Registered nurse circulator legislation in Connecticut

AORN Journal,  April, 2008  by Judith L. Goldberg

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Patient safety is a critically important issue for health care facilities today, and nowhere is an emphasis on patient safety more necessary than in the perioperative arena. Patients in an OR are unable to make their own decisions and must rely on an advocate to look out for their safety and best interests. (1) That advocate is the registered professional nurse circulator.

Perioperative nurses possess clinical knowledge, judgment, and critical thinking skills based on scientific knowledge, which makes them particularly well suited to planning and implementing nursing care that addresses the physical, psychological, and spiritual responses of the patient undergoing a surgical or invasive procedure. (2) These t are ideal traits for an OR circulator to t have, and each patient undergoing a surgical or invasive procedure de serves to have an RN circulator during his or her procedure.

Some states have laws or regulations specifying that the circulator for a surgical or invasive procedure must be an RN, but other states do not. Faced with the worsening nursing shortage and budgetary constraints, hospital administrators in states that do not have RN circulator legislation may look for alternatives to ensuring that each surgical procedure includes one dedicated RN circulator.

The state of Connecticut and the Connecticut Department of Public Health (DPH) currently have no legislative or regulatory language regarding the RN as circulator in operating and invasive procedure rooms. Without prescriptive language, hospitals and ambulatory surgery centers (ASCs) throughout the state may begin to use allied health care providers, such as licensed practical nurses (LPNs), licensed vocational nurses (LVNs), and surgical technologists (STs), to circulate in ORs as the nursing shortage worsens. This represents a major patient safety issue, and perioperative nurses should work toward ensuring the passage of legislation that requires an RN circulator for every surgical procedure across the nation.

THE IMPORTANCE OF HAVING AN RN AS CIRCULATOR

The circulating nurse is the person outside the sterile field during a surgical or invasive procedure. (3) This nurse conducts the preoperative patient interview and assessment and develops an individualized plan of care for the patient that includes nursing diagnoses, interventions, and outcomes. The circulating nurse works with an interdisciplinary team that may include the

* surgeon,

* anesthesia care provider,

* assistant surgeon,

* physician assistant,

* RN first assistant, and

* scrub person.

An expanded team may also include

* residents;

* interns;

* medical, nursing, and other students;

* health care industry representatives;

* blood salvaging personnel; and

* diagnostic imaging and ultrasound personnel, as well as a multitude of other staff members and observers. The nurse coordinates patient care and serves as me advocate for patients throughout their surgical experience. The circulating nurse reevaluates the condition of the patient throughout the procedure and uses critical thinking and assessment skills to reprioritize the care plan to reflect changes in the situation.

The education and training of LPNs, LVNs, and STs is not equivalent to that of an RN. An RN has completed courses in basic science, such as anatomy and physiology, and in pathology, pharmacology, microbiology, chemistry, and other pertinent subjects, depending on the type of program he or she completed. An RN also has learned skills in assessment, planning, and implementation of the appropriately selected interventions and in evaluation of the patient. This education and training provides the perioperative RN with the ability to make accurate decisions in trauma and emergency situations, increasing patient safety. The typical one-year training program for LPNs and LVNs prepares them to provide basic bedside care for the sick and includes courses in the sciences, psychology, food and nutrition, and growth and development, as well as supervised patient care experiences. Programs for STs may last from nine to 24 months and include classroom education in various sciences, ethics, medical terminology, safe care of patients, sterile technique, infections prevention, and handling medications and solutions in addition to clinical experiences. Based on the limited education they receive compared to RNs, LPNs, LVNs, and STs may be less likely to incorporate an expanded level of critical thinking in the perioperative setting and may therefore be less likely to react appropriately during an emergency situation.

The policy of requiring that OR circulators be RNs makes good business sense in addition to providing a safe environment for patients. Although some health care facility administrators may be tempted to try to decrease costs by employing fewer RNs, multiple studies have been conducted on patient outcomes related to RN staffing levels, many of which have indicated that a higher ratio of RNs to patients and of RNs to other allied health care providers results in better patient outcomes. (4-8) One study conducted by Needleman et al (4) showed a correlation between care provided specifically by RNs and several medical outcomes (ie, length of stay and rates of urinary tract infections, upper gastrointestinal bleeding, pneumonia, shock or cardiac arrest, failure to rescue). The more hours of care provided by RNs, the better the outcomes. Although this study examined outcomes for medical and postoperative surgical patients, not for patients undergoing a surgical intervention, it is reasonable to expect that a study of ORs staffed with STs compared with RNs would yield similar results.