CHAPTER 1. Evolution of Perianesthesia Care
Jan Odom-Forren and Theresa L. Clifford
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
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).
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 b.c. 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 immediate 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, hernias, and others.
c. None of the children required hospital admission.
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 reported in 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): one third of preventable postsurgical deaths during an 11-year period could have been eliminated by improved postoperative nursing care.
2. 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
4. Expanding technology led to outpatient complex surgeries.
a. Microscopic surgeries abounded
b. New lasers were developed (yttrium argon gas, argon, carbon dioxide).
c. New laparoscopic instruments facilitated shorter, less invasive laparoscopic procedures.
d. More endoscopic procedures were being performed as outpatient procedures.
e. Video equipment and computer-assisted surgeries were now being performed.
f. Fiberoptics led to advances in ophthalmic surgeries, most of which are performed in outpatient settings.
5. Change in anesthesia techniques and medications
6. 1970s: recovery rooms managed routine postanesthesia patients, including ambulatory, routine, and critically ill patients receiving respiratory and circulatory 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: in some places considered to be extension of 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 ambulatory 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, paving the way for surgery being performed in doctors’ offices.
a. The 1980s brought a shortage of inpatient hospital 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 surgery 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, 984 freestanding outpatient surgery centers performed more than 1.5 million surgical operations.
3. By 1989, there were 984 Medicare-participating freestanding ambulatory surgery centers in the United States.
4. The list of approved procedures that can be conducted 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 post anesthesia care units (PACUs), from the ASU, and from physicians’ offices.
b. Some patients were transferred there from hospitals on their second or third postoperative day.
2. The limits of stay for recovery care centers are defined by 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 surgery was to be performed (hospital hotels; medical motels).
a. Freestanding medical motels are considered a comfortable, affordable, convenient place to recuperate.
b. Patients are cared for by family members.
c. Home health nurses make visits, or a nurse is stationed onsite.
4. In 1996, data from the National Center for Health Statistics Data Center
a. An estimated 31.5 million surgical and nonsurgical procedures were performed during 20.8 million ambulatory visits in 1996.
b. An estimated 17.5 million (84%) of the ambulatory surgery visits were in hospitals and 3.3 million (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 that provided over 12 million surgeries annually.
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 outpatient basis.
c. In the 1990s, 23 home observation units (recovery centers) were established in the United States.
d. The percentage of outpatient procedures approved for payment under Medicare increased.
(1) In 1982, 450 procedures approved
(2) By the early 1990s, 2500 approved procedures
(3) On July 1, 2003, 282 additional procedures 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, rehabilitation centers, and nursing homes.
g. Outpatient facilities eliminate the costs of cafeteria, 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 considered nonhospitalized for purposes of reimbursement 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, providing 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.
d. Patients were able to keep dentures, eyeglasses, and hearing aids with them.
e. Patients felt more involved in decision-making for their care.
f. Family visitation encouraged in phase I PACUs
4. Reimbursement
a. Reimbursement provided by Medicare for outpatient procedures for the elderly made ambulatory 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. Need to identify a special body of knowledge and skills required for practice
1. Groups form to develop educational opportunities.
a. Nineteen groups organized in United States
b. Florida Society of Anesthesiologists initiated yearly seminar in 1969.
(1) Attended by nurses from United States and Canada
(2) Dr. Frank McKechnie: very supportive of recovery room nurses
2. Series of seminars sponsored by American Society of Anesthesiologists (ASA)—1970s
a. Supported by solid attendance and strong interest from nurses in the specialty
b. Interest shown in development of recovery room nursing organization
B. Local and state organizations form national group.
1. Regional nursing representatives met with ASA Care Team to organize 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 (WB Saunders, publisher)
13. 1994: Pediatrics added to Redi-Ref
14. 1994: ASPAN Resource Manual published in collaboration 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 include:
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 observations/interventions after transfer/discharge from phase I or phase II)
c. New position statements
(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. Additions include:
a. “The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery”
b. New position statements:
(1) “Safe Medication Administration”
(2) “Cultural Diversity and Sensitivity in Perianesthesia Nursing Practice”
(3) “Perianesthesia Safety”
39. December 2007: ASPAN’s Safety Model introduced, “Perianesthesia Nursing’s Essential Role in Safe Practice,” published in 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 Model introduced
42. 2008-2010 Standards of PeriAnesthesia Nursing Practice
a. “Smallpox Vaccination Program” position statement retired
b. New position statements:
(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 PeriAnesthesia Data Elements (PDE)
45. 2009: ASPAN Safety Toolkit
46. 2009: Evidence Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia
47. 2009: New 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
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 certified postanesthesia nurse 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: Certified postanesthesia nurse (CPAN) and certified ambulatory postanesthesia nurse (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 CAPAs, and 100 with dual certification
10. 2003: 3921 CPANs, 1730 CAPAs, and 202 with dual certification
11. 2008: 5371 CPANs, 3210 CAPAs, and 297 with dual certification
12. 2009: Computer Based Testing for CPAN and CAPA started
C. Education
1. 1982: national conference and annual educational program started
2. Regional core curriculum workshops (2-day program 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 anesthesia, 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 guideline held in St. Louis, Missouri
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 American Nurses Association (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. 2003: NOLF and NFSNO combine to form new organization of the Alliance: Nurses Organizations Alliance.
13. 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.
14. 2004: ASPAN partners 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.
15. 2003: ASPAN begins partnership with the British Anaesthetic and Recovery Nurses Association (BARNA), and seven ASPAN delegates attended the BARNA Conference
16. July 2006: ASPAN represented at the Nursing Terminology Summit, Nashville, Tennessee
17. September 2006: ASPAN represented at the first summit of the newly formed Society for Perioperative Assessment and Quality Improvement
18. October 2006: ASPAN president invited for the first time to attend 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. November 2007: two ASPAN past presidents were co-leaders for the 2007 People to People delegation to China
21. May 2008: ASPAN president participated in Canadian conference.
E. Other highlights
1. 1983: members encouraged to change name of workplace from recovery room to PACU
2. 1989: postanesthesia nurse awareness week established
3. 1989: definition of immediate postanesthesia nursing expanded to include preoperative and phase II areas to incorporate ambulatory nurses working only 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 achievement awards established
7. 1991: ASPAN becomes an ANA approver and provider of continuing education.
8. 1992-1993: research committee offers grants and conducted the first Delphi study to establish postanesthesia 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 Internet 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)
18. 1996: Journal of Post Anesthesia Nursing name changed to Journal of PeriAnesthesia Nursing
19. April 10, 1997: newly structured board of directors 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. 1998: ASPAN membership is more than 10,000 with 40 components.
25. 2008: ASPAN membership is 13,403.
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
7. Advanced Degree, chartered 2004-2005
8. Perianesthesia Nurse Educator, chartered 2007-2008
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. Jane 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
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