Purpose/goal. Statementt. Objectives After. Requirements. Sponsorship. reading this. 2. Read and. review the. completion. Institute, an.

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1 INSTRUCTIONS & DISCLOSURE STATEMENT Course 2: Competency Assessmen nt Purpose/goal Statementt The purpose of this chapter is to describe the methodology for assessing competency of members of the nursing and ancillary support team responsible for delivery of care in the operative/invasive procedural areas. Target Audience: Perioperative RNs Objectives After reading this chapter, the participant should be able to: 1. Define competency assessment as it pertains to the operative and invasive procedure period. 2. Describee nursing roles in the operating and invasive procedure suite. 3. Identify the patient care events of the operative and invasive procedure suite. 4. Identify the components of the competency continuum. Requirements for Successful Completion Using this self-directed learning module: 1. Review the above learning objectives. 2. Read and review the course which is available at: 3. Access the online quiz which is available at 4. Provide your purchase order number as found on the CCI bookstore order confirmation . If you have trouble locating this, pleasee contact CCI at Completee the evaluation questions and successfully pass the ten item multiple-choice quiz. A score of 70% is equired to pass, and you have two attempts. 6. Receive certificate of completion and 1.4 contact hours in approximately 2-3 weeks. If you hold the CNOR and or CRNFA credential, the contact hours will be added to your online CCI account. Sponsorship Neither the program planners, authors, or reviewers have any conflict of interest related to this program. No commercial or n-kind support has been obtained for this offering. There is no discussion of a product used for a purpose other than for which it is approved by the FDA. This activity was approved for 1.4 contact hours by the Competency and Credentialing Institute, an approved provider of continuing education by the California State Board of Nursing, Provider number Activities that are approved by CCI are recognized as continuing education for registered nurses. This recognition does not imply that CCI or the California State Board of Nursing approves or endorses any product in the presentation. The contact hours for this activity will expire on June 17, 2014.

2 CHAPTER 2 Competency Assessment In the Operative and Invasive Procedure Setting Michelle Byrne INTRODUCTION As operative and invasive procedures and the associated technologies have evolved, becoming more sophisticated and complex, many procedures are being performed in settings such as offices, cardiac catheterization laboratories, interventional radiology suites, gastrointestinal laboratories, and free-standing clinics, as well as the traditional setting of the operating room. Complexity and increased sophistication in the delivery of operative and invasive procedure services have led to advances in patient care and outcomes not imagined a decade ago. However, this complexity and sophistication have also stressed the delivery system, to include the human factor, to the point that agencies such as the Joint Commission and Centers for Medicare-Medicaid Services have focused attention on adverse outcomes and require facilities to provide definitive plans that address these unfortunate events. Competency assessment is one of the tools healthcare facilities can use to build a culture of quality patient care and potentially reduce the number of adverse outcomes. Competency assessment within the operative and invasive procedure setting is a means of determining if nurses, surgical technologists, and other staff members, to include physicians and anesthesia providers, are proficient and have demonstrated the knowledge, cognitive skills, and psychomotor skills necessary to provide safe patient care relevant to their specific role function. This chapter will address competency assessment for members of the nursing team which includes registered nurses, licensed vocational nurses, surgical technologists, and others engaged in delivery, or supporting the delivery of nursing care, in the operative and invasive procedure Chapter Contents 18 Introduction 19 Nursing Roles in the Operative and Invasive Procedure Suite 20 Practice Models for the Delivery of Nursing Care in the Operative and Invasive Procedure Area 25 The Competency Continuum 37 Manufacturer Instructions for Use 37 Conclusion 38 References

3 Chapter 2: Competency Assessment 19 suite. The chapter will discuss practice frameworks for the delivery of nursing care in the operative and invasive procedure setting that can be used to develop competency assessment tools, a model for skill acquisition, methodologies for assessing competency, agencies that provide resources for assessing competency, and sample competency assessment tools. NURSING ROLES IN THE OPERATIVE AND INVASIVE PROCEDURE SUITE Nursing roles within the operative and invasive procedure setting are highly differentiated and include direct patient care as well as roles that indirectly address patient needs. The primary direct patient care roles for the registered nurse are scrubbing and circulating. When performing these roles the registered nurse provides care during patient care events that were previously described in Chapter lists these patient care events which are common to most procedures performed in the operative and invasive procedure setting. Another direct care role is first assistant. Registered nurses performing this role assist the surgeon during an operative procedure. Role functions include handling tissue with instruments and providing hemostasis during the procedure. New knowledge impacts patient care. Informatics, sterile processing, genetics, and environmental issues have pushed the boundaries of nursing practice in the operative and invasive procedure suite. Nurses must continue to learn and integrate new knowledge into existing roles or tasks. Nurses in Advanced Practice Registered Nursing (APRN) roles in operative and invasive procedure settings continue to increase in numbers. Their roles are varied and continue to expand as more specialized knowledge is necessary due to the increasing complexity of patients and the technologies APRN Advanced Practice Registered Nursing Patient Care Events of the Operative and Invasive Procedure Suite Before the Procedure 1. Prepare the patient for the procedure During the Procedure 2. Transfer the patient 3. Assist the anesthesia provider 4. Position the patient 5. Establish and maintain the sterile field 6. Perform sponge, sharp, and instrument counts 7. Provide instruments, equipment, and supplies for the procedure 8. Administer drugs and solutions 9. Physiologically monitor the patient 10. Monitor and control the environment 11. Handle cultures and specimens After the Procedure 12. Facilitate care after the procedure

4 20 Section 1: Conceptual Fundamentals of Practice 2.2 Role Definitions of Roles in the Operative and Invasive Procedure Setting Definition Circulating nurse Scrub person First assistant Advanced practice nurses A registered nurse who coordinates and manages each surgical patient s operating room care by assessing, planning, intervening, evaluating and documenting patient care and patient outcomes. This nurse is the team leader in each operating room and the designated patient advocate. A registered nurse, licensed practical nurse, or surgical technologist who performs hand asepsis and is considered a sterile member of the surgical team. This team member is responsible for maintaining the integrity of sterile instruments and supplies used at the surgical site and passing instruments to the surgeon and first assistant. Another MD or DO, a medical student, a registered nurse first assistant (RNFA), a nurse practitioner (NP), a physician s assistant (PA), or a surgical technologist (ST) who is designated to assist the surgeon at surgery. The first assistant s technical skills may include suturing, providing hemostasis, and retracting tissue depending on state s scope of practice laws, institutional policies, and education level of the individual. The first assistant is a sterile member of the surgical team. Four primary roles include clinical nurse specialist (CNS), certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), and nurse practitioner (NP). These registered nurses have completed a master s or doctoral degree, have specialized in perioperative patient care, and may hold various roles in the perioperative arena. used to care for them (King, 2007). 2.2 lists of some of the current direct-care nurse roles found within the operative and invasive procedure setting. Indirect patient care roles support the registered nurse in providing direct care. These roles include nurse educators, administrators, researchers, or industry consultants who can strongly impact patient care practices and decisions without having a direct hands-on relationship with the patient. There are many professional and paraprofessional personnel with whom registered nurses must work and sometimes supervise. The operative and invasive procedure setting is interdisciplinary and multidisciplinary with physicians and anesthesia providers being integral team members who also provide patient care. Strategies must be developed to inspire teamwork and collaboration. These strategies include communication, patient advocacy, and leadership skills. PRACTICE MODELS FOR THE DELIVERY OF NURSING CARE IN THE OPERATIVE AND INVASIVE PROCEDURE AREA Practice models that provide frameworks for the delivery of patient care within the operative and invasive procedure area should serve as the foundation for the development of competency assessment strategies and tools. Two of these models

5 Chapter 2: Competency Assessment 21 are the Systems-In-Contingency Model for the Patient Undergoing an Operative or Invasive Procedure and the Association of perioperative Registered Nurses (AORN) Perioperative Patient-Focused Model. Other resources for developing competency assessment tools are the Perioperative Nursing Data Set and the AORN Competency Statements in Perioperative Nursing, the Perioperative Nursing Advanced Practice Nurse Competency Statements, and the Perioperative Care Coordinator Nurse Competency Statements. AORN Association of perioperative Registered Nurses 2 The Systems-in-Contingency Model for the Patient Undergoing an Operative or Invasive Procedure Chapter 1 provides an in-depth discussion of the Systems-In-Contingency Model for the Patient Undergoing an Operative or Invasive Procedure. This model is used in this text as the predominant framework for competency assessment within the operative and invasive procedure setting. As shown in 2.1 there are twelve patient care events that the registered nurse performs or manages during the operative and invasive procedure period. Each event can be sub-divided into nursing care activities that range from the very simple to the complex. As an example, 2.3 lists the activities for the patient care event titled Provide Instruments, Equipment, and Supplies. The list is not all-inclusive and may include other activities as identified by the facility. Competency assessment tools developed using the Systems-in-Contingency Model focus on evaluating proficiency of the nurse and others, such as surgical technologists and attendants, doing these activities, or subsets of the activities, particularly if the activity is inherently risky to the patient, if not performed correctly, such as Applying and Removing a Pneumatic Tourniquet. See 2.4 for an example of a competency assessment tool for Applying and Removing a Pneumatic Tourniquet. 2.3 Performance Criteria Provide Instruments, Equipment, and Supplies Identifying the patient s risk for adverse outcomes related to the provision of instruments, equipment, and supplies Selecting appropriate instrumentation, equipment, and supplies for an operative or invasive procedure Delivering instruments and supplies to the sterile field Arranging instruments and supplies on the back table and Mayo tray Passing instruments and supplies to the physician or assistant Preparing and passing sutures to the physician or assistant Preparing and applying patient warming systems Applying and removing a pneumatic tourniquet Preparing air-powered instrumentation for use Implementing electrosurgical safety precautions Applying dressings Assisting with the application of casts and splints Preparing and operating endoscopic equipment

6 22 Section 1: Conceptual Fundamentals of Practice 2.4 COMPETENCY ASSESSMENT: Position the Patient Name Title Unit Date of Validation Type of Validation: Initial (by educator) Annual (by peer) Method of Evaluation: Observation COMPETENCY STATEMENT: The nurse demonstrates competency to position the patient for an operative or invasive procedure. Score Performance Criteria Identifies physical alterations that require additional precautions for procedure-specific positioning Identifies individuals at risk for positioning injury Reviews chart for information on patient s weight, preexisting medical conditions, and laboratory results Interviews patient for history of implanted devices Examines patient skin condition, Loss of Consciousness (LOC), perception of pain, presence of peripheral pulses, and mobility impairments Assesses external devices (eg, drains, catheters, orthopedic immobilizers) Applies antiembolism stockings in a manner to minimize friction injuries Implements measures to prevent inadvertent hypothermia Maintains safe transport environment through use of elevated bed rails, safety straps applied, additional devices secured (eg, oxygen tanks, IV poles, Foley catheter, chest tube) Supervises placement of equipment and/or surgical instruments on patient Monitors patient for external pressures applied by members of healthcare team. Verifies presence of prosthetics or corrective devices Identifies presence of or use of prosthetics or corrective devices and modifies nursing care as indicated for planned procedure Determines presence of metal and synthetic prostheses and implants, pacemakers, automated implanted cardioverter defibrillators (AICD), hearing augmentation devices, intraocular lenses, or plastic/fluid implants (eg, penile implants, testicular implants, breast implants) and notifies appropriate members of healthcare team Individualizes plan of care to accommodate prosthetic or corrective devices. Positions the patient Determines the need for, prepares, applies, and removes devices designed to enhance operative exposure, prevent neuromuscular injury, maintain skin and tissue integrity, and maintain body alignment and optimal physiological functioning Selects positioning devices based on patient s identified needs and the planned operative or invasive procedure Positions patient on stretcher with side rails up and wheels locked when: Awaiting admission to OR. Procedure is completed on the stretcher Determines that devices are readily available, clean, free of sharp edges, padded as appropriate, and in working order before placing patient on the OR bed.

7 Chapter 2: Competency Assessment Modifies OR bed as necessary before attaching positioning devices Reviews chart for information on patient s weight, preexisting medical conditions, previous surgeries, and laboratory results Assesses functional limitations while patient is awake and responsive Assesses patient for presence of skin conditions, LOC, perception of pain, presence of peripheral pulses, and mobility impairments while awake Adapts positioning plan to accommodate limitations Maintains body alignment Maintains proper alignment of legs (uncrossed) Uses positioning devices to protect, support, and maintain patient position Attaches padded arm boards to bed at less than 90 angle Places patient s arms on boards with palms up and fingers extended or secures arms at patient s side in neutral position Places fingers in position clear of table breaks or other hazards Applies safety belt loosely so blood flow is not compromised Protects body parts from contact with metal portions of OR bed Protects patency of tubes, drains, and catheters Prevents limbs from dropping below bed level to prevent compression of peripheral nerves Rechecks body alignment, extremities, safety strap, and all padding if repositioning occurs Removes positioning devices cautiously after surgery while maintaining body alignment and homeostatic status. Evaluates for signs and symptoms of injury as a result of positioning Observes for signs and symptoms of injury to integumentary, neuromuscular, and cardiopulmonary systems as a result of the patient s position during the procedure Examines patient to assess peripheral pulses and/or neuromuscular impairments Examines sites related to positional devices for signs and symptoms of skin/tissue injury Examines pressure areas for signs of skin injury Assesses and monitors vital signs. Scoring 1 Did not demonstrate competency 2 Minimal competency 3 Competency 4 Exceptional competency 5 Outstanding competency Comments (mandatory for scores of 1, 2, 4, or 5) Validator s Signature Employee s Signature Validator s Printed Name Employee s Printed Name

8 24 Section 1: Conceptual Fundamentals of Practice The Perioperative Patient-Focused Model The Perioperative Patient-Focused Model (Fig 2.1) was created to provide a framework for perioperative nursing practice (AORN, 2008). Similar to the Systems-in-Contingency Model, at the center of this model is the patient, thus emphasizing that the patient provides the focus for all activities. Four concentric circles move outward from the patient-centered model. These circles dissect three patient-centered domains addressing patient safety, physiologic responses to surgery, and behavioral responses of the patient and the family. The fourth quadrant addresses the healthcare system within which nursing care is provided. The healthcare system includes benchmarks, positive outcomes with reporting and structural elements all with the goal of providing patient-centered care (AORN, 2008). PNDS Perioperative Nursing Data Set The Perioperative Nursing Data Set (PNDS) The Perioperative Patient Focused Model not only guides patient care but is the foundation for a clinical information infrastructure known as the Perioperative Nursing Data Set (PNDS; AORN, 2007). This data set has been used in perioperative nursing for over 10 years to support safe, outcome-oriented patient care. This PNDS provides perioperative nomenclature that can be used for communicating information that is reliable and valid. The language and taxonomy provide an objective and standardized method for communicating perioperative care across sites and disciplines. Software companies have adopted the PNDS as it provides a language of measurement indicators facilitating benchmarking data for system improvement. Figure 2.1 AORN Model for Perioperative Nursing. Source: Reprinted with permission from AORN s Perioperative Nursing Data Set, revised second edition, pages 16, 19. Copyright 2007 AORN, Inc, 2170 South Parker Road, Suite 300, Denver, CO

9 Chapter 2: Competency Assessment 25 Competency Statements in Perioperative Nursing Another resource is the AORN Competency Statements in Perioperative Nursing which is directly linked to the PNDS. AORN has defined competency as the knowledge, skills, and abilities necessary to fulfill the professional role functions of a registered nursing in the operating room (AORN, 2007, p. 21). Competency statements are useful for employee orientation, continuing education, measurement and documentation for accrediting institutions. In addition to identifying competency statements for perioperative registered nurses, statements have also been articulated for Perioperative Advanced Practice Nurses and Perioperative Care Coordinators (AORN 2008). 2 Using the Perioperative Patient-Focused Model and the PNDS for Competency Assessment The Perioperative Patient-Focused Model in conjunction with the Perioperative Nursing Data Set and Competency Statements in Perioperative Nursing provide a clear map for competency assessment, particularly in the domain of safety. As an example, the interpretive statements of Outcome 05, The patient is free from signs and symptoms of injury related to positioning provide critical information for staff and students learning how to position the patient, such as very specific indicators and examples of nursing interventions and activities. These interventions and activities provide criteria for assessing positioning competency, and can also be integrated into institutional policies, procedures, manuals, and educational offerings. The PNDS is linked with the North American Nursing Diagnosis Association (NANDA) approved nursing diagnoses (Carpenito-Moyet, 2006). These diagnoses can be used as a framework for evaluating cognitive skills related to assessment and diagnosis of patients at risk for adverse outcomes during the operative and invasive procedure period, such as positioning-related injuries. The PNDS also provides consistent terminology that enhances benchmarking and multidisciplinary communication. PNDS taxonomy is the foundation for defining and communicating the activities that comprise nursing practice in the operative and invasive procedure setting. 2.4 shows an example of a competency assessment tool built on Domain 1, Outcome 05 Positioning Injury. NANDA North American Nursing Diagnosis Association THE COMPETENCY CONTINUUM As nurses gain experience, they advance in clinical competency. Consequently, clinical competency is not evaluated the same for all practitioners. Rather it is evaluated according to the practitioner s level of skill acquisition and role expectations. A model frequently used to understand the process of experiential influences on nurse competency is the Dreyfus & Dreyfus Model of Skill Acquisition, which was applied to nursing by Benner (1984). This five-level model describes the process of skill development from no experience (novice) to very experienced (expert) ( 2.5). The following describes characteristics of the five stages of the model as applied to student and practicing nurses. When designing competency assessment tools this model will provide guidance in crafting tools that are appropriate to the experience level of the practitioner.

10 26 Section 1: Conceptual Fundamentals of Practice 2.5 Novice Advanced Beginner Dreyfus & Dreyfus Model of Skill Acquisition The novice nurse has no prior experience upon which to base knowledgeable decision-making. Persons at this level seek concrete rules to follow and find it difficult when the rules do not apply exactly to the situation. When working with novices, it is important to be concrete and provide basic knowledge that can be applied to actions in practice. The advanced beginner nurse has some previous experiences upon which to base decisions. This nurse is able to see gray aspects in previously perceived black-and-white rules or procedures. Although this person acknowledges that situations may vary and actions cannot always be predicted, they usually have a difficult time anticipating subtleties in a situation and prioritizing nursing actions. Nurses at this level are very reactive rather than proactive. Competent Proficient Expert The competent nurse has worked two to three years in the same practice area. Experience enables this nurse to discern commonalities and act toward meeting long-term outcomes or goals. Organization is a characteristic of this nurse and can be typically manifested in his or her deliberate plan for managing patient care priorities. Understanding the complete context rather than focusing on isolated tasks or pending actions is the hallmark of the proficient nurse. This nurse prioritizes easily and relies less on concrete rules and more on perceptions based on experience. Another characteristic is the ability to easily differentiate between the expected and the unexpected. Intuitive knowing is a key characteristic of the expert nurse. Vast experience and cognition enables this nurse to provide high-quality nursing care by sensing subtle changes in the patient s conditions and acting swiftly in response to these changes. Benner, P. (1984). From Novice to Expert: Clinical Judgment-Making in Nursing. Menlo Park, CA: Addison-Wesley. Nurse Competency in the Operative and Invasive Procedure Setting The Dreyfus and Dreyfus Model of Skill Acquisition demonstrates competency assessment tools need to be appropriate for the knowledge, cognitive skills, and psychomotor skill levels of the individual being assessed. Tools need to address minimum competency for the task and also include elements that evaluate staff members as they move along the competency continuum. As an example, advanced beginner to expert nurses might have in their job description the expectation of providing patient care as scrub and/or circulating nurses. In this case, a common element of practice such as Perform Sponge, Sharp, and Instrument Counts would be a focus for competency assessment. The expert nurse, however, may have an additional role expectation such as Designs and Implements Continuing Nursing Education Programs, which would be a focus of competency assessment for the expert nurse. Within the operative and invasive procedure suite there are also overlapping functions that may be performed by staff with different levels of preparation based on education, certification, and licensure. As an example, both the registered nurse and the surgical technologist may transfer the patient, which presents a challenge in designing a competency

11 Chapter 2: Competency Assessment 27 tool that measures performance based on role function. Both the nurse and the surgical technologist need to demonstrate knowledge of the principles of transferring the patient as well as performing the psychomotor skills of implementing the transfer. Nurses would also need to demonstrate competency to identify the patient s risk for an adverse outcome related to the transfer episode and to demonstrate the ability to implement the nursing process related to this patient care event. Designing the Tool Competency Tools that Validate Expectations of Role Functions Overall, a competency tool provides validation that a nurse or other healthcare worker is performing to minimum expectations for his/her designated role functions. Tool design is based on what needs to be assessed and who is going to do the assessment. Annual and peer evaluations, along with skills checklists are used to document nurse competency. One peer evaluation tool commonly used by managers is the 360-degree evaluation, which facilitates multiple perspectives contributing to one s competency. 2.6 shows an example of a 360-degree feedback Survey. Clinical ladder programs, certificates, and professional education also promote professional development. As professionals, nurses have a moral mandate to demonstrate self-awareness of gaps in knowledge and then be proactive in pursuing lifelong learning opportunities and participating in the evaluation of competencies. Self-awareness and assessment of skills can be documented either via skills checklists or reflection forms. Many operative and invasive procedure suites use skills lists during orientation or at an annual evaluation. Reflective learning promotes learning from experience. Thinking about what worked well and what was problematic can enhance clinical decision-making during patient care as well as identify areas for additional knowledge that the nurse must obtain for competence. An example of a reflection form is provided in 2.7. The portfolio is another means of validating competency, especially for nurses as they progress to the next level of the competency continuum. This tool is a portable mechanism for evaluating competencies that may otherwise be difficult to assess, such as practice-based improvements, use of scientific evidence in practice, professional behavior and creative endeavors (Byrne et al. 2007, pg 24 25). The portfolio can be a considered a scrapbook of professional accomplishments and may be kept in a paper or electronic format. As an example, the Competency and Credentialing Institute (CCI) recently initiated an evidence-based, peer-evaluated portfolio to assess the continued competency for perioperative nurses if they recertify or desire to reactivate their CNOR credential (CCI, 2008). s 2.8 shows an example of a competency assessment tool for Provide Instruments, Equipment, and Supplies. This tool would be administered by the appropriate manager, educator, or peer. In this text, similar tools are listed for Chapters 5 through CCI Competency and Credentialing Institute Competency Tools that Validate Performance of Critical Processes Whereas competency validation previously discussed focused on evaluating the overall performance of the practitioner to determine if he or she is practicing

12 28 Section 1: Conceptual Fundamentals of Practice Degree Feedback Survey The purpose of this survey is to provide upward feedback from multiple sources. 360-degree feedback is a tool that can be used to provide feedback to managers from their superiors, peers, direct reports, and customers. Such feedback has been growing in popularity in a number of innovative and empowering organizations in recent years. Ultimately, improved managerial skills resulting from 360-degree feedback will further the goals of your organization. As a part of this process, we would like you to fill out the attached survey that asks you to evaluate one of your peers in a number of areas. As a peer of this person, you have a unique perspective that could be very valuable as he/she tries to get a complete picture of how others evaluate his/her behavior. On the following pages you will find a series of statements relating to his/her behavior. For each statement, please provide a rating describing how often this person engages in each of the behaviors, or activities, listed. Use the nine-point scale shown to rate him or her. Indicate your answer by circling the number that describes how often he/she does the activity listed. Note that the odd numbers (1, 3, 5, 7, and 9) have labels attached to them. These labels are just to give you some anchors or references when using the scale. You may use any number from 1 to 9 (including the even numbers) for your rating. The not applicable category should only be used if you do not think the behavior is applicable or you simply have not had an opportunity to observe it. After you have responded to the statements, you may complete the two fill-in questions at the end of the form. When completing the fill-in section, please make specific, constructive comments about this employee s behavior that could be helpful to the person you are rating. Be assured that your responses will remain anonymous. This survey must be completed and mailed by [date]. When mailing the survey, place it in an unmarked sealed envelop. Place this envelop in the addressed and stamped envelop provided. Thank you for your cooperation. Please indicate how often this case manager engages in each of the following activities or behaviors. This is a survey on: 0 NA 1 Never 2 3 Once in a While 4 5 Sometimes 6 7 Fairly Often 8 9 Always PERSONAL EFFECTIVENESS Accepts feedback without becoming defensive (eg, making excuses, denial, getting angry) Makes tough decisions in a timely manner Is available when needed Provides valuable input into decisions. INTERPERSONAL SKILLS Communicates information in a timely way Keeps people informed about issues, changes, or problems that affect them Is approachable Makes it easy for people to tell him/her what they think.

13 Chapter 2: Competency Assessment 29 INNOVATION, CHANGE AND RISK TAKING Creates an environment that supports change Speaks positively about new initiatives Helps others find new ways to get the job done. CUSTOMER ORIENTATION Shows that internal and external customer satisfaction is a top priority Treats all clients fairly, regardless of differences (eg, sex, ethnicity, beliefs, sexual orientation). TEAMWORK Involves others in problem-solving and decision-making activities that have an impact on them Promotes a spirit of of cooperation between members of the work group Helps resolve conflicts when they occur in the work group Works well with other supervisors and higher management. LEADERSHIP Motivates and encourages others Takes responsibility for the results of his/her actions Displays a positive outlook and enthusiasm Leads by positive example Demonstrates behavior consistent with the organization s vision and values. ADDITIONAL COMMENTS In the spaces below you may make some additional comments to help the person you rated become a better leader. Any comments you write will be typed and given to this person along with all comments made by other peers rating the same person. Your name will NOT be attached to any of these comments. If you do wish to make comments, try to make them short and constructive so that this person will understand what you think his/her strengths are and in what areas he/she could improve. A. List the three most effective strengths of the person you rated in this survey. B. List the three areas in which the person you rated could use more development.

14 30 Section 1: Conceptual Fundamentals of Practice 2.7 Reflection Form Reflection is the process of learning from experience. It allows you to use your experience to determine what you may do differently as a result of the learning. Reflection may raise new questions that will drive you to future learning. It aids in ongoing self-assessment and ensures that your ongoing learning is current and relevant to your practice. This reflection form is designed to help you demonstrate how you incorporated these principles of reflection in the learning process. One completed reflection form must be included for each of the five (5) selected professional activities. Each reflection form must be accompanied by evidence supporting your role in the professional activity. One form must be submitted for EACH activity. Make copies as needed or access the form electronically at Professional Activity: Date(s) of Activity: Thoroughly describe the activity/project/event. What happened or occurred? Clearly describe your role. What do you know now that you did not know before? (What have you learned? What do you do differently? Or how will you build on this experience?) What are the implications for perioperative nursing practice? Reprinted with permission. Competency & Credentialing Institute, Denver, CO. IFU Instructions for Use competently at the expected level, tools that validate competency for performing critical processes focus on high-volume and high-risk processes; processes that if not done correctly, that is competently, may lead to an adverse patient outcome. As stated previously, this text uses the System-in-Contingency Model as a framework for competency assessment. Within the twelve patient care events are specific activities that are high-volume and high-risk, thus making them critical processes and the focus for evaluation. As an example, prepping the patient for an operative procedure is one of the activities of the patient care event Establish and Maintain the Sterile Field. Prepping the patient is a high-volume activity because it is a nearly universal occurrence for patients having an operative procedure. As for being a high-risk activity, if it is not done correctly, particularly for a patient diagnosed as high risk for wound infection, the patient could indeed experience a wound infection secondary to skin preparation. Additionally, if a flammable prepping solution is used, and preparation is not done according to the manufacture s Instructions for Use (IFU), the patient could be

15 Chapter 2: Competency Assessment Competency Assessment: Provide Instruments, Equipment, and Supplies Name Title Unit Date of Validation Type of Validation: Initial (by educator) Annual (by peer) Method of Evaluation: Observation COMPETENCY STATEMENT: The nurse demonstrates competency to provide instruments, equipment, and supplies for an operative or invasive. 2 Score Performance Criteria Identifies the patient s risk for adverse outcomes related to the provision of instruments, equipment, and supplies Selects appropriate instrumentation, equipment, and supplies for an operative or invasive procedure Delivers instruments and supplies to the sterile field Arranges instruments and supplies on the back table and Mayo tray Passes instruments and supplies to the physician or assistant Prepares and passes sutures to the physician or assistant Prepares and applies patient warming systems Maintains safe transport environment through use of elevated bed rails, safety straps applied, additional devices secured (eg, oxygen tanks, IV poles, Foley catheter, chest tube) Prepares air-powered instrumentation for use Implements electrosurgical safety precautions Applies dressings Prepares and operates endoscopic equipment. Scoring 1 Did not demonstrate competency 2 Minimal competency 3 Competency 4 Exceptional competency 5 Outstanding competency Comments (mandatory for scores of 1, 2, 4, or 5) Validator s Signature Employee s Signature Validator s Printed Name Employee s Printed Name

16 32 Section 1: Conceptual Fundamentals of Practice RECQM Return Electrode Contact Quality Monitoring the victim of a surgical fire. Clearly, those responsible for determining the elements of a competency assessment program would be prudent to target prepping the patient for evaluation. 2.9 lists the patient care events of the operative and invasive procedure period and identifies potentially high-volume and/or high-risk activities that should be considered for targeted competency assessment shows an example of a high-risk activity from the patient care event Provide Instruments, Equipment, and Supplies. Assuming that this example concerns a facility where infant and neonatal surgery is occasionally done, Performance Criteria 10, Implement Electrosurgical Safety Precautions, is selected as highrisk because of the infrequent use of return electrode contact quality monitoring (RECQM) infant and neonatal patient return electrodes. Manufacturer IFUs are very explicit about the application of RECQM infant and neonatal patient return electrodes, as well as generator power settings and activation times, indicating that the use of electrosurgery to achieve hemostasis is a potentially a high-risk activity. In this scenario it would be wise to have a focused competency evaluation concerning the patient return application, power settings, and activation times. Evidence-Based Practice as a Foundation for Nurse Competency A current initiative in clinical practice and academic settings is evidence-based nursing practice. Simply, this means nurses make clinical decisions based on sound evidence for successful patient outcomes. Whether patient outcomes are defined as intact skin, successful wound healing, early ambulation, or adequate oral intake, the interventions done by the nurse should lead to positive patient outcomes. Nursing interventions can be guided by past experience, patient preference, and scholarly evidence resulting from clinical research. Information Literacy Information literacy is defined as the ability to access, evaluate and ethically use information. These three abilities should also be considered essential competencies for nurses practicing in the operative and invasive procedure setting. Accessing Information Computers have revolutionized accessing and communicating information. The historical act of physically going to a library, thumbing through a card catalog, and searching the Dewey decimal system for a specific book are long gone. With adequate computer and subscription databases and online journals, nurses can access journals and textbooks online. Specialty experts can be easily located on the Internet. and text messaging promotes prompt and ready communication with national and international experts. Websites are often used because they contain excellent resources for practicing nurses lists organizations that can be used as resources for designing competency assessment tools and delineates some of the available resources. Evaluating and Ethically Using Information Many websites contain invaluable resources, yet the evaluation of information rests upon a nurse s discernment of knowledge claims (Hoss & Hanson, 2008).

17 Chapter 2: Competency Assessment Examples of High-Risk Patient Care Activities of the Operative and Invasive Procedure Period Patient Care Event High-Volume/High-Risk Activities Prepare of the patient for the procedure Preparation of the cognitively impaired patient Transfer the patient Patient and procedure site verification of cognitively impaired, sedated, or comatose patient Transfer of the bariatric patient Transfer of the patient in traction Transfer of the pediatric patient 2 Assist the anesthesia provider Awake induction Bariatric patient induction Trauma induction Use of uncuffed endotracheal tubes for airway procedures and procedures in the head and neck area Position the patient Placing the elderly patient on a fracture table Placing the patient in the lateral decubitus position Placing the patient in the prone position Positioning the bariatric patient Establish and maintain the sterile field Preparing the procedure site with alcohol-based prepping solution Perform sponge, sharp, and instrument counts Provide instruments, equipment, and supplies for the procedure Open operative procedures Applying the pneumatic tourniquet Applying warming devices Oral cavity electrosurgical safety precautions Pediatric electrosurgical safety precautions Suction coagulator safety precautions Use of ground referenced generators Use of isolated generators without return electrode contact quality monitoring Administer drugs and solutions Identification of medications on sterile field Physiologically monitor the patient Conscious sedation performed by registered nurse Monitor and control the environment Evacuating endosurgical smoke Implementing fire safety precautions Flash sterilization Electrosurgery or laser use in oxygen enriched atmosphere Handle cultures and specimens Procedures with multiple specimens Facilitate care after the procedure Discharge instructions for cognitively impaired patients or family members

18 34 Section 1: Conceptual Fundamentals of Practice 2.10 COMPETENCY ASSESSMENT: Pediatric Electrosurgical Safety Precautions Name Title Unit Date of Validation Type of Validation: Initial (by educator) Annual (by peer) Method of Evaluation: Observation COMPETENCY STATEMENT: The nurse demonstrates competency to implement pediatric electrosurgical safety precautions for an operative or invasive procedure. Score Performance Criteria Describes the potential risk factors for adverse outcomes related to the application of electrosurgery. Scar tissue, bony prominence and excessive hair at return electrode site; emaciation; use of a defective return electrode; impaired skin or tissue integrity or perfusion at site of return electrode; use of a ground-reference generator; use of an isolated generator without return electrode monitoring; use of infl ammable agents to prepare the operative site Describes the ideal site for patient return electrode application. Choose a well vascularized, convex area in close proximity to the surgical site; free of scar tissue, no bony prominences, and excessive adipose tissue; in an area where fl uid will not pool Describes how to prepare the PRE site. Clean and dry the application site as needed Describes how to check the return electrode expiration date and what to do it the PRE is expired. Check the expiration date and discard the return electrode if expired Describes what to do after removing the liner from the PRE. Lightly touch the surface of the return electrode to ensure the conductive adhesive is moist Describes when the return electrode would be used with or without the adhesive border around the exterior edge. Would avoid using the adhesive border if the patient is impaired skin or has potential for an allergic reaction Describes what to do after applying the PRE. Ensure the entire conductive surface of the return electrode is in contact with the patient. Apply fi nger pressure to massage the entire return-electrode surface (and adhesive border if used) to ensure secure contact with the patient s skin States the steps of connecting the PRE to the generator. (1) Turn on the generator. (2) Wait for the audible tone and the REM alarm indicator to display red and alarm to sound. (3) Insert the return-electrode connector into the generator to correct the alarm condition Describes how to remove the PRE after the procedure. Slowly remove the return electrode with one hand while supporting the skin with the other to avoid skin trauma.

19 Chapter 2: Competency Assessment States the outcome criteria for evaluating the PRE site following the procedure. Redness indicating an allergic reaction to the patient return electrode conductive adhesive; evidence of postprocedure skin and tissue disruption/destruction at the patient return electrode site or at alternate pathway sites; and an ignition incident during the operative or invasive procedure. Specific Considerations for the Infant Patient Return Electrode States the weight parameters for using the infant PRE. 2.7 kg 13.6 kg (6 lbs 30 lbs) Describes the preferred application site for infants. The preferred sites are the back or torso States the parameters for power setting. The power settings do not exceed 120 watts. Confi rm proper electrosurgical generator settings with the surgeon prior to activation of the active electrode. Specific Considerations for the Neonatal Patient Return Electrode Specific Considerations for the Neonatal Patient Return Electrode. States the weight parameters for using the neonatal PRE kg 2.72 kg (1 lb 6 lbs) Describes the preferred application site for infants. The preferred site is the back, inferior to the shoulder blades and superior to the sacrum States the parameters for generator selection. Only use a generator that has been calibrated by biomedical engineer or technician and posted with the power settings as required by the manufacturer IFU States the parameters for power settings and application of current. Not to exceed 300 milliamps nor be applied for longer than 30 seconds continually. Scoring 1 Did not demonstrate competency 2 Minimal competency 3 Competency 4 Exceptional competency 5 Outstanding competency Comments (mandatory for scores of 1, 2, 4, or 5) Validator s Signature Employee s Signature Validator s Printed Name Employee s Printed Name

20 36 Section 1: Conceptual Fundamentals of Practice 2.11 Resources for Design of Competency Assessment Tools for Registered Nurses Practicing in the Operative and Invasive Procedure Setting Organization Website Resources American Academy of Ambulatory Care Nursing American College of Cardiovascular Nurses American Radiological Nurses Association Association of perioperative Registered Nurses Guide to Ambulatory Care Nursing Orientation and Competency Assessment ECG Competency Assessment Tool Core Curriculum for Radiology Nursing Perioperative Nursing Data Set (PNDA Competency Statements in Perioperative Nursing Outcome Standards for Perioperative Nursing Competency and Credentialing Institute COMPETENCY MODULES Age-Specific Care Aseptic Technique Care of the Bariatric Patient Cultural Competency Designing Competencies that Count Electrosurgery Moderate Sedation/Analgesia Patient Positioning Patient Safety ECRI PATIENT SAFETY, QUALITY, AND RISK MANAGEMENT DOCUMENTS Operating Room Risk Management System Bariatric Services: Safety, Quality, and Technology Guide Medication Safety Solutions Society of Gastroenterology Nurses and Associates, Inc. STANDARDS AND GUIDELINES Performance of Flexible Sigmoidoscopy by Registered Nurses for the Purpose of Colorectal Cancer Screening Guidelines for the Use of High Level Disinfectants and Sterilants for Reprocessing of Flexible Gastrointestinal Endoscopes Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes Guidelines for Preventing Allergic Reactions to Natural Rubber Latex in the Workplace Guidelines for Documentation in the Gastrointestinal Endoscopy Setting Standards of Clinical Nursing Practice and Role Delineation Statements