhere to institutional documentation
guidelines regarding paper or electronic
documentation
(2) Chart objectively
(a) Describe only what you observe and not
what you hear from other colleagues
(b) Do not use words such as seems, appar-
ently, or appears
 20 SECTION ONE • Professional Competencies
(c) Be factual and use quotations for actual
statements if needed
Section
(3) If using paper record, write legibly and use
One
standard abbreviations adopted by the
health care facility
(4) Do not use the chart to criticize or
complain
(a) Use other appropriate avenues if there is
criticism of another nurse
(5) Do not destroy or obliterate
documentation
(a) Do not use correction fluid or any other
kind of eradicator on any part of a paper
patient record
(b) If paper charting, draw one line through
the error, initial, and date the line
(6) Document as promptly as possible after the
care is given
(7) Correct grammar, spelling, and punctua-
tion make a difference
(8) Do not document for someone else or
allow someone else to document for you
(9) Use appropriate procedure for document-
ing a late entry
(10) Document patient and/or family teaching
(11) Document disposition of any personal
belongings
(12) Document any nursing interventions and
patient responses to those interventions
(13) Document any communication with a phy-
sician or supervisor concerning a patient’s
condition
2. Electronic documentation guidelines
a. Protect the user identification code or password
given for personal use
(1) No one else should be given access to that
password or document for the user
b. Only access information and document in chart
as authorized to do so
(1) An attempt to access an electronic chart on
a patient without authorization is a breach
of confidentiality and privacy
c. Never ignore electronic reminders that informa-
tion is coded incorrectly or that important data
has been overlooked or flagged for critical infor-
mation about the patient (e.g., lab work)
(1) Systems alert nurses if a portion of the nurs-
ing process is absent
d. Know the facility procedure for how to handle
late entries
e. Know downtime procedures
f. Stay updated when changes in documentation
format occur
3. Incident/occurrence reports
a. Use has changed from punitive measure to a
documentation of unusual events
(1) Should be no fear of reprisal or other nega-
tive consequences
(2) Atmosphere of trust and cooperation essen-
tial for system to be of best value
(3) Often used to identify and correct systems
issues when similar reports filed from differ-
ent areas
b. All actual and potential injuries must be
reported
(1) Should be initiated by the person who
observed the event or the first to become
aware of the incident
(2) Incorporate patient’s description into the
report by use of direct quotes
c. Documentation should be factual and objective
(1) Include information regarding patient,
description of the incident, any injuries sus-
tained, and outcome of event
d. Allows risk manager to assess situation and
decide on best corrective action
e. Record fact about event in nurses’ notes, but not
fact that incident report filed
4. Telephone calls
a. Document any telephone calls made to report
changes in patient condition
b. Important information to include:
(1) Specific time call was made
(2) Person who made the call
(3) Person called
(4) Person to whom information was given
(5) All information given
(6) All information received
c. Report to attending physician/designee regard-
ing abnormal findings or problems and
document
d. When obtaining consents (and any other time
appropriate), have another witness listen in
(total of two witnesses)
5. Personal accountability
a. Know your state Nurse Practice Act
b. Know the national standards for perianesthesia
nursing practice
c. Continuing education is essential
(1) Read professional journals and books
(2) Attend pertinent seminars
(3) Maintain membership in professional orga-
nization pertinent to specialty
d. Policies and procedures
(1) Will be held accountable for knowing and
following hospital or ambulatory facility’s
policies and procedures
(2) Policies should not conflict with one another
(3) Should reflect actual practice
(4) Report to appropriate resource of any prac-
tice not covered under policy and any
unclear policies
 CHAPTER 2 •
e. Patient relations
(1) Important aspect of prevention of liability
(2) Old adage is true: “A happy patient rarely
sues.”
(3) Do not criticize other health care providers
in the presence of the family or patient
(4) Maintain good communication and rapport
with the patient and family
XII. Legal Process
A. Phases of litigation
1. Evaluation for suit-­review of medical record
2. Pleadings
a. Complaint: outlines alleged negligence, states
the injury, and may indicate an amount of com-
pensation demanded
(1) Notify insurer and hospital after complaint
received
b. Answer: defendant is allowed a certain period to
respond to allegations
(1) Attorney prepares the answer
3. Prelitigation panels: required by some states
a. Medical review panel
b. Medical tribunal
c. Arbitration panel
4. If you have been sued
a. Do not discuss the case with anyone other than
the risk manager or your attorney
b. Do not talk to the plaintiff, the plaintiff ’s attor-
ney, or anyone testifying for the plaintiff
c. Do not discuss with reporters
d. Do not alter patient’s chart or hide any informa-
tion from your attorney
5. Discovery (pretrial phase): attempts to narrow
issues for trial by gathering and clarifying facts
a. Interrogatories: list of written questions that
seeks information to support or refute the
complaint
b. Production of documents: may be requested
(e.g., ambulatory surgery facility records, inci-
dent reports—varies state to state, anesthesia
records, policies and procedures, and discharge
teaching forms)
c. Deposition: oral testimony of any person
thought to have information pertaining to the
case
(1) Testimony given under oath
(2) Recorded by court reporter
6. Settlement negotiations: may continue throughout
process and occur at any time in the process
7. Trial of lawsuit: may be a judge or jury trial
a. Jury selection
b. Opening statements by plaintiff and defendant
c. Plaintiff presents case—uses expert witnesses
Standards, Legal Issues, and Practice Settings 21
d. Defendant presents case—uses expert witnesses
e. Defense may make motion for directed verdict
Section
against plaintiff, argues that the plaintiff has not
One
met the burden of proof
f. Closing statements by plaintiff and defendant
g. Jury instructions by the judge
h. Jury deliberations
i. Verdict
j. Appeal (optional)
XIII. Issues of Consent
A. Informed consent
1. Consent obtained after the patient has been fully
informed by the physician or dentist about the risks
and benefits of the treatment, alternatives, and con-
sequences of no treatment
2. Types of consent
a. Express: given by direct words, either written or
oral
b. Implied: inferred by the patient’s conduct or
may be legally presumed in emergency
situations
3. Treatment without consent
a. Assault and/or battery
b. Negligent failure to obtain consent
4. Exceptions to duty to disclose
a. Some emergencies: life or well-­being of the indi-
vidual is threatened, and consent cannot be
obtained or it would result in a delay of
treatment
b. Therapeutic privilege: physician believes infor-
mation would be harmful to the patient; very
restricted
c. Patient has waived right to consent: does not
want to be informed
d. Lack of decision-­making capacity—information
must be shared with proxy decision maker or
guardian
5. Documentation of consents
a. Nurses who sign as witnesses are only witness-
ing signature of person signing consent form
b. If patient has additional questions, nurse should
refer questions to physician
c. If physician fails to discuss questions further with
the patient, nurse must report that information
through the appropriate chain of command
d. If English is not primary language of patient, an
interpreter must be used
6. Provide health care access to language
B. Advance Directives
1. Living will: directive from competent individual to
medical personnel and family members regarding
treatment he or she wishes to receive when he or she
can no longer make the decisions himself or herself
 22 SECTION ONE • Professional Competencies
2. Natural Death/Right to Die Laws
a. Choose death by refusing treatment
Section
b. State-­legislated, legally recognized living wills
One
with statutory enforcement
c. Protects practitioner and ensures patient’s
wishes are followed
3. Durable power of attorney for health care—allows
competent patients to appoint an individual to
make health care decisions if they become incom-
petent to do so
4. Patient Self-­Determination Act
a. Passed in 1990 as part of federal Omnibus
Budget Reconciliation Act
b. Requires healthcare facilities to ask on admis-
sion whether the patient has completed an
advance directive
c. Requires healthcare facilities to provide infor-
mation to all patients of their rights to refuse
treatments and of any relevant state laws dealing
with advance directives
d. Documentation will occur regarding the presence
or absence of an advance directive, and a copy of
the advance directive requested if completed
5. Do Not Resuscitate (DNR), Do Not Attempt
Resuscitate (DNAR), Do Not Intubate (DNI)
Directives
a. DNR and DNAR directives: require documentation
that the patient’s decision was made after consulta-
tion with physician and understanding of options
b. DNI directive requires documentation that the
patient’s decision was made after consultation
with physician and understanding of options
c. CSPS DNR/DNAR/DNI Checklist (Fig. 2.1)
XIV. Policies and Procedures
A. Policy
1. Definition
a. Set of principles used as a guide for action
b. Organizational rules to define desired outcomes
(1) Define the means to achieve organizational
goals
(2) Reflect and support organization’s vision
and mission
(3) Consistent with all applicable legal and reg-
ulatory requirements
2. The purpose of a policy is to do the following:
a. Give direction—the action to take in a particular
situation
b. Define responsibility and accountability—who is
expected to take action
c. Define boundaries—specific actions included or
excluded
d. Provide consistency—same action in each
circumstance
e. Support objective decision making—reference
for deciding course of action and clarifying
misunderstandings
f. Promote compliance—how to meet professional
standards or external regulatory requirements
g. Assign authority—who oversees defined actions
h. Establish benchmarks—assess performance
related to expectations of policy
B. Procedure
1. Definition
a. Instructions with detailed steps for how to
accomplish a task
b. Specific directions for how to implement a
policy
2. The purpose of a procedure is to do the following:
a. Provide all information necessary to complete
the task/action
b. Explain concisely how to do a task
c. Establish the organization’s approved method of
achieving the goal(s) of a policy
d. Serve as a:
(1) Guide for learning new tasks
(2) Resource for teaching new personnel
(3) Standard to assess performance related to
compliance with accepted procedure
C. Policy and procedure format
1. Defined by organization and consistently applied,
includes:
a. Approving body
b. Dates of implementation, review, and revision
c. Item, page, and section numbering
2. Policy commonly followed by procedure in same
document
a. Policy includes:
(1) Reason the policy exists
(2) Definition of terms
(3) Assignment of responsibilities
b. Procedure includes:
(1) Necessary resources/equipment
(2) Sequential steps
(3) Time frame requirements
(4) Documentation guidelines
(5) References
3. Policies and procedures require a process for
review and revision
4. Policies and procedures are readily accessible to staff
a. Written
b. Electronic format
D. Perianesthesia policies and procedures
1. Guide and define the delivery of care in the peri-
anesthesia setting
a. Congruent with:
(1) ANA Code of Ethics for Nurses with
Interpretive Statements
(2) American Hospital Association Patient Care
Partnership
 CHAPTER 2 • Standards, Legal Issues, and Practice Settings 23

Section
One
“The resuscitation status of all patients brought into the perioperative care setting should be documented explicitly. For the avoidance of error and
confusion, this is particularly important in the case of patients who are or who have been DNR. For those patients in particular, an entry in the
chart should document whether the existing DNR status remains in force and, if not, how it is to be modified upon admission to perioperative care
and upon discharge from perioperative care. Any ambiguity should be addressed with and by the surgeon of record. ”

DNR/DNAR/DNI CHECKLIST GUIDE FOR NURSES DATE:

SETTING RESPONSIBILITY / ACTION YES NO N/A

Pre Admission or • Advance directives and DNR/DNAR/DNI in the patient’s
Inpatient – Day(s) chart
Before Surgery
• DNR/DNAR/DNI surgeon’s orders (retain or suspend) and
intervention plan.

PREOP (on the day of PREOP NURSE:

surgery) • Check and review advance directives.
• Check surgeon’s DNR/DNAR/DNI order and intervention
plan.
• Contact surgeon for clarification:
o If no DNR Suspension surgeon’s order and no
intervention plan on patient with existing
DNR/DNAR/DNI.
o If there is a conflict or unclear DNR/DNAR/DNI
documentation, patient’s advance directives and
physician’s consent.
• Check informed consent for anesthesia care, e.g. type of
resuscitation and duration of intervention plan.
• Assess patient or surrogate decision maker’s concerns and
issues related to DNR/DNAR/DNI and communicate to
physicians as indicated.
• Provide hand off to OR Nurse.
NOTE: If a nurse has an ethical discomfort/concern, inform Nurse
Manager to resolve ethical conflict or concern by finding someone
who is not bothered by the current state of affairs.

INTRAOP OR NURSE:
• Receive hand off report from Preop Nurse
• Implement necessary actions to be taken
NOTE: If a nurse has an ethical discomfort/concern, inform Nurse
Manager to resolve ethical conflict or concern by finding someone
who is not bothered by the current state of affairs.

Post Anesthesia DURING HANDOFF REPORT:

Care Unit (Phase I)
• Receive hand off report from anesthesia provider and OR
Nurse.
• Check physicians’ DNR/DNAR/DNI orders, intervention
plan, and duration of implementation time.
• Check change in physician’s order to resume
DNR/DNAR/DNI and effective time.
• Obtain clear intervention plan throughout the length of
PACU stay and upon transfer.
• Provide hand off report to the receiving nurse upon
transfer to the next level of care.

Do Not Resuscitate (DNR), Do Not Attempt Resuscitate (DNAR), Do Not Intubate (DNI) Directives

Fig. 2.1 CSPS Do Not Resuscitate (DNR), Do Not Attempt Resuscitate (DNAR), Do Not
Intubate (DNI) Directives Checklist. (From Council on Surgical & Perioperative Safety: CSPS’ DNR/
DNRI/DNI checklist guide, Chicago: IL, 2017).

(3) ASPAN Perianesthesia Standards for Ethical (1) State Board of Nursing
Practice (2) State health department/services
b. Comply with standards of accrediting bodies 2. Benefit from collaboration among administrators, man-
(1) The Joint Commission (TJC) agers, and direct care perianesthesia nursing providers
(2) Centers for Medicare and Medicaid Services 3. Incorporate research findings and EBP
(CMS) 4. Require systematic review and timely revision in
(3) Accreditation Association for Ambulatory response to changes in:
Health Care (AAAHC) a. Standards of practice
(4) American Association for the Accreditation b. Regulatory requirements
of Ambulatory Surgical Facilities (AAAASF) c. Technology
c. Consistent with state regulatory and licensing E. The number and scope of policies and procedures in
agencies any practice setting is determined by the:
 24 SECTION ONE • Professional Competencies
1. Nature of the perianesthesia unit or care area
2. Type of health care facility
Section
3. Procedures performed
One
4. Services provided
5. Characteristics of the patient population
F. Examples of perianesthesia policies and procedures
1. Administrative
a. Unit description, hours of operation
b. Job descriptions, hiring prerequisites, required
certifications
c. Staffing patterns, availability, on call, call back
d. Attire, professional conduct, personal communi-
cation devices
e. Employee health, annual testing or screening
2. Patient rights
a. Health Insurance Portability and Accountability
Act (HIPAA)
b. Consents
(1) Surgical, procedural, anesthesia, blood
products
(2) Emergency, minors, incompetency
c. Advance directives
d. Power of attorney
e. Ethical treatment
3. Environment of care
a. Supplies: inventory, procurement, and storage
b. Equipment operation and maintenance
c. Fire and safety plans
d. Emergency preparedness and disaster response
e. Infection control and personal protective
equipment
f. Hazardous material management: medical waste
and anesthetic gases
g. Security: patients, staff, visitors, and volunteers
h. Access to unit, restricted areas, and visitation
4. Patient care (specific to each level of perianesthesia
care)
a. Patient care management
(1) Anesthesia provider responsibilities and
availability
(2) Physician orders: procurement and
implementation
(3) Chain of command: nursing, medical, surgi-
cal, and administrative
b. Admission and discharge criteria for each phase
of care
c. Standards of care: diagnosis and age-­specific
patient care plans or treatment protocols
d. Nurse-­patient ratios
e. Assessment, monitoring, and documentation
guidelines
f. Medications: storage, access, administration,
controlled substances, wastage, and
documentation
g. Patient education and discharge planning
h. Patient handoff, transportation, and transfers
i. Perianesthesia family presence
j. Translation services
k. Special procedure cases
5. Quality management/performance improvement
a. Staff orientation
b. Continuing education
c. Individual performance evaluation and compe-
tency assessment
d. Unit-­specific and organizational performance
improvement program
6. Information management
a. Medical record access and storage
b. Confidentiality and security
c. Release of information
Bibliography
American Hospital Association: The patient care partnership.
Available at: https://www.aha.org/system/files/2018-­01/aha-­
patient-­care-­partnership.pdf, Accessed 21 October 2018.
American Nurses Association: Code of Ethics for Nurses.
Available at: http://nursing.rutgers.edu/civility/ANA-­Code-­
of-­Ethics-­for-­Nurses.pdf, Accessed 21 October 2018.
American Nurses Association: Nursing: scope and standards of
practice. Available at: https://www.nursingworld.org/practice-­
policy/scope-­of-­practice/, Accessed 21 October 2018.
American Nurses Association: ANA position statements. https://
w w w. n u r s i n g w o r l d . o r g / p r a c t i c e -­p o l i c y / n u r s i n g -­
excellence/official-­position-­statements/, Accessed 21 October
2018.
ANA applauds nurse staffing legislation: Available at: https://ww
w.nursingworld.org/news/news-­releases/2018/ana-­applauds-­
nurse-­staffing-­legislation/, Accessed 21 October 2018.
American Society of PeriAnesthesia Nurses: 2019-­2020
Perianesthesia nursing standards, practice recommendations
and interpretive statements, Cherry Hill, NJ, 2018, American
Society of PeriAnesthesia Nurses.
American Society of PeriAnesthesia Nurses: A competency based
orientation and credentialing program for the registered nurse
caring for the pediatric patient in the perianesthesia setting,
Cherry Hill, NJ, 2016, American Society of PeriAnesthesia
Nurses.
American Society of PeriAnesthesia Nurses: A competency based
orientation and credentialing program for unlicensed assistive
personnel in the perianesthesia setting, Cherry Hill, NJ, 2017,
American Society of PeriAnesthesia Nurses.
American Society of PeriAnesthesia Nurses: A competency based
orientation and credentialing program for the registered nurse
in the adult perianesthesia setting, Cherry Hill, NJ, 2019,
American Society of PeriAnesthesia Nurses.
Council on Surgical & Perioperative Safety: CSPS’ DNR/DNAR/
DNI checklist guide. Available at https://www.cspsteam.org/15-­
resuscitation-­plan, Accessed 15 December 2018.
D’Arcy Y: Practice guidelines, standards, consensus statements,
position papers: what they are, how they differ, Am Nurse
Today 2(10):23–24, 2007.
Facts on the nursing shortage in north America: Available at: htt
ps://www.aacnnursing.org/Portals/42/News/Factsheets/Nur
sing-­Shortage-­Factsheet-­2017.pdf, Accessed 21 October
2018.
 CHAPTER 2 • Standards, Legal Issues, and Practice Settings 25

Ferrell KG: clinical editor: Nurse’s legal handbook, ed 6, The Joint Commisson: Health care at the Crossroads: strategies for
Philadelphia, 2016, Wolters Kluwer Health. addressing the evolving nursing crisis. Available at: https://www

Section
Godden BA, Krenzischek DA: Standards, legal issues, and prac- .jointcommission.org/assets/1/18/health_care_at_the_crossro

One
tice settings. In Schick L, Windle P, editors: Perianesthesia ads.pdf, Accessed 21 October 2018.
nursing core curriculum: preprocedure, phase I and phase II
PACU nursing, St. Louis, 2016, Elsevier, pp 12–31.
H.R: 5052 – Safe staffing for nurse and patient safety act of 2018.
Available at: https://www.congress.gov/bill/115th-­
congress/house-­bill/5052/text, Accessed 21 October 2018.
New safe staffing legislation introduced to congress. Available at:
https://dailynurse.com/new-­s afe-­s taffing-­l egislation-­
introduced-­to-­congress/, Accessed 21 October 2018.
Odom-­Forren J: Drain’s perianesthesia nursing: a critical care
approach, ed 7, St. Louis, 2018, Elsevier.
The Joint Commission: 2018 Hospital accreditation standards,
Oakbrook Terrace, IL, 2018, The Joint Commission.
CHAPTER 3
Safety, Quality Improvement, and
Regulatory and Accrediting Agencies
Dina A. Krenzischek
OBJECTIVES
At the conclusion of this chapter, the reader will be
able to do the following:
1. Define health care quality, patient safety, safety
culture, and brief history of safety culture.
2. Describe the American Society of PeriAnesthesia
Nurses (ASPAN) safety goal, safety culture
characteristics, and safety related position statements.
3. Describe organizational and regulatory patient safety
resources.
4. Describe patient safety tools and resources.
5. Describe perianesthesia nursing implications and
approach to data management for analysis.
I. Workplace Definitions
A. Quality of healthcare
1. The degree to which health services for individuals
and populations increase the likelihood of desired
health outcomes that are consistent with current
professional knowledge.
B. Patient safety
1. The prevention of harm to patients with emphasis
on the system of care delivery that:
a. Prevents errors
b. Learns from the errors that do occur
c. Builds on a culture of safety that involves health
care professionals, organizations, and patients
C. Safety culture in workplace
1. A safety culture is an organizational culture that
places a high level of importance on safety
beliefs, values, and attitudes and are shared by
the majority of people within the company or
workplace.
2. Safety culture in nursing
a. A “culture of safety” describes the core values
and behaviors that come about when there is a
collective and continuous commitment to
emphasize safety over competing goals by the:
26
(1) Organizational leadership
(2) Managers and health care workers
3. Brief history of safety culture
a. The Chernobyl disaster in 1986 highlighted the
importance of safety culture and the effect of
managerial and human factors on safety
performance.
b. First used in the 1988 International Nuclear
Safety Group’s (INSAG) summary report on the
post-­accident review meeting on the Chernobyl
“Accident.”
c. Safety culture was described as “That assembly of
characteristics and attitudes in organizations and
individuals which establishes that, as an overrid-
ing priority, nuclear plant safety issues receive the
attention warranted by their significance.”
d. The U.K. Health and Safety Commission (1993)
developed one of the most commonly used defini-
tions of safety culture: “The product of individual
and group values, attitudes, perceptions, competen-
cies, and patterns of behavior that determine the
commitment to, and the style and proficiency of,
an organization’s health and safety management.”
e. The Cullen Report: The Ladbroke Grove rail
crash saw safety culture as “the way we typically
do things around here,” implying that every
organization has a safety culture
f. International Atomic Energy Agency (IAEA)
and U.K. Health and Safety Commission (HSC):
Some characteristics associated with safety cul-
ture include the incorporation of beliefs, values,
and attitudes that are shared by a group.
g. Mearns et al.: Considered safety culture as an
important concept that forms the environment
within which individual safety attitudes develop
and persist, and safety behaviors are promoted.
h. Reason: Considered an ideal safety culture as the
engine that drives the system toward the goal of
sustaining the maximum resistance toward its
operational hazards regardless of current com-
mercial concerns or leadership style.
 CHAPTER 3 • Safety, Quality Improvement, and Regulatory and Accrediting Agencies 27

i. Pidgeon and O’Leary: Considered that a good 3. Competency

safety culture might reflect and be promoted by a. Achieve and support professional competence in

Section
four factors: clinical practice

One
(1) Senior management commitment to safety b. Initiate, support, and provide education for staff
(2) Realistic and flexible customs and practices and patients
for handling both well-­defined and ill-­ c. Demonstrate appropriate clinical judgment and
defined hazards critical thinking
(3) Continuous organizational learning through d. Measure and monitor quality measures and
practices such as feedback systems, monitor- nurse-­sensitive indicators
ing, and analysis 4. Efficiency/timeliness
(4) Care and concern for hazards shared across a. Provide timely interventions, reports, and
the workforce communication
b. Utilize checklists, standardized protocols, and
II. ASPAN Safety Goal, Culture technical process
c. Appreciate cues and initiate appropriate
of Safety Characteristic, and interventions
Safety-­Related Position d. Proactive approach to planned and unplanned
Statements events
5. Teamwork
A. Goals a. Collaborate among health care providers and
1. To promote a safe perianesthesia care setting by other disciplines
providing guidelines for the best practices (1) Team huddles
2. Support a culture of safety by an environment of (2) Transfer of care
caring and guided by principles of research and (3) Safety rounds
evidence-­based practices (4) Briefing/debriefing
B. Characteristics of a safety culture (not inclusive): (5) Shared governance/shared leadership meetings
1. Communication (6) Patient care conference
a. Adopt respectful and effective communication b. Promote staff leadership and empowerment
techniques c. Promote staff engagement, involvement, and
b. Develop and use effective listening skills commitment
c. Complete and systematic approach to hands-­off d. Adherence to comprehensive organizational cul-
processes and transfer of care, such as Situation, ture of safety
Background, Assessment, and C. ASPAN safety-­related position statements
Recommendations (SBAR) 1. Do not resuscitate (DNR), Do not attempt to resus-
d. Reporting errors/safe practices citate (DNAR), Do not intubate (DNI), and
e. Legible documentation Advance Directives
f. Respect civility among all health care teams for 2. On call/call back work schedule
open two-­way communication 3. Intensive care unit (ICU) overflow
g. Prevent workplace violence 4. Safe medical administration
(1) Listen and pay attention 5. Care of older adult, geriatric, pediatric, and perina-
(2) Acknowledge and respect others tal patients
(3) Be inclusive 6. Substance abuse
(4) Be assertive, not aggressive 7. Workflow interruptions
(5) Praise more than complain 8. Alarm management
(6) Be honest 9. Acuity-­based staffing
(7) Build mutual trust among all health care 10. Quality and occupational hazards
providers
2. Advocacy
a. Protect patient from harm
III. Advocacy Organizational and
b. Maintain healthy environment of care Regulatory Patient Safety
c. Uphold ethics of care and patients’ rights Resources
d. Seek and implement best practices
e. Promote culture of accountability and A. American Nurses Association (ANA) Safety Culture
transparency 1. Addressing nurse fatigue to promote safety and
f. Adherence to institutional and organizational health: Joint responsibilities of the registered nurses
standards and practice (RNs) and employers to reduce risks from nurse
 28 SECTION ONE • Professional Competencies
fatigue and sustain a culture of safety, a healthy
work environment, and a work-­life balance.
Section
2. Patient safety: Rights of RNs when considering a
One
patient assignment:
a. The nurse based on their professional and ethi-
cal responsibilities have the professional right to
accept, reject, or object in writing to any patient
assignment that puts patients or themselves at
serious risks for harm.
3. Professional role competence
a. The public has a right to expect RNs to demon-
strate professional competence throughout their
nursing careers.
b. ANA believes the RN is individually responsible
and accountable for maintaining professional
competence.
c. The ANA further believes that it is the nursing
profession’s responsibility to shape and guide
any process for assuring nurse competence.
d. Regulatory agencies define minimal standards
for regulation of practice to protect the public.
e. The employer is responsible and accountable to
provide an environment conducive to competent
practice. Assurance of competence is the shared
responsibility of the profession, individual
nurses, professional organizations, credentialing
and certification entities, regulatory agencies,
employers, and other key stakeholders.
4. Promoting safe medication use in the older adult/
geriatric patients
a. Ongoing evaluation
b. Clear communication of medication
c. Medication reconciliation
d. Research on pharmacodynamics, pharmaceutics,
and pharmacotherapeutics
e. Research on clinical interventions to test the
effects of specific interventions
5. Safe practices for needle and syringe use:
a. Take precautions to minimize the risk of infec-
tion to the patient.
b. The ANA Code of Ethics states that every mem-
ber has a personal responsibility to uphold and
adhere to the ethical standards contained within
the Code of Ethics document.
6. Safety issues related to tubing and catheter
misconnections:
a. The ANA supports the inclusion of policies and
processes that address tubing and catheter con-
nections as part of the health care delivery sys-
tem and the prevention of tubing and catheter
misconnections as a Joint Commission National
Patient Safety Goal.
b. The ANA also advocates collaborative investiga-
tion with nurses, manufacturers, and product
engineers to eliminate tubing and catheter mis-
conceptions by creating a universal design spe-
cific to the function of the tube.
7. Standardization and interoperability of Health
Information Technology (HIT)
a. Promote the adoption and implementation of
standardized nursing data capture within all
vendor products
b. Advocate for standardized nursing data capture
throughout the nursing process and across all
settings of care
c. Promote standardization of installed vendor
products as a strategic imperative to support
interoperability
d. Advocate for a feedback loop to inform direct
care interventions
B. ANA: Healthy work environment
1. The Nurses’ Bill of Rights
a. Nurses have the right to practice in a manner
that fulfills their obligations to society and to
those who receive nursing care.
b. Nurses have the right to practice in environ-
ments that allow them to act in accordance with
professional standards and legally authorized
scopes of practice.
c. Nurses have the right to a work environment
that supports and facilitates ethical practice in
accordance with the Code of Ethics for nurses
with interpretive statements.
d. Nurses have the right to freely and openly advo-
cate for themselves and their patients without
fear of retribution.
e. Nurses have the right to fair compensation for
the work consistent with their knowledge, expe-
rience, and professional responsibilities.
f. Nurses have the right to a work environment
that is safe for themselves and for their patients.
g. Nurses have the right to negotiate the conditions
of their employment, either as individuals or
collectively, in all practice settings.
C. ANA: Healthy nurse
1. Healthy sleep
2. Healthy weight
3. Men’s health
4. Healthy work environment
5. Tobacco cessation
6. More healthy nurse resources
7. Healthy risk appraisal
8. Help for nurses and nursing students with sub-
stance use disorder
D. Professional Regulations
1. National Council of State Board of Nursing
a. Regulate professional nursing practice and licensing
b. Identify scope of practice
c. Practice autonomy of the professional nurse
d. Protect public health
e. Require the ethical and professional conduct
standards to be met
f. Disciplinary actions for unsafe practice
g. Regulations vary by state
 CHAPTER 3 • Safety, Quality Improvement, and Regulatory and Accrediting Agencies 29
h. Some reciprocity of requirements from state to
state but separate licensing
i. Military nursing licenses cross state borders
2. Certification Boards (nursing specialty-­specific).
Example:
a. Certified Post Anesthesia Nurses (CPAN)
b. Certified Ambulatory PeriAnesthesia Nurses
(CAPA)
c. Certified Nurse, Operating Room (CNOR)
d. Certified Registered Nurse Anesthetist (CRNA)
E. Council on Surgical and Perioperative Safety (CSPS)
1. CSPS promotes excellence in patient safety in sur-
gical and perioperative safety.
2. Multidisciplinary coalition of professional organi-
zations related to safe perioperative care. The Board
of Directors consists of representatives from:
a. American Association of Nurse Anesthetists
(AANA)
b. American Association of Surgical Physician
Assistants (AASPA)
c. American College of Surgeons (ACS)
d. American Society of Anesthesiologists (ASA)
e. American Society of PeriAnesthesia Nurses
(ASPAN)
f. Association of periOperative Registered Nurses
(AORN)
g. Association of Surgical Technologists (AST)
3. Safe surgery resources:
a. Universal nomenclature
b. Patient monitoring
c. Transfer of care
d. Safe surgery checklist
e. Sharp safety
f. Foreign body retention
g. Fire safety
h. Perioperative prophylaxis
i. Prevention of ventilator-­associated pneumonia
j. Violence in the workplace
k. Evidence-­based standards of practice
l. Perioperative medication error
m. Operative specimens
n. Maintenance of perioperative normothermia
o. Resuscitation plan
p. Adequate rest period
q. Team education and training
r. Smoke evacuation
s. Disaster relief response
t. Prevention of indwelling catheter infection
u. Noise and distraction
v. Cognitive aid for emergency management
w. Burn out
x. DNR, DNI, and DNAR
F. The Joint Commission (JC)
1. Continuous improvement of patient care outcomes
2. Identification of functions and processes with the
most significant impact on outcomes
3. Emphasis on integrated system rather than inde-
pendent units
Section
4. Emphasis on consistent performance standards
One
5. National performance measurement system for
patient outcomes and care processes
6. Continual data collection, risk adjustment, and
analysis
7. Use of comparative data for performance
improvement
8. Annual National Patient Safety Goals (NPSG)
updates. The 2019 goals:
a. Improve the accuracy of patient identification
(1) Use at least two patient identifiers when
providing care, treatment, and services
(2) Eliminate transfusion errors related to
patient misidentification
b. Improve the effectiveness of communication
among caregivers
(1) Report critical results of tests and diagnostic
procedures on a timely basis
c. Improve the safety of using medications
(1) Label all medications, medication containers,
and other solutions on and off the sterile field
in perioperative and other procedure settings
(2) Reduce the likelihood of patient harm asso-
ciated with the use of anticoagulant therapy
(3) Maintain and communicate accurate patient
medication information
d. Reduce the harm associated with clinical alarm
systems
(1) Improve the safety of clinical alarm systems
e. Reduce the risk of health care associated
infection
(1) Comply with either the current Centers for
Disease Control and Prevention (CDC)
hand hygiene guidelines or the current
World Health Organization (WHO) hand
hygiene guidelines
(2) Implement evidence-­based practice to pre-
vent health care associated infections due to
multidrug-­resistant organisms in acute care
hospitals
(3) Implement evidence-­based practices to pre-
vent central line–associated bloodstream
infections
(4) Implement evidence-­based practices for pre-
venting surgical site infections
(5) Implement evidence-­based practices to pre-
vent indwelling catheter-­associated urinary
tract infections (CAUTI)
f. The hospital identifies safety risks inherent in its
patient population
(1) Identify patients at risk for suicide
g. Universal protocol for preventing wrong site,
wrong procedure, and wrong person surgery:
(1) Conduct a pre-­procedure verification process
 30 SECTION ONE • Professional Competencies
(2) Mark the procedure site
(3) A timeout is performed before the
Section
procedure
One
G. JC safety culture checklist
1. Environment of care:
a. No items stored under the sinks
b. Equipment/furniture: No broken equipment or
furniture stored on the patient care units.
Coverings are intact—no rips or repairs needed
c. Potential safety hazards: Housekeeping and
maintenance carts and buckets are attended and
locked. All fluids are labeled.
d. Laundry and trash chute accesses are locked.
e. Hazardous rooms are locked: EVS closets, supply
closets, mechanical rooms, and electrical panels
f. Hazardous chemicals and flammable agents are
labeled and stored properly.
g. Eyewash stations: Inspection tags are present
and up to date.
h. Refrigerators: Contain only those items designed
for that refrigerator (specimen, medication, or
patient food).
i. Refrigerator: If manually monitored, logs are
complete. Both manual and temperature track
documentation are present for actions taken to
correct out-­of-­range temperatures.
j. Blanket, item warmers: Set to maintain tempera-
ture of 130°F. Necessary logs completed includ-
ing actions taken to out-­of-­range temperature
readings.
k. Electrical safety: Use of hospital-­grade power
strips and maintain plugs and receptacles in
good condition.
l. No outer shipping carton boxes in patient care
areas.
m. No expired items.
n. Preventive maintenance: Equipment checked
with up-­to-­date bio-­med sticker.
o. Central alarm monitor: Logs accurate and
complete.
2. Emergency preparedness
a. Can staff locate medical gas zone shutoff valves?
3. Information management
a. Confidential patient information. Cannot be
overheard or seen by unauthorized person:
(1) Computer terminals signed off when not in
use
(2) Patient information is not discussed in pub-
lic areas
(3) Labels and protected health information
(PHI) are obliterated before discarding in
the trash
b. No clipboard displayed as sign-­in sheets when
multiple patient names on the list.
c. If fax machine is in public area, patient informa-
tion is quickly removed.
4. Life safety
a. Appropriate storage of boxes and patient care
items:
(1) Not directly on floor
(2) 18 inch clearance from sprinkler head
(3) Boxes stored in shelves close to floor must
have solid bottom and high enough to not
incur water damage from mopping.
(4) Volume of combustible materials is not
stored in large quantity as to create a fire
hazard.
b. Oxygen or other combustible compressed gas
cylinders are stored properly:
(1) Secured in floor stand, carrier, or secured to
the wall (not lying on the floor or against
the wall)
(2) Limited for 12 E-­cylinders per smoke
compartment
(3) Greater than 12 stored in a secured room
c. Fire exits and hallways are cleared:
(1) Egress corridors must have 8 ft clearance
(2) Equipment in corridors must be actively
accessed to be in use
d. Fire alarm pull stations, fire extinguishers, medi-
cal gas shutoff valves are not blocked.
e. Fire extinguishers have been inspected monthly.
f. Maximum of two 32 gallon trash cans in a 10
×10 room (unless fire rated).
g. Fire doors are not blocked or propped and when
closed there is a positive latching.
h. Exit signs are illuminated.
i. Evacuation route posted and current.
j. Everyone (staff and visitors) has identification
(ID) badges and are worn appropriately.
k. Ceiling tiles are in place, no cracks, holes, mis-
aligned, or visible stains.
l. Floors, ceiling, walls, and other surfaces intact
and free from holes.
m. Nurse/patient call lights working.
5. Patient Safety National Safety Goals should be
posted in the unit
6. Standard performance improvement or continuous
quality improvement (CQI) projects and dash-
boards posted on the unit
7. Provision of care: Treatment and services: Patient
alarms should be set accordingly and attended to
immediately when sounded
8. Infection Prevention
a. Food and drink in designated areas:
(1) No evidence of it in patient rooms/area,
perches, hazardous chemical storage area,
and laboratory specimen area
b. Hand hygiene products:
(1) No empty alcohol gel bottles
(2) No empty soap or paper towels
(3) No unapproved lotions
 CHAPTER 3 • Safety, Quality Improvement, and Regulatory and Accrediting Agencies 31
c. Personal protective equipment (PPE)
(1) Readily available
(2) Clearly marked
(3) Worn correctly
d. Patient food and drinks
(1) No expired items
e. Biohazard waste:
(1) Discard in red bags with a biohazard symbol
(2) Not overfilled
(3) Covered when transported
f. Soiled linens
(1) Properly stored and not overfilled
g. Separation of clean versus dirty supplies and
equipment:
(1) Clearly marked
(2) Clean items if stored in soiled utility are
covered and clearly marked
h. Patient care supplies
(1) Not expired, damaged, or soiled
i. Linen and linen carts:
(1) Covered and carts have solid bottoms
j. Sharp waste:
(1) Placed in puncture-­resistant sharps
container
(2) Disposed when three-­quarters full or “full”
indicator
(3) Mounted appropriately
k. General cleanliness:
(1) Observe surfaces for high dust and residue,
floors, stairwells, nutritional area, med prep
areas, and patient room and bathrooms
(2) No blood or bodily fluids
l. Air vents clean
m. All items in patient care area that are not dispos-
able to be wiped down
n. Curtains, drapes, or blinds clean
o. Negative and positive pressure air flow rooms
function appropriately
p. Ice machine clean (no slime)
q. Water fountains clean and functioning
9. Medication management
a. Medication rooms are clean and uncluttered
b. Laminar flow hood is used for intravenous
admixture when appropriate
c. Visual inspection of medication containers: No
issues
d. Are free of distractions
e. Medication is appropriately labeled: Expiration
dates, directions, etc.
f. All medications, needles, and syringes are
secured in locked cabinet or locked room or
under constant surveillance
g. Controlled substances stored to prevent
diversion
h. Medications stored appropriately to maintain
stability
i. Medications, formula, and solutions not expired
beyond expiration date
Section
j. Opened multi-­dose vials are initialed. Not expired
One
k. Code carts:
(1) Locked and marked with first drug to expire
(2) Checked per policy
(3) Include defibrillator checks
(4) Extra locks kept secured
(5) All supplies and drugs that are on the inven-
tory list are on the cart
(6) Cart is clean
(7) O2 tank is greater than ½ full
l. Syringes are labeled when in use
m. Medication refrigerators: Only contain milk for
current patients
n. Patient bedside:
(1) Intravenous tubing labeled per policy
(2) Medication secured and labeled
(3) All solutions labeled at the bedside
(4) Medication carts: Doors and drawers locked
10. Rights and responsibilities of the individual
a. Patients and families properly informed of their
rights
(1) Rights and responsibilities statement
b. Family guides provided to all families on
admissions
11. Waived testing/point of care testing
a. Point of care testing lab controls documented
and control solution labeled and dated
(1) Reagents, iStat analyzers, and glucometers
b. Point of care testing quality control:
(1) Consistently and correctly documented
(2) Dates missing initials
(3) Performed by qualified person
(4) Out-­of-­range is followed
(5) Logged numbers match bottle ID numbers
12. Describe the unit’s response to your arrival
a. Greet the team with smiles and introductions
b. Have a space designated for the team to conduct
interviews and file reviews
c. Promptly deliver materials required for review
to the tracer team
d. Any additional comments regarding positive or
suboptimal issues observed
H. Joint Commission Five Components of Safety Culture
Leadership Requirements
1. Assessment: Leaders regularly evaluate the culture
of safety and quality using valid and reliable tools.
2. Strengthening Systems:
a. Leaders prioritize and implement changes iden-
tified by the evaluation of safety culture.
b. Leaders create and implement a process for man-
aging behaviors that undermine a culture of safety.
3. Trust/intimidating behavior: Leaders develop a
code of conduct that defines acceptable behavior
and behaviors that undermine a culture of safety.
 32 SECTION ONE • Professional Competencies
4. Identifying unsafe conditions: The scope of the
safety program includes the full range of safety
Section
issues from potential or no harm errors sometimes
One
referred to as “near miss” to hazard conditions.
5. Accountability/just culture: The leaders provide
and encourage the use of systems for blame-­free
internal reporting of a system or process failure or
the results of a proactive risk assessment.
I. Joint Commission Tenets of Safety Culture:
1. Transparent and non-­punitive approach
2. Clear, just, and transparent risk-­based process
3. Chief Executive Officer (CEO) and leaders are role
models of appropriate behaviors and eradicate
intimidating behaviors
4. Policies support safety culture and reporting
5. Recognize care team members who report adverse
events and close calls
6. Use valid tools to determine baseline organizational
culture
7. Analyze safety culture results and find opportuni-
ties for improvement
8. Use information from safety assessment to develop
and implement unit-­based quality and safety
improvements
9. Embed safety culture training into quality improve-
ment (QI) projects
10. Proactively assess strengths and vulnerabilities
J. Agency for Health Care Research and Quality
(AHRQ) (definition of quality in healthcare)
1. Providers deliver the right care to the right patient
at the right time in the right way
2. Patients can:
a. Access timely care
b. Have understandable and accurate information
about benefits and risks
c. Be protected from unsafe care services and
products
d. Have understandable and reliable information
on their care
3. Clinicians and patients have their rights respected
a. Highlights for nurses: Doing the right things
right the first time
4. Requirements for a culture of CQI
a. Team approach
b. Corporate and organizational commitment to
mission, money, management, and material
c. Non-­punitive, organization-­wide culture that
talks and acts like quality
d. Identification and understanding of customers
and their needs and expectations
e. Ongoing pursuit of customer satisfaction
f. Team emphasis on perfecting systems in deliv-
ery of patient care to affect good outcomes
g. Constant learning and improving
h. Interdisciplinary and cross-­functional
collaboration
i. A planned, systematic approach organized
around the flow of patient care
K. LeapFrog
1. LeapFrog releases the safety grades every fall and
spring. The ratings are based on more than two
dozen quality measures compiled by the Leapfrog
Group, Centers for Medicare and Medicare (CMS),
AHRQ, CDC, and the American Hospital
Association (AHA)
2. Outcome measures:
a. Dangerous object left in patient’s body
b. Air or gas bubbles in the blood
c. Patient falls
d. Infection in the blood
e. Infection in the urinary tract
f. Surgical site infection after colon surgery
g. Methicillin-­resistant Staphylococcus aureus
(MRSA) infection
h.  Clostridium difficile infection
i. Dangerous bed sores
j. Death from treatable serious complications
k. Collapsed lungs
l. Serious breathing problem
m. Dangerous blood clot
n. Surgical wound splits open
3. Process measures
a. Doctors order medication through a computer
b. Safe medication administration
c. Specialty trained doctors care for ICU patients
d. Effective leadership to prevent errors
e. Staff work together to prevent errors
f. Track and reduce risks for patients
g. Enough qualified nurses
h. Handwashing
i. Communication with nurses
j. Communication with doctors
k. Responsiveness of hospital staff
l. Communication about medicines
m. Communication about discharge
L. Institute for Safe Medication Practices (ISMP)
1. Revised guidelines for safe use of automated dis-
pensing cabinet
2. Targeted medication safety best practice for
hospitals
a. Guidelines for optimizing safe subcutaneous
insulin use in adults
b. Guidelines for safe preparation of compounded
sterile preparations
c. Draft guidelines for safe communication of elec-
tronic medication information
d. Guidelines for timely administration of sched-
uled medications (acute)
e. Guidelines for standard order sets
f. Guidelines for safe implementation and use of
smart pumps
M. National Patient Safety Foundation (NPSF)
Another random document with
no related content on Scribd:
 “Just this, Captain Margaret. When a growler. A pug, you
understand; one of the hands forward there. When a seaman comes
aboard a new ship, he always blows at the rate of knots about his
last. You’ll never hear of the ship he’s in. No, sir. She’s hungry. Or
wet. Or her old man’s a bad one. But so soon as he leaves her. Oh,
my love, what a ship she was, my love. Bacon for breakfast; fires to
dry your clothes at; prayers and rum of a Sunday forenoon.
Everything. That’s what I mean by a last ship. So when I says we’d
great times on the lagoon, why, it’s only a way of speaking. I mean
as it seems just beautiful, now it’s over. I’ll just trouble you, Mr.
Perrin, if there’s any more beer in the jug.”
“So that’s the last ship, Captain Cammock,” said Margaret. “Well,
and now tell us what seems great to you, when you think of—of your
last ship, in the lagoon, as you call it.”
Captain Cammock looked at Perrin, who seldom spoke at meals,
perhaps because his intellect was too feeble to allow him to do more
than one thing at a time. Perrin, who hated to be looked at when he
was eating, from some shy belief that no one looked at him save with
a desire to laugh, gulped what he had in his mouth at the moment,
choked, and hid his confusion in his tankard. Captain Cammock did
the same, lest he should appear rude.
“Now that’s no easy question, Captain Margaret,” he said. “It
wasn’t great, now I come to think of it. It was hard work. As hard as
shovelling coal. And hot. Oh, it’s hot in them lagoons. Sometimes our
shirts would be wringing wet with perspiration. And often we were up
to our knees in mud, where we worked, and little red devils biting us,
besides mosquitoes. And there were thorns on the logwood; spikes
as sharp as stings.”
“What were your amusements?” said Margaret.
“Oh, as to them,” replied the captain. “We’d go hunt a wild cow on
Saturdays. Or perhaps fish. Or sometimes we’d go a lot of us among
the Indians, to a paw-waw. And then ships come. We’d great times
when ships come. In the moonlight. We’d sing and drink rum. And
firing off pistols and cheering. Oh, we’d great times.”
“Why don’t you go back to it?” asked Captain Margaret. “You don’t
go back to it. Why not?”
 “It wouldn’t be the same,” said Cammock, as he prepared his
morning’s pipe. “The men I knowed are gone. They’d have new
ways, the new lot. Besides, that sort of thing only goes when you’re
young. When you get the salt in your bones, you find the young
devils don’t like having you around. And the girls get particular. You
can’t get a wife no longer for a yard of blue baize and a stick of
sealing-wax. Excuse me, captain. I’m a sailor. I sometimes talk
rough. But there it is. All a sailor has at the end is just what he can
remember. What I can mind of logwood-cutting is the same as a
trader’s money-bags is to him. I must be off forward, to have my
morning draw.” He spun his chair round, and rose, pressing the
tobacco into his clay pipe. “Give me my hat, stooard.” He bowed to
the two friends, walking slowly to the cabin door. “By the way, sir,” he
called back. “I forgot to ask. I suppose you’ll be going ashore this
fine morning?”
“Yes,” said Margaret, “I am going ashore. I shall want the boat,
captain.”
“Very good, sir,” said Cammock. “Will you want to fill our water,
sir?”
“No,” said Margaret. “I shall sail before sunset, if the wind holds.
We shall fill no more water till we make Virginia.”
“Very good, Captain Margaret,” said Cammock. “If you don’t want
the hands, I’ll try them at the guns. It’s time they got into the way of
doing things.”
He spun upon his heel, leaving the two friends together. The
steward, gathering up the gear, retired to the pantry to wash up.
Captain Charles Margaret, the owner of the Broken Heart, sitting
there in his chair, in the quiet cabin, was not yet forty; but his brown
hair was grizzled, and his handsome face, so grave, so full of dignity,
was marked austerely with lines. He gave one, at first, the
impression of a man who had lived fully, grandly, upon many sides of
life; with a nobility inherent, not to be imitated. It was only after long
months of friendship that the observer could learn the man’s real
nature. He would see then that the real nature, ripened, as it was, on
so many sides, ready, as it was, to blossom wonderfully, had never
come to flower, still less to fruit. It was a great nature, checked by
some hunger of the soul, which (this is the sorrow of all beautiful
desire) would perhaps have destroyed the soul, had it been satisfied.
He was one who had loved for many years. He had paid away all the
gold of his life, for a sorrow and a few copper memories. He had
loved nobly, like a man of the heroic time, letting life go by him with a
smile, so long as the woman whom he loved might be spared one
little moment’s annoyance, one little wrinkling of the beautiful brow.
He had said to himself that he had worn this woman’s glove, and that
he would wear no other woman’s petticoat. And from long brooding
on this wayward beauty who had spoiled his life, he had learned
much of women. He understood them emotionally with a clearness
which sometimes frightened him. He felt that he took a base
advantage of them in allowing them to talk to him. Their hearts were
open books to him. Though the woman said, “Look on this page, or
on this,” his instinct, never wrong, revealed to him the page she tried
to hide; and his indulgence of this sense made him, at times, of little
use in conversation; for the revealed truth amused him more than its
polite screen. At times its possession saddened him, for he knew
that he would never exercise that sense in the tenderness of the
accepted lover, reading the unspoken thought in the beloved eyes. In
his person he was tall and finely built, but a certain clumsiness in his
walk made his appearance ungraceful when he left his chair. His
hands were singularly beautiful. His eyes were grey and deep-set.
His face was pale, inclining to sallow, but bronzed by the wind and
sun. He was careful, but quiet in his dress. He wore a black suit,
precisely cut, like the clothes of a Puritan, but for its fine lace collar
and elaborately carved buttons of scarlet ivory.
He had, as he felt, failed in life, because he had failed in love; a
point of view common among women, in a man a confession of self-
praise, selfishness, almost of vanity. He had allowed his passion to
keep him from action; by which, alone, growth or worth can be
determined. He, as a lover, having, as he thought, created a life for
himself, more beautiful, because intenser, than the lives of others,
even of artists, had lived retired, judging, as all retired men will, all
actions, all life, all things, by an arbitrary standard, his own standard,
the value of which he was incapable of judging. He had been certain,
led away, as he had been, by wild love, that his way was the way of
self-perfection, to which all ways assisted, rightly used. In so far as
his passion had fitted him for the affairs of the world, by adding
graces, or accomplishments to a nature rich already, he had profited.
He had studied arts, some half a dozen different kinds, so that his
mind might have the more facets to twinkle agreeably for his
mistress’s pleasure. But with the confidence of various skill had
come, also, intellectual pride; for to the man who knew a little of
many things, many things seemed little, since none, save a hopeless
passion, seemed great. With this had come a shrinking from the
world, a tolerance of it that was half contempt, a distrust of it that
was half sorrow for it. He lived away from the world, in a fanciful
chamber, where the kings of his imagination offered precious balms
for ever to the aloof lady, queen and saint. It was his fancy, in the
latter years of his passion, to sublime all human experience, to
reduce all action to intellectual essence, as an offering to her. This
had begun from a desire to amuse her in conversation. Later, as his
aloofness from the world drove him still more upon his folly, he had
one day trembled lest she should ask him something that he did not
know, or could not resolve. It had given to him a new interest in the
world; but a fantastic interest; he saw it only for her, to some extent
through her. He searched the measure of his friends’ experience,
trying to find, as he had tried that morning with Captain Cammock,
some purpose or delight, some glory or dignity in the various tale,
which might, in his own hands, become beauteous to her, and to
himself sweet, being, as he never doubted it would prove, less
glorious, less grand, than his daily experience of high emotion.
Now that the two friends were together in the cabin, there was a
silence. Throughout the meal Margaret had kept the old pirate
talking, in order to divert Perrin from the protests which he knew
would come. Now that they were alone, the protests were long in
coming. Perrin fidgeted between the table and the book-case, biting
his thumbs, evidently waiting for his friend to speak. At last, feeling
that he could wait no longer, and speaking crudely because he
spoke from his own initiative, he began—
“Look here, Charles, you ought not to go ashore to-day.”
“Why not?” said his friend. “It’s the end of everything.”
“Her marriage was the end of everything,” said Perrin. “Look here,
man, you’re coming this cruise to get rid of your sorrow. Don’t go
ashore and begin it all over again. You’ll only upset yourself, and
very likely give her pain.”
“You don’t understand, Edward,” said Margaret. “She has been my
whole life for four years. If I could. I don’t know. If I could, it might be
wiser to go away without a word. Ah, no, no. I can’t. You can’t cut off
a part of your life like that. I must go.”
“Well, then,” said Perrin, “I insist on coming with you. You’ll just
see her, and come away. I’m weak, I know, and all that; but I will
save you from making ducks and drakes of your life. If you see her,
you’ll see her with me. But I think you’re very unwise, Charles. If you
weren’t owner, I’d clap you in irons and put to sea. I know one thing.
If you see her, no good’ll come of it. Look here, man; do drop her,
and let’s get away while the wind holds.”
“No. I must see her,” said Margaret stubbornly. “And I couldn’t
have you with me. That’s impossible.”
“Why impossible?”
“Because. Well, we won’t talk of that. My mind is made up. By the
way, Edward, you were up very early, weren’t you?”
“I couldn’t sleep. I wanted to see the sunrise. I’ve heard so much
about sunrise at sea. And I got into talk with the captain. I told him a
little about our plans. I hope you don’t mind.”
“No. I’m glad. We shall have to go into that to-night. By the way,
Edward, I want you, after this, to stand two watches a day. I shall do
the same. We must learn what stuff our men are made of before we
reach Virginia; for in Virginia we shall have to weed out our crew. We
can have no skulkers where we are going.”
“All right, Charles. I’m going on deck now. I think you’re very
foolish. Your going to see her will do no good. So I tell you.
Remember me to her.” He picked up his hat, and walked out of the
cabin to the deck.
Captain Margaret rose from his chair, glanced through the stern-
port at the harbour, and sighed a little.
“Well,” he said abruptly, shrugging his shoulders, “what must be,
must be. Perhaps they’ll be out when I get there. Perhaps she’ll
refuse to see me.”
His mind, which now made none save romantic images, imaged
for him the Broken Heart at sea, under her colours, going over the
water, her owner looking astern at land he would never again tread.
It imaged for him a garden ashore, full of roses and tall white
campanulas. A lady walked there, looking seaward, regretting that
she had not seen him, that she had not bidden him good-bye. Oh,
very sweet, very tender, were the images which rose up in him, for
the ten thousandth time, as he stared out over Salcombe harbour.
And each image, each romantic symbol imagined or created, was a
heavy nail, a heavy copper bolt, nailing him within the coffin of his
past, among the skeletons of starved hopes and strangled passions.
 II.
A FAREWELL

“Farewell, thou art too dear for my possessing.”

Sonnet lxxxvii.

“Here take my picture; though I bid farewell,

Thine, in my heart, where my soul dwells, shall dwell.”
John Donne.

In a little room ashore, in a private suite of a big inn near the church,
Tom Stukeley sat alone at breakfast, staring down the garden,
across the sea, to the moored ships. He was a tall, powerful, well-
made man, of a physical type more common in Ireland than in
England, but not rare here. He was, above all things, a creature of
the body. One had but to look at him to realize that when he died
there would be little for Rhadamanthus. One could not like the man;
for though his body had a kind of large splendour, it was the
splendour of the prize cabbage, of the prize pig, a splendour really
horrible. It is horrible to see any large thing without intelligence. The
sight is an acquiescence in an offence against nature. Tom Stukeley
was designed by nature for the position of publican. He had the
vulgarity and the insolence of a choice English bagman, in the liquor
line, together with this handsome body, red face, and thick black hair.
By the accident of birth he was a gentleman. In seeing him one
realized the tragedy of life’s apportionments. One realized that to
build up this, this mass of mucous membrane, boorishly informed, lit
only by the marsh-lights of indulged sense, the many toiled in
poverty, in enforced though hated ignorance, in life without ease,
without joy.
His coarsely coloured face passed for beauty, his insolence for
strength of character, even for wit, among those men and women
with whom he consorted. His outward manner had something of the
off-handed ease of the inferior actor, who drinks, and tells tales, and
remarks upon the passing women. But he had little of the actor’s
good humour. He had, instead, that air of insolent superiority which
makes the inferior soul, arrogant always, like the dunghill cock,
clamorous of the glory of dung. In company he was rude to all whom
he did not fear. He was more rude to women than to men, partly
because he feared them less; but partly because his physical tastes
were gross, so that he found pleasure in all horse-play—such as the
snatching of handkerchiefs or trinkets, or even of kisses—in gaining
which he had to touch or maul his victims, whether protesting or
acquiescent. Women were attracted by him, perhaps because he
frightened them physically. His love affairs were not unlike the love
affairs of python and gazelle. “They like it,” he would say. “They like
it.”
To men whom he did not fear, to those of them, that is, who had no
advantage of fortune or position from which he could hope to profit,
he acted with studied rudeness, with the unintellectual unvaried
rudeness of a school bully, particularly if they displayed any little
sally of wit, any fondness for art, any fineness of intelligence beyond
him. It is possible to think of him with pity, as of one born out of his
due time and out of his right circle. He was a cad, born a gentleman.
He sat alone at breakfast, with the breakfast dishes pushed far
away from him; for he had risen late, and had sat late at wine the
night before. The thought of food was nauseous to him; he drank
small beer thirstily; and damned his wife under his breath for being
risen from table, as he would, perhaps, have damned her aloud had
she been present. He had been married for some three months and
had begun to find the simulation of virtue tedious. His head ached;
and he was very angry with his wife. He had married her for her
money, and he now found that the money was so tied that her
husband had no power over it; but that the trustees of her father’s
estate, who viewed him with no favour, had powers which he had not
suspected. Much as he had ever hated the law, he had never——
He rose up from his seat with an oath, believing for a wild moment
that the marriage might be set aside. She had misled him; she must
have known that all he wanted was her money. The marriage had
been a secret one. But that belief only lasted for a moment; he was
“married and done for,” and here was the lawyer’s letter refusing
supplies. He had run through their ready money at cards the night
before. All that remained to him was a handful of small change, and
a handful of tradesmen’s bills. All through breakfast the bills had
been arriving, for the word had spread abroad that the Stukeleys
were leaving Salcombe at the end of their third week’s stay. He had
been in awkward corners before; but never in the country, and never
before had he been involved with a wife. He could not think what to
do, for his head ached furiously. He had made too free with the
common purse in the certainty of receiving money that morning.
“Your obedient servants,” ran the letter. He stamped up and down
the room, swearing and biting his nails. He could not return to
London without money; nor did he dare to return; for he had many
debts, and feared arrest. He wondered whether Olivia had any
friends in those parts from whom he or she might borrow money. “It’s
time Olivia got broken in,” he thought.
A servant entered with a letter. He took it from her, staring at her
with the hard insolence of his class. The girl dropped her eyes,
looked confused, and then smiled at him.
“Aha,” he said lightly. He caught her hand and pressed it, still
looking into her eyes.
“No,” said the girl hurriedly. “There’s some one coming.”
“You’re my little duckling, aren’t you?” he said softly, catching her
round the waist.
“Be quiet,” she answered, frightened. “I’m sure I hear some one
coming.”
He listened for a second, maintaining his hold. “Nonsense,” he
said. “Nonsense, Amy.”
“My name’s Jessie,” she said pertly.
He bent and kissed her lips; the girl made some show of virtue by
calling him a bad man.
“Oh law,” said Jessie, breaking from him hastily. “There’s some
one——” She seized two plates upon the table, and made a bustling
pretence at clearing away. On learning that it was a false alarm, she
looked at him with a sort of slinking grace.
“You’ve made my hair untidy,” she said reproachfully.
He walked up to her, laughing. She backed from him with a grin.
“Jess-ie,” came a cry from without.
 “It’s missus,” she said, terrified, going to the door.
“Yes, mum.”
“The man wants an answer for that letter he brought.”
“Yes, mum,” she cried. “In a minute, mum. There’s an answer, sir.
What’s the answer, sir?”
Stukeley tore the paper open. A bill fell out.
“Oh damn,” he exclaimed. “Tell him I’ll look in in the morning.”
Jessie carried the message to the bearer; and returned with
another.
“Please, sir, the man says he won’t go unless he has his money,
sir.”
“Won’t he?” said Stukeley angrily. “I’ll see whether he won’t.”
He picked up his cane and walked out swiftly. The servant listened
at the door for the details of the quarrel.
“Hark-ee,” came Stukeley’s voice. “Here’s your bill. D’ye see it?
There!”—there came a sound of tearing paper—“Now take that back
to your master. Next time you disturb me at breakfast I’ll break your
head. Get out of this.”
The haberdasher’s clerk withdrew. The landlady aided his retreat
with a few words about not having her guests disturbed.
Stukeley returned to his breakfast-room. Jessie looked at him
admiringly.
“Aha, Jessie,” he said. “What nice arms you’ve got. Eh? Haven’t
you? Eh? Beautiful arms.” He pinched them, following her about as
she backed to avoid him.
“You’ve got a wife,” said Jessie. “What do you want with arms?
Don’t! Don’t! You’ll make me scream out.”
Again came the voice of the mistress.
“Jessie! Jessie! Drat the girl.”
The amorous by-play ceased; Jessie went swiftly.
She soon returned, bringing a visitor, a coarse fair-haired man,
with a face not unlike a horse’s face, but without the beauty. His
cheeks were rather puffy; his eyelids drooped down over his eyes,
so that he gave one the impression of extreme short sight, or of
some eye-disease. He peered out under his eyelids. One felt that the
house so lit was a dark, narrow, mean little thieves’ house.
“Mr. Haly to see you, sir,” said Jessie.
 Mr. Haly entered, to find his friend Stukeley retiring through the
other door. He turned back in the doorway on hearing the name.
“Oh, it’s you, Monty,” he said. “What brings you to Salcombe?”
“You took me for a dun,” said Mr. Haly, with a jocular whine
peculiar to him. “You took me for a dun. I’ll sit down, if this pretty
charmer here”—he ogled Jenny, with a look which would have made
a wanton chaste—“will give me a chair. Thank you, my dear.” He sat
down; Jessie left the room.
“I’ve come down with young Killigrew,” he said. “He offered to pay
my expenses. So I thought I’d look you up, to see how married bliss
looks. Hey, Tom? How’s the wife? Hey, Tom? How’s Cupid’s dove?
Hey? I suppose she’s making little clothes already? Hey?”
He laughed pursily; helped himself, unbidden, to the beer, cut
himself a snack from his friend’s untasted breakfast, buttered it
thickly, and began to eat. His friendships were selfish always. “Give
nothing, but take all you can get,” would have been his motto, had he
had sufficient intellect to think it out. It had helped him in the world;
but his greed, never sated, had perhaps helped him less than his
power of flattering those who were richer, but no more intelligent
than himself. Stukeley ignored his friend’s questions, not because he
objected to them, but because he expected something more from Mr.
Haly.
“There was another reason why I called,” said Haly, after a pause.
“I travelled down from town with old Bent, your landlord that was.”
“With old Bent?” said Stukeley, becoming more attentive.
“Yes,” continued Haly. “He’d heard you were in Salcombe. I
believe he wants to see you.”
“Damn it. He does,” said Stukeley.
“Well,” said Haly, “then I hope it’s not a large sum. But still, now
you’re married to an heiress, you lucky dog, why, you can laugh at
old Bent, I should think.”
“Yes,” said Stukeley quietly. “What time is old Bent coming here?”
Haly shrugged his shoulders. “We’re not in town now,” he said.
“He might come any time.”
Stukeley offered his friend some more beer.
“By the way, Tom,” said Haly, “I don’t want to rob you, but could
you lend me a fiver, just to go on with?”
 “I’m sorry, Monty,” said his friend; “I never lend money.”
“Oh, come, Tom,” said Haly. “Don’t be a swine, man. I’d lend it to
you fast enough. I’d not see a friend in want.”
“I know you wouldn’t,” said Tom. “But I never lend money.”
“Damn it,” said Haly, lowering his voice to a whining reproachful
tone. “Well, I wouldn’t be a mean swine. Lord, man! I gave you the
office about Bent. You might have a little gratitude. What’s a fiver to
you? Don’t be a swine, man. I wouldn’t refuse you, I know.”
Stukeley stared insolently at Haly’s blinking eyes. He seemed to
relish the man’s disappointment.
“No! Can’t be done, Monty,” he said. “Have some more buttered
toast, instead—with sugar on it.”
Haly had already eaten plenteously of this dainty; he was not to be
comforted with flagons.
“You are a swine,” he said angrily. “Now you’re married, I suppose
you’re going back on your pals. You dirty swine. My God! I wouldn’t
be mean like that. Well, keep your fiver. But old Bent shall hear
something. Yes, and my new wife shall hear something. My wife
Olivia, Olivia.”
Stukeley watched his friend with careless tolerance, ringing the
bell meanwhile, with a hand stretched idly behind him. He laughed
lightly, bidding Haly to be of good cheer. When Jessie came, in
answer to the bell, he bade his friend good morning, and bowed him
out. Haly disappeared, cursing.
When he had gone, Stukeley wondered if he had done wisely in
choking off Haly so soon. He had made up his mind, during the
months of his honeymoon, to break with his old circle; for his wife’s
friends were rich and powerful, and his own friends, being men about
town, had never been more to him than flash companions. Besides,
he realized that a man like Haly was hardly likely to bring him credit
with his new acquaintances. And anyhow his headache made him
devilish, and he had had pleasure in seeing the horse-face flush, and
the little mean eyes blink with anger. He did not set much store by
the man’s threats. If old Bent had come to Salcombe after him, he
would see his victim, whether Haly helped or refused to help. He did
not rightly know what he could say to old Bent, and his head was
throbbing and in pain; he could not think. Jessie returned to clear
away; but even Jessie would not comfort him, for missus was in the
next room and could hear every word.
“Perhaps after dinner,” said Jessie.
Something in the girl’s coyness stirred his lust. He caught hold of
her, shutting the door with his disengaged hand.
“You are a naughty man,” said Jessie reprovingly.
He drew her head back and kissed her lips and throat. Something
in the girl amused him and excited him. He was conscious of a
sudden anger against Olivia. She needed some devil of wantonness,
he thought. She never moved him as this tavern trollop moved him.
“Do you love me?” said Jessie.
“Yes,” he said passionately.
“I seen you look at me,” said Jessie.
It had been love at first sight. While they kissed, Olivia’s voice
sounded clearly in the passage. “I’ll see him in the breakfast-room,
with Mr. Stukeley.”
“Oh law!” said Jessie, wrenching herself free. “Go inside, Mr.
Stukeley. Don’t let’s be seen together.”
“Bent already,” said Stukeley, slipping into the inner room.
He went so quickly that Jessie’s question, “Is my hair tidy?” was
unanswered. As Jessie dabbed at her hair before the mirror, Olivia
entered. She thought that Jessie’s heightened colour and nervous
manner were signs that she was ashamed of being caught at a
glass. She smiled at the girl, who smiled back at her as she hurried
to remove her tray. Had Olivia looked at Jessie as she left the room
with the table-cloth, the trollop’s gaze of confident contempt would
have puzzled her; she might, perhaps, have found it disquieting.
She had only been married a few weeks; and she loved her
husband so dearly that to speak of him to any one, to an inn-servant,
for example, seemed sacrilegious to her. She felt this very strongly at
this moment, though she longed to ask Jessie where her husband
might be found. She felt some slight displeasure at her husband’s
absence, for he had never before left her for so long. This breakfast
had been the first meal eaten apart since the day of their marriage.
When Jessie had left the room, she looked at her image in the
mirror, straightening the laces at her throat and smoothing the heavy
hair, one of her chief beauties. She loved her husband. All other men
were mere creatures to her—creatures with no splendour of circling
memory, creatures of dust. But the announcement that Captain
Margaret was even then without, waiting to be admitted, was
somehow affecting. She felt touched, perhaps a little piqued. He had
loved her, still loved her, she felt. She had never much cared for him,
though she had found a sort of dreadful pleasure in the
contemplation of her power over him. At the moment, she felt a little
pity for him, and then a little pity for herself. Now that she was
married, she thought, she would be unattractive to him; her power
would be gone; and as that was the first time the thought had come
to her, it made her almost sad, as though she were parting with a
beautiful memory, with a part of her youth, with a part of her youthful
beauty. Her look into the glass was anxious. She was eager to look
her best, to make the most of her pale beauty; for (like less intelligent
women) she believed that it was her beauty which most appealed to
him. As a matter of fact it was the refinement of her voice which
swayed him, her low voice, full of music, full of intensity, of which
each note told of an inner grace, of some beauty of mind
unattainable by men, but sometimes worshipped by them. She was
not a clever talker. Her power lay in sympathy, in creating talk in
others, for when she was of a company it was as though music were
being played; the talk showed fine feeling; at least, the talkers went
away delighted. She had a little beauty. Her eyes were beautiful; her
hair was beautiful; but beautiful beyond all physical beauty was the
beauty of her earnest voice, so unspeakably refined and pure,
coming holy from the inner shrine.
She had not waited a minute, before Captain Margaret entered.
She had expected to see him troubled, and to hear the ring of
emotion in his voice as he greeted her. She had half expected to be
surprised by some rush of frantic passion. But he entered smiling,
greeting her with a laugh. She felt at once, from his manner, from his
obvious dislike for her hand, which he scarcely touched and then
dropped, an implied shrinking from her husband. It gave her
firmness. He looked at her eyes a moment, wondering with what love
they had looked at Stukeley during the night-watches. The thought
came to him that she was a beautiful soiled thing, to be pitied and
tenderly reproved. The image of Stukeley cast too dark a shadow for
any brighter thought of her. When she began to speak she had him
bound and helpless.
“Well, Olivia,” he said gaily, “I’m glad I came in time to catch you.”
“Yes,” she answered, “we were just going. We have been—— And
how did you come here?” She found it harder to talk to him than she
had expected.
“I came here in my ship,” he answered. “I wanted to see you, to
wish you, to hope—to wish you all happiness. Before I leave
England.”
She smiled.
“Thank you very much,” she said. “Are you leaving England for
long?”
“It may be a long time. If all goes well, it will be a very long time.”
“I had not heard that you were going abroad. To what part are you
going? Italy again?”
“No. I’m going to Darien.” It seemed to him to be almost tragical
that she really did not know where Darien lay. “The Spanish Main,”
he added.
“Ah, yes,” she said.
He covered her retreat by saying that he was going to Virginia first.
She looked at him with quickened interest.
“Going in your ship,” she said. “That sounds very grand. Is she in
Salcombe here? Which is she among all those schooners?”
“That one,” he answered, pointing through the window. “The ship
with the flag.”
“And you’re leaving England at once?”
“Yes. This afternoon’s tide.”
“But what are you going to do when you get there?”
“Oh, don’t let’s talk about that,” he answered. “Tell me about
yourself, and your plans. What are you going to do, now you’re
leaving Salcombe? Will you go home to Flaxley?”
“No,” she answered, colouring slightly. “Uncle Nestor was rather
rude to Tom, to my husband.”
The captain bit his lip, and gazed out absently over the sea. He
had heard why Uncle Nestor had been rude. The knowledge made
him doubtful of Olivia’s future happiness.
 “So I suppose you’ll go back to town,” he answered, “and settle
down. What do married people do, when they settle down?”
“Oh,” she said, “I’ve great schemes for Tom. He’s going to stand
for Parliament. But I want to know what you’re going to do in Darien.
What is your scheme?”
“Just to help the Indians,” he answered. “The Spaniards have
robbed them and ill-treated them, and I thought that if some
Englishmen settled on the Isthmus, and opened up a trade with
them. For you see, we could trade with both Jamaica and Virginia.
And if we opened up a trade there, we could check the Spanish
power there, making the Indians our allies.”
“And what would you trade for, or with? It sounds very romantic.”
“The country is very rich in gold. Gold is found in all the rivers. But
of course the gold is not to be our aim. I want, really, to found an
English colony; or a colony of workers, at any rate. The Spanish
colony is just a press, which squeezes the land. Now the land ought,
in a sense, to squeeze the colonists. It ought to bring out all their
virtues. That is what I want. The country will have to be cleared. And
then we shall plant cacao, or whatever the land is fit for, and—— The
scheme is thought out, in detail. I’m confident; but I won’t talk about
it.”
“And the Indians will be your allies?” repeated Olivia; “and the
Spaniards will probably fight you?”
“Yes,” he answered. “And you will be in a townhouse in London,
going to the play, or dancing at a ball, in grey silk.”
“Blue, or grey.”
“And you will give sprigs of verbena to those who see over your
garden in the country.”
“And when will you come for some?”
“Ah! I shan’t see that garden again, for a long, long time.”
“We’re going to plant all sorts of things, when we get home. You
must send some roots from Darien.”
“I should like to do that. We have been such—such friends.”
“In the old days.”
“Yes,” he said, rising. “Now I must be off.”
“Oh, but you ought not to go yet.”
“I only just came ashore to see you.”
 “Oh, you must stay to see my husband. He wants to see you. He’ll
be so disappointed if you don’t stay to see him.”
“You must make my apologies. Good-bye, Olivia.”
She held out her hand without emotion of any kind. She would
have shaken hands with any other acquaintance with just so little
feeling. Margaret wondered what it was that would get within her
guard. He took her hand. He tried hard to say no more, but failed,
being sorely tempted.
“God bless you,” he said. “I hope you will be very, very happy. God
bless you, dear. I wonder if I shall hear of you ever. Or see you
again.”
“If you want to, you will,” she said simply, glad that it had gone no
further.
“Yes, I shall see you again,” he said.
“Of course you will,” she answered. “I hope your colony will be a
success.”
Something in her voice made the conventional words beautiful.
Captain Stukeley, on the other side of the door, hearing that quality
in his wife’s voice, wished that the keyhole were bigger. With an
effort, Captain Margaret rewarded that moving tone.
“When I come back,” he said, “I hope that I shall get to know your
husband. Make my apologies to him.”
“Good-bye again,” she said.
Her voice seemed to come from her whole nature. All that her
lover could remember afterwards was the timbre of the voice; he had
no memory of her face. Her eyes he remembered, and her heavy
antique ear-rings. “Eyes, ear-rings, and a voice,” he repeated,
walking down to the jetty. He wondered what she was. “What is she?
What is she? Oh Lord, what is she?” He could not answer it. She
was beautiful. Most beautiful. Beautiful enough to drive him mad. Her
beauty was not a bodily accident; but a quality of soul, the quality of
her nature, her soul made visible. But what was she? She had talked
commonly, conventionally. She had said no wise thing, no moving
thing. Never once had she revealed herself; she was only kind, fond
of flowers, fond of music, a lover of little children. But oh, she was
beyond all beauty, that dark, graceful lady with the antique ear-rings.
It was her voice. Any conventional, common word her voice made
beautiful. He wondered if she were, after all, divine; for if she were
not divine, how came it that her voice had that effect, that power? He
felt that human beings were all manifestations of a divine purpose.
Perhaps that lovely woman was an idea, an idea of refinement, of
delicate, exquisite, right grace, clothed in fitting flesh, walking the
world with heavenly intention. But if that were so, how the devil came
Stukeley there, that was the puzzle? The blood came into that pale
face sometimes; and oh, the way she turned, the way she looked,
the way of that voice, so thrilling, so infinitely beautiful. Ah well; he
had played and lost, and there was his ship with her flag flying; he
was bound down and away

Along the coast of New Barbary.

But he had loved her, he had seen her, he had been filled with her
beauty as a cup with wine. He would carry her memory into the
waste places of the world. Perhaps in the new Athens, over yonder,
among the magnolia bloom, and the smell of logwood blossom, he
would make her memory immortal in some poem, some tragedy,
something to be chanted by many voices, amid the burning of
precious gums, and the hush of the theatre. On the way, he stopped,
thinking of her personal tastes. He, too, would have those tastes.
Little things for which she cared should come with him to the Main.
He gave the merchant the impression that he was dealing with one
melancholy mad.
Drums sounded in the street, for troops were marching west, to a
rousing quick-step. They marched well, with their heads held firm in
their stocks. The sergeants strutted by them, handling their halberds.
Captain Margaret paused to watch them, just as a sailor will stop to
watch a ship. “They are like the world,” he thought. “The men drop
out, but the regiment remains. It still follows the rags on the
broomstick, and a fool commands it, and a halberd drills it, and
women and children think it a marvellous fine thing. Well, so be it.
I’ve bought my discharge.” The fifes and drums passed out of
hearing. “They’ll never come back,” he said to himself. “Perhaps
twenty years hence I shall meet one of those men, and be friends
with him. Why not now? And why should I see that regiment now?
What does it mean? It is a symbol. All events are symbols. What
does it mean? What is it a symbol of? Why should that regiment
pass to-day, now, after I’ve bidden my love good-bye? And what
ought I to learn from it? What message has it for me?” He was
convinced that it had a message. He stood still, looking down the
road, vacant as a British statue.
He woke up with a start, remembering that he had to buy some
materials for the practice of one of his amusing handicrafts. A little
gold, some silver, and a few stones of small value, together with
glass beads, were all that he needed. He was planning to make
jewels for the Indian princesses. “Beads is what they goes for,” so
Cammock had said. He bought large stores of beads. He also
bought materials for a jewel for Olivia, thinking, as he examined the
gems, of the letter he would send with the gift. “It will be written
under palm-thatch,” he thought, “in the rains.” He was able to plan
the jewel in all its detail. People stared at him with curiosity. He was
speaking aloud as he walked. “Nothing matters very much to me,” he
said. “I know the meaning of life. Life and death are the same to me.”
So saying he arrived upon the jetty, and hailed his boat, which lay at
a little distance, her oarsmen playing dice in the stern-sheets. His
purchases were stowed between the thwarts, a few grocer’s boxes
made an obelisk in the bows. As they shoved off, there came a flash
of fire from the side of the Broken Heart. White smoke-rings floated
up and away, over her topgallant-masts. Grey smoke clung and
drifted along the sea. The roar of the cannon made the Salcombe
windows rattle. The boat’s crew grinned. Being boatmen, they had
escaped the gun-drill. They knew what all hands were getting from
the stalwart Cammock.
He stepped quickly up the side, acknowledging Cammock’s salute
and the pipe of the boatswain. Perrin met him at the break of the
poop. He noticed that Perrin stared rather hard at him. He grinned at
Perrin cheerfully.
“Yes, I saw her,” he said gaily.
It seemed to Perrin that his gaiety was natural, and that, perhaps,
the sight of Mrs. Stukeley, with her husband, had proved an effective
cure. A gun’s crew swayed the gear out of the boat. The other guns’
crews, heaving the heavy trucks, training the guns forward, wished
that they might help. Captain Cammock resumed his drill.
“Starboard battery, on the bow!” he exclaimed. “Port battery, upon
the beam. Imagine them hulks. Them’s the enemy. Bring aft your
train tackles. No. No. Oh, what are you playing at? Drop them
blocks. What in hell are you thinking of there, number three? I’m not
talking to you, port battery. Now. Wait for the word of command. Take
heed. Silence. Silence there. Now. Cast off the tackles and
breechings. Carry on.”
The figures by the guns became active. Though they carried on “in
silence,” there was a good deal of noise, many muttered oaths,
much angry dropping of rammers. Captain Margaret stood by
Cammock, waiting till the guns were fired. He had learned the
practical part of naval gunnery from a book in Cammock’s cabin, The
Mariner’s Friend, or Compleat Sea Gunner’s Vade Mecum. He
watched the drill wearily, knowing how hard and dull a thing it was to
the men who swayed the tackles, and hove the trucks along with
crows. In the moment of peace after the broadsides, he felt a pity for
his men, a pity for humanity. He had hired these men at four shillings
a week apiece. He gave them their food, worth, perhaps, tenpence a
day, with their rum worth twopence more, bought wholesale, out of
bond. “For eleven shillings a week,” he thought, “a man will clog his
heavenly soul with gun-drill, which his soul loathes; and refrain from
drabs and drams, which his soul hungers and thirsts for.” He felt
ashamed that he had not thought more of his men’s comfort.
“You’ve got them into shape already, captain,” he said.
“I’ll get them into trim in time,” answered Cammock. “It takes time.”
“Yes,” said Margaret, “it takes time.” He paused a moment,
remembered his kindly feeling, and continued. “I want to ask you
about fresh meat, captain. Shall I get some fresh meat here, to see
us well into the Western Ocean? Or flour, now? I want the hands
kept in good trim. I don’t want to lose any by sickness.”
“Fresh meat is always good at sea,” said Cammock. “But there’s
better things than meat. For keeping a crew in good shape, you can’t
beat sugar and flour. It takes the salt out of their bones.”
Perrin had joined them. “I’ve ordered fresh meat and sugar,” he
said. “And three dozen fowls. They’ll be off in about an hour’s time.”